Unit 1- Anemia

Question 1

what is anemia defined as?

Answer 1

decrease in RBC mass (Hb) to < 12 g/dL (women) or < 14 g/dL (men)

Question 2

what are clinical presentations of anemia?

Answer 2

fatigue, dyspnea on exertion, exertional chest pain, palpitations/tachycardia, hypovolemia in acute blood loss, pallor, flow murmur

Question 3

what is the reticulocyte production index?

Answer 3

RPI; corrects for dgree of anemia

-normally 1.0, but if 2+ it denotes adequate bone marrow response

Question 4

explain microcytic anemias? what are examples?

Answer 4

1. Fe deficiency anemia
2. anemia of inflammation
3. thalassemia
4. sideroblastic anemia
5. lead poisoning

Question 5

define Fe deficiency anemia? what are blood values?

Answer 5

microcytic anemia

• decreased Hb, Hct, MCV
• low ferritin, serum Fe
• high Fe binding capacity (b/c low serum transferrin receptor)
• low Fe saturation (serum Fe / TIBC)

Question 6

define anemia of inflammation

Answer 6

can be normocytic or microcytic

• associated with autoimmune disorders, chronic infection, chronic inflammatory diseases, and malignancy
• ferritin normal or elevated
• low Fe, low TIBC
• normal serum ransferrin receptor

Question 7

explain macrocytic anemias and examples

Answer 7

1. megaloblastic (with hypersegmented neutrophils)
   - vit B12 deficiency
   - folate deficiency
   - antimetabolites/antivirals
2. non-megaloblastic
   - alcoholism/liver disease
   - MDS (myelodysplastic syndrome)
   - hypothyroidism
   - drugs

Question 8

what happens in vitamin B12 deficiency?

Answer 8

macrocytic, megaloblastic anemia

• occurs in pernicious anemia, bacterial overgrowth, ilial resection/gastrectomy, drugs (metforin)
• causes ataxia, paresthesias, confusion, dementia, decreased vibratory sensation, proprioception

Question 9

what happens in folate deficiency?

Answer 9

macrocytic megaloblastic anemia

• often with chronic alcohol use or malabsorption
• medications like Bactrim, methotrexate, and anticonvulsants cause this

Question 10

describe hemolytic anemia symptoms?

Answer 10

anemia, jaundice, splenomegaly, pigment gallstones

-increased reticulocyte index (overactive bone marrow), elevated LDH, and indirect bilirubin with low haptoglobin

Question 11

describe the lab findings for hemolytic anemia

Answer 11

1. increased hemolysis: elevated LDH, unconjugated bilirubin, reduced to absent haptoglobin
2. increased RBC production - reticulocytosis with Bm erythroid hyperplasia
3. damaged RBC - microspherocytes, slliptocytes, fragments

Question 12

describe extravascular VS intravascular hemolysis

Answer 12

both are hemolytic anemias
Ex: increased urine urobilinogen and fecal stercobilinogen
In: hemoglobinemia with hemoglobinuria

Question 13

describe sickle cell anemia

Answer 13

signs/symptoms of hemolytic anemia with vaso-occlusive pain crises the most common presentation (lasting 5-7 days)
-auto infarction of the spleen

Question 14

describe autoimmune hemolytic anemia

Answer 14

caused by auto-Ab associated with malignancy, collagen vascular disease, or drugs

• warm: IgG autoantibody; idiopathic or associated with malignancy, collagen vascular disease, or drugs
• cold: IgM autoantibody; acute form secondary to infection; chronic form secondary to paraprotein or idiopathic

Question 15

describe microangiopathic hemolytic anemia

Answer 15

caused by traumatic intravascular hemolysis

• mechanical heart valves, DIC, TTP, HUS, vasculitis, eclampsia
• has schistocytes on peripheral smear

Question 16

A 34-year old female presents to your clinic complaining of fatigue for the past several months. She has otherwise been healthy with a medical history only significant for tonsillectomy when she was 12 years old. Her only medication is oral contraceptive to regulate her heavy menses which she started 2 weeks earlier. On physical exam you note a well-nourished woman with pale conjunctiva, flat nails and tachycardia. PE shows no other significant findings. Her CBC reveal a Hb of 9.7 mg/dL, Hct 28%, MCV 73fL, WBC 9.3, Platelets 430,000. You suspect iron deficiency anemia secondary to her heavy menses and you order iron studies. What do you expect to see in her labs?

Answer 16

low ferritin, low Fe, high TIBC

Question 17

A 75-year old male is noted on routine labs to have anemia with Hgb 9.0 g/dL; Hct 27%; MCV 90fL, reticulocyte count 6%; ferritin 110 ng/ml, Vitamin B12 478 pg/ml; folate 20.2 ng/ml. His reticulocyte index of 1.8. He has a history of aortic valve replacement 3 years ago for severe aortic regurge. he is otherwise healthy. Physical exam is unremarkable except for the metallic click of his prosthetic valve. You order more tests which reveal a very low haptoglobin, elevated LDH, elevated uncongugated bilirubin and normal direct Coombs test.
What is the most likely diagnosis?

Answer 17

hemolysis secondary to mechanical valve

Question 18

A 36-yo AA female with SLE presents with acute onset of lethargy and jaundice. On intial exam she is tachycardic, hypotensive, pale, and dyspneic. PE reveals splenomegaly. Hgb 6g/dL, MCV 95, WBC 6300, Plts 294k, Total bilirubin 4g/dL, Retic count 18%, haptoglobin undetectable. Renal function and urinalysis are normal. What would you expect to see on the peripheral smear?

Answer 18

microspherocytes, as undetectable haptoglobin means intravascular hemolysis
-probably warm autoimmune hemolytic anemia

Question 19

You were called to the ED to admit a 45 yo homeless male who was found unconscious in the street. He smells of alcohol and is barely arousable. labs show a Hgb 7.2 g/dL, WBC 4000, Plts 130k. Rest of his labs WNL except for elevated AST and ALT. PBS was reviewed. What is your main suspicion in this patient.

Answer 19

vit B12 and/or folate deficiency