Anemia

Mallikarjuna PV
Ph.D. Research Scholar
Dept of MLT, MCHP
MAHE, Manipal.
Introduction

A person is said to have anemia when his Hb, PCV or RBC count is low or the oxygen carrying capacity is less than
normal for the age & sex of the individual.

Fundamentally anemia is attributable to a) loss of blood, b) excessive destruction of mature red cells c) impaired red
cell production.
In addition to clinical assessment the differential diagnosis is based on morphological characteristics & on the cause.
Morphological Classification

Characteristic changes in the size & hemoglobin content of the red cells occur in various
types of anemias.

This classification is based on the morphology of red cells on stained blood films & the
red cell indices.

Morphological classification with common conditions associated with it is given in the

following table.
Morphologic type of anemia Underlying abnormality Clinical syndrome
Macrocytic Vit B12 deficiency, Folic acid deficiency, drug Pernicious anemia
(MCV>100 fl megaloblastic) induced disorders of DNA synthesis Malabsorption
Nutritional chemotherapy anticonvulsant
Non megaloblastic Accelerated erythropoiesis Hemolytic anemia
Inreased membrane surface area unknown Response to hemorrhage
Liver disorders
Myxedema
Aplastic anemia
Microcytic (MCV<80 fl) Iron deficiency Chronic blood loss,
Disorders of globin synthesis Nutritional Thalassemia
Hemoglobinopathy
Normocytic (MCV 81-99fl) Recent blood loss, Pregnancy, Over hydration,
Over expansion of plasma volume Hemolytic anaemia,
Hemolytic diseases, Aplastic anemia,
Hypoplastic bone marrow Hypothyroidism,
Endocrine abnormality, Chronic disorders – Adrenal insufficiency
Renal disease
Liver diseases
ETIOLOGIC CLASSIFICATION

Normally equilibrium is maintained between the production and delivery of red cells into circulation & their loss or
destruction from the circulation. Alterations in this equilibrium results in anemia. Anemia can be classified according to the
mechanism that resulted in this alteration. (Classification based on the etiology or cause)
a) Excessive Destruction or Loss of red cells
i) Blood loss
Acute
Chronic
ii) Extra Corpuscular hemolytic disease
Antibodies
Infection (e.g. malaria)
Drugs, Chemical
Trauma to red cells
iii) Intra corpuscular hemolytic disease
Various hereditary & acquired hemolytic anemias
b) Inadequate Production of mature red cells
i) Deficiency of essential substances like Iron, Vit B12, folic acid, protein, other
elements like copper, cobalt etc.
ii) Deficiency of erythroblasts
Aplastic anemia
Pure red cell aplasia
iii) Infiltration of bone marrow
Leukemia, Lymphoma
Multiple myeloma
Carcinoma
Myelofibrosis
iv) Endocrine abnormalities
Myxedema vi) Chronic renal disease
Addison’s disease vii) Chronic inflammatory disease
Pituitary insufficiency viii) Cirrhosis of Liver
1. Define anemia
2. What are the 3 main causes of anemia?
3. List 2 methods of classification of anemia.
IRON DEFICIENCY ANEMIA
• It is cause by excessive loss of iron or inadequate absorption of iron.
• It is most often in female than male. Iron absorption is regulated by iron needs &
body stores.
• When iron stores are low, higher proportion of available iron is absorbed & vice
versa. Except, in primary hemochromatosis, thalassemia & megaloblastic anemia
iron absorption remains normal & even elevated despite increased iron stores.
• It is primarily absorbed in upper duodenum.
PATHOPHYSIOLOGY OF IRON DEFICIENCY ANEMIA:

Iron is an essential element for erythropoiesis, tissue respiration & several enzyme
catalyzed reactions.

The average adult body contains 3 to 5 g elemental iron.

Iron is distributed in body in two forms: functional & storage.

I. Functional iron

It exists as Hb, little as myoglobin, transferring & tissue enzymes.

Hb is the oxygen binding protein that transports oxygen from lungs to tissues.

Myoglobin, a hemo protein in muscle accepts oxygen from hemoglobin in the peripheries &
acts as an oxygen store in muscle.

If oxygen supply is limited, it releases oxygen to cytochrome oxidase leading to oxidative

phosphorylation.

Transferrin is a specific iron binding protein that transports iron through plasma &
extravascular spaces. Each molecule of transferrin binds 2 molecules of iron in ferric state.
The TIBC is high in iron deficiency & low in iron overload.
II. Storage iron:

It is in the form of ferritin & hemosiderin, which is located in parenchymal cells of liver &
reticulo endothelial cells of the bone marrow, spleen & liver.

Low iron stores are an early sign of iron deficiency & may help differentiate between iron
deficiency anemia & other causes of anemia.
 FACTORS ASSOCIATED WITH IRON ABSORPTION:

Promoting absorption

Inorganic iron: ferrous form is better absorbed than ferric iron & organically bound iron.

