4.

01

Iron Deficiency Anaemia

Any condition in which the number of red blood cells/mm3, the amount of Hb in 100mL of blood, and/or the volume of packed red blood cells/100 mL of blood are than normal CLINICALLY DEFINED AS: Concentration of oxygentransporting material in a designated volume of blood (in contrast to total quantities as in oligocythemia, oligochromemia, and oligemia) EPIDEMIOLOGY 30% of the total world population is anaemic

have Iron Deficiency (600 million people)

RISK FACTORS & AETIOLOGY OF IRON DEFICIENCY: 1. Dietary lack 2. Impaired Absorption 3. Increased Requirement 4. Chronic Blood Loss

CLINICAL FEATURES General Symptoms (very non-specific) Angina Dyspnea Intermittent Headaches

5. Dietary lack: Infants, Children, Impoverished, Elderly 6. Impaired Absorption - Due to Absorptive disorders, Steathorrhea,
Chronic Diarrhoea, Gastrectomy ( hydrochloric acid and transit time in duodenum)

Palpitations Claudication Fatigue Faintness General Signs Systolic Flow Murmur

7. Increased requirement. Growing infants and children, adolescents, and premenopausal

(especially pregnant) Risk: socioeconomic females with multiple, frequent pregnancies

Cardiac failure Pallor

Tachycardia

Rarely: papilloedema & retinal haemorrhages after acute bleed (can be accompanied by blindness). SIGNS IN SPECIFIC ANAEMIAS

8. Chronic Blood Loss Most common cause of iron deficiency in the Western world.

If bleeding occurs into tissues or cavities of the body, the heme iron can be totally recovered and recycled. However, external hemorrhage, as can occur from the GIT, the urinary tract, or the genital tract, depletes iron reserves

MICROCYTIC: Iron Deficiency Anaemia Tongue Papillae atrophy

t men and postmenopausal women in the Western world must be attributed to GIT blood loss until proven otherwise (important because of possible GIT cancer or other bleeding lesion) Mnemonic: PATHOPHYSIOLOGY Iron Deficiency produces a Hypochromic Microcytic Anaemia. Simultaneously, depletion of essential iron-containing enzymes in cells throughout the body can cause other changes, including koilonychia, alopecia, atrophic changes in the tongue and gastric mucosa, and intestinal malabsorption. - Reserves in the form of Ferritin and Hemosiderin may be adequate to maintain normal hemoglobin and hematocrit levels as well as normal serum iron and Transferrin saturation. - Progressive depletion of these reserves first lowers serum iron and transferrin saturation levels, without producing anemia. - In this early stage, there is increased erythroid activity in the bone marrow. - Anemia only appears when iron stores are completely depleted, accompanied by low serum iron, serum ferritin, and transferrin saturation. Hypochromic microcytic anemia of iron deficiency (peripheral blood smear). Note the small red cells containing a narrow rim of peripheral hemoglobin. Scattered fully hemoglobinized cells, present due to recent blood transfusion, stand in contrast. Patients may be asymptomatic due to: Slow Hb Haemodynamic Compensation & enhancement of O2carrying capacity of blood 2,3-DPG (aka: BPG) Right shift of O2 dissociation curve so that O2 more readily given up to tissues Ferritin: Iron-protein complex, containing ~23% iron; Ferric Ions + Apoferritin; Found in intestinal mucosa, spleen, BM, reticulocytes & liver; Regulates iron storage & transport from intestinal lumen to plasma Hemosiderin: Golden yellow or yellow-brown insoluble protein produced by phagocytic digestion of hematin; found in most tissues, especially liver, spleen, and BM; In the form of granules much larger than ferritin molecules (of which they are believed to be aggregates); Higher content ~37% of iron; stains blue with Perl Prussian blue stain. Transferrin: Iron-transporting protein; Non-heme Beta -1 Globulin of the plasma, capable of associating reversibly with up to 1.25mcg iron/g. EXTRA

Brittle Hair and Nails Angular stomatitis Koilonychia (spoon nails) Epithelial changes Dysphagia & Glossitis (Plummer-Vinson/Paterson-Brown-Kelly syndrome) Destroyed Cells Journey to the Spleen

NORMOCYTIC Haemolytic Anaemia: Dark urine

Chills Jaundice Splenomegaly

Aplastic Anaemia: Bleeding, Infection & Bruising MACROCYTIC Megaloblastic Anaemias Symptoms Malaise (90%) Dyspnea (50%) Mouth soreness (20%) Skin pig. change Impotence Depression Hallucinations

Paraesthesiae (80%) Weight Grey hair Memory Personality change Visual disturbance

Signs Pyrexia Angular Stomatitis (Cheilosis) Skin pigmentation change and Vitiligo Tongue Smooth Heart failure B12 Deficiency Additional Neuro Signs Neurological disease in up to 40% of cases.

Focal demyelination affecting: o Peripheral nerves

INVESTIGATIONS IN MEGALOBLASTIC ANAEMIA (B12 &Folate Def) INVESTIGATION Haemoglobin MCV RCC Blood Film Retic count Leuc count Platelet count Bone Marrow RESULT , may be Usually , commonly > 120 fl for degree of anaemia Oval Macrocytosis, Poikilocytosis, RBC Fragmentation, Hypersegmented Neutrophils for degree of anaemia or N or N Cellularity, Megaloblastic changes in erythroid series, giant metamyelocytes, dysplastic megakaryocytes, increased iron in stores, pathological non-ring sideroblasts often May be from ineffective erythropoiesis Schilling Test: usually <160 ng/L (LLN) Immunoassay for Pernicious Anaemia

DIAGNOSIS Based on Hx & Examination

(see clinical features)

