CHAPTER 2

ANEMIA
Objectives
At the end of this chapter the student will be
able to:
 Define anemia
 Discuss classification of anemia
 Elaborate the morphological classification of anemia
 Describe Microcytic hypochromic, Macrocytic, NCNC anemias
 List the causes of the different categories of anemia
 Discuss the causes and clinical significance of anemias
 Discuss the laboratory findings for each category of
anemia
 Correlate laboratory findings within each category of
anemia
 Perform basic laboratory tests for the diagnosis of
anemias including quality control
Chapter Outline

 Definition of anemia
 Classification of anemias
 Types of anemia
 Red Blood Cell Morphology
 Clinical Significance
 Laboratory findings for the diagnosis of anemias
 Sources of error
Introduction
Definition of Anemia
 Anemia is a decrease in the RBC count, Hgb and/or HCT
values as compared to normal reference range for age,
altitude and gender or as tissue hypoxia
– True anemia:
– decreased RBC mass and normal plasma volume

– Pseudo or dilutional anemia:

– normal RBC mass and increased plasma volume

– An increase in plasma volume can occur in

Pregnancy, fluid volume overload (IVs)
congestive heart failure
– Low Hgb and HCT values

 Blood volume = RBC mass + plasma volume

Definition of Anemia cont’d
Anemia definition cont’d
 Clinical diagnosis of anemia is made by:
 patient history
 physical exam
 signs and symptoms
 laboratory findings
 This definition emphasizes the differences one should expect
when evaluating probable anemia in the different age groups
 Anemia must also relate to the level of hemoglobin the
individual normally possesses
 If an adult male usually maintains a hemoglobin level of
16g/dl, and over a period of days is noted to have decreased
to 14g/dl, this must be considered significant even though
both values are within the normal range for an adult male.
Signs of Accelerated Bone Marrow
Erythropoiesis
 Due to hypoxia, the kidney will produce erythropoetin, which
is responsible for stimulating RBC production in the bone
marrow
 The marrow becomes hypercellular due to a marked increase
in RBC precursors (called erythroid hyperplasia) and the M:E
ratio falls.
 Nucleated RBCs may be released into the blood circulation
along with the outpouring of reticulocytes
 nRBC number tends to correlate with the severity of
anemia
 Increased polychromasia on the Wright's- stained blood
smear is seen due to increased number of circulating
reticulocytes
Signs of Accelerated Bone Marrow
Erythropoiesis

NRBC

Polychromasia

Wright’s stained blood smear

Medullary and Extra Medullary
Hematopoeisis
 If demand exceeds maximal bone marrow activity,
RBC production may occur in extramedullary sites,
liver, spleen (hepatosplenomegaly).
Physiologic Response to Anemia

 Ability to adapt to anemia depends on:

 Age and cardio/pulmonary function
 Rate at which anemia develops (BM can compensate easier
if the onset of anemia is slow),
 Underlying disease
 Symptoms of hypoxia: decreased oxygen delivery to the
tissues/organs causes:
 fatigue, faintness, weakness, dizziness, headaches, dyspnea,
poor exercise tolerance, leg cramps.
 Pallor
Symptoms cont’d

 General physical findings:

 Pallor, rapid pulse,
neurologic problems (see
table)
Methods of Anemia Classification
 Several schemes of classifying anemias exist
1. Morphologic
 Based on RBC morphology and RBC indices
 Anemia is divided into three groups
2. Pathophysiologic
 Anemia is based on causes/mechanisms
Impaired erythrocyte formation (aplastic anemia, IDA,
sideroblastic anemia, anemia of chronic diseases,
megaloblastic anemia)
 RBC loss (GI bleed) and destruction (hemolysis)
Methods of Anemia Classification

 RBC loss (GI bleed) and destruction (hemolysis)

 Increased blood loss (Acute, Chronic)

 Retic count is typically high

 Anemia results when red cell loss exceeds the bone

marrow’s capacity to increase its activity
 Increased destruction of RBCs (hemolytic anemias)

 Retic count is typically high

 Anemia results when red cell destruction exceeds

the bone marrow’s capacity to increase its activity
Classification of Anemia
Morphologic Categories of Anemia
 Originally proposed by Dr.Wintrobe, a morphologic
classification is based on
 how the cells appear on a stained smear and
 correspond with the red cell indices.

1. Microcytic hypochromic
2. Macrocytic Normochromic
3. Normocytic Normochromic (NCNC): anemia due
to decrease in the number of erythrocytes
(e.g. aplastic anemia, or acute blood loss,HA)
Morphologic Categories of Anemia cont’d

1. Microcytic Hypochromic, anemia

 low MCHC
 low MCV
 Examples:
1. iron deficiency anemia
2. sideroblastic anemia
3. Thalassemias
4. anemia of chronic disease (severe time not early )
Morphologic Categories of Anemia cont’d

2. Macrocytic Normochromic anemia

 normalMCHC
 high MCV
 Examples:
1. Vitamin B12 deficiency
2. Folic Acid deficiency
3. Liver disease
Morphologic Categories of Anemia cont’d

3. Normocytic Normochromic (NCNC) anemia

 normal MCV
 normal MCHC

 Examples:
1. anemia of acute hemorrhage
2. aplastic anemias (those characterized by disappearance of
RBC precursors from the marrow)
3. anemias of chronic disease (ACD) at early
4. Hemolytic anemias (those characterized by accelerated
destruction of RBC’s)
 Three Morphologic Categories of Anemia

1 2
1 Microcytic/hypochromic 2 Macrocytic/normochromic

N.B. The nucleus of a small

lymphocyte (shown by the
arrow) is used as a reference to
3 a normal red cell size
3 Normocytic/normochromic
Microcytic Hypochromic Anemias

 Evaluate the laboratory findings associated with

microcytic/hypochromic anemias based on etiology, blood
and bone marrow findings, and tests used to aid in diagnosis
 Iron deficiency anemia
 Sideroblastic anemias (primary and secondary types)
 Anemia of chronic disease
 Alpha and beta thalassemias (major and minor types)
 Microcytic/Hypochromic Anemias
 Characterized by impaired hemoglobin synthesis

Sideroblastic IDA
anemia ACD

Thalassemia ( or)
Abbott Manual
Microcytic/Hypochromic Anemias

Normoblastic RBC maturation  normocytic red cells

RBC maturation in microcytic anemias

Abbott Manual
Iron Deficiency Anemia (IDA)
 Is a condition in which the total body iron content is decreased
below a normal level
 This results in a reduced red blood cell and hemoglobin
production
 Major Causes:
 Nutritional deficiency
 Malabsorption (insufficient or defective absorption)
 Increased need(competition)
 Chronic blood loss (GI bleeding, ulcer, heavy
menstruation)
Iron Deficiency Anemia cont’d
Sequence of iron depletion
 Storage 1st; Serum Iron depletion 2nd; cell morphology 3rd
 1st - Storage iron depletion/ low serum
ferritin; serum iron & TIBC are normal, no anemia,
normal red cells.
 2nd - Serum iron depletion/TIBC increases
(increased transferrin); no anemia, normal red cells.
 3rd - Anemia with microcytic/hypochromic
red cells = IDA.
 Iron Cycle
Iron absorption, Transport and storage

