Heme #2: Approach To Anemia

Front 1

What is the earliest recognizable erythroid precursor called?

How does it differ from a mature erythrocyte?

Back 1

Pronormoblast (proerythroblast)

It has a large nucleus and blue cytoplasm. As cell matures, nucleus shrinks and is extruded and cytoplasm becomes hemoglobinized (more pink).

Front 2

What cells are polychromatic and why? What other feature distinguishes them from mature RBCs?

Back 2

Reticulocytes --> both pink and blue mixed. They are enucleated but retain some cytoplasmic ribosomes which give bluish color

Retics are also slightly larger than RBCs. *use Supravital Stain to identify

Front 3

What does the presence of these cells in the circulation indicate?

Back 3

(nucleated RBCs in peripheral blood) = Abnormal state

Breakin bone-marrow and blood barrier or extramedullary hematopoiesis

Front 4

Where in the body is EPO produced. How does anemia lead to increased EPO production?

Back 4

EPO made in the kidney (mostly) and liver.

"Feedback loop" Anemia --> ↓ O2 production --> O2 sensor in renal tubule detects --> kidney produces EPO to ↑ RBC production

Front 5

What cytokines/growth factors other than EPO contribute to erythropoiesis (RBC production). Hint: there are three.

What happens to EPO levels in anemia?

Back 5

SCF (stem cell factor), IL-3, and GM-CSF

In anemia, EPO levels increase (to make more RBCs)

Front 6

What is meant by "Hemoglobin" when it is measured in the lab?

Why are the normal values different in men vs. women?

Back 6

Hb: gm of Hb / dL of whole blood

Men 15 ± 1.7, RBC count million/ul
Women 13 ± 1.5

Front 7

What is the definition of "Anemia"?

Back 7

Low circulating RBC mass

Either due to decreased number of RBCs, or decreased Hb content.

Front 8

What is a normal HCT? How is it measured?

Clinical pearl: If a person's measured Hb is 13, how do you approximate HCT?

Back 8

HCT= VOLUME of RBCs (when blood is centrifuged, divide packed RBC by total volume of blood including plasma and buffy coat)

HCT is roughly 3 x Hb. So 39 %.

Front 9

What is the effect of the following on Hb:

1. Dehydration
2. Pregnancy
3. High altitude
4. Gender (male)
5. Increased age

Back 9

1. Dehydration- ↑ Hb ( plasma vol is low)
2. Pregnancy- ↓ Hb (plasma vol high)
3. High altitude- ↑ Hb (because EPO levels ↑)
4. Male- ↑ Hb (androgens stimulate BM to make RBC)
5. Age- slight decrease in RBC production

Front 10

Symptoms of anemia?

What specific history do you want to get that would clues to underlying diagnosis?

Back 10

SOB, Fatigue, Angina, Palpitations, headache

Blood loss (menstruation, surgery)
Diet (Alcohol intake- EtOH suppress BM, cirrhosis causes splenomegaly, Vegan)
Family hx (thalassemia, sickle cell, etc.)
Medications
ROS: pica (eating clay, chalk, dirt), neuropsych hx.

Front 11

What physical exam findings are consistent with anemia?

Back 11

Orthostatic hypotension, Conjunctival pallor, Reflex tachy

Jaundice (suggests hemolysis), heart mumur (damaged valve), blood in stool, splenomegaly, Parasthesia/spasticity (B12 deficiency), koilonychia

Front 12

Anemia, neutropenia, and thrombocytopenia suggest what condition?

Elevated WBCs with blasts plus anemia and thrombocytopenia suggest what condition?

Back 12

Pancytopenia--> aplastic anemia or malignancy in bone marrow

Acute leukemia (failure of maturation of WBCs)

Front 13

What is a normal MCV? How is it calculated?

What are 3 causes of microcytic anemia?

Back 13

Normal mean corpuscular volume or size of RBC = 80-100. (10 x Hct)/ RBC count.