FBC Anaemia indicated by Hb on FBC +/- Clinical features Further investigation based on MCV RDW (Red cell distribution width; variation in the size of your RBCs; demonstrates anisocytosis) may also assist in Normal MCV (normocytic anaemia), Low MCV (microcytic anaemia) and High MCV (macrocytic anaemia) Blood Film: Elicits hallmarks of cells indicating diagnosis or further investigation FURTHER INVESTIGATION MICROCYTIC Iron Deficiency Anaemia (IDA) Hx Diet, meds (NSAIDs), bleeding (esp menstrual) Blood Film o Microcytic RBCs (MCV < 80 fL) o Hypochromic (MCH < 27 pg) o Poikilocytosis (variation in shape) o Anisocytosis (variation in size) o Target cells present Iron Studies o Plasma Ferritin - Best single test to confirm IDA (Measures iron stores; very sensitive (other measures affected by many factors) o Transferrin saturation of <16% consistent with iron deficiency but is less specific than a ferritin level BM Aspirate: Difficult cases - Measure iron store levels Further investigations needed to source the cause of deficiency o Loss (bleeds [esp GI, menses], pregnancy, breast feedg) o Absorption (dietary, malabsorption, parasite) OTHER MICROCYTIC CAUSES Iron Anaemia Of Thalassaemia Sideroblastic Def Chronic Trait ( or ) Anaemia Disease MCV or N for degree of in inherited anaemia type;often in acquired type Serum iron Normal Serum TIBC Normal Normal Serum ferritin or N Normal Serum soluble Normal Normal / Normal / transferit recept Iron in marrow Present Present Present Iron in Absent / Present Ring forms Erythroblasts NORMOCYTIC Anaemia of Chronic Disease ACD is difficult to distinguish from iron deficiency (hence above)

Serum Ferritin Plasma LDH Serum Bilirubin Serum Vit B12 Anti-Intrinsic Factor Antibodies Serum Folate normal or , & RBC folate is normal or NON MEGALOBLASTIC Macrocytosis present but no megaloblastic changes in BM

TREATMENT/ MANAGEMENT Need to treat underlying cause where possible. Iron Deficiency Anaemia Oral Iron Ferrous sulphate is the best preparation. Best given on an empty stomach. If side effects such as nausea, constipation, abdo pain occur then can give with food. The Hb should rise by about 2g/dl every 3 weeks. Parenteral Iron should only be given if need to replenish iron rapidly, i.e late pregnancy, or when oral is ineffective (malabsorption) or impractical (active Crohns disease). Megaloblastic Anaemia - B12 and folate need to distinguish malabsorption from inadequate diet. Most cases only need therapy with the appropriate vitamin. If large doses of folate are given in B12 deficiency they cause a haematological response but may aggravate the neuropathy so should not be given alone unless B12 def excluded. Can also give B12 injections. Hb should rise by 2-3g/dl each fortnight Anaemia of Chronic disease can only treat by treating the underlying disorder. Does not respond to iron therapy Should avoid blood transfusion where possible this may lead to fluid overload.

ERYTHROPOIETIN, the hormone principally responsible for stimulating production of red cells in the bone marrow, is normally produced in the kidneys. In many types of renal failure the kidneys' ability to produce erythropoietin is impaired and despite adequate levels of iron, vitamin B 12 and folic acid, anaemia results. A similar anaemia can also be found in many patients with a variety of chronic illnesses including cancer, arthritis or infection. It is thought in these patients that one or more substances produced as part of the immune response impair the ability of the body to release iron from its storage sites in the body. Tests in these patients reveal no evidence of iron deficiency and giving extra iron fails to improve the anaemia. However laboratory research has shown that the developing red blood cells in the bone marrow may not receive adequate amounts of iron to complete maturation. The only effective therapy is to treat the underlying condition following which the anaemia spontaneously improves.

Rule out Iron Deficiency and check ESR for inflammation Haemorrhage Investigations based on Physiological & Pathological causes Haemolytic (can be microcytic) Peripheral blood smear o Fragments of RBC ("schistocytes ") can be present. o Spherocytes may be present (RBCs smaller & rounder than usual) o Reticulocytes o Possible low RBC count

Unconjugated bilirubin: serum level . May lead to jaundice. Lactate dehydrogenase (LDH): serum levels Haptoglobin: serum levels Haemosiderin: in urine- indicates chronic intravascular haemolysis. Haemoglobin: present in urine Urobilinogen: present in urine & faeces. PLUS more obscure things to elicit cause of haemolysis o Rule out Iron Deficiency Uric Acid o Protein electrophoresis Potassium o Platelet count AST o Donald-Landsteiner test Febrile/cold agglutins o Leukocyte alkaline phosphatase

LIFE HISTORY OF RED CELL: GENERATION, LOSS & DESTRUCTION Red cells - formed in the red marrow from Erythroid Stem Cells Mature under influence of erythropoietin (EPO) through a number of divisions leading from Erythroblasts Erythrocytes/RBCs 120 day life span. Normally balance b/w production/destruction Production can be accelerated up to 7X fold if demand (Achieved by expansion of the volume of red marrow and by shortening of the transit time for red cell maturation (skipped divisions). Destruction after their 120 day life span may involve continual loss of membrane components, the accumulation of products of oxidated damage and/or decreased deformability of the RBC Unable to squeeze through the minute (1-2 um) fenestrations in the splenic microvasculature Effete RBC finally phagocytosed by macrophages of the Reticuloendothelial System, mainly in the spleen but also in the Liver and BM. Phagocytosis of RBCs becomes more prominent when red cell survival is shortened (hemolysis). Blood Loss Anaemia Clinical signs are very different in anaemia: Acute: Secondary to blood loss (following trauma or surgery) Acute blood loss anaemia, there are changes in the pulse and BP and the patient may present in a state of shock (Very low BP, Rapid pulse, cold & discoloured extremities, sweating, dilated pupils etc) "Reactive " thrombocytosis (raised platelet count) and a reactive increase in white blood cells (leucocytosis) may occur. Chronic (intermittent or slow bleeding from eg peptic ulcer or heavy menstrual loss - menorrhagia). Compensating mechanisms which allow the patient to function in their day to day activities with relative ease. (Alteration in Hb function allowing oxygen release to the tissues more readily) Chronic blood loss results in iron deficiency It is clear that for a proper assessment of a person with blood loss anaemia there are three critical processes: Careful history (abnormal bleeding, menstrual history in women, symptoms of peptic ulcer, altered bowel habit etc.) Physical examination - signs of acute bleeding, iron deficiency, abdominal masses etc.

