Anemia

Anemia – reduction of the total circulating red cell mass below normal limits
- Diagnosed by reduction in hematocrit (packed red cells/total blood volume)
Morphologic characteristics providing etiologic clues:
- red cell size (normocytic, microcytic, or macrocytic)
- degree of hemoglobinization, reflected in the color of red cells (normochromic or hypochromic)
- shape
Types of anemia:
- microcytic hypochromic anemias
o caused by disorders of hemoglobin synthesis (most often iron deficiency)
- macrocytic anemias
o abnormalities that impair the maturation of erythroid precursors in the bone marrow
- Normochromic, normocytic anemias have diverse etiologies;
o in some of these anemias, specific abnormalities of red cell shape (best appreciated through visual
inspection of peripheral smears) provide an important clue as to the cause.
o The other indices can also be assessed qualitatively in smears, but precise measurement is carried
out in clinical laboratories with special instrumentation.
The most useful red cell indices are as follows:
- MCV: Mean cell volume: the average volume of a red cell expressed in femtoliters (fL)
- MCH: Mean cell hemoglobin: the avg content (mass) of Hgb per red cell, expressed in picograms
- MCHC: Mean cell hemoglobin concentration: the average concentration of hemoglobin in a given
volume of packed red cells, expressed in grams per deciliter
- RDW: Red cell distribution width: the coefficient of variation of red cell volume

Clinical manifestations of anemia

- pallor, weakness, fatigue, malaise, dyspnea
- hypoxia, fatty change in liver, myocardium, kidney
o cardiac failure (angina)
- oliguria/anuria (kidney hypoperfusion)
- CNS hypoxia (headache, vision loss, faintness)
Anemia of Blood Loss
- Acute Blood Loss
o Due to loss of intravascular volume  leading to collapse, shock, death
o Clinical features: depends of rate of hemorrhage, bleeding is external/internal
o Initially: red cells normal in size and color - normochromic, normocytic
o lowered Hct: hemodilution from fluid shift from interstitial to intravascular compartment
o increased erythropoietin: stimulates erythroid progenitors, 5-7 days later increased reticulocytes
 reticulocytes are larger in size than normal red cells (macrocytes) and have a blue-red poly-
chromatophilic cytoplasm.
o if bleeding is massive enough  decrease in BP  leukocytosis: compensatory release of
adrenergic hormones mobilizes granulocytes
o Early recovery from blood loss  thrombocytosis - increased platelet production
- Chronic Blood Loss
o only occurs when rate of loss > regenerative capacity of marrow or when iron reserves are
depleted and iron deficiency anemia appears
Hemolytic Anemia
General Characteristics of Hemolytic Anemias
 Premature destruction of RBCs (<120days) in phagocytes -> splenomegaly
 Elevated erythropoietin levels
 Accumulation of hemoglobin degradation products
 Increased number of reticulocytes

**increased erythropoietin -> normoblasts ->prominent reticulocytes

**phagocytosis  hemosiderosis (accumulation of hemosiderin in spleen, liver, bone marrow)
**severe  extramedullary hematopoiesis in liver, spleen, lymph nodes
**chronic hemolysis  elevated biliary excretion of bilirubin  pigment gallstone

Extravascular Hemolysis
- reduced deformability of RBCs  RBC sequestration and phagocytosis by macrophage
- symptoms: anemia, splenomegaly, jaundice
o decreased plasma haptoglobin (from binding extra hemoglobin)
- Tx: splenectomy

Intravascular Hemolysis (less common)

- caused by: mechanical injury, complement fixation, intracellular parasites (malaria), exogenous toxic
factors (clostridial sepsis)
- symptoms: anemia, hemoglobinemia, hemoglobinuria, hemosiderinuria, jaundice (or pigment
gallstones); decreased serum haptoglobin (complexes are phagocytosed)
- Hb  oxidizes to methemoglobin (brown color)

Hereditary Spherocytosis (HS)

- autosomal dominant disorder with defect in RBC cell membrane skeleton proteins – ankyrin, band 3,
spectrin, or band 4.2
o ankyrin and band 4.2 binds spectrin to band 3
o Protein 4.1 binds spectrin to glycophorin A
- sphere-shaped, non-deformable, easily sequestered RBCs
- RBC lifespan 10-20 days, hyperchromic, increased MCHC
- symptoms: splenomegaly, anemia, jaundice, aplastic crises
(cessation of erythropoiesis), pigment gallstones
- Tx: splenectomy (corrects anemia but not RBC shape)
- Dx: family hx, hematologic findings, lab evidence
- INCREASED MCHC – due to dehydration caused by loss of K+ and
water

