A Practical

Approach to Anemia

How to efficiently and accurately

work up an anemic patient ?

Dr.R.V.S.N.Sarma., M.D., M.Sc., (Canada)

Consultant Physician & Chest Specialist
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 What is Anaemia ?

Important to remember
• Anemia is a clinical sign of disease
• It is not a single disease by itself
• Need to look for the underlying cause !
• Will we ignore a fever with out investigation ?
• Its diagnosis is not that simple !! We’ll make it
• Its very common and imp. in our practice
• Drug Rx. depends on the cause
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 Definition of Anaemia

• Decrease in the number of circulating red blood

cell mass and there by O2 carrying capacity
• Most common hematological disorder by far
• Almost always a secondary disorder
• As such, critical for all practitioners to know
how to evaluate / determine its cause / treat

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 Erythron

• Erythron is the machinery of RBC production

• EPO, IL, Growth factors, Cytokines – stimulate it
• Hypoxia is strong stimulus for the Erythron
• Its functioning is influenced by
1. Normal renal production of EPO
2. A functioning Erythroid marrow
3. An adequate supply of substrates for Hb production

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 The RBC Lineage

Let us meet the Grand Parents !

 Haemopoesis in Bone Marrow

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 Pro Erythroblast

Large purple nucleus

Thin rim of cytoplasm
Basophilic in stain
Cell > 35 µ

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 Early Normoblast

Large purple nucleus

Denser nucleus
Thin rim of cytoplasm
Basophilic in stain
Cell > 25 µ

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 Intermediate Normoblast

Medium sized nucleus

Reticulated nucleus
More cytoplasm
Neutral in stain
Cell > 20 µ

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 Late Normoblast

Small dense nucleus

Darkly staining
Increased cytoplasm
Pink in stain
Cell > 15 µ

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 Reticulocyte

No definite nucleus
Reticulum of RNA
Deep blue staining
Light blue cytoplasm
Cell size about 10 µ

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 Normal Red Cells

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 Normal Red Cells

No nucleus, Enzyme packets

Biconcave discs – Haem + Gl
Center 1/3 pallor
Pink cytoplasm (Hb filled)
Cell size 7 - 8 µ - capill. 2 µ
EM pathway, HMP
Negative charge – no phago
Na less, K more inside
100-120 days life span
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 The Factory – Bone Marrow

Sternum, pelvis, vertebrae, long

bones, skull bones, Tibia (paed)
From stem cells (pleuripotent)
75% of marrow for WBC
25% of BM for Red cells
Erythrod / Granulocyte Ratio 1:3
E:G ratio increased in Anaemia
Large white areas are marrow fat
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 Normal BM High Power

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 Hemoglobin (Hb)

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 First Question

• The onset of Anaemia

• Acute versus chronic
• Clues
– Hemodynamic stability
– Previous CBC
– Overt blood loss

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 Types of Anaemia

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 Screening Tests – Anaemia

• Clinical Signs and symptoms of Anaemia

• Look for bleeding – all possible sites
• Look for the causes for anemia
• Routine Hemoglobin examination
• Cut off marks for Hb –
– US < 13.5 g WHO < 12.5 g
– India Less than 12 g%
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 Clinical Signs to be looked for

• Skin / mucosal pallor,

• Skin dryness, palmar creases
• Bald tongue, Glossitis
• Mouth ulcers, Rectal exam
• Jaundice, Purpura
• Lymph adenopathy
• Hepato-splenomegaly
• Breathlessness
• Tachycardia, CHF
• Bleeding, Occult Blood
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 PCV or Hematocrit

• 57% Plasma

• 1% Buffy coat – WBC

• 42% Hct (PCV)

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 The Three Basic Measures

Measurement Normal Range

A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. Hematocrit 45 38 to 50

A x 3 = B x 3 = C - This is the rule of thumb

Check whether this holds good in given results
If not -indicates micro or macrocytosis or hypochro.
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 The Three Derived Indicies

Measurement Normal Range

A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. Hematocrit 45 38 to 50

MCV C ÷ A x 10 = 90 fl
MCH B ÷ A x 10 = 30 pg
MCHC B ÷ C x 100 = 33%
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 Causes of Anaemia

1. Decreased production of Red Cells

- Hypo proliferative, marrow failure
2. Increased destruction of Red Cells
- Hemolysis (decreased survival of RBC)
3. Loss of Red Cells due to bleeding
- Acute / chronic blood loss (hemorrhagic)
M = P x S ( L)

