9/12/2023

Anemia and polycythemia

A presentation by Dr. Qais Baryalai

A presentation by Dr. Qais Baryalai 1

Anemia
• Deficiency of hemoglobin in the blood, caused by low RBCs or low
hemoglobin in the cells
• Normal blood hemoglobin in males varies from 14 to 18 g/100 ml
whereas in females it varies from 12 to 14 g/100 ml of blood.
• Hemoglobin below 13.5g/dL in men and below 12g/dL in women
• Mechanism:
1. Decreased production of RBC
2. Increased destruction of RBC
3. Excess loss of blood from the body

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Types of anemia
1. Normocytic Anemia: RBCs are normal in size, but RBC count is less.
(80-100 femtoliter)
2. Macrocytic Anemia: RBCs are larger in size, and RBC count is less.
(>100fL)
3. Microcytic Anemia: RBCs are smaller in size and RBC count is less
(<80fL)

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• Pearls
• Microcytic anemia causes:
1. Loss of iron (IDA, and
ACD)
2. Loss of heme Hemoglobin subunit
(Sideroblastic anemia,
lead poisoning)
3. Loss of globin
(Thalassemia)

Heme Globin

Ferrous
Porphyrin
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Macrocytic anemia that

occurred due to DNA Anemia
defects are called
Megaloblastic anemia

Normocytic
Microcytic Macrocytic
• Non-hemolytic • Hemolytic anemias
(Low (High reticulocyte
reticulocyte index)
• Iron deficiency anemia index) 1. Extrinsic cause:
• Anemia of chronic disease • Iron deficiency • Antibody,
• Thalassemia • Folate/B12 deficiency
anemia infection, trauma
• Alcohol
• Lead poisoning • Anemia of 2. Intrinsic cause:
• Liver disease
• Sideroblastic anemia chronic disease • Membrane,
• Renal failure enzyme or
• Aplastic protein defects
anemia
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Hemolytic Anemia
• Hemolysis means destruction of RBCs.
• Anemia due to excessive destruction of RBCs which is not compensated by
increased RBC production is called hemolytic anemia.
• Types of hemolytic anemia
1. Extrinsic hemolytic anemia: caused by Antibodies, infection, mechanical
trauma
2. Intrinsic hemolytic anemia: caused by membrane, enzymes or globin chain
defects

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Pernicious anemia or Addison’s anemia

• It is an autoimmune disease caused by atrophy of gastric mucosa
(including parietal cells) because immune system attack gastric
mucosa.
• When intrinsic factor is produced at low levels >> vitamin B12 is absorbed
poorly >> It result in deficiency of Vitamin B12 and megaloblastic anemia

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Aplastic Anemia
• Aplastic anemia occur when Red bone marrow is degraded or
replaced by different causes
• As a result WBC and platelet counts are also decreased
• Causes: Exposure to X-rays, gamma rays, TB, viral infections, cancer, drugs
• Anemia is of normocytic type

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Anemia of Chronic Diseases

• The second most common type of anemia after iron deficiency
anemia
• It is a mild anemia
• This type of anemia develops after few months of chronic diseases
like cancers, rheumatoid arthritis, TB, Chronic renal failure.
• Mechanism:
1. Chronic kidney disease >> decreased erythropoietin production
2. Inflammation (IL-6) >> Increased hepcidin prodcution >> binds ferroportin
on intestinal mucosal cells and macrophages >> Inhibiting iron release
from macrophages and intestinal cells to blood

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Effect of anemia on cardiovascular system

• Anemia decrease blood viscosity
1. Decreased blood visocisty >> increased blood flow to tissues and heart >>
Increase cardiac output (blood ejected from the heart)
2. Dilation of blood vessels due to tissue hypoxia >> increase blood return to
heart >> Increase cardiac output
3. In exercise >> greatly increases tissue demand for oxygen >> extreme tissue
hypoxia >> acute cardiac failure (possibility)

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Clinical presentation
• Fatigue
• Weakness
• Skin and conjunctival pallor
• Dyspnea
• Palpitation
• Light-headedness
• Clinical scenarios:
• A pregnant women or of childbearing age, present with weakness and fatigue and
light headedness and palpitation
• A woman complain that her son 2 years old son grow slowly, is pale and not as active
and playful as his older brother when he was 2 years old

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Polycythemia
• An abnormal increase in the RBC count.
• hematocrit of >52% in male
• hematocrit of >48% in female
• Hb > 18.5g/dL in males
• Hb >16.5g/dL in female
• Types of polycythemia:
1. primary polycythemia (Polycythemia vera)
2. secondary polycythemia

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What is polycythaemia vera?

• Polycythaemia vera is the condition where red blood cell count
increases as high as 7 to 8 million/mm3.
• It is due to tumorous condition of the organs that produce red blood
cells.

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What is secondary polycythaemia?

• When tissues become hypoxic, larger number of red blood cells are
produced resulting in polycythaemia.
• This is called secondary polycythaemia.
• It occurs due to following reasons:
1. At high altitudes due to decreased PO2 in atmosphere, hypoxic hypoxia results
which causes polycythaemia, which is also called physiological polycythaemia.
2. Hypoxia caused due to cardiac failure
• Mechanism:
• All these conditions lead to hypoxia which stimulates the release of erythropoietin.
• Erythropoietin stimulates the bone marrow resulting in increased RBC count..

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Primary Polycythemia – Polycythemia Vera

• A disorder of increased RBC count due to mutation
• Clinical presentation:
1. Asymptomatic
2. Facial flushing
3. Episodic severe burning pain with red blue discoloration of the skin
4. Intense itching after shower

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What is the effect of polycythaemia on

circulation?
1. Effect on cardiac output:
• Polycythaemia increases the viscosity of blood. This results into decreased rate of
blood flow which leads to decreased venous return to the heart and decreased
cardiac output.
• However, decrease in cardiac output is almost totally compensated because
polycythaemia increases the blood volume.
• Therefore, actually there is no change in cardiac output.
2. Effect on arterial pressure:
• In one third of people of polycythaemia arterial pressure rises because
polycythaemia increases the viscosity of blood and increase blood pressure.
3. Cyanosis:
• Colour of the skin depends on the amount of deoxygenated blood in skin capillaries.
• Polycythaemic person easily develops cyanosis because of increased viscosity and
reduced rate of blood flow and greater deoxygenation of blood.
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References
• Guyton and hall, 2016. Textbook of medical physiology, 13th ed.
ELSEVIER
• K.E. Barret; S.M. Barman; Scott Boitano; H.L.Brooks, 2016 Ganongs
review of medical physiology, 25th ed. LANGE
• Linda. S. Costanzo, 2011. BRS physiology, 5th ed. Lippincott, Williams
and wilkins
• R. R. Preston; Thad. E. Wilson, 2013. Lippincott illustrated review of
physiology, 1st ed. Lippincott, Williams and wilkins
• K. Sembulingam, Prema. Sembulingam, 2019. Essentials of Medical
physiology, 8th ed. JAYPEE

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