1.05 Anemia

Manish KUMAR (s170203)
Module: Blood- Anaemia

Problem 1.05
What are the components of Blood?
Blood is composed of fluid and formed elements. The varied functions of the blood include transport, regulatory
and protective functions. As you familiarise with the various components of the blood, you should be able to
explain the role of the various components of the blood in carrying out these functions
BLOOD
▪ Blood is a connective tissue

▪ Composed of liquid extracellular matrix (blood plasma) + interstitial fluid (bathes surrounding cells)
▪ Blood is a specialized body fluid composed of multiple items which serve its various functions. Blood
constitutes of RBC, WBC, platelets and Plasma
Functions of Blood
1. Transportation
▪ Oxygen& Carbon Dioxide: Transports oxygen from lungs to cells of the body and carbon
dioxide from body cells to lungs for exhalation- haemoglobin
▪ Hormones: Transport of hormones is done by proteins such as albumin and globulin
▪ Nutrients
▪ Wastes
▪ Heat: Thermogenesis
2. Regulation
▪ Maintains homeostasis
▪ Regulates pH levels (Buffer Systems)- haemoglobin
▪ Helps adjust body temperature (heat absorbing +coolant properties of water in blood
plasma and also by variable rate of flow through the skin.
▪ Blood osmotic pressure influences the water content of cells mainly by interaction of
dissolved ions and proteins
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3. Protection
• Clotting (reduces excessive lost)/ Clotting of blood prevents excess blood loss from the
cardiovascular system after an injury
▪ WBC protect against disease (phagocytosis)
▪ Antibodies/ Interferon’s/Complement/ Also blood proteins e.g. antibodies and complement
protect against disease
Physical Characteristics of Blood
▪ Denser
▪ More viscous than water (Sticky)
▪ Temp=38°C
▪ pH=7.35-7.45
▪ 20% extracellular fluid
▪ 8% of total body weight
▪ Volume= 5-6 L (adult Male)
▪ Volume= 4-5 L (adult Female)
▪ Blood volume + osmotic pressure controlled by hormones (ANP, ADP, Aldosterone)
• Color is bright red in presence of O2 and dark red in lack of O2
Components of Blood
These functions are carried out by the different components of blood. Blood is made up of two parts; liquid plasma and a
cellular part. The cellular part is made up of red blood cells (erythrocytes), white blood cells (leukocytes) and platelets
(thrombocytes).
Blood
Blood Plasma Formed Elements

(Cell and cell fragments) (45%)
(Watery liquid extracellular
matrix that Contains → Red Blood Cells (99%)
dissolved substances) →White blood cells (less than 1%)
(55%) →Platelets
Components of Blood in a Normal Adult
NB: The centrifugation of blood has been with respect to the densities.
RBC accordingly, appears denser/ drowns than plasma which is only the fluid portion of the blood.
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Source: Book of Anatomy and Physiology; Tortora 14th Edition
Structure of Plasma
Plasma is the straw colored liquid portion of blood – a protein-salt solution in which red and white blood cells and
platelets are suspended. Plasma, which is 92 percent water, constitutes 55 percent of blood volume. Plasma
contains albumin (the chief protein constituent), fibrinogen (responsible, in part, for the clotting of blood) and
globulins (including antibodies).
• Plasma contains 6–8 percent proteins. One critical group is the coagulation proteins and their inhibitors,
synthesized primarily in the liver.
• When blood clotting is activated, fibrinogen circulating in the blood is converted to fibrin, which in turn helps
to form a stable blood clot at the site of vascular disruption.
• Coagulation inhibitor proteins help to prevent abnormal coagulation (hypercoagulability) and to resolve clots
after they are formed. When plasma is allowed to clot, fibrinogen converts to fibrin, trapping the cellular
elements of blood. The resulting liquid, devoid of cells and fibrinogen, is called serum.
• Plasma serves a variety of functions, from maintaining a satisfactory blood pressure and volume to supplying
critical proteins for blood clotting and immunity.
• Plasma is derived when all the blood cells—red blood cells (erythrocytes), white blood cells (leukocytes), and
platelets (thrombocytes)—are separated from whole blood
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• It also serves as the medium for exchange of vital minerals such as sodium and potassium and helps to
maintain a proper pH (acid-base) balance in the body, which is critical to cell function. Plasma is obtained by
separating the liquid portion of blood from the cells.
• Plasma is frozen quickly after donation (up to 24 hours) to preserve clotting factors, stored up to one year,
and thawed shortly before use. It is commonly transfused to trauma patients and patients with severe liver
disease or multiple clotting factor deficiencies.
• Plasma derivatives are concentrates of specific plasma proteins prepared from pools (many donor units) of
plasma. Plasma derivatives are obtained through a process known as fractionation. The derivatives are
treated with heat and/or solvent detergent to kill certain viruses like those that cause HIV, hepatitis B, and
hepatitis C.
• Other proteins called alpha and beta globulins transport lipids such as cholesterol as well as steroids, sugar,
and iron.
• The gamma globulins, or immuneglobulins, are an important class of proteins that are secreted by B
lymphocytes of the immune system. They include most of the body’s supply of protective antibodies
produced in response to specific viral or bacterial antigens.
• Cytokines are proteins synthesized by cells of various organs and by cells found in the immune system and
bone marrow in order to maintain normal blood cell formation (hematopoiesis) and regulate inflammation.
• For example, one cytokine called erythropoietin, synthesized by specialized kidney cells, stimulates bone
marrow blood progenitor cells to produce red blood cells. Other cytokines stimulate the production of white
blood cells and platelets.
• Another protein system in the plasma, called complement, is important in mediating appropriate immune and
inflammatory responses to a variety of infectious agents.
• The electrolytes and acid-base system found in the plasma are finely regulated. For example, potassium is
normally present in plasma in a concentration of only 4 milliequivalents per litre.
• A slight rise in plasma potassium (to 6–7 milliequivalents per litre) can result in death. Likewise, sodium,
chloride, bicarbonate, calcium, and magnesium levels in the plasma must be precisely maintained within a
narrow range.
• Smaller molecules such as sodium, potassium, glucose, and calcium are primarily responsible for the
concentration of dissolved particles in the plasma.
• However, it is the concentration of much larger proteins (especially albumin) on either side of semipermeable
membranes such as the endothelial cells lining the capillaries that creates crucial pressure gradients
necessary to maintain the correct amount of water within the intravascular compartment and, therefore, to
regulate the volume of circulating blood.
• So, for example, patients who have kidney dysfunction or low plasma protein concentrations (especially low
albumin) may develop a migration of water from the vascular space into the tissue spaces, causing edema
(swelling) and congestion in the extremities and vital organs, including the lungs.
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The constituents and their functions are discussed in the table below.
(From: Principles of Anatomy and Physiology)
Difference between plasma and serum:
▪ Plasma
 Watery liquid of the blood
 Contains proteins + other dissolved substances
▪ Serum
 Plasma without clotting factors (fibrinogen)
 Contains all other organic solutes except clotting factors
 Serum- is the blood plasma minus its clotting proteins
Formed Elements
▪ Erythrocytes= Red blood cells (RBC)
▪ Leukocytes= White blood cells (RBC)
▪ Thrombocytes= Platelets
▪ Hematocrit
 % of blood volume occupied by RBC
 Usually around 45%
 Adult females (38-46%)=Avg=42%
 Adult male (40-54%)=Avg= 47%
 Testosterone (Stimulates synthesis of erythropoiten[EPO] =stimulates RBC production) contributes
to higher hemacrits
 Significant drop in Hematocrit=ANEMIA
 Abnormal increase in Hematocrit (>65%)= POLYTHEMIA
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NB: another type of plasma protein is gamma globulins which are formed when certain blood cells develop into
cells that produce gamma globulins. These are also called antibodies or immuno-globulins because they are
produced during certain immune responses.
Foreign substances (antigens) e.g. bacteria stimulate production of antibodies. An antibody binds specifically to
antigen that stimulated its production n disables it.
Platelets
• Lack nucleus
• Disc shaped
• Has many vesicles
• They release various chemicals that cause blood clotting and regulate the inflammatory response.
• Hemopoietic stem cells also differentiate into cells that produce platelets.
• Under the influence of the hormone thrombopoietin, myeloid stem cells develop into megakaryocyte-
colony-forming cells that in turn develop into precursor cells called megakaryoblasts. Megakaryoblasts
transform into megakaryocytes, huge cells that splinter into 2000 to 3000 fragments. Each fragment,
enclosed by a piece of the plasma membrane, is a platelet (thrombocyte). Platelets break off from the
megakaryocytes in red bone marrow and then enter the blood circulation.
• Life span – 5-9 days. Dead platelets removed by fixed macropahges in over n spleen.
Function
• Blood clotting by platelet plug
• Release chemicals that convert fibrinogen→ fibrin
White Blood cells (leukocytes)
These cells have nuclei and the full complement of organelles that all cells have but do not contain haemoglobin.
These white blood cells combat infection either by phagocytosis or the immune response. There are many types
of WBC’s. These are: neutrophils, eosinophils, basophils, lymphocytes and monocytes that are grouped into two
main divisions; the granulocytes and agranulocytes depending on the conspicuous chemical-filled cytoplasmic
granules (vesicles) that are made visible by staining when viewed through a light microscope.
Functions of WBC
 Defense against pathogens- Once pathogens enter the body, the general function of white blood cells is
to combat them by phagocytosis or immune responses. To accomplish these tasks, many WBCs leave
the bloodstream and collect at sites of pathogen invasion or inflammation.
 Once granular leukocytes and monocytes leave the bloodstream to fight injury or infection, they never
return to it. Lymphocytes, on the other hand, continually recirculate—from blood to interstitial spaces of
tissues to lymphatic fluid and back to blood.
 Only 2% of the total lymphocyte population is circulating in the blood at any given time; the rest are in
lymphatic fluid and organs such as the skin, lungs, lymph nodes, and spleen.
 Also leukoctosis WBC count greater than 10000 and leucopenia WBC count less than 5000.
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1. GRANULAR LEUKOCYTES (HAVE GRANULES)
a. Eosinophil- large, uniform sized granules that are esinophilic —they stain red-orange with acidic dyes. The
granules usually do not cover or obscure the nucleus, which most often has two lobes connected by a thick
strand of chromatin.
b. Basophilic- round, variable-sized granules are basophilic- they stain blue-purple with basic dyes. The
granules commonly obscure the nucleus, which has two lobes.
c. Neutrophils- are smaller, evenly distributed, and pale lilac in color; the nucleus has two to five lobes,
connected by very thin strands of chromatin. As the cells age, the number of nuclear lobes increases.
Because older neutrophils have several differently shaped nuclear lobes, they are often called
polymorphonuclear leukocytes (PMNs). Younger neutrophils are often called bands because their nucleus is
more rod-shaped.
2. AGRANULAR LEUKOCYTES
• Possess cytoplasmic granules, the granules are not visible under a light microscope because of their
small size and poor staining qualities.
a. Lymphocyte- The nucleus is round or slightly indented and stains darkly. The cytoplasm stains sky blue
and forms a rim around the nucleus. The larger the cell, the more cytoplasm is visible. Lymphocytes
may be as small as 6–9 micro m in diameter or as large as 10–14 micro m in diameter. Types: T-
lymphocytes (T- Cells), B lymphocytes (B Cells) and Natural Killer (NK cells)
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b. Monocytes- are 12–20 micro m in diameter. The nucleus of a monocyte is usually kidney shaped or
horseshoe shaped, and the cytoplasm is blue-gray and has a foamy appearance. The color and
appearance are due to very fine azurophilic granules, which are lysosomes. The blood transports
monocytes from the blood into the tissues, where they enlarge and differentiate into macrophages
(large eaters).
Some become fixed macrophages, which means they reside in a particular tissue e.g. alveolar
macrophages in the lungs. Others become wandering macrophages, which roam the tissues and
gather at sites of infection or inflammation.
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What is the structure, function, and life-cycle of the red blood cell?
Erythrocyte/ Red Blood Cell

Red blood cells, or erythrocytes, are the most abundant cells in the bloodstream and contains hemoglobin, the
compound that carries oxygen through the body. While hemoglobin can occur in a free state in some animals, in
the human body it has to be contained within a cell – the red blood cell. Any disruption of the red blood cells, its
quantity, shape, size, structure or life cycle can therefore affect the oxygen-carrying capacity of the blood.
Apart from carrying oxygen, which is the main function of the RBC, it can also conduct the following functions.
1. Release the enzyme carbonic anhydrase which allows water in the blood to carry CO 2 to the lungs
where its expelled
2. Control the pH of the blood by acting as an acid-base buffer.