NORMAL BONE MARROW FUNCTION Bone marrow array of cells, specialized functions - Host defence (granulocytes, monocytes, lymphocytes ie white cells) - Oxygen transport (erythrocytes ie red cells) - Haemostasis (platelets released by megakaryocytes) Haemopoiesis takes place in the bone marrow after 7 months gestation, & prior to this in the fetal liver & spleen. The haemopoietic stem cell: - is capable of self renewal - is capable of differentiation ("multipotent or pluripotent") to erythroid, lymphoid or myeloid (granulocytic, monocytic, erythroid, or megakaryocyte) progenitors. - has no unique morphological characteristics & is morphologically identical to a small to intermediate sized lymphocyte. Exposure to haemopoietic growth factors stem cell becomes committed (differentiation). Commitment to a lineage is irreversible & the capacity for self-renewal is lost as maturation progresses. Growth factors continue to influence cell maturation & subsequently function. Haemopoietic growth factors are produced by an array of haemopoietic & stromal cells which reside in the marrow. EPO is an exception in that its main source is the kidney Growth factors are in general stimulatory although inhibitory factors also exist. Growth factors act in synergy with each other especially in low concentrations. Bone marrow microenvironment provides a suitable structural, nutritional & hormonal environment for haemopoiesis. The microenvironment includes: Stromal cells (macrophages, fibroblasts, reticulum cells, fat cells & endothelial cells). Stromal cells are one important source of haemopoietic growth factors & other cytokines. They have an important role in haemopoietic cell adhesion, through cell adhesion molecules, & hence determine the localisation of haemopoiesis. Extra-cellular matrix (ECM including components such as: fibronectin, laminin, collagen & proteoglycans) Microvascular network of thin walled venous sinusoids allowing communication with the rest of the body through the systemic circulation Some haemopoietic growth factors have established roles in clinical practice eg EPO (erythropoietin), G-CSF (Granulocyte - Colony Stimulating factor) & GM-CSF (Granulocyte/Monocyte - Colony Stimulating Factor). Most common nutritional deficiency that lead to alterations in haemopoiesis are deficiencies of Vitamin B 12, Folate & Iron Other Factors Required for Normal Haemopoiesis (Especially Erythropoiesis): Metals - iron, manganese, cobalt Vitamins - vitamin B 12 , folic acid, vitamin C, E, B 6 , thiamine, riboflavin & pantothenic acid Amino acids

Hemolytic Anemia - any anemia resulting from an increased rate of erythrocyte destruction CONSEQUENCES OF DEFICIENCIES OF ESSENTIAL HAEMATINICS Deficiency of one or more of these elements involved in haemopoiesis Anaemia Diagnosis relies on history, physical examination and laboratory tests, commencing with a blood count and examination of the blood film. Iron deficiency is the commonest cause of anaemia throughout the world. In underdeveloped countries this is due to gastrointestinal blood loss from hookworm infestation. In our society, the commonest cause of iron deficiency is menstrual blood loss in fertile women. This is so common as to be considered almost "normal for age". In older women and men, the diagnosis of iron deficiency which cannot be explained by obvious blood loss must be followed by a search for a source of occult bleeding, possibly from a carcinoma of the gastrointestinal tract or from peptic ulceration of the stomach. Iron deficiency anaemia is also common in infants and young children due to poor iron intake. 48711500 Dr Hambury Ronald Cooper chlormycetin eye drops - patient MICROCYTOSIS: The laboratory hallmark of iron deficiency is the presence of small red blood cells. This can be best appreciated from the electronically derived mean corpuscular volume (MCV). Normal MCV is 80-100fl but in iron deficiency the MCV falls to under 80fl. Specific studies: serum iron level, serum transferrin and serum ferritin (the best measurement of overall iron stored in the body). MACROCYTOSIS: Reductions in the amount of folic acid or vitamin B 12 in the body result in anaemia characterised by an increase in red cell size and specific appearances within the bone marrow (megaloblastosis). The MCV is over 100fl and the blood film shows large red cells and variations in size and shape. There may also be changes in the neutrophils which can show marked nuclear hypersegmentation. Not all causes of macrocytosis induce megaloblastosis of the bone marrow Excess alcohol consumption for example is the commonest cause of macrocytosis in our community but is not associated with megaloblastic anaemia. Unlike iron deficiency, the lack of folic acid or vitamin B 12 is rather uncommon. Deficiency of vitamin B 12 Can cause profound neurological damage. Lack of vitamin B 12 is most commonly caused by poor absorption from the bowel. Autoimmune disease known as pernicious anaemia Ab produced by the patient's own immune system destroys gastric cells which normally secrete a substance known as intrinsic factor. Intrinsic factor must bind to vitamin B 12 in the stomach for vitamin B 12 to be absorbed in the terminal ileum. When intrinsic factor is no longer secreted vitamin B 12 absorption ceases. Other non-immune causes for vitamin B 12 deficiency also exist including surgical removal of stomach or terminal ileum. Folic acid absorption occurs in the jejunum and does not require intrinsic factor. Diseases affecting the small bowel (eg coeliac disease) or surgical removal of large segments of small intestine can therefore impair its absorption. Some groups of patients with poor diets eg the elderly, severely depressed individuals and adolescents can also become deficient from inadequate folic acid intake.

