1. Diagnostic Approach to Anemia
Prof. Dr. Teoman SOYSAL

2. Definition of anemia Anemia: A reduction in
red cell mass
O2-carrying capacity of blood
It is expressed in terms of reduction in the concentration of Hb (or RBC or Hct%) compared to values obtained from a reference population.
(2 SD below normal)

3. Reference values (adults) (I)
Parameter Female Male
RBC (x1012/L)
Hb (g/dL)
Htc (%)

4. Definition of anemia
Hb level of a patient which is below the normal ranges of that age and sex.
For adults:
WHO criteria define anemia as
hemoglobin
<12 g/dL in women and
<13 g/dL in men
But: The reference values for red cells ,Hb or Hct may difer according to
sex/age
Race
Altitude
Socioeconomical changes
Study/reference etc

5. BEUTLER andWAALEN BLOOD, 1 MARCH 2006 VOLUME 107, NUMBER 5

6. Age and blood count changes
WBC
Neutrophyls
Eos.
Baso
Lenfo
Mono Hb
12 mo
6-17.5
0-0.20
4-10.5
4 y
5.5-15
2-8
0-0.8
6 y
5-14.5
1.5-8
0-0.65
1.5-7
10 y
4.5-13
1.8-8
0-0.60
21 y
4.5-11
0-0.45
1-4.8
E: 16
K: 14
WBC: x10E3/mm3 Hb:g/dL

7. Reference values (II) Ret (% / n) 0.5-2.5 / 50-100x109/L MCV (fl) 90+7
MCH (pg)
MCHc (g/dL) 34+2
RDW (%)

8. RBC %
RBC % 50 50 fl fl
100
100
200
200

9. RBC %
RDW: Red cell distribution width 50 fl
100
200

10. RBC % 50 fl
100
200

11. Reticulocyte Normal Ranges Male: % 0.8 - 2.5 Female: % 0.8 - 4.1
Increased counts
Hemolysis
Acute bleeding
Response to treatment
Normal Ranges
Male: %
Female: %
Corrected Rtc: Patient Hb/Normal Hb x Rtc %
Reticulocytosis: > /mm3

12. Diagnosis and investigation:
Is the patient anemic?
What is the type of anemia?
What is the cause of anemia?

13. Classification of anemia
Morphologic
Normocytic: MCV= fL
Macrocytic: MCV > 100 fL
Microcytic : MCV < 80 fL
Pathogenic (underlying mechanism)
Blood loss (bleeding)
Decreased RBC production
Increased RBC destruction/pooling

14. !!!!!
Plasma volume changes have to be considered before determining a diagnosis of anemia .
Volume contraction:Underestimation of anemia
Volume overload: Underestimation of Hb level

15. Volume changes/acute bleeding and anemia1 2 3 4 5
Increased plasma volume Hct: Low
Dehydration Hct:Increased
normal
Hct:Normal
Acute blood loss(early) Hct:unchanged
Chronic anemia Hct: Low

16. !!!!!
A normal Hb in a patient in whom an elevated Hb level is expected may represent anemia .(eg:COPD + Hb:N)

17. !!!!!! Low Hb, high RBC, low MCV,normal RDW Hb: 10 g/dL (anemia)
Different red cell measures of a patient may give discordant values in special conditions.
eg:Thalassemia trait
Low Hb, high RBC, low MCV,normal RDW
Hb: 10 g/dL (anemia)
RBC: 6.5 million/mm3 (erythrocytosis)
MVC : 65 fL
RDW: Normal

18. !!!! Anemia is rarely a disease by itself,
It is mostly a manifestation or consequence of an underlying (genetic or acquired) disease.
The finding of anemia has to start attempts to disclose an underlying disease .
What is the cause of anemia ?

19. Normocytic Anemias Acute post-hemorrhagic anemia
Hemolytic anemia (except thalassemia and some other Hb disorders)
Aplastic anemia
Pure red cell aplasia
Bone marrow infiltration
Endocrin diseases
Renal failure
Liver disease
Chronic disease anemia
Protein malnutrition
Hypovitaminosis C

20. Microcytic anemias Iron deficiency anemia Thalassemia
Sideroblastic anemia
Lead poisoning
Anemia of chronic diseases
(some cases)