Shape and Size of a Red Blood cell
Functional Anatomy of the Erythrocyte

A RBC is a biconcave/ doughnut shaped dis.
Simply it’s a round ball that is squeezed from two opposite ends to appear, widest at the sides and narrowest in
the middle. A red blood cell measures about 6-8 µm in diameter [average: 7.8µm] with an average thickness of 2
µm [2.5µm at the thickest point and less than 1 µm at the center].
Although a RBC is wider than some capillaries, its flexibility allows it to become distorted as it squeezes through
narrow passage and then restores to its original shape.
Mature RBC’s have a plasma membrane that is strong yet flexible to allow for deformity so that they can pass
through narrow blood capillaries. The membrane also contains glycolipids that function as antigens for the ABO
blood types. The RBC also does not contain nucleus or organelles and therefore do not reproduce or metabolise.
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• Certain glycolipids in the plasma membrane of RBCs are antigens that account for the various blood
groups such as the ABO and Rh groups.
• RBCs lack a nucleus and other organelles and can neither reproduce nor carry on extensive metabolic
activities.
• The cytosol of RBCs contains hemoglobin molecules; these important molecules are synthesized before
loss of the nucleus during RBC production and constitute about 33% of the cell’s weight.
Quantity of RBC in the Human Body

The average male adult has about 5million rbc per cubic millimeter of blood, while the average female adult has
has about 4.5 million rbc per cubic milliliter of blood. This may vary by about 300, 000- 500, 000 rbc. The number
of rbc my vary depending on the geographical location- a person who lives in high altitudes will have more rbc
Structure of Red Blood Cells
Red blood cells have an unusual structure compared to other cells in the human body. It lacks a nucleus,
mitochondria or endoplasmic reticulum. However enzymes within the red blood cells allow it to produce small
amounts of energy (ATP from glucose). The most important part of a red blood cell is hemoglobin, which is
essentially the functional component of the cell.
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Physiology of Erythrocytes
The anatomy of the RBC allows for the ability to carry oxygen. The lack of nucleus and organelles ensures that
all the space is available for transport of oxygen. The same is achieved by the biconcave shape that increases
the surface area.
Hemoglobin Structure
Hemoglobin is the molecule that is responsible for the O 2 carrying capacity of a RBC. It also gives these
cells a red color and is a combination of heme and globin.
Heme is formed when Succinyl-CoA binds with glycine to form a pyrrole molecule. Four of these pyrrole
molecules combine to form photoporphyrin IX which binds with iron to form the heme molecule. Globin
is a long polypeptide chain.
When a heme molecule and globin molecule combine, it forms a hemoglobin chain. There may be slight
variations in the hemoglobin chains designated as alpha, beta, gamma and delta chains.
For these chains need t combine to the final hemoglobin molecule and the common combination in the
human body, termed hemoglobin A is made up of two alpha and beta chains.
Each RBC consists of about 280M haemoglobin molecules. Each haemoglobin molecule consists of two
α-helixes and two β-sheets with a “heme” prosthetic group containing an iron (II) ion [Fe2+] that binds
reversibly with oxygen.
Each iron molecule can bind with one oxygen molecule, which contains two oxygen atoms. Since each
hemoglobin chain has one iron atom and each hemoglobin molecule has 4 chains and therefore 4 iron
molecule,s each hemoglobin molecule can carry 8 oxygen atoms.
Each oxygen molecule picked up from the lungs is bound to an iron ion. As blood flows through tissue
capillaries, the iron–oxygen reaction reverses. Hemoglobin releases oxygen, which diffuses first into the
interstitial fluid and then into cells.
Every 100 milliters of blood, which contains various blood components, has about about 15 grams of
hemoglobin.
Hematocrit- percentage of total blood volume occupied by RBC’s.
• NB: males have higher value for hematocrit or greater number of RBC’s because testosterone which is
present in much higher conc. in males than in females, stimulates synthesis of erythroprotein (EPo), the
hormone that in turn stimulates RBC production.
• In females a lower hematocrit level may be due to menstruation during reproductive years.
• A significant drop in hematocrit indicates anaemia- a lower than normal number of RBC’s.
• In polycythemia, the percentage of RBC’s is abnormally high. This increase viscosity of blood therefore
increase resistance to flow and makes blood more difficult for the heart to pump. Increased viscosity
also leads to high BP and increase risk of stroke. Causes of polycythemia are abnormal increases in
RBC production, tissue hypoxia, dehydration n blood doping/ use of EPo by athletes.
Structure of RBC’s and Haemoglobin
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RBC’s also transports 23% of the total carbon dioxide by combining it with the amino acids of haemoglobin. In
addition to this RBC’s also regulate blood flow and blood pressure. As endothelial cells produce nitrous oxide
(NO) it is picked up by the RBC’s and released when needed. The Nitric oxide causes vasodilation upon release
from haemoglobin. This virtually improves the blood flow and enhances the oxygen delivery to cells near site of
NO release.
Trigger for RBC Production

• Normally, erythropoiesis and red blood cell destruction proceed at roughly the same pace. If the oxygen-
carrying capacity of the blood falls because erythropoiesis is not keeping up with RBC destruction, a
negative feedback system steps up RBC production.The controlled condition is the amount of oxygen
delivered to body tissues.
• Cellular oxygen deficiency, called hypoxia may occur if too little oxygen enters the blood. Oxygen
delivery may also fall due to anemia, which has many causes: Lack of iron, lack of certain amino acids,
and lack of vitamin B12 are but a few. Circulatory problems that reduce blood flow to tissues may also
reduce oxygen delivery.
• Whatever the cause, hypoxia stimulates the kidneys to step up the release of erythropoietin, which
speeds the development of proerythroblasts into reticulocytes in the red bone marrow. As the number of
circulating RBCs increases, more oxygen can be delivered to body tissues.
• Premature newborns often exhibit anemia, due in part to inadequate production of erythropoietin. During
the first weeks after birth, the liver, not the kidneys, produces most EPO. Because the liver is less
sensitive than the kidneys to hypoxia, newborns have a smaller EPO response to anemia than do
adults. Because fetal hemoglobin (hemoglobin present at birth) carries up to 30% more oxygen, the loss
of fetal hemoglobin, due to insufficient erythropoietin production makes the anemia worse.
Why it is important for Oxygen to be carried by haemoglobin?

Oxygen is carried by haemoglobin so that it can be carried to the specific sites of o2 need and is not mixed
with other components in blood.
Important substances involed in RBC production
1. Vitamin B12- Needed for haemoglobin production/ synthesis. When there is Vit B12 in the intestine, it
binds to the intrinsic factor which prevents breakdown of Vit B 12. The intrinsic factor than carries the Vit
B12 to the ilium where it is absorbed into the bloodstream. There may be decrease absorption of Vit B12
when there is a problem in the gastric mucosa.
2. Amino Acids- needed for the globin portion of haemoglobin. This can be taken in from the diet or
manufactured by the body
3. Iron- is taken in from the diet in the small intestine. The iron combines with apotransferrin in order to
form tranferrin which is carried in the blood plasma and is released when needed for haemoglobin
synthesis.
4. Folic acid- also taken from the diet and is essential in forming the DNA which it does so together with
Vit B12 and also for the maturation division of cells.
Role of Erythropoietin
▪ Erythropoietin Stimulates Red Cell Production, and Its Formation Increases in Response to
Hypoxia.
▪ It is usually activated by Testosterone hormone (Higher Testosterone levels in males than females)
▪ erythropoietin, a glycoprotein with a molecular weight of about 34,000

▪ In the normal person, about 90 per cent of all erythropoietin is formed in the kidneys
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Role of VITAMIN B12 /FOLLIC ACID
▪ important for final maturation of the red blood cells are two vitamins, vitamin B12 and folic acid
▪ Both of these are essential for the synthesis of DNA both affecting formation of Thymidine Triphosphate
an important component of DNA
▪ Therefore, lack of either vitamin B12 or folic acid causes abnormal and diminished DNA and,
consequently, failure of nuclear maturation (Maturation Failure) and cell division
▪ Vit B12 is absorbed via the Ileum in the GI tract
▪ Vit B12 absorption is made possible by attachment of Intrinsinc factor released by Parietal Cells of the
GI tract. (Protects Vit B12 from being broken down)
▪ Vit B12 is stored in the Liver then released slowly in the Bone Marrow when needed.
▪ Folic acid is a normal constituent of green vegetables, some fruits, and meats (especially liver).(
However, it is easily destroyed during cooking)
▪ Also, people with gastrointestinal absorption abnormalities, such as the frequently occurring small
intestinal disease called sprue, often have serious difficulty absorbing both folic acid and vitamin B12.
▪ Therefore, in many instances of maturation failure, the cause is deficiency of intestinal absorption of
both folic acid and vitamin B12.
Role of IRON
▪ Iron is important for the formation not only of haemoglobin but also of other essential elements in the
body (e.g., myoglobin, cytochromes, cytochrome oxidase, peroxidase, catalase)
▪ Excess iron in the blood is deposited especially in the liver hepatocytes and less in the reticulo-
endothelial cells of the bone marrow.
▪ Iron is absorbed from all parts of the small intestine
▪ Iron is the major component responsible for transporting Oxygen in RBC haemoglobin
Reticuloenothelial Cells
▪ Albuminoid or scleroprotein cells lining vascular and lymph vessels and are capable of phagocytosing
Bacteria/Virus/colloidal particles
▪ Form immune bodies against foreign substances.
Reticuloendothilial System (RES)
▪ System of defence against infection and disposal of products of the breakdown of cells
▪ Includes Macrophages/ the Kupffer cells of the liver/bone marrow spleen/lymph nodess
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Life Cycle of Erythrocytes
 Erythrocytes are produced in the red bone marrow through a process called haemopoiesis.
 Red blood cells are manufactured from the hemopoietic stem cells in the bone marrow. These cells are
known as erythtropietic bone marrow cells and are partially differentiated.
 When red blood cells have to be manufactured, these cells go through various phases of development
until the mature red blood cell can be released into the bloodstream.
 About 0.05% to 0.1% of the red bone marrow is stem cells called pluripotent stem cells or
hemocytoblasts that are derived from mesenchyme. In order to form blood cells the pluripotent stem
cells further divide into myeloid and lymphoid stem cells (this problem deals with the myeloid stem cells).
 During haemopoiesis the myeloid stem cells differentiate into progenitor cells some of which are colony-
forming units (CFU’s). The CFU’s are designated a letter that shows what they later form; CFU-E forms
erythrocytes.
 The CFU-E then form blasts specifically proerythroblast. This cell divides several times and begins to
produce haemoglobin. A cell near the end of the development ejects its nucleus and becomes a
reticulocyte.
 This causes the sides to indent and causes the typical biconcave shape of a RBC.
 These then produce the erythrocytes.
 The hormone erythropoietin (EPO) regulates the production of RBC’s. It is produced by the kidneys
(more specifically by the peritubular interstitial cells)
Clinical Connection: Haematocrit