HAEMOLYSIS - Premature Destruction of RBCs RBC survives 120 days; shortening in time = haemolysis Survival measurement: radiolabel RBC with Chromium-51 and reinject, sample at intervals of several days to measure removal (rarely used) Haemolytic Amaemia Lab Tests:

VITAMIN B12 AND THE NERVOUS SYSTEM B12 involved myelin (and other protein) synthesis by glial cells Deficiency fatty deposits in the myelin and coalesce (largest fibres most affected) Slower AP conduction cant sustain high frequency information blocked transmission

Hb Rapidly reduced due to either Haemolysis of Blood Loss. If

Haemolysis, confirm with clinical presentation of Scleral jaundice & splenomegaly (from RBC destruction) Reticulocytes Bilirubin (from haem breakdown from Hb)

May affect: (1) Peripheral Nerves, (2) Spinal Cord, (3) Brain

Lactic DeH (LDH; found in RBCs) Haptoglobulin Absent (haptoglobin binds haem and prevents renal excretion) Blood Film Examination look for morphological changes erythroid hyperplasis ( RBC precursors)

Bone marrow examination (rarely performed) - May show

antiglobulin tests) if immune mediated hemolysis suspected Mechanisms of Haemolysis: - Abnormalities of RBC membrane and underlying cytoskeletal proteins loss of surface lipid and spherocyte formation (eg hereditary spherocytosis) - Enzyme deficiencies in RBC: Commonest is G6P DeH (RBC cant make NADPH antioxidant; Excessive oxidant stress denatures Hb Haemolysis) - Abnormalities of the Hb structure or synthesis (inherited) (e.g. Sickle Cell and Thalassaemia) - Autoimmune destruction in spleen and liver (due to production of Abs)

1. Peripheral Nerves - Peripheral Neuropathy of: Sensory Neurons: Numbness and Parasthesias ("pins and needles") in hands and feet, often symmetrically (glove and stocking distribution). Due to slowing and asynchrony of APs in sensory neurones Motor Neurons Motor weakness due to wasting of peripheral muscles may occur Stretch reflexes are diminished in affected regions 2. Spinal Cord - Two major pathways affected in the white matter of the spinal cord (combined degeneration)

Coombs Test: Looks for Abs on the cell surface (direct

I. II.

Dorsal Or Posterior Columns (will cause Sensory Difficulties, Proprioception loss (particularly in the dark), Loss of the sense of Vibration)

Lateral Corticospinal Tract (will cause Stretch reflexes are exaggerated, Motor tone is increased, Babinski sign is present) 3. Brain - Demyelination results in Confusion, Depression, Moodiness, Memory Losses, Overt Psychosis Prognosis:

Symptoms rapidly resolve with B

12 treatment Recovery from demyelination and associated axonal damage slow, especially in long standing lesions

OTHER MICROCYTIC HYPOCHROMIC ANAEMIAS Anaemia of Chronic Disease Normocytic, can be normochromic Mild Hb rarely <9.0g/dl iron and TIBC (total iron binding capacity sTfR normal, serum ferritin normal or Pathogenesis: related to: - in iron release from macorphages to plasma due to hepcidin. Released from liver in inflammation. - red cell lifespan and - inadequate erythropoietin response to anaemia - due to effects of IL-1, TNF on erythropoiesis. Need to correct underlying cause, does not respond to iron therapy Sideroblastic Anaemia Increased marrow iron, hypochromic cells in periphery. - can be hereditary - or acquired - Primary due to myelodysplase, secondary due to other malignant diseases of marrow. Characterised by presence of pathological ring sideroblasts in marrow. Causes of microcytic anemia = TAILS: T - Thalassemia, A - Anemia of chronic disease, I - Iron deficiency anemia, L - Lead toxicity associated anemia, S - Sideroblastic anemia. MACROCYTIC NON MEGALOBLASTIC ANAEMIAS Exact mechanisms are not cleasr, but lipid deposition on red cell membrane or alterations of eryrthroblas maturation time in marrow may be implicated. Alcohol is most frequent cause of MCV in absence of anaemia. Reticulocytes are bigger than mature red cells and so haemolytic anaemia is an important cause of macrocytic anaemia. Other underlying causes include: Myelodysplastic syndromes, cytotoxic drugs, pregnancy, smoking, myeloma, liver disease, myxedema, reticulocytosis. Haemolytic Anaemia Features of red cell breakdown: - serum bilirubin, unconjugated and bound to albumin Urine urinobilinogen Faecal stercobilinogen Serum haptoglobins absent as they are saturated with Hb complex and removed by RE cells. Features of red cell production Reticulocytosis - Bone marrow erythroid hyperplasia Damaged red cells - Morphology microspherocytes, elliptocytes, fragments etc Osmotic fragility, autohaemolysis Red cell survival shortened Many different types of haemolytic anaemia, Paroxysmal nocturnal haemoglobinuria, G6PD, hereditary spherocytosis et. See appendix 2 for intravascular vs extravascular haemolysis and antibody tests Aplastic Anaemia usually normocytic, normochromic Syndrome of marrow failure associated with pancytopenia. The markedly hypocellular bone marrow is largely devoid of hematopoietic cells; often only fat cells, fibrous stroma, and scattered or clustered foci of lymphocytes and plasma cells remain.

