Anemia DLM Tinjauan PK Kuliah Ums

Anemia dalam tinjauan
patologi klinik
Dr Niniek Yusida SpPK MSc
| the erythrocyte: an overview
2.
1
Partners in Global Health Education
Contents page
*L.O. Link the components of red cell structure to red cell development and
function
START HERE
Function
The primary function of the erythrocyte
is the carriage of oxygen from the lungs
to the tissues and CO2 from the tissues
to the lungs.
The red cell also plays an important role

in pH buffering of the blood.
Lifespan: Because the fully

developed red blood cell has no
nucleus the cell cannot divide or
repair itself. The lifespan is
therefore relatively shortFINISH
(120 HERE
days).
Haemoglobin content: unique to
the red cell, it is this metaloprotein
molecule which is pivotal in red cell
development and Oxygen transport
due to its affinity for O2.
To achieve these functions the red

cell has several unique
properties.
Image: scanning electron microscope of

red blood cell
Biconcave shape: increases

surface area available for gaseous
exchange.
Flexibility: the red

cell is 7.8 m across
and 1.7 m thick and
yet it is able to fit
through capillaries of
only 5 m diameter.
This is in-part due to
the flexible
membrane and
shedding of the
nucleus.
Strength: it has a
strong but flexible
membrane able to
withstand the
recurrent shear
forces involved in the
circulation of blood.
| Erythropoiesis
Contents page
2.1. The erythrocyte:
an overview.
2.2. Erythropoiesis
2.
2
An erythrocyte is a fully developed, mature red blood cell. The adult human makes approximately
1012 new erythrocytes every day by the process of erythropoiesis. This is a complex process that
occurs within the bone marrow. Before an erythrocyte arrives fully functioning into the blood
stream it must develop from a stem cell through an important number of stages. This module
has simplified this process and highlights the key stages. Follow the numbered red boxes through
to the end before continuing to the next slide.
3. EPO
continues to
stimulate
primitive
erythroid cells
(red blood cells)
in the bone
marrow and
induce
maturation.
2. EPO stimulates
stem cells within
the bone marrow
which differentiate
into erythroid
precursors.
START HERE
1: Erythropoietin (EPO),
a growth factor, is
synthesized primarily (90%)
from peritubular cells of the
kidneys (renal cortex).
Macrophages surround and

supply iron to these
erythroprogenitor cells that
become erythroblastic islands.
Stem
cells
Bone marrow
Erythroid
precursors
As with much
human physiology,
this system works
via a feedback
mechanism.
Red blood cells in

circulation
erythropoietin
Kidney
FINISH HERE
4. There is no store of EPO. The production of
erythropoietin is triggered by tissue hypoxia
(oxygen tension sensed within the tubules of the
kidney) and stops when oxygen levels are normal.
LO List the key components of erythropoiesis (red cell production)
|Red cell precursors and the sequence of erythropoiesis

an overview.
2.2. Erythropoiesis
Key point!
Contents page
2.
2
Reticulocytes are an important cell in haematology as they increase in number following a

haemorrhage, haemolytic anaemia or from treatment of a haematinic deficiency. They provide
an excellent measure of red cell production and the age of the red cell population. In normal
blood there is usually about 1 reticulocyte : 100 erythrocytes.
marro
w
Pronormoblast: This is the earliest and largest cell

with a large nucleus and no haemoglobin.
Normoblasts: these cells go through a large
number of progressive changes.
Fundamentally
they reduce in cell size but increase the
haemoglobin concentration in the cytoplasm. The
nucleus proportionally decreases until it is extruded
before the cell is released in to the blood.
3.4. Reticulocytes: Considered the teenagers of
the the life cycle! This is the FINAL stage of
development before full maturation. These cells are
now anucleate and contain roughly 25% of the final
haemoglobin total.
They reside mostly in the
marrow but in healthy individuals a small number
can be found in the peripheral blood. They contain
some cell organelles.
blood
Sequence: amplification and
maturation of the erythrocyte
3.5 Erythrocyte: after 1 week the mature

erythrocyte emerges with no organelles and
high haemoglobin content.
Key point!
Anaemia of
chronic disease.
In individuals living
with a chronic
disease (e.g.
rheumatoid
arthritis),a complex
interaction of
inflammatory
cytokines interferes
with the red cell
lifecycle by
impairing iron
metabolism and
inhibiting red cell
precursors. The end
result is a
normocytic anaemia.
|haematinics
Check the haematinics this is a phrase

used frequently on the hospital ward!
Contents page
an overview.
2.2. Erythropoiesis
2.3. The red cell
membrane
2.4 Haematinics
haemoglobin
deficiency;
Click here see all
key causes.
iron life cycle;
Click here to see
the key stages
Click here to see
a schematic
diagram of
vitamin B12
absorption
2.
4
Erthropoiesis is also regulated by the availability of haematinics

So what exactly are the haematinics? These are the key micronutrients that must be present if a
red blood cell and its haemogoblin are to develop in a normal fashion.
These major micronutrients, provided in a balanced diet, are iron, vitamin B12 and
folate
A deficiency in any one of these micronutrients can result in anaemia through impaired
red cell production within the bone marrow
Assessing haematinic status is key to the investigation of the cause of anaemia
Iron:
At the centre of the haem molecule is an atom of iron which binds oxygen in a reversible manner.
Haemoglobin concentration in the developing red cell is a rate limiting step for erythropoiesis. In
iron deficiency, red cells undergo more divisions than normal and, as a result, are smaller
(microcytic) and have a reduced haemoglobin content (hypochromic). Iron deficiency is the
leading cause of anaemia worldwide.
Vitamin B12 (cobalamin) and folate (pteroylglutamic acid):
These are key building blocks for DNA synthesis and essential for cell mitosis. DNA synthesis is
reduced in all cells that are deficient in either folate or vitamin B 12. The bone marrow is the factory
for blood cell production. In haematinic deficiency, DNA replication is limited and hence the number
of possible cell divisions is reduced leading to larger red cells being discharged into the blood i.e.
less DNA, less divisions and larger cells. This leads to enlarged, misshapen cells or megaloblasts in
the marrow and macrocytic red cells in the blood.
|haematinics in haemoglobin
2.
4
Iron
Click here to
return
Iron
deficiency
Chronic
inflammatio
n
Malignancy
Chronic infections and

