Systematic Approach in Anemia

Evaluation and Review of Peripheral

Smears
Dr.Eman Mosaad

Obj ti
Objective
z

Recognize abnormal peripheral

blood smear
z Review
R i
differentials
diff
ti l th
through
h
systematic approach

A
Approach
h to
t Dx
D
z

Duration, onset, subjacent illness, blood

loss (GI,
(GI menstruation,
menstruation surgery),
surgery ) diet,
diet
medications, toxic exposure, occupation,
family Social
family,
Complete exam including skin (jaundice,
petechiae),
t hi ) Abdomen
Abd
(hepatosplenomegally), lymphatics, rectal,
and
d pelvic
l i

B i Labs
Basic
L b to
t Start
St t
z

Repeat CBC w/ manual differential

(WBC, RBC, HCT, HGB, PLT, indices- MCH,

MCHC, MCV, RDW)
z

Peripheral Smear
z Reticulocyte count

R ti l
Reticulocyte
t countt
z
z
z
z

Retic count = % immature RBC

Normal 0.5-1.5% (for non-anemic)
<1% Inadequate production
>=1% Increased production (? adequacy)

R ti l
Reticulocyte
t Correction
C
ti
z
z

%Retic count frequently overestimates

R ti countt should
Retic
h ld be
b compared
d to
t nonanemic RBC count to assess adequacy of
response
Corrected Retic count = %Retic X HCT/45

R ti l
Reticulocyte
t Production
P d ti Index
I d
z
z

z
z
z

Correction for left shift (early release from bone

marrow) Retic lifespan is increased in blood
RPI = % Retic X Hct/45 X 1/CF
Hct
Correction factor (CF)
40 45
40-45
1
1.0
0
35-39
1.5
25-34
25
34
2.0
15-24
2.5
Normal RPI = 1 (for non-anemic pt)
RPI < 2 : hypoproliferative
RPI >=2 : hyperproliferative

R ti P
Retic
Production
d ti
Index
I d
z

RPI < 2
hypoproliferative
yp p
(inadequate response)

- Iron def. anemia

- B12/folate def.
- Chronic disease
- Sideroblastic anemia
- Aplastic
A l ti anemia
i
- Myeloproliferative

- Hemolytic disease
- Hemoglobinopathy
(i l di thalassemia)
(including
th l
i )
- Treated B12/folate def.

RPI >= 2 :
hyperproliferative
yp p
(adequate response)

P i h
Peripheral
l smear
z

Optimal area for review

z RBC morphology, WBC differential, PLT
(
(clumping?)
p g )

RBC morphology
z
z
z
z

7-9
7
9 m with
ith 1/3 central
t l palor
l
Lifespan of 110-120 days
About the size of nucleus of normal
lymphocyte
y p
y
Poikilocytosis & Anisocytosis

B
Basophilic
hili stippling
ti li
z
z
z
z

Precipitated RNA
lead or heavy
metal poisoning
p
g
ETOH abuse
Hemolytic anemia

B
Burr
cells
ll
z
z
z
z
z
z

Altered lipid in cell

membrane
artifact
Uremia
Renal failure
gastric CA
transfused old blood

Elli t
Elliptocytes/ovalocytes
t /
l
t
z
z

Abnormal cytoskeletal
proteins
Hereditary
elliptocytosis

H
Howell
ll Jolly
J ll body
b d
z
z
z
z

Nuclear remnant
DNA
Megaloblastic
aneamia
hemolytic anemia
absent or
hypofunction spleen

S hi t
Schistocyte/helmet
t /h l t cells
ll
z

z
z
z
z
z
z

Fragmented
(mechanical or
phagocytosis)
DIC
TTP
HUS
Vasculitis
prosthetic heart valve
severe burns

Si kl cells
Sickle
ll
z
z
z

Molecular aggregation
of Hgb-S
Hgb S
SS, SC, S-thal
rarely S
S-trait
trait

NRBC
z
z

Common in newborn
severe degree of
hemolysis

S h
Spherocyte
t
z
z
z
z

Absent central
palor
look smaller
Hereditary
spherocytosis
immune hemolytic
anemia
i

