1. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia Prof. A. B. Skotnicki M.D. Ph.D.

2. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia Decreased haemoglobin concentration and/or PCV

3. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Internal iron exchange. Absorption - about 1 mg/d is required from the diet in men, 1.4 mg/d in women transferrin saturation 20 to 60% Absorption - about 1 mg/d is required from the diet in men, 1.4 mg/d in women transferrin saturation 20 to 60%

4. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Iron storage and transport Tissue ferritin Tissue ferritin Serum transferin 20 umol/l Serum transferin 20 umol/l Bone Marrow Erythroblasts Bone Marrow Erythroblasts

5. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Classification of anaemia Morphological Based on red cell measurement Morphological Based on red cell measurement Aetiological Based on cause Aetiological Based on cause

6. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Aetiological classification of anaemia Hb ER Excessive blood loss -haemorrhage Post – haemorrhagic anaemia Excessive red destruction cell destruction Haemolitica anaemias Inadequateproduction of red cells - decreased Aplastic anameia Bone marrow infiltrattion -abnormal Cytoplasmic defect Fe Nuclear defect B12

7. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Morphological classification of anaemia B12 fol.ac. B12 fol.ac. Fe Acute blood loss Haemolysis Bone marrow aplasia Bone marrow infiltration Acute blood loss Haemolysis Bone marrow aplasia Bone marrow infiltration MCV and MCH normal MCV and MCH normal Normocytic normochromic anaemia Normocytic normochromic anaemia MCV MCH MCV MCH Macrocytic hyperchromic Megaloblastic anaemia Macrocytic hyperchromic Megaloblastic anaemia MCV MCH MCV MCH Microcytic hypochromic anaemia Microcytic hypochromic anaemia Chronic disease Chronic disease

8. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia – signs and symptoms General General signs and symptoms universal for all anaemias specific Signs and symptoms specific for a particular cause General General signs and symptoms universal for all anaemias specific Signs and symptoms specific for a particular cause

9. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland General symptoms of anaemia Hb O2 carrying capacity of blood TISSUE HYPOXIA O2 carrying capacity of blood TISSUE HYPOXIA Clinical manifestations Palpitations Tachycardia Heart murmurs Palpitations Tachycardia Heart murmurs dyspnoea pallor Cardiac overactivity Cadiorespiratory insufficiency Cadiorespiratory insufficiency Skin vasoconstriction redistribution of blood flow (brain, heart) Skin vasoconstriction redistribution of blood flow (brain, heart) Compensatory mechanisms mobilised to contract hypoxia Compensatory mechanisms mobilised to contract hypoxia

10. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia – general signs and symptoms CSN: Headaches Tinnitus CSN: Headaches Tinnitus General: Shortness of breath Fatigue Weakness Susceptibility to infections General: Shortness of breath Fatigue Weakness Susceptibility to infections CVS: Tachycardia Functional murmur Stenocardiac pain CVS: Tachycardia Functional murmur Stenocardiac pain Pale skin & mucous membranes

11. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia – major types Iron deficiency anaemia Iron deficiency anaemia Megaloblastic anaemia Megaloblastic anaemia Haemolytic anaemia Haemolytic anaemia Aplastic anaemia Aplastic anaemia Anaemia of chronic disease Anaemia of chronic disease Nutritional factor deficiency Nutritional factor deficiency

12. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Normal erythropoiesis MCV=90 fl MCHC=32 g/l MCH=32 pg Fe B12 haemoglobinisation RBC production HB N N E =

13. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Erythropoiesis in IDA or after bleeding MCV=70 fl MCHC=28 g/l MCH=25 pg Fe B12 haemoglobinisation RBC production HB N/>N <N E =

14. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Iron deficiency anaemia (IDA) - causes Inadequate intake Chronic blood loss GI Urinary Tract Chronic blood loss GI Urinary Tract IncreasedrequirementIncreasedrequirement IronmalabsorbtionIronmalabsorbtion

15. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland IDA – causes of chronic blood loss Haematemesis Haemoptysis Urinary tract bleeding – haematura: Renal disorders Inflammation Tumour Urinary tract Calculosis Polyps Urinary bladder tumours Genital tract bleeding: Menorrhagiae Metrorrhagiae Uterine myoma Gastrointestinal tract bleeding: Hiatus hernia Gastritis haemorrhagica Peptic ulcer Gastric cancer Intestinal polyposis Colonic cancer Colitis ulcerosa Haemorrhoidal varices Melaena

16. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland IDA - signs and symptoms Skin: Dry, cracked Cheilitis angularis rhagades Tongue Glossitis anaemica General signs and symptoms PLUS tissue asiderosis General signs and symptoms PLUS tissue asiderosis Hair: Fragility, coming out Early gray Nails: Brittle, spoon nails Atrophic changes Dysphagia Plummer-Vinson syndrome Eyes: Bluish sclera Pica Gastric troubles Neurovegetative dystonia

17. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Moderately severe iron deficiency anaemia This example of moderately severe iron deficiency anaemia shows anisocytosis, anisochromasia, hypochromia, microcytosis and poikilocytosis. The poikilocytes include several particularly long elliptocytes, sometimes referred to as 'pencil cells'. Elliptocytes are characteristic of iron deficiency but not pathognomonic. This example of moderately severe iron deficiency anaemia shows anisocytosis, anisochromasia, hypochromia, microcytosis and poikilocytosis. The poikilocytes include several particularly long elliptocytes, sometimes referred to as 'pencil cells'. Elliptocytes are characteristic of iron deficiency but not pathognomonic.

18. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Severe iron deficiency anaemia Blood film from a patient with severe iron deficiency anaemia. The film shows anaemia, microcytosis, hypochromia, anisocytosis, anisochromasia and poikilocytosis. Blood film from a patient with severe iron deficiency anaemia. The film shows anaemia, microcytosis, hypochromia, anisocytosis, anisochromasia and poikilocytosis.

19. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Pallor in iron deficiency anaemia The hand of a patient with iron deficiency anaemia showing pallor. The hand of a non- anaemic person is pictured for comparison. Pallor is a non-specific feature of anaemia. The hand of a patient with iron deficiency anaemia showing pallor. The hand of a non- anaemic person is pictured for comparison. Pallor is a non-specific feature of anaemia.

20. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Pale conjunctiva in iron deficiency anaemia The best places to check for pallor that may indicate anaemia are the conjunctiva, the nail beds and the palms of the hands. This patient with iron deficiency anaemia has conjunctival pallor. The best places to check for pallor that may indicate anaemia are the conjunctiva, the nail beds and the palms of the hands. This patient with iron deficiency anaemia has conjunctival pallor.

21. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Pallor in iron deficiency anaemia Pallor in a patient with iron deficiency anaemia. The patient's hand is pictured together with the hand of a healthy person. (Courtesy of Dr D. Samson.) Pallor in a patient with iron deficiency anaemia. The patient's hand is pictured together with the hand of a healthy person. (Courtesy of Dr D. Samson.)

22. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Oral changes in iron deficiency anaemia Angular cheilosis and atrophic glossitis in iron deficiency anaemia. These features are typical of moderately severe iron deficiency anaemia and indicate the effect of iron deficiency on tissues other than the bone marrow. (Courtesy of Dr D. Samson.) Angular cheilosis and atrophic glossitis in iron deficiency anaemia. These features are typical of moderately severe iron deficiency anaemia and indicate the effect of iron deficiency on tissues other than the bone marrow. (Courtesy of Dr D. Samson.)

23. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Cheilitis Angularis in IDA

24. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Koilonychia in iron deficiency anaemia Koilonychia or spoon- shaped nails in iron deficiency anaemia. Koilonychia has a high degree of specificity for iron deficiency but it is a relatively uncommon feature, occurring only in severe chronic iron deficiency. Koilonychia or spoon- shaped nails in iron deficiency anaemia. Koilonychia has a high degree of specificity for iron deficiency but it is a relatively uncommon feature, occurring only in severe chronic iron deficiency.

25. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Typical changes in blood count in IDA Normal Blood Count Normal Blood Count Hb 14 g/dl Hb 14 g/dl RBC 4,50 x 10^12/l RBC 4,50 x 10^12/l PCV40 % PCV40 % MCV90 fl MCV90 fl MCH 30 pg MCH 30 pg Ret0,5 % Ret0,5 % WBC 7,5 x 10^9/l WBC 7,5 x 10^9/l Differential normal Differential normal Platelets 400x10^9/l Platelets 400x10^9/l Normal Blood Count Normal Blood Count Hb 14 g/dl Hb 14 g/dl RBC 4,50 x 10^12/l RBC 4,50 x 10^12/l PCV40 % PCV40 % MCV90 fl MCV90 fl MCH 30 pg MCH 30 pg Ret0,5 % Ret0,5 % WBC 7,5 x 10^9/l WBC 7,5 x 10^9/l Differential normal Differential normal Platelets 400x10^9/l Platelets 400x10^9/l Blood Count in IDA Blood Count in IDA Hb 7,5 g/dl Hb 7,5 g/dl RBC 4,05 x 10^12/l RBC 4,05 x 10^12/l PCV26% PCV26% MCV64 fl MCV64 fl MCH 18,5 pg MCH 18,5 pg Ret2,6% Ret2,6% WBC 7,5 x 10^9/l WBC 7,5 x 10^9/l Differential normal Differential normal Platelets 530x10^9/l Platelets 530x10^9/l Blood Count in IDA Blood Count in IDA Hb 7,5 g/dl Hb 7,5 g/dl RBC 4,05 x 10^12/l RBC 4,05 x 10^12/l PCV26% PCV26% MCV64 fl MCV64 fl MCH 18,5 pg MCH 18,5 pg Ret2,6% Ret2,6% WBC 7,5 x 10^9/l WBC 7,5 x 10^9/l Differential normal Differential normal Platelets 530x10^9/l Platelets 530x10^9/l

26. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Iron deficiency is NOT a diagnosis but a symptom Clinical & laboratory findings Clinical & laboratory findings Iron Deficiency anaemia Iron Deficiency anaemia Aetiology ? Aetiology ?

27. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Iron deficiency anaemia 53 old male 53 old male Tiredness Hb 7 g/l MCV 69 fl Serum ferritin 8ug/l Occult faecal blood test positive (+) Colonoscopy 53 old male 53 old male Tiredness Hb 7 g/l MCV 69 fl Serum ferritin 8ug/l Occult faecal blood test positive (+) Colonoscopy Carcinoma of the colon

28. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland 22 years old patient with ACD (Hodgkins lymphoma)

29. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Megaloblastic Anaemia Abnormal changes in blood cell formation leading to macrocytic anaemia and varying degrees of pancytopenia as a result of abnormal DNA synthesis because of single or combined deficiency of folate and/or vitamin B12

30. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Normal erythropoiesis MCV=90 fl MCHC=32 g/l MCH=32 pg Fe B12 haemoglobinisation RBC production HB N N E =

31. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Erythropoiesis in B12 deficiency MCV=100 fl MCHC=32 g/l MCH=40 pg Fe B12 haemoglobinisation RBC production HB <N N E =

32. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Megaloblastic anaemia - causes Inadequate intake Disturbed metabolism Increased requirement Malabsorbtion

33. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Megaloblastic anaemia - causes COBALAMIN DEFICIENCY. Inadequate intake: vegetarians (rare) Malabsorption: Defective release of cobalamin from food:Gastric achlorhydria, Partial gastrectomy, Drugs that block acid secretion Inadequate production of intrinsic factor (IF): Pernicious anemia; Total gastrectomy: Congenital absence or functional abnormality of IF Disorders of terminal ileum Competition for cobalamin Other COBALAMIN DEFICIENCY. Inadequate intake: vegetarians (rare) Malabsorption: Defective release of cobalamin from food:Gastric achlorhydria, Partial gastrectomy, Drugs that block acid secretion Inadequate production of intrinsic factor (IF): Pernicious anemia; Total gastrectomy: Congenital absence or functional abnormality of IF Disorders of terminal ileum Competition for cobalamin Other FOLIC ACID DEFICIENCY Inadequate intake: unbalanced diet (common in alcoholics, teenagers, some infants) Increased requirements: Pregnancy, Infancy, Malignancy, Increased hematopoiesis, Chronic exfoliative skin disorders Malabsorption: Tropical sprue, Nontropical sprue, others FOLIC ACID DEFICIENCY Inadequate intake: unbalanced diet (common in alcoholics, teenagers, some infants) Increased requirements: Pregnancy, Infancy, Malignancy, Increased hematopoiesis, Chronic exfoliative skin disorders Malabsorption: Tropical sprue, Nontropical sprue, others

34. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Megaloblastic anaemia - causes CauseB12 deficiencyFolic acid deficiency 1. Dietary deficiency: 2. Malabsorbtion: Atrophic gastritis Hipochlorchydria Lack of intrisinc factor Small bowel diseases Post gastrectomy 3. Increased demands: Pregnancy 4. Disturbed metabolism: anticonvulsives cytostatics rarely +++ + + often (alcohol abuse, parenteral nutrition, age) ++ - ++ +

35. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Megaloblastic anaemia– symptoms and signs CSN: Headaches Tinnitus Glossitis Hunteri smooth Reddened Burning Reduced in size Loss of appetite Loss of taste Loss of body weight Abdominal pains Atrophic gastritis Diarrhoea Achlorchyrdia Visual disturbances Optic nerve disturbances Psychiatric disturbances Irritability Sleepiness Dementia Peripheral neuropathy Paresthesia Pins and needles Unsteady gait Reduced Sensation Imbalance Dysuria Reduced heat and cold sensibility Average age – 60 Often - women Specific PLUS General signs and symptoms Specific PLUS General signs and symptoms

36. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Blood film in megaloblastic anaemia In megaloblastic anaemia the most characteristic features in the peripheral blood film are hypersegmented neutrophils and macrocytes, particularly oval macrocytes [arrow]. The neutrophil shown has six lobes and is therefore classified as hypersegmented

37. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Haemolytic anaemia premature destruction or removal Decrease in the total number of circulating erythrocytes that is caused by premature destruction or removal of red cells from the circulation

38. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Haemolytic anaemia Classifications of HA according to Classifications of HA according to Type of defect Type of defect Site of defect Site of defect Site of haemolisis Site of haemolisis

39. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Classification of HA according to Type of defect Hereditary Membrane defect Metabolic defect Hemoglobinopathies Hereditary Membrane defect Metabolic defect Hemoglobinopathies Acquired Immunologic defect Mechanical defect Intravascular coagulopathy March hemoglobinuria Infection Membrane abnormality Acquired Immunologic defect Mechanical defect Intravascular coagulopathy March hemoglobinuria Infection Membrane abnormality

40. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Classification of HA according to Type of defect Hereditary Membrane defect HS Hereditary elliptocytosis Metabolic defect GdPD deficiency PK deficiency Hemoglobinopathies Thalassemias Sickle cell diseases Other hemoglobinopathies Hereditary Membrane defect HS Hereditary elliptocytosis Metabolic defect GdPD deficiency PK deficiency Hemoglobinopathies Thalassemias Sickle cell diseases Other hemoglobinopathies Acquired Immunologic defect Drug-induced hemolysis Isoimmune and alloimniune hemolysis (neonatal and delayed transfusion reactions) Mechanical defect Rapid turbulent flow of blood, tumors, hypertension, aortic stenosis, Prosthetic valve leaks Intravascular coagulopathy March hemoglobinuria Infection Membrane abnormality (stem cell abnormality) Acquired Immunologic defect Drug-induced hemolysis Isoimmune and alloimniune hemolysis (neonatal and delayed transfusion reactions) Mechanical defect Rapid turbulent flow of blood, tumors, hypertension, aortic stenosis, Prosthetic valve leaks Intravascular coagulopathy March hemoglobinuria Infection Membrane abnormality (stem cell abnormality)

41. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Classifications of HA according to Site of defect Intracorpuscular factors Red cell membrane abnormalities (HS and related abnormalities PNH) Hemoglobinopathies (Thalassemias, Sickle cell disease and related hemoglobinopathies, Methemoglobinemia, Unstable hemoglobin diseases ) Enzymopathies (G6PD deficiency Others) Extracorpuscular factors Antibodies (Autoimmune hemolytic anaemia, transfusion-related haemolytic reactions, Drug- related hemolytic reactions) Mechanical or traumatic factors (Prosthetic heart valves, High-flow red cell damage, Intravascular coagulopathy) Infections (Bacterial, Parasitic) Cell membrane lipids (Liver disease, Lipid disorders)

42. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Classifications of HA according to Site of Haemolysis Intravascular hemolysis Traumatic hemolysis Immune hemolysis Infections Intravascular hemolysis Traumatic hemolysis Immune hemolysis Infections Extra vascular hemolysis Autoimmune hemolytic anemia Red cell membrane defects Spur cell anaemia Red cell metabolism defect Unstable haemoglobin diseases Extra vascular hemolysis Autoimmune hemolytic anemia Red cell membrane defects Spur cell anaemia Red cell metabolism defect Unstable haemoglobin diseases

43. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Clinical signs and symptoms of haemolytic anaemia General General signs and symptoms universal for all anaemia specific Signs and symptoms specific haemolysis Jaundice Increased billirubin (unbound) Increased reticulocitosis General General signs and symptoms universal for all anaemia specific Signs and symptoms specific haemolysis Jaundice Increased billirubin (unbound) Increased reticulocitosis

44. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Example of blood film in HA Microangiopathic haemolytic anaemia Blood film showing the features of microangiopathic haemolytic anaemia in haemolytic uraemic syndrome. There are schistocytes including one microspherocyte

45. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Aplastic anaemia Acellularhypocellular pancytopenia Acellular or hypocellular marrow that causes bone marrow failure and lower level of cell production, leading to pancytopenia. Etiology: Idiopathic Secondary Acellularhypocellular pancytopenia Acellular or hypocellular marrow that causes bone marrow failure and lower level of cell production, leading to pancytopenia. Etiology: Idiopathic Secondary

46. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Causes of Secondary Aplastic Anaemia Drugs and toxins Chloramphenicol Cancer chmotherapy Chemicals Infections Viral hepatitis CMV Infectious mononucleosis Parvovirus 19 Drugs and toxins Chloramphenicol Cancer chmotherapy Chemicals Infections Viral hepatitis CMV Infectious mononucleosis Parvovirus 19 Proleukaemic and leukaemic conditions Paroxysmal nocturnal haemoglobinuria Genetic or constitutional conditions Proleukaemic and leukaemic conditions Paroxysmal nocturnal haemoglobinuria Genetic or constitutional conditions

47. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Normal Bone marrow Normal Bone marrow Fat cells WBC RBC PLT Bone marrow in AA Bone marrow in AA Bone marrow in AA Fat cells Residual haemopoesis

48. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Signs and symptoms of AA The results of pancytopenia Anaemia (general signs) Thrombocytopenia (bleeding tendency) Granulocytopenia (infections) The results of pancytopenia Anaemia (general signs) Thrombocytopenia (bleeding tendency) Granulocytopenia (infections)

49. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Normal bone marrow (right) and in aplastic anaemia (left) trephine biopsies normal AA

50. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia of chronic disease (ACD) Common type of anaemia that occurs in patients who present with any of several chronic inflammatory and malignant diseases

51. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia of chronic disease (ACD) Anaemia of chronic disease Anaemia of chronic disease caused by a defect in incorporation of iron into haemoglobin as a consequence of infection, inflammation or malignant disease. caused by a defect in incorporation of iron into haemoglobin as a consequence of infection, inflammation or malignant disease. Bone marrow iron stores are usually normal or increased. The anaemia is initially normocytic and normochromic but when it becomes severe is hypochromic and microcytic. Bone marrow iron stores are usually normal or increased. The anaemia is initially normocytic and normochromic but when it becomes severe is hypochromic and microcytic. Anaemia of chronic disease Anaemia of chronic disease caused by a defect in incorporation of iron into haemoglobin as a consequence of infection, inflammation or malignant disease. caused by a defect in incorporation of iron into haemoglobin as a consequence of infection, inflammation or malignant disease. Bone marrow iron stores are usually normal or increased. The anaemia is initially normocytic and normochromic but when it becomes severe is hypochromic and microcytic. Bone marrow iron stores are usually normal or increased. The anaemia is initially normocytic and normochromic but when it becomes severe is hypochromic and microcytic.

52. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Signs and symptoms of ACD General signs and symptoms of anaemia Blood film as in IDA No tissue asiderosis General signs and symptoms of anaemia Blood film as in IDA No tissue asiderosis

53. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland ACD & IDA: clinical & laboratory differences FeatureACDIDA Severity +++ Tissue asiderosis -+++ Chronic disorder ++++ ESR: fever; WBC; PLT; pain; lymph nodes ++- Serum iron Serum ferritin Serum transferin TIBC

54. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Signs and symptoms in anaemia AnaemiaSigns and symptoms Aplastic Marrow failure Iron deficiency Tissue asiderosis B12 & follic acid deficiency Neuro & gastrointestinal Chronic disease Without tissue asiderosis Haemolytic Haemolysis

55. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Anaemia of chronic disease - bone marrow

56. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Comparison of blood films in anaemias Normal Haemolytic IDA Macrocytic

57. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Fe, TIBC and UIBC TIBC 60 umol/l TIBC 60 umol/l Fe 20 umol/l Fe 20 umol/l UIBC NORMAL Fe overload IDA, pregnancy Infections cancers Infections cancers

58. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland Oral iron absorbtion test

59. YOUR LOGO HERE Department of Haematology, Collegium Medicum Jagiellonian University, Kraków, Poland MCV in anaemia Microcytic (MCV<N) Normocytic(MCV=N)Macrocytic(MCV>N) Iron deficiency Fe N Aplastic Reticulocytes < N B12 <N Chronic disease Fe>N, Ferritin=,>N Haemolytic Reticulocytes > N Folic acid <N Talasemia Fe >N, Ferritin >N Acute blood loss Reticulocytes > N