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Anaemia Tutorial Flashcards

1
Q

What are the 4 main causes that lead to anaemia?

A

Reduced production of red cells / haemoglobin in the bone marrow

Reduced survival of red cells in the circulation (haemolysis).

Bleeding / blood loss

Pooling of red cells in a very large spleen

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2
Q

A patients presents with low MCV, low Hb, low RBCs and low MCH

What is the differential diagnosis for this?

A

Microcytic anaemia (low haemoglobin count)

Issue with RBC production - could be iron deficiency or anaemia of chronic disease

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3
Q

What are the differentials for microcytic anaemia?

A

Iron deficiency anaemia, thalassaemia, anaemia of chronic disease

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4
Q

What do these test results show?

Low ferritin
Low Serum iron
High Transferrin 
Low transferrin saturation 
No increase HbA2 in Hb electrophoresis

What does this data suggest towards the cause?

A

Iron deficiency

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5
Q

What further questions would you ask to a patient presenting with iron deficiency anaemia suggestive test results?

A

Diet - vegetarian or non-vegetarian

GI symptoms e.g. dysphagia, dyspepsia, abdominal pain, change in bowel habit, haematemesis, rectal bleeding, malarna, post-menopausal bleeding

Medications - aspirin, NSAIDs, other steroids

Weight loss

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6
Q

What is haemolysis?

How long does a typical RBC last?

What is anaemia caused by haemolysis?

A

Destruction of RBCs / shortened life span or RBCs

120 days

Haemolytic anaemia - due to G6PD deficiency

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7
Q

Where is haemolytic anaemia common? And why?

A

Africa - protects against malaria

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8
Q

What is a common name for a type of haemolytic anaemia?

Who is it more common in and why?

A

Sickle Cell Anaemia (SCA)

More common in males = recessive disorder

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9
Q

What is the clinical significance between conjugated and unconjugated bilirubin?

A

UNCONJUGATED = haemolysis

Conjugated = liver disease

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10
Q

Blood count shows:
low Hb
High MCV
High reticulocytes

What does this show?

A

Reticulocyte = baby RBCs

Bone marrow trying to compensate for anaemia- likely haemolysis due to unconjugated billurubin

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11
Q

What would a blood film for G6PD deficiency show?

Why do we see this?

A

Ghost cells- shows there’s been intravascular haemolysis
Heinz body- precipitated oxidised Hb
Hemighost

These are all indicators of oxidant damage to the red cells

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12
Q

How can G6PD deficiency be confirmed?

A

By assay

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13
Q

What advice would be given to a patient with G6DP deficiency?

A

Avoid oxidant drugs
Avoid broad beans (fava beans)
Avoid naphthalene
Beware haemolysis can result from infection - be mindful getting ill can precipitate a crisis

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14
Q

What are symptoms of SLE with acquired autoimmune haemolytic anaemia?

A 
Fluctuating multi-system disorder:
Ploy arthritis
Shortness of breath
Facial skin rashes
Hepatitis
Tiredness
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15
Q

Blood tests show:

Low Hb
High Bilirubin
B12 and folate normal
High MCV

What information does this tell us?

A

Macrocytic anaemia

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16
Q

A patient with haemolytic anaemia has high LDH, why?

A

Cells are being broken down so intracellular contents are leaking out

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17
Q

What does high unconjugated bilirubin suggest?

A

Haemolytic anaemia

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18
Q

How can acquired haemolytic anaemia present and what can cause this?

A 
Non-immune:
Microangiopathic Haemolytic uraemic syndrome 
Malaria 
Snake venom
Drugs

Immune mediated:
Auto immune
Allo immune (post blood transfusion)

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19
Q

How is a direct antiglobulin test carried out?

A

Human antibodies (immunoglobulin) bind to the antigens on saline suspended RBCs

Add to the saline suspended blood cells rabbit antibody, these bind to human immunoglobulin - causes cells to clump giving a positive DAT

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20
Q

When does Autoimmune Haemolytic anaemia occur?

A

Associated with immune system disorders:

  • Systemic auto immune disease
  • Underlying lymphoid cancer (lymphoma)

Idiopathic

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21
Q

What is unconjugated bilirubin?

A

Pre-hepatic bilirubin - has not yet passed through the liver

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22
Q

What would we see on a blood film for hereditary spherocytosis?

A

Spherocytes - reduced diameter, no central palor = suggests she has something that causes spherocytosis

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23
Q

What is hereditary spherocytosis?

A

Progressive loss of the RBC membrane - cells get more rigid = rigid spheres

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24
Q

What might we also see on a blood film for hereditary spherocytosis?