This is the concentration of RBC’s in the blood. A haematocrit of 40 means that 40% of blood is RBC.
The normal range of the haematocrit is 38-46 in females and 40-54 in males.
Diagram of RBC Formation
Pluripotent Stem Cells
Myeloid Stem Cells
CFU-E
Proerythroblast
Reticulocyte
Erythrocyte
Its takes some 5- 7 days in the production of erythrocytes.
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 The life span of a red blood cell is approximately 120 days but may be removed out of circulation at any
time if it is severely damaged and non-functional.
 Most of the red blood cells self-destruct rather than being actively removed from the circulation and
destroyed. The primary site where this occurs is in the spleen.
 Once a red blood cell ruptures, hemoglobin is released into the circulation for processing. This is
primarily done by the Kupffer cells of the liver and macrophages in the spleen and bone marrow.
 These macrophages release iron which is carried by transferrin to the bone marrow where it can be
reused for the production of new red blood cells.
 The remaining porphyrin portion of the hemeglobin molecule is converted to bilirubin by the
macrophages. The liver cells (hepatocytes) take up the bilirubin, conjugate it and release it in the bile.
This occurs as follows:
1. Macrophages phagocytise the ruptured and worn out RBC’s

2. The globin and heme are split apart
3. Globin is broken down into amino acids
4. The heme is removed as Fe3+ which associates with the plasma protein transferrin
5. In the muscles and macrophages the Fe3+ detaches and combines with ferritin for storage
6. On release from storage or absorption from GI tract it again attaches to transferrin
7. This complex is taken to the red bone marrow where precursors to RBC’s take it up through
receptor mediated endocytosis.
8. Erythropoiesis of new RBC
9. When iron is removed from the heme group the non-iron portion is converted to biliverdin and then
to billirubin, a yellow orange pigment
10. Billirubin is transported to the liver by blood
11. Billirubin is released by liver cells into bile which passes into small intestine and then into the large
intestine
12. In the large intestine bilirubin is converted to urobilinogen by bacteria
13. Most of the urobilinogen is excreted into faeces as sterobilin, a brown pigment
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• The final stage of maturation requires two important vitamins – vitamin B12 and folic acid.
• This process of developing from erythropoietic bone marrow cells to mature red blood cells takes about
7 days. The stimulus for producing red blood cells is hypoxia (low oxygen state).
• However, hypoxia alone will not be sufficient to trigger the production of new red blood cells unless the
hormone erythropoietin is circulating in the bloodstream.
• This hormone is primarily produced by the kidneys. The process of manufacturing red blood cells in
known as eryrthropoiesis.
RBC Life cycle
Areas of the Body That Produce Red Blood Cells.
▪ In the early weeks of embryonic life, primitive, nucleated red blood cells are produced in the yolk sac.
▪ During the middle trimester of gestation, the liver is the main organ for production of red blood cells, but
reasonable numbers are also produced in the spleen and lymph nodes.
▪ Then,during the last month or so of gestation and after birth, red blood cells are produced exclusively in
the bone marrow.
▪ The bone marrow of essentially all bones produces red blood cells until a person is 5 years old.
▪ The marrow of the long bones, except for the proximal portions of the humeri and tibiae, becomes quite
fatty and produces no more red blood cells after about age 20 years.
▪ Beyond this age, most red cells continue to be produced in the marrow of the membranous bones, such
as the vertebrae, sternum, ribs, and ilia.
▪ Even in these bones, the marrow becomes less productive as age increases.
Regulation of Erythropoiesis
• This occurs via a negative feedback mechanism. This is through the effect of EPO (discussed earlier).
• The input for this mechanism is hypoxia which is detected by kidneys and other body cells. This
stimulates the kidneys to produce EPO.
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• In addition to this the adrenal hormones epinephrine and norepinephrine together with several of the
prostaglandins can stimulate the kidneys to produce EPO.
• EPO speeds up RBC production by stimulating the proerythroblast to undergo its stages of
differentiation and development at a faster rate and thus increasing the RBC count.
• This accounts for the slow action of EPO; it is produced within minutes with peak production at 24 hours
but the increase in numbers of RBC is usually seen after a minimum of 5 days.
• Once the RBC count has been restored the rate of EPO production decreases to maintain the RBC
count according to the physiologic demands.
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Destruction of RBC
Red cells have an average life span of 120 days. Although they use glucose to produce energy necessary for
their survival, they cannot synthesize protein; therefore reparative processes are not possible.
As red cells age, wear and tear leads to loss of some of the protein, and the activity of some of the essential
enzymes decreases. Chemical reactions necessary for the survival of the cell are consequently impaired. As a
result, water passes into the aging red cell, transforming its usual discoid shape into a sphere. These
spherocytes are inelastic, and, as they sluggishly move through the circulation, they are engulfed by phagocytes.
Phagocytic cells form a part of the lining of blood vessels, particularly in the spleen, liver, and bone marrow.
These cells, called macrophages, are constituents of the reticuloendothelial system and are found in the lymph
nodes, in the intestinal tract, and as free-wandering and fixed cells. As a group they have the ability to ingest not
only other cells but also many other microscopic particles, including certain dyes and colloids.
Within the reticuloendothelial cells erythrocytes are rapidly destroyed. Protein, including that of the hemoglobin, is
broken down, and the component amino acids are transported through the plasma to be used in the synthesis of
new proteins. The iron removed from hemoglobin passes back into the plasma and is transported to the bone
marrow, where it may be used in the synthesis of hemoglobin in newly forming red cells.
Iron not necessary for this purpose is stored within the reticuloendothelial cells but is available for release and
reuse whenever it is required. In the breakdown of red cells there is no loss to the body of either protein or iron,
virtually all of which is conserved and reused. In contrast, the porphyrin ring structure of hemoglobin, to which
iron was attached, undergoes a chemical change that enables its excretion from the body. This reaction converts
porphyrin, a red pigment, into bilirubin, a yellow pigment. Bilirubin released from reticuloendothelial cells after the
destruction of erythrocytes is conveyed through the plasma to the liver, where it undergoes further changes that
prepare it for secretion into the bile. The amount of bilirubin produced and secreted into the bile is determined by
the amount of hemoglobin destroyed. When the rate of red cell destruction exceeds the liver's capacity to handle
bilirubin, the yellow pigment accumulates in the blood, causing jaundice. Jaundice can also occur if the liver is
diseased (e.g., hepatitis) or if the egress of bile is blocked (e.g., by a gallstone).
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Blood Conditions
• Hemorrhage (bleeding): Blood leaking out of blood vessels may be obvious, as from a wound
penetrating the skin. Internal bleeding (such as into the intestines, or after a car accident) may not be
immediately apparent.
• Hematoma: A collection of blood inside the body tissues. Internal bleeding often causes a hematoma.
• Leukemia: A form of blood cancer, in which white blood cells multiply abnormally and circulate through
the blood. The abnormal white blood cells make getting sick from infections easier than normal.
• Multiple myeloma: A form of blood cancer of plasma cells similar to leukemia. Anemia, kidney failure
and high blood calcium levels are common in multiple myeloma.
• Lymphoma: A form of blood cancer, in which white blood cells multiply abnormally inside lymph nodes
and other tissues. The enlarging tissues, and disruption of blood's functions, can eventually cause organ
failure.
• Anemia: An abnormally low number of red blood cells in the blood. Fatigue and breathlessness can
result, although anemia often causes no noticeable symptoms.
• Hemolytic anemia: Anemia caused by rapid bursting of large numbers of red blood cells (hemolysis). An
immune system malfunction is one cause.
• Hemochromatosis: A disorder causing excessive levels of iron in the blood. The iron deposits in the
liver, pancreas and other organs, causing liver problems and diabetes.
• Sickle cell disease: A genetic condition in which red blood cells periodically lose their proper shape
(appearing like sickles, rather than discs). The deformed blood cells deposit in tissues, causing pain and
organ damage.
• Bacteremia: Bacterial infection of the blood. Blood infections are serious, and often require
hospitalization and continuous antibiotic infusion into the veins.
• Malaria: Infection of red blood cells by Plasmodium, a parasite transmitted by mosquitos. Malaria
causes episodic fevers, chills, and potentially organ damage.
• Thrombocytopenia: Abnormally low numbers of platelets in the blood. Severe thrombocytopenia may
lead to bleeding.
• Leukopenia: Abnormally low numbers of white blood cells in the blood. Leukopenia can result in difficulty
fighting infections.
• Disseminated intravascular coagulation (DIC): An uncontrolled process of simultaneous bleeding and

clotting in very small blood vessels. DIC usually results from severe infections or cancer.
• Hemophilia: An inherited (genetic) deficiency of certain blood clotting proteins. Frequent or uncontrolled
bleeding can result from hemophilia.
• Hypercoaguable state: Numerous conditions can result in the blood being prone to clotting. A heart
attack, stroke, or blood clots in the legs or lungs can result.
• Polycythemia: Abnormally high numbers of red blood cells in the blood. Polycythemia can result from
low blood oxygen levels, or may occur as a cancer-like condition.
• Deep venous thrombosis (DVT): A blood clot in a deep vein, usually in the leg. DVTs are dangerous
because they may become dislodged and travel to the lungs, causing a pulmonary embolism (PE).
• Myocardial infarction (MI): Commonly called a heart attack, a myocardial infarction occurs when a
sudden blood clot develops in one of the coronary arteries, which supply blood to the heart.
1. List the factors that maintain red cell size.

Presence of isotonic solution; lack of nucleus; lack of cytoplasmic organelles; presence of adult hemoglobin.
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2. Describe the primary function of the RBC. What other functions does the RBC have?
o Transport of O2 from lungs to peripheral tissues.
o Transport of CO2 from peripheral tissues to the lungs for elimination.
o Buffering organic acids produced by the cells of the body during metabolism, until they can be
eliminated by the kidney. (Proteins of the RBC are a secondary buffer, rather than the first-line buffer
found in the bicarobonate ions of plasma).
o Possible role in regulation of blood pressure.
3. Describe the hemoglobin molecule.

Hemoglobin is made up of heme and globin. The globin portion is composed of 4 polypeptide chains (2 alpha
and 2 beta chains). Within each chain is a heme ring. Attached to the heme ring is an iron atom (Fe2+),
which is the binding site for oxygen.
4. Why is hemoglobin carried in RBCs, and not dissolved in the plasma?

Hemoglobin dissolved in plasma would leak out of capillaries, or be lost in the urine.
5. Describe the role of iron in the red blood cell.
Iron is bound to the heme rings within the globin molecule, and is the site of reversible O2 attachment.
6. Oxygen is poorly dissolved in plasma. Describe how hemoglobin carries oxygen to the tissues.
Four molecules of O2 are transported per molecule of hemoglobin, reversibly attached to the iron molecule
(Fe2+) which is found in the middle of the hemoglobin. 98.5% of total O2 carried in the blood is carried by
hemoglobin. Hemoglobin, by binding oxygen, enables the blood to carry much more oxygen than it would be
able to carry if oxygen were dissolved in plasma alone.
7. Describe the shape of the erythrocyte (RBC), and the advantage of this.
Erythorcytes are biconcave discs in shape. Its biconcavity of the red cell results when the nucleus is
extruded.
- Compared to a sphere of the same volume, a biconcave disc has more surface area available
through which gases (oxygen and carbon dioxide) can diffuse for transport to or from the tissues.
- It also allows the RBC to assume a small shape to fit through tiny capillaries.
8. The RBC contains no mitochondria. What is the advantage of this?

