1. Anemia Presented by M.A. Kaeser, DC Fall 2009 http://t0.gstatic.com/images?q=tbn:udh8H6fKbssNxM:http://wwwhttp://t0.gstatic.com/images?q=tbn:udh8H6fKbssNxM:http://www. cancerquest.org/images/RBC.jpg

2. Definition Reduction in hemoglobin and hematocrit values below the normal range

3. Signs and Symptoms FatigueDyspneaPallorTachycardia Degree of symptomatology depends on magnitude and rapidity of fall, adequacy of physiologic corrective mechanisms and presence of associated diseases http://wpcontent.answers.com/wikipedia/commons/thumb/9/91/Symptoms_of_ anemia.png/260px-Symptoms_of_anemia.png

4. Diagnostic Classification System Types of anemia Microcytic hypochromic Microcytic hypochromic Macrocytic Macrocytic Normochromic normocytic Normochromic normocytic

5. Microcytic Hypochromic Causes – impairment of hemoglobin synthesis within the developing RBC which leads to hypochromic cells due to decreased hemoglobin and smaller than normal cells due to an increase in cell division Examples Iron deficiency – lack of total body iron Iron deficiency – lack of total body iron Thalassemia – production of globin is impaired Thalassemia – production of globin is impaired Sideroblastic – production of porphyrin is impaired Sideroblastic – production of porphyrin is impaired *Remember: hemoglobin consists of heme moieties attached to a globin molecule; the heme moiety consists of iron attached to a porphyrin – if the RBC lacks iron or can’t synthesize the porphyrin or the globin properly, it can’t produce hemoglobin Index Low MCV (Mean corpuscular volume) and MCHC (Mean corpuscular hemoglobin concentration) Low MCV (Mean corpuscular volume) and MCHC (Mean corpuscular hemoglobin concentration)

6. Iron Deficiency Anemia Can be confirmed by TIBC (total iron binding capacity) Also confirmed by trial of iron therapy Should increase the reticulocyte count within approx. 4 days Should increase the reticulocyte count within approx. 4 daysCauses Pregnancy – insufficient dietary iron to supply the rapidly expanding red cell mass as iron shifts to the fetus Pregnancy – insufficient dietary iron to supply the rapidly expanding red cell mass as iron shifts to the fetus Dietary deficiency is extremely rare except in children under 4 years Dietary deficiency is extremely rare except in children under 4 years Menstrual blood loss (M/C cause) with flow in excess of 100 mL Menstrual blood loss (M/C cause) with flow in excess of 100 mL GI bleeding – postmenopausal women and adult males GI bleeding – postmenopausal women and adult males Malabsorption Malabsorption

7. Thalassemia A low MCV (mean corpuscular volume) coupled with a normal serum iron level Thalassemia major is rare Thalassemia minor is relatively common Cause Defective synthesis of the globin molecule Defective synthesis of the globin molecule

8. Sideroblastic Anemia Least common microcytic hypochromic anemia Porphyrin synthesis is deficient and iron accumulates within the mitochondria May occur as a rare congenital disorder, acquired idiopathic bone marrow disorder or in association with alcoholism, lead poisoning, isoniazid therapy, RA, carcinoma and other disorders

9. Macrocytic Causes Megaloblastic Megaloblastic B 12 deficiency Folate deficiency Chemotherapy Normoblastic (nonmegaloblastic) Normoblastic (nonmegaloblastic) Some hemolytic and acute blood loss anemia due to increased reticulocytosis Liver disease HypothyroidismIndex Increased MCV above 100 Increased MCV above 100

10. Megaloblastic Macrocytic Anemia Impaired maturation of the nucleus B 12 deficiency Daily requirement is 1 mg Daily requirement is 1 mg Body stores large amounts Body stores large amounts Available in all animal foods (including dairy products) Available in all animal foods (including dairy products) Takes 3 - 4 years to exhaust the body’s stored supple Takes 3 - 4 years to exhaust the body’s stored supple Malabsorption is M/C reason for deficiency Malabsorption is M/C reason for deficiency Pernicious anemia-atrophic gastritis diminishes production of intrinsic factor and causes malabsorption of B 12 Pernicious anemia-atrophic gastritis diminishes production of intrinsic factor and causes malabsorption of B 12 Sprue, regional enteritis, disease of the terminal ileum, fish-tapeworm infestation, blind loop syndrome Shilling Test – detects vitamin B 12 malabsorption Folic acid deficiency More common than B 12 deficiency More common than B 12 deficiency Sources are green vegetables and liver Sources are green vegetables and liver Exhausted in 2 – 3 months Exhausted in 2 – 3 months Common in malnourished individuals and alcoholics Common in malnourished individuals and alcoholics

11. Normoblastic Macrocytic Anemia Mild degrees of macrocytosis are associated with this group Liver disease Hypothyroidism Aplastic anemia Refractory anemia

12. Normochromic Normocytic- Underproduction Causes Causes Chronic disease Chronic disease Renal failure Renal failure Liver disease Liver disease Hypothyroidism Hypothyroidism Myelophthisic anemia-due to replacement of marrow by malignant lesions or by myelofibrosis Myelophthisic anemia-due to replacement of marrow by malignant lesions or by myelofibrosis Aplastic anemia-increase in cellular elements in the bone marrow and increased fat in the bone marrow Aplastic anemia-increase in cellular elements in the bone marrow and increased fat in the bone marrow Refractory anemia-bone marrow is hyperplastic with failure of cells to mature properly and subsequently die- sometimes represents preleukemic states Refractory anemia-bone marrow is hyperplastic with failure of cells to mature properly and subsequently die- sometimes represents preleukemic states Index Index Normal or low reticulocyte count Normal or low reticulocyte count

13. Normochromic Normocytic-Increased Red Cell Destruction (Hemolysis) Causes Hereditary hemolytic anemias Hereditary hemolytic anemias Acquired hemolytic anemias Acquired hemolytic anemiasIndex Elevated reticulocyte count Elevated reticulocyte count

14. Hereditary Hemolytic Anemias M/C is hemoglobinapathies Abnormal hemoglobins, S and C Abnormal hemoglobins, S and C M/C in blacks M/C in blacks Sickle cell anemia – homozygous SS disease Sickle cell anemia – homozygous SS disease Milder sickle cell anemia – heterozygous SC disease Milder sickle cell anemia – heterozygous SC disease Hereditary Spherocytosis Severe to mild anemia Severe to mild anemia Splenomegaly Splenomegaly Hereditary Nonspherocytic hemolytic anemia Due to red cell enzyme deficiencies Due to red cell enzyme deficiencies G6PD (glucose-6-phosphate dehydrogenase) deficiency and pyruvate kinase deficiency G6PD (glucose-6-phosphate dehydrogenase) deficiency and pyruvate kinase deficiency

15. Acquired Hemolytic Anemias Hypersplenism Splenic hyperfunction Splenic hyperfunction Coombs’-positive anemia Microangiopathic hemolytic anemia Large numbers of red cell fragments (schistocytes) Large numbers of red cell fragments (schistocytes) Causes: collagen vascular disease, disseminated intravascular coagulation, kidney desease assoc. with malignant hypertension Causes: collagen vascular disease, disseminated intravascular coagulation, kidney desease assoc. with malignant hypertension Paroxysmal nocturnal hemoglobinuria