inflammatory disorders
cause chronic anaemia as a
result of;
1. slightly shortened red
blood cell life span
2. sequestration of iron in
inflammatory cells called
macrophages
Both procedures result in a
decrease in the amount
of iron available to make
red blood cells.
Protoporphyrin
Haem
Globin
Haemoglobi
n
Thalassaemi
a
|haematinics: the normal iron cycle
2.
4
An iron deficiency
profile.
Serum Iron: Reduced
Serum total ironbinding capacity
(TIBC): Increased- the
body works hard to bind
free iron.
Iron deficiency can be identified best by assessing the appearances of the red cells on a blood
film. Iron indices in a blood sample are helpful to confirm a lack of iron. In order to interpret these
indices, it is vital to understand how the body handles iron ..
Iron is a key constituent of haemoglobin (60-70% of total
body iron is stored here) and its availability is essential
for erythropoiesis. In iron deficiency, there are more
divisions of red cells during erythropoiesis than normal.
As a result the red cells are smaller (microcytic) and
have a reduced haemoglobin content (hypochromic).
Soluble transferrin receptors,

sTfR are on the red cell surface.
These can be measured and are
increased in iron deficiency.
Red blood
cells
In iron deficient states, bone marrow

iron is reduced.
Serum ferritin:
Reduced-since iron
stores are low
Erythroid bone
marrow
(normoblasts)
Some iron binds to

apoferritin to form
ferritin, a storage
compound.
Serum soluble
transferrin receptors:
Increased-since red
cells attempt to absorb
more iron.
Liver
2. Iron is then attached to
a protein, transferrin in
the serum (plasma),
where it is transported to
the bone marrow for
haemoglobin synthesis.
Serum
transferrin
Fe
Click here to
return
Duodenum
Reticuloendothelial system;
Spleen & macrophages
3. Dying red cells

are recycled by
macrophages in
the spleen and
iron is recycled
into the plasma
for further use.
1. Iron is absorbed from the small

intestine in the ferrous state (Fe2+;
approx. 1mg/day).
STAR
T
|haematinics: vitamin B12
2.
4
There are a number of key steps in the absorption of Vitamin B 12. The two key locations
are the stomach and the terminal ilium. Dietary vitamin B 12 binds with intrinsic factor
(IF) in the stomach, a transport protein produced by gastric parietal cells. The B12-IF
complex then travels through the small intestine and is absorbed by special receptors in
the distal ileum. This pathway is important when considering possible causes of Vitamin
B12 deficiency.
Oesophagus
Causes of vitamin
B12 deficiency
1. Pernicious
anaemia
Stomach
IF Intrinsic factor
2. Inadequate
intake
3. Poor absorption
Distal ileum
Site of B12
absorption
Click here to
return
Vitamin B12
ingested
Vitamin B12 deficiency can

take up to two years to
develop as the body has
sufficient stores for this
period.
Pernicious anaemia: the
leading cause of B12
deficiency. IgG autoantibodies
target gastric parietal cells
and its product IF causing an
atrophic gastritis. This results
in reduced secretion of
intrinsic factor and therefore
reduced B12-IF complex for
absorption in the distal ileum.
Welcome to section 2! | defining anaemia

Contents
1. 1Introduction
1.2 use this module
1.3 Learning outcomes
2.1. The erythrocyte

2.2. Erythropoiesis
2.3. Red cell membrane
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
2.7. Ageing and death
Quiz 1
3.0. Defining
3.0.
Defininganaemia.
anaemia.
3.1.
Prevalence
3.1. Clinical
Prevalence
features
3.1. Clinical features
Quiz 2
Quiz 2
4.0.
Classifying anaemia
4.0. red
4.1.
Classifying
cell indices.
anaemia
4.1. Morphological
4.2.
red cell indices.
4.2. Morphological
classification
classification
4.3.
Aetiological
4.3. Aetiological
classification
classification
5.0. Blood film: a basic
interpretation.
interpretation.
5.1.
Anaemia cards
Quiz 3.
Quiz 3.
6.0. Glossary
6.0. Glossary
7.0. References
please
click on
7.0.
References
contents to repeat
a section.
What exactly is anaemia?

Anaemia is defined as haemoglobin concentration less than the normal reference range.
Reference ranges differ according to age, sex and altitude. However, in general, anaemia
is defined as Hb concentration
For adult males < 13.5 g/dl

For adult women < 11.5 g/dl
As well as reduced [Hb], anaemia is usually accompanied by a reduction in the number of
red cells (red cell count) and packed cell volume (PCV). However this is not always
the case. Red cell count and PCV may be normal in some patients with lower than
normal haemoglobin levels (and hence anaemic). The total circulating haemoglobin
concentration is therefore determined by.
the circulating plasma volume
the total circulating haemoglobin mass.
The following circumstances should therefore be taken in to consideration

| Acute significant blood
loss |
Following acute blood loss

it may take up to a day for
the plasma volume to be
replaced and anaemia to
present. Therefore, clinical
features of shock and
reduced blood volume
may occur before a fall in
haemoglobin
| Pregnancy or
splenomegaly |
These can produce an

increase in plasma volume
reducing the apparent
haemoglobin
concentration even though
circulating haemoglobin
levels are normal.
| Dehydration |
Reduced plasma volume

may mask anaemia.
|clinical features of anaemia

Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1
3.0. Defining anaemia.