Glucose-6-Phosphate Dehydrogenase Deficiency

- X-linked recessive; abnormality in glutathione metabolism ->
RBCs not protected against oxidative injury (reduced NADPH)->
hemolysis
- mutation may be protectant against malaria
- older RBCs hemolyse > younger RBCs
- Symptoms worse with exposures to oxidative stress (infections,
drugs, foods)
- oxidants cause intravascular and extravascular hemolysis ->
Heinz bodies, bite cells, spherocytes
- symptoms: increased reticulocytes, hemolysis is self-limited
Sickle Cell Disease
- point mutation in β-globulin causes replacement of glutamate with valine (HbS)
- Trait: heterozygous for HbS -protects against malaria
- HbS molecules polymerize when deoxygenated, cytosol gels and HbS aggregates form
- chronic hemolysis, microvascular occlusion, tissue damage
- Variables: Hb interactions, MCHC, intracellular pH, RBC transit time
- Pathogenesis of Sickle Cell Disease
o Deoxygenation -> influx of Ca2+ outflux of K+ and H2O -> sickling
o if reoxygenated: sickle cells -> become bi-concave but with dehydration and membrane damage, if
redeoxygenated -> sickling and microvascular occlusion
o -if membrane-damaged: sickle cells hemolyse
o vicious cycle - deoxygenation ->sickling -> hypoxia -> more sickling
- Sickle Cell Clinical Manifestations
o Howell-Jolly bodies; "crew-cut" Xray
o vaso-occlusive "pain" crises: fever, cough, chest pain, pulmonary infiltrates
o anemia, reticulocytosis, hyperbilirubinemia, sickled cells on blood smear
o children: hand-foot syndrome/dactylitis
o Sequestration crisis: splenomegaly, hypovolemia, shock; Aplastic crisis: parvovirus
o Altered kidney function -> hyposthenuria
o susceptibility to infxn (pneumonia, H. flu, meningitis)
o Tx: hydroxyurea (DNA synthesis inhibitor)

β Thalassemia
- β0 mutation  no β-globulin; β+ mutation -> reduced β-globulin
- mutations  deficit in HbA synthesis -> hypochromic, microcytic RBCs, reduced O2 capacity, decreased
RBC lifespan; membrane damage  ineffective erythropoiesis (erythroid hyperplasia and
extramedullary hemotopoiesis and extravascular hemolysis  cachexia), iron overload (from decreased
hepcidin)
- Pathogenesis of β-Thalassemia
o hallmark = aggregates of unpaired α-globulin chains (not seen on blood smears)
- β-Thalassemia syndromes
o β-Thalassemia Major (β0-β0, β+-β0, β+-β+) -
elevated HbF, severe transfusion-
dependent anemia 6-9 months after birth;
anisocytosis, poikilocytosis, microcytosis,
hypochromia, reticulocytosis, "crew cut"
x-ray, iron overload
o β-Thalassemia Minor (trait) (β0-β, β+-β) -
mild asymptomatic microcytic anemia
o β-Thalassemia Intermedia - severe non-
transfusion dependent anemia
- Clinical Features of β-Thalassemia
o growth retardation and early death in
untreated children
o Cardiac disease from iron overload and
secondary hemochromatosis (from
transfusions) -tx with iron chelators
o Tx: bone marrow transplant
α-Thalassemia
- inherited deletions that result in reduced or absent synthesis of α-globulin chains
- anema from lack of adequate hemoglobin and excess unpaired non-α-chains (β,γ,δ)-> Hemoglobin Barts
and HbH
- α-Thalassemia Syndromes
o severity depends on number of defective genes (there are 4 α-globulin genes)
o carrier=1: asymptomatic, no RBC abnormality (silent carrier state)
 trait=2: asymptomatic, microcytic anemia
 HbH disease=3: severe, non-transfusion-dependent anemia
 hydrops fetalis=4: lethal in utero w/o transfusions; b/c hemoglobin Barts doesn't release O2

Paroxysmal Nocturnal Hemoglobinuria

- acquired (X-linked lyonized) mutation in PIGA gene (enzyme for cell surface protein synthesis)
- blood cells are deficient in GPI-linked proteins that regulate complement activity: CD55, CD59 (C3
convertase inhibitor that prevents spontaneous complement activation), CD8
- intravascular hemolysis at night when blood pH is lower -> hemosiderinuria -> iron deficiency
- thrombosis is leading cause of death (dysfunctional platelets)
-dx: flow cytometry tx: bone marrow transplant

