Anemia (general, microcytic, macrocytic) Flashcards Preview

Hematology STEP 2 > Anemia (general, microcytic, macrocytic) > Flashcards

Flashcards in Anemia (general, microcytic, macrocytic) Deck (91):
1

all forms of anemia can present with identical symptoms if they have the same hematocrit. Symptoms are based on ... and not on the

based on severity
not in etiology

2

The best initial test in evaluating of anemia

Complete blood count

3

Hematocrit - symptoms regarding the severity

- more than 30-35%: none
- 25-30: dyspnea (worse on exertion), fatigue
- 20-25: lightheadedness, angina
- 20-25: syncope, chest pain

4

Ultimetly, cardiac ischemia from anemia proves fatal - why

Myocytes in the heart cannot distinguish between
1. anemia 2. hypoxia 3. coronary artery disease
4. CO poisoning
All result in decreased oxygen delivery

5

Although CBC establishes anemia, ..... is the first clue to the etiology of anemia

Mean Corpuscular volume (MCV)

6

causes of low MCV anemia (microcytosis)

1. iron def
2. thalassemia
3. sideroblastic
4. Anemia of chronic disease

7

Microcytic anemias generally have also ....(explain)

a low reticulocyte count
Most causes of microcytosis are production problems.
ONLY a-thalassemia with 3 genes deleted has an elevated reticulocyte count

8

Microcytic anemias - routine blood smear

not effective in telling the difference between the types. --> all are hypochromic and potentially give target cells

9

Sideroblastic anemia - MCV

either microcytic or macrocytic

10

Microcytic anemias with elevated reticulocyte count

a-thalassemia with 3 genes deleted

11

causes of high MCV anemia (macrocytosis)

1. B12 + follate deficiency
2. sideroblastic anemia
3. Alcoholism
4. antimetabolite medications (azathioprine, 6-MP, hydroxyurea)
6. liver disease
7. hypothyroidism
8. medications such as zidovudine or phenytoin
9. myelodysplastic syndrome

12

....can falsely elevate MCV by ....

Cold agglutinins
by clumping cells

13

acute blood loss - anemia

drop in hematocrit so rapid that there is no time for the MCV to change --> ultimately leads to iron def na dmicrocytosis
eventually hemolysis will increase the reticulocytes and this will rise MCV

14

Methrotrexate - anemia MCV?

high

15

Reumatoid arthritis anemia - MCV

normal

16

causes of normocytic anemia

1. nonhemolytic: iron (early), chronic disease (early), aplastic, chronic kidney disease
2. hemolytic: Membrane defect (hered spherocytosis), RBC enzyme deficiency (G6PD, pyruvate), HBC, Paroxysmal noctural, SCA

17

severe anemia - treatment

packed red blood cells

18

indications for transfusion in anemia

- symptomatic patient
- very low hematocrit in an elderly patient or one with heart disease (HCT: 25-30)

19

symptomatic anmie means

1. shortness of breath
2. lightheaded, confused, syncope
3. hypotension and tachycardia
4. chest pain

20

Remember - it is not necessary to transfuse anemia if

the patient is young and asymptomatic

21

Packed red blood cells?

concentrated form of blood / a unit of whole blood with about 150 ml of plasma removed
hematocrit about 70-80

22

each Packed red blood cells can raise the hematocrit by about

3 points per unit,
or 1g/dl of Hg

23

Fresh frozen plasma?

replace coagulation factors in those with an elevated PT, aPTT, or INR and bleeding.
used also as replacement with plasmapheresis

24

Fresh frozen plasma is not a choice for

hemophilia A or B
VWD

25

Cryporecipitate contains

fibrinogen, factor 8, factor 9, vwf, fibrinocten
in smaller plasma volume

26

Cryporecipitate it is used to

replace fibrinogen and has some utility in DIC
also hemorophilia and VWD

27

Cryoprecipitate - it is used first for

never used first for anything

28

platelets for transfusion are pooled from

the donation of multiple donors

29

platelets transfusion - indications / contraindications

1. ind: bleeding + platelets less than 50.000
2. contr: TTP

30

thalassemia trait - symptoms

most are asymptomatic

31

Iron - amount needed per day

1-2 mg per day
menstruating women: 2-3
pregnant womern: 5-6

32

menstruation - iron deficiency mechanism

menstruating women need 2-3 mg/d/ The duodenum can absorb 4 mg a day. Hence as little as a teaspoon 5 ml a day of blood loss will lead to iron def anemia over time

