Anaemia

Stem cell
Erythropoiesis
 Erythropoietin (EPO)

• hormone produced by the kidney in NB and by

liver in fetus
• promotes the formation of red blood cells
• kidney cells make and release erythropoietin
in response to hypoxia
• Action through mRNA
Normoblasts
• Full metabolic
functions

• Low O2 carrying
capacity

• Looses nucleus by
extrusion
Reticulocytes
• 1% of the red cells

• develop and mature into

RBC

• have a reticular network

of ribosomal RNA

• visible with Methylene

blue
Poikilocytosis
RBC
• Looses nucleus to accommodate HB
• Increased 02 carrying capacity
• Flexible disc
• Contain 40 enzymes
• No mitochondria
• ATP by anaerobic and pentose pathway
• Energy needed to keep iron in ferrous
state and to neutralize oxidants
• 60-90 days life span
• Utilize glucose without insulin
 Normal values
Hb%:
• Male: 13.8 to 17.2 gm/dL; Female: 12.1 to 15.1 gm/dL
RBC Count:
• Male: 4.7 to 6.1 million cells/mcL; Female: 4.2 to 5.4 million
cells/mcL
MCV:
• 80 to 100 femtoliter(fl)
MCH:
• 27 to 31 picograms/cell
MCHC:
• 32 to 36 grams/dl
packed cell volume (PCV):
• 48% for men and 38% for women.
Red blood cell distribution width
• a measure of the variation of
RBC size.

• red blood cells of unequal sizes,

is known as anisocytosis.

• Normal RDW is 11 - 14%.

• iron deficiency anaemia shows

an increased RDW.
• RDW = ( standard deviation of MCV ÷
mean MCV) × 100
 Anemia
Definition:
1. WHO: A hemoglobin (Hb) concentration 2 SDs below the mean
Hb concentration for a normal population of the same gender
and age range
2. US National Health and Nutrition Examination Survey: anemia is
defined as a Hb concentration of less than 11.0 g/dL for both
male and female children aged 12 through 35 months.
3. For certain populations (ie, people living at high altitudes),
adjustment of these values may be necessary.
• Anaemia is a sign of an underlying pathology (it is not a
diagnosis)
 Classification of anemia
I. Etiologic classification
1. Impaired RBC production
2. Excessive destruction
3. Blood loss
II. Morphologic classification
1. Macrocytic anemia
2. Microcytic hypochromic anemia
3. Normochromic normocytic anemia
III. Types of RBCs
1.Normocytic 2.Microcytic 3. Macrocytic
 Classification
1. Association of anemia with other hematologic abnormalities.
I. Thrombocytopenia, abnormalities in white blood cell
numbers, or the presence of abnormal leukocytes:
I. Aplastic anemia,
II. Leukemia, or other
III. Malignant marrow disease.
2. Association of anemia with reticulocytosis.
1. Bleeding
2. Ongoing hemolysis.
3. Association of anemia with reticulocytopenia
 Types of RBCs
Normocytic Microcytic Macrocytic
 Iron-Deficiency Anemia
1. The most common nutritional deficiency in children
and is worldwide in distribution.
2. 30% of world population is anemic
3. 40–50% of children under 5 years of age in
developing countries are iron deficient.
4. 5.5% in school children
5. 2.6% in pre-adolescent children
6. 25% in pregnant teenage girls
 Normal daily iron requirement