Mitochondria, containing enzymes of the Kreb's cycle and the electron transport chain, are the site of aerobic
metabolism, and would use oxygen to generate ATP. Mitochondria-less RBCs engage in anaerobic
metabolism for their own energy needs, and thus do not used for their own needs any of the oxygen they are
carrying for delivery to the tissues.
9. Describe the stages of a developing RBC. At what stage does the developing RBC acquire
hemoglobin?
- PHSC → myeloid stem cell → CFU-E → proerythroblast → initial normoblast → intermediate
normoblast → late normoblast → reticulocyte → RBC.
- Hemoglobin comes in at the intermediate normoblast stage.
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10. Describe what a reticulocyte is.
A reticulocyte is an immature RBC in the circulation, just after it exits the marrow. It is a bit larger than a
normal erythrocyte, and it still has within it reticulin fibres, the remnants of the nucleus, which are gradually
lost as the RBC ages.
11. State the percentage of the total number of RBCs that is destroyed daily. How are they replaced?
About 1% of circulating RBCs is destroyed daily, due to senescence and removal from the circulation. The
RBC has a life span of 100-120 days, thus each day, 1/100th to 1/120th of the total red cells is destroyed.
They are replaced with newly produced RBCs from the marrow. This process of removal and replacement is
in balance, assuring a steady number of RBCs in the circulation.
12. List the organs where reticuloendothelial (RE) cells are found. List the functions of the RE cells.
- Reticuloendothelial cells are macrophages. They include the Kupffer cells of the liver, alveolar
macrophages in the lungs, microglia in the brain, and tissue macrophages of the spleen and lymph
nodes. Also bone marrow and bone osteoblasts.
- RE cells play a key function in immunity; produce clot promoting factors; and destroy red blood cells.
13. Where can a bone marrow sample be obtained in a 20 year old man being investigated for anemia?
From the sternum of iliac crest.
14. Describe the role of erythropoietin. Explain the homeostatic mechanism which controls the level of
erythropoietin.
- Erythropoietin, produced by the kidney, stimulates RBC production.
- The erythropoietin level is determined by the concentration of oxygen at the tissue level.
- A low oxygen concentration at the tissue level, which could be causes by a low number of red blood
cells, or by a situation where the oxygen being breathed in is at a low concentration (such as occurs
when living at a high altitude), would cause an increase in erythropoietin secretion.
- Erythropoietin is thus controlled by a negative feedback loop.
Pathophysiology of Faeces Production in relation to the RBC degradation
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Study Guide 3 – BLOOD
Clinical Manifestations and Effects of Anaemia
1. Functions of Red Blood Cells
- Transporting oxygen and carbon dioxide to and from body tissues and the lungs.
- Haemoglobin aids in maintaining pH by binding to H+ ions. (acts as a buffer system)
- Nitric oxide is released by RBC to cause vasodilation
2. What would happen if there were insufficient numbers of these cells or their components to
carry out these functions?
These functions would be altered and the rate at which these functions occur would decrease drastically
causing there to be insufficient transport of these gases, the pH level would be affected i.e. acidosis
would occur since H+ ions won’t be kept at normal level and vasodilatation would be affected as well as
in times of need.
3. What Colour is Blood?
Normal blood is red in colour.
4. What gives it this colour?
Haemoglobin is the principal determinant of the colour of blood in humans. Each molecule has 4 heme
groups and their interactions with various molecules alter the exact colour.
Arterial blood and capillary blood is bright red as oxygen imparts are a strong red colour to the heme
group. Deoxygenated blood is a darker shade of red, this is present in veins.
5. What would happen to the colour of blood if there were less of this?
Hypochromic anaemia results, which is a type of anaemia in which the erythrocytes are paler than
normal. A normochromic RBC has a central pallor but due to hypochromic anaemia, this pallor
increases. This decrease in redness is due to disproportionate reduction of red cell haemoglobin in
proportion to the volume of the cell. This is common in iron deficiency anaemia.
6. When doing physical examination, where would we best look for to find this change in colour?
Why?
Pallor of Lips, Palmer creases, nail beds, dorsum of tongue, oral mucosal surface, palpebral
conjunctiva.
Clinical pallor in these anatomical sites is due to the capillary beds being visible through the skin or
mucosa which contains the pale blood being circulated.
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Check the oral mucosal surface, dorsum of tongue and palmar creases for jaundice = Increase blood
destruction = Anaemia
Check dorsum of tongue = for macrocytic anaemia
7. What would be the Clinical Effects of Insufficient RBC?

 The patient would present with lethargy, as the amount of oxygen reaching all body parts would
be drastically reduced (more than required).
 Acidosis of blood would occur as not enough haemoglobin would be present to bind with H+ ions
and maintain the pH of blood (7.35-7.45 = normal)
 Dizziness, light-headedness due to lack of oxygen to brain
 Inflammatory reactions may become impaired as vasodilatation is affected
 In times of increased blood volume, the BP may remain high as vasodilatation effect is impaired.
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8. Would these manifestations differ if the anaemia occurred suddenly, as in someone with sudden
blood loss, or slowly over the course of several months, as in someone with iron deficiency
anaemia? Explain the difference?
Acute anaemia occurs when there is a large amount of blood loss in a short period of time e.g. due to
laceration whereas chronic anaemia occurs when blood loss and decreased RBCs level occurs little by
little over a long period of time e.g. in iron deficiency anaemia. There are some differences in the clinical
manifestations of acute and chronic anaemia.
In acute anaemia, capillary refill may increase and the skin is cold to the touch, with progressive shock,
the skin is cold to touch and becomes pale, when blood loss exceeds 40% of total volume, the patient
may lose consciousness, tachypnea (increased breathing rate) will result with blood loss greater than
15% of total volume and even urinary output is decreased.
In chronic anaemia, fatigue, weakness, irritability, headache, dizziness, vertigo (whirling motion-
dizziness), tinnitus (buzzing sound in ear), dyspnea (breathlessness) especially with physical activity,
palpitations (patient feels the heart rate increasing), difficulty in concentration, thirst, anorexia,
decreased urine output and bowel irregularity together with pallor develops gradually after the time of
developing anaemia.
Clinical Manifestation of Anaemia
A patient with anaemia may present with the following:

• Weakness
• Tiredness
• Dyspnoea
• Fatigue
• Postural dizziness
• Trachycardia
• Conjuctival and general pallor
• Jaundice: only in haemolytic anaemia
• Koilonychia: dry, brittle, ridged spoon shaped nails- severe iron deficiency anaemia
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In addition to the above the patient can also present with leg ulcers and splenomegaly in cases of
megloblastic and haemolytic anaemia. The patient will also have systolic ejection murmurs on
cardiovascular examination due to a compensatory rise in cardiac output.
Complications of Chronic Anaemia

Chronic anaemia can be an indication of impaired renal function or rheumatoid arthritis.
The complications of anaemia include:
• Damage to kidneys and liver: haemolytic anaemia

• Reduced productivity
• Slower growth
• Tissue necrosis
• Slower intellectual development
• Damage to spleen
• Lowered activity levels
9. Complications of Chronic Anaemia
If a child has chronic anaemia, what would be the effect in terms of

➢ Normal Activity – the normal activity rate will decrease as not enough oxygen will reach all
body parts so these parts will become more inactive.
➢ Growth and Development – will decrease as all body parts have processes which require
oxygen to occur but lack of RBCs signifies lack of oxygen supply to all sites of metabolism and
hence not enough oxygen is present to provide sufficient energy for growth and development to
occur.
➢ Intellectual Development – it will decrease as oxygen supply to the brain will decrease and
the brain won’t have enough energy to carry out all activities that it is supposed to carry out
especially intellectual development.
10. You should be familiar with when it is that we currently screen children and adults regularly for
the presence of anaemia and Why?
Iron deficiency anaemia is more common in women than in men as they are child bearing and undergo
menstruation.
 For adult women, during pregnancy, they are regularly screened for anaemia as their iron
requirement increases due to the iron requirement of the growing foetus.
Anaemia is serious problem especially during pregnancy
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 For infants of low birth weight (<2.5kg) screening for anaemia is done till 6 months old as 2-
4mg/kg/day of iron is administered to them to eliminate risk of anaemia.
 Routine screening is done for infants between 9-12months of age and again 6 months later as Fe
demand is high during this time.
 For adolescent females, it is done from ages 12 to 18 years during the period of which
menstruation starts and hence, changes for developing iron-deficiency anaemia is quite high is
unscreened.
 Vegetarians of all ages are screened for iron deficiency anaemia and given iron supplements.
1. How is a sign different from a symptom?

A sign is an objective finding discovered on physical examination whereas a symptom is something the
patient reports or complains of.
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2. List some clinical manifestations of a child with chronic anaemia and explain how they would result
from anaemia.
- Tired and sleepy due to inadequate delivery of oxygen and nutrients to the periphery.
- Poor concentration at school perhaps for the same reason as mentioned above. It may also be due to a
direct effect of a lack of iron, separate from the effect of decreasing haemoglobin.
- Pallor due to a decrease in red blood cell number and haemoglobin content, which confers a red colour
to skin and mucus membranes.
- Loss of appetite.
- Pica is occasionally seen.
3. List some clinical manifestations of a person with acute onset anaemia.
- Shortness of breath.
- Weakness.
- Tachycardia.
- Dizziness
4. Explain why the symptoms are different as the duration of the anaemia differs.
Symptoms differ with the duration of the anaemia because the body compensates and adapts to the
changes in the blood. A sudden drop in haemoglobin results in a sudden loss of oxygen carrying capacity
and the body has not had the opportunity to adapt to the lower oxygen delivery to the tissues.
5. List two long term, and perhaps permanent complications, of chronic iron deficiency anaemia.
- Lowered IQ.
- Developmental delay.
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Guide 4
What Investigations could be done to Determine the Cause of Anaemia?
1. The Haemoglobin Level
• Refers to concentration of the haemoglobin in the blood.
• The unit of measurement used: g/dL (1x10-1) or gm%
• Normal Values of Haemoglobin Level- Male: 13.6-17.2g/dL, Female: 12-15g/dL
2. The Hematocrit (Hct)- Packed Cell Volume(PCV)
• Refers to the percentage of RBC in the blood or RBC mass volume

• Units of Measurement: % by volume of blood
• Normal Values: depends on the age, and after adolescent depends on sex, decreases gradually as you
grow up.
How Hb Level and Hematocrit are related?

