Objectives…

Clinical assessment should gauge its

severity
Define the underlying cause
Is the patient bleeding?
actively/ in the past?
Evidence of increased RBC destruction
Is the bone marrow suppressed??
Is the patient nutritionally deficient??
Past medical history???
Onset of symptoms
Acute/chronic

Menstrual history
Menorrhagia –common cause in pre-menopausal females

Dietary history
Assess intake of iron and folate
needs > intake (pregnancy, growth spurt)

Past medical history

Rheumatoid arthritis (anemia of chronic disorder)
Diarrhoea – malabsortion of iron and/or vitaminB12
GI bleeding – acute blood loss
Melena?
Blod in vomitus??
Past surgical history
Resection of stomach or small bowel- malabsorption of
iron and/or vit B12

Family history
Suspicion of hemolytic anemias – hemoglobinopathies
& hereditary spherocytosis

Drug history
NSAIDS aspirin – blood loss
sulphonamides – hemolysis
Chloramphenicol - aplasia
 Iron deficiency anaemia

• Koilonychia
• Angular stomatitis(cheilosis)
• Atrophy of lingual papillae
(Glossitis)
• Poor school performace
• Lack of Attention children
• Blue sclera(rare)
• Pica- especially
for ice
 IDA continue…

• Dysphagia with solid food Plummer-Vinson

syndrome(esophageal web + middle age(50yr)
woman + post cricoid Ca).
• In pregnancy- edema of legs, soft systolic murmur in
mitral area
 Anaemia of chronic disease

1. Chronic kidney disease

• Skin - Pallor
• Neurovascular - Decreased cognitive ability
• Eyes - Pale conjunctivae
• Cardiovascular - Orthostatic hypotension,
tachyarrhythmias
• Pulmonary - Tachypnea
• Abdomen - ascites, hepatosplenomegaly
1. rheumatoid arthritis- tender joints, deformitis,
nodules.
2. SLE- malar rash, oral ulcers, arthritis…
3. Cancers- weight loss, gum hypertrophy,…
4. Crohn’s disease & ulcerative colitis-wt loss, perianal
disease, bloody diarrhea…
5. Chronic lead poisoning- A blue line along the gum
with bluish black edging to the teeth, known as a
Burton line
Megaloblastic anemia
• Glossitis
• Lemon yellow hue

• Dermatologic signs
include hyper/hypo pigmentation of the skin and
abnormal pigmentation of hair
• A wide range of mental changes, from irritability to
psychosis, as well a peripheral neuropathy
• Tachycardia often is present and may be
accompanied by flow murmurs
• The liver may be enlarged in association with
congestive heart failure
• A splenic tip is palpable in about 20% of patients
• Suspect pernicious anemia in all patients with
recent loss of mental capacities. Somnolence,
dementia, psychotic depression, and frank
psychosis
• Subacute combined degeneration occurs in
cobalamin deficiency. Patients who present with
abnormal gait, loss of balance, speech impairment,
and loss of proprioceptive and vibratory senses.
Blindness due to optic atrophy may occur
• Aplastic anemia
• Anemia: May manifest as pallor, headache,
palpitations, dyspnea, fatigue, or foot
swelling
• Thrombocytopenia: May result in mucosal
and gingival bleeding or petechial rashes
• Neutropenia: May manifest as overt
infections, recurrent infections, or mouth
and pharyngeal ulcerations
In any case of suspected aplastic anemia, look for physical
stigmata of inherited marrow-failure syndromes, such as the
following:

