A Systematic Approach to Anemia

Syllabus by Allan Platt, PA-C, MMSc aplatt@emory.edu www.EmoryPA.org

NORMAL BLOOD
Blood is the life sustaining substance of mankind. Without the circulation of blood in the body,
organs and tissues quickly cease to function and die. Blood is 54% water based plasma, 1% white blood
cells and platelets, and 45% red cells. The blood transports life sustaining elements such as oxygen,
glucose, proteins, vitamins, enzymes, and electrolytes to every living cell in the body through arteries,
veins, and capillaries.
Red Blood Cells
Red blood cells, or erythrocytes, are the predominant cellular component of blood. Red cells
usually make up 45% of the blood volume and are primarily responsible for carrying oxygen from the
lungs to the peripheral tissues and organs returning to the lungs with carbon dioxide as a waste product
to be exhaled. A 170-pound person has about 30 trillion red cells about 300 million in each drop of blood.
The red cell is perfectly designed as a pliable biconcave disc (7 - 8 micron size) to traverse the small
capillary beds (3 - 4 micron size) of the micro vasculature. The red cell contains the oxygen carrying
protein hemoglobin and enzymes for energy production all encased by a semipermeable and pliable lipid
membrane.
Hemoglobin
Hemoglobin is the predominant protein in the red cell with a wonderful design for transporting
oxygen molecules from the lungs for peripheral cellular metabolism and carbon dioxide as a waste
product for exhalation. The normal red blood cell is composed of three types of hemoglobin, type A
(97%), F (1%) or fetal, and A (2%). Fetal hemoglobin, predominant in utero, tightly binds oxygen
2
facilitating transfer from mother to fetus across the placenta. A manufacturing switch occurs at birth to
decrease F and produce A. The most abundant hemoglobin present after one year of life is type A. This
hemoglobin is composed of two beta globin chains and two alpha globin chains bonded to four iron
containing heme groups. Hemoglobin production requires iron , the synthesis of the protoporphyrin ring
and production of the globin chains. Reductions in any of these result in anemias. The globin chains are
protein made up of a precise sequence of amino acids that are coded by genes located on chromosome
16 and chromosome 11 contained in the nucleus of the bone marrow stem cells.
Any alteration of the amino acid sequence or "blue print" on the chromosomes that code the
production of the beta globin chain results in one of the over 600 different types of hemoglobins identified
through out the world. Common variants result from substituting valine for glutamic acid in the 6th
position of the beta chain producing sickle hemoglobin or Hb S and substituting lysine for valine results in
hemoglobin C or Hb C. Other abnormal hemoglobins are formed by other amino acid substitutions.

An inherited deletion or dysfunction of one or more of the alpha or beta gene decreases alpha or
beta chain production causing thalassemia. The degree of decreased production is related to the inability
to manufacture functioning RNA. If alpha chains are reduced alpha thalassemia results and
compensatory increase in hemoglobin H (beta4) and Barts (gamma4). If beta chains are reduced, Beta
thalassemia results with compensatory increase in hemoglobin A2 and F.
Cell Production
In the adult, red cells, white cells and platelets are all manufactured in the axial skeleton bone
marrow factory where stem cells divide and differentiate into the various cell types under regulation by
growth factors. The proper building materials must be supplied to keep the factory producing such as
amino acids, carbohydrates, lipids, vitamin B12, folate, vitamin C, and iron. Most of these elements are
obtained from absorption in the digestive tract of one partaking of a balanced diet, from recycling red cell
breakdown products, and from body stores. Iron is transported to the marrow by transferrin, then once in
the maturing red cell, it is incorporated into the hemoglobin molecule. As the red cell matures and forms
the hemoglobin necessary for it's life span, the nucleus is extruded and a reticulocyte is expelled into the
blood circulation. This juvenile red cell still retains some residual RNA for 2 days that can be identified by
staining with methyline blue. The normal reticulocyte count is between 0.8 and 2.4% of the red cell
number. Increase or decrease reflects red cell production by the bone marrow factory. If intense marrow
Anemia, Platt Page 1

