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formation
1-Intrautrine life:
Blood cells are formed in the liver and
SITES spleen up to the fifth months.
After 5th month : bone marrow share in the
formation of these cells.
2-After birth:
Formation of these cells will be restricted
to the bone morrow.
STEPS
Blood 3-Adulthood
formation
The active bone morrow will be:
Restricted to axial skeleton : flat bones,
vertebrae, ribs, sternum, ilia .
SITES
Some extension to the proximal ends of
long bone mainly femur.
Extramedullary haemopoiesis: When demand for
blood formation is increased:
The active red BM extends into the shafts of
the long bones.
The spleen and liver will regain their ability
to produce blood elements when bone
morrow is affected by some diseases.
Blood Pleuri-potent cells
formation
BFU-E
CFU-E CFU-G
Proerythroblast Myleloblast
SITES Basophilic Promyelocyte CFU-Mega
erythroblast Myelocyte Megakaryoblast
Polychromatic Metamgelocyte Megadaryocyte
erythroblast Juvenil Platelet
Othrochromatic Granulocyte
erythroblast (PML)
Reticulocytes
STEPS
Erthrocyto- Granulocyto-
Thrambocytopoiesis
poiesis poiesis
Blood
formation
STEPS
Blood
formation Blood Constituents
A. Microcytic-hypochromic anaemias:
Thalassaemia.
Iron deficiency anaemia.
Types Anaemia of chronic disease.
Sideroblastic anaemia:
Hereditary
Chronic lead poisoning.
Anemia MORPHOLOGICAL CLASSIFICATION
B- Normocytic-normochromic anaemias:
Acute post –haemorrhagic anaemia.
Hemolytic anaemia.
Types Aplastic anaemia.
Myelophthisic anaemia.
Anaemia of chronic diseases .
Anemia MORPHOLOGICAL CLASSIFICATION
1-Tissue Hypoxia
Impaired functions of the tissues, the
Types degree of impairment depends an the need
of the tissue to O2 so CVS, CNS and
skeletal muscles are much affected.
C/P
I- PATHOPHYSIOLOGY
Anemia
The clinical feature of the anaemia could be
explained by the following factors.
2- Compensatory mechanisms
Increased COP.
Increased O2 delivery from HB to the tissue.
Increased erythropoietin production with
stimulation of erythropoiesis
C/P symptom.
4- Cause:
II- GENERAL SYMPTOMS OF ANAEMIA:
Anemia
1-Neurological
Dizziness, fainting, lack of concentration
Blurred or diminished vision
Headache, tinnitus
Paraesthesia in the fingers and toes
Insomnia, irritability.
2-CVS:
• Angina, dyspnea, palpitation and intermittent
claudication by exertion
C/P • HF in severe cases or presence of other
organic cardiac disease, it is high COP failure.
3-Musculo skeletal:
Easy fatigability.
Tiredness and lassitude.
II- GENERAL SYMPTOMS OF ANAEMIA:
Anemia
4-GIT:
Dyspepsia and anorexia
5-Gental
Loss of libido & impotence
Menstrual abnormalities as amenorrhea.
6-May be polyuria.
C/P
III- PHYSICAL SIGNS:
Anemia
Pallor of the skin and mucous membranes
The colour of the skin is unreliable
because it depends upon the degree of
skin pigmentation and the amount of fluid
in the subcutaneous tissues.
Best examined : palmer creases, nail bed,
and mucous membrane .
Peripheral oedema :
Slight oedema of the legs probably due to
increase in the capillary permeability
C/P
secondary to hypoxia.
High COP failure.
Fever :
Mild fever may occur in sever anaemia but
other causes should be excluded
III- PHYSICAL SIGNS:
Anemia
Fundal changes:
Retinal hemorrhages of the flame shape
type, exudates and rarely papilloedema.
The cardiovascular system:
Increased velocity with decreased
viscosity of the blood in addition to
capillary dilation:
Pulse; tachycardia, bounding pulse
Cardiac examination :
C/P Loud HS
S3 over mitral or tricuspid area
Haemic murmur: ejection systolic,
hearted allover the precordium
Raised jugular venous pressure.
