OS 216: Hematology: Topic Conference 1: Anemias
OS 216: Hematology: Topic Conference 1: Anemias
OS 216: Hematology: Topic Conference 1: Anemias
Edwin Trinidad
Topic Conference 1: Anemias Exam 1
mortality and morbidity associated with IDA. It is common reticuloendothelial system) and the body recycles the
in toddlers, adolescent girls and women of childbearing released iron.
age.
The National Nutrition Survey (1998) conducted There is no excretory pathway for iron. The only
by the Food and Nutrition Research Institute, Department mechanisms by which iron is lost from the body are blood
of Science and Technology revealed that the following
loss and the turnover of epidermal cells from the skin and
groups were anemic or suffering from IDA:
gut. The amount of dietary iron required to replace
5-6 out of 10 infants aged 6 months to less ongoing losses averages about 1.0 mg among men and
than 1 year 1.4 mg among women of childbearing age, equivalent to
3 out of 10 children aged 1 to 5 years the amount absorbed in the diet. The following figure
3 out of 10 young children aged 6 to 12 summarizes the process or iron absorption, usage, and
years
storage.
3 out of 10 teenagers aged 13 to 19 years
2-3 out of 10 adults aged 20 to 59
3-4 out of 10 older persons aged 60 years Figure 1.
and over
5 out of 10 pregnant women
4-5 out of 10 lactating women
stores are absent and serum ferritin levels are below 15 Anemia develops slowly after the normal stores
μg/L. Hemoglobin synthesis is impaired when transferrin of iron have been depleted in the body and in the bone
saturation drops to 15-20%. marrow. Women of child-bearing age, in general, have
smaller stores of iron than men and have increased loss
In iron-deficiency anemia, iron stores are through menstruation, placing them at higher risk for
already inadequate to maintain hemoglobin production. anemia than men. Other high-risk groups include pregnant
This stage is reflected by low hemoglobin and hematocrit or lactating women who have an increased requirement
levels. Microcytic red cells and hypochromic reticulocytes for iron, infants, children, and adolescents in rapid growth
begin to appear. Transferrin saturation is now at 10-15%. phases and those with a poor dietary intake of iron.
When there is moderate anemia (hemoglobin of 10-13
g/dL), the bone marrow remains hypoproliferative. With IDA during infancy
severe anemia (hemoglobin of 7-8 g/dL), there is
prominent hypochromia and microcytosis. Target cells
Iron deficiency anemia is a common nutritional
and poikilocytes also appear on the blood smear. The
deficiency that affects children, especially during the
erythroid marrow also becomes more inefficient. Erythroid
first two years of life (around 6-20 months). There are
hyperplasia of the marrow, instead of hypoproliferation,
several factors affecting the development of IDA in
occurs with prolonged IDA.
infants, such as sex (more common in males), rate of
Figure 2. Comparison the 3 stages of iron deficiency weight gain (faster gain associated with IDA), term,
iron stores of the mother, and episodes of intra-
and/or extrauterine bleeding.
adequate intake of iron in their diet. Iron is necessary the signs and symptoms of iron-deficiency anemia are true
for the formation of maternal and fetal hemoglobin, for all kinds of anemia.
the oxygen-carrying component of blood. Normally
during pregnancy, erythroid hyperplasia of the marrow The main manifestations in EM’s case were the
occurs, and RBC mass increases. However, a following: fainting, dizziness, exertional dyspnea, pale
disproportionate increase in plasma volume results in
conjunctiva, pale nail beds and a soft systolic murmur.
hemodilution (hydremia of pregnancy). Since a
woman's blood volume increases by 25 to 50 percent
during pregnancy, and the baby is manufacturing The major symptom of all types of anemia,
blood cells too, more iron is needed to make more including iron-deficiency anemia, is fatigue (feeling tired).
hemoglobin for all that additional blood. The Fatigue is caused by having too few red blood cells to
increased need for iron puts the mother at risk for carry oxygen to the body. This lack of oxygen in the body
anemia. Furthermore, during the last trimester, the can cause people to feel weak or dizzy, have a headache,
baby draws from the mother some of the iron or even pass out when changing position (for example,
reserves that it will need during the first four to six
months of life. Thus, it is really essential that the standing up).
mother has sufficient iron stores all throughout the
pregnancy. The increased blood volume and iron Since the heart must work harder to move the
stores will also help the mother’s body adjust, to some reduced amount of oxygen, signs and symptoms may
degree, to the blood loss that occurs during childbirth. include shortness of breath and chest pain. This can lead
to a fast or irregular heartbeat or a heart murmur.
The causes of IDA during pregnancy may be
poor intake of iron, loss of blood from bleeding In anemia, the red blood cells don't have enough
hemorrhoids or gastrointestinal bleeding. Maternal hemoglobin. Common signs of lack of hemoglobin include
iron deficiency anemia is associated with an pale skin, tongue, gums, and nail beds. Pallor of the skin
increased incidence of anemia in the baby during the may be difficult to appreciate in dark skinned individuals,
first year of life. Pregnant women with iron deficiency
therefore scleral or palmar pallor may be more reliable as
anemia, particularly in the first and second trimesters,
have an increased risk for premature delivery and for a finding.
delivering a low-birth weight infant.