3.1. Prevalence
Quiz 2
4.0. Classifying anaemia

4.1. red cell indices.
4.2. Morphological
classification
4.3. Aetiological
classification
interpretation.
Quiz 3.
6.0. Glossary
7.0. References
please click on
contents to repeat
a section.
Tissue hypoxia is the end result of the bloods reduced oxygen carrying capacity. The
compensatory mechanisms in response to hypoxia cause the clinical
manifestations to develop.
An anaemic individual will have the following two key compensatory mechanisms;
1. The cardiovascular system

Cardiac compensation is the major adaptation. Both stroke volume and heart rate
increase mobilizing greater volumes of oxygenated blood to the tissues. This can present
with palpitations, tachycardia and heart murmurs. Dyspnoea which occurs in severely
anaemic patients may be a sign of cardio-respiratory failure.
2. The skin
A common sign is generalised pallor due primarily to vasoconstriction with redistribution
of blood to key areas (brain, myocardium).
| clinical features of anaemia

General symptoms and signs

Click images for explanation of signs!
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1

3.1. Prevalence
Quiz 2

4.2. Morphological
classification
4.3. Aetiological
classification
interpretation.
Quiz 3.
6.0. Glossary
7.0. References
please click on
contents to repeat
a section.
General Symptoms
Headaches
Shortness of
breath: particularly
on exercise.
Palpitations
Confusion and symptoms of

cardiac failure in elderly
Weakness and
lethargy
General Signs
Some specific signs

This is a list of general symptoms and signs; we will cover more specific clinical
features as we progress through the module.
Signs:
Pallor of mucous
membranes (most
common sign). This is a
general sign.
Beware: pallor is quite
subjective and NOT a
reliable clinical sign. Be
careful not to exclude
anaemia on the basis of
absence of pallor alone
RETURN

Signs:
Nail bed; demonstrating

koilonychia (spoonshaped nails). This is
specific to iron
deficiency.
RETURN

Signs
Atrophic glossitis; red

large swollen tongue.
This is seen in both
vitamin B12 and folate
deficiency.
RETURN

Signs
Angular stomitis;
fissuring at corners of
mouth. This is seen in
both vitamin B12 and
folate deficiency.
RETURN

Signs
Dysphagia: pharyngeal
web (Paterson-Kelly
syndrome). This occurs
in iron deficiency.
RETURN

Signs
Peripheral
oedema. A
general sign.
RETURN

Signs
High flow murmur, bounding

pulse and/or tachycardia: All
features of a compensatory
hyperdynamic circulation.
These are general signs!
RETURN
Welcome to section 3!|classification of anaemia

Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1

3.1. Prevalence
Quiz 2
4.0. Classifying
anaemia
4.2. Morphological
classification
4.3. Aetiological
classification
interpretation.
Quiz 3.
6.0. Glossary
please
click on
7.0.
References
contents to repeat
a section.
Essentially there are two ways to classify anaemia, by red cell size
(morphological classification) or by cause (aetiological classification). Both have
their purpose and both need to be fully understood to gain a rounded
understanding of anaemia.
Morphological classification
Aetiological classification
This is a practical and clinically useful

classification for establishing a differential
diagnosis of anaemia.
This classification is based on cause and

illuminates the pathological process
underlying anaemia.
It is done by examining red cells in a blood

stained smear and by automated
measurements of red cell indices
*Key point: In order to understand this classification it is essential to

understand red cell indices reported in the full blood count (FBC). There is
great reward in understanding these indices as they enable one to identify
some of the underlying processes leading to anaemia and, importantly, help
to formulate a differential diagnoses.
|red cell indices

These are the key measures of red cell indices. They relate to the haemoglobin content and
size of the red blood cells.
MCV: Mean cell volume; the average volume of the red cells. MCV does not provide an indicator
of either haemoglobin concentration within the cells, or the number of red cells. It enables us to
categorize red cells into the following;
Microcytic
(MCV <80fL)
Normocytic (MCV of 80-99fL)
Macrocytic (MCV > 99fL)
a small red blood cell.

a normal size red blood cell.
a large red blood cell.
This is a key index that is used daily in medical settings across the world to
categorize the type of anaemia present.
It is reliable in most cases; one exception is when two pathologies occur at the same
time such as vitamin B12 and Iron deficiency. MCV reports average cell volume; further
assessment of cell size and how this varies within an individual can be ascertained from
the red cell distribution width (RDW; see below).
MCH: Mean corpuscular haemoglobin ( normal range 26.7-32.5pg/cell): the average

haemoglobin content of red blood cells.
Cells with a reduced haemoglobin content are termed
hypochromic and those with a normal level are termed normochromic (see below).
RDW: Red cell distribution width; an index of the variation in sizes of the red cell population
within an indiviual. This will be raised if two red cell populations are present. Occasionally useful if
there is doubt about multiple causes of anaemia. A common cause for an increased RDW is the
presence of reticulocytes.
Normochromic implies normal staining of the cells in a thin blood film. The central area
of pallor is normally about 1/3 of the cell diameter
Hypochromic
indicates reduced staining with increase in the central area of pallor
|interpretation of red cell indices

Microcytosis & hypochromia
Normocytosis & normochromia
Macrocytosis & megaloblastosis
Microcytic
abnormally small red blood cells.
Microcytic anemia is not caused by
reduced DNA synthesis. It is not
fully understood but is believed to
be
due
reduced
erythroid
regeneration.
Normocytic normochromic
anaemia develops when there is a
decrease in the production of normal
red blood cells.
Macrocytic megaloblastic
red blood cells have an unusual misshapen
appearance, which is due to defective
synthesis of DNA. This in turn leads to
delayed
maturation
of
the
nucleus
compared to that of the cytoplasm and the
cells have a reduced survival time.
Hypochromic
hypochromic cells due to a failure of
haemoglobin synthesis.
Normocytic
Many processes causing anaemia do
not effect the cell size or haemoglobin
concentration within cells.
In clinical practice megaloblastic anaemia is

almost always caused by a deficiency of
vitamin B12 or folate which are key
building blocks in DNA synthesis.
Pathologies;
anemia of chronic disease (some)
aplastic anemia
Haemolysis: a increased destruction
(some)
Hemolysis ;or loss of red blood
pregnancy/fluid overload: an inbalance or
an increase in plasma volume compared
to red cell production
Macrocytosis:
The exact cause of the pathological
mechanisms behind these large cells is not
fully understood.. It is thought to be linked
to lipid deposition on the red cell membrane.
Alcohol is the most frequent cause of a
raised MCV!
Pathologies;
Iron deficiency; iron is an
essential building block of
haem.
Failure of globin synthesis; this
occurs in the thalassemia's.
Crystallization of haemoglobin:
sickle cell disease and
haemoglobin C.
Alcohol | Liver disease | hypothyroidism |
| morphological classification of anaemia

