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Anemia 101Case Studies
Peter A. Kouides MD
Associate Professor of Medicine,
University of Rochester School of Medicine
Attending Physician,
The Rochester General Hospital
Anemia classification based on the mechanism
• Kinetic Classification (based on retic count)
– Decreased production
• Morpholgical classification (based on MCV)
– Microcytic
– Normocytic
– Macrocytic
– Increased destruction
• Immunological classification (based on Coomb’s test)
– Immune-mediated
– Non-immune mediated
The Medical Student’s Approach to Anemia
1. Check the reticulocyte count to determine if the anemia is from
decreased production (“hypoproliferative”, “reticulocytopenic”) or
increased destruction (“hemolytic”)/acute blood loss (“reticulocytosis”)
2. If decreased production, narrow down the causes in terms of the MCV– If the MCV is low, then do iron studies then Hb electropheresis
– If the MCV is normal, check the serum creatinine and TSH, if they
are WNL then consider bone marrow exam
– If the MCV is high check a folate and vitamin B12 level
3. If the the reticulocyte count is increased– Check a direct Coomb’s test
4. Look at the peripheral blood smear to confirm/support the diagnosis
Anemia Algorithm
• Patient with anemia and decreased reticulocyte countWhat is the MCV ??
B12, Folate
Diseases in Bone
Renal vs. Liver vs.
Endocrine vs.
•Solid Tumor
Anemia of Inflammation •Myeloma
Other: sideroblastic anemia
(meds,PB,Zn excess,Cu def)
•Aplastic anemia
Anemia Algorithm, continued
• Patient with anemia and increased reticulocyte count=
Anemia Algorithm, continued
• Patient with anemia and increased reticulocyte countWhat is the result of a Coomb’s test ??
Extrinsic red cell
Intrinsic red cell
(autoimmune hemolytic anemia)
The Attending’s Approach to Anemia
1. Stool guiacs x 3
2. If the MCV is low, then prescribe iron
3. If the MCV is high, then check a folate level and
vitamin B12 level
– if folate level returns low or “indeterminate”, then
begin folic acid 1 mg po qd
– if B12 level returns low or “indeterminate”, then begin
IM vitamin B12
The Pharmacologist’s Approach to Anemia
(“refractory”) Anemias
with cellular marrow
iron deficiency anemia
anemia of chronic disease
B12 deficiency
folate deficiency
Metastatic tumor
sideroblastic anemia
Thalassemia trait
erythropoietinwith hypocellular marrow
aplastic anemia
renal failure anemia
hypoplastic AML
Case #1-A 67-year-old
man is referred for
evaluation of
dyspnea. The
hematocrit is 28%,
white blood cell
count 4500/mm3,
platelet count
550,000/mm3, and
reticulocyte count
4%. The MCV is 78
and the blood smear
reveals basophilic
stippling and a small
population of
microcytic red cells.
Serum Fe 225, TIBC
260, Ferritin 490
Case #2-Patient H.M.
• A 57-year-old woman presents to the clinic
for evaluation of ataxia, weakness, and
parathesias. The patient has been taking a
multivitamin preparation.
• Hematocrit is 38%
• white blood cell count 4,000; platelet count
• What tests would you order next ?
Case #3- A 65-year-old man
with a Hematocrit of 33%
and a reticulocyte count of
7% is admitted to the
hospital with right upper
quadrant abdominal pain.
Peripheral blood smear
reveals occasional
Case #4- Patient R.B.
• A 26-year-old woman presents
to the hospital with pleuritic
chest pain. She gives a history
of episodic arthralgias for a
number of months, plus one
episode of frank arthritis
involving the small joints of
both hands occurring 2 months
prior to admission. The patient
has a hematocrit of 29%, a
white blood cell count of 4000,
and a reticulocyte count of
12%. The smear reveals
normocytic, normochromic red
blood cells with
polychromatophilia, and
occasional spherocytes,
occaisonal NRBC.
Case #5- Patient F.D.
• A 60-year-old woman is hospitalized because of
severe fatigue and dyspnea of 2 weeks' duration.
Five years ago, the patient had a total
hysterectomy and bilateral salpingooophorectomy for ovarian adenocarcinoma. She
received a course of oral melphalan as adjuvant
Patient F.D. continued
• Three years ago a restaging
laparotomy reveals no evidence
of tumor, and blood counts were
• Now, except for a temperature of
38.4°C (101.1°F) and pallor, she
has normal findings.
• Laboratory studies: Hematocrit
17%, MCV 108 fL. , WBC
4,500, platelet count 50,000,
reticulocyte count 0.8%
MDS vs. Folate/B12 Deficiency
• Think of MDS when the anemic patient is elderly and
the MCV is increased
• in one study of the elderly, MDS was the fourth most
common cause of anemia after:
– acute blood loss/Fe Deficiency
– anemia of chronic disease
– anemia of renal insufficiency
• the B12 level can be borderline low in elderly patients
but it is not true B12 deficiency if– a serum total homocysteine level is normal
– a urine methylmalonic acid level is normal
Case #6- Patient G.D.
• A 28 year-old black man plans a trip to India and
is advised to take prophylaxis for malaria. Three
days after beginning treatment, he develops dark
urine, pallor, fatigue, and jaundice
• Hematocrit is 26% (it had been 43%), MCV 100;
WBC 3.4, Platelets 199,000
Patient G.D. continued
• Reticulocyte count 13%
• What test should be
• And, why do I say
“should” instead of “is
Drugs Causing Anemia
Decreased Production:
Increased Destruction
Anti-Tb drugs=
Sideroblastic Anemia
Valproic acid=
Pure Red Cell Aplasia
AZT, Dilantin= Macrocytic
Qunidine, PCN, Aldomet=
Auto-immune Hemolytic
Dapsone, Pyridium=
G6PD Deficiency
Case # 7
A 21-year-old woman with sickle cell anemia has had a fever and severe pain in
the right shin for 3 weeks. The painful area is hot, swollen, tender and
Case #8
• A 66-year-old-man presents with increased fatigue and anemia.
Hypothyroidism was detected 3 years ago and thyroid hormone
therapy was administered. Anemia was diagnosed 2 years ago, but
findings on bone marrow examination were normal, and there was
no response to oral therapy with iron. Sexual function has
diminished during the last 2 years. He has a blood pressure of 90
Hg systolic and 60 mm Hg diastolic, pallor, absence of axillary
hair, and sparse pubic hair. There is no gynecomastia, but the
testicles are soft, and the prostate gland is small. The result of an
examination of the stool for occult blood is negative. Laboratory
studies: hematocrit 36%, leukocyte count 5800/µL, platelet count
255,000/µL, peripheral blood film - normochromic normocytic
erythrocytes with anisocytosis or poikilocytosis, MCV: 86 fl,
serum creatinine - normal.
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