III- PHYSICAL SIGNS:
Anemia
Proteinuria and impairment of the
concentrating power of kidneys due to anoxia
of renal tubules.
Dietary sources :
Red meat and liver, bread, eggs and green
vegetables, mainly in ferric form,
Daily minimum requirement 10-12mg of which
about 1mg is absorbed.
Microcytic
Anemia
Basic nutritional features and metabolism of iron
Absorption
Transport
There is a diurnal rhythm with higher level in
the morning, iron is transported in the
plasma bound to transferrin.
Utilization : incorporation into Hb, myoglobin
and tissue enzymes.
Microcytic
Anemia
Basic nutritional features and metabolism of iron
Storage :
About two-thirds of the total body iron is in the
circulation as haemoglobin.
Iron is stored in reticulo-endothelial cells,
hepatocytes, spleen, bone marrow and skeletal
muscle about two thirds as ferritin and one-
third as haemosiderin.
Iron loss: (0.5 mg/day). Via
Hair and nail growth
Epithelium of the skin and mucus membrane.
body excreta : stool and urine
Microcytic
Anemia
True deficiency (defective intake) Rare:
Prolonged starvation and famines.
Aetiology Infancy (milk is poor in iron)
Conditioned deficiency (normal demand and
intake but there are defective absorption and
C/P utilization) Not common:
Ferric form cause.
Decreased HCL
Lab Iron binder: phosphate, phytate, tannates
Malobsorption syndrome.
Relative deficiency : (increased requirement )
DD common cause.
Menstruating females.
Pregnancy, labor.
Growing children .
TTT
Convalescence from disease.
Microcytic
Anemia
Chronic blood loss : the commonest cause
Frank blood loss
Aetiology
Menorrhagia
Repeated GI bleeding, haemeptysis,
epistaxis, haematuria
Bleeding tendencies
Repeated blood donation
Occult blood loss via GIT:
Anckylstoma & schistomiasis
Oozing OV, PU.
Neoplasm.
Inflammatory bowel disease ulcerative
colitis
TB enteritis.
Microcytic
Anemia
General manifestations of anaemia
Especial manifestations of iron deficiency
Aetiology anaemia .
Epithelial changes:
GIT manifestations
C/P Angular stomatitis.
Atrophic glossitis (red, glazed, smooth
tongue).
Lab Atrophy of the gastric mucosa
Small splenomegaly
Dermatological changes
DD Brittle nails thinning and ridging and loss of
luster.
Koilonychia; spoon-shaped nails in severe
cases:
TTT
Brittle hair
Microcytic
Anemia
Features of special types:
1- Plummer-Vinson –syndrome:
Common in middle aged female
Postcricoid esophageal web cause
dysphagia
C/P 2- Ankylostoma infestation:
Perverted appetite: (pica) eating mud,
stones and chalk.
Epigastric pain (DD= D. ulcer ), altering
bowel habits
Endemic parasites (trapezoid face)
The symptoms are mild and to variable.
Investigations:
Stool: Ova.
CBC: eosinphilia.
Microcytic
Anemia
A.To diagnose iron deficiency anaemia
Aetiology CBC:
The red cells are microcytic, (MCV<80f1)
and hypochromic (MCH < 27pg)
C/P anisocytosis and poikilocytosis
(variation in size and shape).
Eosinophilia is present in cases of
Lab ankylostoma infestation.
Bone Marrow:
Absent iron store,
DD Normoplastic hyperplasia,
Hb in maturely erythroblasts.
TTT
Microcytic
Anemia
A.To diagnose iron deficiency anaemia
Serum iron study
Decreased serum iron (n=70-170 mg%).
Increased total iron binding capacity
(TIBC).(n=250-450mg%).
Decreased serum ferritin levels .
Reflect iron stores.
The normal values are 30-300 mg/L in
Lab males and 15-200 mg/L in females and
investigation of gastrointestinal tract
are often required.
Falsely raised value in cases of acute
phase reactant e.g malignancy .
Decreased transferrin saturation (n=25-
50%)
Microcytic
Anemia
B- Investigation for the causes
Stool analysis:
Occult blood , ankylstoma & Bilharizasis .
GI cause:
Imaging : barium swallow, meal or
enema.
