Anemia

CBC
Blood loss vs
BoneMarrow
Problems
RI more than
2% means the
bone marrow is
functioning okay,
look for
hemolysis
Microcytic Anemia
Order erritin
Or iron !anel"
Macrocytic Anemia
Blood
#mear
Megaloblastic
Check B $2 and olate
If the le%el are normal order
METHOMELONIC ACID
Elevated MMA = B! De"
&ornal MMA ' olate (ef
)*omocysteune +e%els
are increaed in both"
&on,Megaloblastic
Anemia
,+i%er !roblems can
be an etiology
,Alcohol
,Meds -A./, 012
*y!er#egmented
&eutro!hils ' Megaloblastic
&ormocytic
Hemol#sis vs Bleeding
Bilirubin, +(* and *a!toglobin
Hemol#sis
(" Bili Increased,
Increased +dh
and low
*a!toglobin"
After CBC Best Initial Test
Microcytic erritin or Iron 3anel
&ormocytic / bili, (" Bili, +(* and
*a!toglobin
Macrocytic Blood #mear
olate (ef
#ource4 +eafy 5eg
At Risk4 3reg and /ea and
/oast (iet
B$2
#ource4 Animal 3roducts
At Risk4 5egans -I"e for a decade2
,3ernicious Anemia or /erminal Ileul
resection
,&euro #6 are irre%ersible" (orsal
#!inothalamic tracts are affected
,3O %s IM" -7i%e IM if 3ernicious
Anemia or /erminal Ileum resection
&ormal Iron8erritin
'
THALA$EMIA
As6' Minor
#6' Ma9or
Hb Electro%&oresis
Presence o" HgB'
or HgBA! (! al%&a
! delta) diagnoses
Beta thalasemia
Al!ha thal is d6 of
e6clusion
*I7* #:R1M IRO&
$ideroblastic
Anemia
Re%ersible4 Alcohol,
+ead or Co!!er def
Irre%ersible4 Cancer,
B ; (ef<
IRO&
3A&:+
erritin
-#torage2
#erum e %#at /IBC
I&5:R#: of
:RRI/I&
e (ef +ow +ow +ow *igh
An"Chr"(ise *igh +ow +ow
#ideroblasti
c Anemia
5ariable HI*H 5ariable
/halasemia &ormal &orm &ormal
A
Hemorr&age
olate (ef
#ource4 +eafy 5eg
At Risk4 3reg and /ea and
/oast (iet
Hemoglobin"
Al!ha4 = /y!es of alleles"
If $4deleted a#6,
2 deleted4 Mild form,
> is se%ere"
=4 *ydro!s fetalis
Beta4 2 Allels
If $ (eleted4 Mild
If 2 (eleted4 #e%ere
&ormal *bA$' 2 Al!ha and 2 Beta
In Beta thal you will see *gb and
*gBA2
/64 /ransfusion -would need Iron
chelators to !re%ent Iron O%erload R6
(efero6amine

$ic+le Cell
A,- HgB $$
/riggers4
Acidosis,
*y!o6ia and
dehydration
Initial D. is
made b# Hgb
Electro%&oresis
In Crises look for
#ickle Cells on
smear
#ickle Cell Crisis
Management
,./
H#dro.#0rea
-increaeses
*gb2, luids,
O2 and 3ain
control"
I' %ria%ism-
stro+e or ac0te
c&est %ain t&en
E1CHAN*E
T,AN$'2$ION
*3PD DE'ICIENC4
7reek man takes a%abeans,
(a!sone, Ato%a?uone or
Infection and leads to
increased o6idati%e stress @
HEMOL4$I$
D1/
D2,IN* C,I$I$/
(g;!d would be normal as
normal cells didnAt die2
Bait ;,C weeks after the
e%ent andthen measureg;!d
le%els
HE,EDITO,4
$PH,EOC4TO$I$
D1/ Osmotic ragility /est
-outdated, new on is in
1world2
R64 #!leenectomy,
su!!lement with folate and
iron"
A0toimm0ne Hemol#tic
Anemia
Diagnostic Test is COOB$
TE$T
5A,M/ Igm- asc with +u!us
and Cancer R64 #teroids or
:culiDumab
COLD/ IgM (Nose- Ti%s o"
'inger- asc with Mono and
Myco!lasma 3neumonia
E1T,IN$IC PATH5A4
-e':EC+1#I5:
'O&+F O&: AC/OR2
AC/OR G
iNT,IN$IC PATH5A4
HiI&C+1(:# all other
factors
More factors, more
words hence 3 / /
And * : 3