21. Macrocytic anemias
Megaloblastic
Oval macrocytes
Non-megaloblastic

22. Megaloblastic Macrocytic Anemias
Vit B12 deficiency
Folic acid deficiency
Other.

23. Non-megaloblastic Macrocytic Anemias
Anemia of acute bleeding
Hemolytic anemias
Leukemias
(esp: acute)
Myelodysplastic syndromes
Liver disease
Aplastic anemia
Diseases infiltrative to the bone marrow
Alcoholism
Hypothyroidism
Scurvy

24. Pathogenic classification (Causes of anemia)
Relative (increased plasma volume)
Decreased RBC production
Blood loss
Anemia due to acute bleeding
Increased RBC destruction

25. Pathogenic classification (Causes of anemia)
Decreased RBC production
Decreased Hb production
Defective DNA synthesis
Stem cell defects
Pluripotent stem cell
Erythroid stem cell(progenitors)
Other less defined reasons
Blood loss
Anemia due to acute bleeding
Increased RBC destruction
Relative(increased plasma volume)

26. Decreased Hb production
Iron deficiency anemia
Thalassemia
Sideroblastic anemia
Lead poisoning

27. Defective DNA synthesis
Vit B12 deficiency
Folic acid deficiency
Other.

28. Pluripotent stem cell defects
Aplastic anemia
Leukemia or myelodysplastic syndromes
Defective erythroid stem cell
Pure red cell aplasia
Anemia of chronic renal failure
Endocrin disease anemia
Congenital dyserythropoetic anemias

29. Decreased RBC production due to multipl or undefined mechanisms
Anemia of chronic diseases
Bone marrow infiltration
Anemia due to nutritional defects

30. Anemias caused by increased RBC destruction (hemolytic anemias)
Can be classified as;
Hemolysis due to intracorpuscular defects
Hemolysis due to extracorpuscular defects Or
Hereditary hemolytic diseases
Acquired hem. diseases
Intravascular hemolysis
Extravascular hemolysis etc.

31. A Very Simple Classification of Hemolytic Anemias
Intracorpuscular
1- Abnormalities of RBC interior
a. Enzyme defects
b. Hemoglobinopathies & Thalassemia M
2-RBC membrane abnormalities
a. Hereditary spherocytosis, elliptocytosis etc
b. Paroxysmal nocturnal hemoglobinuria
c. Spur cell anemia
3- Extrinsic factors
a. Hypersplenism
b. Antibody : immune hemolysis
c. Traumatic & Microangiopathic hemolysis
d. Infections , toxins , etc
Hereditary
Extracorpuscular
Acquired

32. Is the patient anemic ?
RBC count
HB level
Hct level
Volume status

33. What is the type of anemia?
History and physical exam.
RBC,HB,Hct ,
MCV, MCH,RDW
Red cell morphology ( peripheral smear)
Reticulocyte count
Incresed ?
Other Lab. investigations

34. Lab. investigation of anemia(1)
WBC count and differential
Platelet count and morphology
ESR
Biochemistry, special tests and others
Bone marrow exam.(only when indicated)

35. Lab. investigation of anemia(2)
Serum values of
Iron
TIBC
Ferritin
Bilirubins
Proteins / electrophoresis
LDH
Vit B12 and /or Folic acid
(None of these tests are routine screening tests)

36. Lab. Investigation of Anemia(3)
Liver, renal, endocrin functional tests
Urinalysis
Hemosiderin
Occult GIS bleeding / parasites etc
(tests should be chosen individually-do not order routinly )
Tests to diagnose the type of hemolytic anemia
If hemolytic anemia is considered

37. Normocytic anemia Retic. count normal/low
Secondary anemia
Renal, Hepatic, Endocrin , Chronic disease
(Normal marrow)
Hypoplastic Marrow
AA, pure red cell aplasia
Bone marrow infiltrative diseases
Leukemia , Myelofibrosis Metastatic disease
Dysplastic marrow: MDS
Retic. count increased
Response to treatment
Hemolytic anemia
Acute bleeding
No sign of secondary anemia
Other signs of bone marrow disease may be +

38. Microcytic anemia Serum iron high Serum iron normal /high
Bone marrow iron content and sideroblasts
Sideroblastic anemia
Serum iron
normal /high
Hemoglobin studies
Thalassemia , HbC , others
Serum iron decreased
Ferritin low
Iron deficiency
Ferritin: Normal or increased
Anemia of chronic diseases

