Podcast
Questions and Answers
What is the normal range of hemoglobin for women in grams per deciliter (g/dL)?
What is the normal range of hemoglobin for women in grams per deciliter (g/dL)?
Which of the following parameters assists in identifying macrocytic anemia?
Which of the following parameters assists in identifying macrocytic anemia?
Which cell function does NOT pertain to red blood cells?
Which cell function does NOT pertain to red blood cells?
What is the normal leukocyte (WBC) count range in adults measured in thousand per microliter (× 103/microL)?
What is the normal leukocyte (WBC) count range in adults measured in thousand per microliter (× 103/microL)?
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Which of the following conditions would most likely present with a decreased reticulocyte count?
Which of the following conditions would most likely present with a decreased reticulocyte count?
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What is the normal platelet count range for women in thousand per microliter (× 103/microL)?
What is the normal platelet count range for women in thousand per microliter (× 103/microL)?
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Which type of anemia is typically associated with a reduction in the number of reticulocytes?
Which type of anemia is typically associated with a reduction in the number of reticulocytes?
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What is the typical range for the mean corpuscular volume (MCV) in adults measured in femtoliters (fL)?
What is the typical range for the mean corpuscular volume (MCV) in adults measured in femtoliters (fL)?
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Which of the following parameters is NOT typically used to diagnose anemia?
Which of the following parameters is NOT typically used to diagnose anemia?
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What does a reduction in the proportion of red blood cells indicate?
What does a reduction in the proportion of red blood cells indicate?
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What is the primary physiological response of the body to compensate for anemia?
What is the primary physiological response of the body to compensate for anemia?
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Which characteristic is most likely associated with microcytic anemia?
Which characteristic is most likely associated with microcytic anemia?
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When is it most appropriate to refer a patient to a hematologist?
When is it most appropriate to refer a patient to a hematologist?
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What distinguishes macrocytic anemia from other types?
What distinguishes macrocytic anemia from other types?
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Which symptom is less likely to be associated with anemia?
Which symptom is less likely to be associated with anemia?
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Study Notes
Anemia in Adults
- Basic evaluation of anemia in adults is a significant topic, with yearly office visits reaching 2.8 billion and emergency department (ED) visits exceeding 778,000.
- Annually, anemia is a primary diagnosis in 2.8 billion office visits, 778,000 ED visits, and 5,380 associated deaths (CDC, 2015).
Objectives
- Review of cell lineages and functions is crucial.
- Metabolic and physiological responses to anemia (patient presentation) need discussion.
- Classifications (microcytic, normocytic, and macrocytic) of anemia, including their morphologies, causes, diagnoses, and treatments must be examined.
- Guidelines for hematology referrals should also be reviewed.
Cell Lineage
- The presentation includes diagrams illustrating erythrocyte, platelet, granulocyte (granular leukocytes), granulocyte, and lymphocyte development, as well as eosinophil, basophil, and monocyte development, and neutrophil development.
Red Blood Cell (RBC) Function
- RBCs transport oxygen from the lungs to tissues and carry carbon dioxide (Kuhn et al., 2017).
- They also transport electrolytes, hormones, vitamins, antibodies, heat, and immune cells.
Normal Hematologic Parameters
- Hemoglobin (g/dL) and hematocrit (%) ranges differ between men and women. Also, the presentation includes RBC count, MCV, MCHC, RDW, Reticulocyte count values, platelet count, and WBC count along with their respective normal ranges for both men and women.
Anemia Definition
- Anemia is defined as a reduction in the proportion of red blood cells. Critically, hemoglobin levels below 13.5 g/dL in men, and below 12.0 g/dL in women are indicative of anemia.
Microcytic Anemia
- Circulating red blood cells (RBCs) are smaller than normal (microcytic).
- RBCs frequently exhibit a reduced red color (hypochromic).
- Microcytosis is indicated by mean corpuscular volume (MCV) values less than 80.
- Hypochromia is characterized by mean corpuscular hemoglobin concentration (MCHC) values less than 33.
- Various causes of microcytic anemia are listed, including iron deficiency, thalassemia, lead poisoning, sideroblastic anemia, copper deficiency, hemolysis, inflammation, and anemia of chronic disease.
Iron Deficiency Anemia (IDA)
- Iron is essential for blood production, is recycled and conserved.
- Iron levels fluctuate throughout the day.
- Ferritin, a storage form of iron, plays a crucial role.