33

Sideroblastic anemia can e macrocytic when associated with

1. myelodysplasia
2. preleukemic syndrome

34

MCC of sideroblastic anemia

alchohol suprressive effect on the bone marrow

35

Less common causes of of sideroblastic anemia

lead poisoning, isoniazid, vit 6 deficiency

36

sideroblastic anemia - mechanism (simply)

inability of iron to be incorporated with heme

37

sideroblastic anemia - labs

increased iron
normal/decreaesd TIBC
increased Ferritin
ringed sideroblasts (Prussian blue) in bone marrow
basophilic stippling in peripheral blood smear

38

Anemia of chronic disease - diseases? / mechanism

any form of cancer or chronic infection
- the iron is locked in storage or trapped in macrophages or in ferritin (hepsidin regulates iron absoprtion -->
- in RF --> EPO deficiency

39

Target cells are most common with

thalassemia
(they could be in anny microcytic anemia)

40

Best initial test for microcytic anemia

unique findings on iron studies

41

Unique featrues and diagnosis of iron studies (and what type of anemia)

1. low ferritin: iron def
2. high iron: sideroblastic
3. normal iron studies: thalassemia

42

iron def - ferritin

a low ferritin is extremely specific for iron def. Nearly 1/3 of patients have normal or increased ferritin --> any counter current infection or infl can raise the ferritin level

43

Both iron def and ACD are associated with

low serum iron level
however iron def has increased TIBC (measure of unbound sites of trasferin

44

anemia of chronic disease - iron

serum iron is low, becasue is trapped in storage. That's why the ferritin or stored iron is elevated, or normal. However the TIBC IS LOW

45

mirocytic anemia with elevated circulating iron

sideroblastic

46

thalassemia - iron

normal

47

Anemia of chronic disease pathophysiology

Inflammation--> increases hepsidin --> binds ferroportin (on intestinal mucosal and macrophages) inhibiting iron trnasport--> decreases the releasing of iron from macrophages and decrease absorption

48

Pregnancy (ocp use) - iron status

Increases the Transferin/TIBC
Decrease the transferin saturation

49

iron deficiency anemia - iron status

1. low serum iron (1ry)
2. high transferrin or TIBC
3. low ferritin
4. very low trasnferrin saturation (serum iron/TIBC)

50

chronic disease anemia - iron statis

1. low serum iron
2. low trasnferrin or TIBC
3. high ferritin (primary)
4. normal saturation

51

hemochromatosis - iron status

1. high serum iron (primary)
2. low trasnferrin or TIBC
3. high ferritin
4. very high trasnferrin saturation

52

pregnancy/OCP use - iron status

1. serum iron normal
2. trasnferin or TIBC increased (primary)
3. ferritin normal
4. trasnferrin saturation low

53

sideroblastic anemia - most accurate test / other unique test

prussian blue stating for ringed sideroblastic anemia
Basophilic stippling can occur in any cause of sideroblastic anemia

54

Unique lab tests for Iron def anemia (explain)

- increased red cell distribution (RDW): This is because the newer cells are more iron deficient and smaller. As the body rans out of iron, the newer cells have less Hb and get progressively smaller
- elecated platelets
- bone marrow biopsy for stainable iron which is decreased

55

Iron def anemia - single most accurate test

bone marrow biopsy for stainable iron which is decreased
RARELY DONE

56

the most accurate test for thalassemia

Hb electrophoresis
for α-thalassemia, genetic studies are the most accurate

57

α-thalassemia - abnormal hb

only with 3 gene deletion

58

thalassemia - RDW

all forms have normal RDW

59

α-thalassemia is diagnosed by

DNA analysis

60

alpha thalassemia - 1 + 2 + 3genes deleted - symptoms

1: normal
2: mild anemia
3: moderate anemia

61

α-thalassemia - Hb

α: normal in 1 or 2 genes deleted. HbH in 3 genes deleted (which is beta 4 tetrads),