A

Polychromatic macrocytes = reticulocytes

Suggests her bone marrow is producing more RBCs than normal - to replace RBCs that are lost

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25
Haemolysis VS haemolytic anaemia?
Haemolysis = lowered RBC lifespan <120 days Haemolytic anaemia = cannot compensate for lowered RBC count
26
How do patients with chronic haemolysis get treated?
Folic acid - need due to increased DNA synthesis Splenectomy (if severe) to increase red cell life span - spleen takes out the rigid RBCs (spehrocytes) out of the circulation
27
18 yr patient, previously diagnosed with hereditary spherocytosis, presents with acute upper right abdominal pain and tenderness Jaundice more marked High conjugated bilirubin What is going on?
Gallstones at young age due to increased breakdown of Hb to bilirubin Stone obstructed bile duct = obstructive jaundice Liver = still able to conjugate bilirubin but it cannot go anywhere
28
62F - ``` Severe tiredness Decreased exercise tolerance Funny feeling on her feet - walking on cotton wool Paler skin and yellowish tinge Depigmentation affecting the face ``` ``` Blood test shows Low Hb High MCV Low WBC Low platelets High unconjugated bilirubin Low vit B12 ``` What does this information tell you?
Megaloblastic anaemia due to vit B12 deficiency
29
What does a blood film for megaloblastic anaemia show?
Hypersegmented neutrophils Very macrocytic RBCs Poikilocytosis - funny shaped RBCs = tear shapes, ovals, etc.
30
What are differential for megaloblastic anaemia?
MDS (myelodysplasia) B12 deficiency Folate deficiency Chemotherapy drugs
31
What are megaloblastic features?
Megaloblasts = large with nucleocytoplasmic dissociation Impaired DNA synthesis, nuclear maturation and cell division Adequate cytoplasmic maturation and cell growth So the maturation of the cytoplasm and nucleus is dyssynchronous (not synchronised) = impaired DNA synthesis
32
What are B12 and Folic Acid required for?
Vitamin B12 is required for: 1. DNA synthesis 2. Integrity of the nervous system Folic acid is required for: 1. DNA Synthesis 2. Homocysteine metabolism
33
How can you become B12 or folate deficient?
``` B12 deficiency: Dietary - malnourishment, veganism Gastric - gastrectomy, autoimmune (pernicious anaemia) Bowel - crohn's disease, ileal resection ``` Folic acid deficiency: Reduced availability - poor diet, poverty, alcoholism, malabsorption (coeliac disease, jejunal resection) Increased demand - pregnancy, lactation, increased cell turnover (haemolysis)
34
How can B12 and folate deficiencies be treated?
B12 deficiency due to diet = oral supplements B12 deficiency due to gastric or bowel issues = hydroxocobalamin injections (intramuscular) Folic acid deficiency = oral supplements
35
What neurological disorders can present due to Vit B12 and folic acid deficiency?
Vit B12: dementia, SACD (sub-acute combined degeneration) of spinal cord Folic acid: developmental neural tube defects
36
Areas of depigmentation suggests?
Vitiligo
37
What does a medical history of other autoimmune conditions suggest?
Autoimmune - pernicious anaemia Due to vitiligo which is already an autoimmune condition
38
Summarise megablastic anaemia and its causes:
Anaemia due to asynchronous nucleocytoplasmic maturation in the bone marrow Most common causes = Vit B12 and/or folic acid deficiency
39
# Define the terms: Macrocytic anaemia Pernicious anaemia Megaloblastic anaemia
Macrocytic anaemia = anemia with small RBCs Pernicious anaemia = autoimmune Megaloblastic anaemia = nucleus and cytoplasm maturation in bone marrow not synchronised; B12 or folic acid deficiency
40
Case Study: 45M - severe rheumatoid arthritis Has taken NSAIDs over time and corticosteroids for chronic inflammation Anaemic - Hb 85 Hb used to be 115 at previous attendance ``` MCV = 70 = normal Reticulocytes = 54 x 10^9 = lower end of normal Platelets = 550 x 10^9 = high ``` What does the FBC suggest?
Low reticulocyte for anaemia High platelet count = due to inflammation Hb = low Microcytic anaemia
41
What are common causes for microcytic anaemia?
Iron deficiency
42
Patient's blood test shows: ``` Hb low MCV low Ferritin high Serum iron low Transferrin low Transferrin saturation normal ESR 79 mm/hr ``` Which of these results are most important and why?
Ferritin high (can be normal in iron deficiency) Serum iron low Transferrin low Free iron = v. toxic to the body, normally have v.low serum iron In blood iron is bound to transferrin, in organs iron is bound to ferritin
43
What does a blood film for anaemia of chronic disease show?
Hypochromic, microcytic, RBCs | Rouleaux (aggregations of RBCs)
44
What does the high ferritin count suggest? What does the low transferrin count suggest?
High ferritin = high storage of the iron in the organs Low transferrin = inappropriately low as it should be raised to allow for iron to be transported around the body where it is required
45
What is the likely diagnosis?