 Iron absorbed from duodenum and jejunum in the GI Tract,

moves via circulation to the bone ,where it is incorporated with
protoporphyrin in mitochondria of the erythroid precursor to
make Heme
 Three proteins are important for transporting and storage of iron
 Transferrin: transports iron from the plasma to the
erythroblasts in the marrow for erythropoiesis
 Transferrin will bind to Transferrin receptor on the
erythroblast membrane
 Excess iron is stored as Ferritin and hemosiderin in the
reticuloendothelial system
Lab Investigation of microcytic
hypochromic anemia
 Iron tests
►Used to differentiate microcytic hypochromic anemias or
detect iron overload (repeat transfusion)
 Iron circulates bound to the transport protein transferrin
which carries iron to bone marrow red cells for Hgb
synthesis or to tissue sites (liver, spleen, bone marrow) for
storage as ferritin
 Transferrin is normally ~33% saturated with iron

 Iron tests include serum iron, Total Iron Binding Capacity

(TIBC), serum ferritin
 Serum iron level
 measures the amount of iron bound to transferrin
 Does not include the free form of iron
Lab Investigation cont’d

1. Serum iron level - measures the amount of iron bound to

transferrin; normally about 33% of transferrin binding sites are
occupied with iron (% saturation).
2. Total iron binding capacity (TIBC) - measures the total
amount of transferrin can bind when fully saturated
 Is an indirect measure of the amount of transferrin protein.
 Inversely proportional to the serum iron level
 If serum iron is decreased, total iron binding capacity of

transferrin increased (transferrin has more empty space

to carry iron)
3. Serum ferritin level - indirectly reflects storage iron in
tissues without doing a bone marrow or tissue biopsy.
Lab Investigation cont’d

 Serum ferritin cont’d

 found in trace amount in plasma
 It is in equilibrium with the body stores
 Variation in the quantity of iron in the storing
compartment is reflected by plasma ferritin
concentration
e.g.Plasma ferritin is decreased in IDA
Plasma ferritin increased in ACD
Lab Investigation cont’d
 Transferrin Saturation

Formula:
TS = plasma iron/plasma TIBC X 100.

Percentages below 16% in adults and children and below

12% in infants suggest insufficient iron delivery to the
hematopoietic tissues.
 Lab Investigation cont’d
Erythrocyte protoporphyrin: protoporphyrin combines
with iron to form heme. Under ID conditions, the lack of iron
determines an increase in erythrocyte protoporphyrin, which
cannot combine with Iron. Increased values of erythrocyte
protoporphyrin indicate impaired erythropoiesis due to iron
deficiency. (High FEP also found in lead poisoning, in some cases
of sideroblastic anemias)
Bone marrow iron (Tissue iron)
Tissue biopsy of bone marrow
Prussian blue stain
Type of iron is hemosiderin
Lab Investigation of Anemia cont’d

 Transferrin levels are regulated by iron availability

 ↑ synthesis of Transferrin in iron deficient states…↓ serum
iron, ↑ TIBC
 ↓ synthesis of Transferrin in iron overload states…↑ serum
iron, ↓ TIBC
 ↓ synthesis of Transferrin in inflammatory states or
malignancy …↓ serum iron, ↓ TIBC, ↑serum ferritin (in
ACD)
Lab Investigation of Anemia cont’d
Iron Deficiency Anemia

Blood smear

 Lab findings
 Low RBC, Hgb, Hct
 Low MCV, MCH, MCHC
 Normal WBC and PLT
Blood findings in untreated IDA:

1. Mild to severe anemia (11 to 5 g/dl Hgb);

microcytic/hypochromic RBCs.
2. Low RBC indices (MCV 50-70 fl; MCH < 27 pg; MCHC
<32%).
3. Aniso with high RDW; ovalocytes/pencil cells, may see target
cells, normal or elevated platelet count.
4. No basophilic stippling - if present, rules out IDA and helps
differentiate IDA from thalassemia minor.
5. No pappenheimer bodies (composed of iron) are seen in IDA.
6. Low retic count – red cell production is restricted by lack of
iron.
7. Low serum iron, high TIBC, low serum ferritin (stores), low %
saturation of transferrin. *Increased transferrin
synthesis occurs in iron deficient states.
Iron Deficiency Anemia cont’d

 RBC morphology
 Hypochromia
 Microcytosis
 Anisocytosis
 Poikilocytosis
 Pencil cells (cigar cells)
Blood smear
 Target cells
 no RBC inclusions
 Iron parameters
 Low serum iron,
 High TIBC,
 Low serum ferritin
 Iron Deficiency

Ovalocytes - Pencil forms

No RBC inclusions

Wright’s stained blood smear

Iron Deficiency Anemia

 Bone marrow (not usually performed)

 No stainable iron
 Increased NRBC
 Erythroid hyperplasia with decreased M:E ratio

Bone marrow 10x

Bone marrow

Ringed Sideroblast

No stainable iron (-) Prussian

NRBC with ring of iron
blue iron stain
Prussian 38
blue stain
Sideroblastic Anemia (SA)
 This group of anemias are characterized by defective
protoporphyrin synthesis (blocks) resulting in iron loading
(leads to iron overload )and a microcytic/hypochromic
anemia due to deficient hemoglobin synthesis.
Sideroblastic Anemia Continued
 Siderocytes are Mature RBCs in the blood containing iron
granules called Pappenheimer bodies....abnormal.
 Sideroblasts are immature nucleated RBCs in the bone
marrow containing small amounts of iron in the
cytoplasm....normal.
 Sideroblastic anemia is characterized by the
accumulation of iron in the mitochondria of immature
nucleated RBCs in the bone marrow; the iron forms a
ring around the nucleus  these are called ringed
sideroblasts....abnormal.
 The iron accumulation in the mitochondria is the result of
blocks in the protoporphyrin pathway.
Sideroblastic Anemia cont’d

Lab findings:
 Microcytic/hypochromic red cells, low MCV and MCHC;
variable anemia, low retic.
 RBC inclusions: Basophilic stippling and Pappenheimer
bodies (siderocytes). (May see target cells).
 High serum iron and high serum ferritin (stores); low TIBC
and high % saturation.
 *Decreased transferrin synthesis occurs in iron overload
states.
 Bone marrow: ringed syderoblasts (Hallmark of
Sideroblastic Anemia)
 Sideroblastic Anemia (SA)