Ascorbic acid: Convert ferric iron to ferrous iron

Acids Gastric: HCl promotes the release & conversion of dietary iron to the ferrous form

Chelates Iron: chelated to low mol wt sub (sugars, amino acids, succinates ) facilitates iron
binding to the intestinal mucosa

Clinical states: Iron deficiency, increased erythropoiesis, pregnancy, anoxia & pyridoxine
deficiency.
Reducing absorption

Alkaline: Antacids, alkaline pancreatic secretions containing phosphate convert iron to

insoluble ferric hydroxide

Dietary: Dietary phosphates & phytates in cereals & tannins in tea probably complex iron

Clinical states: Chronic diarrhea, steatorrhea, adequate iron stores, decreased

erythropoiesis, acute or chronic inflammation
FACTORS ASSOCIATED WITH IRON DEFICIENCY:

Factor Association

Dietary: Starvation, poverty, vegetarianism, religious practice, food pads

Blood loss:

Women & Girls: Menstruation, postmenopausal bleeding, pregnancy

General: Peptic ulcer, drug induced gastritis, carcinomas of colon & stomach, ulcerative
colitis, hemorrhoids, renal or bladder lesions, hookworm infestations, frequent blood
donation, athletic training, widespread bleeding disorders

Malabsorption: Celiac disease, inflammation partial & total gastrectomy, chronic

Increased requirements: Rapid growth, pregnancy
 SIGNS & SYMPTOMS:

• Developmental delays
• Behavioral disturbances
• Altered central nervous system development
• Impaired work capacity
• Preterm delivery
• Delivery of low birth weight baby
• Others like brittle or spoon shaped nails, angular stomatitis, atrophic tongue &
pharyngeal & esophageal webs causing dysphagia & atrophic gastric mucosa.
 DIAGNOSIS:

• Medical history, full blood count & peripheral smears.

• Blood Hb concentrations & erythrocyte numbers are normal in mild cases.

• As deficiency worsens MCV & erythrocyte count & Hb decreases & RDW increases.
• Hypochromia or poikilocytosis shown when Hb conc are 7.0 g/dl or less for women & g/dl
or less for men.

• Absence of stainable iron in bone marrow aspirates is ultimate proof of deficiency but is
painful & expensive so not used routinely.

• After hemorrhage or iron therapy reticulocytes increase.

PREVENTION:

It can be done by identifying the underlying cause of iron deficiency & correcting it
through diet or supplementation.

Dietary manipulation:

Food fortification is best recommended.

When dietary iron supplementation is not possible or adequate, oral supplementation
should be initiated.
THANK YOU
MEGALOBLASTIC ANEMIA/PERNICIOUS ANEMIA
• It is cause by insufficient of hemopoiesis.

• In this condition stomach decreases the production of intrinsic factors because they
decrease the absorption of vitamin B12.

• It is a sub class of the macrocytic anemias.

• It is characterized by a lowered blood Hb mass due to reduced erythropoiesis

secondary to defective DNA synthesis in the developing erythroid cells of the bone
marrow.
CAUSES:

It can be mainly due to deficiencies of vitamin B12 and folate.

It can be by drug induced interferences, either direct or indirect, i.e. with DNA synthesis
or nutritional status.
THALASSEMIA
• It is an inherited disease.
• Thalassemia is also the hemolytic anemia in which hemoglobin production is decreased.
• The RBCs are small, pale and short lived.
• It required the blood transfusion for life.
• Hemolytic disease of the newborn Rh+ antibodies of a sensitized Rh– mother cross the
placenta and attack and destroy the RBCs of an Rh+ baby.
• Rh– mother becomes sensitized when exposure to Rh+ blood causes her body to
synthesize Rh+ antibodies.
• The drug RhoGAM can prevent the Rh– mother from becoming sensitized

• Thalassemia is a group of hereditary disorders of Hb synthesis characterized by

impaired production of one or more of the normal polypeptide chains of globin.

• The most prevalent thalassemia syndromes are those that involve diminished or absent
synthesis of the α or β globin chains of HbA1.
PATHOPHYSIOLOGY:

The thalassemia syndromes are collectively one of the most common genetic disorders of
the human.

Reduced production of normal α2 β2 tetramer of HbA1 results in the production of

smaller erythrocytes with a low Hb content.

The synthesis & accumulation of excess normal globin chains within the red cells lead to the
formation of unstable aggregates, which may precipitate & cause cell membrane damage
These deformed cells undergo premature destruction either in the bone marrow
(Extravascular hemolysis) or the peripheral circulation ( intravascular hemolysis).

Chronic hemolysis is a primary complication of the clinically significant α & β thalassemia

syndromes. (Hb H disease & β thalassemia major ).