Anaemia chronic disease - characteristic findings = Low / normal transferrin when it should be high whilst you're anaemic And typically high ferritin
46
Chronic disease anaemia VS iron deficiency anaemia:
``` Disease | Anaemia of Chronic Disease | Iron Deficiency Anaemia Hb | low | low MCV | low/normal | low Ferritin | high | low Serum iron | low | low Transferrin | low/normal | high Transferrin saturation | normal | low ESR | high | (may be) high ```
47
What is anaemia of chronic disease?
Anaemia in unwell patients with no obvious cause e.g. no bleeding, no haeomlysis, no marrow infiltration, no iron / B12 / folic acid deficiency Caused by inflammation - e.g. from infections, TB, HIV, autoimmune disorders, rheumatoid arthritis, malignancy etc. Must treat it which allows anaemia to get better
48
What is iron haomeostatis?
Excess iron = potentially toxic to organs esp. heart and liver No physiological mechanism to remove iron from the blood Therefore, iron absorption is tightly controlled - regulated by hepcidin (hepcidin blocks absorption and release of storage iron)
49
What happens to hepcidin production when there is increased inflammatory (like in anaemia of chronic disease)? How does this cause an erythropoeitin production issue eventually leading to anaemia?
Hepcidin production is increased Hepcidin reduced iron absorption, iron transport and iron availability This decreases EPO (erythropoeitin) production leading to anaemia
50
What are the 3 common causes of reduced red cell survival?
Hereditary spherocytosis Autoimmune haemolytic anaemia G6DP deficiency
51
What are the 3 common causes of reduced red cell production?
Iron deficiency anaemia Anaemia of chronic disease Megaloblastic anaemia
52
What is meant by the terms: Microcytic Macrocytic Normocytic What are each of these normally accompanied by?
Microcytic - RBC smaller than normal, usually also hypochromic Macrocytic - RBC normal, usually also normochromic Normocytic - RBC larger than normal, usually also normochromic
53
Can anaemia be classified on basis of cell size?
Yes
54
What does microcytic anaemia indicate?
Generally indicates defect in haem synthesis: - Iron deficiency anaemia - Anaemia of chronic disease Or defect in globin synthesis (thalassaemia): - Defect in alpha chain synthesis (alpha thalassaemia) - Defect in beta chain synthesis (beta thalassaemia)
55
How does iron deficiency anaemia and thalassaemia differ in an FBC?
``` Condition | Iron deficiency anaemia | Thalassaemia trait Hb | low | low MCV | low | low MCH | low | low MCHC | low | preserved RBC | low | high Ferritin | low | normal ```
56
How can thalassaemia be distinguised between alpha and beta?
Hb electrophoresis: ``` Alpha = normal Beta = Hb A2 raised ```
57
What does macrocytic anaemia indicate?
Lack of vitamin B12 or folic acid (megaloblastic anaemia) Use of drugs interfering with DNA synthesis Liver disease and ethanol toxicity Haemolytic anaemia (reticulocytes increased)
58
What can lead to haemolysis?
Reduced erythrocute function due to: - Loss of integrity of membrane e.g. hereditary spherocytosis, autoimmune haemolytic anaemia - Change in Hb structure and function e.g. sickle cell anaemia (SCA) - Change in cellular metabolism e.g. G6PD deficiency
59
What may cause normocytic anaemia?
1. Recent blood loss e.g. GI haemmorrhage, trauma 2. Failure of RBC production e.g. early stages of iron deficiency, bone marrow failure or suppression (chemotherapy), bone marrow infiltration (leukaemia) 3. Pooling of RBCs in the spleen e.g. hypersplenism (liver cirrhosis), splenic sequestration in SCA (sickle cell anaemia)
60
What are some clinical signs of iron deficiency anaemia?
Koilonychia | Glossitis Angular stomatitis
61
What are causes of iron deficiency anemia?
Increased loss (blood loss): - Commonest cause in adults - Hookworm commonest cause worldwide - Menstrual (menorrhagia) - Gastrointestinal (often occult) Insufficient iron intake: - Dietary - Vegetarians - Malabsorption - Coeliac disease (gluten-induced enteropathy) - H. pylori gastritis Increased iron requirements: - Physiological - Pregnancy - Infancy
62
If a patient presents with weight loss, change in bowel habits, rectal bleeding and iron deficiency anaemia, what investigations would you do?
Investigate blood in stool: faecal immunological test | GI investigations: Upper GI endoscopy, duodenal biopsy, colonoscopy
63
What are symptoms of iron deficiency anaemia?
Tiredness Lethargy Breathlessness at rest, worst on exertion Ankle swelling at end of day
64
In what 2 conditions are spherocytes seen in? | How can I differentiate between the two?
Hereditary spherocytosis Acquired autoimmune haemolytic anaemia Use direct antiglobulin test to differentiate- positive for AAHA
65
What is laboratory evidence of haemolytic anaemia?
High LDH Unconjugated hyperbilirubinemia Reduced haptoglobins High reticulocytes

BRS Year 2 (110 decks)

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