Contents
1. 1Introduction
1.2 use this module
Anaemia type

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1

3.1. Prevalence
Red cell
indices
Microcytic
hypochromi
c
MCV < 80 fl
MCH < 27 pg/L
Normocytic
normochromi
c
normal
Macrocytic
Megaloblastic
MCV > 98 fl
Quiz 2

4.2. Morphological
classification
4.3. Aetiological
classification
interpretation.
Quiz 3.
6.0. Glossary
7.0. References
please click on
contents to repeat
a section.
Common
examples
Iron deficiency
Haemolysis
Thalassaemia
Chronic disease
Sideroblastic
Marrow infiltration
Folate
deficiency
B12deficienc
y
|aetiological classification of anaemia

Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1

3.1. Prevalence
Quiz 2

4.2. Morphological
classification
4.3. Aetiological
classification
interpretation.
Quiz 3.
6.0. Glossary
This classification is based on cause and illuminates the pathogenic process

leading to anaemia.
You can look at anaemia from a production, destruction or pooling point of view.
Reduced Production
Insufficient production: If you consider the bone marrow to be the factory it
must have enough raw material (Iron, vitamin B12 and folate) to make new blood
cells. These raw material are called haematinics. If there is not enough of the raw
material (a deficiency of one or more of the haematinics), then there is insufficient
production.
Inefficient production (erythropoiesis): some problem with maturation of the
erythroid in the marrow. Occurs in bone marrow infiltration
(malignancy/leukaemia), aplastic anaemia or in the macrocytic megaloblastic
anaemia.
Destruction
Reduced Cell lifespan
This is either due to loss of red blood cells in a haemorrhage (a bleed) or the
excessive destruction of red blood cells in haemolysis. Haemolysis is an important
cause of red cell destruction and anaemia.
7.0. References
please click on
contents to repeat
a section.
Pooling: Hypersplenism.
|classification
anaemia
based on pathology
|classification
of anaemiaofbased
on pathology
Contents
anaemia
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Increased
destruction of
red cells
(haemolytic
anaemia
Quiz 1

3.1. Prevalence
Quiz 2

4.2. Morphological
classification
4.3. Aetiological
classification
interpretation.
Quiz 3.
6.0. Glossary
7.0. References
please click on
contents to repeat
a section.
Inherited /
inside the
cell
Acquired /
outside cell
immune
Autoimmune
warm
Autoimmune
cold
Adverse
drug
reaction
Haemolytic
disease of
the newborn
Dilution of red
cells by increased
plasma volume
(e.g.
hypersplenism)
Loss of red
cells due to
bleeding
Reduced
Reduced bone
bone
marrow
marrow erythroid
erythroid
cells
aplastic
aplastic anaemia
anaemia
Leukaemia
Leukaemia or
or
malignancy
malignancy
Nonimmun
e
Abnormal
red cell
membrane
Sperocytes
Elliptocytes
Malaria
Burns
Mechanical
heart valve
Hypersplenism
PNH
Failure of
production of
red cells by the
bone marrow
Nutritional
Nutritional
(haematinic)
deficiency
deficiency
Iron
Iron
vitamin
vitamin B
B12
12
folate
folate
Abnormal
haemoglobin
Thalassaemia
Sickle cell
anaemia
Ineffective
Ineffective red
red cell
cell
formation
formation
Chronic inflam.
Thalassaemia
Thalassaemia
renal
renal disease
disease
Abnormal
red cell
metabolism
Pyruvate
kinase
deficiency
G6PD
deficiency
|blood film: a basic interpretation

Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1

3.1. Prevalence
Quiz 2

4.2. Morphological
classification
4.3. Aetiological
classification
A blood film is an essential investigation in classifying and diagnosing the cause of anaemia. A blood sample
(anticoagulated venous sample) is smeared onto a glass slide, fixed and stained. Red cells are examined
along with white cells, granulocyte precursors, blast cells and platelets.
Red blood cells appear paler in the centre of the cell due to their biconcave shape. The pinkish colour one
observes in a normal blood film is a result of the cells unique haemoglobin content. Shape, size and colour
are the key variables to observe.
Please click on each cell to see the blood film and its
causes.
Normal red
cell
Microcytic
hypochromi
c
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Macrocyte
Tear drop
poikilocyte
Please click here to compare blood films
Target cell
Pencil cell
5.0. Blood film: a

basic
interpretation.
Quiz 3.
6.0. Glossary
please
click on
7.0.
References
contents to repeat
a section.
Spherocyte
Acanthocyte
Basket case
Malarial parasit
Normal red blood film
Elliptocyte
Stomatocyte
Microcytic hypochromic
Fragments
Sickle cell
Macrocytic megaloblastic
Fragments
Target cells
Pencil cells
Spherocyte
Bite cells
Malaria
Acanthocyte
|anaemia essential bites

Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1
Microcytic anaemia
iron deficieny
R.C.I: a microcytic hypochromic anaemia
Epi:
affecting around
this is the most common cause of anaemia worldwide

500million daily.
Aet:
BLOOD loss
1. The most common cause of iron deficient anaemia is