Immunohemolytic anemia
- caused by antibodies against RBCs  premature destruction
- sometimes caused by a drug
- dx: direct and indirect Coombs test
- Warm antibody type, cold agglutinin type, cold hemolysin type
Warm antibody type (immunohemolytic anemia)
- most common - 50% idiopathic, rest is autoimmune, drug-induced (penicillins, cephalosporins, α-
methyldopa), or lymphomas
- IgG antibodies against Rh antigens coat RBCs which bind to Fc receptors on phagocytes  partial
phagocytosis  spherocytosis  splenomegaly and extravascular hemolysis
Cold agglutinin type (immunohemolytic anemia)
- IgM antibodies bind to RBCs at low temperatures
- antibodies appear after infxns (mycoplasma pneumoniae, EBV, CMV influenza, HIV)
- agglutination occurs in "cold skin" areas (fingers, toes, nose, ears) -> pallor, cyanosis, Raynaud
Cold hemolysin type (immunohemolytic anemia)
- "paroxysmal cold hemoglobinuria"  intravascular hemolysis and hemoglobinuria (sometimes fatal)
- autoantibodies (IgG) bind to P group RBC antigens in cool areas of body  complement-mediated lysis
occurs when RBCs move to warm areas of body
- most cases follow viral infections and are transient
- treatment involves removing offending factors (drugs), or treating with immunosuppression and
splenectomy

Hemolytic anemia resulting from mechanical trauma to red cells

 mechanical trauma from cardiac valve prostheses -hemolysis occurs from shear forces from turbulent
flow and pressure gradients across mechanical valves
 microangiopathic disorders (DIC, TTP, HUS, malignant hypertension, SLE, disseminated cancer) -luminal
narrowing (deposition of fibrin and platelets)
 dx: RBC fragments (schistocytes), burr cells, helmet cells, triangle cells
Megaloblastic Anemias
- impairment of DNA synthesis that leads to morphologic changes-
- pernicious anemia (vit B12 and folate deficiency)
- RBCs are macrocytic and oval, MCHC is not elevated, reticulocyte count is low, neutrophils are
macropolymorphonuclear

Pernicious anemia: Vitamin B12 deficiency

- caused by autoimmune gastritis and attendant failure of intrinsic factor production which leads to vit
B12 deficiency
- Symptoms: atrophic glossitis, CNS lesions from demyelination of lateral and dorsal tracts ( parathesia,
ataxia, paraperesis)
- Dx: megaloblastic anemia, leukopenia, low vitB12, high homocysteine and methylmalonic acid
- may have inc risk for gastric carcinoma and vascular disease
- Normal Vitamin B12 Metabolism
o cobalamin complex; humans can't synthesize it (comes from microorganisms), usually from animal
food products
o bound B12 is released by pancreatic proteases then associated with intrinsic factor (secreted by
parietal cells in stomach), transported to ileum and endocytosed, then associated with
transcobalamin II and secreted into plasma
o high bioavailability of vitamin B12 supplements
- Biochemical Functions of Vitamin B12
o 1) methylcobalamin is a cofactor for conversion of homocysteine to methionine by methionine
syntheses via FH4
 folic acid is needed for this rxn, and if deficient causes the anemia -supplement cures
anemia
o 2) isomerization of methylmalonyl CoA to succinyl CoA -> demyelination ->-neurologic
complications (not cured with folate supp.)
- Other disorders of Vitamin B12 deficiency
o achlorhydria and loss of pepsin secretion
o gastrectomy (no intrinsic factor)
o loss of exocrine pancreas function
o ileal resection (reduced absorption)
o tapeworms (competes for host vitB12)
o hyperthyroidism, pregnancy, disseminated cancer, chronic infection (increased vitB12 demand)