Lab Endoscopic studies: upper and lower.
Achlorhydria
Haemostatic profile.
Microcytic
Anemia
Aetiology
C/P
Microcytic anaemia
Anaemia of chronic disease
Lab
DD
TTT
Microcytic
Anemia
The aim of the treatment is to correct the
Aetiology anaemia and build up iron stores
Correction of underlying cause if
possible
C/P Iron replacement
Oral iron:
200 mg anhydrous ferrous sulphate three
Lab times daily.
The response is a rise in Hb
concentration of 1 gm/dl per week,
DD Side effects nausea, abdominal pain,
diarrhea or constipation.
TTT
Microcytic
Anemia
Parenteral iron:
Indication :
General intolerance of oral preparation
even at low dose.
Severe malabsorption and those who
have gastrointestional diseases.
Rapid iron loss.
Preparation
Iron sucrose ( ferrosac – venofer)
Good safety and efficacy profile.
Given IV or slowly IV infusion.
Amp: 5ml = 100 mg.
TTT
Microcytic
Anemia
TTT
Microcytic
Anemia
Transfusion therapy :
It should be packed RBCs.
Indications:
Sever (Hb < 7 gm/dl) and symptomatizing
anemia/dl)
Complicated anaemia:- HF
TTT
Microcytic
Anemia
Aetiology
Lab
TTT
Microcytic
Anemia
Aetiology
Lab
TTT
Microcytic
Anemia
Aetiology
Mechanism
Should be targeting the cause.
Lab
TTT
Microcytic
Anemia
Serum
Normal Normal Reduced Raised
TIBC
Normal or Serum
Raised Normal Reduced
raised ferritin
Iron in
Absent or
Ring forms Present Absent erythroblast
reduced
s
Macrocytic
Anemia
MACROCYTIC ANAEMIAS
.Megaloblastic type-1
Hematological values
II-condition deficiency
A-Decreased absorption .
1-Decreased intrinsic factors commonest cause.
*Pernicious anaemia.
*Total or partial gastrectomy
*Atrophic gastritis.
*Gastric cancer.
*Non- Addisonian pernicious anaemia
a- In association with hypogammaglobulinemia,
gastric atrophy, achlorhydria and absent intrinsic
factor but no antibodies
b-In infancy: Selective failure of IF, normal mucosa.
C- Juvenil PA failure of IF secretion with gastric
atrophy rarely with antibodies
Macrocytic
Anemia
.Malabsorption syndrome-2
:Ileal diseases-3
Terminal ileum resection *
.TB enteritis *
.Chron’s disease *
.Blind loop syndrome with bacterial over-growth *
Infestation by fish tape worm Diphyllobothrium *
. latum
Macrocytic
Anemia B-Decreased utilization:
*Rare congenital enzyme deficiency.
*Lack of transcoblamin II.
PERNICIOUS ANAEMIA
(ADDISONIAN ANAEMIA)
DEFINITION
Both vit Bi2 and folic acid are essential for DNA
synthesis and maturation.
So anaemia is multifactorial-4
Defective erythropoiesis -
.Intramedullary haemolysis -
. Destruction by the spleen -
Thrombocytopenia
Due to deficient DNA synthesis .
1- Haemtological manifestations
-Hepatosplenomegaly.
-Angular stomatitis .
b- Dementia
c- Optic atrophy
d- psychosis rare
Macrocytic
Anemia
Association with other autoimmune -4
features: (in pernicious anaemia)
Thyrotoxcoais -1
.Hashimoto’s disease -2
Vitiligo-3
Rheumatoid disease-4
a- RBCs:
Marocytic normochromic anaemia .
Poikilocytosis and anisocytosis
Howell-Jolly bodies may be present
b-WBCs:
Moderate Leucopenia.
Shift to the right
Giant hyperpigmented neutrophil.
C -Platelets
Moderate thrombocytopenia.