intense marrow stimulation occurs, larger stress reticulocytes or shift cells may be observed on the
peripheral smear. These cells mature after 2 to 3 days in the circulation and may artificially inflate the
reticulocyte count.
The normal red cell has a life span of 120 days. It is metabolized in the reticuloendothelial system
( spleen , liver, and bone marrow) and the iron, amino acids, carbohydrate and lipids are reclaimed.
(Haptoglobin binds free serum hemoglobin released in the blood from red cell lysis for transport to the
reticuloendothelial system.) A breakdown product of hemoglobin is bilirubin which is conjugated in the
liver and excreted in the biliary system into the gut. Isolated increase in indirect, or pre-liver, bilirubin is a
very specific indicator of increased red cell breakdown.
The kidney cells secrete erythropoeitin in response to low tissue oxygen levels. Erythropoeitin
stimulates bone marrow red cell production. This hormonal feedback loop is less responsive to anemia in
renal disease and can cause elevated hemoglobin levels with chronic hypoxia.
The Workup of Anemia and Bleeding
Anemia is clinically suspected by the presenting symptoms and signs of weakness, fatigue,
palpitations, increased heart rate, dyspnea, positional dizziness, syncope, bleeding from any site,
increased or new onset angina. It may be suspected when the physical findings of tachycardia,
orthostasis, pallor, or jaundice are observed. Anemia may be found on the routine diagnostic screening
CBC. The diagnostic approach should contain a thorough history, physical examination and laboratory
evaluation .
HISTORY
- History of melena, abdominal pain, Aspirin or non-steroidal anti-inflammatory agents (NSAIDs) use,
anticoagulant use, past peptic ulcer disease, then consider GI bleeding or platelet dyfunction
- In females the menstrual history quantifying the amount of blood loss, or possible pregnancy
should be obtained.
- History of pica or abnormal craving for ice, clay, starch dysphagia then consider iron deficiency.
- Poor diet, then consider iron or folate deficiency, and general malnutrition
- History of gastric surgery, distal paresthesias, gait problems -consider B12 deficiency
- History of alcohol abuse - consider folate deficiency or liver disease
- If moonshine use or lead paint/pipe exposure, consider lead toxicity.
- Family history of blood cell disorder: consider Sickle Cell disease, G6PD,and Thalassemia
- History of jaundice, transfusion, new medication, infection - consider hemolytic process
- History of weight loss, Cancer, HIV, rheumatoid arthritis, thyroid disease, renal disease
-History of fever and chills, cough, dyspnea, then consider Infection.
- History of prolonged bleeding, epistaxis, gum bleeding, easy bruising - consider low platelets
or dysfunction.
PHYSICAL EXAM
GENERAL INSPECTION- Pallor in conjunctiva, nails, or palmar creases
Nails - Spoon nails- consider Iron deficiency; Petechiae or purpura- Low platelets, clubbing in TB or
lung cancer
Skin- Hypothyroid, SLE, Bruises, lesions, Petechiae or purpura- Low platelets
Weight - Loss in Cancer, HIV, Chronic disease, gain in hypothyroid
VITAL SIGNS- Pulse: Tachycardia from increased cardiac output
Respirations: Tachypnea from decreased oxygen transport
BP: Orthostatic if volume depleted
Temp: Fever in infections and drug or transfusion reactions, hypo in hypothyroid
HEENT- Eye: Jaundice if hemolysis, pallor in palpebral conjunctiva
Mouth: Glossitis and angular stomatitis in iron or B12 deficiency
NECK- Thyroid enlargement or nodules, lymph nodes
HEART- Increased output/murmur- consider high output failure
LUNG- consider infection, lesion
ABDOMINAL- Liver/spleen size, masses, tenderness, surgical scars
RECTAL- Stool guaiac, prostate exam in men
PELVIC/BREAST- Uterine abnormality, Pap smear, Breast nodule
LYMPHNODES- consider lymphoma, leukemia, Infection, connective tissue disease
NEUROLOGIC- Decreased vibratory and position sense in B12 deficiency
Anemia, Platt Page 2

LABORATORY- INITIAL SCREENING TESTS:

URINANALYSIS- Hematuria/proteinuria in renal disease hemoglobinuria in hemolysis.
CBC, red cell morphology and white blood cell differential, Reticulocyte count, Platelet count,
Chemistry profile (LDH, Bilirubin- Direct and Indirect, BUN, Creatinine, GPT)
Anemia
Anemia is from the Greek word anaimia, meaning without blood. Anemia is defined as a
reduction in the number of red blood cells, blood hemoglobin content, or hematocrit. There are three
primary causes of anemia: (1) reduced production of red blood cells in the bone marrow factory, (2)
excessive destruction of red blood cells, and (3) excessive blood loss.