Blood Bone marrow Bone marrow

Ringed Sideroblast
Pappenheimer bodies Sideroblast

RBC with iron NRBC with iron NRBC with ring of iron
Wright’s stain Prussian blue stain Prussian 42
blue stain

Be aware that the diagram at the top is similar with the stained preparation at
the bottom
Sideroblastic Anemia (SA)
Blood Blood

Basophilic stippling/stippled RBCs

Pappenheimer bodies
Wright’s stain

 Peripheral blood Blood

Pappenheimer bodies
films stained with Prussian blue iron stain
either Wright’s or
Prussian blue
stain
 How diff PB & BS?
Types of Sideroblastic Anemia (SA)
 Blocks in the synthesis of protoporphyrin may be
 primary and irreversible (idiopathic = cause unknown) or
 secondary and reversible
Types of Sideroblastic anemia cont’d
 Blocks in the protoporphyrin pathway can be primary or
secondary.
 Primary ‑ cause of protoporphyrin blocks are unknown
(can't identify blocks) and are not reversible....called
Idiopathic or primary Sideroblastic anemia.
1. Elderly, responds to no treatment. Requires transfusion
support if severe anemia.
2. Characterized by a dimorphic red cell population -
micro/hypo red cells with
3. normocytic and/or macrocytic red cells....MCV is variable
and RDW is high.
4. Primary type of sideroblastic anemia is one of
myelodysplastic syndromes called Refractory Anemia
with Ringed Sideroblasts; may terminate in leukemia
Secondary Types of SA

 cause of blocks in the protoporphyrin pathway can be

identified and are reversible.....removal of the drug/toxin
corrects the anemia.
1. Alcohol inhibits vitamin B6/pyridoxine
2. Anti-tuberculosis drugs inhibit vitamin B6
3. Lead poisoning causes multiple blocks
Stippled RBCs – Lead poisoning

Wright’s stained blood smear

 Secondary Types of SA cont’d
 Lead intoxication/poisoning – inhaled or ingested and
causes multiple blocks:
1. Microcytic/hypochromic RBCs with **coarse basophilic
stippling; low MCV.
2. Lead blocks several enzymes in the protoporphyrin
pathway for blocks.
3. *Abnormal lead level; lead line; abdominal pain;
neurologic problems.
 Children - serum iron and iron stores may not be
increased due to accompanying iron deficiency.
 Lead chelation therapy (EDTA).
 Pyridoxine therapy
Anemia of Chronic Disease (ACD)

Definition
 Associated with systemic diseases, including
 chronicinflammatory conditions such as arthritis
 Chronic infections such as TB

 A long-term chronic illness causes impaired release

of iron from storage and may also impair the
response of the bone marrow to erythropoietin
stimulation.
Anemia of Chronic Disease cont’d
 ACD – is due to inability to use iron and decreased
response of the BM to EPO
 Complex etiology, pts have iron but are unable to use
it, history is important
 Associated conditions
 Persistent infection (e.g. HIV),
 Chronic inflammatory or collagen disorders (e.g. RA,
SLE)
 Malignant disease (e.g. Hodgkin lymphoma, cancer)
 ACD pathogenesis
1. Dysregulation of iron homeostasis
Bind to macrophage and liver cells (because they have receptor
for lactoferrin and Over-expression of hepcidin
Lactoferrin is an iron biding protein in the granules of neutrophils
 Its avidity for iron is greater than transferrin
 During infection or inflammation, neutrophil-lactoferrin
released into plasma. Reduce iron in bone marrow
2. Impaired proliferation of erythroid progenitor cells
Cytokines: Produced by macrophages during inflammation and
contribute to ACD by inhibiting erythropoiesis (Inadequate
erythropoiesis )
3.Blunted erythropoietin response
Increased cytokines interleukin-1 and TNF-a which directly inhibit
erythropoietin
Lab Diagnosis/Blood findings
 Early stage: normocytic normochromic
 Late stage: hypochromic microcytic,
 severity parallels disease
 Very common anemia
 Leukocytosis
 Abundant storage of iron in macrophage (Prussian blue)
 Low serum iron, low TIBC, normal or high serum ferritin
 Decreased synthesis of transferrin occurs due to inflammation.
 Treat underlying disorder if possible
 Alternative is Iron therapy for (harmful), EPO may help in
some patients
Thalassemias
 Inherited hemoglobinopathy due to
 decrease in alpha or beta globin chain synthesis needed
for Hgb A; quantitative defect
 All have microcytic/hypochromic RBCs and target
cells
 Genetic mutations classified by:
 ↓ beta chains = beta thalassemia…Greek/Italian
 ↓ alpha chains = alpha thalassemia…Asian
 Both in African ancestries

Beta

Alpha

Target cells/Codocytes
52
Thalassemias

 A normal adult will synthesize four types of globin chains to

produce hemoglobins
 Normal globin chain production is balanced with alpha and
beta chains produced in about a 1:1 ratio
(high α, high β).
 Normal adult Hgb contains
 HgbA (95-98%
 HgbA2 (2-3%)
 HgbF <1%, Hgb S absent , Hgb C absent
Thalassemias

 α –Thalassemia is more common than β-Thalassemia

 Severity ranges from lethal, to severe transfusion-

dependency, to no clinical abnormalities
 Major types - severe, no alpha or no beta chains
made
 Minor/trait types – mild, slight ↓ in normal hgb types
Thalassemias

 Impaired alpha or beta

globin synthesis results in
an unbalanced number of
chains produced that
leads to:
 RBC destruction in
beta thalassemia
major
 Production of
compensatory hgb
types in beta thals (F
and A2)
 Unstable or non-
functional hgb types in
alpha thals, beta or
gamma chains
Beta Thal Major (Homozygous)
 Both beta genes abnormal
 Marked absence of beta chains leads to alpha chain
excess…no Hgb A is produced
 Excess alpha chains are unstable and preciptate in
the cell
 Rigid RBCs with Heinz bodies destroyed in bone
marrow and blood (ineffective erythropoiesis)

Heinz bodies Excess

alpha chains Supravital
stain
Beta Thal Major (Homozygous)
 Clinical findings
 Lab findings
 Severe anemia with microcytic hypochromic picture
 Hgb as low as 2-3gm/dL in homozygous state, and
 markedly reduced red cell indices (MCV, MCH, MCHC),
anisocytosis, poikilocytosis, many target cells, RBC
inclusions (basophilic stippling), increased RDW,
polychromatophilia, Reticulocytosis, nRBCs

 compensatory Hgb F
 Hgb F high , Hgb A2 low or high , No Hgb A
 Beta Thal Major (Homozygous)
 decreased osmotic fragility,
 moderately increased bilirubin,
 increased serum iron,
 Hgb electrophoresis reveals increase Hgb-F &
decreased Hgb-A2
Target cell