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 Hypoproliferative Anaemias
Failure of cell
maturation
Nuclear Cytoplasmic
breakdown breakdown

Folate or B12 deficiency Haem defect Globin defect

Defective DNA synthesis Fe Phorph Sickle cell A

Megaloblastic Anaemia IDA, SA Thalassemia

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 Anaemia – First Test

RETICULOCYTE COUNT %
• ‘RBC to be’ or Apprentice RBC
• Fragments of nuclear material
• RNA strands which stain blue
Normal
Less than 2%

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 Reticulocytes

Supravital Leishman’s
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 Reticulocyte Production Index

For example the RPI is calculated as follows

Reticulocyte count 9%
Hb content 7.5 g%
1. Correction for Anaemia
= 9 x (7.5 ÷ 15) = 9 x 0.5 = 4.5 %
2. Correction for increased life span
4.5 ÷ 2 = 2.25 %
3. Thus, the RPI is 2.25

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 Anaemia

Hb% < 12, Hct < 38%

Hypoproliferative Hemolytic

RPI < 2 RPI > 2

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 Normal CBC

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 Workup – Second Test

• The next step is ‘What is the size of RBC’ ?

• MCV indicates the Red cell volume (size)
• Both the MCH & MCHC tell Hb content of RBC
• If the RPI is 2 or less
• We are dealing with either
– Hypoproliferative anaemia (lack of raw material)
– Maturation defect with less production
– Bone marrow suppression (primary/ secondary)

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 Red Cell Size

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 Mean Cell Volume (MCV)

• RBC volume (rather) is measured by

• The Mean Cell Volume or MCV and RDW
MCV

Microcytic Normocytic Macrocytic

< 80 fl 80 -100 fl > 100 fl

< 6.5 µ 6.5 - 9 µ >9µ

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 Anaemia Workup - MCV

MCV

Microcytic Normocytic Macrocytic

Iron Deficiency IDA Chronic disease Megaloblastic anemias
Chronic Infections Early IDA Liver disease/alcohol
Thalassemias Hemoglobinopathies Hemoglobinopathies
Hemoglobinopathies Primary marrow disorders Metabolic disorders
Sideroblastic Anemia Combined deficiencies Marrow disorders
Increased destruction Increased destruction
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 Anaemia Workup – 3rd Test
Red cell Distribution Width – RDW

RDW < is1313

RDW
Mean
MCV90
90 fl
fl

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 Red cell Distribution Width - RDW

MCV

Microcytic Normocytic Macrocytic

Left Mean 90 Right

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 Anaemia Workup - 4th Test
Peripheral Smear Study
• Are all RBC of the same size ?
• Are all RBC of the same normal discoid shape ?
• How is the colour (Hb content) saturation ?
• Are all the RBC of same colour/ multi coloured ?
• Are there any RBC inclusions ?
• Are intra RBC there any hemo-parasites ?
• Are leucocytes normal in number and D.C ?
• Is platelet distribution adequate ?
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 IDA -CBC

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 Severe Hypochromia

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 Microcytic Hypochromic - IDA

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 Microcytic Hypochromic Anaemia
Serum Ferritin

< 33 pmol / l 33-270 pmol / l > 270pmol / l

TIBC

HIGH N or ↓

- BM Fe +
Iron Deficiency Anaemia IDA Not IDA, Other Mi A
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 IDA – Special Tests

Iron related tests Normal IDA

Serum Ferritin (pmo/L) 33-270 < 33
TIBC (µg/dL) 300-340 > 400
Serum Iron (µg/dL) 50-150 < 30
Saturation % 30-50 < 10
Bone marrow Iron ++ Absent
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 IDA Summary
• Microcytic MCV < 80 fl, RBC < 6 µ
• RDW Widened and shift to left
• HypochromicMCH < 27 pg, MCHC < 30%
• RPI <2
• Retic. count May be > 2 %
• Serum ferritin Very low < 30 (p mols/L)
• TIBC Increased > 400 (µg/dL)
• Serum Iron Very low < 30 (µg/dL)
• BM Fe Stain Absent Fe
• Response to Fe Rx. Excellent
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 IDA- Some Nuggets
• Look for occult blood loss – 2 days non veg. free
• Pica and Pagophagia – Ice sucking
• Absorption of Haem Iron > Fe ++ > Fe+++
• Food, Phytates, Ca, Phosphate, antacids ↓absorption
• Ascorbic acid ↑absorption
• Oral iron Rx. always is the best, ? Carbonyl Fe
• FeSO4 is the best. Reserve parenteral Rx.
• Packed cell transfusion in emergency
• Continue Fe Rx at least 2 months after normal Hb
• 1 gram ↑in Hb every week can be expected
• Always supplement protein for the Globin component
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 Microcytic Anaemias

