Anaemia - Evaluation

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Slide 1:

In the name of God, Most Gracious, Most Merciful

Evaluation of a case of anaemia:

Dr. Mohammed Sadiq Azam PG M:1 (Dr. Siraj’s Unit) DCMS @ PEH Evaluation of a case of anaemia

Case HisTories::

Case HisTories : 22/F presented with complaints of shortness of breath (NYHA GR IV), orthopnoea +, chest discomfort and palpitations on exertion which gradually increased over the last 6 months to attain present severity. H/s/o Pica+, H/o passing worms in stools+. No h/o rash, photosensitivity or seizures. O/E: Pallor+ , BPPE+, JVP , s3 gallop+, b/l basal creps (fine)+, no organomegaly , no FF. 45/F presented with c/o shortness of breath (NYHA GR II-III), no orthopnoea , no PND. Past h/o jaundice+. H/o blood transfusion in past +. O/E: Pallor++ , Icterus+++, Hepatomegaly~2 cm below C/m, Splenomegaly~15cm, no FF. 75/F presented with c/o fatigability and lethargy over last 8 month, initially mild now increased in intensity. H/o sob on exertion (NYHA GR I-II). No H/o orthopnoea /PND. No H/o chest discomfort. Not a known diabetic. H/s/o malena +. H/o loss of appetitie , loss of weight+ over last 5 months. O/E: Pallor++ , anicteric no PE, CVS/RS – NAD, P/A- NAD.

Evaluation – history::

Evaluation – history: Age/Sex Rate of onset – Rapid/Slow Blood loss – Haematemesis / malena / bleeding piles / menorrhagia / metorrhagia / epistaxis / hematuria / haemoptysis Abdomen – Appetitie / weight loss / dysphagia / regurgitation / dyspepsia / abd pain / diarrhoea / constipation / jaundice / soreness of tongue / previous abd surgeries Reproductive – Menstrual history in detail / number & interval between pregnancies / miscarriages Urinary system – Nocturnal polyuria CNS – P arasthesiae / difficulty in walking

Evaluation – history::

Evaluation – history: Bleeding tendency – Easy bruising / prolonged bleeding after trivial injuries / bleeding from more than one site Skeletal system – Bone pain / Arthritis / Arthralgia Temperature – Fever / Night sweats Drug ingestion – Previuos / current Occupation – Metal dusts / solvent fumes / lead Diet Social history – Alcoholism Past H/o – Previous anaemia : diag & Rx, response to Rx Family H/o – Anaemia / recurrent jaundice / IUD & childhood deaths

Evaluation – EXAMINATION::

Evaluation – EXAMINATION: Skin – Colour , texture, petechiae , ecchymoses , scratch marks. Nails – Brittleness, longitudinal ridging, koilonychia Conjunctiva/Sclera – Pallor, icterus, haemorrhages Retina – Haemorrhages , s/o HTN/renal failure, other changes Mouth – Mucous membrane: Pallor, petechiae Gums: Bleeding, hypertrophy Tongue: Redness, atrophy of papillae Abdomen – HSM, either HM or SM, tenderness, mass, ascites CVS – BP, valvular , vascular prosthesis CNS – Peripheral neuritis, s/s/o SADSC

Evaluation – EXAMINATION::

Evaluation – EXAMINATION: Supf LN – Enlargement of cervical, axillary, inguinal, epitrochlear nodes Bones – Tenderness (esp. of sternum), tumour Legs – Ulcers / scars of healed ulcers P/R – Haemorrhoids / CA Rectum Pelvic – Menorrhagia, metorrhagia , uterus, cervix Torniquet test Urine – Protein, urobilinogen , BS/BP

The approach …:

The approach … Provisional Diagnosis: Anaemia for evaluation

Slide 9:

Is anemia associated with other haematological abnormalities? Yes No BM Examination Leukemias Aplastic anaemias MDS / MF Myelophthisis Megaloblastic anaemia Is there an appropriate reticulocyte response to anaemia? Yes No Evidence of haemolysis? Yes No Evaluate cause of haemolysis Evaluate: haemorrhagic causes RBC Indices MCV >100 MCV 80-100 MCV <80 Evaluate: Macrocytic anemia Evaluate: Normocytic anemia Evaluate: Microcytic anemia (Ref: Bertil Glader: Anaemia: General Considerations, Wintrobe’s Clinical Haematology 11/e, 2004: 951-978)

reticulocytosis: a word:

Retic count = % reticulocytes in RBC population Retic count corrected for anaemia = % retculocytes x pt Hb /15 or pt Hct /45 BUT, Retics released under intense EPO stimulation remain in circulation for approx 2x the usual 1 day survival of non stress retics , so: Corrected Retic index = Retic count corrected for anaemia x 0.5 < 2.5 = inadequate response – hypoprolifertive / maturation disorder (marrow prod impaired) ≥ 2.5 = adequate response – haemolytic / haemorrahgic Absolute retic count = % retics x RBC count/l 3 Low retic count + active marrow erythropoiesis = ineffective erythropoiesis IDA Sideroblastic anaemia Thalassemias (Also associated with  LDH) reticulocytosis : a word

Slide 11:

(Ref: Bertil Glader: Anaemia: General Considerations, Wintrobe’s Clinical Haematology 11/e, 2004: 951-978) Macrocytic anaemia Does the P/S reveal hypersegmented neutrophils / macroovalocytes? Yes No Megaloblastic anaemia – BM to confirm Test for B12/Folate levels B12 def No def Folate def Schilling’s test: Corrects with IF Yes No Pernicious anaemia: Gastric resection Ileal disease Previous ileal Sx Small bowel bac overgrowth Fish tapeworm Drug induced malabsorption Inherited disorders of DNA syn Drugs tht interfere with DNA syn Poor diet Drug induced malabs Jejuneal resection Tropical sprue Gluten sensitivity  Needs - Pregnancy - Chronic hemolysis Nonmegaloblastic anaemia Reticulocytosis  Haemolytic N /  Consider: - Alcohol - Hypothyroidism - Liver disease If NO: BM exam - MDS - Red cell aplasia - Acq siderobl anaemia - Herid dyserythropoietic anaemia (I& III)

Slide 12:

(Ref: Bertil Glader: Anaemia: General Considerations, Wintrobe’s Clinical Haematology 11/e, 2004: 951-978) Microcytic anaemia Appropriate age: Rule out malignancy Reticulocytes Low / N Increased P/S: Abnorm morphology Labs for  RBC destruc Hb studies Homozygous β thal Haemolytic elliptocyt Herid pyropoikilocytosis Iron Profile  Fe  TIBC  Ferritin  Fe N/  TIBC N/  Ferritin N. Fe N. TIBC N. Ferritin  Fe N. TIBC  Ferritin Iron deficiency  ESR, CRP+ or other studies s/o underlying Inflammatory disorder AOCD Hb electrophoresis α Thal trait β Thal trait Hb E syn Hb C disorder BM examination with Fe stains Sideroblastic anaemia

Slide 13:

(Ref: Bertil Glader: Anaemia: General Considerations, Wintrobe’s Clinical Haematology 11/e, 2004: 951-978) Normocytic anaemia Reticulocytes  RBC prod N./ RBC prod H/o jaundice, splenomegaly Presence of P/S abnormalities  Bilirubin / LDH Yes No Haemolysis Haemolytic anaemia S.Fe Low N. / High AOCD Early IDA - S. Chemistries to screen for renal, hepatic, endocrine disease - Consider EPO levels, thyroid studies Positive Negative Anaemia of renal disease Anaemia of liver disease Anaemia due to endocrine failure BM aspirate & Bx Infiltrative disorder ( Leuk , myeloma, MF, Mets) Red cell aplasia MDS Dyserythropoietic anaemia (Type II)

HAEMORRHAGIC ANAEMIA::

Retic index ≥ 2.5. Polychromatophilic macrocytes ++ in P/S Marrow examination is rarely required if retic index is increased appropriately. RBC indices are typically normocytic or slightly macrocytic (reflects  retics) HAEMORRHAGIC ANAEMIA: Blood loss Acute Subacute Chronic Missed No reticulocytosis Modest reticulocytosis Presents ///ar to IDA Observe for 2-3 weeks Signs of recovery - Hb  - Retic count 

