Anemia

Where is bone marrow found in infants

ALL BONES

Is the bone marrow 4% of our body weight.

yes

what is Meshwork of Stromal Cells Comprised of

Reticulum that extends
into the marrow cords
– Fat

Histiocytes
– Endothelial cells

What is the functions of bone marrow

Supplies mature cells for circulation in steady state or
for increased demand

Where can you aspirate bone marrow on an adult

posterior superior iliac
crest

Where can you aspirate bone marrow on a child

top of tibia below
the knee

What is the M:E ratio

The number of myeloid (granulocytic) cells
divided by the number of erythroid cells = M:E
ratio

What is the normal M:E ratio

3:1

What is the M:E ratio for Erythroid Hypoplasia

> 5:1

What is the M:E ratio for Myeloid Hypoplasia

<3:1

What is the M:E ratio for Erythroid Hyperplasia

1:1

What is the M:E ratio for Myeloid Hyperplasia

>5:1

What are some symptoms of anemia

Tachycardia (heart arrhythmia)
• Shortness of breath
• Headaches
• Pallor
• Fatigue

What is the Reference Range for HGB in women

12-16 g/dL

What is the math formula for MCV

HCT x 10

RBC

What is the math formula for MCH

hgb X10

RBC

What diseases affect the blood production of bone marrow

Anemia
Polycythemia

Leukopenia or unexplained leukocytosis

Immature or abnormal cells in peripheral

Thrombocytopenia or thrombocytosis

Cancer
• Hodgkin’s lymphoma

TB
• Fungal infections

Granulomas

Gauchers

What would the CBC results look like for a patient with anemia

Decrease RBC

Decrease HGB

Decrease HCT

• MCH may be low, normal, or high
• MCV may be low, normal, or high
• M:E ratio in most anemia is 1:1 (Normal is 3:1)

Which conditions are related to Macrocytic

Megaloblastic (B12 and folate)
– Liver disease
– Myelodysplastic disorders (rare)
– Reticulocytosis

Which conditions are related to Microcytic, hypochromic

Iron deficiency – iron deficient
– Thalassemia – globin abnormality
– Lead poisoning – heme synthesis
– Chronic disease – cells are slightly small
– Sideroblastic anemia – cells are slightly small

Which conditions are related to Normocytic, normochromic

Hemolytic
– Aplastic
– Most hemoglobinopathies
• Not thalassemia
– All others
• Leukemia, kidney disease, heart disease, etc.

What are some Physiologic Causes of Anemia

Decrease iron deficiency

decrease megaloblastic

decrease aplatic

Increased destruction or loss
– Hemolytic conditions
• Intrinsic
• Extrinsic
– Acute blood loss

What does Thymidine Triphosphate Deficiency cause

Causes retarded nuclear maturation and
mitosis

Where can a patient get there B12 or cyanocobalamin from?

Meat, eggs, dairy products and liver

How is B12 metabolism in our body?

1. 1 eat Meat, eggs, dairy products and liver

2. 2 Intestinal absorptions by glycoprotein called
   Intrinsic Factor (IF)

3. 3 F-B12 complex attaches to receptors on ileac
   mucosal cells for absorption

4. 4 After absorption vitamin is released and
   attaches to transcobalamin II, then go to the bone marrow and liver.

5. 
   

How is folate metabolism in our body?

1 eat green leafs, meat and
some fruits

2 After folate is absorbed it is carried by
albumin to the bone marrow and liver

What can cause Vitamin B12 Deficiency

absorption problem

Lack of intrinsic factor – Pernicious Anemia
– Inflammation or surgery involving stomach or small
intestine
• Chronic gastritis, sprue, bowel resection
– Diphyllobothium latum – fish tapeworm
– Strict veganism
• Diagnose with vitamin assay

What can cause Pernicious Anemia

Caused by autoimmune disorder with
autoantibodies produced by parietal cells

How can a Doctor diagnoses Pernicious Anemia

anti-parietal cells assay

What treatment is use for Pernicious Anemia

injections of vitamin B12

What can cause Folate Deficiency

Dietary– usually due to inadequate intake (more
common problem)
• Alcoholism, poverty, overcooking of vegetables
– ETOH has an antagonistic affect on folate absorption
– Increased need during pregnancy
– Increased cell turnover in hemolytic anemia and
leukemia

How can a doctor treat Folate Deficiency

oral folic acid

How much iron is needed for each mL of RBC

1mg

What can cause an Iron deficiency

Inadequate intake

Impaired absorption

Increased loss

What is the value for serum iron

50-160 μg/dL

What is the value for TIBC-Total Iron Binding Capacity

250-400 μg/dL

What is the value for % Transferrin Saturation

20-55%

What is the value for Ferritin in males

40-400 ng/mL

What is the value for Ferritin in Females

12-160 ng/mL

What can cause Thalassemia

Globin chain is not produced in adequate amounts

What RBC is most abundant in Thalassemia

Target cells

What are the characteristic of Lactoferrin

Iron binding protein located in granules of neutrophils
• Involved in preventing phagocytized bacteria from using intracellular
iron from their own metabolic processes
• Released into plasma during infection/inflammation and scavenges
excess iron
• RBCs are deprived of this source of plasma iron because they do
not contain lactoferrin receptors

What are the characteristic of Ferritin

Acute phase reactant
• Iron-apoferritin complex
• Increased levels will bind some iron
• Not available to RBCs

What are the lab results for Anemia of Chronic Inflammation

↓ Serum Iron
• ↓ TIBC
• Serum Ferritin ↑
• Soluble transferrin receptors (sTfRs): Normal
• Sloughed from cells in the plasma

