Chapter 12

Anemia

INTRODUCTION
CLASSIFICATION
SIGNS AND SYMPTOMS

INTRODUCTION MORPHOLOGICAL CLASSIFICATION

the sze
Anemia is the blood disorder characterized by the red depends upon
Morphological cassiication mean
is d e t e m i n e d by
uction in: color of RBC. Size of RBC 1

1. Red blood cell (RBC) count. puSCular volume (MCV)

Color s detemined by
concentation (MCHC. Ey
2. Hemoglobin content corpuscular hemogiobin into Dur peS (
3. Packed cell volume (PVC). method. the anemia is classfed
12.1): anemia.
1. Nomocytic nomochromic
Causes for Reduction in RBC Count normochromic anemia.
2. Macrocytic
Hemoglobin Content and PCV
3. Macrocytic hypochromic anemia
4. Microcyic hypochromic anem
Generally, reduction in RBC count. hemoglobin content
and PCV occurs because of any of the following inci-
dents: ETIOLOGICAL CLASSIFICATION
1. Decreased production of RBC. On the basis of etiology (stucty of cause or origin), ane
2. Increased destruction of RBC. mia is divided into five types (Table 12.2)
3. Excess loss of blood from the body. 1. Hemorhagic anemia.
All these incidents are caused either by inherited 2. Hemohytic anemia
disorders or environmental influences such as nutritional 3. Nutrition deficiency anemia.
problem, infection and exposure to drugs or toxins. 4. Aplastic anemia.
5. Anemia of chronic diseases.
CLASSIFICATION OF ANEMIAA
1. Hemorrhagic Anemia
Anemia is classified by two methods:
A. Morphological classification. Hemorthage refers to excessive loss of biood (refer
B. Etiological classification. Chapter 112). Anemia due to hemorrhage is known as
TABLE 12.1: Morphological classification of anemia

Type of anemia Size of RBC MCV (cu p Color of RBC MCHC )

Normocytic normochromic Normal 90 Nomal 30
Normal 90 Less
Normocytic hypochromic Less than 30
Macrocytic hypochromic Large More than 90 Less Less than 30
Microcytic hypochromic Small Less than 78 Less
Less than 30
 Chapter 12 Anemia
TABLE 12.2: Etiological classificatiorn of anemia 87
Causes
Type of anemia Morpholo9y of RBC
ACute loss
emorrhagic anemia Excess loss of blood by internal or external bleeding Normocylic,
Chronic loss. Microcytic.and nornochromic,
and
Extrinsic hemolytic anemia:
i. Liver failure
hypochromic
i. Renal disorder
ii. Hypersplenism
iv. Burnss
v. Infections hepatitis, malaria and septicemia
vi. Drugs - penicillin, antimalarial drugs and sulfa drugs Normocytic normochromic
Hemolytic anemia vii. Poisoning by lead, coal and tar
vii. Presence of isoagglutinins like anti-Rh
xi. Autoimmune diseases rheumatoid arthritis and
ulcerative colitis

Intrinsic hemolytic anemia Sickle cell anemia

Sickle shape
Hereditary disorders Thalassemia Small and irregular
Iron deficiency
Nutrition deficiency Protein deficiency
Microcytic, hypochromic
anemia Vitamin B2 deficiency
Macrocytic, hypochromic
Folic acid deficiency
Macrocytic, normochromicihypochromic
Aplastic anemia Bone marrow disorder
Megaloblastic, hypochromic
i. Non-infectious inflammatory diseases
Normocytic, normochromic
-

rheumatoid
Anemia of chronic arthritis
ii. Chronic infections tuberculosis
diseases
ii. Chronic renal failure Normocytic, normochromic
iv. Neoplastic disorders Hodgkin's disease

hemorrhagic anemia. It occurs both in acute and chronic Due to continuous loss
hemorrhagic conditions. of
blood.
causing iron deficienoy.lotThis afects
from the body of ron
is os
Acute hemorrhage
synthesis of
hemoglobin resulting less
in
te