1. 1 mg /day is the daily requirement

2. Only 10% is absorbed from the gut
3. Hence 10 mg is the daily requirement
4. Peak Fe demand
1. Late infancy: Rapid growth; low iron in milk
2. Adolescence(>Girls): growth spurt; menstrual loss
 Iron Deficiency Anaemia
1. Iron content of newborn is .5gm ; adult is 5 gm
2. 0.8 mg should be absorbed daily for 15 years to reach
this value.
3. Loss of iron is 1 mg/day through hair, epithelium and
neils
4. 1 mg /day is the daily requirement
5. Only 10% is absorbed from the gut
6. Hence 10 mg is the daily requirement
 Causes of iron deficiency
1. Deficient intake
2. Inadequate absorption: inflammatory bowel disease,
celiac disease; chelators; lack of acidity
3. Increased demand: Periods of rapid Growth; preterm;
cyanotic CHD
4. Blood loss: cow milk allergy; Meckel’s diverticulitis;
polyps, hemorrhoids; purpuras
5. Impaired absorption: short bowel; gastrectomy
6. Defect in transport: Atransferrinemia
7. intracellular transport:Defects of heme biosynthesis
 Causes so Iron deficient anemia
1. Newborn:
1. Early cord clamping < 2 mts.
2. Blood sampling
2. Infants:
1. Milk has less iron
2. Lack of cereal diet
3. Cows milk allergry
4. Peptic ulcer
5. Meckel’s diverticulitis
6. Rectal polyp
7. Hemaangioma
8. Chronic diarrhea
 Causes of anemia
Adolescents
1. Growth spurt
2. Menstrual loss
3. Iron chelators- eg. Tea
4. Iron deficient food- faddism
5. Peptic ulcer
6. Hook warm
7. Helicobacter pylori
 Stage 1
1. The first stage of iron deficiency is storage iron
depletion.
2. Anisocytosis and an increased percentage of
microcytic cells are the first hematologic
abnormalities.
3. During this stage, no deficit of iron supplied to the
erythroid marrow for red blood cell (RBC)
production occurs
 Stage 2
1. If the negative iron balance continues, iron-
deficient erythropoiesis (IDE) will occur.
2. Mean corpuscular volume (MCV) and mean
corpuscular hemoglobin (MCH) decrease.
3. During this stage, erythroid iron supply is
diminished, but hemoglobin concentration remains
in the normal range.
 Stage 3
1. If the negative iron balance persists, IDA finally develops.
2. The third stage is characterized by a decrease in the hemoglobin
concentration and reduction in RBC size and hemoglobin
content.
3. Hematologic abnormalities in iron deficiency progress as
impairment of hematopoiesis progresses.
4. Characterized by:
1. Low MCH
2. Hemoglobin concentration < 9 g/dL

3. Transferrin saturation < 16%

Symptoms
• Chronic anemia is compensated

• Acute or severe anemia: symptoms develop

• Pallor

• Tiredness, easy fatigability and irritability

• generalized muscle weakness

• Phagophagia and pica

• School failure

• Loss of hair

• Cardiac de compensation
 NON-HEMATOLOGICAL MANIFESTATIONS

• Gastrointestinal tract:
1. Anorexia-
2. Pica
3. Atrophic glossitis
4. Dysphagia
• Central nervous system:
1. Irritability
2. Fatigue
3. shorter attention span
4. Reduced cognitive performance
5. Breath-holding spells
• Cardiovascular system:
1. Hyperdynamic state
2. Cardiac hypertrophy
3. CCF
• Musculoskeletal system:
1. Deficiency of myoglobin and cytochrome C
2. Fatique
3. Weekness
4. Lactic acidosis
5. Poor fracture healing
• Immune:
1. Lower frequency of bacterial infection
2. Increased frequency of respiratory infection
Decreased myeloperoxidase in leukocytes
 Lab tests
1. Hb% < 11 g/dl
2. PCV: decreased
3. Serum ferritin - 10-12 µg/l
4. Serum Iron:
1. Males: 50-150 mcg/dL
2. Females: 35-145 mcg/dL
5. Iron binding capacity- 250-400 mcg/dL
6. Blood Smear study
7. Stool occult blood
8. Bone marrow
 Differential diagnosis

• Thalassemia trait & Hb E disease

– Hb A2 increased

– Hb F increased

– Serum iron and IBC normal

• Lead poisoning:
– Basophilic stipling

– Free erythro protoporphyrin (FEB) increased

• Sideroblastic anemia:
– amino levulinic acid synthase deficiency
– Defective heme synthesis

– Sideroblasts

• Atransferrinemia
– No stainable iron in normoblasts
1. Thalassemia (α and β)
2. Disorders of heme synthesis:
1. a. Lead
2. b. Pyrazinamide
3. c. Isoniazid
3. Sideroblastic anemias
4. Hereditary orotic aciduria
5. Hypo- or atransferrinemia
6. Copper deficiency
7. Inborn error: Congenital defect of iron transport to
red cells
Basophilic stippling Sideroblasts
 Treatment
• Ferrous sulphate best absorbed
– bad taste,
– gastric upset
– Constipation

• Contains 20 % elemental iron

• 4-6 mg / kg in 3 divided doses
• Treat for 8 weeks
 Prevention
• Iron fortified formula
• Reduce milk to 500
ml/day
• Iron rich food
• Avoid iron chelators
 Response

• Hb raises by .5 gm / day
• Reticount increases
Blood Transfusion:
– Rarely necessary
– Precipitates CCF
– Give 2-3 ml/kg packed cells
 Physiological anemia of infancy

Site of production
• Fetus lives in sterile
condition and less need Yolk sac
mesoblastic
for WBC

• Lives in hypoxic
Liver
condition and hence Hepatic

need for RBCs more

Bone marrow
Myeloid
 Physiological anemia of infancy
• Newborn: • Causes:
– PCV: 45-65% – Decreased RBC life span
– Reti. Count: 2-8% – Decreased eryhtropoietin
– Hb: 16-18gm% – Rapid increase in body
• 6-8 weeks weight

– Hb: 10 gm%

– PCV 30%