Giant platelets
d-Reticulocyte
are decreased but increased by treatment with vit
B12 or folic acid
Macrocytic
Anemia :II- Bone marrow
Methodology*
Large dose of unlabelled B12 (1000ug) is given IV to
.saturate body sores
Radiolabelled B12 (lug) is given orally, the amount of
.radio labellol B12 on the urine
Urine of the next 24 hours is measured
Results
Function
It is essential for nucleic acid synthesis maturation. It
is deficiency lead to
Nuclear maturation defect., of blood cells and
megaloblastic erythropoiesis.
GIT: mucosal cells.
Macrocytic
Anemia
a) Decreased absorption
* Malabsorption: in small bowel disease.
* Drugs : pill or anticonvulsant.
b) Decreased utilization
* Glossitis.
MACROCYTOSIS WITHOUT
MEGALOBLASTIC CHANGES
2) Pathological
* Alcohol excess
* Liver disease
* Reticulocytosis
* Hypothyroidism
* Some haematological disorders (e.g aplastic
anaemia, sideroblastic anaemia
* Drugs (e.g cytotoxics as azathioprine)
* Agglutinated red cell measured on red counters.
* Cold agglutinis due to autoagglutination of red cells,
MCV decreases to normal with warming of the
sample to 37OC.
HAEMOLYTIC ANAEMIAS
: Definition
Reticuylocytosis is hallmark.
:Congenital Abnormalities )1
:Membrane defects
* Hereditary spherocytosis
* Hereditary elliptocytosis
•Hereditary stomatocytosis
Haemoglobinopathies:
* Sickle cell anaemia
* Thalassaemia
Enzymopathies
1) Abnormal aerobic glycolysis e.g. G6PD deficiency
2) Abnormal anerobic glycolysis e.g pyruvate kinase
deficiency
3) Non glycolytic enzymopathies
Haemolytic 2) Acquired Abnormalities
Anemia 1- Paroxysmal nocturnal haemoglobinuria
2- Vitamin E deficiency
B- EXTRACORPUSCULAR CAUSES:
1- Immune mechanisms
a ) Alloimmune antibodies (iso-immune):
* Incompatible blood transfusion
* Haemolytic disease of the newborn
* After allogenic BM or organ transplantation
* Idiopathic
* Secondary to CLL, Lymphoma, SLE and rheumatoid
disease
* Secondary to drugs e.g methyldopa.
Haemolytic
Anemia
2- Cold reactive antibodies (react at 32oC and
usually agglutinates and haemolyse red cells,
type of AB = IgM).
* Snake venom
* Lead
* Naphthaline
* Phenacetin
* Sulpha drugs
* Hypophosphataemia
Haemolytic 4- Infections
Anemia
* Clostridium welchii septicemia (Secondary to
septic abortion)
* Malarial infestation (Black water fever)
5- Metabolic causes
* A betalipoproteinemia : A canthocytosis
* Liver porphyria :
* Spurr cell anaemia
* Zieve’s syndrome
* Wilson disease
* Severe hypophosphataemia
7-Hyperslenism
CLINICAL FEATURES OF HAEMOLYTIC ANAEMIA
Haemolytic General features of anaemia
Anemia General features of haemolytic anaemia
1)Haemalytic jaundice .
* Mild degree.
* Skin is lemon yellow
* Sclera tinge of jaundice .
* Dark stool.
* Normal urine which darken on exposure to air
2)Heapatosplenomegaly:
* Common in chronic haemolysis except in cases of
sickle cell anaemia where there self-splenectomy
3) Biliary obstruction and /or gall bladder stones.
* Pigment stones: extra hepatic obstruction .
* Viscid bile: intrahepatic obstruction.
NB. In this situation jaundice becomes, mixed
( haemolytic + obstructive) and abdominal pain my be
present.
4- Leg ulcer:
Chronic leg ulcer surrounded by pigmentation cause
by extra vascular iron deposition . Ulcers develop on the
malleoli
Haemolytic 5-Different types of crisis:
Anemia a) Heamolytic crisis
* Fever, rigors: pyrogen release from RBCs .
* Generalized bone pain
* Acute abdominal pain, backache, may be vomiting.
* Aggravation of anaemia (pallor), deepening as jaundice,
and dark colouration of urine
* Investigations:
- Dark urine: haemoglobinuria.
- Increased serum biliurbin
- Reticulocytosis
- BM erythroid hyperplasia.