2. reduced intake (diet)
3. Increased demand (pregnancy)
4. Malabsorption (coeliac, gastrectomy)
IX.
Si/Sy.
Vinson
gastritis.
Koilonychia, sore tongue, angular stomatitis, Plummersyndrome (dysphagia due to oesophageal web), painless
Tx.
and MCV
Treat underlying cause, give ferrous sulphate until Hb

normal (4-6months).
Epi:
common cause of a
worldwide aff ecting around
daily.
the most
naemia
500million
Aet:
anaemia, malabsorpion,
gastrectomy
pernicious
post total
Ix.
platelets. IF
folate levels
B12MCV
antibodies,
Si/Sy:
Gradual
deterioration, Irritability,
Loss of
memory, Painless jaundice,
Loss of
sensation , Feeling of pins
and needles in
extremities. ataxic
Txt
Intramuscular
(IM) of 1mg of
hydroxycobalamin (Vitamin B12). There is
G6PD deficieny
Epi:
Aet:
consumption
dietary
folate antagonist
methotrexate).
increased
(pregnancy),
deficiency,
(drugs eg;
Ix.
folateMCV transferrin
Endoscopy/
if suspected blood
saturation.
colonoscopy
loss.
haemoglobin
breakdown
G6PD is a key enzyme in the hexose monophosphate shunt. An

important
funtion of the shunt is maintain a health
by removing oxidant
stresses. W ihtout the enzyme, Hb
resulting in haemolytic aneamia.
Aet:
X-linked
Si/Sy:
deterioration,
Loss of memory,
jaundice, Loss of
Feeling of pins and
extremities. ataxic
Txt
Intramuscular (I M) of 1mg of
Gradual
Irritability,
Painless
sensation ,
needles in
Ix.
Direct assay during haemolysis
Si/Sy:
Koilonychia, sore tongue, angular stomatitis, PlummerVinson syndrome (dysphagia due to

painless gastritis.
hydroxycobalamin (Vitamin B12).
There is
no oral
Path
oesophageal web),
Rx
Avoid precipitants of oxidative stress; drugs (anti-malarials,

analgesics), fava beans.
Tx.
Blood transfusion if required.
form.
no oral
Hereditary
spherocytosis;
-Thalassaemia
R.C.I.:
a microcytic hypochromic anaemia
Epi:
One of the most common autosomal inherited
disorders. Common in Mediterranean, Africa and middle east. Gene
carriers are protected from
p.falciprum malaria.
Path:
Ineffective
Reduced beta globin (of haemoglobin) production.

erythropoiesis and haemolysis
IX.
blood film, Hb electropheresis
Si/Sy.
anaemia, low MCV.
Heterozygotes: often asymptomatic, mild
Epi:
the most common cause of anaemia w orldwide affecting around

500million daily.
Aet:
The most common cause of iron deficient anaemia is BLOOD loss

reduced intake (diet)
Increased demand (pregnancy)
Malabsorption (coeliac, gastrectomy)
Ix.
FBC, ferritin, serum iron, TIBC, transferrin

saturation. Endoscopy/colonoscopy if suspected blood
first 6 months of life,

extramedullary
Tx.
Quiz 2

interpretation.
5.1. Anaemia cards
Quiz 3.
Vitamin B12 &

Folate deficiency
Haemolytic anaemias
form.

3.1. Prevalence

4.2. Morphological
classification
4.3. Aetiological
classification
FBC, ferritin, serum iron,

TIBC, serum transferrin saturation.
Endoscopy/colonoscopy if suspected blood loss.
Macrocytic anaemia
loss.
Si/Sy:
Homozygote: severe anaemia, failure to thrive in

splenomegaly, bone hypertrophy (secondary to
haemopoisis).
blood transfusion and iron
painless gastritis.
chelation.
Aet:
A group of autosomal recessive genetic disorders
due to a haemoglobin chain mutation. Part of the haemoglobinopathies
that primarily affect those of
African origin (sickel cell
trait can afford some protection against malaria.
Epi:
Path:
Abnormal haemoglobin (HbS) undergo a sickling
transformation in a
deoxygenated state and a permenant
conformational change of shape. The
red cell looses its ability
to deform becoming rigid. This can cause
occlusion of small vessels.
These crises are precipitated by hypoxia,
dehydration, infection and
the cold.
IX.
Electropherisis, haemoglobin solubility test.
Si/Sy:
pigment gallstones.
Txt
required.
Bone pain, if chronic haemolysis- jaundice and
Treat underlying cause, give ferrous sulphate until Hb and MCV

normal.
Aquired Haemolytic
anaemias;
Sickle cell disease

R.C.I.:
Koilonychia, sore tongue, angular stomatitis, PlummerVinson syndrome (dysphagia due to oesophageal web),
Txt
For major Thalassaemia treat with repeated
the most common cause of anaemia worldwide aff ecting around

500million daily.
Aet:
The most common cause of iron deficient anaemia is BLOOD loss

reduced intake (diet)
Increased demand (pregnancy)
Malabsorption (coeliac, gastrectomy)
Ix.
FBC, ferritin, serum iron, TIBC, transferrin

saturation. Endoscopy/colonoscopy if suspected blood
loss.
Si/Sy:
Koilonychia, sore tongue, angular stomatitis, PlummerVinson syndrome (dysphagia due to oesophageal web),
painless gastritis.
Txt
Supportive; analgesia, fluids and antibiotics if

normal.
6.0. Glossary
7.0. References
please click on
contents to repeat
a section.
KEY
Epi. Epidemiology
Ix. Investigations
R.C.I. Red Cell Indices
Si/Sy. Signs and Symptoms
Aet. Aetiology
Path. Pathology
Tx. Treatment
Blood film
RBC morphology:
normocytic,normochromic.
|blood
film: a basic interpretation
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3. Red cell structure
2.3.1. Cell membrane
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
3.2 Clinical features
4.0. Classifying
anaemia
4.1. red cell indices
4.2. Morphological
4.3 Aetiological
classification
A blood film can provide key evidence in diagnosing anaemia. It is therefore is an essential part of all
investigations into anaemia. A blood sample (anticoagulated venous sample) will be smeared onto a glass
slide, fixed and stained. Red cells are examined along with white cells, granulocyte precursors, blast cells.
Definitions
Red cells appear paler in their
centre of the cell due to their biconcave. The pinkish colour one observes in a
normal blood film is a result of the cells unique haemoglobin content. Shape, size and colour are the key
Normocytic:
A cell with an MCV within the normal
variables to observe.
range
Normochromic:
concentration of anaemia is within
the normal
Please click on each cell to see the
bloodrange
film, causes and explanation.
The biconcave red cell when stained shows a classical central
area of pallor on a blood film.
Normal red
cell
Microcytic
hypochromi
c
Macrocyte
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell
5.0 Blood film: a basic