39. Myelodysplastic syndrome Bone marrow infiltration
Macrocytic anemia
Peripheral smear
Retic. count
Retic. count Increased
Hemolysis
Acute bleeding
Retic. count Normal/ decreased
Megaloblastic
Deficiencies of VitB12 ,Folic acid or other causes
Non-Megaloblastic
Liver diseases
Myelodysplastic syndrome
Bone marrow infiltration
Acute leukemia
Aplastic Anemia,
Alcoholism
Hypothyoidism etc

40. Case I
38 years old, ♀
Tiredness, hair loss, nail changes

41. Microcytic anemia Serum iron high Serum iron normal /high
Bone marrow iron content and sideroblasts
Sideroblastic anemia
Serum iron
normal /high
Hemoglobin studies
Thalassemia , HbC , others
Serum iron decreased
Ferritin low
Iron deficiency
Ferritin: Normal or increased
Anemia of chronic diseases

42. Microcytic anemias May change None Iron deficiency Normal N
Diagnosis
(type of anemia)
MCV
RDW
Serum Iron
Iron binding capacity
Ferritin
ESR/acute phase signs
Hemogl. changes
Iron deficiency
May change
None
Thalassemia N
Normal
May be diagnostic
Chronic disease anemia
Elevated
RBC count:
Thalassemia minor >Iron deficiency

43. Case I
38 years old, ♀
Tiredness, hair loss, nail changes

44. What is your diagnosis? What is the next step? Prove iron deficiency
Serum iron, TIBC, Ferritin
Find out the cause of iron deficiency
Chronic blood loss / excessive need-inadequate intake
Menstruel bleeding, Pregnancy
GI bleeding
Inadequate intake or malabsorbtion etc
Treat both iron deficiency and the cause

45. Case II 26 y o Slight symptoms Decreased excercise tolerence Paleness
Long history of being anemic on routine CBC’s ,non responsive to iron
RBC: /mm3
Hb: 10 g/dL
MCV: 60 fL
RDW: 14.3
Retic: %2
WBC: 5000/mm3
Plt: /mm3
Name the blood picture.
Further questions to ask to the patient?
Further tests to do ?
Ferritin : slightly elevated
HbA2: slightly elevated, Hb F: normal
Final Diagnosis ?

46. Case III WBC: 2.300/µl Hgb: 11 g/dL Hct: %33 MCV: 122 fL MCH: 39pg
70 y o, male
Fatigue, weakness
Sore tongue, poor taste sensation
Papill. atrophy-beefy tongue
Paresthesias
Loss of position sense, ataxia
Decreased deep tendon reflexes
3 units of red cell transfusion made before admission
WBC: /µl
Hgb: g/dL
Hct: %33
MCV: 122 fL
MCH: 39pg
MCHC: %34
RDW: 30.5
Plt: /µl
Retic: 1%
Macrocytosis Anisocytosis, neutrophyl hypersegmentation, oval macrocytes

47. Retic. count Increased Macrocytic anemia
Peripheral smear
Retic. count
Retic. count Increased
Hemolysis
Acute bleeding
Retic. count Normal/ decreased
Megaloblastic
Deficiencies of VitB12 ,Folic acid or other causes
Non-Megaloblastic
Liver diseases
Myelodysplastic syndrome
Bone marrow infiltration
Acute leukemia
Aplastic Anemia,
Alcoholism
Hypothyoidism etc

48. What is the blood picture ? (The type of the disorder)
What is your diagnosis?
Why?

49. Normocytic anemia Retic. count normal/low
Secondary anemia
Renal, Hepatic, Endocrin , Chronic disease
(Normal marrow)
Hypoplastic Marrow
AA, pure red cell aplasia
Bone marrow infiltrative diseases
Leukemia , Myelofibrosis Metastatic disease
Dysplastic marrow: MDS
Retic. count increased
Response to treatment
Hemolytic anemia
Acute bleeding
No sign of secondary anemia
Other signs of bone marrow disease may be +

50. ? ? ? 60 y o Normocytic anemia Reticulocytes: 1% Hoarse voice Lethargy
Hair loss
Dry skin
Weight gain
Poor memory
Bradycardia
Pale, pruritus, hypertension
Urea + creatinin elevated
Symmetric polyarthritis
Morning stiffness
Sc nodules ? ? ?