* Cause may be infection
B- A plastic crisis
* Inability of BM to replaced the destructed RBCs
- Severe anaemia without jaundice.
- Reticulocytopenia .
- BM erythroid hypoplasia.
* Cause: viral infection especially parvovirus B19 and
HBV.
Haemolytic
Anemia C- Sequestration crisis
Trapping and pooling of RBCs in the spleen (mainly
and liver).
D- Megaloblastic crisis
* Anaemia severe without jaundice .
* Decreased reticulocytic count
* Macrocytic anaemia.
* BM : megabloblastic
Cause: folic acid deficiency.
COMPLICATIONS
* Haemolytic crisis:.
* A plastic crisis:
* Folate deficiency caused by increased BM requirement
* Gall stones
*In sickle cell anaemia: signs and symptoms of thrombotic
phenomena.
Haemolytic
Anemia INVESTIGATION FOR CASE OF HAEMOLYTIC
ANAEMIA
1- CBC
3- Bone marrow
* Hypercellular normabloastic marrow.
* Hypocellular in a plastic crisis.
* Megaloblastic in folate deficiency.
* RBC morphology.
* Osmotic fragility .
* Hb electrophoeresis.
* Estimation of G6 PD.
* Coomb’s test.
Haemolytic
Anemia
HEREDITARY SPHEROCYTOSIS
Pathogenesis:
CLINICAL PICTURE:
biconcave.
* Reticulocytosis .
* Anaemia of moderate degree.
2- Osmotic fragility
TREATMENT :
ELLIPTOCYTOSIS
AETIOLOGY
COMPLICATIONS
1) Thrombosis
2) Plastic anaemia .
INVESTIGATIONS
TREATMENT :
1- Symptomatic
2- Prodinisone .
3- BMT .
HAEMOGLOBINPATHIES
Haemolytic
Anemia
Normally haemoglobin consists of .
* Globin :protein which is formed from 4 polypeptide
chain
* Haem : iron-protoporphyrin complex
Haemoglobinopathies:
4 (-thalassaemia) - H Abnormal
4(Homozyqous - thalassaemia) - Barts production
* Ischemic cardiomyopathy
1) Susceptibility to infections
1) CBC
2) Hb electrophoresis:
a) prophylaxis
* Genetic counseling
* Prenatal diagnosis
* Prevent exposure to hypoxia
* Vaccination
b) Active treatment
THE THALASSAEMIAS
A- Alpha thalassaemia
Production of alpha chain is decreased. It is replaced by
gamma or beta chain with for motion of Hb Bart (4g) or Hb
H (4b) types.
1- a-Thalassaemia major
- Homozygosis (2abnormal gene)
- Hb Bart & Hb H are 80-90%.
- In compatible with life and results in intrauterine fetal
death from hydrops foetalis
2- a-Thalassaemia minor
- Heterozygous (only one abnormal gene).
- H B Barts & Hb H are 10-20%.
- Presented by mild Microcytic hypochromic anaemia,
jaundice, and splenomegaly
Types
1- b-thalassaemia major
-Homozygous (2 abnormal gene)
-Hb F > 80-90%
3- b Thalassaemia intermedia
-Mild anaemia
-Rarely requiles treatment.
Haemolytic
Anemia
b- THALASSEMIA
Thalassaemia intermedia
CLINICAL PICTURE:
INVESTIGATIONS
1) CBC
2) Serum iron
decreased serum iron binding capacity and high serum
iron and ferritin levels are caused by multiple blood
transfusion.
3) Hb electrophoresis
shows an increase in HbF, reduced or absent HbA and
Hb A2 is normal or slightly increased.
4) X-ray
* Skull X-ray show the characteristic hair on end
appearance of bony trabeculae as a result of
expansion of bone marrow and thinning of bone
cortex .
- genetic counseling
- prenatal diagnosis
B) Active treatment
CLINICAL PICTURE
TREATMENT
CLINICAL PICTURE:-
INVESTIGATIONS
TREATMENT
APLASTIC ANAEMIA
DEFINITION
a
Haemolytic
Anemia
a
Haemolytic
Anemia
a
Haemolytic
Anemia
a
Haemolytic
Anemia