62

α-thalassemia with 4 genes deleted - Hb and presentation

HbF (γ) or Hb BART
CHF causes death in utero (hydrops fetalis)

63

β-thalassemia - Ηβ

increased HbF and A2
beta thalassemia intermedia: normal Hb (no transfusion dependence)

64

iron def anemia - treatment

replace iron with oral ferrous sulfate --> if insufficient, occasionally patients are treated with IM iron

65

Chronic disease anemia - treatment

correct underlying disease
if RF --> EPO

66

sideroblastic anemia - treatment

1. correct the cause
2. some patients respond with B6 (pyridoxine) replacement

67

thalassemia -treatment

- trait is not treated
- beta-thalassemia major (Colley anemia) is managed with chronic transfusion lifelong

68

iron overload due to transfusion is managed with

- oral iron chelators: deferasirox, dereriprone
- parental chelator: deferoxamine

69

Megaloblastic anemia is

the presence of hypersegmented neutrophils

70

Causes of megaloblastic anemia

B12 or folate deficiency
antimetabolite medications

71

macrocytic anemia - firsta step

peripheral blood smear --> to detect hypersegmented neutrophils --> if there are, then B12 and folate levels

72

causes of B12 def

1. pernicious anemia
2. pancreatic insufficiency
3. dietary deficiency (vegan, strict vegeterian)
4. Crohn, celiac or tropical sprue, RADIATION or any disease damaging the terminal ileum
5. Blind loop syndrome (gastrectomy or gastric bypass for weight loss)
6. Diphyllobothrium latum
7. HIV

73

infections that can cause B12 def

1. Diphyllobothrium latum
2. HIV

74

Celiac disease can cause ...... (deficiencies)

1. B12
2. Folate
3. iron

75

folate def is caused by

1. dietary def (goat's milk has ni folate and provides only limited iron and B12)
2. psoriasis and skinn loss or turnover
3. Drugs: phenytoin, sulfa, methotrexate
4. malabsoprion (eg. celiac)

76

drugs that can cause folate def

phenytoin, sulfa, methotrexate

77

folate vs b12 regarding site of absorption

B12 --> ileus
folate --> jejunum

78

alcohol vs b12 def in anemia

both can give macrocytic anemia and neurological problems, but only b12 def gives hypersegmented neutrophis

79

B12 - neuropathy

- it can give any neuropathy
- peripheral neuropathy is more common / dementia is the least common
- posterior column damage to position and vibratory sensation is common
- subacute combined degeneration of the cord is classic (corticospinal + spinocerebellar + posterior)
- LOOK FOT ATAXIA

80

Labs common to both b12 + folate def

1. Meg anemia 2. decreased Reticulate count
3. Increased LDH and increased indirect bilirubin
4. hypercellular bone marrow 5. macroovalocytes
6. INCREASED HOMOCYSTEINE LEVELS

81

labs - b12 vs folate def

only b12 def has increased methylmalonic acid levels

82

megaloblastic anemia - mechanism of increased LDH, Low reticulocytes, high bilirubin

ineffective erythropoiesis
(THEY ARE DESTROYED AS THEY LEAVE MARROW)

83

megaloblastic anemia with neurological diagnosis but with equivocal B12 levels - next step

methylmalonic acid levels
(B12 is normal in 1/3 of B12 anemia because the carrier protein, transcoboloamin, is an acute phase reactant and can be elevated from stress)

84

macrocytic anemia - Schilling test

NEVER the right answer
(4 stage test that determines if the cause is dietary insufficiency or malabs)

85

pernicious anemia is confirmed by

anti-instrict factor and anti-parietal cell antibodies

86

beside anemia, folate and B12 def could also cause

pancytopenia (if severe)

87

b12 associated neurological abnormalities - can be improved?

only if they are minor (eg. peripheral) and short of duration

88

b12 def - both neurological symptoms and anemia

no --> it can be 1 of them or both.
it doesn't have to be both

89

b12 and follated def - treatment

replace what is deficient
(follate never correct the neurological problems)

90

complication of b12 or folate replacement (why)

hypokalemia: extremely rapid cell production in the bone marrow causes hypokalemia (esp with pacytopenia)

91

role of pancreatic enzymes in B12 absorption

they remove b12 from R-protein so it can bind with IF