CLASSIFICATION OF

ANEMIA

Dairion Gatot, Azmi Sariedj Kar

Divisi Hematologi-Onkologi Medik

Departemen Ilmu Penyakit Dalam FK-USU/
RS H.Adam Malik, Medan 2007.

HP: 08126030962
Erythrocyte diseases
ANAEMIA :
Is defined as a condition in which the
haemoglobin concentration is below reference
range for the age, sex, method & altitude
Deficient in O2 carrying capacity hypoxia
CUT OFF POINT ANAEMIA IN INDONESIA
Pre school age 11 g/dL
School age 12 g/dL
Pregnant women 11 g/dL
3 month post partum 12 g/dL
Female 12 g/dL
Male 13 g/dL
CLASSIFICATION OF ANAEMIA
Morphologic classification :
1. Macrocytic anaemia
2. Microcytic hypochromic anaemia
3. Normocytic anaemia.
Morphologic classification :

1. Macrocytic anaemia
-Defisiensi Megaloblastic
-Defisiensi Asam Folat
-Probable Haemolytic anemia
-Posible liver disease
Morphologic classification :

2 Microcytic hypochromic anaemia

- Iron defisiensi anemia
- Thalasemia/Hemoglobonopathies
- Sideroblastic anemia
Morphologic classification :
3. Normocytic anemia
-Blood loss
-Autoimmune haemolytic anemia
- Other haemolytic anemia
(Parasites, Hypersplenism, Microangiopathic, haemolysis
Hereditary spherocytosis, Paroxysmal noctural haemoglobinuria,
Enzyme deficiencies, Drug or toxin, Haemoglobinopathies

-Other
(Renal disease, infection,malnutrition, aplastic anemia, radiation)

-Myelophthisic (tumor, myelofibrosis, infection, leukemia)

 CLASSIFICATION OF ANAEMIA

Etiologic classification :
1. Blood loss
1.1. Acute
1.2. Chronic
2. Impairment of RBC formation
2.1. Insufficient erythropoiesis (nutritional)
2.2. Ineffective erythropoiesis
3. Decreased RBC life span (haemolytic anaemia)
3.1. Congenital defect : membrane, enzyme Hb defect
3.2. Acquired defect : malaria, some drugs,
infectious, immunologic.
DIAGNOSIS OF ANAEMIA

Basic steps are :

1. Evaluation of clinical information from a
review of the history & physical examination
2. Evaluation of the basic blood examination &
specialized laboratory examination
3. When necessary, bone marrow examination
History

Poorly nourished patient on insufficient diets

Jaundice : haemolytic anaemia, malaria
Ingestion of certain drugs, chemicals exposure
Preexisting of renal diseases
Bleeding : gynaecologic, GI iron deficiency anaemia
Ethnic, geographical consideration, genetic back
grounds
Diet
Infectious disease problems.
Physical examination

Pallor, bruising , shock

Organomegaly : spleen, liver, lymph nodes
Jaundice
Leg ulcer in HbS anaemia / thalassaemia
Neurological abnormalities : vit B12 deficiency
Koilonychia, angular cheilosis
Angular cheilosis Koilonychia

Leg ulcer (HbSS)

Laboratory studies

Hb level, leukocyte, platelet, reticulocytes count, PCV,

ESR
Red cells indices (MCV, MCH, MCHC)
Examination of peripheral blood film
BM examination
Special tests : Ham & Sugar water tests, G-6PD tests
SI / TIBC, ferritin
 DIAGNOSIS OF MACROCYTIC ANAEMIA
LABORATORY TEST
INTERPRETATION

Peripheral smear Macrocytic anaemia

Bone marrow Megaloblastic No megaloblastic

examination changes changes

Reticulocyte Low High Low

count

Therapeutic Responds Responds to Probable Possible liver

response to vit B12 folic acid haemolytic disease
anaemia (evaluate liver
(continue function tests)
Diagnosis Vit B12 Folic acid workup)
deficiency deficiency
(determine
if dietary or
abnormal
absorption
Macrocytic Microcytic hypochromic

Normocytic normochromic
Hypersegmentation Macro ovalocyte with cabot
ring inclusion
 DIAGNOSIS OF HYPOCHROMIC MICROCYTIC
ANAEMIA
LABORATORY TEST INTERPRETATION
Peripheral Hypochromic & microcytic
smear anaemia

Iron Absent Increased

(Bone marrow)

Ringed sideroblasts

Haemoglobin Normal Abnormal Normal

electrophoresis

Iron Thalassaemia Sideroblastic

Diagnosis deficiency haemoglobino anaemia
anaemia -pathies
SI/TIBC, PERRITIN
Causes of microcytic hypochromic anaemia
DIAGNOSIS
1. BLOOD FILM
RBC Deficiency Fe Thalassaemia major

Microcytic : Hb < 10 g/dL Ht < 30% Markedly microcytic hypochronic

Hypochrom : Hb < 9 g/dL, Ht < 27%

Anisocytosis, poikilocytosis (pencil cells) Bizarre variation in size & shape

Target cells : + ++ 5-30%
NRBC : - ++
Polychromatophilia : - ++
WBC count normal increased
Platelet count normal increased/normal
Iron deficiency anaemia Target cells

b thalassaemia major b thalassaemia minor

2. BONE MARROW

Deficiency Fe Thalassaemia major Anaemia sideroblastic

Hypercellular Hypercellular Hypercellular
No iron stores Iron stores increased Iron stores increased
Ring sideroblasts +
3. IRON
Deficiency Fe Thalassaemia major Anaemisideroblastic
SI
TIBC N N
TS
Ferritin
Iron values in the development of iron deficiency anaemia

