Clinical Hematological

Assist Prof. Dr. Mudhir S. Shekha

Anemia
Differential
diagnosis
anaemia
depend on
MCV
RDW
Leukemia is cancer of the body's blood-forming
tissues, including the bone marrow and the lymphatic
system
 Platelet disorders
Iron Metabolism and Iron Deficiency
Anemia
• Iron-deficiency anaemia is the most common
and, to the generalist, most important
anaemia because it:
• is a significant public health problem
• may be the presentation of an occult
gastrointestinal carcinoma at a curable stage
• is highly treatable whatever its cause
Iron occurrence in human body
• Total body content : 25-30 gm
• Occurrence : Liver , Bone marrow ,muscles

75%-Hemoglobin

Blood (14.5 gm 5% -Myoglobin

%)
15 % Ferritin
Recommended Dietary Allowances (RDAs) for
Iron 
Dietary Sources of Iron
Dietary source Iron content per 100gm
Green Leafy vegetables 20 mg
Cereals 10mg
Liver 50mg
meat 20mg
Biochemical functions of Iron
Biochemical functions : iron mainly exerts
its function through biomolecules in
which it is present.
1. Hemoglobin & Myoglobin –transport of
oxygen & CO₂
2. Cytochromes & certain non-heme proteins
electron transport chain & oxidative
phosphorylation
3.Peroxidase ( lysosomal enzyme ) –phagocytosis &
killing of bacteria by neutrophils .
4. Iron associated with effective immune
competence of human body.
Factors affecting Iron absorption

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 IRON TRANSPORT
• Transferrin is the major protein responsible for
transporting iron in the body.
• Transferrin receptors, located in almost all cells of the
body, can bind two molecules of transferrin.
• Both transferrin concentration & transferrin receptors
are important in assessing iron status.
• Tissues with higher requirement for iron ( bone
marrow, liver & placenta) contain more transferrin
receptors. storage ferritin & hemosiderin
Iron Deficiency Anemia
• Clinical Manifestations
• Most common: pallor
• inflammation of the tongue (glossistis)
• Cheilitis = inflammation/fissures of lips
• Sensitivity to cold
• HAIR LOSS

• Weakness and fatigue

• Occult blood  bleeding in the GI tract
• women > men ( female (9.9%) than males (7.8%))
• > 1 biliion
• 80% of iron is in Hb rest stored as ferritin & hemosiderin
• 5% of women between the ages of 20 and 49 have iron deficiency with
anemia
• 11% have iron deficiency without anemia
Koilonychia
STOMATITIS
Glossitis
 Etiology of IDA
• The etiology of IDA is multifaceted. It generally results from
inadequate intake of iron due to poor quantity/quality of
diet, impaired absorption, or increased demand for iron.
Chronic blood loss from any site is an important cause of
IDA. Bleeding from GIT (ulcers, parasites, malignancies) as
also from any other site causes IDA
Iron Deficiency Anemia
1.Hookworm infestation: Loss of blood ( 0.3 ml /day )
Rural area poor sanitation ,300 worms/ individual
loss of 1% total body /day
2.Nutritional
deficiency of Iron
3.Repeated pregnancy( loss 1gm iron loss /delivery after
pregnancy
4. Nephrosiskidney glomerular mechanism insufficiency 
proteinuria ( Haptoglobin,Hemoplexin , & transferrin lost in urine (
Thus iron deficiency anemia common in nephritis )
5.Chronic blood loss  peptic ulcer , uterine hemorrhages , piles
6.Lack of absorption : subtotal gastrectomy , Achlorhydria
7.Lead & absorption oppose each other : Lead toxicity  Iron
absorption decreased ,Hb synthesis decreased Iron deficiency
 Lead absorption increased ( viscous cycle ) e
Laboratory Diagnosis of IDA
• 1. Complete Blood Counts Hemoglobin (Hb) and
Hematocrit (Hct).Patients with IDA have mild-moderate
reduction in Hb concentration and Hct. Hb < 13 g/dL in
males and <12 g/dL
• Red cell count and indices. Total RBC count, MCV, and MCH are
reduced while MCHC is reduced in long-standing/severe disease.
• The total leucocyte count is usually normal.
• Thrombocytosis is observed in these patients with counts being
1.5–2 times normal
• Red cell distribution width (RDW). This is a measure of an
isocytosis of red cells and is elevated early in IDA. It can be
measured as coefficient of variation (RDW-CV) or standard
deviation (RDW-SD). RDW can be used to distinguish between
IDA and β-thalassemia trait (normal RDW).
• Reticulocyte Hb content (CHr). CHr provides a measure of
the iron available to recently produced red cells. It is a
strong predictor of ID as it provides a more real-time view
of bone marrow iron status. In the early phase of ID, there
is fluctuation in the iron supply to the marrow resulting in
reticulocytes with less Hb and decrease in CHr before the
development of anemia. CHr less than 29 pg is diagnostic of
IDA
• Reticulocyte Hb equivalent. This is available on some
automated hematology analyzers and is a reliable, sensitive,
and specific parameter to identify iron-deficient states
• Percentage of hypochromic red cells. This is a measure of
the concentration of Hb in red cells and takes into account
the absolute amount of Hb as also the size of the red cell. As
the size of the red cell changes with storage, it does not give
reliable results on stored samples necessitating the need for
a fresh sample.
• Examination of a Stained Peripheral Blood Film (PBF)
• The blood smear shows microcytes with an increase in central
pallor. The number of erythrocytes affected and the degree of
hypochromia are related to the severity of anemia. In severe
disease, most of the red cells appear as rings. Poikilocytes in the
form of elongated cells may be seen