St
Stomatocyte
t
t
z
z
z
z
z

Mouth like
M b
Membrane
defect
d f t
Smear artifact
H
Hereditary
dit
stomatocytosis
Li er disease
Liver

T
Target
t cells
ll
z
z
z
z

Increased redundancy
of membrane
hemoglobinopathies
thalassemia
liver disease

T
Tear
drop
d
cells
ll
z
z
z
z
z

Distorted drop
p shaped
p
Smear artifact
myelofibrosis
promyeloblastic
leukemia
space occupying
lesions of marrow

MCV/smear

Mi
Micro

N
Normo

M
Macro

Iron panel

Retic

Retic

Low

High
Iron/B12/Folate

Go to *Occult Blood Loss

**Normal

Low

Bone Marrow Bx

Anemia of Chronic Dis.

High

B12/Folate

B12 Low

Folate/Lo
Folate/Low
*Occult Blood Loss

Normal

Yes

MMA/Homocysteine

MMA high B12 Low

No

Coombs (+)

Homocysteine high Folate Low

Coombs (-)

Normal Go to **

First use size (MCV) to sort the

Diff
Differential
ti l Dx
D
MCV
Micro

Normo

Macro

Mi
Microcytic
ti anemia
i
z

Get Iron panel- serum iron, TIBC, ferritin

Iron def.
dec
inc
dec
anemia
Siderobla inc
dec
inc
-stic
anemia
Thalasse inc/nl dec/nl inc/nl
-mia
mia
Chronic
dec
dec
inc
disease

I
Iron
def.
d f Anemia
A
i
z
z
z
z

Low Retic count

High RDW
Due to chronic blood
loss
Diet deficiency

Th l
Thalassemia
i
z
z
z
z
z

Normal to inc. RPI

Normal RDW
Target cells
Mentzer index <13
=MCV/RBC
confirm w/ Hgb
electrophoresis
l
h
i

Th l
Thalassemia
i continues
ti
Alpha-thalassemia
z SE Asia & Africa
z aaaa - normal
z aaaa^ - silent carrier
z aaa^a^ - trait (mild)
z aa^a^a^ - HbH (Bart)
hemolytic disease
z a
a^a^a^a^
a a a - hydrops
fetalis (stillborn)

Beta-thalassemia
z Mediterranean
z Beta-thal minor
one beta gene,
gene
increased HbA2/HbF
z Beta-thal
Beta thal major
2 beta genes,
severe, failure
f il
to
t
thrive, sig HbF

Sid
Sideroblastic
bl ti anemia
i
z

z
z

z
z

Accumulation of
mitochondrial
it h d i l iron
i
in
i
erythroblasts
Hereditary
Drugs - INH, lead,
zinc, alcohol,
chloramphenicol,
cycloserine, plavix
Hypothermia
Confirmiron stain

Sample question #1

Anemia of chronic disease is due to

inadequate production of
of, or poor
response to, which one of the following?
A.
B
B.
C.
D
D.
E.

Iron
Folate
Erythropoietin
F
Ferritin
iti
Hemosiderin

A
Anemia
i off chronic
h
i disease
di
z

Infections: TB, SBE,

osteo, chronic UTI or
pyelo, fungal

Malignancy: mets,
y
leukemia, lymphoma,
myeloma

Chronic inflammatory
disorders: RA, SLE,
Sarcoid, collagen
vascular disease,
polymyalgia
rheumatica, chronic
hepatitis decubitus
hepatitis,
ulcer

M
Macrocytic
ti anemia
i
Macro

RPI >= 2

RPI < 2

Check Occult Blood Loss

Check B12 and folate

No

Coombs test

Yes

M
Macrocytic:
ti RPI < 2
B12/Folate
B12 Low

Normal

Folate Low

MMA
A High
i

MMA
Homocysteine
i
Normal

Homocysteine
High

Consider
Liver, Renal,
Thyroid,
Alcohol,
Chronic dis.
dis

Consider
Bone Marrow
Bx

Macrocytic: RPI < 2

Megaloblastic Anemia
Folate
F
l t
B12
z Inadequate intake
z Inadequate absorption
z Synthesized by plants
z Synthesized by
and micro-organism
bacteria
z Green leafy veges
vege s
z Meat, fish, dairy (strict
z Fruits
vegans)
z Absorbed in jjejunum
j
z Absorbed as B12-IF
complex in ileum
(gastrectomy)

Sample question #2

Which of the following tests can be useful in

determining if an elderly patient has folate
deficiency?
A.
B.
C
C.
D.

