SYSTEMATIC PLAN FOR THE DIAGNOSIS OF ANAEMIA

 
 INTRODUCTION
• Anaemia is not a disease or diagnosis in itself
but a manifestation of an underlying disease
• It is the most common manifestation of
disease worldwide
 DEFINITION OF ANAEMIA
• The word anaemia is a Latin word meaning "no blood.
• Ideally defined as a reduction of more than 10% from the
normal value for the total number of red blood cells (RBCs),
amount of circulating haemoglobin (Hb), and RBC mass for a
particular patient.
• OR
• A more conventional definition is hence: A decrease in the
RBCs, Hb, and or haematocrit (Hct) ( and consequently a
reduction in the oxygen carrying capacity ) below the
established normal values for healthy persons of the same
age, gender, and race and under similar environmental
conditions.
SUMMARY OF DEFINITION

↓RBC

↓Hb

↓O2 carrying
capacity
 HAEMOGLOBIN THRESHOLD FOR ANAEMIA

Age or gender group Hb threshold (g/dl) Hb threshold

(mmol/l)
Children (0.5–5.0
yrs) 11.0 6.8
Children (5–12 yrs) 11.5 7.1
Teens (12–15 yrs) 12.0 7.4
Women, non- 12.0 7.4
pregnant (>15yrs)
Women, pregnant 11.0 6.8
Men (>15yrs) 13.0 8.1
 REFERENCE RANGES FOR
HAEMOGLOBIN AT DIFFERENT AGES
Age/gender Normal haemoglobin Anaemic if Hb
range (g/dl) range less than: (g/dl)*
Birth (full-term) 13.5-18.5 13.5 (Hct 34.5)
Children: 2-6 months 9.5-13.5 9.5 (Hct 28.5)
Children: 6 months-6 years 11.0-14.0 11.0 (Hct 33.0)
Children: 6-12 years 11.5-15.5 11.5 (Hct 34.5)
Adult males 13.0-17.0 13.0 (Hct 39.0)
Adult females: non- 12.0-15.0 12.0 (Hct 36.0)
pregnant
Adult females: pregnant    
First trimester: 0-12 weeks 11.0-14.0 11.0 (Hct 33.0)
Second trimester: 13-28 10.5-14.0 10.5 (Hct 31.5)
weeks
Third trimester: 29 weeks- 11.0-14.0 11.0 (Hct 33.0)
term
 PHYSIOLOGIC ADAPTATION TO
ANAEMIA
• Myocardial Myocardial
• Erythropoietic – An increased heart
• Metabolic rate, increased
circulation rate, and
increased cardiac
Erythropoietic:
output.
– HIF stimulate the kidney,
leading to production of – Preferential shunting
Erythropoitin >> more of blood flow to the
red cells prdn vital organs.
PHYSIOLOGIC ADAPTATION TO ANAEMIA 2

Metabolic: • Decreased O2 in the

• Increased production tissues leads to anaerobic
glycolysis, which leads to
of 2,3 DPG, resulting
the production of lactic
in a shift to the right acid, which leads to a
in the O2 dissociation decreased pH and a shift
curve, thus to the right in the O2
permitting tissues to dissociation curve. Thus,
more O2 is delivered to the
extract more O2 from
tissues per red blood cell.
the blood.
METABOLIC ADAPTATION
• Tissue hypoxia stimulate
enzymes in the gylcolytic
pathway leading to
increased production of
2,3‐
diphosphoglycerate(2,3‐
DPG)
• 2’3-DPG shifts the curve to
the right
 SIGNIFICANCE OF ANEMIA AND
COMPENSATORY MECHANISMS
• The signs and symptoms of anemia range
from slight fatigue to life threatening
reactions depending upon
– Rate of onset
– Severity
– Ability of the body to adapt
 RATE OF ONSET AND SEVERITY
• In slowly developing anemias, a very
severe drop in hemoglobin of up to 50%
may occur without the threat of shock or
death.
– This is because the body has adaptive or
compensatory mechanisms to allow the
organs to function at hemoglobin levels of
50% of normal.
 RATE OF ONSET AND SEVERITY
• With rapid loss of blood:
– Up to 20% may be lost without clinical signs
at rest, but with mild exercise the patient
may experience tachycardia (rapid heart
beat).
– Loss of 30-40% leads to circulatory collapse
and shock
– Loss of 50% means that death in imminent
 CLINICAL FEATURES
SYMPTOMS SIGNS
Depends on severity ,speed of General
onset $ age. it includes: • Pallor of mucus membrane
• Easy fatigability • Tachycardia
• Dizziness • Bounding pulse
• Palpitation • Cardiomegaly
• Dyspnea • Systolic flow murmur
• Retinal haemorrhages
• Headaches
Specific
• Angina pectoris • Koilonycahia-iron deficiency
• Intermittent • Jaundice-haemolysis/megaloblastic ana.
claudication/confusion • Leg ulcer-SCD
• Visual dist/tinnitus • Bone deformities-thalassaemia
• Bleeding/infection- BM failure
Pallor of the conjunctival mucosa (a) and
of the nail bed (b) Retinal haemorrhages
 CLINICAL FEATURES 2
Degree of Clinical features
anaemia