THE COMPLETE BLOOD COUNT AND OTHER RELATED TESTS

PARAMETER NORMAL ADULT COMMENTS

HB - Hemoglobin Male= 15.5 +/- 2 mg/dl Low = Anemia

Female = 13.5 +/- 2 High = Polycythemia
HCT - Hematocrit Male= 46.0 +/- 6% "
Female= 41.0 +/- 6% "
RBC - Red Blood Male = 4.3 - 5.9 Million/uL "
Cell Count Female= 4.0 - 5.2 "
WBC - White 4.5 - 11.0 K/uL Low = Leukopenia
Blood Cell Count High = Leukocytosis
Platelet Count 150 - 400 K cell/uL Low = Thrombocytopenia
High = Thrombocytosis
Retic - Reticulocyte Count 0.5 -1.5 % Low in anemia = low
25 - 85 K cell/ul High = RBC loss
RED CELL INDICIES
MCV - Mean Corpuscular 80 - 90 fl Low = Microcytosis
Volume High = Macrocytosis
MCH - Mean Corpuscular 27 -32 pg Low = Hypochromic
Hemoglobin High = Hyperchromic
MCHC - Mean Corpuscular 30 - 36 gm/dl Low = R/O Fe Deficiency
Hemoglobin Concentration High = R/O Sperocytosis
RDW - Red Cell Distribution 11.5 - 14.5 Variation in RBC size
Width
Red Cell Morphology - Have human eyes look at the blood smear
Burr Cells Uremia, Low K, artifact, Ca stomach, PUD
Spur Cell Post-splenectomy,
Stomatocyte Hereditary, Alcoholic liver disease,
Spherocyte Hereditary, Immune hemolytic anemia,
water dilution, post-transfusion
Schistocyte - helmet TTP, DIC, vasculitis, glomerulonephritis,
heart valve, burns
Elliptocyte - Ovalocyte Hereditary, Thalassemia, Iron deficiency,
Myelophthistic, megaloblastic anemias
Tear Drop Iron deficiency, Myelophthistic, megaloblastic
Sickle Cells Sickle cell disease
Target Cells Thalassemias, hemoglobinopathies
Parasites Malaria, babesiosis
Basophilic Stippling Lead toxicity
Bite Cells G6PD Deficiency
Anisocytosis Red cells are of unequal size.(high RDW) iron def.
Poikilo cytosis Red cells are of different shapes
Anemia, Platt Page 3

Reticulocyte Count
The reticulocyte count must be corrected for the reduction in red cell count to accurately reflect
marrow production of erythrocytes. The most accurate correction is to determine the absolute reticulocyte
count, obtained by multiplying the red cell count by the recticulocyte percentage. The normal mean is
50,000 +/- 25,000/ml. Alternatively the raw reticulocyte percentage can be multiplied times the observed
hematocrit or hemoglobin divided by the normal hematocrit or hemoglobin as shown:
Corrected Retic Raw Retic Pt's Hematocrit
=
Percentage Percentage X 45 (normal)
The normal corrected reticulocyte percentage is 1 - 2%.
Hypoproliferative Anemias:
A corrected reticulocyte percentage greater than 2.0 indicates that the anemia is caused by red
cell loss either from bleeding or hemolysis. A corrected reticulocyte percentage less than 2.0 indicates
that the anemia is from decreased production of erythrocytes . Once this value is known to be under 2,
the mean red cell volume or MCV is the next critical value needed to guide the diagnostic work-up. An
MCV greater than 94 leads to a macrocytic work-up, an MCV of 80 - 94 leads to a normocytic path, and
an MCV under 80 leads to the microcytic differential diagnosis. Figure 2 is a summary of the diagnostic
pathway:

Reticulocyte Production Index

<2 Decreased Production >2 Increased Loss

Red Cell Indicies MCV Hemolysis Bleeding

>94 80-94 <80

Macro Normo Micro Extrinsic Intrinsic

Coombs Coombs Membrane Hb Enzyme

Positive Negative

Drug Warm Cold

Antibody Antibody

If the reticulocyte count is reduced, the bone marrow factory has slowed or stopped production
because of a lack of erytropoeitin stimulation, a lack of raw materials such as iron, protein, lipids, folate,
vitamin B or the marrow is infiltrated or insulted by a virus, toxin or cancer. In this setting, the mean
12,
corpuscular volume or MCV is the next parameter to guide your evaluation. If the peripheral blood tests
do not indicate the diagnosis, referral to a hematologist for a bone marrow aspirate is appropriate.
Specific therapy is based on the underlying cause, but in the symptomatic patient, a type specific blood
transfusion may be needed to improve oxygen carrying capacity.