T&is also gives
o"" D6DIME,
I&(ICA/OR O
COA71+A/IO&
AC/I5I/F
AC/I5A/:( /O
T&rombin
("actor !) AC/I5A/:( /O
A+#O M:(IA/:( BF
AC/OR 0
P,OTH,OMBIN
'ibrin -factor $2
AC/I5A/:( /O
'INB,INO*EN
+I5:R
Protein $
Protein C
In&ibits "actor
7
AC/OR 0 +:I(:&
Mutation leads to a factor 0 thats always on
leading to *y!ecoagulation
3rotein C and # deficiency also leads to
*y!ercoaguable state
3rothrombin 2J2$J
Mutation o" %rot&rombin t&at ma+es it
more active 8 H#%ercoag0lable state
Anti,thrombin (eficiency
+ess work against /hrombin @ O%eracti%e
/hrombin @ *y!ercoaguable
+131# A&/ICOA71+A&/
A,TE,IAL AND 9ENO2$ COA*2LANT
5it K,L actors 2,G, M $J
3rotein C and # le%els fall of earlier than
factors !roduced by the li%er hence if you
start on warfarin without he!, you will ha%e
initial hy!ercoaguable state
/!a acti%ates
!lasminogen to
%lasmin -this will
s!lit fibrin2
Inacti%ated by Anti,/hrombin
III -/his is acti%aed by he!arin2
/*ROMBOCF/O3:&IA
TTP
'/ fe%er
A/ anemia
T/ thrombocyto!enia
,/ renal "ail0re
N/ Ne0ral s#m%toms
6H#alin Clots form in the blood %essels" /his
!rocess uses u! !latelets"" Rbc get torn
a!art due to the clots making interru!tion in
flow leading to anemia" Occulusion due to
clots leads to Renal ailure and ministrokes
-leading for neuro #62
(64 Blood #mear would show sc&istioc#tes
-due to microangio!athic hemolytic anemia"
Also rule out DIC
'actors and 'ibrinogen levels and D6
Dimer wo0ld be normal)
T./ E.c&ange trans"0sion:
6Platelets trans"0sion is contraindicated
as it wo0ld onl# ma+e more clots
DIC
3t that get (ic are already sick"
3t would bleed from e%erywhere because
!latelets and co,ag factors get used u! in
making fibrin clots all o%er the body -I"e
ooDing I5 sites2
(64 Blood #mear4 #chistocystes
+AB4 Low "ibrinogen- Low "actors (Hence
Hig& PT and PTT)- Elevated D6Dimer:
/64 treat underlying disease, meanwhile gi%e
fluirs, transfusion etc"
He%arin ind0ced T&romboc#to%enia
3t started on he!arin and G,$= days later
their !latelets start to decrease,
#1((:& (RO3 I& 3+A/:+:/ N
/64 #to! *e!arin and start Argatroban
D./ Hit antibodies (not eno0g& time to
c&ec+ "or t&is- sto% &e% and give
argatroban)
ITP
emale, autoimmune, (6 of e6clusion"
/64 $teroids or I9I*- i" re"ractor# t&en
s%leenectom# or ,it0.imab
Megakaryocytes can be !resent"
M2LTIPLE
M4ELOMA
Monoclonal
%roli"eration o"
one %lasma cell
It !roduces *17:
amount of Ig*
3roflieration takes u! marrow
s!ace and body canAt make
any more Ig hence @
IN'ECTION$
3roduce Bence Oones
3rotein @ Renal ailure
1rine :lectro!horesis4 M6$%i+e
1!regularion of
Osteoclasts @ non
traumatic fractures
#keletal #ur%ery4
+ytic +esion
#erum :lectro!horesis4 M6$%i+e
3t4 Older,
C4 hy!erCalcemia
R4 Renal ailure
A4 Anemia
B4 bone !ain
Diagnosis/
$2 #3:3, 13:3 amd #keletal #ur%ey
Con"irm Diagnosis by doing BM B6, would show $J%P
3lasma cytosis
Treatment
&o /reatment o%er GJ, 1nder GJ trans!lant
M*2$
3ositi%e !rotein ga!<
#3:3 3ositi%e, but 2PEP and $+eletal $0rver# is
negative and %t doesnt &ave crabs:
Bone marrow bio%s#/ +ess than $J% !lasma cytosis"
2% !er year risk of Multo!le Myeloma so 9ust OB$E,9E
5aldenstrom;s
Pat&/ IgM !lasma (yscrasias
3resents with hy!er%iscocity syndrome -MI,
stroke etc2
#3:34 3ositi%e 13:3 and #keletal
#ur%ery will be &egati%e
BM4 more than $% +ym!hocytes"
R64 Chemo or cell trans!lant
#ym!toms of MM
$
st
#te!4 13:3, #3:3 and #keletal #ur%ey
M0lti%le M#eloma
All > 3ositi%e, confirm
diagnosis of MM %ia BM B6
-L$J% !lasmacytosis2
$PEP PO$ITI9E in all t&ree
2PEP $+eltal $0rver#
Negative
Bone Marrow Bio%s#
L$J% +ym!hocytosis '
5aldenstroms
P$J% 3lasmacytosis is
M*2$
L#m%&oma
3t4 NON tender l#m%&adeno%at&#
O!tion #6 4e%er weight loss

