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1
Even the most expert clinical appraisal does not
supplant accurate measurement of the blood for the
detection, quantification and characterization of
anemia.
Laboratory tests:
I. Red cell count- hgb, hct, reticulocyte
count, RBC indices
II. White Blood cell count- diff’l, nuclear
segmentation of neutros
III. Platelet count
IV.Peripheral smear morphology
V. Iron Studies
VI. Bone marrow examination
CASE STUDIES
•Case 1
Mr. Santos, 48 years old farmer consulted
because of progressive weakness and pallor.
No jaundice nor hepatosplenomegaly on
P.E.
Petechiae noted on both L.E.’s
CBC Result:
Hb: 7 gm/dl
Hct: 21
WBC: 4,000
Normal bone marrow (LPO) lymph: 48%
segs: 52%
Platelet count: 80,000
Reticulocyte Count:5 x 10-3
APLASTIC ANEMIA
•A type of hypoproliferative anemia characterized by
pancytopenia with marrow hypocellularity
•Etiology:
2
1. Primary
a. Congenital
•Most common cause of anemia worldwide
Fanconi’s Anemia •Iron is absorbed primarily in the duodenum
b. Idiopathic and upper jejunum
2. Secondary
a. Radiation •Picture : causes of iron anemia
b. Drugs and Chemical
Regular effects
Idiosyncratic effects • Case 3
c. Viruses Mrs. Cruz, 75 year old female consulted
d. Immune diseases because of progressive weakness and loss of balance.
e. PNH She also complains of numbness and tingling sensation
f. Pregnancy in all extremities. She has no gastrointestinal
Pathogenesis: complaints.
• Depletion of hematopoietic cells by an agent or - not a diabetic but is hypertensive
event that kills stem cells - prefers to eat vegetables and fish
• Suppression of proliferation and maturation of stem because of poor dentition
cells by an immunologic or lymphocyte mediated
mechanism P.E.
Patient is pale with smooth, red tongue.
Clinical Features: No organomegaly noted
- symptoms related to decrease RBC, Laboratory Results
WBC, platelets CBC: Hb: 80 g/L WBC: 9 x 109/L
-Physical exam: lymphadenopathy and Hct: .26
MCV: 102fL
seg:
lymph: 20%
74%
splenomegaly not typical
MCH: 36 pg eos: 2%
-Laboratories: Pancytopenia, decrease MCHC: 38% mono: 4%
reticulocyte count platelets: adequate
Bone marrow: fatty marrow
Peripheral Smear: Macrocytes
Management Options:
• Transfusion support MEGALOBLASTIC ANEMIA
• Bone marrow transplantation -disorder caused by impaired DNA synthesis
• Immunosuppression with anti-thymocyte globulin,
with or without steroids -Cell primarily affected: blood cells
• Androgen stimulation GI epithelial cells
-slowed nuclear cell division with normal progression of
•Case 2 cytoplasmic maturation
Megaloblastosis
J.K., 35 year old housewife complains of progressive
easy fatigability of about 3 months duration. Folate sources: mainly fruits and vegetables
Review of System: (-) epigastric pain Cobalamin sources: meat & dairy foods
(-) hematochezia nor
melena Cause: B12 or/& Folate Deficiency
menses – 28 days cycle, 7 days duration,
3 days profuse flow consuming
5-6 fully soaked pads/day Clinical Manifestations:
(-) bruises/ecchymoses
Anemia with slight icteresia
P.E. Pale, no jaundice GI manifestations – glossitis, smooth,
(-) hepatosplenomegaly beefy red tongue, malabsorption
3. Neurologic manifestations (Cobalamin) - subacute
Laboratory results: combined degeneration of CNS
peripheral neuropathy – numbness,
CBC: Hb: 60g/L WBC: 6 x 109/L weakness, ataxia, paresthesia,
Hct: .21 seg: 70% disturbances of mentation
MCV: 80fL lymph: 25%
MCH: 25 pg eos: 3% •Management:
MCHC: 28% mono: 2% 1. Treatment of underlying problem
platelets: adequate 2. Replacement therapy
Reticulocyte count: 1.5 x 10-3 oral folic acid
parenteral B12
Peripheral smear: HYPOCHROMIC
Iron studies:
•Case 4
Ferritin: 8ug/L Mrs. Santos, 50 year old male was referred for
Iron: 10 (N.V.9 - 27 umol/L) evaluation of anemia. She begun to experience easy
TIBC: 60 (N.V. 54 – 64 umol/L) fatigability about 5 weeks PTC. She also noticed
Percent Saturation: 17% passage of highly colored urine.