Hematocrit value (%) is 3x the value of haemoglobin (g/dL)
Investigations of Anaemia
Anaemia can be detected by a few simple haematological tests. These are:
1. Haemoglobin levels (Hb): this is the amount of haemoglobin in a decilitre of blood. The unit of
measurement is g/dL.
2. Haematocrit: see clinical connection box on page 4.
3. The Red Blood Cell Indices

-Helps to determine the size/ volume and colour of the cells. Important ones include:
The Mean Cell Volume, Mean Cell Haemoglobin, and Mean Cell Haemoglobin Concentration, Red Blood
Cell Distribution width (Coefficient of variation of RBC volume). [11.5-14.5]
4. The Mean Cell Volume (MCV)

Or Mean Corpuscular Volume – find cell size
- Measure of average red blood cell volume
Units of Measurement: femtolitres (fl) or µm 3
Normal Values: 82-96 fl
MCV (1x10-15) = PCV x10

Total RBC Count in millions
Value less than 78/80 = microcytic, small RBCs, caused by lack of iron
Value more than 100 = macrocytic, large RBCs, are due to Vitamin B12 deficiency which helps in
classification of this particular anaemia.
5. Mean Cell Haemoglobin (MCH)

It is the average mass of haemoglobin per red blood cell.
MCH = Hb x10
RBC count
Units of Measurement: pictograms (pg)
Normal Values : 27-33 pg
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6. Mean Cell Haemoglobin Concentration (MCHC)
- Measure of the concentration of hemoglobin in a given volume of packed RBC
- Used to determine whether RBC is hypochromic, hyperchromic or normochromic.
MCHC (%) = Hb x 100

PCV
Normal Values: 33-37%

MCHC < 32 = Hypochromic
MCHC > 38 = Hyperchromic
7. The Blood Film – The Peripheral Blood Smear

- Made to check for anaemia, if the colour appears pale then the person has anaemia
- Also a blood film is used to check for size and colour, if the RBCs are:
- Macrocytic, normocytic or microcytic
- Hyperchromic, hypochromic, or normochromic
 If the RBC is normochromic, normocytic, then anaemia is due to blood loss.

 If the RBC is microcytic and hypochromic (small and pale), then the anaemia is due to iron deficiency.
In such cases, check for its cases:
✓ Lack of iron in the diet
✓ Improper absorption of iron due to problem in gastric mucosa
✓ Hookworms – chronic blood loss (small amounts/longer time). If hookworms are found, deforming
should be done and iron supplements should be given. Also a diet rich in iron should be recommended.
 If the RBC is macrocytic and normochromic, then anaemia is due to Vit B12 and Folic Acid deficiency (due
to low Vit B12 taken in food or lack of intrinsic factor [IF]= Pernicious Anaemia)
 If RBC is macrocytic and hypochromic, anaemia is due to Vitamin B12, Folic Acid and Iron Deficiency
The parameters from a normal complete blood count (CBC) are shown here.
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With iron deficiency anemia, the MCV of the red blood cells is decreased, the zone of central pallor is increased, and the
overall sizes and shapes of the RBC's are less uniform (increased anisocytosis and poikilocytosis).
Here is another peripheral blood smear demonstrating changes with iron deficiency anemia. Note the increased
zone of central pallor and the more irregular shapes of the RBC's.
The CBC demonstrates a decreased MCV in association with the decreased Hgb and Hct in this case of iron deficiency
anemia.
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The peripheral blood smear

The blood smear provides useful information regarding the cause of anaemia by showing the size of the RBC.
• Hypochromic cells: iron deficiency anaemia
• Macrocytic cells: cells are large and oval in shape-megloblastic anaemia
• Spherocytic anaemia: cells are numerous but small and lack central pallor. This is known as
microcytic cells and can also be an indication of an auto immune disorder that causes haemolytic
anaemia.
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(Blood Smears from: Clinical Examination: A Systemic Guide to Physical Diagnosis)
Conclusions of Blood Smears
Microcytic cells:
The red cells are microcytic with a MCV of <80 fL and hypochromic (MCH <27pg). There is also poikilocytosis
and aniscocytosis. Microcytic cells however do not confirm iron deficiency and serum iron and total iron binding
capacity (TIBC) together with serum ferritin levels must be checked. Iron deficiency is confirmed if transferrin
saturation (serum iron / TIBC) falls below 19% and serum ferritin falls below normal (male: 11.6-144 nmol/L and
female: 5.8-96 nmol/L).
Differential Diagnosis of Microcytic Anaemia
(From: Clinical Medicine, Kumar and Clark)
Macrocytic anaemia
This can be of many types. The common one is discussed below:
Megaloblastic anaemia
This is characterised by bone marrow showing erythrocytes with immature nuclei. The cells are also twice as
large as normal RBC (MCV > 96fL). This type of anaemia is normally due to:
✓ Vitamin B12 deficiency or abnormal vitamin B12 metabolism

✓ Folic acid deficiency or abnormal folic acid metabolism
✓ DNA synthesis defects
✓ Myelodysplasia due to dyserythropoeisis
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The Reticulocyte count
This can show a problem with erythropoiesis. The number of reticulocytes is observed by making a blood smear
stained with methylene blue which stains the ribosomes that are still present. For the reticulocyte count to be
used effectively the value is corrected as follows:
o Multiply reticulocyte percentage by the ratio of patients Hb or haematocrit to the expected Hb or

haematocrit.
o The new value is divided by a shift factor is there is premature release of reticulocytes as seen by a
peripheral blood smear.
This value after correction is referred to as the reticulocyte production index. If this value is >2 in an anaemic
patient it shows lowered production of reticulocytes.
The Reticulocyte Count

Reticulocytes are premature RBC’s, they contain remnants of the ribosomal RNA which was present in larger
amounts in the cytoplasm of the nucleated precursors from which they were derived.
Reticulocyte count refers to the amount of reticulocyte in blood released by Red Bone Marrow.
Units: %
Normal Value: 0.5-1.5%
Increased Reticulocyte count indicates:

- Bleeding/ Blood Loss
- Loss of RBC or Increased RBC Destruction
- Hypoxia
Decreased Reticulocyte Count indicates:
- Kidney failure
- Inability of Red Bone Marrow to respond to erythropoietin
- Malnutrition
Reason: kidney failure = lack of erythropoietin = decrease in erthropoiesis

Bone marrow doesn’t respond to erythropoietin (aplastic anaemia) therefore decrease in erythropoiesis.
Malnutrition- (Fe, Vit B12 and Folic Acid Deficiency) disrupts erythropoiesis.
Shortage of iron: lack of heme group: decrease in reticulocyte count.
Reason – bleeding leads to excess RBC loss Increased destruction of RBC
Causes Hypoxia at Tissue Level
Detected by Renal Tubular Cells of Kidneys
Increase the release of Erythroprotein
Goes to Bone Marrow
Erythropoiesis Occurs
Reticulocyte Formation
Increase Number of RBCs = Increase Reticulocyte Count
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➢ An increase in reticulocyte count is an indicative of hypoxia which is a cause of anaemia
➢ It could be due to Fe deficiency that more reticulocytes are being produced than normal or due to Vit B12
deficiency that a lot of reticulocytes are produced that are unable to mature into red blood cells due to lack
of Vit B12
➢ A decrease in reticulocyte count is an indicative of renal failure as not enough erythropoietin is then
produced to trigger erythropoiesis and hence lack of reticulocytes develops. Or, bone marrow destruction
could lead to decrease in retinoculocytes as enough erythropoietin may be being produced but the marrow
may not be responding to it and hence reticulocytes decrease in number.
➢ The retic count is generated manually because a peripheral smear must be stained with a supravital dye so
that the number of reticulocytes can be enumerated.
➢ Most RC are given as “corrected RC” which compensates for a false elevated retic count with anaemia:
Study guide 4
1. Explain what is meant by the hemoglobin level. Which unit of measurement is it reported in?
The hemoglobin level is a measure of the amount of hemoglobin in a volume of blood. This hemoglobin is
within RBCs. The unit of measure is grams of hemoglobin per deciliter of blood (g/dL).
2. Explain what the PCV is and how it is maintained.

The PCV (packed cell volume) is also called the hematocrit. It is the percentage of blood made up of red
cells.
It is usually determined by centrifuging blood, which forces cellular elements to the bottom, and then simply
measuring the proportion of packed red cells in relation to the total blood volume.
3. Explain what MCV and MCHC mean, and how they are determined, and what their values reflect.
- The MCV (mean cell volume) is the average volume of the red blood cells in the circulation. It is usually
measured directly by electronic counters. The unit of measure is femtoliter (fL).
- The MCHC (mean cell hemoglobin concentration) is a measure of the hemoglobin content within a red blood
cell, and is expressed as grams of hemoglobin per 100 mL of packed red cells.
It is usually a value calculated from the other indices:
MCHC (grams of Hb/100) = Hb (g/dL) x 100

Hct (%)
4. Explain what a blood film is (peripheral smear).

A drop of blood is spread onto a microscopic slide in a very thin layer, and then stained and viewed
microscopically.
The layer of blood is so thin that there is only one layer of blood cells, which can be viewed in order to
determine their morphology (size, shape, etc).
5. Where on the blood film is the optimal area to look in order to describe blood cells morphology?
The feathered edge of the blood film i.e. the edge where the smeared blood thins out most finely, where
individual cells can be seen and assessed.
6. Which of the blood cells are able to be viewed on a blood film?

All: RBCs, WBCs, platelets are all visible and assessable on a blood film.
7. When viewing a blood film, explain how you can tell whether the red blood cell is normocytic,
microcytic, or macrocytic. Explain what these terms mean.
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8. List 2 causes of macrocytic anemia, and briefly describe how the cause might lead to macrocytosis.
Folic acid deficiency, and vitamin B12 deficiency. Both micronutrients are necessary for DNA synthesis in the
nucleus. Delayed DNA synthesis in the nucleus would allow the cytoplasm to continue expanding
uninhibited, until the nucleus finally reached the stage where it could be extruded and the cell enter the
circulation.
9. List 2 causes of normochromic, normocytic anemia.

Hemolysis, acute blood loss, bone marrow failure such as aplastic anemia or leukemia.
10. What would you expect the erythropoietin level to be in someone with folic acid deficiency? In
someone with iron deficiency? In someone with acute hemolysis? Explain?
11. A patient with iron deficiency anemia is started on oral iron medications. Two weeks later, his
reticulocyte count has risen. What does this tell you? What is the mechanism?
Reticulocytes are immature red cells. Their rise tells you that he is responding to the iron treatment by
producing red cells. It also tells you that he is receiving and absorbing the medication.
The reticulocyte count is usually the first laboratory investigation to improve following the start of treatment of
someone with iron deficiency anemia.
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Study Guide 5 Common Causes of Anaemia
Substances Needed for RBC Production
1. Iron
Iron is a mineral found in every cell of the body. Iron is considered an essential mineral because it is
needed to make part of blood cells.
The human body needs iron to make the oxygen-carrying proteins hemoglobin and myoglobin.
Hemoglobin is found in red blood cells and myoglobin is found in muscles. Iron also makes up part of
many proteins in the body.
Metabolism of Iron
• The iron intake can from two sources: heme iron from animals or non heme iron from plant sources and
fortified food. Since heme iron is more easily absorbed than non heme iron, meat products usually
provide more usable iron.
• Heme iron mostly contains Fe2+ whereas non heme iron contains Fe3+ which accounts for the
differences in absorption.
• Absorption of iron is further enhanced by compounds that stabilise the ferrous ion such as ascorbic acid
or vitamin C and inhibited by compounds that stabilise the ferric ion such as tannins.
• From absorption the two ions form a common pool and are transported to where they are needed.
This is shown in the diagram below.
(From: Pathologic Basis of Disease)

Dietary sources
The best sources of iron include:
• Dried beans
• Dried fruits
• Eggs (especially egg yolks)
• Iron-fortified cereals
• Liver
• Lean red meat (especially beef)
• Oysters
• Poultry, dark red meat
• Salmon
• Tuna
• Whole grains
•
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Iron from vegetables (broccoli, spinach), fruits, grains, and supplements is harder for the body to absorb.
If you mix some lean meat, fish, or poultry with beans or dark leafy greens at a meal, you can improve
absorption of vegetable sources of iron up to three times. Foods rich in vitamin C also increase iron
absorption.
Some foods reduce iron absorption. For example, commercial black or pekoe teas contain substances
that bind to iron so it cannot be used by the body.
Absorption and Storage