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood film
film:
a basic
RBC morphology:|blood
Microcytic
hypochromic.
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
4.0. Classifying
anaemia
4.2. Morphological
4.3 Aetiological
classification
interpretation
Red cells appear paler in their centre of the cell due to their biconcave. The pinkish colour one observes in a
Explanation
Red cells are smaller and lighter than normal and
displaying a typical area of central pallor.
Please click Cause

on each cell to see the blood film, causes and explanation.
Iron deficient anaemia

Normal red
cell
Thalassaemia
Microcytic
Macrocyte
hypochromi
c
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood film
RBC morphology:
macrocytic
(More oval)
|blood
film: ,megaloblastic
a basic interpretation
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
4.0. Classifying
anaemia
4.2. Morphological
4.3 Aetiological
classification
Cause
Macrocytic
megaloblastic:
Please click on Macrocytic:
each cell to see the blood film, causes
and explanation.
Liver disease
Alcoholism
Normal red
cell
Microcytic
hypochromi
c
Vitamin B12
Folate
Macrocyte
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood film
|bloodtarget
film:cell
a
RBC morphology:
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
4.0. Classifying
anaemia
4.2. Morphological
4.3 Aetiological
classification
basic interpretation
Extra:
it is also
possible to see
one neutrophil
andbe
twosmeared
platelets.onto a glass
investigations into anaemia. A blood
sample
(anticoagulated
venous
sample) will
normal blood film is a result of the cells
unique haemoglobin content. Shape, size and colour are the key
Cause
Target cells are found in peripheral blood films in a number of
Please click on each

cell to see the blood film, causes and explanation.
conditions.
Normal red
cell
1. Liver disease (obstructive jaundice).

2. Thalassaemia
major.
Microcytic
Macrocyte
Target cell
3.
Sickle
cell
anaemia.
hypochromi
c
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood film
RBC morphology: basket/blister cell.

Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
4.0. Classifying
anaemia
4.2. Morphological
4.3 Aetiological
classification
Explanation:
Please click on each cell to see the blood film, causes and explanation.
Oxidant damage
Normal red
cell
Cause:
Microcytic
Macrocyte
hypochromi
c G6PD deficiency
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood filmBlood film

Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
4.0. Classifying
anaemia
4.2. Morphological
4.3 Aetiological
classification
film:
a basic interpretation
RBC|blood
morphology:
basket
RBC morphology:
Elliptocyte.
Bloodcell.
film shows characteristic
A blood film can provide key elliptical
evidence(elongated)
in diagnosing
It is therefore is an essential part of all
redanaemia.
cells.
Explanation
Please click onCauses

each cell to see the blood film, causes and explanation.
Normal red
cell
Oxidant
damagedue to a defective cell membrane
Hereditary
elliptocytosis:
protein (Spectrin,Macrocyte
band 4.1).
Basket case
Microcytic
Target cell
G6PD deficiency
hypochromi
c
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
4.0. Classifying
anaemia
4.2. Morphological
4.3 Aetiological
classification
Blood film
Blood film
film:
a basic
RBC|blood
morphology:
basket
cell.
RBC morphology: Fragments
RBC morphology: Elliptocyte.
interpretation
Cause Explanation
Causes Please click on each cell to see the blood film, causes and explanation.
Disseminated
OxidantIntravascular
damage Coagulation (DIC)
Hereditary elliptocytosis
Microangiopathy
TTP G6PD deficiency
Basket case
Normal red
Microcytic
Macrocyte
Target cell
cell
Burns
hypochromi
c Cardiac valves
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Blood film
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence
4.0. Classifying
anaemia
4.2. Morphological
4.3 Aetiological
classification
film:
a basic
RBC|blood
morphology:
basket
cell.
RBC morphology: Tear drop poikilocyte
interpretation
Definition: Poikilocyte; an individual cell of abnormal shape
Explanation
Please click on Cause

Normal red
cell
Oxidant damage
Myelofibrosis
ExtramedullaryMacrocyte
haemopoiesis
Microcytic
G6PD deficiency
hypochromi
c
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Blood film
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence

4.2. Morphological
4.3 Aetiological
classification
RBC morphology:
Pencil
cell.
These
thin elongated
film:
a basic
interpretation
RBC|blood
morphology:
basket
cell. are
cells. Often occur alongside microcytic
A blood film can provide key evidence in diagnosing
anaemia. It
is therefore
is an
hypochromic
cells,
poikilocyte
andessential part of all
targetgranulocyte
cells.
slide, fixed and stained. Red cells are examined alongoccasional
with white cells,
precursors, blast cells.
Explanation
Explanation
Iron deficiency
Oxidant damage
Normal red
cell
Microcytic G6PD deficiency

Macrocyte
hypochromi
c
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Blood film
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence

4.2. Morphological
4.3 Aetiological
classification
RBC morphology:
Ring-forms
P.falciprum
film:
a inbasic
interpretation
RBC|blood
morphology:
basket
cell.
Intracellular malarial parasite
Explanation
Explanation
of
malarial infection. It can lead to DIC and intravascular
Oxidant damage
haemolysis.
certain
of blood
haemolysis
occursand
with
all types
Please click onAeach
cell amount
to see the
film, causes
explanation.
Normal red
cell
Basket case
Microcytic
Macrocyte
Targetcauses
cell up to 3
Malaria: Transmitted
by the mosquito this disease
G6PD deficiency
hypochromi
million deaths a year and is a major cause of anaemia within the
c tropics! See malaria module for more information.
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Blood film
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence

4.2. Morphological
4.3 Aetiological
classification
RBC morphology:
basket cell.
RBC morphology:
Stomatocyte
Explanation
Please click on Explanation