What are the 3 CATEGORIES OF NORMOCYTIC,
NORMOCHROMIC ANEMIA

Hemolytic

Aplastic Anemia

Acute Blood loss

What is Fanconi Anemia

Autosomal Recessive Chromosomal instability disorder
• Skin pigmentation, short stature, hypogonadism
• Pancytopenia, ↓ reticulocytes, hypocellulular BM

What is Dyskeratosis Congenita-Bone marrow failure disease

Abnormal skin pigmentation, dystrophic nails, oral leukoplakia
• Bone marrow failure

What is Shwachman-Bodian-Diamond Syndrome

Pancreatic insufficiency, cytopenia, skeletal abnormalities,
predisposition for hematologic malignancies
• Neutropenia and immune dysfunction
• Normal sweat chloride test

What RBC do a tech see in Megaloblastic anemia

Large, oval red cell

What RBC do a tech see in Iron deficiency anemia

Size is 5 microns with decreased hemoglobin content

What RBC do a tech see in Multiple myeloma

Stacks of coins

What description are given to Sickle cell

Elongated with pointed ends

What description are given to Echinocyte

Evenly spaced projections

What description are given to Schistocyte

Fragmented

What description are given to Stomatocyte

Rectangular central pallor

What description are given to Spherocyte

Small round, no central pallor

What description are given to Polychromasia

Size is 8 microns and is pale blue

What description are given to Codocyte

Resembles target

What description are given to Dacrocyte

Single pointed extension resembling a pear

What description are given to Acanthocyte

Irregular spaced projections of varying length

What description are given to Howell-Jolly body

One dense, round granule

What description are given to Basophilic stippling

Blue-purple granules scattered throughout

What description are given to Pappenheimer bodies

Doublet or triplet clusters of granules

What description are given to Cabot rings

Figure-eights

What description are given to Heinz bodies

Not visible on Wright stain

What description are given to Hb C crystals

Hexagonal crystal

What description are given to Malaria

Ring forms or trophozoites

What description are given to Nucleated RBC

Round, dense blue-purple body about to be extruded

Howell Jolly Body

DNA; seen in post-splenectomy, megaloblastic anemias, some hemolytic
anemias

Reticulocyte:

RNA; associated with decreased RBC survival/hemorrhage, erythroid hyperplastic
marrow

Pappenheimer body

Iron; seen in sideroblastic anemia, thalassemia

Heinz Body

Precipitated Hemoglobin; seen in G6PD deficiency
• Can only be seen with supravital stain

C Crystal

Crystalized hemoglobin C

Ringed Sideroblast

Iron

Basophilic stippling:

RNA aggregates; seen in thalassemia and lead poisoning

What is the characteristic for Hereditary Spherocytosis

Inherited defect in spectrin
• Decreased cell surface
• Peripheral smear:
• Spherocytes (MCHC >36%)
• Polychromasia
• ↑ Osmotic fragility with hemolysis beginning at a NaCl
concentration > 0.5%

What is the characteristic for Paroxysmal Nocturnal Hemoglobinuria

Clonal stem cell disorder with cells sensitive to complement lysis
• Red urine
• Urine hemosiderin +
• Sucrose +
• Ham’s test +

What is the characteristic for Auto Immune Hemolytic Anemia (warm)

Secondary to autoimmune disease
• Idiopathic
• Peripheral Smear:
• Spherocytes
• Polychromasia
• +DAT

What is the characteristic for Auto Immune Hemolytic Anemia (cold)

Occurs after infection with Infectious Mononucleosis or
Mycoplasma
• Patient will build antibody to I or i
• Peripheral Smear:
• Agglutination
• Interferes with electronic counters

What is the characteristic for Sickle Cell

Beta Chain substitution (β6Glu→Val)
• Cells form rods at low O2
• Sickle Solubility +
• Confirm with Hb electrophoresis
• Peripheral Smear:
• Sickle Cells
• Target Cells

What is the characteristic for Hgb C

Beta Chain substitute
• Milder than Hgb S
• Peripheral Smear:
• C crystals
• Target cells

What is the characteristic for Hgb E

Beta Chain substitute
• Mild Hemolytic Anemia
• Peripheral Smear:
• Target Cells
• Differentiate from C on
cellulose and A on citrate

What is the common cause of Folate deficiency?

• Diet

What is increased in hemochromatosis?

Iron

What anemia is found in mononucleosis?

Cold agglutinin

What percent of transferrin is bound to iron?

30%

How is intravascular distinguished from extravascular hemolysis?

Urine Hemosiderin

What other tests are utilized in the detection of hemolytic anemia?

Bilirubin, haptiglobin, urine hemosiderin

What is the reticulocyte value for anemia?

Hemolytic anemias ↑
• Nutritional deficiency ↓ until nutritional need is met

Which of the anemias are life threatening?

Alpha Thalassemia major
• Microangiopathic Anemia (DIC, HUS, TTP)

How can IDA and Thalassemia be differentiated?

Hemoglobin electrophoresis

How can HGB A with Hgb S be confirmed?

Hemoglobin Electrophoresis using citrate agar

How can IDA and anemia of chronic disease be differentiated?

Ferritin and TIBC

What will the bone marrow of anemia indicate?

Erythroid hyperplasia (M:E ratio of 1:1)

What is the purpose of the Schilling test?

Detects malabsorption of B12 found in Pernicious Anemia

What is the breakdown product of hemoglobin?

Urobilinogen

What is a product of heme synthesis?

One of the porphyrins- protoporphyrin, uroporphyrin, coproporphyrin

Which thalassemia is more serious?

Alpha Thalassemia major

What microscopic power is used to see BM megakaryocytes

Low power, 10X

What do karryohexis and asynchrony indicate?

Defective DNA synthesis