Absorption - Iron is absorbed from all parts of the small intestine, mostly by the following
mechanism.The liver secretes moderate amounts of apotransferrin into the bile which flows through the
bile duct into the duodenum. Here, the apotransferrin binds with free iron and also with certain iron
compounds, such as hemoglobin and myoglobin from meat, two of the most important sources of iron in
the diet. This combination is called transferrin. It, in turn, is attracted to and binds with receptors in the
membranes of the intestinal epithelial cells. Then, by pinocytosis, the transferrin molecule, carrying its
iron store, is absorbed into the epithelial cells and later released into the blood capillaries beneath these
cells in the form of plasma transferrin.
Storage of iron is in the liver, spleen and bone marrow. Iron is most abundant in the blood.
Iron deficiency
Iron deficiency is the commonest cause of anaemia world-wide. It is also the commonest cause of a microcytic
hypochromic blood. Iron is needed in the early normoblast step wherby haemoglobin is formed.
Causes of iron deficiency are:

• chronic blood loss (e.g. peptic ulcer; carcinoma of stomach, caecum, colon or rectum; menorrhagia)
• increased requirements (e.g. in childhood and pregnancy)
• malabsorption (due to gastrectomy)
• malnutrition.
2. Vitamin B12
Vitamin B12, also called cobalamin, is a water soluble vitamin with a key role in the normal functioning
of the brain and nervous system, and for the formation of blood. It is also needed for DNA synthesis and
division and maturation of RBC’s. Vitamin B12 was discovered from its relationship to the disease
pernicious anemia, which is an autoimmune disease that destroys parietal cells in the stomach that
secrete intrinsic factor. Intrinsic factor is crucial for the normal absorption of B12, so a lack of intrinsic
factor, as seen in pernicious anemia, causes a vitamin B12 deficiency.
Dietary sources
Vitamin B12 is found in foods that come from animals, including:
• fish and shellfish
• meat (especially liver)
• poultry
• eggs
• milk and milk products

Absorption of vitamin B12 actually begins in the mouth, where small amounts of unbound crystalline B12
can be absorbed through the mucous membrane. Protein-bound vitamin B12 must be released from the
proteins by the action of digestive proteases in both the stomach and small intestine. Gastric acid
releases the vitamin from food particles. Once the vitamin B12 is released from the proteins it is bound
to intrinsic factor which helps in absorption.
Storage of vitamin B12 is in the liver.
3. Folic Acid
Folic acid or folacin is a yellow crystalline complex needed for normal RBC production together with
vitamin B12 as well as in DNA synthesis. The active form is folinic acid.
Dietary sources
Foods with folic acid in them include:
• Leafy green vegetables
• Fruits
• Dried beans, peas and nuts.
• Enriched breads, cereals and other grain products also contain folic acid.
• Liver and liver products also contain high amounts of folate
• Kidney
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Absorption of folic acid occurs mostly in the small intestine.
Storage – folic acid is stored in the liver.
Folate and Vitamin B12 deficiency
Folate and vitamin B12 (cobalamin) are essential for DNA synthesis as wells as for maturation and division of
RBC’s. Deficiency of either impairs cellular regeneration; the effects are seen most severely in haemopoietic
tissues, resulting in megaloblastic changes and macrocytic anaemia (the RBC’s are macrocytic and
normochromic). In addition, vitamin B12 deficiency also causes subacute combined degeneration of the spinal
cord. If there is less of folic acid, the RBC’s are replaced with larger multinucleated cells and leads to
megaloblastic anaemia.
Folate deficiency may result from:

• dietary insufficiency (principal source is fresh vegetables)
• intestinal malabsorption (e.g. coeliac disease-Ch. 15)
• increased utilisation (e.g. pregnancy, tumour growth)
• anti-folate drugs (e.g. methotrexate).
Vitamin B12 deficiency may result from:

• autoimmune gastritis resulting in loss of intrinsic factor, thus causing pernicious anaemia
• surgical removal of the stomach (e.g. gastric cancer)
• disease of the terminal ileum, the site of absorption (e.g. Crohn's disease-Ch. 15)
• blind loops of bowel in which there is bacterial overgrowth
• infestation with Diphyllobothrium latum, a parasitic worm.
Note: If all three nutrients ie Iron, Vit B12 and Folic acid are deficient then the RBC’s will be macrocytic and
hypochromic.
Haemolytic anaemia
Haemolysis refers to the breakdown of erythrocytes and releasing its components into the blood plasma.
Hemolytic anemias share the following features:
• A shortened red cell life span (normal = 120 days); that is, premature destruction of red cells
• Elevated erythropoietin levels and increased erythropoiesis in the marrow and other sites, to
compensate for the loss of red cells (hence there will be an increased reticulocyte count more than 2%)
• Accumulation of the products of hemoglobin catabolism, due to an increased rate of red cell destruction
The physiologic destruction of senescent red cells takes place within the mononuclear phagocytic cells of the
spleen. In the great majority of hemolytic anemias, the premature destruction of red cells also occurs within the
mononuclear phagocyte system (extravascular hemolysis), which undergoes a form of work-related hyperplasia
marked by splenomegaly.
Much less commonly, lysis of red cells within the vascular compartment (intravascular hemolysis) predominates.
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Reticulocyte
Reticulocytes are immature red blood cells, typically composing about 1% of the red cells in the human body.
Reticulocytes develop and mature in the red bone marrow and then circulate for about a day in the blood stream
before developing into mature red blood cells.
Like mature red blood cells, reticulocytes do not have a cell nucleus. They are called reticulocytes because of a
reticular (mesh-like) network of ribosomal RNA that becomes visible under a microscope with certain stains such
as new methylene blue.
Reticulocyte Count
A reticulocyte count is a blood test that measures how fast red blood cells called reticulocytes are made by the
bone marrow and released into the blood. Reticulocytes are in the blood for about 2 days before developing into
mature red blood cells.
Normal count (adults) – 0.5 – 1.5%
The reticulocyte count rises when there is a lot of blood loss or in certain diseases in which red blood cells are
destroyed prematurely, such as hemolytic anemia. Also, being at high altitudes may cause reticulocyte counts to
rise, to help you adjust to the lower oxygen levels at high altitudes.
A decreased reticulocyte count indicates renal failure which leads to inability to produce erythropoietin and hence
decreased number or reticulocytes and RBC’s (decreased blood production will be the cause of anaemia in this
case).
Why It Is Done
A reticulocyte count is done to:
• See whether anemia is caused by fewer red blood cells being made or by a greater loss of red blood
cells.
• Check to see if treatment for anemia is working. For example, a higher reticulocyte count means that
iron replacement treatment or other treatment to reverse the anemia is working.
Causes of Anaemia
Anaemia can be caused by many different mechanisms. These will be discussed below.
Anaemia due to Decreased Erythropoiesis

Anaemia can be caused due to decreased production of RBC’s. This reduction can either be due to intrinsic or
extrinsic causes. This form of anaemia can take many forms.
The common type of anaemia is megloblastic anaemia (see macrocytic anaemia above). Megloblastic anaemia
usually shows the classic macrocytic cells in a blood smear (see diagram on page 11). The large, ovoid cells
lacking the central pallor are characteristic of this type of anaemia. This form of anaemia also shows hyper
segmented neutrophils (see diagram below)
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Blood Smear of Megaloblastic Anaemia- Note the cells with a circle drawn around them.
Hyper-segmented neutrophil
(From: Pathologic Basis of Disease-Modified)
This type of anaemia can be caused due to the following:

o Vitamin B12 deficiency either due to reduced intake or impaired absorption
o Folic acid deficiency by decreased intake, increased requirements, impaired absorption, increased loss
and impaired utilization.
Anaemia due to Vitamin B12 deficiency

• This is a form of megaloblastic anaemia associated with the impaired maturation of RBC’s.
• Vitamin B12 is the essential micronutrient that helps to form thymidine triphosphate, a building block of
DNA.
• Lack of this nutrient therefore impairs the rate of production as well as that it causes the erythrocyte to
have a flimsy membrane thereby having a lifespan of only half or one third of the normal lifespan.
• Vitamin B12 is first absorbed in the ileum by the brush borders of the microvilli as a vitamin-intrinsic
factor complex by pinocytosis.
• This intrinsic factor is produced by parietal cells of the stomach gastric glands. Therefore in the event of
Vitamin B12 deficiency anaemia an underlying GI Tract problem particularly atrophy of the gastric
mucosa should be suspected.
• The vitamin B12 is then carried to the liver where is stored and released when needed. Since the body
can store about 1000 times the required amount of 1-3µg this form of anaemia usually only shows after
a prolonged period of deficiency.
Anaemia due to Folic Acid Deficiency

 Folic acid is needed by the body in the same way as vitamin B12 therefore both forms of anaemia show
the characteristics of megaloblastic anaemia (see page 11 for blood smear).
 The only source of folic acid for this use is through the food intake. This is usually sufficient (50-
200µg/day) in most people except in those using folic acid antagonists and chronic alcoholics.
 The richest sources of folic acid are the green vegetables. These vegetables must however be eaten
raw or partially cooked as heat destroys 95% of the total folic acid content.
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Iron deficiency anaemia
This form of anaemia is the most common nutritional disorder in the world. Blood smears of iron deficiency
anaemia shows hypochromatic cells (see page 13), the amount of which depends on the severity of the anaemia.
Blood smear of iron deficiency anaemia-notice the microcytic and hypochromatic cells.
From: Pathologic Basis of Disease)
Anaemia can also occur if the homeopoietic cells are damaged or in extreme cases absent completely from the
red bone marrow.
This can happen in cases of chronic diseases such as rheumatoid arthritis and also in cases of metastasis of
cancer when the cancerous tissue infiltrates the bone.
Haemolytic Anaemia
Red blood cells have a lifespan of 120 days. In haemostasis and without disease the rate of production equals
destruction but certain conditions can lead to increased destruction of the RBC’s.
As destruction exceeds the production rate it is compensated by erythropoiesis but when the available nutrients
run out the production decreases or the blood cells do not mature and this leads to anaemia. The increased
destruction also directly leads to a low RBC count.
Anaemia from Blood Loss