HJB NRBC
 When heterozygous,
Stippled NRBC
mild hypochromic
microcytic anemia
(β-Thalassemia
minor) Wright’s stained blood smear
Beta Thal Major (Homozygous)
Blood smear

Howell-Jolly
body

Target cells
NRBC Pap bodies

Target Transfused
cell RBC Blood smear

Transfused RBC
 Treatment
 Transfusion
dependent
 Splenectomy
Hypercellular Bone Marrow (10x)
 Iron chelation
 Beta Thal Minor (Heterozygous)
 One abnormal beta gene
 Slight decreased rate of
beta chain production
 Blood picture can look
similar to iron deficiency but Stippled RBC
normal Iron test
 Lab findings
 Mild anemia, target cells, no
NRBCs, stippled RBCs Target cell

 No Heinz bodies Ovalocytes

 Normal iron tests Wright’s stained blood smear
 Compensates with
Hgb
A2,
Alpha Thalassemia
 α -Thalassemia: characterized by deletion or
mutation of α -globin chains
 classified into 3 types on the basis of deletion of
one or more of the 4 alpha genes (2 on each
chromosome).
 The severity of disease correlated to the number of
genes deleted.
 The deletion of 4 alpha genes is fatal (frequent
cause of stillbirth in South East Asia)
 Barts Hydrops Fetalis = Alpha thalassemia major
(homozygous)
All four alpha genes are deleted (--/--);
normal (αα/αα).
Alpha Thal Major/Homozygous

 Deletion of all 4 alpha genes results in complete

absence of alpha chain production
 All four alpha genes are deleted (--/--); normal (αα/αα).
 No normal hemoglobin types made
 The fetal Hgb in this situation is composed of 4 gamma
chains and is designated as “Bart’s Hgb”.
 Bart’s Hgb has high affinity for O2 and is unable to
release O2 to the fetal tissues
 Known as Barts Hydrops Fetalis
 Die of hypoxia
 The fetus is usually stillborn b/n 28 and 40 weeks
Alpha Thal Intermedia = Hgb H Disease
 Three alpha genes deleted
 Moderate decrease in alpha chains leads to beta
chain excess
 unstable Hgb H (has high affinity for O2 )
 Moderate anemia
 Lab findings: Hgb, and red cell indices (MCV,
MCH, MCHC) decreased, Retics increased, Hgb
electrophoresis reveals Hgb-H (4-30%)
 Decreased hemoglobin A by ~80%
 Deletion of three alpha genes, (--/-α).
 Rigid red cells with Heinz bodies are destroyed in spleen.
Alpha Thal Intermedia = Hgb H Disease

Heinz bodies Excess

beta chains Supravital
stain

Target cells

Wright’s stain blood smear

 Alpha Thal Minor (Heterozygous)
 One or two alpha genes deleted (group are silent carrier)
 Slight decrease in alpha chain production
 Mild or no anemia, few target cells
 Essentially normal electrophoresis; many
undiagnosed
 Deletion of 1 or 2 alpha genes, 2 or 3 normal genes
Thalassemia cont’d

 Thalassemia minor (silent carrier) -only one

functional alpha gene missing the remaining 3
direct normal synthesis of alpha chains for normal
Hgb synthesis—Normal haematologic finding
 α-thalasemia trait : 2 alpha genes missing;
imbalance between alpha and beta chain syntheis
creats excess beta chains, which joins in tetrads to
form Hgb-H. mild microcytic hypochromic anemia
manifested
The genetics of alpha thal.
Beta Thalassemias (summary)
Alpha Thalassemias (summary)
Differential Diagnosis of Microcytic
Anemia
Macrocytic Normocytic
Anemias
 Characterized by elevated MCV & MCH values; normal
MCHC
 Includes Megaloblastic and non-Megaloblastic anemia

Wright’s stained blood smear

 Lab Investigation of Anemia

This flow chart reviews tests used to differentiate macrocytic anemias based on
larger than normal MCV and shown on the lower right hand side of the chart.
Megaloblastic Anemia

 Macrocytosis due to a deficiency of Vitamin B12 or Folic

Acid (folate )that causes impaired nuclear maturation
 VitaminB12 & folate are DNA coenzymes necessary
for DNA synthesis and normal nuclear maturation
 Results in megaloblastic maturation…nucleus lags
behind the cytoplasm (asynchrony)
 Both deficiencies cause enlarged fragile cells
 Many cells die in the marrow (ineffective)
 Show a similar blood picture and clinical findings
 Only vitamin B12 deficiency causes neurological
symptoms…required for myelin synthesis
Megaloblastic Anemia
Megaloblastic RBC maturation  macrocytic red
cells

Normoblastic RBC maturation  normocytic red

cells

RBC maturation in microcytic anemias…IDA

Abbott Manual
Megaloblastic anemia Lab findings
 Mild to severe anemia; MCV 100-160 fl; increased
MCH, normal MCHC. Low RBC and HGB values
with mildly decreased WBC and PLT counts
(fragile cells) due to ineffective hematopoiesis
 Low reticulocyte - due to high RBC death in bone
marrow
 Macrocytic ovalocytes, teardrops; marked
anisocytosis and poikilocytosis is typical
 Schistocytes/microcytes - due to RBC breakage
upon leaving the bone marrow
Megaloblastic Anemia
Lab findings cont’d
 Advanced anemia: multiple Howell-Jolly bodies,
NRBCs, basophilic stippling, pappenheimer
bodies, Cabot rings
 Megaloblastic anemias are noted for markedly
increased LD levels and high bilirubin & iron
levels due to destruction of fragile red cells in
the bone marrow and blood
 Hypersegmented neutrophils (>5 lobes) - 1st
change to appear and last to disappear.
 May see giant platelets
Megaloblastic Anemia

 Peripheral blood films of patients with megaloblastic

anemia

Howell-Jolly body

Teardrop
Schistocyte

Blood NRBC Blood

Macrocytic Ovalocytes
Megaloblastic Anemia

Stippled RBC &

Cabot Ring

Giant Platelet
Pap bodies Hypersegmented neutrophil >5
lobes

 Left side: Wright’s stained peripheral blood film

containing iron appears as blue granules in the
cytoplasm of RBCs, representative of Pappenheimer
bodies, which need to be confirmed with Prussian Blue
stain.
 Right side: >5-lobed neutrophil
 Megaloblastic Anemia

 Clinical findings:
 Vitamin
B12 and folate deficiency ‑ pale skin,
weakness, smooth sore tongue = glossitis, jaundice.