RBC folate concentration

Serum homocysteine level
Serum ferritin level
Serum methylmalonic acid level
AFP, Oct. 1, 2000

Macrocytic: RPI < 2

Megaloblastic Anemia
Smear
z Macro-ovalocytic
z Polychromasia
z Hypersegmented neutrophil
Other Labs
z Homocysteine Folate def.
z Methylmalonic acid B12 def.
z Intrinsic Factor Ab test very
specific for pernicious anemia
but only
y 50%
% sensitive
z Parietal cell AB test quite
sensitive (90%) but not specific
z Schilling
S hilli test
t t

Macrocytic: RPI < 2

Non-megaloblastic
z

z
z
z
z

Consider Liver, Renal,

Endocrine (thyroid),
( y
),
alcohol, drugs
Consider anemia of
chronic
h
i disease
di
Get Bone Marrow
Biopsy
Myelodysplastic
Myeloproliferative
y p
Leukemia, Lymphoma,
Multiple Myeloma

Macrocytic: RPI < 2 continues

Aplastic Anemia
z
z
z
z
z
z

Fanconi anemia congenital

Di
Direct
t stem
t
cell
ll destruction
d t
ti
external
t
l
radiation
Drugs - chloramphenicol, gold, sulfonamides, felbamate
Other Toxins - Solvents,, degreasing
g
g agents,
g
,p
pesticides
Viral infection - parvovirus B19, HIV, other
Idiopathic

M
Macrocytic:
ti RPI >=
> 2
Occult Blood Loss?

Yes

Investigate source

No

Check for Hemolysis

Peripheral smear

Coombs (DAT)

Sample question #3

Of the following laboratory results, which

one does not occur in hemolytic anemia?
A.
B.
C.
D
D.
E.

Reticulocytosis
Increased unconjugated
j g
bilirubin
Increased haptoglobin
Increased LDH
Hemosiderinuria
AFP, June 1, 2004

Macrocytic: RPI >= 2

Hemolytic Anemia
Other Lab Characteristics
z Peripheral blood smear
z Serum haptoglobin
z Serum LDH
z Unconjugated
j g
bilirubin
z Hemoglobinuria
z Hemosiderinuria

Macrocytic: RPI >= 2

Hemolytic Anemia
Coombs (DAT)

Positive

Immune Hemolysis
Drug related Hemolysis
Transfusion, Infection, Cancer

Negative
g

G6PD, PK, Spherocytosis,

Eliptocytosis, PNH, TTP, DIC

Coombs positive with Spherocytes

Autoimmune hemolytic anemia
Warm AIHA
z Abrupt onset
z IgG
z Anti-Rh,, e,, C,, c,, LW,, U
z Jaundice
z Splenomegaly
g y
z SLE, CLL, Lymphoma
z Drugs: methyl-dopa,
mefenamic
f
i acid,
id
cimetidine, cefazolin

Cold AIHA
z Insidious onset
z IgM, complement
z Anti-I,, I,, Pr
z Cold agglutinin titer
z Absent jjaundice
z Mycoplasma
z Virus

Coombs positive with Spherocytes

Other immune hemolytic anemia
Alloantibody hemolytic anemia
z Transfusion reaction
z Feto-maternal incompatibility (Kleihauer-Betke test)
Drug related Hemolytic anemia
z Toxic immune complex (drug+Ab+C3)
- Quinine,
Quinine Quinidine,
Quinidine Rifampin,
Rifampin INH,
INH Sulfonamides,
Sulfonamides
Tetracyclin
z Hapten
H t fformation
ti (anti-IgG)
( ti I G)
- PCN, methicillin, ampicillin

Macrocytic, hyperproduction (RPI >= 2)