mild Mild dyspnea on exertion, palpitation

moderate As with MILD ANEMIA, may also have
excessive fatique

severe Dyspnea at rest, tachycardia with

pounding pulse, weakness, dizziness,
syncope,,headache,insomnia
 DIAGNOSIS OF ANAEMIA-

Essential for diagnosis

include:
• Thorough and good Hx
• Thorough physical
examination
• Systematic
investigation
 DIAGNOSIS OF ANAEMIA-
patients history
Historical information

Symptoms of anaemia and Dyspnea, palpitation, dizziness, fatique postural hypotension

severity

Age of onset Inherited/acquierd; recent/continous

Family hx $ racial background

Hx chronic blood loss Menstral, GIT,-black stools, preg. Hx

Hx suggestive of haemolysis Jaundice, dark urine

Dietary Hx Alcohol, stable diet, unusual diet

Toxic exposures Drugs, hobbies, occupational exposure

Underlying disease Ureamia, CLD, Hypothyoidism, leukaemia

 DIAGNOSIS OF ANAEMIA-
physical examination
PYSICAL SIGNS ASSOCIATED DISEASE
Skin and mucous membrane
pallor Any anaemia
scleral icterus Hemolytic anaemia
smooth tongue Pernicious anaemia, severe iron deficiency
petechiae Aplastic anaemia,thrombocytopenia, BM
replacement
ulcers Sickle cell disease
Lymph node- Lymphoma,leukaemia,infectious mononucleosis
lymphadenopathy
Heart
cardiac dilatation, ↓HR, Severe anaemia
loud murmur
soft murmur Anaemia, usually mild
 DIAGNOSIS OF ANAEMIA-
physical examination
Physical sign Associated disease

abdomen

splenomegaly Leukaemia, lymphoma,infectious mononuceosis,

hyperspenism

massive splenomegaly CML, myelofibrosis

hepatomegaly +Ascitis Liver disease

Cental nervous system

Subacute combined degeneration of Pernicious anaemia

cord

delayed achilles tendon reflex hypothyroidism

 DIAGNOSIS OF ANAEMIA
Investigations
• FBC and cell indices
• BLOOD FILM examination
• Reticulocyte count:
– % recticulocyte normal range- 0.5 -2.5%
– Absolute retic count; 25-75 x 109/L
– Corrected retic count
– Reticulocyte production index:2-3%
• Bone marrow examination
– Aspiration for cytology
– Biopsy for histology
OTHER LABORATORY INVESTIGATIONS

• Complete urinalysis including microscopy

• Fecal analysis
– occult blood
– Microscopic examination for parasites
• Other special test may be required based on
the morphologic type of anaemia e.g. Serum
ferritin
 LABORATORY INVESTIGATIONS CONT
BLOOD SMEAR: FULL BLOOD COUNT:
• RBC
• INDICES
– Size
– Shape – MVC
– Inclusions – MCH
– Colour – MCHC
– Arrangement
– RDW
• Other cells
– Blood cells • BLOOD COUNTS
• Platelets
• WBC
– Micro-organism
• Parasite, fungal, bacterial
 BLOOD FILM EXAMINATION
• The most important examination in the
workup of an anaemia is to examine the
peripheral blood smear/film.
• Complements the analytical information from
cell counter
Some of the more frequent variations in size (anisocytosis) and
shape (poikilocytosis) that may be found in different
anaemias.
Red blood cell (RBC) inclusions
• The reticulocyte RNA and Heinz
bodies are only demonstrated by
supravital staining (e.g. with new
methylene blue). Heinz bodies are
oxidized denatured haemoglobin.
• Siderotic granules (Pappenheimer
bodies) contain iron. They are
purple on conventional staining
but blue with Perls’ stain.
• The Howell–Jolly body is a DNA
remnant. Basophilic stippling is
denatured RNA.
DIAGNOSIS OF ANEMIA
MORPHOLOGICAL CLASSIFICATION OF
ANEMIAS
MACROCYTIC ANEMIAS
 IN CONCLUSION:
• Anaemia is not a disease or diagnosis in itself.
• Attempt should always be made to find the
cause and not just treat the symptom
• A good and systemic approach Is necessary

•Thanks for listening