Normal red
cell
Oxidant damage
Liver disease
Alcoholism
Macrocyte
hypochromi
c
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Blood film
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence

4.2. Morphological
4.3 Aetiological
classification
film:
a basic
RBC|blood
morphology:
basket
cell.
RBC morphology:
Sickle cell
interpretation
Explanation
In sickle cell anaemia the red blood cell undergoes a

sickling process due the cell containing haemoglobin S.
Explanation
Normal red
cell
In a deoxygenated state this haemoglobin undertakes a permanent

Oxidant damage
conformational change creating large polymers. As a result these
cells become rigid and unable to deform. The red cell eventually
Basket case
Macrocyte
Target cell
looses its cell membrane and becomes damaged as it travels
hypochromi
through the circulation changing into the sickled shape we see. This
c
eventually leads to an early cell death (hemolysis).
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Blood film
RBC morphology:
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence

4.2. Morphological
4.3 Aetiological
classification
Micro-Spherocyte. This slide shows spherocytes

caused
by hereditary
They sit amongst
|blood
film:
aspherocytosis.
basic
RBC
morphology:
basket
cell. interpretation
larger
polychromatic
red cells.
Cause | Explanation
Explanation
Please click on each cell toAbnormality

see the blood
film, causesproteins.
and explanation.
of cytoskeleton
These cells
Normal red
cell
are excessively
Oxidant
damage permeable to sodium influx. Cell
looses membrane on passage through
reticuloendothelial
cell osmotic
fragility
Basket case
Microcytic G6PD
Macrocyte system. Red
Target
cell
deficiency
hypochromi is characteristically increased.
c
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Spherocyte
Acanthocyte
Malarial parasit
Blood film
Blood film
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.3.2 DNA synthesis
2.4. Red cell
metabolism
2.5.Haemoglobin
2.6 O2 dissociation
curve

3.1. Prevalence

4.2. Morphological
4.3 Aetiological
classification
RBC morphology:
cell. echinocytes.
RBC morphology:
Pricklebasket
cell or small
A blood film can provide key evidence
diagnosinginanaemia.
It is therefore
is an essential part of all
Especiallyinprominent
postsplenectomy
patients.
slide, fixed and stained. Red cells
are examined
along with
cells, granulocyte
precursors, blast cells.
Definition:
Echinocyte:
cellwhite
with abnormal
blunt or sharp
projections on surface. Can be up to 30 projections per cell.
Explanation
Please click on Explanation

Oxidant
Pyruvate
kinase damage
deficiency
Normal red
cell

Macrocyte
hypochromi
c
Target cell
return
Elliptocyte
Fragments
Stomatocyt
e
Sickle cell
Tear drop
poikilocyte
Pencil cell

interpretation.

interpretation.
6.0. Glossary
7.0. Quiz
Basket case
Spherocyte
Acanthocyte
Malarial parasit
|glossary
Contents
1. 1Introduction
1.2 use this module

2.2. Erythropoiesis
2.4. Haematinics
2.5. Red cell
metabolism
2.6. Haemoglobin
Quiz 1

3.1. Prevalence
Quiz 2

4.2. Morphological
classification
4.3. Aetiological
classification
interpretation.
5.1. Anaemia cards
Quiz 3.
6.0. Glossary
7.0. References
please click on
contents to repeat
a section.
Anaemia:
Haemoglobin:
delivery. It is
haem group.
a haemoglobin concentration in peripheral blood below normal

range for sex and age
a metalloprotien inside a red blood cell that is responsible for oxygen
composed of four globulin chains each containing an iron containing
Macrocytic:
Red cells of average volume (MCV) above normal.
Mean cell volume:
the average volume of circulating red cells
Mean Corpuscular Haemoglobin (MCH):
The average haemoglobin content of red blood cells.
Microcytic:
red cells of average volume (MCV) below normal
Normoblast:
nucleated red cell precursor normallyy found in the bone marrow
Poikilocytosis:
variation in shape of peripheral blood red cells
Reticulocyte:
in the
a non-nucleated young red blood cell still containing RNA. Can be found
peripheral blood and bone marrow.
Stem cell:
the
resides in the bone marrow and by division and differentiation gives rise to all
blood cells
Sickle cell disease:

from the
haemoglobin
an inherited disorder of haemoglobin of varying severity. The name arises

deformed shape of the red blood cell takes when the abnormal
inside them polymerizes at low oxygen concentrations.
Thalassaemias:
a spectrum of inherited disorders of haemoglobin where there is an inbalance in

globin chain production.
iron deficient anaemia; an overview

R.C.I: a microcytic hypochromic anaemia
Epi:
this is the most common cause of anaemia worldwide affecting around

500million people.
Aet:
1. The most common cause of iron deficient anaemia is blood oss

2. reduced intake (diet)
3. Increased demand (pregnancy)
4. Malabsorption (coeliac, gastrectomy)
Ix.
FBC, ferritin, serum iron,

TIBC, serum transferrin saturation.
Endoscopy/colonoscopy if suspected blood loss.
Colon cancer
microcytic hypochromic
blood film.
Si/Sy. Koilonychia, sore tongue, angular stomatitis, Plummer-Vinson

syndrome (dysphagia due to oesophageal web), painless gastritis.
Tx.
normal (4-6months).
Return
-Thalassaemia
R.C.I.:
Epi:
One of the most common inherited disorders. Common in
Mediterranean, Africa and Middle East.
Path: Reduced beta globin (of haemoglobin) production. Ineffective
erythropoiesis and haemolysis
Ix.
blood film, Hb electrophoresis
Si/Sy. Heterozygotes: often asymptomatic, mild anaemia, low MCV.

