Updated: 3/17/2021

Anemia Overview

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Snapshot
  • A 20-year-old woman who is a vegan with a history of heavy menses presents with fatigue.  She states that she barely has the energy to do anything anymore.  She denies substance abuse and states she gets a good 9 hours of sleep every night.  On exam you see a thin young woman who is tired appearing with palor of her conjunctivae on physical exam.  Her blood pressure is 95/60 mmHg and pulse is 88/minute.
Introduction

  • Defined as low hematocrit and/or hemoglobin relative to normal values
  • Risk factors include
    • neoplasia
    • family history
    • alcoholism
    • GI bleeding
    • vegan diet
    • African-American descent
    • Mediterranean descent
Presentation
  • Symptoms
    • weakness
    • fatigue
    • dyspnea on exertion
  • Physical exam
    • pallor
    • tachycardia
    • systolic flow murmor
    • jaundice
    • positive stool guiac
  • May present as angina
Evaluation
  • Initially assess 
    • hematocrit
    • MCV
    • reticulocyte count
    • peripheral blood smear
  • If microcytic follow with
    • ferritin
    • iron
    • TIBC
  • If macrocytic follow with
    • RBC folate
    • serum B12
  • If normocytic follow with
    • Coombs test
    • iron studies
    • bilirubin
  • Screen for malignancy, haptoglobin levels, and Guiac
Differential
 
Microcytic Anemias
Findings
Iron deficiency  
Low ferritin
Low serum Fe
High TIBC
Thalassemia HbF increased, low MCV, hemolysis
Sideroblastic Anemia
High ferritin
High serum Fe
Low TIBC
Lead poisoning Low MCV, basophilic stippling, increased free erythrocyte porphyrins            
Macrocytic Anemia
Labs and Miscellaneous
B12 / Folate deficiency  Increased MCV, increased LDH, decreased haptoglobin
Hemolytic Anemia Mechanical Increased reticulocyte count
Immunologic Positive Coombs test
Drug exposure History of phenytoin, phenobarbital, or MTX
Diamond-Blackfan  Congenital "pure RBC anemia" with triphalangeal thumbs and a webbed neck 
Normocytic
Labs and Miscellaneous
Hypoproliferative Anemia
Hemorrhage Watch CVP, not the Hct 
Chronic disease
High ferritin
Low serum Fe
Low TIBC
Renal failure
Infection Osteomyelitis, HIV, Mycoplasma, or EBV
Bone marrow disease  Leukemia, lymphoma, or myelodysplasia
Intrinsic Hemolysis
G6PD Decreased serum haptoglobin
Hereditary spherocytosis Decreased serum haptoglobin
Extrinsic Hemolysis
Cold agglutinins Osteomyelitis, HIV, Mycoplasma, or EBV
Autoimmune  Increased LDH, K+ and bilirubin, decreased haptoglobin
Mechanical destruction Microangiopathic Hemolytic (TTP, HUS, or DIC)

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(M2.HE.16.4691) A 35-year-old woman comes into your office because she has been feeling fatigued over the last few months. She states that she has no history of thyroid disease, but admits to menorrhagia since she was about 18 years old. She states she has to change pads every 2 hours for the first five days of her period and that her periods last 9-10 days on average. Her complete blood count (CBC) is significant for hemoglobin (Hgb) of 10.8, white blood cell count (WBC) of 5.5. The mean corpuscular volume of her RBCs is 73 and her iron studies are show low ferritin with increased total binding capacity (TIBC). Her peripheral blood smear is shown in Figure A. What is the most likely cause of her anemia?

QID: 107604
FIGURES:
1

Iron deficiency

80%

(4/5)

2

Sickle cell disease

20%

(1/5)

3

Vitamin B12 deficiency

0%

(0/5)

4

Folate deficiency

0%

(0/5)

5

Anemia of chronic disease

0%

(0/5)

M 6 D

Select Answer to see Preferred Response

(M2.HE.15.95) A 73-year-old woman presents to her primary care physician with complaints of fatigue, night sweats, fever, and easy bleeding for 10 days. She reports no antecedent illness and denies sick contacts. She is otherwise healthy, with a medical history including hypertension. Her medications include lisinopril and amlodipine. Lab studies reveal white blood cell count of 2,100/uL with circulating blasts, hematocrit of 22%, MCV 88fL, and platelet count of 22,000/uL. A bone marrow biopsy (Figure A) is performed, and confirms the suspected diagnosis. Which of the following describes the pathophysiology of this patient's decreased hematocrit?

QID: 104735
FIGURES:
1

Peripheral destruction of RBCs

6%

(2/32)

2

GI tract losses

0%

(0/32)

3

Chronic inflammatory state

3%

(1/32)

4

Bone marrow infiltration

88%

(28/32)

5

Medication side effect

0%

(0/32)

M 5 D

Select Answer to see Preferred Response

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EXPERT COMMENTS (9)
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