Anaemia: Most common problem in medical clinics the world over. Major public Health importance
Chronic disability
Poor quality of life
Low income


Definition:
The level of circulating Hb or Red cell is lower than that in healthy subjects of the same sex and age group and in the same environment.

Anaemic patient suffers from tissue hypoxia, the consequence of a low oxygen carrying capacity of the blood.

Clinical manifestations are determined by its aetiology and pathogenesis.

Clinical features of anaemia

Symptoms
May be asymptomatic (Increase in 2 -3 DPG)
Fatigue
Headaches
Dizziness and faintness
Angina
Palpitations
Intermittent claudication

Signs
Pallor
Tachycardia
Cardiac failure
Papilloedema
Retinal heamorohages
Angular stomatitis
Koilonychia
Brittle Nails and hairs
Atrophy of tongue papillae
Dysphagia and glossitiis (Plummer – Vinson syndrome )
Chronic leg ulcers
Bone deformities – gnathopathy etc.
Beefy Red, Sore tongue
Polyneuropathy
Sub-acute combined degeneration
Symmetrical paraesthesia ( fingers & toes)
Loss of vibration sense
Ataxia
Dementia
Optic atrophy

Normal Haematological Values

Nigeria U.K.
Retics 25 - 85X109/L 25 - 85X109/L
WBC 3.0 - 9.0 3.7 – 10.0X109/L
Platelets 100 – 300 130 – 400X109/L
Hb 12 – 17 13 – 17g%
Hct 0.37 – 50 0.40 – 0.5 L
MCV 80 – 95 82 – 102fl
MCH 27 – 32 27 – 32 pg
MCHC 32 – 35 31.5 – 35 g%
RDW 10 – 15% 10 – 15%
RBC 3.8 – 5.8 4.4 – 5.5X1012/L

Laboratory Tests in the Diagnosis of Anaemia

Hct Manual (cv 2%)
Automated
Hb
RBC
Red Cell Indices
MCV
MCH
MCHC
RDW
HDW
% Microcytic
% Hypochromic
Retic Count and Retic Indices
ESR


RED CELL MORHPHOLOGICAL ABNORMALITIES

Macrocytes
Macro ovalocytes
Microcytes
Miccrospherocytes
Ovalocytes (Elliptocytocytes)
Sickle cells (Drepanocyctes)
Schistocytes (RBC Fragments)
Acanthocytes
Hypochromia
Poly chromasia
Basophilic Stippling
Howell - Jolly bodies ( nuclear remnants)
Heinz bodies
Cabot Rings
Nucleated RBC
Target Cells
Ecchinocytes (Burr Cells)


Other specific tests in anaemias?

Hb electrophoresis PH 8.4
PH 6.8
Sickling Tests
Osmotic fragility
Globin Chain synthesis
DNA analysis
B12
Serum and RBC folate assay
Hams Test for PNH)
Urine Haemosiderin
NAP
Viral Studies (HBV, HCV, HIV, EBV)
Red cell survival studies
M protein , Igs, Skeletal survey
Bone Marrow culture for TB
Marrow Examination for Leishmaniasis
FNAC/LN Biopsy
Splenic aspirate
Rheumatoid Factor
ANA
Abdominal US and CT Scan
Laparotomy and Splenectomy


Megaloblastic anemia

Hb (g/dL) 6.2
Hct (%) 21.3
RBC (x 106/µL) 1.70
MCV (fl) 125.7
RDW (%) 20.9
MCHC (g/dl) 34.5
HDW (g/dl) 4.10
% Macro 60.4
%Hypo 3.2
Platelets (x 103/µL) 184
MPV (fl) 9.7


Megaloblastic anemia Rectic Profile

%Reticulocytes 2.1
Absolute reticulocytes

(x 109/l) 63
%low staining-intensity 68.2
%Medium staining-intensity 24.6
%High staining-intensity 7.2
MCVr (fl) 138.5
RDWr (%) 14.9
CHCMr (g/dl) 24.8
HDWr (g/dl) 3.1
CHr (pg) 33.5
CHDWr (pg) 5.5


Iron-Deficiency anemia

Hb (g/dL) 8.2
Hct (%) 26.8
RBC (x 106/µL) 3.36
MCV (fL) 79.9
RDW (%) 17
MCHC (g/dL) 31.1
HDW (g/dL) 3.89
MCH (pg) 24.4
% Micro 6.1
%Hypo 22.3


Iron-deficiency anemia Retic Profile

% reticulocytes 2.0
Absolute reticlocytes (x 109/L 98
%low staining-intensity 86.9
%Medium staining-intensity 9.5
%High staining-intensity 3.6
MCVr (fL) 89.5
RDWr (%) 22.3
CHWr (g/dL) 20.3
HDWr (g/dL) 3.50
CHr (pg) 17.2
CHDWr (pg) 3.6


ANAEMIA IN CHRONIC RENAL DISEASE

Acute or chronic Renal failure produces a normochromic-normocytic anaemia
Ecchinocytes (Burr cells) in the blood film
Retic count: normal or low
Bone marrow: normoblastic erythropoiesis without erythoid hyperplasia
Dominant cause of anaemia in Renal failure is reduced level of EPO

ANAEMIA IN CHRONIC RENAL DISEASE {contd}

*anaemia occurs in 60-80% of patients with renal impairment
Low Hb is an independent risk factor for increased mortality

Causes of anaemia in Renal Disease
Diminished EPO production
Bleeding: Platelet dysfunction, thrombocytopaemia
MAHA
Vit K deficiency (nutritional)
Folate deficiency: associated with haemodialysis
Fe deficiency: associated with haemodialysis
Blood loss at haemodialysis
Neocytolysis (selective destruction of young RBC; can be precipitated by bolus IV EPO


Bleeding Disorders

===> Acquired Bleeding Disorders
===> Inherited Bleeding Disorders

The acquired coagulation disorders

Deficiency of Vit K – dependent factors,
Haemorrhagic diagnosis of the new born.
Biliary obstruction
Malabsorption of Vit K Sprue & gluten-induced enteropathy
Vitamin k – antagonist therapy if Coumains
Liver Diseases
DIC
Inhibition of coagulation
Specified inhibitors – e.g. antibodies to FVIII
Non specified - antibodies SLE, Rheum, arthritis
Miscellaneous
Dxs with M-protein production
L – Asparaginese
with heparin, defibrinating agents
Massive transfusion syndrome.


DIC

Definition: Pathological syndrome resulting from the formation of thrombin, subsequent activation and consumption of certain coagulant proteins, and production of fibrin thrombin.


Normal Response to tissue damage.

Thrombin ⇒ Coagulation
⇗ released of blood ⇘
Tissue
Damage
stops blood clot



Thrombotic features
↑
Unregulated ⇁ Free ⇀ Widespread
Thrombin Thrombin microvascular
thrombosis
Body attempts vascular ⇃
Patency
⇃ Tissue Ischaemia
+
Plamin ++ → Haemorrhagic Organ Damage
manifestation
⇃
Systemic and Local
fibrinogenolysis


Thrombin is naturally contained by antithrombin / Protein C



Causes of DIC

Acute DIC Chronic DIC
- Infection Malignancy
- Obstetric complications Retained Dead fetus
- Trauma Liver Disease
- ABO incompatible red cells Liver Disease
- Liver Dx Sever localized
Intravascular coagulation


INHERITED Bleeding Disorders

Haemophilia A
B
C
Von Wille brands Sisease
History
Haemostatic challenge
Severity



Source: http://www.medicalnigeria.com/2017/10/anaemias-and-bleeding-disorders.html