As blood is lost the nutrients needed are lost together with loss of RBC’s that are replaced by the compensatory
mechanism using EPO.
However this requires about five days and if blood loss is continued it can lead to depletion of the iron sources
and lead to iron deficiency anaemia.
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1. Describe causes of anemia that result from a problem of production.
Causes of anemia that result from a problem of production include those that arise from nutritional
deficiencies. Iron deficiency, folic acid deficiency, and vitamin B12 deficiency are by far the most common
causes of anemia due to inadequate production.
Another possible production problem would arise from damage to the marrow itself from a toxin or from an
unknown cause resulting in hypoplastic or aplastic anemia.
A marrow infiltrated by cancer cells which had spread to it from elsewhere would also result in inadequate
production leading to anemia: normal blood-producing marrow cells are replaced by cancer cells.
2. Describe the role of folic acid, and food sources which contain it.
Folic acid is necessary for DNA synthesis in the nucleus of the red cell during normal RBC production. (The
nucleus is removed from the red cell before it emerges from the bone marrow and enter the circulation). Folic
acid is found in green leafy vegetables and liver.
3. Describe the role of vitamin B12, and food sources which contain it.
Folic acid is necessary for DNA synthesis in the nucleus of the red cells during normal RBC production.
Vitamin B12 is found only in animal sources, is not found in vegetables, and can't be synthesized by the
human.
4. Describe the role of iron, and food sources which contain it. Explain the difference between heme
and non-heme iron.
Iron is the central atom of the heme molecule of hemoglobin, necessary for the binding of oxygen by
hemoglobin. Iron deficiency leads to decreased production of hemoglobin. Iron is found in green leafy
vegetables as well as in animal sources (meat, chicken, fish.
5. List 5 factors that predispose children to iron deficiency anemia in the Pacific. Describe how each
leads to iron deficiency.
i.) Poor diet (i.e. a diest lacking iron-containing foods): there is a normal obligatory loss of iron each day
in the stool, which must be replaced in the diet. If it is not replaced, the body's iron stores are
depleted, eventually leading to anemia.
ii.) Hookworm infestation: hookworm latches on to the intestinal mucosa, essentially sucks blood and
ingests it. This results in a loss of iron, which if not replaced, leads eventually to anemia.
iii.) Poor weaning habits: breast milk provides an adequate amount of iron for infants up to 6 months of
age, at which point weaning foods which contain iron must be added to the diet. This is a variation on
the first cause.
iv.) Low-birth weight babies: "iron stores" in infancy are essentially made up of high hemoglobin that
newborns are born with (which is the result of the low pO2 in utero, making necessary a high
hemoglobin, and hence a high oxygen-carrying capacity). Once born, this high hemoglobin is no
longer necessary. RBCs break down, the iron is recaptured and stored, and the store is usually
sufficient for the first 6 months of life. Newborns of low birth weight, however, also have less blood.
They gain weight more quickly than their non-low-birth-weight peers, and so more quickly outstrip the
stores of hemoglobin, becoming anemic sooner.
v.) Introduction of cow's milk and excessive tea drinking in some populations: cow's milk is notoriously
low in iron content, and may also actually cause microhemorrhaging in the intestine in the first 6-12
months of age. Tea inhibits absorption of iron in the intestine.
6. List foods that are rich in iron and available in the Pacific.
Rourou, bele, roasted nuts (peanuts), dried peas and beans, oatmeal, starchy root crops, liver (of any
animal), fish, red meat.
7. Describe 2 causes of anemia that result from blood loss.

The most common cause of anemia due to blood loss is seen in women of reproductive age. The monthly
menstrual cycle results in an obligatory loss of blood each month, which involves a loss of iron as well, which
must be replenished with a diet which contains adequate amounts of iron. (It is the unreplaced loss of iron
each month, rather than frank blood loss, which leads to anemia).
8. Describe two causes of anaemia that result from increased breakdown of red blood cells.
- Malaria due to a parasite invading and destroying red blood cells.
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- Any type of haemolytic anaemia in which red blood cells are destroyed in unusually large numbers due
to antibodies formed against them or due to drug induced haemolysis which is seen in some people
after taking certain medications.
9. Explain how infestation with the hookworm parasite leads to anaemia.
In the intestine, this parasite acts much like a vampire and sucks blood from the host. One adult worm sucks
an average of 0.05 ml of blood every day. Anaemia is caused by this chronic blood loss which results in a
loss of iron as well and results in iron deficiency anaemia.
10. Briefly describe the lifecycle of the hookworm parasite. What do hookworm ova in a stool specimen
look like when viewed under the microscope? How do hookworm ova found on examination of stool
relate to the lifecycle of the hookworm?
Eggs in human faeces drop to the ground where they hatch. The hatched larva burrows through the sole of
the feet/palms of the hands and enters the circulation. From the circulation they lodge in the pulmonary
capillaries, burrow into the alveoli and migrate up the trachea. They are then swallowed by the host, pass
through the stomach and into the intestine and the adult worm lodges in the small intestine. They release
their eggs into the bowel and the cycle continues.
11. Explain the risk factors for hookworm infestation.

Hookworm ova are found on the ground and get there from unsatisfactory sanitation in a community. This
situation is then compounded by not wearing shoes.
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Epidemiology
Highlights of the National Nutritional Survey: 1993
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Epidemiology of Anaemia
Basics of Epidemiology
Epidemiology is derived from the Latin words epi (among), demos (people) and logos (study). Thus epidemiology
is the study of distribution and determinants of health related states or events in s specified population and the
application of this study to the control of health problems (John M Last, 1988)
Distribution of Disease
This is studying the distribution of a particular disease; the increase and decrease of the disease over a
timespan, differences of disease in subgroups of a community, differences between age groups and sex.
Distribution of Anaemia
Anaemia is the most prevalent in the following groups:
1. Pregnant women
2. Young women
3. People over 50
4. Children
5. Adolescents
6. Vegetarians
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Implications of Iron and Other Nutritional Deficiencies in the Pacific
Major Island Foods that Contain Iron, Vitamin B12 and Folic Acid
Food sources of Vitamin B12
• Liver
• Fish and other seafood eg. shrimps and shellfish
• Lean red meat eg. lamb
• Sardines
• Poultry
• Eggs
• Milk and milk products
Food sources of Folic Acid
• Leafy green vegetables

• Fruits eg. citrus fruits, melons
• Enriched breads, cereals and other grain products also contain folic acid.
• Liver
• Kidney
• Beans and legumes
• Wheat bran and other whole grains
• Dark green leafy vegetables
• Poultry
• Pork
• Shellfish
NB: psychomotor performance – the coordination of sensory and motor functions will also be lowered especially
in babies delivered from anaemic mothers as well as anaemic children due to mostly iron deficicency as
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1. What are some of the richest sources of iron in the diet?
Whole-grain cereals, molasses, legumes, and dark green leafy vegetables; as well as liver, red meat, and
pork.
2. Explain the difference between iron from animal sources and iron from vegetables.
Bioavailability of iron in animal food sources, which is heme-iron, is greater than the bioavailability of iron in
vegetable food sources, which is non-heme iron. (Bioavailability has to do with the ability of the body to
absorb the substance from the intestine). This means that a greater amount of iron in vegetable sources
must be taken in, in order to get the same effect as a smaller amount of iron in meat or liver.
3. List some functions of iron.

Iron forms part of hemoglobin in the red blood cells, myoglobin in muscle cells, and cytochromes which are
components of the electron-transport chain in mitochondria. Iron also functions as a cofactor for some
enzymes, including those involved in the synthesis of collagen and various neurotransmitters. Iron is also
needed for immune function, and plays a role in drug detoxification pathways.
4. List and explain some of the causes of anemia.

Causes of anemia include blood loss associated with menstruation, and parasitic infections such hookworm.
But an inadequate intake of iron appears to be the main cause (i.e. hookworm and menstruation would not
cause anemia if the iron lost in these ways was replaced with an adequate amount of iron in the diet).
Deficiencies of dietary essentials such as folic acid, vitamin A, vitamin C, riboflavin, and various minerals can
also contribute to anemia.
5. What are the signs and symptoms of iron deficiency anemia?

The main signs and symptoms are: paleness of the tongue, and inside the lips, tiredness and
breathlessness.
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Hookworms
Key facts
• Soil-transmitted helminth infections are caused by different species of parasitic worms.
• They are transmitted by eggs present in human faeces, which contaminate the soil in areas where
sanitation is poor.
• Approximately 1.5 billion people are infected with soil-transmitted helminths worldwide.
• Infected children are physically, nutritionally and cognitively impaired.
• Control is based on:
o periodical deworming to eliminate infecting worms
o health education to prevent re-infection
o improved sanitation to reduce soil contamination with infective eggs.
• Safe and effective medicines are available to control infection.
Global distribution and prevalence
More than 1.5 billion people, or 24% of the world’s population, are infected with soil-transmitted helminth
infections worldwide. Infections are widely distributed in tropical and subtropical areas, with the greatest numbers
occurring in sub-Saharan Africa, the Americas, China and East Asia.
Over 270 million preschool-age children and over 600 million school-age children live in areas where these
parasites are intensively transmitted, and are in need of treatment and preventive interventions.
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Transmission
Soil-transmitted helminths are transmitted by eggs that are passed in the faeces of infected people. Adult worms
live in the intestine where they produce thousands of eggs each day. In areas that lack adequate sanitation,
these eggs contaminate the soil. This can happen in several ways:
• eggs that are attached to vegetables are ingested when the vegetables are not carefully cooked,
washed or peeled;
• eggs are ingested from contaminated water sources;
• eggs are ingested by children who play in the contaminated soil and then put their hands in their mouths
without washing them.
In addition, hookworm eggs hatch in the soil, releasing larvae that mature into a form that can actively penetrate
the skin. People become infected with hookworm primarily by walking barefoot on the contaminated soil.
There is no direct person-to-person transmission, or infection from fresh faeces, because eggs passed in faeces
need about 3 weeks to mature in the soil before they become infective. Since these worms do not multiply in the
human host, re-infection occurs only as a result of contact with infective stages in the environment.
Means of transmission are namely:
1. faecal-oral transmission of eggs or larvae passed in the faeces of one host and ingested with food/water by
another (e.g. ingestion of Trichuris eggs leads directly to gut infections in humans, while the ingestion of
Ascaris eggs and Strongyloides larvae leads to a pulmonary migration phase before gut infection in
humans).
2. transdermal transmission of infective larvae in the soil (geo-helminths) actively penetrating the skin and
migrating through the tissues to the gut where adults develop and produce eggs that are voided in host
faeces (e.g. larval hookworms penetrating the skin, undergoing pulmonary migration and infecting the gut
where they feed on blood causing iron-deficient anaemia in humans).
3. vector-borne transmission of larval stages taken up by blood-sucking arthropods or undergoing