The ineffective erythropoiesis & microcytic, hypochromic anemia described earlier are
associated with a compensatory →in the absorption of dietary iron.
CLINICAL PRESENTATION:

• This may contribute to the iron overload due to blood transfusion therapy.
• In erythropoietic activity in the bone marrow& in extramedullary sites.
• In severe form, excessive erythropoiesis causes significant bone marrow
hypertrophy, growth retardation, lymphadenopathy & hepatosplenomegaly.
• Bone marrow expansion in untreated patients leads to skeletal deformities &
fragility
i. α – THALASSEMIA :

Four genes are involved in the production of α globin chains,

with one pair occurring on each
DNA strand (αα/αα).
The most common form of it result from deletion of one or
more of these genes.
Excess production of β & chains result in the formation of
unstable & nonfunctional 4 (Hb Bart‘s) & β4 (Hb H) tetramers.
ii. β-THALASSEMIA:

It results from faulty mRNA transcription of the β gene.

Excess of α-chain accumulate & cause membrane damage in
RBC precursors.
So premature destruction of the cells in the bone marrow or
peripheral blood.
α- & β- chain production is usually unaffected & so levels of Hb
A2 (α2 β 2).
Heterozygous
Minima Normal None None
Minor (trait) >100 Mild anemia Genetic/medical counseling
Homozygous
Intermedia 70 - 100 Mod – sev anemia, impaired growth &
splenomegaly
Intermittent blood transfusion & chelation therapy
Major 20 - 70 Sev anemia, abnormal skeletal growth,
splenomegaly, iron load complications
Chronic blood transfusion & chelation therapy
SICKLE CELL ANEMIA
The term sickle cell disease encompasses a variety of
hemoglobinopathies, including sickle cell
anemia, sickle Hb C (SC) disease, & sickle cell thalassemia.
Although the clinical presentations of all are often similar, the
manifestations of sickle cell are
more severe & so mainly considered.
DIAGNOSIS:
Hb electrophoresis---types & proportion of Hb present.
Is rapid & inexpensive screening test
It establishes the patients genotype.
If both parents have the AS genotype there is a 1 in 4 chance
that their child will
Have homozygous SS disease.
Prenatal diagnosis also possible.
HEMOLYTIC ANEMIAS:
It is caused by an increased rate of RBC destruction.
It can be because of the production of the defective or damaged RBC‘s (megaloblastic
anemias, thalassemias, sickle cell anemias) or drug induced.
CLASSIFICATION:

I. INHERIDTED
a. Globin synthesis defect
Sickle cell anemia
Thalassemia
Unstable Hb disease
b. Erythrocyte membrane defect
Hereditary spherocytosis
Hereditary elliptocytosis
Hereditary stomatocytosis
c. Erythrocyte enzyme defect
HMP shunt defect
Glycolytic enzyme defect
Other enzyme defect ( adenylate kinase )
II. ACQUIRED
A. Immune mediated
a. Warm reacting Ab ( IgG )
Primary ( idiopathic )
Secondary ( collagen vascular disease,
lympho proliferative disorders )
Drug induced
b. Cold agglutinin disease ( IgM )
Acute (mycoplasma pneumonia,
infectious mononucleosis )
Chronic ( lymphoid neoplasms,
c. Paroxysmal nocturnal hemoglobinuria
d. Transfusions reactions
e. Hemolytic disease of newborns
B. Microangiopathic & traumatic
Disseminated intravascular coagulation
Hemolytic uremic syndrome
Thrombotic thrombocytopenic purpura
Prosthetic or diseased heart valves
C. Infection
D. Exogenous substances
E. Others
Liver disease
Hypophosphatemia
PATHOPHYSIOLOGY

It involves hemolysis of RBC within the circulation (intravascular

haemolysis) or taken up by the
RES & destroyed (extravascular hemolysis ).
Intravascular hemolysis may be caused by trauma to the RBC,
complement fixation to the RBC
(immune mediated), or exposure to exogenous substances.
During hemolysis, if haptoglobin binding capacity is exceeded,
unbound Hb levels , resulting in
hemoglobinemia.
Free Hb is filtered through the glomerulus & usually is
reabsorbed by the proximal tubules.
In severe intravascular hemolysis, the reabsorptive capacity is
exceeded, causing
hemoglobinuria.
Some Hb molecules are transferred from hemopexin to
albumin forming
methemalbumin.
CLINICAL PRESENTATION & DIAGNOSIS:

I Inherited hemolytic anemia : G6PD deficiency :

It is the most prevalent inherited RBC enzyme defect, a sex linked ( X chromosome ) disorder.
The G6PD enzyme, with glutathione & NADP acts as a protective antioxidant for RBCs against
external oxidative stresses.
In G6PD deficiency, oxidative stresses on the RBC viz drugs, infection or acidosis can lead to
denaturation of the globin chains which ppts intracellularly onto the cell membrane as Heinz
bodies & premature hemolysis occurs oxidative hemolysis.
II Several factors affecting patient’s susceptibility for deficiency:

The type of G6PD genetic variant present (i.e. type A- or

mediterranean type).
Patient age
Other sources of oxidant stress
Dosage of an offending drugs (nalidixic acid, cephalosporin,
nitrofurantoin, etc.)
Patient metabolism & excretion of offending drugs.
III Acquired hemolytic anemia: Autoimmune hemolysis
Autoimmune hemolytic anemia results from the binding of
complement or anti-RBC antibodies
to the red cell membrane in affected patients.
These disorders are classified according to the temperature at
which the antibodies have the
greatest affinity for & interaction with red cells.

1. Cold agglutinin hemolytic anemia

2. Warm autoimmune hemolytic anemia:
1. Cold agglutinin hemolytic anemia Here, IgM antibodies bind
to RBCs at low temperatures
This agglutination process is reversed quickly during warming.
Most don‘t appreciably shorten RBC survival.
It is associated with mycoplasma pneumonia or infectious
mononucleosis.
Chronic disease occurs with lymphoproliferative disorders &
results in poor peripheral
circulation.
It involves preventing exposure to cold environments.
Folic acid supplementation
Blood transfusions ( if necessary )Treating any underlying
diseases.
Occasssionaly patients may respond to plasmapheresis or
cytotoxic agents such as
cyclophosphamide or chlorambucil
2. Warm autoimmune hemolytic anemia:
IgG or occasionally IgA have greatest affinity for red cells at room temperature (37°C)
Hemolysis involves the attachment & subsequent destruction of IgG coated erythrocytes to
receptors on macrophages in the RES.
It may be idiopathic, secondary to an underlying disease that affects immune system (chronic
lymphocytic leukemia, non Hodgkins lymphoma, or systemic lupus erythematosus), or
secondary to certain drugs.
When hemolysis is clinically significant, corticosteroid therapy is
effective & blood transfusions
may be needed.
Splenectomy
Alternative therapies include immunosuppressive agents,
danazol, IVIG & cyclosporin
HEREDITARY SPHEROCYTOSIS
Definition
This is an anemia characterized by the presence of many small
red cells or spherocytes in the blood. The abnormal shape of
the red cells is due to the lack of one or more of the
cytoskeletal proteins (mainly spectrin and ankyrin) of the red
cell membrane. The abnormal shape results in lack of flexibility
of the cell membrane while passing through small capillaries.
The red cells are trapped in the microcirculation and have a
decreased life span.
Etiology This red cell membrane defect is usually an inherited
disorder. It is inherited as an autosomal dominant trait and
affects both sexes equally.

Clinical Presentation Young males and females present with

history of repeated attacks on mild jaundice, fever, gall stones,
leg ulcers and splenomegaly. Rarely when the defect involves
more than one protein, there may be neonatal
hyperbilirubinemia.
Laboratory Diagnosis
1. Hemoglobin, PCV, RBC count are mildly decreased
2. MCV and MCH are normal, MCHC is increased
3. Peripheral blood smear (figure 4) characteristically shows
spherocytes which are well hemoglobinized red cells with a
low mean cell diameter. Spherocytes lack the central pallor
which is encountered in normal red cells. The number of
spherocytes per high power field varies from patient to
patient. Poikilocytes and polychromatophils may be seen.
Spherocytosis can also be seen in autoimmune hemolytic
anemia, ABO hemolytic disease of the newborn and
bacterial toxins like Clostridium.
4. WBC and platelet counts are normal
5. Osmotic fragility test This test demonstrates that the surface
area to volume ratio is reduced in the presence of
spherocytosis. Normal red cells can withstand hypotonicity and
can increase in size by about 70% (because of the biconcave
shape) before their membrane is stretched. Spherocytes on the
other hand when placed in progressively more hypotonic
solutions, because of their round shape, are unable to swell
further as water enters the cells and they rupture sooner than
normal red cells. Thus spherocytes, whatever the reason for
their formation will show increased osmotic fragility. Osmotic
fragility is also increased in hereditary elliptocytosis and
hereditary stomatocytosis. Iron deficient microcytic
hypochromic red cells and thalassemic red cells show
decreased osmotic fragility.
6. Direct Coomb’s test must be performed to rule immune
cause for the formation of spherocytes.

7. Biochemical tests show indirect bilirubinemia, increased

excretion of urobilinogen and stercobilinogen and increased
serum LDH.

8. Analysis of cytoskeletal proteins to demonstrate the protein

responsible may be done by SDS-PAGE (sodium dodecyl
sulphate polyacrylamide gel electrophoresis)

9. Flow cytometric (dye binding) test