1. FULL BLOOD COUNT PRESENTATION Clinical Practice A
GROUP C

2. Iron Deficiency Anaemia
Caused by a lack of adequate iron to synthesize haemoglobin and meet body demands in such as during periods of rapid growth and pregnancy
Usually due to a diet insufficient in iron or from blood loss
Diagnosis includes
- Often, the platelet count is elevated (>450,000X109/L)
- WBC is usually within reference ranges

3. Iron Deficiency blood loss: uterine e.g. menorrhagia gastrointestinal
malignancy
increased demands:
pregnancy
prematurity
growth
others:
malabsorption e.g. gastrectomy, coeliac disease
dietary iron deficiency

4. Investigation and Diagnosis
Biochemistry:
decreased serum ferritin - best biochemical marker
increased total iron binding capacity (TIBC)
decreased TIBC saturation - less than 30%; often the best parameter with which to monitor treatment
decreased serum iron

5. Investigation and Diagnosis
Haematology:
microcytic, hypochromic anaemia
blood film shows occasional target cells and pencil-shaped poikilocytes
platelet count may be at or above the upper limit of normal if there is persistent bleeding
The best proof of iron deficiency anaemia is that the anaemia is cured by administration of iron.

6. Microcytosis
Defined as a reduced mean cell volume – average volume of a single red cell - of less than 80 femtolitres in adults (norm range fl)
Characterized by the presence of microcytes (abnormally small red blood cells) in the blood.

7. Causes iron deficiency anaemia - the commonest cause
Vit A, C, copper deficiency
sideroblastic anaemia
thalassaemias
anaemia of chronic disease
lead poisoning

8. Clinical Features Possible symptoms: pallor fatigue dyspnoea anorexia
headache
bowel disturbance

9. Investigation
to investigate microcytic anaemia , patient has a blood film, then serum iron levels are measured.
blood film - iron deficiency anaemia has a microcytic, hypochromic blood film showing anisocytosis and poikilocytosis
serum iron, ferritin and total iron binding capacity:
- iron deficiency anaemia - low serum iron, low serum ferritin, raised TIBC
- other causes are iron loading conditions characterised by raised serum iron, raised ferritin, low total iron binding capacity

10. Patient Investigation
FBC Hb
65 g/L
MCV
74 fL
80-100
Platelets
500 X 109/L
X 109/L
Serum ferritin
5ug/L
10-230
Serum B12
220pmol/L
Serum folate
2.0nmol/L
7-45
Red cell folate
100nmol/L

11. Case History 25 year old female Suspected iron deficiency anaemia
Never been pregnant, no change in menstrual flow
Normal diet/No medications
No GIT problems
Low MCV
High platelets
Normal Serum B12
Low Serum Folate
Low Red Cell Folate
Low haemoglobin

12. Is the MCV result consistent with a diagnosis of iron deficiency?
Yes in iron deficiency anaemia, MCV is low, however microcytosis is not always caused by iron deficiency anaemia
WHY?

13. Because…
In the majority of cases, microcytosis is the result of impaired hemoglobin synthesis. Disorders of iron metabolism and of porphyrin and heme synthesis, as well as impaired globin synthesis, lead to defective hemoglobin production and to the generation of microcytosis.

14. Could this patient also have associated B12 or folate deficiency?
Serum folate, RBC folate and Vitamin B12 levels differentiate between folate and B12 deficiency
The patient:
Low haemaglobin: anaemia
Serum B12: Normal
Serum folate and RBC folate: LOW
Thus there is a folate deficiency

15. Folate Deficiency
Low folate levels can cause macrocytic anaemia – indicated by high MCV
The patient has a low MCV - indicates microcytic anaemia due to iron deficiency

16. Anisocytosis
However, blood film showed anisocytosis: RBC are of unequal size (large and small)
Patient can have both
 iron deficiency anaemia: small size RBC
 folate deficiency anaemia: large size RBC

17. Main causes of folate deficiency
Dietary – inadequate intake (Common)
Blood loss
Increase physiological requirements eg infant growth or pregnancy
Malabsorption due to GIT problems eg Coeliac disease, Crohn’s disease
Other: Drugs eg Phenytoin, Trimethoprim, Methotrexate, Oral Contraceptives
 Patient doesn’t display any of these factors

18. Is the data typical for patient’s with iron deficiency anaemia?
Data is normal as in iron deficiency anaemia, patients display low MCV and low serum ferritin levels
Folate levels are not normally low in iron deficiency anaemia. Thus the levels must be investigated for other possible causes.

19. Patients Blood Film Shows: Hypochromic, Microcytic Cells
Marked Anisocytosis
Piokilocytosis
- Pencil Cells
- Target Cells
Occasional Howell-Jolly Bodies
Hypersegmented Neutrophils

20. Anisocytosis RBC show abnormal size variation
Normal RBC diameter = 6-8 µm. Grades 14 depending on % of abnormality
Normal RDW (Red cell Distribution Width) is Increased RDW suggest anisocytosis
Significance: Sign of many anaemias - Iron deficiency, Vit B12 deficiency

21. Target Cells Target cells AKA Codocytes
Characterised by thin “bulls-eye” shape and an increase in the surface membrane area to volume ratio due to a decrease in Hb
Significance: A sign of Iron Deficiency Anaemia, Vit B12 deficiency Anaemia and other disorders eg Liver Disorders, Thalassemia,

22. Pencil Cells
Oval to elongated, ellipsoid shape with central area of pallor and hemoglobin at both ends of cell
Significance: Iron deficiency anaemia (Elongated cells), Vitamin B12 deficiency anaemia (Oval Cells), can also be Inherited, where by >25% elliptocytes are oval.

23. Howell-Jolly Bodies Smooth, round nuclear fragments made up of DNA
Observed when erythropoiesis is active
>3% is significant and indicates Megaloblastic Anaemia

24. Hypersegmented Neutrophils
Neutrophils with five or more lobes
Significance: an important clue to the presence of deficiency of vitamin B12 or folic acid

25. Folate Deficiency Anaemia
Conclusion
Patient FBC and Blood film suggest:
Iron Deficiency Anaemia
AND
Folate Deficiency Anaemia
As evidenced by Low MCV and Low Folate combined with the presence of Hypochromic, Microcytic Cells, Marked Anisocytosis, Howell-Jolly Bodies, Hypersegmented Neutrophils