 Seen in B12 deficiency ONLY ‑ CNS damage with

symptoms of tingling, numbness, and difficulty walking
or personality changes (megaloblastic madness).
Important to correctly identify a B12 deficiency.
 Vitamin B12 (Cobalamin) Deficiency
 1. Dietary deficiency – rare (except when long term
deficiency especially in strict vegetarians)
 Vitamin B12 deficiency develops after 3-6 years; high
stores.
 2. Pernicious anemia most common cause
 caused by lack of intrinsic factor (IF)
 IF is a glycoprotein secreted by the parietal cells, along with
HCL, and is needed to bind B12 for absorption into the
intestine. (B12 is extrinsic factor).
 Acid pH (HCL) is needed for the B12/IF complex to form.
 Total gastrectomy: ‑ removes parietal cells which secrete IF
and HCL.
 May develop B12 and iron deficiency with macro and micro
red cells…a dual (dimorphic) RBC population
Vitamin B12 (Cobalamin) Deficiency
 Concurrent IDA can develop due to the lack of an acid pH
needed to reduce iron to Fe+2 for absorption. May see a
dimorphic RBC population due to the production of both
microcytic and macrocytic red cells.MCV unreliable (falsely
normal) and RDW is high.
 3. Competition for B12
 Diphyllobothrium latum - fish tapeworm competes for B12
 Intestinal blind loops - bacteria use B12.
 4. Malabsorption syndromes
 Regional enteritis - inflammation of small bowel or
gastrointestinal tract is inflamed over a long period of time.
 Non‑tropical sprue with steatorrhea - chronic wasting
disorder.
Vitamin B12 (Cobalamin) Deficiency
 Pernicious anemia
 defined as the absence of IF and/or the presence of
antibodies to IF or parietal cells; autoimmune factors
 Seen in older adults, often with English, Irish, and
Scandanavian ancestries
 Characterized by achlorhydria (40%) and atrophy of
the gastric parietal cells; results in decreased IF
secreted
 Autoimmune factors involved - a high percentage of
patients produce autoantibodies to IF, parietal cells,
anti-B12-IF complex
 Low B12 level is followed by antibody tests to IF or
parietal cells. The clinical history is important
Vitamin B12 (Cobalamin) Deficiency
Folate (Folic acid) Deficiency
 1. Dietary deficiency – leading
cause, low stores, develops quick
Two RBC populations
 Increased need Dimorphism
 Pregnancy; may develop
concurrent iron deficiency and a Macrocytic
dimorphic population of red RBCs
cells with a falsely normal MCV
 Growing Microcytic
infants
RBCs
 Disorders associated with rapid
proliferation – high folate use by
rapidly dividing cells; leukemias
and severe hemolytic anemias
like sickle cell disease.
 Folate (Folic acid) Deficiency
 2. Alcoholic
cirrhosis - due to poor diet and alcohol is a
folate antagonist; a frequent problem in alcoholics.
 3. Malabsorption syndromes
 Non‑tropical sprue - wasting disorder
 Celiac disease of children - atrophy of intestine.
 Dilantin - anti-convulant drug which competes for folate
absorption.
 Regional enteritis - bowel inflammation
 Drug induced - impaired use of folic acid is often seen in
cancer/leukemia patients receiving chemotherapeutic anti-
folate drugs, e.g. Methotrexate.

Non-Megaloblastic Anemia

 Non-megaloblastic anemia is a macrocytic anemia that is

NOT due to Vitamin B12 or folate deficiency
 Cause: example accelerated erythropoiesis
1. Regenerating marrow or marked retic response
following recent blood loss

NRBC

Polychromatophilic RBCs
Wright’s stain
 Non-Megaloblastic Anemia
2. Liver disease (including alcoholics)
 Complex & multiple problems
 Degree of anemia varies, round macrocytes
 Target cells/acanthocytes - due to abnormal lipid metabolism. Echinocytes are also commonly found
on the smear in liver disease

Target cells

Echinocytes
Acanthocytes

Stomatocytes, Alcoholic
 Differential Diagnosis of Macrocytic
Anemia

 Megaloblastic and
non-Megaloblastic
 Perform B12 and
folate levels
 Specific
morphology

Blood smear
 Differential diagnosis of macrocytic anemia
Peripheral smear Macrocytic anemia

Bone marrow exam Megaloblastic Non-megaloblastic

Reticulocyte count Low High Low

Vit B12 Folic Acid Probable Probable

deficiency deficiency Hemolytic Liver
anemia disease
Lab Investigation of Anemia
Normocytic/Normochromic Anemias
 Due to increased RBC loss or decreased RBC
production
 Majority of hemolytic anemias are caused by
increased destruction
 The common type are: Hemolytic anemia and Aplastic
anemia
 Classification of hemolytic anemias
1. Mode of transmission
 Hereditary versus acquired

2. Type of defect
 Intrinsic, the red cell is abnormal

 Extrinsic, an external agent or trauma destroys red

cell
3. Site of destruction

Primary Cause and Type of Hemolysis
Normocytic/Normochromic Anemias

 Compensated hemolytic disease

 RBC replacement = RBC destruction
 Anemia does not develop; marrow

production keeps up with loss

 Uncompensated hemolytic disease
 RBC destruction > RBC replacement by
marrow
 anemia with high retic count but too low to

keep up with rate of RBC loss

Normocytic/Normochromic Hemolytic
Anemias due to Intrinsic Defects

• Hereditary hemolytic anemias

– Intrinsic defects of the RBC membrane, hemoglobin
molecule or enzymes decrease RBC lifespan
• Severity depends on rate of hemolysis and the
degree of bone marrow compensatory response
– Increased retic count but loss > production
• Characterized by abnormal RBC destruction
tests and damaged/rigid red cells
Hemolytic Anemia
Normocytic/Normochromic Hemolytic
Anemias due to Extrinsic Defects

 Acquired hemolytic anemias

 Extrinsicdefects due to antibodies, trauma, infectious
agents, heat, drugs/chemicals decrease lifespan
 Severity depends on rate of hemolysis and the degree of
bone marrow compensatory response
 Increased retic count but loss > production
 Characterized by abnormal RBC destruction tests and
damaged/rigid red cells
Definitions for Immune Anemias
 Antigens and antibodies
 Antigen (Ag) on RBC membrane
 Antibody (Ab) in serum/plasma; 5 immunoglobulin
types
 IgM – cold, room temp; large, can visually see
 IgG – warm, body temp; small, can’t see; need to
do Direct Antiglobulin Test (DAT)
 DAT detects IgG antibody and/or complement that
has coated the red cell membrane in vivo
 Normally, antibodies are not formed against antigens
you possess
 Iso/alloantibody is formed against a foreign (non-self)
antigen after exposure
 Autoantibody is produced against host ‘self’ antigens
Antigen/Antibody Reactions