51. Case IV 65 y o , male One month history of fever, cough and hemoptysis
ESR: 80mm/h; high CRP
Sputum + for TBC bacteria; chest x-ray shows right apical infiltrate
Normocytic anemia, MCV normal, RDW ↑,
What is the type of anemia?
What is the diagnosis?
This case could also present as a microcytic anemia .What would you expect from the iron studies in that situation?
Low iron, Low TIBC, High Ferritin
Retic.: 2%

52. Normocytic anemia How to decide the next step? History PE Smear
Retic. count normal/low
Secondary anemia
Renal, Hepatic, Endocrin , Chronic disease
(Normal marrow)
Hypoplastic Marrow
AA, pure red cell aplasia
Bone marrow infiltrative diseases
Leukemia , Myelofibrosis Metastatic disease
Dysplastic marrow: MDS
Retic. count increased
Response to treatment
Hemolytic anemia
How to decide the next step?
History PE
Smear
Other tests
Acute bleeding
No sign of secondary anemia
Other signs of bone marrow disease

53. Case IX 67 y o, male Anemia symptoms Severe bone pain CBC
Normocytic anemia
What is your possible diagnosis?
What is the next step?
ESR:>100mm/h
Hypercalcemia
Hyperglobulinemia
Renal failure

54. Morphologic abnormalities in hemolytic anemias
Sickle cell:
Target cels:
Schistocytes:
Agglutination:
Heinz bodies:
Sickle cell anemia
Thalassemia, HbC disease, liver disease,
splenectomy
Microangiopathic hem anemia, uremia, DIC,
malignant hypertesion, eclampsia,
disseminated vasculitis or malignancy,
Cold agglutinin disease
Unstable Hb, G6PD deficiency and oxidant stress

55. Special Lab. Examinations
Coombs antiglobulin test - immune hemolysis
Osmotic fragility test - spherocytosis
Autohemolysis- G6PD,PK, spherocytosis
Red cell enzyme assays- RBC enzyme defects
Membrane protein analysis- membrane defects
Red cell sickling, HbS- sickle cell anemia
Hemoglobin electrophoresis and HbA2, Hb F , HHb,etc - Hemoglobinopathies and thalassemias
HAM and sucrose lysis tests and GPI-linked protein analysis by flow cytometry- PNH
Oxygen dissociation curve- High oxygen affinity Hb

56. Case V
18 y o , male
Weakness, paleness, slight icterus, splenomegaly, bile stones
Family history +
Normal RBC
WBC: 5600/µl
Hgb: 9,6 g/dL
MCHC: %37
Plt: /µl
Retic: %9 ?
spherocyte
Ind Bil: slightly elevated
LDH: elevated
Haptoglobin : low
Red cell osmotic fragility increased ?

57. Case VI 38 y o Cough , fever WBC: 12.000/µl Hgb: 11 g/dL Hct: 22 %
MCV: 130
MCH: 40
MCHC: 36
RDW:28
Plt: /µl

59. Case VII CBC WBC: 33.000/mm3 Hb: 7 g/dL Retic: 1% Plt: 12.000/mm3
34 y o, male
2-3 weeks history of
Decreased exercise capacity
Paleness
Headache, sore throat
2 days history of
Cough and fever
Red spots on the skin
CBC
WBC: /mm3
Hb: 7 g/dL
Retic: 1%
Plt: /mm3

60. Case IX 60 y o, female Sudden onset CBC Hb: 8 g/dL WBC: 10.000/mm3
Pallor, palpitation
Slight scleral icterus
splenomegaly
CBC
Hb: 8 g/dL
WBC: /mm3
Plt: /mm3
Retic: 10%
What is your diagnosis?
What is your next step?
Indirect bilirubin: high
LDH: high
Haptoglobin: low
D/I: Coombs +

61. Case X 70 y o , male +One month history of WBC: 8000/mm3 Hb: 8 g/dL
Under examination for prostat enlargement
+One month history of
Bone pain
Symptoms of anemia
WBC: 8000/mm3
Hb: 8 g/dL
MCV: 88 fL
RDW: 14
Retic: 2%
Plt: /mm3

62. Morphologic abnormalities in hemolytic anemias
Polychromasia:
Spherocyte :
Elliptocytes:
Stomatocytes:
Acanthocytes:
Echinocytes:
Reticulocytes
Hereditary spherocytosis, immune hem. anemia,
burns, chemical injury to RBC
Hereditary ovalocytosis,
Hereditary stomatocytosis, alcoholism
Spur cell anemia with liver disease,
abetalipoproteinemia
Pyruvate kinase deficiency, uremia