MCV < 80 fl Serum Iron TIBC BM Perls stain

Iron Def. Anemia ↓↓ ↑↑ 0
Chronic Infection ↓↓ ↓↓ ++
Thalassemia ↑↑ N ++++
Hemoglobinopathy N N ++
Lead poisoning N N ++
Sideroblastic ↑↑ N ++++
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 Ringed Sideroblasts in BM
Prussian Blue Stain

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 Macrocytic Anaemias

A. Megaloblastic Macrocytic – B12 and Folate↓

B. Non Megaloblastic Macrocytic Anaemias
1. Liver disease/alcohol
2. Hemoglobinopathies
3. Metabolic disorders, Hypothyroidism
4. Myelodystrophy, BM infiltration
5. Accelerated Erythropoesis - ↑destruction
6. Drugs (cytotoxics, immunosuppressants, AZT,
anticonvulsants)
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 Anemia - Macrocytic (MCV > 100)

Premature gray hair – consider MBA

Macrocytic anemias may be asymptomatic until
the Hb is as low as 6 grams
MCV 100-110 fl
must look for other causes of macrocytosis
MCV > 110 fl
almost always folate or B12 deficiency

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 Macrocytosis of Alcoholism

• 25-96% of alcoholics
• MCV elevation usually slight (100-110 fl)
• Minimal or no anemia
• Macrocytes round (not oval)
• Neutrophil hyper segmentation absent
• Folate stores normal
Smoking increases the Red Cell Mass
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 Megaloblastic Hematopoiesis

Marrow failure due to

• Disrupted DNA synth. & ineffective erythropoesis
• Giant precursors (Megaloblasts)
• Nuclear : Cytoplasmic dyssynchrony in marrow
• Neutrophil hyper segmentation & macro ovalocytes
• Anemia (and often leukopenia & thrombocytopenia)
• Almost always due to B12 or folate deficiency
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 MBA

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 Macrocytosis -MBA

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 Anisocytosis - Macrocytic Anaemia

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 HSN - MBA

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 HSN - MBA

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 Basophilic Stippling - MBA
BS occurs in Lead poisoning also

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 Megalocyte in PS

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 MBA - BM

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 MBA - BM

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 Megaloblast – FA deficiency

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 Pernicious Anaemia - Tongue

Bald, smooth, lemon

yellowish red tongue

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 Normocytic Anaemias

1. Chronic disease
2. Early IDA
3. Hemoglobinopathies
4. Primary marrow disorders
5. Combined deficiencies
6. Increased destruction
7. Anaemia of investigations -ICU
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 Anaemia of Chronic Disease

• Thyroid diseases • IBD

• Malignancy – Ulcerative Colitis
• Collagen Vascular Disease – Crohn’s Disease
– Rheumatoid Arthritis • Chronic Infections
– SLE – HIV, Osteomyelitis
– Polymyositis – Tuberculosis
– Polyarteritis Nodosa • Renal Failure

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 ‘Dimorphic’ Anaemia

• Folate & Fe deficiency (pregnancy, alcoholism)

• B12 & Fe deficiency (PA with atrophic gastritis)
• Thalassemia minor & B12 or folate deficiency
• Fe deficiency & hemolysis (prosthetic valve)
• Folate deficiency & hemolysis (Hb SS disease)
• Peripheral smear exam is critical to assess these
• RDW is increased very much
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 RBC Size – Anisocytosis
Different sizes of RBC

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 Poikilocytosis
Different Shapes of RBC

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 Polychromasia - Spherocytosis

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 Target Cells

1. Liver Disease
2. Thalassemia
3. Hb D Disease
4. Post splenectomy

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 Tear Drop Cells

1. Myelofibosis
2. Infiltration of BM
3. Tumours of BM
4. Thalassemia

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 Hair on end - Thalassemia Major

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 Drepanocytes - SS

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 Sickle Cell Anaemia

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 Autosplenectomy - SS

Normal spleen is 8 to 12 cm

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 Hemolytic Anaemia

Anemia of increased RBC destruction

– Normochromic, normocytic anemia
– Shortened RBC survival
– Reticulocytosis – due to ↑ RBC destruction
Will not be symptomatic until the RBC life span is
reduced to 20 days – BM compensates 6 times