Coombs Negative
Coombs
z
z
z
z
z
z

Episodic - G6PD def., PNH

Sickle crystals or target cells Sickle,
Hemoglobinopathy
Elli t
Elliptocytosis
t i
Spherocytosis
Fragmented RBCs - DIC, TTP
Treated (known) B12/folate def.
def

Coombs Negative Hemolytic Anemia

Membrane Defects
Spherocytosis
z Common among
Northern European
z Autosomal dominant
z Decreased spectrin
z Osmotic fragility test
z Autohemolysis test

Elliptocytosis
z 90% with no clinically
significant hemolysis
z Abnormal membrane
protein
t i

Coombs Negative Hemolytic Anemia

Deficiency of RBC Enzymes
Pyruvate Kinase Def.

G6PD Def.
z
z

z
z

X-linked
X
li k d
Mediterranean,
African American,, and
Asian
Oxidant drugs ASA,

z
z
z

quinine, primaquine,
chloroquine, sulfacetamide,
sulfamethoxazole,
nitrofurantoin, chloramphenicol,
procainamide quinidine
procainamide,

Infections
Quantitative test

Severe anemia
S
i in
i
newborns
Adults symptomatic
Jaundice
Splenomegaly
Fluorescent screening
test
Quantitative test

Coombs Negative Hemolytic Anemia

Hemoglobinopathy
HbS disease
z Valine substitution for
Glutamic acid at the
position of b-chain
6th p
z Sickle crises
z Severe anemia
z Screening test - Na
Metabisulfite solubility
y
z Hgb electrophoresis

Coombs Negative Hemolytic Anemia

Hemoglobinopathy continues
HbC disease

HbSC disease

z
z
z
z

Mild hemolysis
Splenomegaly
Lysine substitution
HbC crystals
y
bar of g
gold
Hgb electrophoresis

Sickle and SC crystals

Washington
Washington monument
monument
z Less crises
z More retinopathy/aseptic
necrosis

Coombs Negative Hemolytic Anemia

Paroxysmal Nocturnal Hemoglobinuria
z
z
z
z
z
z

Rare chronic condition

Recurrent abdominal pain,
pain vomiting,
vomiting
headaches, eye pain, thrombophlebitis
Episodic Hgb in urine,
urine Hemosiderinuria
Abnormal cell membrane - increased lysis
b complement
by
l
t
Screening - Sucrose hemolysis test
Confirm - Acid hemolysis test (Hams test)

Coombs Negative
g
Hemolytic
y Anemia
Fragmented RBCs & Thrombocytopenia
TTP HUS
TTP-HUS
z
z

Thrombocytopenia
Microangiopathic
hemolytic anemia
z Neurologic symptoms and
signs
z Renal failure
z Fever
z

Idiopathic - 37 %
Drug associated - 13 %
Drug-associated
Autoimmune disease - 13 %
Sepsis - 9 %
Pregnancy - 7 %
Bloody diarrhea - 6 %
Hematopoietic cell
transplantation - 4 %

DIC
z Depletion of clotting factor
(TTP normal)
z Thrombocytopenia
z Bleeding (64%)
z Renal dysfunction (25%)
z Hepatic dysfunction (19%)
z Respiratory dysfunction
(16%)
z Shock (14%)
z Thromboemboli (7%)
z Central nervous system
involvement (2%)
z Sepsis,
S
i trauma,
t
malignancy
li

TTP HUS / DIC

TTP-HUS

Normocytic Anemia
H
Hyperproliferative
lif
ti (RPI >= 2)
z

Use same flow chart as macrocytic

hyperproliferative
Occult Blood Loss?

Yes

Investigate source

No

Check for Hemolysis

Peripheral smear

Coombs (DAT)

Normocytic Anemia
H
Hypoproliferative
lif
ti (RPI < 2)
1. Get iron panel (ferritin)/B12/folate
- some clue from RBC indices to check early
disease, high RDW, peripheral smear.
2. Consider liver, renal, drugs, toxin, endocrine
(thyroid), and anemia of chronic disease.
3. Get BM bx
- Leukopenia,
Leukopenia thrombocytopenia,
thrombocytopenia CRI < 0.1
01
- Aplastic anemia/pancytopenia
- Abnormal (leukoerythroblastic) cells on smear

Q ti ?
Questions?