Anemia of folate deficiency

- causes megaloblastic anemia similar to vitamin B12 deficiency (through reduced DNA synthesis)
- via FH4 participates in 1)purine synthesis, 2)homocysteine->methionine 3) deoxythymidylate
monophosphate synthesis
- Etiology of Anemia of folate deficiency
1. decreased intake (cannot be synthesized, sensitive to heat, not stored) -usually in general
malnutrition setting, certain drugs impair absorption
2. increased requirements (pregnancy, infancy, hemolytic anemias, etc)
3. impaired utilization (folic acid antagonists-methotrexate-inhibit dihydrofolate reductase)
- Clinical manifestations of Folate deficiency anemia
o decreased levels of folate in serum and RBC
o no neurological effects
o folate administration may exacerbate neuro symptoms in vit B12 deficiency anemia (so check
levels first)
Iron deficiency anemia
- most common nutritional disorder in the world
- 20% of heme iron from diet is absorbed
- 80% of functional iron is in hemoglobin (myoglobin and iron-containing enzymes (catalase and
cytochromes) contain the rest)
- storage pool (hemosiderin and ferritin) = 15-20% of total body iron
- iron is recycled extensively, it is transferred by iron-binding glycoprotein transferrin (synthesized in liver)
o free iron is highly toxic so storage iron must be sequestered (by binding to ferritin or hemosiderin)
o plasma ferritin is derived from the storage pool of body iron, its levels correlate with body iron
store levels
- major function of plasma transferrin is to deliver iron to cells
- iron balance is maintained by regulating GI absorption – there is no regulated pathway for excretion
- luminal non-heme iron is Fe3+ and must be reduced to Fe2+ (ferrous) by ferrireductases (b cytochromes
and STEAP3)
- iron that enters duodenal cells enters via transport to the blood or storage as mucosal iron
- Iron absorption is regulated by hepcidin
o inhibits iron transfer from the erythrocyte to plasma by binding to ferriportin and causing it to be
endocytose and degraded
o it also suppresses iron release from macrophages -alterations in hepcidin have a central role in
diseases involving disturbances of iron metabolism
- Rare form of microcytic anemia caused by mutations that disable TMPRSS6 (hepatic transmembrane
serine protease) that normally suppresses hepcidin production when iron stores are low
o affected pts have high hepcidin levels, reduced iron absorption and failure to respond to iron
therapy
- Hepcidin is low in hemachromatosis (systemic iron overload) – primary is associated with inherited
mutations in hepcidin gene or genes that regulate hepcidin expression
- Secondary hemachromatosis can occur in diseases associated with ineffective erythropoiesis (-
thalassemia major and myelodysplastic syndromes)
- Etiology of Iron Deficiency Anemia
1. Results from dietary lack of iron: men need 7-10mg, women 7-20mg (avg intake is 15-20mg)
a. Heme iron is more absorbable than inorganic iron –absorption of inorganic iron is enhanced
by ascorbic acid, citric acid, amino acids and sugars –it is inhibited by tannates, carbonates,
oxalates, and phosphates
b. Dietary iron deficiency usually occurs in infants, elderly, impoverished, teenagers
2. Impaired absorption –due to sprue, other causes of steatorrhea, chronic diarrhea, gastrectomy,
achlorhydria
3. Increased requirement – infancy and childhood and pregnancy (esp if pregnancies are close
together)
4. Chronic blood loss **most important and most common
a. External hemorrhage or internal bleeding into GI, urinary or genital tracts depletes iron
reserves
b. Iron deficiency in adult men or postmenopausal women MUST be attributed to GI bleed
until proven otherwise
- Pathogenesis
o iron deficiency causes microcytic, hypochromic anemia
o anemia only appears when iron stores are completely depleted and is accompanied by low serum
iron, ferritin and transferrin levels
- Clinical Features
o features of general anemia
 o iron depletion in cells causes: koilonychia (spoon nails), alopecia, atrophic changes to tongue
(glossitis) and gastric mucosa, and intestinal malabsorption, depletion of iron from CNS may cause
pica
o Plummer-Vinson Syndrome – triad: esophageal webs, microcytic hypochromic anemia, atrophic
glossitis
o Dx: decreased H&H, microcytosis, hypochromia, poikolocytosis, serum iron and ferritin are low,
total plasma iron-binding capacity (increased trasferrin levels) is high, hepcidin levels are low
o in uncomplicated iron-deficiency anemia tx is iron supplements, reticulocytes appear in 5-7 days

Anemia of chronic disease

- impaired red cell production associated w/ chronic diseases: most common anemia in hospitalized pts
- Illnesses associated:
1. Chronic microbial infections (osteomyelitis, bacterial endocarditis, lung abscess)
2. Chronic immune disorders (RA, regional enteritis)
3. Neoplasms (carcinomas of lung and breast, Hodgkin lymphoma)
- occurs in setting of chronic inflammation
- associated with low serum iron, reduced total-binding capacity, abundant iron in tissue macrophage
- -Inflammatory mediators (esp IL-6) stimulate increase in hepatic production of hepcidin (inhibits
ferriportin function in macrophages and reduces transfer of iron from the storage pool to developing
erythroid precursors in the bone marrow (as a result erythroid precursors are starved for iron)
- erythropoietin is low (maybe b/c hepcidin suppresses production)
- iron may be sequestered to prevent access to microbes
- hepcidin is structurally related to defensins (antibacterial)
- anemia is usually mild, RBCs are normochromic and normochromic OR microcytic and hypochromic
- increased storage of iron in marrow macrophages, high serum ferritin level, reduced total iron-binding
capacity rules out iron-deficiency anemia
- Tx: treat underlying disease, sometimes (with cancer) erythropoietin