- Normal values for iron, total iron-binding capacity (TIBC), percent saturation of transferrin, and ferritin are provided.
- Causes of IDA include blood loss (GI ulcers, lesions, malignancy, menorrhagia, milk anemia in infants), and malabsorption (gastric resection, celiac disease, inflammatory disorders).
- Common symptoms may include fatigue, exercise intolerance, shortness of breath (SOB), headache, concentration difficulties, and pallor. Less common symptoms include pica, glossitis, cheilosis, koilonychia, and dysphagia.
- Diagnosis involves evaluating CBC and iron studies, which often include decreased serum iron, increased TIBC, decreased percent saturation, and decreased ferritin.
- Treatment options include oral ferrous sulfate and IV iron supplementation. Also, investigating the cause of iron loss is important. Referral to hematology may be necessary under certain conditions.
Thalassemia
- Inherited blood disorders characterized by a disruption in the ratio of alpha/beta globin production due to mutations in globin genes.
- Results in variable degrees of anemia and extramedullary hematopoiesis (bone marrow outside the bone).
- Alpha Thalassemia, including major, minor, and minima are discussed. Their various presentations are described with the associated hemoglobin abnormalities.
- Beta Thalassemias, major, intermedia, and minor forms are described and include the various presentations with distinct hemoglobin abnormalities.
Lead Poisoning
- Lead is a naturally occurring metal.
- It binds to proteins and alters their function, potentially competing with calcium.
- Symptoms vary depending on the blood lead level (BLL).
- Exposure can occur in various settings (workplace, paint, gasoline, bullets, drinking water, cosmetics/personal care products, herbal supplements).
- Potential symptoms include abdominal pain, constipation, anorexia, joint pain, muscle aches, excessive fatigue, and sleep disturbances; high BLLs may lead to central nervous system effects.
- Impacts RBCs, inhibiting heme synthesis, increasing fragility leading to shorter lifespan, and degrading red blood cell RNA, causing hemolysis.
- Diagnosis involves measuring BLL, ideally above 10 mcg/dL.
- Treatment focuses on removing the lead source and providing supportive care; chelation therapy may be considered.
Sideroblastic Anemia
- A group of blood disorders, either congenital or acquired.
- Characterized by defective maturation of developing erythroid cells.
- Iron is unable to be used by the body to make hemoglobin, causing it to accumulate in the mitochondria of red blood cell precursors.
- Ringed sideroblasts are a key cellular finding due to the ring-like appearance of the nucleus.
- Various causes are listed in the slides, including congenital defects, acquired conditions (alcohol use, medications), and other underlying diseases.
Macrocytic Anemia
- Circulating red blood cells (RBCs) are larger than usual (macrocytic).
- RBCs have a normal color (normochromic).
- Macrocytosis is indicated by mean corpuscular volume (MCV) values above 100.
Macrocytic Anemia Causes
- Causes of macrocytic anemias include vitamin B12/folate deficiency, medications, liver disease, and myelodysplastic syndrome (MDS).
B12 Deficiency (Cobalamin)
- Water-soluble vitamin critical for RBC formation, cell metabolism, nerve function, and DNA production.
- Intrinsic factor, produced by stomach parietal cells, is essential for B12 absorption.
- Normal values for B12 are between 200-900 ng/dL.
- Causes of B12 deficiency include malabsorption (ileum dysfunction, nonfunctional intrinsic factor, gastric resection, IF autoantibodies), and anatomical changes.
Folate Deficiency
- Folate is essential for DNA synthesis; absorbed in the jejunum, and metabolized.
- Normal folate levels are typically below 4.2 ng/dL.
- Causes include dietary restrictions, increased requirements during pregnancy or hemolytic anemia, loss during hemodialysis, and medications that interfere with metabolism; gastric resection or bypass surgery also can contribute.
Anemia of Chronic Disease (ACD)
- Immune-mediated dysregulation of iron homeostasis, characterized by hepcidin production by the liver (a major iron regulator).
- Cytokines (e.g., IL-6, IL-1β, TNF-α) induce hepcidin production, leading to increased macrophage iron uptake, reduced erythropoietin production, and decreased RBC survival.
- Causes include inflammatory diseases, malignancy, and infections.
- Symptoms typically mirror the underlying inflammatory condition, although fatigue, shortness of breath, and pallor are common.