MICROCYTIC ANEMIAS
An MCV of less than 80 with pale, poorly hemoglobinized red cells on peripheral smear
characterizes this group of anemias. All result from a disorder in cytoplasmic maturation caused by
reduced hemoglobin production. Hemoglobin is produced using iron, protoporphyrin and globin chains.
Microcytic anemia can result if iron delivery to the marrow is decreased as in iron deficiency and the
anemia of chronic inflammation, heme synthesis is defective as in sideroblastic anemias, or globin chain
synthesis is defective as in thalassemias. The differential diagnosis is remembered by the mnemonic
Anemia, Platt Page 4

"TICS": Thalassemias, Iron Deficiency, Chronic diseases and Sideroblastic. Diagnostic evaluation is
initiated by excluding iron deficiency. Iron stores are assessed using the serum ferritin, iron, Total Iron
Binding Capacity - TIBC (amount of transferrin to transport iron), and percent saturation ( the % of
transferrin saturated with iron). The iron and TIBC will also allow diagnosis of the anemia of chronic
inflammation. If iron deficiency and the anemia of chronic inflammation are excluded, hemoglobin
electrophoresis with quantification of hemoglobin A2 and F will aid the diagnosis of thalassemia.
Diagnosis of sideroblastic anemia ultimately requires a bone marrow aspirate stained for iron. The most
common sideoblastic anemia is caused by lead toxicity. This treatable cause should always be suspected
and worked-up with lead levels.
Summary of Findings in Microcytic Anemias
Iron Chronic Sideroblastic
Deficiency Inflammation Anemia Thalassemia
__________ __________ __________ ___________
Red Cells Microcytic Normocytic or Dimorphic Microcytic
Hypochromic Microcytic Hypochromic

Serum Decreased Decreased Increased Normal or

Iron Increased

TIBC Increased Decreased Normal Normal

Saturation < 16% 10-20% 50-100% 30-100%

Serum Decreased Increased Increased Normal or

Ferritin Increased

Bone Marrow Absent Increased Increased Increased

Iron Storage

Sideroblasts Absent Absent or Increased & Increased

Decreased Ring Forms
DIFFERENTIAL DIAGNOSIS: "TICS"
T: The thalassemia syndromes result from inherited genetic abnormalities that cause decreased
synthesis of a-globin or ß-globin chains, and thus, decreased production of hemoglobin A. In ß-
thalassemia major, or Cooley’s anemia, patients present with severe anemia, jaundice, and
hepatosplenomegaly in the first year of life.

In ß-thalassemia minor, splenomegaly may be present, and the peripheral smear often shows target cells
and basophilic stippling. Iron study results are normal. Hemoglobin electrophoresis shows increases in
hemoglobin types A2 and F.10 Symptoms are usually absent, and no specific therapy is required.
Therapeutic iron supplements are not recommended unless a low serum ferritin level confirms concurrent
iron deficiency.11

a-Thalassemia has its highest incidence in peoples of Southeast Asian, Mediterranean, and African
descent. Diagnosis is based on CBC evidence of more microcytosis than anemia and an elevated red cell
count. Hemoglobin electrophoresis is normal.

I: Iron deficiency anemia occurs when body iron stores are depleted by prolonged bleeding without
adequate replacement.9,11 The daily iron requirement for a man or a nonmenstruating woman is 1.0 mg;
for a woman who menstruates, 2.0 mg; and for a pregnant woman, 3.0 to 4.0 mg. The normal daily diet
contains 10 mg of iron, of which 5% to 10% is absorbed. Bleeding can lead to a loss of 50 mg of iron per
100 cc of whole blood.
Anemia, Platt Page 5

Laboratory findings may include anemia with a low reticulocyte production index, low MCV, and low mean
corpuscular hemoglobin concentration. Physical examination may reveal glossitis, koilonychia (spoon
nails), gastritis, and angular stomatitis. The clinician must determine the deficiency’s underlying cause by
excluding occult gastrointestinal bleeding, excessive menstrual loss, and inadequate dietary intake.
Replacement therapy is Ferrous Sulfate 300mg TID on empty stomach. May give with vitamin C to
enhance absorbtion. Follow – up in 3-4 weeks hemoglobin should be normalized and the Ferritn should
be normal in 8 weeks.

C: Anemia of chronic inflammation. Long-standing infections, neoplastic diseases, and chronic

inflammatory processes (eg, rheumatoid arthritis, systemic lupus erythematosus) block iron transportation
from the storage sites to the bone marrow factory.12,13 An elevated Westergren sedimentation rate or C-
reactive protein level can be a nonspecific indicator of inflammation. A normal or elevated ferritin level
with a high percent saturation should prompt a close review of the electronic CBC (which may reveal an
elevated red cell count, suggesting thalassemia), hemoglobin electrophoresis, the blood smear, and a
lead level.

