A practical approach to a common problem

1. Anemia
Low hemoglobin
Women<12 gm/dl; Men<13 gm/dl

2. Clinical presentation
 Asymptomatic in majority
 Malaise, fatigue, DOE, pica
 Palpitation, angina, CHF when severe
 Amenorrhea/menorrhagia
 Pallor, jaundice, koilonychia
 Tachycardia, wide pulse pressure, flow
murmurs, cardiomegaly
 Splenomegaly

3. Evaluation
 CBC- Hb, TLC/DLC, platelets, MCV
 PBS examination
 Reticulocyte count
 Ferritin
 RFT- creatinine, LFT, TFT
 Stool- occult blood
 Bone marrow examination
 Other- Coomb’s test, Hb electrophoresis,
vitamin B12/RBC folate levels

4. Poikilocytes
 Abnormally shaped RBC
 Types-
 Acanthocyte- spur cell- abetalipoproteinemia, liver disease
 Codocyte- target cell- thalassemia, HbC disease,
post-splenectomy
 Echinocyte- burr cell- uremia
 Ovalo/elliptocyte- hereditary ovalo/elliptocytosis
 Spherocyte- hereditary spherocytosis, AIHA
 Drepanocyte- sickle cell- sickle cell anemia
 Dacrocyte- tear-drop cell- myelofibrosis
 Schistocyte- fragmented, irregular RBC- MAHA

5. Causes
 Blood loss
 Acute- trauma, GI bleed
 Chronic- GIT, menstrual, urinary
 Decreased production
 Iron deficiency
 Vitamin B12/FA deficiency
 BM defect- aplastic, myelophthisic
 Increased destruction
 Hemolytic anemia- AIHA, SCD, thalassemia

6. Morphologic classification
 Microcytic- MCV<80
 Iron deficiency
 Thalassemia
 Sideroblastic
 Macrocytic- MCV>100
 Vitamin B12/FA deficiency
 Drugs- methotrexate, zidovudine
 CLD, alcoholism, hypothyroidism
 Normocytic- MCV 80-100
 Hemolytic
 Aplastic/Myelophthisic
 Anemia of chronic disease
 Acute blood loss

7. Treatment
Correct underlying cause
Packed RBC transfusion
Replacement- iron, vitamin B12/FA

8. Chronic hyperproliferative BM
 MDS-
myelodysplastic
syndrome
 RA- refractory
anemia
 RAEB
 Sideroblastic
anemia
 CMML
 MPD-
myeloproliferative
disorders
 Polycythemia vera
 CML
 Essential
thrombocythemia
 Myelofibrosis

9. Aplastic anemia
 Typically pancytopenia
(PRCA- anemia only)
 Causes- autoimmune, chloramphenicol,
carbamazepine, radiation, benzene
 s/s- of pancytopenia
 Dx- bone marrow examination- biopsy
 Rx- ATG/ALG with Cyclosporin-in
elderly or HSCT-in young

10. HSCT
 Hematopoietic stem cell transplantation
 BMT or PBSCT (preferred) or cord blood
 Indications-
 Multiple myeloma
 AML in remission, ALL in second remission, CML
 Relapsed lymphoma
 Aplastic anemia
 MDS
 Congenital storage disorders, immunodeficiencies,
hemoglobinopathies
 Collagen vascular disease
 Autologous or Allogeneic

11. HSCT considerations
 Cost
 HLA matched donor (allogeneic)
 Complications-
 Infections
 Mucositis
 Hepatic veno-occlusive disease
 GVHD (allogeneic)- acute or chronic
 Mortality- 10-20%