- Diagnosis usually involves CBC, retic count, peripheral smear, checking iron studies (including ferritin, serum iron, and TIBC), and checking inflammatory markers (ESR, CRP).
Anemia in Chronic Renal Insufficiency (CRI)
- Decreased erythropoietin (EPO) production due to kidney damage impairs red blood cell (RBC) production.
- Waste products accumulate and coat RBCs, further impacting production and function.
- Symptoms typically include fatigue, weakness, dyspnea, pallor, headache, concentration difficulties, orthostatic symptoms, and palpitations.
- Treatment options may include erythropoiesis-stimulating agents and supportive care; managing the underlying kidney disease is crucial.
Aplastic Anemia
- A bone marrow suppression disorder that often has an unclear cause (idiopathic). Also, viral infections, radiation, chemotherapy, exposure to toxic chemicals, and autoimmune disorders are possible causes.
- Symptoms include fatigue, SOB, tachycardia, pallor, frequent or prolonged infections, unexplained bruising, nosebleeds, unusual bleeding from cuts, skin rash, dizziness, and headache.
- Diagnosis often involves checking blood counts for pancytopenia, and sometimes bone marrow biopsy.
- Treatment focuses on identifying and addressing the cause, potentially by removing medication toxicities, and providing supportive care; bone marrow transplantation may be considered, particularly in severe cases.
Anemia and Hypothyroidism
- Hypothyroidism can cause anemia through several mechanisms, including decreased erythropoietin production, bone marrow depression, and associated nutrient deficiencies.
- Anemia and hypothyroidism are frequently treated together due to the potential for comorbidities.
- Possible underlying causes include bone marrow depression; decreased erythropoietin production; concomitant iron, B12, or folic acid deficiency.
- Presentation often includes fatigue, exercise intolerance, SOB, pallor, weight gain, unexplained bruising, insensitivity to cold, constipation, edema, thinning hair, or concentration difficulties.
- Diagnosis may typically include a CBC, thyroid studies, and evaluation for concomitant vitamin deficiencies.
Anemia and Medications
- Certain medications (e.g., azathioprine, hydroxyurea, and others) can contribute to anemia through bone marrow suppression. A comprehensive review of patient medications is crucial.
Approach to New Onset Anemia (Shotgun Approach)
- A diagnostic approach to evaluate new-onset anemias includes CBC, comprehensive metabolic panel (CMP), iron studies, B12/folate levels, MMA, LDH, reticulocyte count, haptoglobin, indirect bilirubin, ESR, CRP, and erythropoietin levels, and peripheral blood smear.
Macrocytic Anemia Summary Table
- The presented table summarizes the differential diagnoses for macrocytic anemia, including B12 deficiency, folate deficiency, liver disease, myelodysplastic syndrome (MDS), and medications.
Liver Disease and Excess Alcohol
- Alcohol can directly affect liver cells, impacting hematopoiesis and nutrient metabolism.
- Malnutrition, stomach bowel dysfunction, and other factors may also lead to anemia.
- Other mechanisms from the liver are listed, including digestive function, and maldigestion/malabsorption; alcohol-induced liver disease can lead to a range of nutritional deficiencies.
Myelodysplastic Syndrome (MDS)
- A clonal hematopoietic stem cell disorder characterized by bone marrow abnormalities.
- Insufficient maturation of blood cells (blasts).
- Various subtypes of MDS exist.
- Symptoms might include cytopenia, myelodysplasia, ineffective hematopoiesis, and high possibility of progression to acute myeloid leukemia (AML).
Summary Table: Differentiating IDA and ACD
- A table is presented summarizing serum iron, % saturation, TIBC, and ferritin levels in IDA and ACD, which can help differentiate between these conditions.
Anemia in Chronic Renal Insufficiency (CRI)
- Decreased erythropoietin (EPO) production due to kidney damage impairs red blood cell (RBC) production.
- Waste products accumulate and coat RBCs, further impacting production and function.
- Symptoms typically include fatigue, weakness, dyspnea, pallor, headache, concentration difficulties, orthostatic symptoms, and palpitations.
- Treatment options may include erythropoiesis-stimulating agents and supportive care; managing the underlying kidney disease is crucial.
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Description
This quiz provides a comprehensive overview of anemia in adults, focusing on cell lineages, classifications, and metabolic responses. It covers essential topics such as the different types of anemia, their causes, diagnoses, and treatment options. Additionally, it emphasizes the importance of referrals to hematology specialists.