st
$te%/ E1CI$IONAL
BOP$4 O' THE NON
TENDE, BIOP$4
,EED $TE,NB2,* CELL
P,E$ENT<
Hodge+in;s Non6Hodg+ins

st
$te%/ $TA*IN*
CER
C/ Abdo8!e%is83:/ scan
Bone Marrow Bio!sy
#tagning is done by &unber
of lym!hnodes and distance
from diag!hragm
#tage $4 $ +ym!h nodes
#tage >4 2Q +ym!hnodes on
2 sides of the dia!hragm
#tage =4 Mets
yes
&O
Le0+emia
3t4 C&ronic vs Ac0te
Chronic4 mature normal BBC @ a#6, accidental finding
Acute4 more Blasts cells
In chronic look at the
CELL DI''E,ENTIAL
If &eutro!hils @ CM+
If +ym!hos @ C++
Confirm (6 using BM B6
CM+ res%onds to/ Imatinib
(t: +inase in&ibitor)
C++ @ Chemo8 cell
trans!lant
Acute leukemia will ha%e
fe%er, infections, anemia,
bleeding and bone !ain"
Founger 3atients
$MEA, would show
&eutro!hils @ AM+
+ym!hos @ A++
(6 using BM B6
AM+ @Chemo8 5itamin A
A++ @ Chemo
AM+ *istory of e6!osure to BenDene,
Chemo or radiation, can be 3t with
CM+ under blast crisis
D./ ) $MEA, and t&en BM B.
=M#elo%ero.idase) (M "or M#elo:)
if Aur rods then @ M> sub%ariant @
R64 9itamin A- non,M> @ Chemo
A++ (6 on #M:AR and the BM B6 to
confirm" 2
has to ha%e L2J% Blasts -!ositi%e for
C++A or /dt2, R64 Chemo" 3ro!hyla6is
with intrathecal Ara,C as it tends to go
to C&#
CM+ (6 with (iff then BM B6"
On B6 you see >:!! translocation
(%&ilade%l%&ia c&romosome) T./
Imatinib
(rug only !rolongs but e%entually they
will go to Blast Crisis -AM+2
C++ (iff then BM B6" 3t would die with it
rathr than from it" Mostly obser%e is no
donor and o%er GJ" Chemo is an o!tion
with !latelets go low"
Bleeding
$0%er"icial Dee%
+ab4
3latelet
Count
*:MAR/*RO#I#, *:MA/OMA,
3RO+O&7:( 3B+::(I&7 A/:R
#1R7:RF, deficiency in secondary !lug
' 'ACTO, P,OBLEM$
/hink Mucosal -bleeding gums, hea%y
menses2, !etichie
/his is an I&(ICA/OR O 3RIMARF 3+17
3ROB+:M 'PLATELET P,OBLEM
3latet D4$'2NCITON
) v5'
!) *P b (Bernard
$o0llier)
?) *P !?BA
@) Platelet Activation
%roblems (N$AID$)
7 2,EMIA
3latelet
(estruction
, A%lastic
Anemia
6HIT- TTP- DIC-
ITP
#e?uestered
3latelets in
#!leen
Lab/ 3//,
3t, I&R
Congenital
6*emo!hillia A and
B
5B may also
!resent as a factor
bleeding as it
stabaliDes factor C
AcA0ired
,+i%er (iseases4
CanAt make 2, G ,
M, $J
,5it K (ef"
:le%ated 3/ 3//
and I&R
If 5it K doesnAt fi6
then its li%er
!roblems, needs
trans!lant and
factors
&ormal 3latelet
Count' 3lateket
(ysfunction
/hrombocyto!enia
95' DI$EA$E
3t" !resents with 3latelet Bleed, &ormal
Count, ma# %resent as "actgor bleed
as it stabalises "actor B
D./ v5' E$$A4
T./ DDA9P (Desmo%ressin 8 ind0ces
e.%ression o" v5" on endot&eli0m
((E4 Bernard #oulier -73$B2
7lansman thrombos!enia -732B2
(rugs like &#AI(
1R:MIA

D. Hemo%&ilia
wit& mi.ing test