(+) weight loss of about 5 lbs in the last 2 months
IRON DEFICIENCY ANEMIA (+) febrile episodes
3
•P.E. icteric sclerae
(+) cervical lymphadenopathy
(-) hepatomegaly
(+) splenomegaly
4
Splenectormy – for moderate to
CBC: Hb: 70 g/L WBC: 13x 109/L severe hemolysis
Hct: .21 seg: 80% Folic Acid supplementation
MCV: 98fL lymph: 20% APPROACH TO THE BLEEDING PATIENT
MCH: 35pg
MCHC: 36%
platelets: adequate SCREENING HISTORY
•A history taken to evaluate hemostasis should answer
Reticulocyte count: 80 x 10-3/L these questions:
Peripheral smear: spherocytes
Other tests: •Has the patient experienced abnormal bleeding or
Direct Coombs: +++ bruising? If so, are symptoms recently acquired or do they
Peripheral Smear: SPHEROCYTES date back to childhood?
•Is there a history of an acquired disorder that would impair
hemostasis? E.g., chronic liver disease, SLE, uremia or a
IMMUNE HEMOLYSIS hematologic malignancy.
Warm-antibody Immunohemolytic Anemia •Is the patient taking a drug that could interfere with
-induced by IgG or IgM Abs reacting specifically on hemostasis?
antigens on RBC membrane •Have other members of the family bled abnormally?
Diagnosis: (+) Coomb’s test In questioning a parent about significant bleeding in a small
child, one should ask specifically about:
Management:
Steroids
•Bleeding from umbilical stump
Splenectomy •Bleeding after circumcision
Immunosuppresants •Bleeding from cuts in mouth
•Frequency & size of hematomas of scalp
•Case 5 •Extent of bruising from minor trauma, eg. Falls from
JA, 18 year old male consulted because of
recurrent jaundice and pallor. Jaundice was first noted swings or bicycles or down steps
when he was 4 years old. •Nosebleeds that stop w/in mins, even if frequent, suggest
No history of blood transfusions. that hemostasis is N. Prolonged nosebleeds requiring
Family history is positive for another sibling with medical intervention arouse suspicion of impaired
similar problem. hemostasis.
In assessing bleeding history of an adult patient, one
evaluates:
P.E. Icteric sclerae
moderate splenomegaly •Abnormal bruising, ask specific questions:
CBC: Hb: 81 g/L
•How often do you notice a new bruise on your body?
Hct: .30 •Do you develop bruises larger than a 1in dm without
WBC: 11.5 x 109/L remembering how you got the bruise? If so, how big
seg: 75% was the largest of these bruises?
lymph: 24% •Do you notice bruises after injections?
eos: 1%
platelets: adequate •Excessive bleeding from small cuts
Reticulocyte count: 60 x 10-3/L
Peripheral smear: (+) spherocytes •Bleeding after previous surgery
•Bleeding after dental extractions. Bleeding that lasts
HEREDITARY SPHEROCYTOSIS >24h after extraction of a permanent tooth or that starts
-inherited RBC membrane abnormality – autosomal again after 3-4 days is suggestive of a hemostatic
dominant pattern of inheritance abnormality.
-Characterized by spherical RBC due to a molecular defect DRUGS THAT INTERFERE WITH HEMOSTASIS
in one of the proteins of the cytoskeleton of the RBC
membrane
•Aspirin, clopidogrel, dipyridamole
ankrin •Drugs that interfere with blood coagulation: heparin, oral
Protein 3 anticoagulants, (?) herbal medications
Spectrin
PHYSICAL EXAMINATION
Clinical Manifestations:
anemia
•Bleeding into skin and soft tissues
jaundice •Petechiae: characteristic of vessel & platelet problem.
cholelithiasis Usually pinhead size but maybe bigger.
Characteristically develops 7 regress in crops. Most
Diagnosis: spherocytes on smear conspicuous in areas of increased venous pressure.
reticulocytosis Must be distinguised from small telangiectsias &
(-) Coomb’s test angiomas
(+) Osmotic fragility test •Ecchymoses, hematomas: large superficial
hematomas maybe seen in coagulation disorders.
Management: •Palpable purpuras may be seen in vasculitis
5
•Hemarthorses – bleeding into synovial joints and virtually
diagnostic of a severe hereditary coagulation disorder. May
develop without discoloration or other external evidence of
bleeding.
•Traumatic bleeding
Response to trauma is an excellent “screening test” for
the presence of hereditary hemorrhagic disorder. A
history of surgical procedures or significant injury w/o
abnormal bleeding is equally good evidence against
presence of such disorder.