Acute bin content in the cells. The cells hemogl-

hemorrhage refers to sudden loss of a large also become
quantity of blood as in the case of accident. Within about Hence, the RBCs are microcytic and smal.
24 hours after the Table 12.2). hypochromic refer
hemorrhage, the plasma portion of
blood is replaced. However, the
replacement of RBCs
does not occur quickly and it takes at 2. Hemolytic Anemia
least 4 to 6 weeks.
So with less number of
RBCs, hemodilution occurs. Hemolysis means destruction of RBCs Anemia due
However, morphologically the RBCs are
normochromic. normocytic and toexcessive hemolysis which is not compensated by
increased RBC production is called hemolytic anemia. It
Decreased RBC count causes
lates the bone marrow to hypoxia, which stimu- s classified into two
types:
produce
So, the condition is corrected
more number of RBCs. A. Extrinsic hemolytic anemia.
within 4 to 6 weeks. B. Intrinsic hemolytic anemia.
Chronic hemorrhage
A. Extrinsic hemolytic anemia
Chronic hemorrhage refers to loss of blood RBCs by
or external by internal The type of anemia caused by destruction of
in
bleeding, over a long
period time. It occurs
of external factors. Healthy RBCs are hemolyzed by fac-
conditions like peptic ulcer, antibodies, chem-

menorrhagia. purpura, hemophilia and ors outside the blood cells such as

cals and drugs.

 characterize
C o o l e y ' s

disorder,
as

Common
Fluids inhorited known
Body
Section 2Blood and
i. Thalassomia
Mediterranean
m o r e
a l s o

c o u n -

88 an
is
It
anemia. t
1S

anemia inc- is
hemoglobin.
hemolytic halassomia
Common
causes of extrinsic
abnormal
Mediterranoan o x t e n t
in

by
lude: or
to
some

i. Liver failure a n e m l a

Thalland
and

t y p e s :

i. Renal disorder n
Innormalhemoglobin,numberofa-andp-polypeptide
two
of two
Thalassemia is these

ii. Hypersplenism. tries

a m o n g

iv. Burns. a-thalassemia common

malaria and septicemia. these
. I n f e c t i o n s like hepatitis, and of
antimalarial drugs
very
B-thalassemia.

penicillin, B-thalassemia is production

syn.
vi. Drugs such
as the
defective

The thalassemia, of the

sulfa drugs. s u b s t a n c e s like
lead, coal because precipitation o f
chemical In to
vii. Poisoning by equal.
imbalanced
the leading
chains
is c a u s e s

occ
R B s ,

and tar b e c o m e s

like anti-Rh.
This also
immature

vii. Presence of isoagglutinins arthritis chains g e n e s .

precipitation
the
ofglobin
rheumatoid
such as in The
Autoimmune diseases anemia thesis c h a i n s hemolysis.
ix. hemolytic erythropoiesis.
colitis. Extrinsic polypeptide
in
and ulcerative autoimmune
hem-
in r e s u l t i n g

autoimmune disease is disturbance

cells,
due to red
In
m a t u r e

olytic anemia. urs in infancy.

or
life
anemia a - t h a l a s s e m i a

in
fetal
In adults
B. Intrinsic hemolytic
a b n o r m a l .

o c c u r s

are
of RBCs a-thalassemia or y-chains

by destruction
absent

anemia is caused
This type of The less, children,
of and
There is production are
and in
defective RBCs.
e r y t h r o p o i e s i s
a - c h a i n s

because of the this, e x c e s s

and are destroyed in d e f e c t i v e

may die
which are short lived or
are
to
unhealthy RBCs,
P-chains stillborn

inherited andit
leads
This be
soon. Intrinsic hemolytic anemia is often in
e x c e s s .