Homozygote: severe anaemia, failure to thrive in first 6 months
of life, splenomegaly, bone hypertrophy (secondary to extramedullary
haemopoiesis).
Tx.
-thalassaemia major requires repeated blood transfusion and
iron
chelation.
Return
Sickle cell disease (HbSS); an overview

R.C.I.:
Aet: Autosomal recessive genetic disorders due to mutation of the

gene for HbA. Affect primarily people of African origin. Sickle cell trait
(HbAS) affords strong protection against malaria.
Path: Abnormal haemoglobin (HbS) undergoes a sickling
transformation when in a deoxygenated state resulting in a permanent
conformational change of shape. The red cell looses its ability to
deform becoming rigid. This can cause occlusion of small vessels and
result in sickle cell crises precipitated by hypoxia, dehydration, infection
and the cold.
IX.
Dactylitis in a child
Electrophoresis, haemoglobin solubility test.
Si/Sy: Bone pain, jaundice, pigment gallstones, leg ulcers, dactylitis in

infants.
Txt
Supportive; analgesia, fluids and antibiotics during crises.
Blood film: sickle cells
Return
Vitamin B12 deficiency

path: Vitamin B12 binds to IF intrinsic
factor in the stomach and is
absorbed in the terminal ileum
Aet:
Pernicious anaemia,
malabsorpion, post total
gastrectomy
Folate deficiency
Aet:
increased consumption
(pregnancy), dietary
deficiency, folate antagonist
(drugs
eg; methotrexate,
alcohol).
Ix.
Ix.
B12MCV platelets. IF
antibodies. Check folate levels.
serum folate, red cell

folate. MCV
Si./Sy: Gradual deterioration, Irritability,

Loss of memory, Painless jaundice,
Loss of sensation , Feeling of pins
and needles in extremities,
ataxic.
Si/Sy: Jaundice. Weight loss. GI

disturbances. Glossitis.
Txt.
Intramuscular (IM) of 1mg of
hydroxycobalamin (Vitamin B12).
There is no oral form.
Txt.
Folic acid supplementation.

Exclude Vitamin B12
deficiency first.
Glossitis.
Blood film; Microcytic hypochromic
Return
G6PD deficient anaemia; an overview

Path G6PD is a key enzyme in the hexose monophosphate shunt. An
important function of the shunt is maintain healthy haemoglobin by protection
from oxidant stress. In G6PD deficiency, haemolytic anaemia occurs.
Aet:
X-linked
Ix.
Direct assay of G6PD activity
Drugs
Si/Sy: None other than those of acute / chronic anaemia

Rx
Avoid precipitants of oxidative stress; drugs (anti-malarials,
analgesics), fava beans.
Tx.
Blood transfusion if required.
Fava beans
Return
Hereditary spherocytosis; an overview

Epi:
1 in 5000 people in Northern Europe.
Aet:
Autosomal dominant
Path. Defective cell membrane protein (spectrin) causes a loss of cell

membrane, progressive spherocytosis and eventually premature
death
(haemolysis). Increased sensitivity to infections such as parvo-virus.
Ix.
Blood film
Blood film; spherocytes

Increased osmotic fragility.
negative antiglobulin test.
Si/Sy: asymptomatic.
Jaundice, splenomegaly
General features of anaemia
Txt
Give ferrous sulphate , ferritin if deficiency
Return
Autoimmune haemolytic anaemia; an overview

These anaemias can be split into warm and cold types. This is dependent on the temperature at
which the antibody reacts with the body.
WARM
Aet:
associated with the production of
autoantibodies of IgG. They attach to the red cell at
body
temp and are removed early by the
reticuloendothelial
system.
Path:
Idiopathic or precipitated by drugs or autoimmune

disease, leukaemia.
IX.
Bloods: unconjugated haemoglobin, LDH,
Reticulocytes.
Positive direct antiglobulin test.
Si/Sy: Jaundice, general features, splenomegaly
Txt
Steroids, splenectomy as 2 line. Vaccination
against H. Influenza, Men C and Pneumococcus.
nd
COLD
Associated with the production of autoantibodies
of IgM and are removed early by the
reticuloendothelial
system. Usually self-limiting.
Aet:
Path:
Idiopathic or secondary to infection or
lymphoma.
IX.
Bloods: unconjugated haemoglobin, LDH,
Reticulocytes.
Positive direct antiglobulin test.
Si/Sy: Worse in cold weather, acrocyanosis (purpling
skin), Reynaud's phenomenon.
Txt
Remove precipitants, keep patient warm,
consider immunosuppression.
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of
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Anemia dalam tinjauan

| the erythrocyte: an overview

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The red cell also plays an important role

Lifespan: Because the fully

To achieve these functions the red

Image: scanning electron microscope of

Biconcave shape: increases

Flexibility: the red

Macrophages surround and

Red blood cells in

LO List the key components of erythropoiesis (red cell production)

|Red cell precursors and the sequence of erythropoiesis

2.1. The erythrocyte:

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Reticulocytes are an important cell in haematology as they increase in number following a

Pronormoblast: This is the earliest and largest cell

3.5 Erythrocyte: after 1 week the mature

Check the haematinics this is a phrase

Erthropoiesis is also regulated by the availability of haematinics

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Chronic infections and

|haematinics: the normal iron cycle

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Soluble transferrin receptors,

In iron deficient states, bone marrow

Some iron binds to

3. Dying red cells

1. Iron is absorbed from the small

|haematinics: vitamin B12

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Vitamin B12 deficiency can

Welcome to section 2! | defining anaemia

2.1. The erythrocyte

What exactly is anaemia?

For adult males < 13.5 g/dl

The following circumstances should therefore be taken in to consideration

Following acute blood loss

These can produce an

Reduced plasma volume

|clinical features of anaemia

2.1. The erythrocyte

3.0. Defining anaemia.

4.0. Classifying anaemia

1. The cardiovascular system

| clinical features of anaemia

General symptoms and signs

2.1. The erythrocyte

3.0. Defining anaemia.

4.0. Classifying anaemia

Confusion and symptoms of

Some specific signs

| clinical features of anaemia

| clinical features of anaemia

Nail bed; demonstrating

| clinical features of anaemia

Atrophic glossitis; red

| clinical features of anaemia

| clinical features of anaemia

| clinical features of anaemia

| clinical features of anaemia

High flow murmur, bounding

Welcome to section 3!|classification of anaemia