 Most Ag/Ab reactions

require complement
 End result of C3
activation is lysis
 If RBC = hemolysis
 Macrophages have IgG &
C3 receptors
Warm and Cold Autoantibodies

Spherocytes

Agglutination
Warm Autoimmune HA (WAIHA)
 Altered immune response causes production of an IgG
autoantibody against ‘self’ RBC antigens
 Antibody attaches to RBC antigen  spherocytes
 Primary (idiopathic);antibody production is unknown.
 secondary to disease which alter immune e.g CML
Spherocytes & polychromasia

Blood
Warm Autoimmune HA (WAIHA)
 Lab findings
 Moderate to severe anemia, few to many spherocytes,
high MCHC
 Increased retics/polychromasia, NRBCs, few
schistocytes
 Erythrophagocytosis: ingestion of Ab/C’ coated red
cells by monocytes or neutrophils.
 Looks similar to Hgb H spherocytosis but positive DAT
 Increased OFT result due to the spherocytes.
 Increased bilirubin; increased plasma Hgb and
decreased haptoglobin if severe.
 Bone marrow (if done) - erythroid hyperplasia.
Warm Autoimmune HA (WAIHA) cont’d
 Treatment:
 Treat underlying disease if possible.
 Give steroids to suppress immune response.
 Difficult to transfuse! No compatible blood.

Ingestion of coated RBC

Blood Electron
Microscopy
RBC

RBC
Monocyte with ingested RBC
Cold Autoimmune HA (CAIHA)

 Altered immune response causes production of an IgM

autoantibody against ‘self’ RBC antigens
 Antibody/C3 attaches to RBC antigen  agglutination
 Primary (idiopathic) or
 secondary to disease e.g mycoplasma pneumonia
50x 100x

RBC Agglutination
Cold Autoimmune HA (CAIHA)
 Few clinical problems unless IgM antibody titers are
high (>1:1000)
 Symptoms of acrocyanosis/Raynaud’s phenomenon
 the agglutination of red cells in
extremities....ears, toes, fingers, nose  tissue
damage  gangrene.
 Lab findings
 Anemia severity varies with seasons….avoid the
cold
 IgM antibodies cause RBC agglutination
 e.g. RBC clumping, both macroscopically and
microscopically.
Cold Autoimmune HA (CAIHA) cont’d
 Reticulocytosis

 Positive DAT(specific to detect complement-coated red

cells)

 Hemolysis is intravasular during attack.

 RBC agglutination causes problems obtaining valid RBC

count and MCV measurements on automated instruments.
 Blood sample must be warmed prior to analysis
Hemolytic Transfusion Reaction
 Incompatible blood transfusion
 Recipient has antibodies to antigens on the donor red cells received
 Donor cells are destroyed
 ABO is worst
 Intravascular hemolysis that is complement-induced lysis…immediate
 increased plasma hgb, hemoglobinuria.

 Can be life-threatening....renal failure, respiratory failure, and DIC may

develop.
 Cells are immediately lysed; none on blood smear.
 Normal Newborn Blood Picture
 High RBC count, Hgb (~20 g/dL) and HCT (~60%)
 Macrocytic RBCs (MCV ~110 fL) b/c of high #retics
(2.0‑6.0%.); MCV value decreases with age.
 Up to 10 NRBCs/100 WBC

NRBC
Blood
Normal Newborn Blood Picture cont’d
 RBC production decreases within days; Hgb level
drops.
 HGB value <14 g/dl is considered anemic for
newborn.
 Occasional to few spherocytes is a normal finding.
 WBC count increased (9.0‑30.0/109/L) 1st day with a
few immature cells and decreases to normal levels
within a week.
 Granulocytes predominate at birth but by 4‑10 days,
lymphocytes predominate.
 Lymphocytes remain elevated for 5 to 10 years;
larger immature lymphocytes.
 Children have different differential ranges as
compared to adults.
 Platelets are low adequate (100.0‑250.0/109/L).
Hemolytic Disease of the Newborn
 Caused by maternal IgG antibodies directed against baby
RBC antigens
 IgG Abs cross placenta and destroy fetal red cells
 HDN due to Rh incompatibility (Erythroblastosis fetalis)
 Rh negative mother forms Rh antibody after exposure;
next pregnancy with Rh+ baby  destruction of Baby’s
RBC
 Lab findings:
 Severe - anemia with low hemoglobin <8.0 g/dl.
 High number of NRBC's (>10) - baby tries to
compensate for RBC destruction.
 Positive DAT
 Kernicterus – extremely high bilirubin levels can cause
brain damage.
 Treatment - exchange transfusion in utero or at birth
 HDN due to Rh is no longer a common problem with the
use of Rh immune globulin (RhoGam)
Hemolytic Disease of the Newborn (HDN)

 HDN due to ABO incompatibility

 Mother is type O with anti-A and anti-B in her serum.
 Baby is type A or B, has A or B antigens on red cells.
 Mother’s IgG Antibody (usually very little) crosses
placenta and coats the baby’s red cells.
 Lab findings:
 Mild/Asymptomatic - anemia is uncommon, with a HGB
(>14 g/dl).
 Spherocytes present - a few coated RBCs are
phagocytized.
 May have slight to moderately elevated bilirubin level.
 Treatment – phototherapy
Hemolytic Anemias due to Trauma
 Fragmentation syndromes…most common finding on
smear are schistocytes; anemia varies
 Severe trauma causes intravascular hemolysis
 Types of trauma
 Mechanical (e.g. Prosthetic heart valves or cardiac
abnormalities)
 Moderate to severe anemia with schistocytes and
polychromasia.
 Microangiopathic (MAHA) trauma occurs in small
vessels (e.g.DIC, HUS)
 March hemoglobinuria
 Hemolytic Anemias due to Trauma
 In DIC, clotting factors and platelets form fibrin  fibrin
deposited in the microvessels and fragmented red cells.
 Anemia with schistocytes on smear, decreased platelets
and depletion of coagulation factors  leads to severe
bleeding; can be fatal.
 Hemolytic uremic syndrome (HUS) - most often occurs in
children following GI infection (E. coli); noted for renal failure
 fibrin damages kidney; hemolytic anemia with echinocytes
and schistocytes, decreased platelets; often requires
dialysis; can be fatal.
 March Hemoglobinuria
 Transient, occurs after forceful contact of body with hard
surfaces....joggers, soldiers after long march, bongo drum
players.
 Hemoglobinuria; schistocytes may be present on smear
Hemolytic Anemias due to Trauma