MEGALOBLASTIC ANAEMIAS MACROCYTIC Vitamin B12 and Folate Deficiency - Macrocytic (MCV>95fl, as high as 120-140gl) - Macrocytes typically oval in shape - Reticulocyte count low, - May be moderately reduced platelet and WCC - Hypersegmented neutrophils (6 or more lobes) - serum bilirubin, hydroxybuturate and lactate dehydrogenase as result of marrow cell breakdown - Marrow hypercellular, large erythroblasts, giant and abnormally shaped metamyelocytes Pathogenesis: Folate causes anaemia by inhibiting thymidylate synthesis, a rate limiting step in DNA synthesis. Folate is delivered to cells as Methyl THF, which is a coenzyme for this reaction. B12 is also involved in this step as is demethylates methyl THF to THF to be used in synthesis of folate. the proximate cause of anaemia in B12 deficiency is folate deficiency see appendix 1 for more info B12 and Pernicious anaemia: - due to autoimmune attack atrophy of stomach. Wall of stomachbecomes thin, plasma cell and lymphoid infiltrate oflamina propria. There is achlorhydria and absent secretion of Intrisic Factor (IF) which is necessary for absorption of B12

SICKLE CELL ANAEMIA Pathogenesis: When deoxygenated, HbS molecules undergo aggregation and polymerization. Initially, the red cell cytosol converts from a freely flowing liquid to a viscous gel as HbS aggregates form. With continued deoxygenation, aggregated HbS molecules assemble into long needle-like fibers within red cells, producing a distorted sickle or holly-leaf shape

Sickling of red cells is initially a reversible phenomenon; with oxygenation, HbS depolymerizes and the cell shape normalizes. However, with repeated episodes of sickling, membrane damage occurs and cells become irreversibly sickled, retaining their abnormal shape even when fully oxygenated. - The precipitation of HbS fibers also causes oxidant damage, not only in irreversibly sickled cells but also in normal-appearing cells. calcium, which is normally excluded rigorously. Calcium ions activate a potassium ion channel, leading to the efflux of potassium and water, intracellular dehydration, and an increase in the mean cell hemoglobin concentration.In addition, lesions produced by repeated episodes of deoxygenation render sickle red cells abnormally sticky. These membrane changes are important in the pathogenesis of microvascular occlusions.

WARM ANTIBODY IMMUNOHEMOLYTIC ANEMIA. - MOST COMMON FORM (48% TO 70%) OF IMMUNE HEMOLYTIC ANEMIA. - Mostly IgG but sometimes IgA - Mostly extravascular destruction - IgG-coated red cells bind Fc receptors on monocytes and splenic macrophages, which results in loss of red cell membrane during "partial" phagocytosis. As in hereditary spherocytosis, the loss of cell membrane converts the red cells to spherocytes, which are sequestered and removed in the spleen, the major site of red cell destruction in this disorder. Thus, moderate splenomegaly is characteristic of this form of anemia. Cold Agglutinin Immunohemolytic Anemia. caused by so-called cold agglutinins, IgM antibodies that bind and agglutinate red cells avidly at low temperatures (0 to 4C). - accounts for 16% to 32% of cases - Antibodies appear acutely after mycoplasma pneumonia and infectious mononucleosis self limited, clinical features rare. - Other infectious agents assoc. with this form of include CMV, influenza virus, HIV. - Chronic anemias occur in association with certain lymphoid neoplasms or as an idiopathic condition. - Clinical symptoms binding of IgM to red cells at sites such as exposed fingers, toes, and ears where temp <30C. IgM binding agglutinates red cells and rapidly fixes complement on their surface. As the blood recirculates and warms, IgM is rapidly released, usually before complement-mediated hemolysis can occur. Appendix 1 Two reactions in humans are known to require vitamin B12. 1) Methylcobalamin is an essential cofactor for methionine synthase, an enzyme involved in the conversion of homocysteine to methionine. In the process, methylcobalamin yields a methyl group and is regenerated from N5-methyltetrahydrofolic acid (N5-methyl FH4), the principal form of folic acid in plasma. 2) In the same reaction, N5-methyl FH4 is converted to tetrahydrofolic acid (FH4). FH4 is crucial, since it is required (through its derivative N5,10-methylene FH4) for conversion of deoxyuridine monophosphate to deoxythymidine monophosphate, an immediate precursor of DNA It has been postulated that the fundamental cause of impaired DNA synthesis in vitamin B12 deficiency is the reduced availability of FH4, most of which is "trapped" as N5-methyl FH4.34 In addition, the deficit in FH4 can be exacerbated by an "internal" folate deficiency caused by a failure to synthesize metabolically active polyglutamylated forms.35 This may stem from a requirement for vitamin B12 in synthesis of methionine, which contributes a carbon group needed in the metabolic reactions that create folate polyglutamates . Whatever the mechanism of internal folate deficiency, lack of folate is the proximate cause of anemia in vitamin B12 deficiency, as the anemia inevitably improves with administration of folic acid. Appendix 2 Intravascular haemolysis Caused by: - mechanical injury: caused by defective cardiac valves, thrombi within the microcirculation, or repetitive physical trauma (marathon running, bongo drum beating) can physically lyse red cells. - complement fixation: can occur on antibody-coated cells during transfusion of mismatched blood. - infection by intracellular parasites such as falciparum malaria, or exogenous toxic factors: Toxic injury is exemplified by clostridial sepsis, which releases toxins that attack the red cell membrane. Intravascular hemolysis is manifested by hemoglobinemia and hemoglobinuria jaundice hemosiderinuria Methalbuminaemia. Decreased serum haptoglobin Free hemoglobin in plasma is promptly bound by an 2-globulin (haptoglobin), producing a complex that is rapidly cleared by the mononuclear phagocyte system, thus preventing excretion into the urine. When haptoglobin is depleted free hemoglobin prone to oxidation to methemoglobin, which is brown in color. The renal proximal tubular cells reabsorb and catabolize much of the filtered hemoglobin and methemoglobin, but some passes out with the urine, imparting a redbrown color. Iron released from hemoglobin can accumulate within tubular cells, giving rise to renal hemosiderosis. Concomitantly, heme groups derived from the complexes are catabolized to bilirubin within the mononuclear phagocyte system, leading to jaundice. In hemolytic anemias, the serum bilirubin is unconjugated and the level of hyperbilirubinemia depends on the functional capacity of the liver and the rate of hemolysis. When the liver is normal, jaundice is rarely severe. Excessive bilirubin excreted by the liver into the gastrointestinal tract leads to increased formation and fecal excretion of urobilin Extravascular hemolysis extreme alterations in shape are required for red cells to navigate the splenic sinusoids successfully, reduced deformability makes the passage difficult and leads to sequestration within the cords, followed by phagocytosis. This is an important pathogenetic mechanism of extravascular hemolysis in a variety of hemolytic anemias. With extravascular hemolysis, hemoglobinemia and hemoglobinuria are not observed, and its principal features are anemia and jaundice. However, some hemoglobin inevitably escapes from phagocytes, leading to decreases in plasma haptoglobin. The morphologic changes are identical to those in intravascular hemolysis, except that "work" hyperplasia of the mononuclear phagocyte system often leads to splenomegaly.