Other Signs and Symptoms of Anemia
IDA during lactation
Other signs and symptoms of anemia can include:
Studies have shown that anemia is common Cold hands and feet as well as brittle nails
among lactating women. Ensuring adequate intake of Swelling or soreness of the tongue and cracks in the sides
all hemopoietic nutrients during lactation is also of the mouth
critical. The benefits of iron supplementation during An enlarged spleen
Frequent infections
pregnancy to reduce the risk of anemia during
Additional findings include blue sclera, koilonychias,
pregnancy and improve iron stores beyond 6 months
angular stomatitis, and functional gastrointestinal tract
postpartum are well established. Although providing
abnormalities.
supplements during lactation is not contraindicated,
the efficiency of absorption is much higher during
pregnancy. In contrast to iron, the requirements for Signs and Symptoms of Iron-Deficiency Anemia
folate and vitamin B12 are increased during lactation.
Symptoms of iron-deficiency anemia include
The iron content of breastmilk is relatively unusual cravings for nonfood items such as ice, dirt, paint,
protected and not influenced by maternal nutritional or starch. This craving for nonfood items is called pica.
status, but depletion of maternal stores can result
among poorly nourished women who are already Another symptom of iron-deficiency anemia is
anemic prior to lactation. A randomized clinical trial of developing restless legs syndrome (RLS). RLS is a
pregnant women showed that iron supplementation disorder that causes an uncomfortable feeling in the legs
during the last trimester of pregnancy did not alter the that can only be relieved by movement. Sleep is difficult
concentrations of iron, copper, selenium and zinc in for people with RLS.
breast milk. In contrast, there is evidence that the
Age of onset of anemia is an important clue, as
breast milk level of other hemopoietic nutrients such
iron deficiency is uncommon before 4 to 6 months of age
as folic acid, vitamin A and vitamin B12 are affected
in the absence of prematurity. In infants and young
by maternal status.
children, signs and symptoms include a poor appetite,
being irritable, and a slower rate of growth and
* See Appendix 2 for Pathologic Correlation for EM’s development.
Case
Some of the signs and symptoms of iron-
V. Clinical Manifestations
deficiency anemia are related to its causes, such as blood
Signs and symptoms of anemia depend on the loss. Blood loss is most often seen with very heavy or long
severity of the condition. People with mild anemia or lasting menstrual bleeding or vaginal bleeding in women
anemia that has come on very slowly may have no after menopause. Other signs of internal bleeding are
symptoms at all. However, if the anemia is severe, the bright red blood in the stool or black, tarry-looking stools.
symptoms increase and become more serious. Many of
Diagnostic Work-Up
I. CBC count
o May also indicate severity of anemia Usually, Low serum ferritin iron deficiency
In chronic iron deficiency anemia, the cellular
indices show a microcytic and hypochromic However, normal serum ferritin can be seen in patients
erythropoiesis
who are deficient in iron and have coexistent diseases
both the mean corpuscular volume
(MCV) and mean corpuscular (hepatitis, anemia of chronic disorders)
hemoglobin concentration (MCHC)
have values below the normal range May be used in distinguishing iron deficiency anemia from
(Normal ranges: MCV=83-97 fL; other microcytic anemias.
MCHC=32-36 g/dL
Platelet count is usually elevated
(>450,000/µL) while WBC count is
within normal ranges (4500-11,000/µL). IV. Bone Marrow Aspirate/Biopsy
Note: If the CBC count is obtained
succeeding blood loss, values reach o Can be used to diagnose iron deficiency through the
abnormal levels only after most of the absence of stainable iron in a bone marrow aspirate
RBCs produced before bleeding are that contains spicules and a simultaneous control
destroyed at the end of their lifespan specimen containing stainable iron (no lab tests)
(120 days). o Largely replaced by the diagnosis of iron deficiency
anemia through the measurement of serum Fe, TIBC
and serum ferritin.
II. Peripheral Blood Smear o Diagnostic in identifying/ruling out the sideroblastic
anemias (with ringed sideroblasts in the aspirate
o The presence of microcytic and hypochromic stained with Perls stain)
erythrocytes in the examination of a peripheral smear
is indicative of chronic iron deficiency anemia.
Microcytosis is apparent way before MCV values V. Serum Levels of Transferrin Receptor Protein
decrease after an event causing iron deficiency.
Platelet count is often elevated. o Transferrin receptor protein (TRP or TfR)
o No target cells (rules out thalassemia), anisocytosis
Found most abundantly on the surface of
and poikilocytosis not marked erythroid cells than on any cell in the body and
o No intraerythrocytic crystals (rules out Hb C disorders) released into circulation
Serum levels reflect total erythroid mass
Normal values: 4-9 g/L
III. Serum iron, total iron-binding capacity (TIBC), and Distinguish between iron-deficiency anemia
serum ferritin (elevated TRP) and anemia of chronic disease
(normal TRP)
o Serum iron
Reflects the amount of circulating iron bound to
transferring VI. Other tests
Normal range: 50–150 mcg/dL
Clinician must be aware of the diurnal variation o Test for fecal occult blood
To rule out the possibility of a GI source of
bleeding (most common cause of iron-
o Total Iron Binding Capacity (TIBC) deficiency anemia in adult men and post-
An indirect measure of the circulating menopausal women)
transferrin. o Endoscopy
Normal range: 300–360 mcg/dL To rule out GI malignancy
o Tissue lead concentrations
Chronic lead poisoning may cause mild
o Transferrin saturation microcytosis. Patients with iron deficiency are
serum iron x 100 ÷ TIBC at higher risk for lead poisoning due to
Normal range: 25–50%, Iron-deficiency state: increased absorption of lead in this condition.
<18%
For EM’s case, the main cause of IDA is blood loss due to prolonged menstruation, a result of irritation to the
intrauterine lining from the inserted IUD. The following figure summarizes the pathogenesis of EM’s condition.
Menorrhagia
Menses prolonged for 7 days;
(6 napkins/day) fully soaked decreased hematocrit; increased turbulence
w/ blood for first 4 days decreased blood viscosity
Fainting
Appendix 3.