Schistocytes

Fibrin Strands

RBC

RBC fragmentation on fibrin strands

Hemolytic Anemias due to Infectious
Agents, Thermal Burns
 Hemolytic anemias vary, with severe hemolysis common
 Schistocytes and spherocytes on blood smear
 Parasitize
RBC, elaborate lytic toxins or cause direct
damage to red cell membrane

Schistocytes & Spherocytes

Hemolytic Anemias due to Infectious
Agents, Thermal Burns

Clostridia (autopsy
specimen)

P. vivax gamete

Malarial ring forms, P.

falciparum

P. falciparum ‘bananas’
Flow Chart of Anemia
Flow Chart of Hemolytic Anemia

The chart introduces hereditary hemolytic anemias due to intrinsic survival

defects versus acquired hemolytic anemias due to extrinsic defects, including
tests.
Hemolytic Anemias due to Membrane
Defects
 Hereditary Spherocytosis
(HS)

Spherocytes
Hereditary Spherocytosis

 Problems with membrane loss/↓ flexibility/abnormal

permeability
Hereditary Spherocytosis ‑ inherited autosomal
dominant; most common membrane defect.
 Characterized by variable degree of anemia,
splenomegaly, and spherocytes on the blood smear,
a hallmark finding
 Defect – decreased spectrin and increased
permeability of RBC membrane to sodium ions, results
in increased glycolysis to pump sodium out of the RBC
and loss of membrane fragments → rigid
spherocytes are trapped/removed in the spleen.
H Spherocytosis cont’d
Lab findings:
 Hgb varies; 9‑12 to 3‑4 g/dl in a crisis
 Fewto many spherocytes; MCV normal or slightly
reduced; MCHC may be >36%. HS is still classified as a
normocytic/normochromic anemia
 Increased retics/polychromasia
 Increased Osmotic Fragility test
 Increased bilirubin leads to jaundice
 Negative direct antiglobulin test (DAT) - no antibody is
involved
 Bone
marrow shows erythroid hyperplasia (increased
RBC precursors)
H Spherocytosis cont’d
 Treatment for Hereditary Spherocytosis is splenectomy
 Any post-splenectomy picture
 Increased poiklocytosis
 Increased inclusions
 Increased platelets

H Spherocytosis Post-splenectomy

HJBs
Polychromasia

Spherocyte
Hereditary Ovalocytosis/Elliptocytosis

 Membrane defect is
polarization of cholesterol
or hemoglobin at ends
H Ovalocytosis
and increased sodium
permeability
 Over 25% ovalocytes
 Most asymptomatic
 Mild anemia in 10-15%
Normocytic ovalocytes
Hereditary Elliptocytosis/Ovalocytosis

 autosomal dominant.
 Most persons are asymptomatic with no anemia due to
normal RBC lifespan. Normal Osmotic Fragility test.
 10‑15% develop a mild hemolytic anemia due to
decreased RBC lifespan. Increased Osmotic Fragility
test, increased Retics. May treat with splenectomy if
severe. [May be related to Hereditary
pyropoikilocytosis.]
Hereditary Stomatocytosis
 Membrane defect is abnormal
permeability to sodium and
potassium causing swelling.
 20-30% stomatocytes on
blood smear
 Group of inherited disorders
 Mild to severe
hemolytic
anemia
 Increased osmotic fragility H Stomatocytosis
test, increased Reticulocytes
 May remove spleen.
Hereditary Acanthocytosis

 Increased membrane cholesterol due to abnormal

plasma lipids
 Numerous acanthocytes on smear
 Mild anemia
 Also known as abetalipoproteinemia

H Acanthocytosis =
Abetalipoproteinemia
Hereditary Acanthocytosis cont’d
 Also known as Abetalipoproteinemia – autosomal
recessive inheritance. (abeta = no beta lipid transport
proteins]
 Characterized by numerous acanthocytes on smear.
 Defect – often increased cholesterol in membrane due to
abnormal plasma lipids.
 Mild anemia, normal Osmotic Fragility test.
 Serum contains no Beta lipoprotein to transport lipids.
 Neurological and retinal abnormalities; impaired fat
absorption.
 Defect is increased membrane cholesterol due to
abnormal plasma lipids
 Numerous acanthocytes on smear
 Mild anemia
 Also known as abetalipoproteinemia
Hemolytic Anemias due to
Enzyme Defects
 Inherited enzyme deficiencies that lead to premature
RBC death
Hemolytic Anemias due to Enzyme
Defects

 Pyruvate kinase deficiency

 Most common enzyme
deficiency in EMB pathway PK Deficiency
 G-6-PD deficiency
 Most common enzyme
deficiency in HMP pathway
 PK deficiency Echinocytes
 ↓ATP impairs cation pump
 Severe hemolytic anemia
 Echinocytes
G-6-PD Deficiency
 X-linked inheritance pattern;
malarial belt
 Exposure to oxidants induce
Heinz body formation and RBC
destruction G-6-PD Deficiency
 Primaquine, sulfa drugs, fava
beans, infection
 Unable to protect hemoglobin
due to decreased NADPH
 No clinical problems unless
Normal RBCs if no
exposed to oxidants exposure to oxidant
 Normal G-6-PD variant = 100%
enzyme activity
 African variant
 Mediterranean variant
G-6-PD Deficiency
 Blood findings after oxidant exposure:
 Moderate to severe anemia
 Schistocytes, spherocytes due to pitting out of Heinz
bodies by spleen
 Enzyme assay

G-6-PD deficiency after G-6-PD deficiency

exposure to oxidant Hemolytic episode

Heinz bodies - denatured hgb Damaged RBCs

Supravital stain Wright’s stain
6.3.4. Normocytic anemias due to
hemoglobinopathies
 Inherited hemoglobin defect with production of
structurally abnormal globin chains; qualititative
 All have target cells
 Beta chain amino acid substitution = variant hgb
 Hgb S = valine substituted for glutamic acid at 6th
position of ß chain
 Hgb C = lysine substituted for glutamic acid at 6th
position of ß chain

Target cells/Codocytes
Hemoglobinopathies
 Severity depends on inheritance
of homozygous or heterozygous
state
 Homozygous = disease; both
beta chains abnormal
 Heterozygous = trait; one
beta chain is abnormal Sickle cells
 Hemoglobin S disorders are
most common
 RBCs contain Hgb S 
sickle when oxygen is
removed or low pH Target cell

 Rigid sickle cells block Sickle Cell Disease

vessels leading to organs,
increases tissue hypoxia
 Irreversibly sickled forms on
blood smear
 Hemoglobin S Disorders
 Hemoglobin S disease/Sickle
cell anemia/Hgb SS
 Two sickle cell genes
inherited
 Symptomatic by 6 months of
age
Target cell
 Clinical findings
 Vascular occlusive disease;
organ damage & pain
Sickle cell
 Laboratory findings
 Severe anemia
 Targets, sickle cells
HGB S Disease (Hgb SS)
 NRBCs, inclusions
 No Hgb A, >80% Hgb S, ↑ F
Sickle Cell Anemia

