ANEMIA

Tim Lee
7/26/2019
Olivo Medical Wellness
CC/HPI

■ CC: Dizziness x 2-3 months

■ HPI:
– 75 y/o HM w/ PMHx of vitiligo
– Dizziness x 2-3 months, worsened in the last 2 weeks
– Exacerbated by standing and movement and improved by lying
down
– Denies any LOC, numbness, tingling, headaches, falls, and weight
loss
– No medications
ROS/Hx

■ ROS:
– Constitutional: no chills, fever, or fatigue
– Head: dizziness, no headache or fainting
– Eyes: no blurry or double vision
– Respiratory: no cough or SOB
– CV: no chest pain, palpitations, or swelling of legs
– Neuro: no blackout, LOC, or tingling
■ PMHx: vitiligo
■ SHx:
– Cigarettes: 570 pack-years
– Alcohol: used to drink 6-12 beers a day until 3 years ago
Physical Exam/Labs

■ Vitals: BP – 123/52; Pulse – 77; Temp – 98.3; RR – 18; SpO2 – 98%

■ General appearance: awake, alert, well developed, well groomed
DDx: Approach to Anemia
ED/HOSPITAL
■ Dx:
– CBC, Chem, Iron, B12, folate
– Smear: hypochromic erythrocytes, no schistocytes or other
evidence of hemolysis
– Hemolysis w/u: haptoglobin, retic count, LDH
– Rectal Guaiac – negative
– EKG: HR 70’s, sinus rhythm, ST segment and T wave
abnormalities in I and AVL, no ectopy
– Imaging: CXR
■ Admission – severe blood loss
DDx/Plan
■ DDx:
– B12/folate deficiency
– Myelodysplastic syndrome
– GI malignancy
– Occult bleeding (gastritis/peptic ulcer)
– Cirrhosis/hepatitis
■ Rx:
– Protonix 40mg qd
– Transfuse 2 units PRBC -> keep Hb > 7
■ Dx:
– EGD
– Hepatitis panel
 World J Gastroenterol. Apr 7, 2018; 24(13): 1419-1428
Published online Apr 7, 2018. doi: 10.3748/wjg.v24.i13.1419

EGD

■ Chronic atrophic gastritis

■ Stomach bx: intestinal metaplasia, mild chronic gastritis; negative for dysplasia, H. pylori
■ Duodenum bx: superficial duodenal mucosa with preserved villous architecture, no
significant increase in intraepithelial lymphocytes
Langan, RC and Goodbred, AJ. Am Fam Physician. 2017 Sep 15;96(6):384-389.
Coombs (Direct vs Indirect)

Evan M. Braunstein, MD, PhD. Autoimmune Hemolytic Anemia. Merck Manuals.

https://www.merckmanuals.com/professional/hematology-and-oncology/anemias-caused-by-
hemolysis/autoimmune-hemolytic-anemia# Accessed 20 Jul 2019.
DISCHARGE SUMMARY

■ Warm autoimmune hemolytic anemia combined w/ B12 deficiency

■ Discharge:
– Cyanocobalamin 1000mcg qd x 30 days
– Folate 1mg qd x 30 days
– Prednisone 20mg tid x 7 days, taper
■ Follow up w/ Heme and GI
Autoimmune hemolytic anemia (AIHA)

Warm > 37ºC Cold < 37ºC

Etiology Primary: idiopathic Idiopathic (chronic)
Secondary: SLE, CLL, drugs Infectious (acute)
Lymphoproliferative
Autoantibodies IgG IgM
SSx Severe anemia – CP, syncope, HF, Mild hemolytic anemia + cryopathic sx
mild splenomegaly (Raynaud syndrome, acrocyanoses)
Dx peripheral smear, retic count, LDH + direct antiglobulin test (DAT)
Rx Blood transfusion IF severe, IVIG, Avoidance of cold, treat underlying
corticosteroids disorder
Pernicious anemia

■ Epi: all age groups, most frequently > 60; US prevalence 151/100,000;
European/African > Asian decent
■ Pathophys: IF antibody and PCA
■ SSx:
– Heme: pallor, fatigue, dizziness, lightheadedness, tachycardia, SOB
– GI: abdominal pain, LOA, weight loss, diarrhea
– Neuro: PN, paresthesia, weakness, ataxia, forgetfulness, psychosis
■ Dx: CBC, B12, peripheral smear -> IF antibody, PCA, Schilling test?
■ Treatment: 1000mcg B12 IM or PO
■ Complications: pancytopenia (BM suppression), thromboembolic events, glossitis,
subacute combined degeneration
SOURCES

■ Bross, M. Am Fam Physician. 2010 Sep 1;82(5):480-487.

https://www.aafp.org/afp/2010/0901/p480.html
■ Braunstein, E. Autoimmune hemolytic anemia. Merck Manuals. 2019 Mar.
https://www.merckmanuals.com/professional/hematology-and-oncology/anemias-
caused-by-hemolysis/autoimmune-hemolytic-anemia
■ Langan, R. Am Fam Physician. 2017 Sep 15;96(6):384-389.
https://www.aafp.org/afp/2018/0915/p354.html
■ Philips, J. Am Fam Physician. 2018 Sep 15;98(6):354-361
https://www.aafp.org/afp/2017/0915/p384.html