Past Exams MEQs 2003 MEQ paper 1: Brian Murphy is a 77 year old man who presents to your surgery complaining of tiredness and dyspnoea. You note that he is pale and has signs of heart failure. His haemoglobin measures 87g/L (normal range 125-165 g/L). 1. Name 3 laboratory test results that would suggest the anaemia is due to haemolysis rather than reduced red cell production. Model Answer raised reticulocyte count positive direct antiglobulin (Coombs) test raised bilirubin level absent haptoglobin in serum raised serum LDH presence of methaemalbumin in serum 2. a) Which components of the red cell are responsible for blood groups? b) The direct antiglobulin (Coombs) test is requested and is positive. What does the direct antiglobulin test detect? Model Answer a) Surface glycoproteins and/or glycolipids Cellular carbohydrate transferases b) The presence of immunoglobulin and/or complement on the surface of red blood cells 3. Describe two possible mechanisms of destruction of circulating red cells which become coated with immunoglobulin/antibody. Model Answer (i) antibody fixes complement and red cells lyse in the circulation (ii) antibody fails to fix complement and red cells are removed from circulation in the liver or spleen via Fc receptors of reticulo-endothelial cell macrophages) 4. The patient is treated with oral prednisone. Name two short term and two long term complications of oral corticosteroid administration. Model Answer Short term: mood change, insomnia, hyperglycaemia, hypertension, Long term: obesity, skin thinning, bruising, cataracts, adrenal suppression, osteoporosis, infection 2001 MEQ paper 1: Sarah Weiss is a 15 year-old girl who comes to the GP with her mother who is concerned that Sarah has lost weight, seems tired all the time and appears pale. Up until 10 months ago, Sarah was a good eater and was a normal and active girl. Her weight is now 58 kg (was previously 68 kg) and her height is 165 cm. The GP orders a full blood count (FBC) and blood film which show: FBC Sarahs Reference Blood film results range WCC 8.1 x 109/L 4.513.0 x Hypochromia + 109/L Platelets 598 x 150600 x Microcytosis + 109/L 109/L Haemoglobin *81 g/L 120160 g/L Poikilocytes + MCV MCHC *71 fl 7895 fl *295 g/L Pencil cells occasional (thin elongated cells) 320360 g/L

1. Regarding Sarahs blood film and red cell indices, which 2 features are most helpful in suggesting the cause of her anaemia is iron deficiency? Model Answer Hypochromia (as shown by low MCHC) and microcytosis (as shown by low MCV) are characteristic findings of iron deficiency anaemia. Other red cell changes such as pencil cells are less reliable indicators of iron deficiency. The platelet count at the upper end of the normal range (borderline thrombocytosis) suggests that blood loss may be a factor. 2. You plan to do additional tests to confirm the diagnosis. List 3 additional blood parameters you would test which would confirm a diagnosis of iron deficiency. Specify whether you would expect each to be high, low or normal. Model Answer Confirm the diagnosis of iron deficiency with appropriate iron studies (eg, low serum iron, high serum transferrin and total iron binding capacity, low iron saturation, low serum ferritin) For the past year Sarah has not eaten meat, fish, chicken, eggs, or milk products. She changed to a vegan diet consisting of green vegetables, legumes and cereals because of concerns about killing animals and eating animal products. 3. a) Give 2 foods or food types which would have been the major sources of iron in her diet during the past year. b) How might the bioavailability of iron be increased in her diet? Model Answer a) Cereals and legumes b) By taking in more foods containing vitamin C, eg, citrus, tomatoes. 2005 RFA 2: Cynthia Salakas is a 78-year old widow who presents with dyspnoea, palpitations on exertion and "pounding in the ears". She also describes unsteadiness on standing with occasional falls. Mrs Salakas lives alone with no family support and prepares her own meals. On examination, she is pale and anxious, with a tachycardia of 100 beats/min and BP of 130/80. The spleen is just palpable but there is no lymphadenopathy. A full blood count shows the following: Indices Hb MCV WBC Mrs Salakas' Results 68 g/L 124 fl 3.5 x 10 /L
9