Native sickle cells (1) are found only in homozygous

sickle cell anemia, otherwise only target cells (2) are present.
Sickle cell test (d) under reduced oxygen tension: almost all
erythrocytes appear as sickle cells in the homozygous case
presented here.
Hemoglobin S Disorders

 Hemoglobin S trait/Sickle cell

trait/Hgb SA
 One sickle cell gene
inherited
Target cells only NO
 Lab findings Sickle cells
 Asymptomatic, targets only
 No anemia or sickle cells
 ~60% Hgb A, ~40% Hgb S
HGB S Trait (Hgb SA)
 Potential problems if hypoxic
 Surgery, pregnancy…screen
for Hgb S
 Methods for inducing sickling
Sickle cells versus Ovalocytes
and Pencil forms
Sickle cells

Ovalocytes

Sickle Cells

Sickle cells

Pencil forms

Target cell
 Hemoglobin C Disorders

 Hemoglobin C disease/Hgb CC
 Two C genes inherited C crystals

 Lab findings
 Mild anemia
Target cell
 Many target cells
 Intracellular C crystals
HGB C Disease (Hgb CC)
 No Hgb A, >90% Hgb C
Hemoglobin C Disorders

 Hemoglobin C trait/Hgb CA HGB C Trait (Hgb CA)

 One C gene inherited
 Lab findings
 Asymptomatic, no anemia
 Targets, no C crystals
Target cells only NO
 ~60% Hgb A, ~40% Hgb C C crystals
Hemoglobin SC Disease

 Hemoglobin SC
disease/Hgb SC HGB SC Disease (Hgb S & Hgb C)
 One sickle gene and one
C gene inherited
 Laboratory findings
 Intermediate in severity
SC Crystals
between Hgb SS & SA
 Several target cells
Target cells
 Many bizarre SC crystals
 No Hgb A, ~50% Hgb S,
~50% Hgb C, ↑ F
SC Crystals versus Schistocytes

Schistocytes

SC Crystals
Hemoglobinopathies Summary

Target cells
Normocytic Anemias due to Marrow
Failure
 Impaired cell production and/or pancytopenia
 Normal or decreased Retic count
 Nothemolytic, normal RBC destruction tests and
damaged red cells are not evident on blood smear
 Marrow replacement anemia
 Infiltration or replacement of normal marrow cells
 Immature WBCs (neutrophils) & immature RBCs
(nucleated RBCs) escape from bone marrow
 Leukoerythroblastic blood picture
 May result in extramedullary production
Aplastic Anemia
 Conditionof blood pancytopenia caused by bone
marrow failure,decreased production of all cell lines
 Due to damaged stem cells, damaged bone marrow
environment or suppression by immune mechanisms
 No extramedullary hematopoiesis to compensate for
bone marrow failure
 because the injury also affects hematopoietic cells
in the liver and spleen
Aplastic Anemia
 Types of aplastic anemia
 Primary/idiopathic: about 50%, no cause of injury
identified
 Secondary/acquired….

 Chemicals (benzene, insecticides), radiation,

drugs, (chloramphenicol, sulfonamides), infections
(viral)
 Congenital/hereditary.Fanconi’s Anemia

 Aplasia plus dwarfism, skeletal abnormalities,

mental retardation, abnormal skin pigmentation.
High association with leukemia development
 Aplastic Anemia
 Blood findings
 Pancytopenia Normal RBCs
No Platelets
 Moderate to severe anemia with
normocytic or slight macro RBCs
 Hypocellular marrow < 30%
cellularity
Blood
 M:E ratio ~3:1 - no change since
all cell precursors are decreased 10X
in number.
 Complications
 Bleeding & infection

Bone marrow, decreased #

precursor cells
Normocytic/Normochromic Anemias
 Acute post‑hemorrhagic anemia - Normocytic anemia
with high retic
 Lab findings:
 Plasma and red cells are lost (surgery/accident) so
initially no change in Hgb/Hct values. In a few hours,
PLTs and WBCs increase
 In 12-24 hrs, fluid replacement occurs....normocytic
anemia with low Hgb/Hct/RBC & relatively normal red
cell findings on the smear.
 In 3-5 days following hemorrhage, a reticulocyte
response is observed....increased polychromasia and
possibly nucRBC's; a very high # of circulating retics
may increase the MCV
Normocytic/Normochromic Anemias
cont’d
 increased WBCs (neutrophilia) and increased PLTs
due to bone marrow outpouring of WBCs and PLTs
along with RBCs
 The findings in acute blood loss are different than those
of chronic blood loss.
 The loss of blood over a long period (months) causes iron
deficiency to develop (due to iron loss) – most often caused by
GI bleeding.
 See anemia with microcytic/hypochromic red cells
Summary

 This chapter discussed:

 the clinical signs and symptoms of anemias,
 the classification of anemias by cause and red blood
cell morphologies
 typical laboratory indications of microcytic
hypochromic, macrocytic normochromic and
normocytic normochromic anemias
Case Study
 Begins with CBC/FBC
parameters and blood
smear evaluation
 Detects mild (~10 g/dl
Hgb) to
 Severe anemia (<8
g/dl Hgb)
 RBC indices (MCV)
are used to classify
anemia
 RBC morphology
abnormalities can
be diagnostic or
suggest a cause that
guides further testing
 WBC & PLT counts
are normal or
increased in most
anemias but low in Damaged RBCs
aplastic anemia
Review

 Hgb electrophoresis
 Detects and quantitates both normal and abnormal Hgb types
 Useful for thalassemias and haemoglobinopathies
 Electrophoresis may be preceded by a screen for the presence
of haemoglobin S
Case Study

Recurrent dizziness

 Her anemia is best classified as:

 Microcytic
 Macrocytic
 Normocytic
Review Question

Is the patient’s
increased rate
of RBC
production
keeping up
with RBC
loss?

No, high retic

count but
destruction >
production
Review Question

1 2

Normocytic RBCs & polychromasia Microcytic & hypochromic RBCs

Which blood picture is most consistent with a recent

acute hemorrhage?
1 – Normocytic red cells with a retic response, acute
blood loss
2 – Microcytic red cells, chronic blood loss; iron deficiency
develops
Bibliography
 MA Lichtman, E Beutler, U Seligsohn, K Kaushansky, TO
Kipps (Editors). William’s Hematology. 7th Ed. McGraw-
Hill Co. Inc. 2008
 Dacie, John V and Lewis, S.M. Practical Hematology 10th
Edition Churchill-Livingstone 2006
 Wintrobe, Maxwell M. Clinical Hematology 11th Edition
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