PBF of patient with IDA showing microcytic hypochromic red cells. Few elongated
cells (arrow) are also seen (Leishman stain ×400)
Biochemical Tests of Iron Status
• Serum Iron (SI), Total Iron Binding Capacity (TIBC), and
Percent Transferrin Saturation (%TS)
• Serum Ferritin (SF)
• Zinc Protoporphyrin (ZPP)/Free Erythrocyte
Protoporphyrin (FEP)
• Serum TfR
• sTfR/Log Ferritin (sTfR-F Index)
• Serum Hepcidin
• Examination of Bone Marrow Aspirate for Iron
• Examination of stained bone marrow aspirates for hemosiderin is a
specific test for ID and is still considered the gold standard for
evaluation of iron stores
• On staining with Prussian blue, iron granules can be identified in
erythroid precursors and macrophages. The positivity is graded on
the basis of intensity of staining from 1 to 6. Normoblasts which
show siderotic blue granules are called sideroblasts. In normal
individuals, about half of the normoblasts are sideroblasts, each of
which contains less than five small granules. If the granules form a
ring; complete or partial around the nucleus of the normoblast, the
cell is a ring sideroblast which is seen under pathological conditions.

Perl’s stain of BM aspirate (×400) showing

absent iron stores in a patient with IDA. Inset
shows normal
iron stores (×400)
Treatment
• Oral iron – ferrous sulfate is best (200 mg, 67 mg
iron per tablet) before meals three times daily.
• Intravenous iron is used in patients with
malabsorption or who are unable to take oral iron.
Ferric hydroxyide sucrose (Venofer), iron dextran
(Cosmofer), ferric carboxymaltose (Ferinject) and
iron isomaltoside (Monofer) are useful to treat
iron deficiency anaemia and replenish iron stores.
In the United States ferumoxytol (Feraheme) is
also used.

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Iron overload
• Iron overload is the pathological state in
which total body stores of iron are increased,
often with organ dysfunction as a result of
iron deposition.
• Normal body iron stores
= 3-4gm
• Daily iron absorption
and excretion = 1mg/d in
males and 1.5mg/day in
females.
• In hemochromatosis
daily absorption increases
to 4mg/day whereas 27
excretion remains same
PATHOPHYSIOLOGY
• Increased absorption of dietary iron
in upper intestine.
• Decreased expression of iron
regulatory hormone hepcidin.
• Altered function of HFE protein.
• Tissue injury and fibrogenesis
induced by highly toxic non
transferrin bound iron (NTBI).
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HEPCIDIN MODEL IN HFE MUTATION

29
Laboratory features
• Raised serum iron and transferrin saturation.
• Raised serum ferritin.
• Increased iron in liver (histology, chemical or MRI estimation).
• Abnormal liver function tests. Alpha-fetoprotein, an indicator of
hepatocellular carcinoma, is tested regularly if cirrhosis is present.
• Increased urinary iron excretion in response to iron chelator therapy.
• Cardiomyopathy causes abnormal echocardiographic findings, e.g.
reduced left ventricular ejection fraction or arrhythmia.
• MRI is used to measure tissue iron. The T2* technique is best to
measure liver and heart iron simultaneously . It may detect iron excess
in the heart before clinical or echocardiographic abnormalities.
• Endocrine abnormalities, e.g. raised blood glucose, low testosterone,
oestrogen or pituitary hormone levels.
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Treatment
• Genetic haemochromatosis: regular
venesections to reduce iron level to normal,
assessed by serum ferritin, serum iron and
total ironbinding capacity and by liver biopsy
or MRI.
• Transfusional iron overload: iron chelation

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