amplification in aquatic molluscs (e.g. Onchocerca microfilariae ingested by blackflies and injected into new
human hosts, Schistosoma eggs release miracidia to infect snails where they multiply and form cercariae
which are released to infect new hosts).
4. predator-prey transmission of encysted larvae within prey animals (vertebrate or invertebrate) being eaten
by predators where adult worms develop and produce eggs (e.g. Dracunculus larvae in copepods ingested
by humans leading to guinea worm infection, Taenia cysticerci in beef and pork being eaten by humans,
Echinococcus hydatid cysts in offal being eaten by dogs).
How does hookworm lead to anaemia
The most serious consequence hookworm infection is chronic blood loss from the small intestine leading to the
development of iron deficiency anaemia. This is because the hookworms suck the blood from your small intestine
which is rich in iron and other micronutrients. Hence these are taken up by them leading to micronutrient
deficiency such as iron and vitamin B12 leading to anaemia.
Life cycle of the hookworm
The hookworm life cycle:
• Adult worms live in the lumen of the small intestine, where they attach to the intestinal wall with resultant
host blood loss.
• Eggs are passed in the stool, and under favorable conditions (moisture, warmth, shade), hatch in 1 to 2
days.
• Larvae are released, grow in the feces and/or the soil, and after 5 to 10 days (and two molts) have
become filariform (L-3) larvae that are infective.
• These infective larvae can survive 3 to 4 weeks in favorable environments.
• On contact with the human host, the larvae penetrate the skin and are carried through the veins and the
heart to the lungs.
• They penetrate into the pulmonary alveolae, ascend the bronchial tree to the pharynx, and are
swallowed.
• Upon reaching the small intestine, they undergo two more molts yielding fourth stage larvae (L4) and
then adult worms.
• Five weeks or more are required from invasion by the L3 to oviposition by the adult female.
• Most adult worms are eliminated in 1 to 2 years, but longevity records can reach several years.
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Summary: Hookworms, or nematode larvae, hang out in contaminated soil until they encounter a host : you. Then
they penetrate your skin, go for a swim in your bloodstream where they can travel to other areas, such as your
lungs, eventually ending up in your small intestine and subsisting off your blood. Over time, someone infected
with hookworms can develop anemia and become chronically fatigued. Some A. duodenale larvae, following
penetration of the host skin, can become dormant (in the intestine or muscle!). In addition, infection by A.
duodenale may probably also occur by the oral and transmammary route. (N. americanus, however, requires a
transpulmonary migration phase.)
(Hookworm Life Cycle)
How does someone contract hookworm
Hookworm eggs are passed in the feces of an infected person. If the infected person defecates outside (near
bushes, in a garden, or field) of if the feces of an infected person are used as fertilizer, eggs are deposited on
soil. They can then mature and hatch, releasing larvae (immature worms). The larvae mature into a form that can
penetrate the skin of humans. A person can get hookworms if they don't have the right protect: not wearing shoes
when outside or digging with your hands in damp soil. Upon contact with human skin (such as walking barefoot
outdoors) the larvae latch on and burrow into the skin. After entering the blood vessels, the tiny larvae are carried
to the heart and then the lungs
Risk factors for hookworm infestation
• Poor sanitation
• Inadequate personal hygiene
• Use of human feces as fertilizer
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What can be done to decrease the risk of hookworm infestation
• Treating the Environment: The larvae of hookworms can live several weeks in cool, moist soil, but die
rapidly in freezing or hot, dry conditions. Yards and kennels should be cleaned daily. All fecal material
should be removed, since organic material will decrease the effectiveness of cleaning solutions. A
bleach solution of 3 cups of household bleach to a gallon of cool water should be sprayed or mopped on
the area. Any feces in yards should be picked up on a daily basis. Flaming the surface soil can kill the
larvae. Gravel runs are best treated with sodium borate applied at the rate of 10 lbs/100 sq. ft (lbs
means pounds). (Sodium borate will kill vegetation.) Since mice and other rodents can serve as
transport hosts, their control is important. Remember that mouse and rat poisons are poisons for dogs,
cats, and other animals as well.
• Good hygiene: To prevent human infection, good hygiene is extremely important. Teach children,
especially, to wash their hands after playing and before eating. Do not let children play in areas where
dogs or cats may have defecated. Do not allow cats to use sandboxes or the garden as litter boxes.
Animals should not be allowed to defecate on beaches and people should not walk barefoot through the
sand.
• Having protective wear: having proper footwear when walking on the ground rather than walking
barefoot. When gardening, wear shoes and gloves.
• Proper sanitary facilities: Having proper toilets for passing of feces and not using the bush or the yard
when passing feces.
The curative mechanism:

1. Mebendazole is one of the three most common hookworm medications prescribed today. It’s
commercial brand name is Vermox, and it may be administered in one of two ways. Vermox may be
taken as a one time dose of 500mg or taken as 100mg twice a day for three days. If hookworm isn’t
gone in 3-4 weeks, a second dose may be required. Mebendazole is usually administered only to
humans.
2. Albendazole is the second most common hookworm treatment prescribed by physicians these days.
Its commercial brand name is Albenza. It is usually taken as a 400mg dose only once, but for
children it is often taken in 200mg doses for three days and then repeated after three weeks to
ensure that the hookworm infection is absolutely cured. Hookworms can cause serious problems in
small children and the elderly, not the least of which is anaemia.
3. Pyrantel pamoate is used in both humans and pets. Its commercial brand name is Antiminth or Pin-
X. It is also used to cure pinworms. For human patients, the recommended dose is 11mg once a day
for three days.
Implication of Anaemia
1. General implications:
• Decreased activity
• Lowered work capacity
• Low response to exercise
2. Specific implications
a. Pregnant women- low birth weight, preterm delivery and perinatal mortality
b. Infants and children- impaired psychomotor performance, lowered growth rate, lowered intellectual
growth.
Application of the Ottawa Charter
The principles of the Ottawa Charter can be applied to the prevention of anaemia. This can be done in the
following manner:
1. Laws made so that companies produce iron fortified products.

2. Educating school children to eat iron rich food
3. Having school canteen policies so that junk food consumption is reduced
4. Creating awareness in the community
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5. Women should be educated about the food sources that are good for small children
6. Involve restaurants and fast food outlets in the health policy
Hookworms - A Cause of Iron Deficiency Anaemia
Life Cycle of a Hookworm

The generalised life cycle of a soil-transmitted nematode such as the hookworm (Ancylostoma duodenale and
Necator americanus) is summarised in the following diagram.
A hookworm develops as follows. A first stage larva develops from the eggs in faeces that are deposited in soil.
These larvas feed on bacteria and organic wastes and molt into the second stage larva that also feeds. These
then molt to give the infective third stage larva. The third stage larva enter the body through the skin and also by
oral means and establish in the small intestine where they feed on blood.
Morbidity and symptoms
Morbidity is related to the number of worms harboured. People with light infections usually have no symptoms.
Heavier infections can cause a range of symptoms including intestinal manifestations (diarrhoea and abdominal
pain), general malaise and weakness, and impaired cognitive and physical development. Hookworms cause
chronic intestinal blood loss that can result in anaemia.
Nutritional effects
Soil-transmitted helminths impair the nutritional status of the people they infect in multiple ways.
• The worms feed on host tissues, including blood, which leads to a loss of iron and protein.
• The worms increase malabsorption of nutrients. In addition, roundworm may possibly compete for
vitamin A in the intestine.
• Some soil-transmitted helminths also cause loss of appetite and, therefore, a reduction of nutritional
intake and physical fitness. In particular, T. trichiura can cause diarrhoea and dysentery.
The nutritional impairment caused by soil-transmitted helminths is recognized to have a significant impact on
growth and physical development.
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WHO strategy for control
In 2001, delegates at the World Health Assembly unanimously endorsed a resolution (WHA54.19) urging
endemic countries to start seriously tackling worms, specifically schistosomiasis and soil-transmitted helminths.
The strategy for control of soil-transmitted helminth infections is to control morbidity through the periodic
treatment of at-risk people living in endemic areas. People at risk are:
• preschool children,
• school-age children,
• women of childbearing age (including pregnant women in the second and third trimesters and
breastfeeding women),
• adults in certain high-risk occupations such as tea-pickers or miners.
WHO recommends periodic medicinal treatment (deworming) without previous individual diagnosis to all at-risk
people living in endemic areas. Treatment should be given once a year when the baseline prevalence of soil-
transmitted helminth infections in the community is over 20%, and twice a year when the prevalence of soil-
transmitted helminth infections in the community is over 50%. This intervention reduces morbidity by reducing the
worm burden. In addition:
• health and hygiene education reduces transmission and reinfection by encouraging healthy behaviours;
and
• provision of adequate sanitation is also important but not always possible in resource-poor settings.
Morbidity control aims to reduce intensity of infection and protect infected individuals from morbidity through
periodic treatment of at-risk populations.
Periodic deworming can be easily integrated with child health days or supplementation programmes for preschool
children, or integrated with school health programmes. In 2015, over 361 million schoolchildren were treated with
anthelminthic medicines in endemic countries, corresponding to 63% of all children at risk.
Schools provide a particularly good entry point for deworming activities, as they allow the easy provision of the
health and hygiene education component, such as promotion of handwashing and improved sanitation.
WHO recommended medicines
The WHO recommended medicines – albendazole (400 mg) and mebendazole (500 mg) – are effective,
inexpensive and easy to administer by non-medical personnel (e.g. teachers). They have been through extensive
safety testing and have been used in millions of people with few and minor side-effects.
Both albendazole and mebendazole are donated to national ministries of health through WHO in all endemic
countries for the treatment of all children of school age.
Global target
The global target is to eliminate morbidity due to soil-transmitted helminthiases in children by 2020. This will be
obtained by regularly treating at least 75% of the children in endemic areas (an estimated 873 million).
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1.05 Anemia

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1.05 Anemia

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Manish KUMAR (s170203)

Module: Blood- Anaemia

What are the components of Blood?

▪ Blood is a connective tissue

Physical Characteristics of Blood

Blood Plasma Formed Elements

Components of Blood in a Normal Adult

Source: Book of Anatomy and Physiology; Tortora 14th Edition

(From: Principles of Anatomy and Physiology)

Difference between plasma and serum:

White Blood cells (leukocytes)

Erythrocyte/ Red Blood Cell

2. Control the pH of the blood by acting as an acid-base buffer.

Functional Anatomy of the Erythrocyte

Quantity of RBC in the Human Body

Structure of Red Blood Cells

Hematocrit- percentage of total blood volume occupied by RBC’s.

Structure of RBC’s and Haemoglobin

Trigger for RBC Production

Why it is important for Oxygen to be carried by haemoglobin?

Important substances involed in RBC production

▪ erythropoietin, a glycoprotein with a molecular weight of about 34,000

Role of VITAMIN B12 /FOLLIC ACID

Reticuloendothilial System (RES)

 These then produce the erythrocytes.

Clinical Connection: Haematocrit

Diagram of RBC Formation

Pluripotent Stem Cells

Myeloid Stem Cells

Its takes some 5- 7 days in the production of erythrocytes.

This occurs as follows:

1. Macrophages phagocytise the ruptured and worn out RBC’s

RBC Life cycle

Areas of the Body That Produce Red Blood Cells.

• Disseminated intravascular coagulation (DIC): An uncontrolled process of simultaneous bleeding and

1. List the factors that maintain red cell size.

3. Describe the hemoglobin molecule.

4. Why is hemoglobin carried in RBCs, and not dissolved in the plasma?

8. The RBC contains no mitochondria. What is the advantage of this?

Pathophysiology of Faeces Production in relation to the RBC degradation

Clinical Manifestations and Effects of Anaemia

1. Functions of Red Blood Cells

- Haemoglobin aids in maintaining pH by binding to H+ ions. (acts as a buffer system)

- Nitric oxide is released by RBC to cause vasodilation

3. What Colour is Blood?

Normal blood is red in colour.

4. What gives it this colour?

7. What would be the Clinical Effects of Insufficient RBC?

Clinical Manifestation of Anaemia

A patient with anaemia may present with the following:

Complications of Chronic Anaemia

The complications of anaemia include:

• Damage to kidneys and liver: haemolytic anaemia

9. Complications of Chronic Anaemia

If a child has chronic anaemia, what would be the effect in terms of

Anaemia is serious problem especially during pregnancy

1. How is a sign different from a symptom?

What Investigations could be done to Determine the Cause of Anaemia?

1. The Haemoglobin Level

• Refers to concentration of the haemoglobin in the blood.

• The unit of measurement used: g/dL (1x10-1) or gm%

• Normal Values of Haemoglobin Level- Male: 13.6-17.2g/dL, Female: 12-15g/dL

2. The Hematocrit (Hct)- Packed Cell Volume(PCV)

• Refers to the percentage of RBC in the blood or RBC mass volume

How Hb Level and Hematocrit are related?

3. The Red Blood Cell Indices

4. The Mean Cell Volume (MCV)

MCV (1x10-15) = PCV x10

5. Mean Cell Haemoglobin (MCH)

MCHC (%) = Hb x 100

Normal Values: 33-37%

7. The Blood Film – The Peripheral Blood Smear

 If the RBC is normochromic, normocytic, then anaemia is due to blood loss.

✓ Lack of iron in the diet

✓ Improper absorption of iron due to problem in gastric mucosa

The peripheral blood smear