infants
may
thalassemia. The
anemia and
includes sickle cell
hemolysis.
immediately after birth.
cell anemia
Because of the
abnormal shape in sickle
and
become more fragile
the RBCs a b s e n t or
and thalassemia, B-thalassemia number,
susceptible for hemolysis. are
less in
B-chains The
a-chains pre-
B-thalassemia, a-chains.
In of
and hemolysis.
excess
anemia
i. Sickle cel abnormal with an
erythropoiesis
char defective
inherited blood disorder,
Sickle cell anemia is an
also cipitate causing
blood cells. It is
acterized by
sickle-shaped red Nutrition Deficiency Anemia
disease.
sickle cell
SS disease or
called hemoglobin sub-
of African origin. of a nutritive
It is c o m m o n in people Anemia that occurs due to deficiency
abnormal hemoglobin called nutrition
Sickle cell anemia is
due to the
In this, stance necessary for erythropoiesis is
cell hemoglobin). are n e c e s -
called hemoglobin S (sickle anemia. The substances which
a-chains are normal
and B-chains are abnormal. Ihe deficiency
are
vitamins
iron, proteins and
S polymerize into long chains sary for erythropoiesis
molecules of hemoglobin nutrition deficien
the cells. like C, B. and folic acid. The types of
inside
and precipitate cy anemia include the following.
Because of this, the
RBCs attain sickle (crescent)
more fragile leading
to hemolysis
shape and become Iron deficiency anemia
when a person
cell anemia occurs
(Fig. 12.1). Sickle from each parent). Iron deficiency anemia is the most common type of
inherits two abnormal genes (one
sickle cells aggregate and anemia. It develops due to inadequate availability of
In children, hemolyzed
to infarction (stop- iron for hemoglobin
block the blood vessels, leading synthesis. RBCs are microcyticC
The infarction is common in and hypochromic.
page of blood supply).
infarcted small bones in hand and foot Causes of iron
small bones. The
results
small bone
in varying length in the digits. This condition is i. Loss of blood. deficiency anemia:
known as hand and
foot syndrome. Jaundice also i. Decreased
intake of iron.
children. ii. Poor
occurs in these
absorption of iron from intestine.
 m a r -

b o n e

red
Fluids of fatty
90 Section 2 Blood and Body 4 . A p l a s t i cA n e m i a
d i s o r d e r
r e p l a c e d
by
f o l l o w i n g

the and
to
conditions like growth is
due
in
the

Increased demand for iron in

r e d u c e d

iv. a n e m i a

marrow
is o c c u r s

radia-
pastic disorder

and pregnancy. Red

bone
marrow
ray
OW g a m m a

Features of iron deficiency anemia

Bone
or
tissue X-ray
salts,
to
nails (koil- conditions: gold
Features include brittle nails, spoon-shaped
exposure

q u i n i n e ,

and
of papilla in tongue
e p e a t e d

onychias), brittle hair, atrophy

toxins,

tion. bacterial

dysphagia (difficulty in swallowing) of

benzene, radium, etc.
P r e s e n c e i n f e c t i o n s .

HIV and
Protein deficiency anemia and normocytic
ii. T u b e r c u l o s i s .
hepatitis

the synthesis of hemoglo- like are

Due to deficiency of proteins, infections

the
RBCs

are macrocytic
and hypo VViral
bin is reduced. The RBCs
anemia,

aplastic
in
chromic. n o r m o c h r o m i c .

Addison 's anemia type

Pernicious anemia or
D i s e a s e s
c o m m o n

Chronic
second
of char-
anemia due to deficiency of 5. A n e m i a is the It is
Pemicious anemia is the d i s e a s e s anemia).
distur-
due to
called Addison's anemia. It is by
chronic
of d e f i c i e n c y

vitamin B,. It is also Anemia iron

caused

because of autoimmune anemia

(next to of
RBCs, e r y t h r o p o i e t i n

atrophy of the gastric

mucosa
to
results in of by
short
lifespan
r e s i s t a n c e
sustained

destruction of parietal cells. The gastric atrophy acterized m e t a b o l i s m

or months
of
in iron few
factors and poor absorp-
decreased production of intrinsic
bance after normochromic.

develops
and
which is the maturation factor for RBC. action.
Anemia
diseases
are:

tion of vitamin B, RBCs are

normocytic

of
chronic
immature with almost normal or disease. anemia such as
The RBCs are larger and causes
of diseases

level. Synthesis of hemoglobin is auto-

Common
inflammatory

slightly low hemoglobin i.