13-16
1316
12-14
13-16
 DIAGNOSIS OF NORMOCYTIC ANAEMIA
LABORATORY TEST INTERPRETATION
PERIPHERAL SMEAR NORMOCYTIC ANAEMIA

RETICULOCYTE COUNT INCREASED REDUCED

BLOOD IN STOOL OR
OTHER SOURCE OF POSITIVE NEGATIVE
BLEEDING IDENTIFIED

ANTIHUMAN GLOBULIN POSITIVE NEGATIVE NEGATIVE

(COOMBSTEST)

BONE MARROW AND HYPERCELLULAR HYPERCELLULAR DECREASED REPLACEMENT OF

BONE MARROW BIOPSY ERYTHROID ERYTHROID CELLULARITY NORMAL MARROW
HYPERPLASIA HYPERPLASIA ELEMENTS

DIAGNOSIS BLOOD AUTO IMMUNO OTHER HAEMOLYTIC OTHER MYELOPHTHISIC

LOSS HAEMOLYTIC ANAEMIAS Renal disease Tumor
ANAEMIA ANAEMIA
Parasites Infection Myelofibrosis
Erythroblastosis
Hypersplenism Malnutrition Infection
foetalis
Microangiopathic Aplastic Leukaemia
Transfusion
haemolysis anaemia
reaction
Hereditary Radiation
Collagen
spherocytosis
vascular
Paroxysmal noctural
disease
haemoglobinuria
Enzyme deficiencies
Drug or toxin
Haemoglobinopathies
NORMOCYTIC NORMOCHROMIC ANAEMIA & RETICULOCYTOSIS

1. Acute blood loss

Bleeding

Phase I Post hemorrhagic anaemia Thrombocytopenia

(normocytic anaemia)
(day 1-3)
Hypovolumic stage
Plasma volume Thrombocytosis
RBC mass Leukocytosis
Neutrophilia
Haemodilution
after 24 hour

Erythropoiesis
activity

BM hiperplasia
Phase II
(day 3-5) Reticulocytosis
Regeneration stage polychromatophilia RBC
macrocytosis
2. Haemolytic anaemia

Rate of RBC destruction

RBC production

Reticulocyte counts
Reticulocytosis in haemolytic
anaemia
 DIAGNOSIS OF MACROCYTIC ANAEMIA
LABORATORY TEST
INTERPRETATION

Peripheral smear Macrocytic anaemia

Bone marrow Megaloblastic No megaloblastic

examination changes changes

Reticulocyte Low High Low

count

Therapeutic Responds Responds to Probable Possible liver

response to vit B12 folic acid haemolytic disease
anaemia (evaluate liver
(continue function tests)
Diagnosis Vit B12 Folic acid workup)
deficiency deficiency
(determine
if dietary or
abnormal
absorption
Causes of megaloblastic anaemia
1. Folic acid deficiency
a. Inadequate diet
b. Alcoholism
c. Steatorrhea or sprue
d. Other causes of malabsorption, including partial
gastrectomy
e. Pregnancy and lactation
f. Leukaemia, myelofibrosis, and chronic
haemolytic anaemia
2. Vitamin B12 deficiency
a. Pernicious anaemia
b. Gastrectomy
c. Sprue
d. Long-term dietary deficiency
e. Parasites (Diphyllobothrium latum)
Causes of megaloblastic anaemia

3. Drug induced megaloblastic anaemia

a. 6-mercaptopurine
b. 5-fluorouracil
c. Cytosine arabinoside
d. Vinca alkaloids
e. Diphenylhydantoin
f. Antifolate compounds
4. Congenital disorders (very rare)
a. Orotic acidure
b. Congenital dyserythropoietic anaemia
c. Juvenile pernicious anaemia
5. Leukaemia
6. Di Guglielmos syndrome
 DIAGNOSIS
1. BLOOD SMEAR
A. RBC : Megaloblastic Liver diseases Haemolytic
Great variation Less macrocytic Polychromatophilia
in size & shape uniform in size RBC
Howell Jolly & shape
bodies
Circulating
megaloblast cells

B. WBC
Hypersegmented
PMN ( 6 lobes)
or > 5% PMN
have 5 lobes

C. Platelet
Thrombocytopenia
Normal erythropoiesis in the bone marrow
Megaloblastic changes in the BM
2. BONE MARROW
Hypercelluler
Increased in erythroid elements & accumulation
of prorubricyte (megaloblastic cells)
Giant & abnormality shape of metamyelocytes
FOLIC ACID AND VIT. B12

Source of vitamin B12

Synthesized by bacteria form large bowel
Liver & kidney
Dairy products, fish, shellfish

Source of folic acid

Green vegetables liver, yeast
Destroyed by prolonged boiling & acid pH
 Deficiency Folic acid Serum
vit. B12
Serum RBC
Folic acid N

Vit B12 N/

Folic acid & B12

4. THERAPEUTIC TRIALS
Contraindications :
patients on critical ill
angina pectoris
congestive heart disease
thrombocytopenia with bleeding
THERAPEUTIC TRIALS
Usual diet

0,2 mg folic acid

oral
1 week
reticulocyte response

+ -
+ 1-2 mg vit B12
reticulocyte response