Abnormal skin pigmentation

Short stature
Renal, cardiac, and gastrointestinal (GI) abnormalities
Microcephaly
Microphthalmos
Hypogonadism
Skeletal anomalies
The oral pharynx, hands, and nail beds should be carefully
examined for clues of inherited bone marrow-failure
syndromes
Shwachman–Diamond syndrome
• Short stature (~70%),
• Ichthyotic skin rash (~60%).
• Metaphyseal dysostosis ~75%
• Other abnormalities include
• hepatomegaly,
• rib/thoracic cage abnormalities,
• syndactyly, cleft palate, dental dysplasia,
• ptosis and skin pigmentation.
Fanconi’s
Dyskeratosis congenita
anemia:
• Triad of reticulated skin
• Skeletal and
renal defects hyperpigmentation, nail
dystrophy, and oral
• Hyperpigment
leukoplakia
ation
• Small stature • Telangiectasia
• Hypogonadis • Alopecia
m • Abnormal sweating
• Chromosomal • Mental retardation
change • Growth failure and
hypogonadism
 Signs of haemolytic anaemia
• Anaemia- pallor
• Jaundice- icterus
• Splenomegaly (except SCA)
• Crises-
Aplastic crises
Hemolytic crises
Megaloblastic crises
Vaso-occlusive crises
• Gall stones
• Leg ulcers
• Bony abnormality
 Red cell membrane defect
• Hereditary spherocytosis
A-Family history present
B-Most cases are asymptomatic compensated chronic haemolytic
state.
C-Splenomegaly is the rule. Detected in more than 75% of the cases.
D-Jaundice
E-Pigmented gall stones in 50% of the cases may cause cholecystitis
causing upper right abdominal pain. Cholelithiasis may be the first
sign
Clinical course may be complicated by crises-
1. Haemolytic crises
2. Megaloblastic crises
3. Aplastic crises
• Herediatry elliptocytosis
A-Usually asymptomatic
B-Occasional cases result in neonatal haemolysis
or chronic compensated haemolytic state
C-Presents with fatigue, shortness of breath and
jaundice
D-Splenomegaly
E-Cholelithiasis (right upper abdominal pain)
 Red cell enzymopathies
• Glucose 6 phosphate dehydrogenase deficiency-
1. Vast majority are clinically asymptomatic
2. Neonatal jaundice
3. Acute hemolytic anaemia
Drugs, Infection or acute illness,Fava beans.
There is malaise, weakness and abdominal or lumbar pain.
After several hours there is jaundice or dark coloured urine,
development of acute renal failure can occur.
4.Small minority have chronic nonspherocytic hemolytic
anemia- pt is male,history of NNJ, anaemia, jaundice, or
gall stones, spleen maybe enlarged.
• Pyruvate kinase deficiency-
NNJ, features of chronic hemolytic anaemia.
• Pyrimidine 5’ nucleotidase deficiency-
Features of chronic hemolytic anaemia,
common in jews, mediterranean and african.
 Autoimmune hemolytic anaemia
Triad- abrupt, jaundice, splenomegaly
• Hemoglobinuria
• May develop as a part of autoimmune disease- mainly
SLE
WARM AIHA-
• Insidious development of symptoms of anaemia, and
other nonspecific symptoms like- fever, coughing,
bleeding, abdominal pain and weight loss.
PAROXYSMAL COLD HEMOGLOBINURIA-
• Triggered by viral infection, self limiting and in children
COLD AGGLUTININ DISEASE-
• Associated with low grade
B cell Lymphoma
• Cold, painful and often
blue fingers, toes, ears or
nose
PAROXYSMAL NOCTURNAL
HAEMOGLOBINURIA
• Reddish brown early
morning urine
• venous thrombosis is
unusual site like liver or
abdomen.
 Allo immune haemolytic anaemia
• Unmatched transfusion
• Maternal sensitization to paternal or foetal red cell
(haemolytic disease of the new born)
Non immune haemolytic anaemia
•Physical trauma-
Mechanical heart valves, march haemoglobinuria,
thermal injuries
•Infection-
Plasmodium falciparum malaria, clostridium
perfringens septicemia
•Chemicals or drugs-
Dapsone and sulfasalazine
haemoglobinopathies
• Sickle cell anaemia
A-Painless hematuria
B-Due to chronic hemolysis-
Severe anaemia, jaundice, splenomegaly
(only initial stage then
autosplenectomy), gall stones, leg
ulcers,painful enlargement of the organs
Priapism in male.
Severe pain in right upper abdomen due
sequestration in the liver.
C-Aplastic crises-
Infection with human parvovirus B19, very
low haemoglobin>> heart failure
C-Due to microvascular
occlusion-
Severe pain in the bone,
abdomen, chest.
dactylitis
Systemic response with
tachycardia sweating, fever
Retinal artery occlusion-
retinopathy or blindness
Brain- ischemia, hemorrage,
infarction
ARDS
Cor pulmonale due to
pulmonary hypertension
D-Resistance to malaria
• Thalassaemia
Beta thalassaemia major-
 Severe anaemia,
 Growth retardation,
 Features of haemosiderosis- failure of
sexual development, diabetes mellitus,
liver failure, heart failure.
 Haemolytic anaemia causes-
Hepatosplenomegaly, gall stones, leg
ulcers and high output congestive heart
failure.
 Bony changes- expansion of bone
marrow- tower shaped skull, prominent
maxillary bone, depressed nasal bone
(thallasemic/chipmunk facies),
pathological fractures
• Thalassemia Intermediate-moderate anemia,
hepatosplenomegaly, growth failure and jaundice.
Age of onset is generally around 2-4 years of age.
• Beta thalassemia minor- asymptomatic with anaemia
• Alpha thalassemia 2 trait- asymptomatic
• Alpha thalassemia 1 trait- asymptomatic
• HbH disease- moderately severe haemolytic anaemia
• Hb barts- hydrops foetalis