HAEMORRHAGIC ANAEMIA::

HAEMORRHAGIC ANAEMIA: Volume of blood loss (ml) Blood volume (%) Symptoms 500-1000 10-20 Few if any symptoms 1000-1500 20-30 Asymptomatic while at rest in a recumbent position; light headedness and hypotension when upright; tachycardia 1500-2000 30-40 Symptoms present when recumbent; thirst, SOB, clouding or LOC; BP, CO, venous pressure decrease, pulse usually rapid; extremities become cold, clammy & pale 2000-2500 40-50 Lactic acidosis, shock; irreversible shock, death

Haemolytic anaemia::

Least common form of anaemia High retic count: Reflects the ability of the erythroid marrow to compensate for haemolysis, and, in the case of extravascular haemolysis, the efficient recycling of iron from the destroyed RBC to support RBC production. Intravascular haemolysis – PNH – loss of Fe – limits marrow response Hence, the level of marrow response depends on: The severity of anaemia The nature of the underlying disease process Hemoglobinopathies – mixed picture. (Retic count is  but  with respect to degree of marrow erythroid hyperplasia). Haemolytic anaemia :

Haemolytic anaemia::

Presentation varies: Acute self limiting illness (autoimmune/EM pathway/GR defects) Chronic process (Hb defects/ RBC defects) with a typical history HS: chronic course – present with complications such as bilirubin gallstones or splenomegaly and not anaemia per se. Chronic haemolysis also prone to aplastic anaemia if infections occur. Haemolytic anaemia :

HAEMOLYTIC ANAEMIA: INTRAVASCULAR LYSIS:

PNH Erythrocyte fragmentation disorders Transfusion reactions resulting from ABO incompatability Paroxysmal cold haemoglobinuria AIHA (occasionally) Infections: Blackwater fever in falciparum malaria Clostridial sps Chemical mediated: Arsine poisoning Snake & Spider venoms Acute drug reactions with G6PD def I.V. admin of distilled water Thermal injury HAEMOLYTIC ANAEMIA: INTRAVASCULAR LYSIS

HAEMOLYTIC ANAEMIA: LABS:

Morphological abnormalities: Spherocytes, Elliptocytes, Stomatocytes, Acanthocytes, Echinocytes, Sickle cells, Target cells, Schistocytes Direct Antiglobulin test (Coomb’s test): +ve in IHA (2-5% false neg) Osmotic fragility test : HS (Osmotic gradient ektacytometry is more sensitve & specific, but not widely available) Tests for Heinz bodies (supravital staining): G6PD def, unstable Hb disease, thalassemias, chemicals. (Not seen when spleen is intact) HAEMOLYTIC ANAEMIA: LABS

HAEMOLYTIC ANAEMIA: D/D:

Asso with anaemia & retculocytosis: Hemorrhage Recovery from iron, folate or vitamin B12 deficiency Recovery from marrow failure Asso with jaundice & anaemia: Ineffective erythropoiesis (intramedullary erythropoiesis) Bleeding into a body cavity or tissue Asso with jaundice without anaemia Defective bilirubin conjugation Crigler-Najjar syndrome Gilbert syndrome Marrow invasion Myoglobinuria HAEMOLYTIC ANAEMIA: D/D

conclusion::

Any case of anaemia requires a detailed work up starting with history. Stepwise approach is the golden rule. IDA in elderly – avoid being ‘Penny wise, Pound foolish’ In tropical countries, tropical malabsorption syndromes are more rampant than we realize – LOOK OUT, it may be missed unless you look for it. Better not to start any IFA or B12 supplements until we diagnose the cause of anaemia. Bone marrow is not the answer to every anaemia – AVOID indiscriminate use. No cost is greater than the patient’s life. Investigate what’s mandatory. Delayed diagnosis is better than a wrong diagnosis – DO NOT hurry to treat. conclusion:

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