Non-infectious

(chronic
inflammatory

anemia. So, cells are mac-

almost nomal in this type of rheumatoid
arthritis

rocytic and normochromic/hypochromic. disorder affectingjoints) (infection

cau-
immune tuberculosis

Before knowing the cause of

this anemia, it was veryy infections like
and abscess
i. Chronic
to treat the patients and
the disease was con Mycobacterium
tuberculosis)
in lungs.
difficult by
sed infected tissue)
called pernicious anemia. in the
sidered to be fatal. So, it was (collection of pus erythropoietin
which the
Pernicious anemia is common
in old age and it is renal failure in neces-
ii. Chronic erythropoietin is
females than in males. It is
associated (since
more c o m m o n in secretion decreases
to produce
like disorders of thyroid of bone m a r r o w
with other autoimmune diseases
stimulation
sary for the
features of c a u s e s anemia).
etc. Characteristic RBCs, its deficiency
gland, Addison's disease, and disorganized
color of skin (due
this type of anemia are lemon yellow iv. Neoplastic disorders (abnormal
and red sore such as Hodgkin's dis-
to anemic paleness and mild jaundice) growth in tissue or organ)
and can-
tongue. Neurological
disorders such as paresthesia ease (malignancy involving lymphocytes)
tingling, burning, cer of lung and breast.
(abnormal sensations like numbness,
weakness and ataxia (muscular The RBCs are generally normocytic and normochro-
etc.), progressive
incoordination) are also observed
conditions.
in extreme mic in this type of anemia. However, in progressive dis-
ease associated with iron deficiency, the cells become
Megaloblastic anemia
microcytic and hypochromic.
of anoth-
Megaloblastic anemia is due to the deficiency
er maturation factor alled folic acid. Here, the RBCs SIGNS AND SYMPTOMS OF ANEMIA
not matured. The DNA synthesis is also defective,
are
11. METABOLISM
so the nucleus remains immature. The RBCs are mega
Basal metabolic rate increases in
loblastic and hypochromic. severe anemia.
Features of pernicious anemia appear in megalo-

blastic anemia also. However, neurological disorders 12. SPLEEN

may not develop. Spleen enlarges (splenomegaly) in some
types of anemia.
 Chapter 12 Anemia
5. KIDNEY
3. LIVER
Renal function is
91
Enlargement of liver (hepatomegaly) and
liver dysfune
disturbe Albuminuria
tion occur in sickle cell anemia 6 . SKIN
AND MUCOUS rmmrn
4. DIGESTION Color of the skin and
mucos
MEMBRANE
Anorexia, nausea, vomiting. abdominal
discomfort and Paleness is more constant
Paleness re
rmembrare
and
COnstipation are common. In pernicious
anemia, there
oharyngeal nucOUS proninert rimes
prominen ale
In aplastic anemia lobes. paln and nail mernbrane. in
brra
atrophy of papillae
rotic lesions appear
in

in
tongue.
mouth and pharynx. Color of
becomes thin and dry.
hair occur. The
be Skin niunefivae
oses
loses the
Thinning. loss
ard
an
the elastirty
its aar
nails loss and
Stools changes to black or maroon.
becorme brittle and aarearty and
sasity ranens
and
f
breakatle

Neuromuscular system Metabolism

Spleen
BMR
Digestion

Headache and dizziness Increase in BMR

Fatigue and weakness Enlargement
NauseaAnorexia
and vcmiting
Color change n
Respiration stools

Liver

Anemia

Hyperventilation
Dyspnea
Enlargement
Heart
Reproductive system Skin and mucosa
Kidney

Tachycardia
Increased cardiac output Menorrhagia Become Disturbed function
Angina Oligomenorrhea or pale or yellowish Albuminuna
Heart attack Amenorrhea
FIGURE 12.2: Symptoms of anemia
 92 Section 2 Blood and Body Fluids
Skin becomes yellow due to
anemia. jaundice in
hemolytic 9 . REsPIRATION
RESPIRAI and force
of respiration
7 . REPRODUCTIVE SYSTEM is increase in rate shortness
an
nere Sometimes, it leads to
In (hyperventilation). dissociation
females, the menstrual cycle is Or Dreath (dyspnea).
Oxygen-hemoglobin
be
menorrhagia, oligomenorrhea disturbed. There may
curve is shifted to right.
Chapter 77). oramenorrhea (refer
8 . CARDIOVASCULAR SYSTEM 10. NEUROMUScULAR SYSTEM
increased
Common neuromuscular symptoms include
There is an increase in concentration, rest-
heart rate sensitivity to cold, headache, lack of
cardiac output. Heart is dilated (tachycardia) and or vertigo
are
produced.
and
The velocity of blood
The H cardiac murmurs lessness, irritability, drowsiness, dizziness
u There
c ed .
is angina or heart
blood flow is increased. (especially while standing) and fainting.
attack in severe anemia Muscles become weak and are fatigued quite
often
(Fig. 12.2).
and quite easily. The patient feels lack of energy.