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Anaemia A comprehensive review Definition • Blood haemoglobin concentration below the normal range for sex and age. • Adult male <13.5 g/dl • Adult female <11.5 g/dl Symptoms • • • • • • • • • Fatigue Headaches Faintness SOB Palpitations Angina Intermittent Claudication Pica Recurrent minor infections……. Signs • Pallor – face, lips, tongue, conjunctivae etc. • Glossitis, Angular stomatitis, Oesophageal webs • Koilonychia • Hypersplenism • Bleeding……… Primary Investigations • FBC • • • • • • • • Hb RBCs HTC/PCV MCV (79-96fl) MCHb MCHbC (27-32pg) Reticulocyte count White cells + plts Classification Microcytic Normocytic Macrocytic Fe deficiency Acute Blood B12 deficiency Thalassaemias Haemolysis Folate deficiency Chronic disease Pregnancy Liver Disease Renal failure Alcohol Chronic disease Myelodysplasia Bone marrow failure Hypothyroidism Causes of Anaemia Blood Loss • Acute • Following initial hypovolaemia, fluid shift produces a normochromic normocytic anaemia • Full rbc restoration may take up to 6 weeks • Chronic • Commonest cause of Fe deficiency anaemia • Common Sites – GI&GU tracts • Menorrhagia Haemolysis • Reduced rbc lifespan and increased rbc destruction • Assoc. w/ Reticulocytosis, Splenomegaly, Jaundice, Haemoglobinuria Haemolysis • Hereditary – Haemoglobinopathies eg. Sickle cell, Thalassaemia – Cell membrane defects eg. Spherocytosis – Enzyme deficiencies eg. G6PD & PK deficiency • Acquired – Incompatible Blood product transfusion/Haemorrhagic disease of the newborn – Auto Immune (Cold IgM & Warm IgG) – Mechanical (Heart valves, DIC, HUS) – Infectious eg. Malaria Micronutrient deficiencies: Macrocytic anaemias 1. Vit B12: serum level < 100pg/ml – Dietary deficiency (rare) – ↓production of IF: pernicious anaemia, gastrectomy, HP infection, congenital – Competition for vit B12 binding sites in gut: blind loop syndrome, fish tapeworm, – Pancreatic insufficiency – Decreased absorption: ileal resection, Crohn’s – Transcobalamin def (rare) Treatment B12 def: • IM B12 100ug • Daily for 1 week, Weekly for 1st month OR Alt days for 2 weeks • Monthly for life • Respond immediate sense of well being • CNS signs reversible if short duration • cont 2. Folic acid: normal serum B12 levels – Dietary def: fruit and veg – Decreased absorption: Tropical sprue, Drugs: phenytoin, sulfasalazine, trimethoprim- sulfa methoxazole – Increased requirements: Chronic haemolytic anaemia, preg, exfoliative skin disease – Loss: dialysis Folic acid def. Rx: • 1mg/d orally • Rapid improvement Fe def anaemia: < 12micrograms or absent bone marrow stores • microcytic • Deficiency in diet: sources • Decreased absorption: tannins, phosphates • Increased requirements: preg, lactation • Blood loss: GI, menstrual, blood donation • Haemoglobinuria Rx Fe deficiency: • • • • Oral: FeSO4 200mg 12-8hrly Continue until Hb is normal 3 months to replenish stores Dietary advice Dyserythropoiesis • Defective RBC formation • Anaemia of chronic disorders: – TB, RA, Cancer, renal/liver failure – Normocytic + normochromic – Failure of macrophages to transfer iron to bone marrow – ↓marrow response to epo Dyserythropoiesis • Myelodysplastic/Refractory – Increasing marrow failure – Similar etiology to leukaemias (can be 2° to chemo) • Sideroblastic – Defective haem synth → accumulation of iron in reticulocyte cytoplasm transforming to – ring sideroblasts + hypochromic Aplastic anaemia • Severe life threatening, bone marrow failure • Etiology idiopathic or autoimmunity, radiation, drugs, toxins, viruses. • Peripheral blood smear pancytopenia Marrow infiltration • • • • Leukaemias Myelofibrosis Disseminated carcinoma Disseminated lymphomas Summary