Normal Range 115 - 165 g/L 76 - 96 fl 4.0 - 11.0 x 109/L

Platelets

89 x 109/L

150 - 500 x 109/L

1. List at least THREE common causes of a macrocytic anaemia. Model Answer Liver disease, Vitamin B12 deficiency, Folate deficiency, Alcohol excess, Myelodysplastic syndromes, Drug effect (drugs interfering with DNA synthesis cytotoxics and immunosuppressive agents), Haemolysis or haemorrhage (reticulocytosis) She has had difficulty preparing her own meals over the past few months as she feels very unsteady and has resorted to toasted cheese or tomato sandwiches several evenings per week as her main meal. She often consumes only half to three-quarters of her usual intake and she has noticed some weight loss which she is becoming concerned about. 2. What nutritional assessment methods could you use to decide if Mrs Salakas is malnourished? (Give THREE) Model Answer 1) Diet history and food frequency: ask the patient for all foods and fluids consumed over a typical week and how this may have changed over the past few months-compare previous to now. Also do a food frequency of major food items consumed over 1 week. Compare intake to recommendations for her age and gender. Consider the patients barriers to be able to obtain a normal intake. 2) Anthropometry: ask the patient for a weight history over the past 6-12 months. 3) Laboratory results: consider the current results obtained and determine if further studies are required to determine if anaemia is likely due to poor diet and if the patient also has overall malnutrition. Further testing shows a serum B12 level of 60 pmol/L (normal range 130-600 pmol/L) with normal red cell folate level. 3. Describe the typical blood film of B12/folate deficiency. Model Answer Variable anaemia, red cells are macrocytic, with increased oval forms and a marked variation in size (anisocytosis) and shape (poikilocytosis), Variable leukopenia. Neutrophils show hypersegmentation (greater than 6 lobes) with occasional giant forms (macropolycytes), Variable thrombocytopenia, with giant platelets You perform a neurological examination on Mrs Salakas. Her perception of position, sense and vibration is impaired in the feet and hands. Tendon reflexes are generally brisk with upgoing plantars. Her gait is abnormal, with unsteadiness on walking. 4 a) Describe the location and nature of the pathological effects of B12 deficiency on the nervous system. b) Describe at least TWO of the main neurological signs associated with B12 deficiency. Model Answer a) Primarily affects white matter of the dorsal and lateral columns of the spinal cord, and cerebral cortex Myelin degeneration and loss of nerve fibres in dorsal and lateral tracts, nerve degeneration in dorsal root ganglia and peripheral nerves (subacute combined degeneration) b) Confusion, impaired memory, Sensory changes dominate symmetric altered sensation, paraesthesiae in glove-stocking, distribution. Later changes include ataxia, gait problems, reduced vibration and position sense, Upper motor neurone signs weakness, increased tendon reflexes and Babinskis sign, late in disease (lateral column disease). Mrs Salakas is transfused initially and commenced on a course of parenteral B12 replacement. After two weeks in hospital she feels much improved and is anxious to return home. 5. You are about to discuss handing over her care with her local GP. List at least TWO community services or agencies that could provide support following her assessment as fit to go home. Give a brief explanation of each agency's role and why she might require their involvement. Model Answer Agencies Role Home/community nursing Supervision of medications, wound dressings, review of function at home, sometimes showering/personal hygiene Home care Assistance with cleaning home, showering/personal hygiene Meals on wheels Meals OT home assessment Minimise risk of falls from instability Outpatient physiotherapy and transportation Continued improvement of neuromuscular function 2004 RFA 2: Soraya Mahfouz is a 73 year old woman, widowed one year ago. She has been brought to you, her GP, by her son who is concerned that she is not coping. Mrs Mahfouz reports that she doesnt feel up to much, and while insisting that she is managing at home, is clearly avoiding activity due to fatigue and breathlessness on exertion that has become more of a problem in the last three months. She has lost 4-5 kg in the last year but has no specific symptoms on system review other than

features of moderate depression. On examination she has pallor of mucous membranes and nailbeds and you suspect that she is significantly anaemic. She has no evidence of bruising or splenomegaly, but her liver edge is palpable 2 cm below the costal margin. 1. Identify two features from this womans history and/or examination suggestive of anaemia. For each of these features state why they are suggestive. Model Answer * Fatigue and breathlessness with physical activity may reflect a rise in cardiac output in compensation for a decreased erythrocyte mass * Pallor of mucous membranes and nailbeds these are sites which allow reliable detection of pallor, from which one can infer a decrease in the oxygen-carrying capacity of the blood Her haemoglobin is 93 g/L, (normal range 115 - 165 g/L), mean corpuscular volume is 72 fL (normal range 80 - 100 fL) and mean corpuscular haemoglobin concentration is 295 g/L (normal range 310 - 350 g/L). Platelet and white cell measures are normal, as is the blood film. 2. Describe the physiology of red blood cell production. Pay particular attention to key nutritional components and any other relevant stimulatory factors. Model Answer Red blood cells are produced in the bone marrow. They require numerous micronutrients including iron for haem and vitamin B12 and folate which are essential for maturation. The hormone erythropoietin stimulates their production and is secreted in response to hypoxic conditions in the kidney, such as after haemorrhage or in high altitude living. 3. What is the most likely micronutrient deficiency underlying this womans anaemia and why? Model Answer The most likely deficient micronutrient is iron, because the MCV and the MCHC are both reduced (microcytic, hypochromic anaemia). B12 and folate deficiencies produce a megaloblastic anaemia. 4. List 3 additional blood parameters you would test which would confirm a diagnosis of iron deficiency. Specify whether you would expect each to be high, low or normal. Model Answer Confirm the diagnosis of iron deficiency with appropriate iron studies (eg, low serum iron, high serum transferrin and total iron binding capacity, low iron saturation, low serum ferritin) 5. Describe the mechanisms by which the biochemical environment in the tissues mediates oxygen delivery to active cells from haemoglobin in red cells. Model Answer In active tissues, higher temperature, acid pH, high concentrations of CO2 and 2,3- diphosphoglycerate (product of anaerobic glycolysis) all shift the haemoglobin dissociation curve to the right, decreasing the affinity of haemoglobin for oxygen. You confirm that she has a significant iron deficiency, with depleted iron stores. 6. a) What is the most likely cause of iron deficiency anaemia in a woman of this age? b) What tests would you recommend to confirm the most likely cause? Model Answer a) In post-menopausal females, the commonest cause of iron deficiency is gastrointestinal blood loss. b) Gastroscopy and colonoscopy or other imaging of the gastrointestinal tract 7. Soraya is likely to need some services to help her live in the community. A referral is made to the Aged Care Assessment Team (ACAT). a) Write a short paragraph describing, for Soraya and her son, the role of the ACAT team. b) Write another short paragraph explaining what they should know about Community Aged Care Packages (CACPs). Model Answer a) * ACATs help older people and their carers work out what kind of care will best meet their needs when they are no longer able to manage at home without assistance * ACATs provide information on suitable care options and can help arramge access or referral to appropriate community or residential care *They are usually attached to hospitals or community centres * They provide thorough assessments of care needs * The team usually consists of doctors, nurses, social workers and allied health professionals (including occupational therapists, physiotherapists and speech therapists)