Microcytic <80
1. Fe deficiency
2. ↓ Heme synthesis (lead poisoning)
3. ↓ Globin synthesis (Thalassemia)

Front 14

What are 4 causes of macrocytic anemia?

Back 14

Macrocytic= MCV >100

1. Megaloblastic anemia (B12 deficiency, folate deficiency)
2. Increased Retics
3. Increased Target cells (liver disease)
4. Myelodysplasia

Front 15

What is the MCV in anemia from acute blod loss pre compensation? what about after compensation?

Back 15

Normocytic initially.
After compensation- macrocytic (because of ↑ retics)

Front 16

What does the RDW measure?

Back 16

RBC distribution width = measures variability in size of RBC aka. anisocytosis

*can help distinguish Thalassemia from Fe-deficiency anemia

Front 17

Formula for reitculocyte count? What is a normal Retic count?

What is a more accurate expression of reticulocyte count and how do you calculate it?

Back 17

# Reticulocyte/ Total RBCs
Normal = 1%

Reticulocyte index= retic count x (pt Hb/ nl Hb)
*this adjusts for the degree of anemia

Front 18

Elevated reticulocyte indexes suggest what type of anemias?

What about normal or low retic indexes?

Back 18

Elevated= BM appropriately responding (ex: acute bleed or hemolytic anemia)

Normal/Low= impaired BM rbc production (ex: Fe, B12, folate deficiency, tumors or lymphoma replacing marrow, or aplastic anemia)

Front 19

What type of anemia is shown here? How can you tell? What does the arrow point to? What is the MCV?

Back 19

Fe deficiency Anemia-
1) Microcytic, 2) central pallor >1/3rd of cell, 3) pencil cells (elongated RBCs)

Arrow= lymphocyte. MCV = microcytic

Front 20

What type of anemia is shown here? What is the MCV?

Back 20

Thalassemia (problem in globin production). Target cells = large. Macrocytic.

Front 21

What type of anemia is shown here? What would the MCV be? What about the retic index?

Back 21

B12 deficiency (megaloblastic anemia). Macrocytic. Note the hypersegmented polys.

Retic index is normal to low (inappropriate compensation).

Front 22

What are these cells called? What two conditions are characterized by these cells?

What RBC index would you expect to be elevated?

Back 22

Spherocytes (no central pallor, tiny RBC packed with Hb).

1. Hereditary Spherocytosis, 2. Warm autoimmune hemolytic anemia


MCHC = Mean corpuscular Hb conc. is essentially Hb/HCT.Elevated in diseases that cause spherocytes

Front 23

This type of cell is seen in what two conditions?

Back 23

Teardrop cells-
1. Myelofibrosis, 2. metastatic cancer of BM

Front 24

What are these cells called? What conditions might they be seen in?

Back 24

Schistocytes (helmet cells), seen in some hemolytic conditions (ex: chewed up RBC or going past poorly fitted aortic valve).

Front 25

This particular pattern of RBCs is seen in what condition?

Back 25

Rouleaux cells- Multiple Myeloma (RBCs lose normal charge that repels cells and they stack on each other)

Front 26

What is seen here? What is it associated with?

Back 26

Non-specific RBC clumping

Cold Autoantibodies --> Cold agglutinin disease

Front 27

This finding indicated what about the patient?

Back 27

Howell-Jolly bodies

That they are asplenic (usually spleen removes the tiny nuclear remnant that stays behind when nucleus is extruded from RBC).

Front 28

What is seen in the cell that the arrow is pointing to?

Back 28

Sporozoites

*seen in Malaria (always consider when pt has travel history + cyclic/chronic fever and fatigue)

Front 29

What is the most common cause of anemia worldwide? If you see it, what should you immediately evaluate for?

Back 29

Fe-deficiency anemia. Evaluate for blood loss, especially occult GI bleed.

Front 30

When do you examine Bone Marrow in a patient with anemia?

What is beneficial about doing an aspirate? a biopsy?

Back 30

Examine BM when there is low retic count and cause of anemia is not clear from preliminary testing.

BM aspirate- gives cellular detail, BM biopsy- appreciate marrow architecture