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 Tests Used to Diagnose Hemolysis

1. Reticulocyte count
2. Combined with serial Hb
3. Serum LDH
4. Serum bilirubin
5. Haptoglobin
6. Urine hemosiderin
7. Hemoglobinuria
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 Findings in Hemolytic Anaemia

Reticulocyte count and RPI Increased

Serum Unconjugated Bilirubin Increased
Serum LDH 1: LDH 2 Increased
Serum Haptoglobin Decreased
Urine Hemoglobin Present
Urine Hemosiderin Present
Urine Urobilinogen Increased
Cr 51 labeled RBC life span Decreased
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 Tests to define
the cause of hemolysis
1. Hemoglobin electrophoresis
2. Hemoglobin A2 (βeta-Thalassemia trait)
3. RBC enzymes (G6PD, PK, etc)
4. Direct & indirect antiglobulin tests (immune)
5. Cold agglutinins
6. Osmotic fragility (spherocytosis)
7. Acid hemolysis test (PNH)
8. Clotting profile (DIC)
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 MAHA
Micro Angiopathic Hemolytic Anaemia

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 MAHA
Micro Angiopathic Hemolytic Anaemia

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 Hyperactive BM – Skull
Hemolytic Anaemia

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 Spherocytosis

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 Spherocytosis
Hereditary Spherocytosis

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 Spherocytosis

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 Elliptocytes
Hereditary Elliptocytosis, B12 or Folate↓

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 Stomatocytes
Slit like central pallor in RBC

1. Liver Disease
2. Acute Alcoholism
3. H Stomatocyosis
4. Malignancies

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 Echinocytes
Evenly distributed spicules > 10

1. Uremia
2. Peptic ulcer
3. Gastric Ca
4. PK-D
Called Burr Cells

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 Acanthocytes
5-8 spikes of varying length, irregular intervals
Called Spur Cells, Occur in A H A

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 Shistocytes
Fragmented, Helmet or triangle shaped RBC
1. MAHA
2. Prosthetic valves
3. Uremia
4. Malignant HT

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 Leukoplakia - Aplastic Anaemia

1. Chloramphenicol
2. Neomercazole
3. Sulfonamides
4. Analgin
5. Phenytoin
6. Butazolidin group
7. Anti Ca drugs
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 Normal BM High Power
E:G=1:3

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 Shift in E : G Ratio
E:G=2:1

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 BM - Aplastic Anaemia

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 Myelofibrosis

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 Post transfusion - CBC

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 Howell-Jolly Bodies
Absence of Splenic function; Nuclear chromatin in RBC

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 Pelger-Huet Anomaly

• Inherited condition
• PMN - Spectacles
• Heterozygous
• Homozygous fatal
• Neutrophil Bands ↑
• Normal WCC
• No e/o infection
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 Anaemia Diagnosis -Algorithm

Anaemia Suspected

Thorough Clin, Bleed Hb%, RCC, Hct Decreased

Ca, Leukemia, Ulcer

RPI, Retic count <2 RPI, Retic count >2
Identify the cause

MCV, MCH, MCHC, PSE Hemolytic Anaemia

Microcytic hypochromic Macrocytic hypo/normo Coombs DAT, IDAT

Iron Def. Anaemia Megaloblastic Normoblastic Hb electrophoresis

Ferritin, TIBC, BM Fe Folate defici. ALD, CLD, Drug Osmotic fragility

Thalassemia, Hb pathy B12 def., PA Chr. Renal dis. Acid hemolysis

Sederoblastic Anaem. Hypothyroid Cold agglutinins

Chr. Infection, Lead BM infiltration Coagulopathy, DIC

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 Anaemia - Summary
• If Hb% is low – Do not start on Iron straight away
• Ask for RCC, Hematocrit – Derive MCV, MCH, MCHC
• Order for Reticulocyte count – Is RPI < 2 % or > 2%
• Thoroughly look for blood loss – acute / chronic / occult
• Is it hypo-proliferative or hemolytic or hemorrhagic anaemia
• If hypo proliferative – Microcytic or Macrocytic? (MCV, RDW)
• If microcytic – IDA or others – Spl. Iron tests, BM Iron
• If macrocytic – Megaloblastic (B12, FA) or Normoblastic BM
• If normocytic – Anaemia of chr. Disease – Liver, MRD, Ca
• Peripheral smear study for RBC size, shape, colouration etc.
• If retic. count is ↑- HA work up; Hb EP, spl. tests
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 Thank You ALL

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