* They are usually accessed via the local doctor or sometimes during hospital admission b) * Community Aged Care Packages (CACPs) are planned and coordinated packages of care to help older people remain living in their own homes * They may include help with bathing, showering or personal hygiene, social support, transport, laundry, meal preparation and gardening * The Australian Government provides a subsidy to local service providers and clients pay a portion of the fee (depending on their own income and ability to pay) * For people on a basic pension, fees must not exceed 17.5% 0f that pension. * People on higher incomes may be asked to pay additional fees (limited to 50% of any income above the maximum pension rate) * Access to CACPs is only possible following an assessment and referral by the ACAT team Past Exams SBAs Case 6 Mrs Mehar Singh is a 45 year old woman who complained of increasing lethargy over the past month and was found to have pale mucosa on examination. Her blood count shows a haemoglobin of 90 g/L (115-165 g/L) with mean cell volume of 60 fL (75-100 fL), white cell count of 6 x 109/L (4-11 x 109/L) and platelets of 510 x 109/L (150-400 x 109/L). Her GP notes that a previous haemoglobin result at the time of her hysterectomy twelve months ago was normal. Investigations demonstrate that she is iron deficient. 25. Further investigations should include: 1 A) Isotope tests of vitamin B12 absorption 2 B) Bone marrow examination 3 C) Upper endoscopy and colonoscopy 4 D) Duodenal biopsy for adult coeliac disease Answer C 26. The best immediate marker of a response to iron therapy would be: 1 A) Normalisation of the platelet count 2 B) Increasing reticulocyte count 3 C) Increase in haemoglobin 4 D) Reduction in pallor Answer B 27. Which of the following is most correct regarding dietary iron absorption? 1 A) The major site of absorption is the lower small intestine 2 B) Iron in eggs and vegetables is as well absorbed as iron in meat 3 C) Ferrous iron is more readily absorbed than ferric iron 4 D) Increased body iron stores result in increased dietary iron absorption Answer C 28. Which one of the following proteins is the major carrier of iron in blood? 1 A) Albumin 2 B) Ferritin 3 C) Transcobalamin 4 D) Transferrin Answer D 29. Iron plays a key functional role for all of the following proteins EXCEPT: 1 A) Cytochrome oxidase 2 B) Hemoglobin 3 C) Insulin receptor 4 D) Myoglobin 5 Answer C Case 4 Ron Porter is a 53 year old solicitor who presents to his GP in Mosman with mild dyspnoea on exertion and a history suggestive of angina. There is no history of blood loss. Results of a full blood count are given in the table below. An occult blood test was performed on a stool specimen and reported to be negative. He is considered for a blood transfusion. Indices Mr Porters Results Normal Range

Haemoglobin MCV MCHC White Cell Count Platelets

75 g/L 65.3 fL 317 g/L 4.7 x 109/L 426 x 109/L

130 180 g/L 80 100 fL 300 350 g/L 4.0 11.0 x 109/L 150 400 x 109/L

19. Which of the following disorders may manifest as hypochromic microcytic anaemia? 1 A) Haemolytic anaemia 2 B) Thalassaemia trait 3 C) Liver disease 4 D) Acute blood loss Answer B 20. Which one of the following series of results would be consistent with iron deficiency? 1 A) Increased iron saturation, elevated serum ferritin, and normal serum transferrin 2 B) Normal serum ferritin, reduced serum iron, and reduced total iron binding capacity 3 C) Reduced serum ferritin, reduced iron saturation, and increased total iron binding capacity 4 D) Reduced serum transferrin and reduced serum transferrin receptor Answer C Explanation:A-False: This pattern suggests haemochromatosis. B-False: This pattern suggests anaemia of chronic disease.C-True: This combination is typical of iron deficiency. D-False: Serum transferrin and transferrin receptor levels are typically elevated in iron deficiency. 21. Which of the following is correct about iron? 1 A) Iron is more readily absorbed in the ferric (Fe3+) form 2 B) Iron absorption is enhanced in the presence of ascorbate 3 C) Transferrin is the main reservoir of iron in the liver 4 D) Ferritin represents the major circulating form of iron Answer B Explanation: The ferrous form of iron is more readily absorbed and iron is stored as ferritin, not transferrin. Transferrin is the major circulating iron binding protein . 22. The transfer of oxygen from haemoglobin to the tissues is: 1 A) Decreased by 2,3-diphosphoglycerate (2,3-DPG) 2 B) Increased at low pH 3 C) Not affected by the storage of red cells at 4oC 4 D) Enhanced by fetal haemoglobin Answer B Explanation: 2,3-DPG lowers the affinity of haemoglobin for oxygen, thereby facilitating oxygen delivery to the tissues. Acidosis (lower pH) lowers the affinity of haemoglobin for oxygen, resulting in a shift to the right of the haemoglobin oxygen dissociation curve. The affinity for oxygen is greater in foetal than in adult haemoglobin. PBL Reference: 4.01, Lecture 1: Role of haemoglobin in oxygen delivery to tissues 23. Which one of the following is the most likely cause of anaemia in Mr Porter? 1 A) Dietary iron deficiency 2 B) Malabsorption 3 C) Diverticulitis 4 D) Gastrointestinal malignancy Answer D 24. Which of the following red cell concentrate transfusions would be incompatible and cause a serious haemolytic transfusion reaction? 1 A) Donor Group O RhD Negative to Patient Group A RhD Positive 2 B) Donor Group A RhD Positive to Patient Group A RhD Negative 3 C) Donor Group AB RhD Positive to Patient Group B RhD Positive 4 D) Donor Group O RhD Positive to Patient Group AB RhD Positive

Most examined material in SBAs

4.01Lec 3 Introduction to anaemia 4.01 Lec 4 Iron deficiency 4.04 LT1 Microcytosis 4.01 LT3 Consequences of deficiency 4.05 LT6 Iron metabolism, 4.05 LT7 Tests of iron status in anaemia

Answer C