Iyad Sultan, MD
Tel 079-6102051
Images were taken from this lecture
isultan@khcc.jo
History
• Age: Anemia is most common in toddlers 1-3 years old
and in menstruating teenagers
• Diet: meat, Milk ↓ absorption, tea ↓ absorption, vit C ↑
absorbtion
• Blood loss: Milk allergy, GI problems.
• Perinatal history: maternal diet, jaundice at birth, LBW.
• Pagophagia: the desire to ingest unusual substances
such as ice or dirt indicating iron deficienc
• R.O.S.: Recurrent pain, swelling of hands and feet
(sickle cell anemia).
• Chronic illness, previous infections (anemia of chronic
disease)
• FH of hemolytic anemia: anemia, blood transfusion,
gallstones, G6PD.
P/E
• Pallor. General conditions.
• Vital signs. Height, Weight.
• Irritability.
• Lymphadenopathy.
• Hepatosplenomegaly.
• Stigmata of bone marrow
failure syndrome (Fanconi
anemia): skin pigmentation,
skeletal deformities, short
stature, abnormal faces.
CBC
• Hemoglobin level: is the child anemic?
• WBC ↓ , platelet ↓ : Pancytopenia.
• Indices: MCV –Normocytic,microcytic,
macrocytic.
– Lowest MCV = 70 + age in years
• RDW: RBC disribtution width: Variation in
size of RBCs: Typically increased with iron
deficiency anemia >14.5
• Reticulocyte count Should be appropriately
increased
So … you have a patient with anemia. It is
iron deficiency anemia unless:
• Wrong age ( an adolescent boy with anemia).
• Symptoms suggestive of hemolysis (jaundice,
abnormal urine color).
• FH.
• Abnormal P/E: organomegaly,
lymphadenopathy.
• Severe anemia (Hb<8 gm/dL).
• Normocytic anemia or Low RDW.
• Pancytopenia
• Failure to respond to therapeutic iron trial.
Approach to Anemia
•CBC:MCV, RDW
•Retic
•Blood film
Normocytic Normocytic
Microcytic
Decreased production Increased destruction
•Confirm iron deficiency •Confirm hemolysis.
(ferritin). •Bone marrow •Blood film.
•Search for an etiology aspirate/biopsy. •G6PD.
of Fe deficiency. •Osmotic fragility.
•Hb electropheresis for
•Hb electropheresis
thallassemia
•Coomb’s
•Start PO iron
Iron deficiency anemia
• WHO: approximately 2 billion
people worldwide with iron U.S. data - Fe deficiency
deficiency anemia.
• (UNRWA) reported maternal and 14
infant iron deficiency anemia in 12
50-65% of the Palestinian
population with highest 10
prevalence in infants 6-12 mo. 8
COOK R. UNRWA Annual Report 1990 %
• In 192 preschool children 6
between 3-60 mo of age, 11.5% 4
had subclinical iron def (low
TIBC and/or low ferritin) and 2
34.4% had iron def anemia 0
(hb<10.5). Madanat, F. Acta Haematol 1984 1 year 2 year adolescent women
girls
Anemia (Hb<10.5)
70
60
50
40
%
30 Subject
20 Control
10
0
6mo 9mo 12 mo
Age
Therapeutic Therapeutic
1ml TID 5ml Q day
Prophylactic Prophylactic dose
0.5ml TID 2.5ml PO Qd
No safety cap No safety cap
Supply lasts only for 10 days Supply lasts for 30 days
Unstable>25 C Unstable > 25 C
Response to iron
Time After Iron Response
Administration
12–24 hr Replacement of intracellular iron
enzymes; subjective improvement;
decreased irritability; increased
Appetite
36–48 hr Initial bone marrow response;
erythroid hyperplasia
48–72 hr Reticulocytosis, peaking at 5–7 days
Production
• Normocytic anemia
• Elevated reticulocyte count
• Elevated bilirubin
• Elevated LDH
• Decreased Haptoglobin
• Urine: Blood +ve with no RBCs.
• Blood film
• Specific tests: Direct coomb’s test, G6PD level,
hemoglobin electrophoresis, Osmotic fragility
Case 1
• A 2 year old girl comes to your clinic for
regular checkup.
• Her mother noticed that her color is
different from her siblings.
• Height, weight and HC on 25th percentile.
• Patient is pale with mild icterus.
• Mild splenomegaly (1cm BCM).
• You suspect hemolytic anemia
History
• Headache, fatigue, decreased appetite
• Jaundice, color of urine
• Recent infections
• PMHx:
– Jaundice at birth
– Recurrent infections, rash, arthritis, mouth ulcers
• FHx:
– Hx of gallstones, anemia, Favism, transfusions,
consanguinity, Splenectomy
Labs
• CBC: Hemoglobin 8.3, MCV 67, MCHC 40
g/dL, RDW 16%, Platelet 160k, WBC 7.4,
Lym 61%, Neu 33%
• Reticulocytes: 6%
• Direct Coomb’s –
ve
• Osmotic fragility:
– Increased
Spherocytosis
• caused by a defect in the skeleton of the
RBC membrane that generally affects the
spectrin component.
• HS is the most common cause of
hemolytic anemia in people of Northern
European heritage, with a prevalence of 1
in 5,000,
• Inheritence: Autosomal dominant 75%
Spherocytosis: Management
• Folate supplementation 1mg/d
• Splenectomy
• Cholecystectomy
• PRBCs transfusion
Case #2
• Patient is a 9 month old boy who
presented to your office with severe pallor
and decreased activity.
• No FH, Normal perinatal hx
• History of a “Cold” 2 weeks prior to
presentation
• PE shows mild icterus, pallor, no
hepatosplenomegaly
•CBC: Hemoglobin 5.6, MCV 73, MCHC 31
g/dL, RDW 18%, Platelet 196k, WBC 11.4,
Lym 69%, Neu 22%
•Reticulocytes: 12%
•Direct Coomb’s
+ve
Direct Coomb’s test
Indirect Coomb’s test
Autoimmune Hemolytic Anemia
AIHA : Management
• Hb level: Q4 hours- Q week
• Reticulocyte count, spleen size,
Haptoglobin level
• PRBC transfusion.
• Prednisone 2-10mg/kg/day
5. 10 79 4% 0 3% 25% 0 72%