S: Sideroblastic anemias are a diverse group characterized by the presence of “ringed” sideroblasts in
the bone marrow; basophilic stippling may be present on a peripheral smear. Acquired sideroblastic
anemias are associated with use of antituberculous medications (eg, isoniazid, pyrazinamide14), alcohol
abuse, lead poisoning, chronic inflammation, and preleukemic states, especially after chemotherapy.
Lead levels should be obtained in children and in patients exposed to lead-based paints, car batteries, or
“moonshine,”15 and in those with crampy abdominal pain, peripheral neuropathy, or encephalopathy.

NORMOCYTIC ANEMIAS.
MCV between 80-94 with normochromic normocytic red cells present on peripheral blood smear.
Reviewing the patient's Blood Urea Nitrogen (BUN), Creatinine, SGOT, Alkaline Phosphatase, Bilirubin,
Erythrocyte Sedimentation Rate (ESR), Urinalysis, and Thyroid profile may help in the diagnosis. A
aspirated bone marrow biopsy is often necessary to aid the diagnosis if these simple tests do not provide
the diagnosis
DIFFERENTIAL DIAGNOSIS: "NORMAL SIZE"
N: Normal pregnancy. Anemia of pregnancy results in part from a 30% expansion in the plasma volume.2

O: Overhydration and expanded plasma volume.

R: Chronic renal disease. Anemia resulting from relative decrease in EPO production responds to
recombinant EPO therapy.2,7,23

M: Myelophthisic anemia results from replacement of the bone marrow by a tumor, granulomatous
infectious disease, fibrosis, or leukemia.24

A: Acute blood loss.

L: Leukemia and liver disease. Chronic hepatitis, alcoholism, and cirrhosis may increase plasma volume
and alter red cell survival.

SI: Systemic inflammation (anemia of chronic inflammation).12,13

Z: Zero production. Aplastic anemia usually presents with pancytopenia.25

E: Endocrine disorders (eg, hypothyroidism, hyperthyroidism, adrenal insufficiency, hypogonadism).2

MACROCYTIC ANEMIAS.
Common causes include Vitamin B12 and folate deficiency. Macrocytosis is seen with high
reticulocyte counts, liver disease, obstructive jaundice, hypothyroidism, post splenectomy, and
Anemia, Platt Page 6

megaloblastic anemias. Megaloblastic anemias result from impaired nuclear maturation secondary to
defective DNA synthesis.. Less common causes are related to inherited defects in DNA synthesis,
vitamin metabolism, chemotherapy or marrow malignancy. Abnormal nuclear maturation also occurs in
white cells, megakaryocytes, and other rapidly dividing cells. The peripheral blood changes include:
Anemia with decreased reticulocyte count, increased MCV, and macro ovalocytes; neutropenia with
hypersegmented neutrophils; and thrombocytopenia with large platelets. In the bone marrow, inhibition of
DNA synthesis is reflected by a delay in nuclear maturation relative to cytoplasmic maturation and by
ineffective erythropoiesis. Erythroid precursors are large with immature nuclear chromatin despite
cytoplasmic maturity reflected by normal concentrations of hemoglobin. In myeloid cells this nuclear
cytoplasmic asynergy is reflected by giant bands, giant metamyelocytes, and hypersegmented polys (
over 6 lobed nucleus). Megakaryocytes are large with increased polyploidy. Despite reticulocytopenia,
neutropenia, and thrombocytopenia, the marrow is usually hypercellular reflecting ineffective
erythropoiesis. Measurement of serum and red cell vitamin levels represents the most important first
step in evaluating the megaloblastic anemias. Because of complex interactions, serum B12, serum
folate, and red cell folate should be determined to make an accurate diagnosis. Patterns in folate and
B12 deficiency are outlined in the Table below
Vitamin B12 and Folate Levels in Deficiencies

Vitamin Status Serum B 12 Serum Folate RBC Folate

_____________ __________ __________ _________
Normal Normal Normal Normal

B12 Deficiency Low Normal or Low Normal or High

Folate Deficiency Normal or Low Low Low

Folate Deficient Normal Low Normal

(early)
Folate Deficient Normal or Low Normal Low
(refed)
Because B12 is required for cellular uptake of folate, RBC folate is low in 1/3
of patients with B12 deficiency. In 1/2 of cases of severe folate deficiency, the serum B12 is low for
unexplained reasons and will normalize with folic acid administration. Serum folate will fall within three to
four weeks of initiating a folate poor diet, however, RBC folate will remain normal for three to five months
reflecting tissue levels. Additional technical problems with the radioimmunoassay for B12 cause low
serum B12 without other evidence of true deficiency. Increased urinary excretion of methylmalonic acid is
specific for B12 deficiency and can be of diagnostic utility in difficult cases. Carefully supervised
therapeutic trials of the vitamins may also be helpful
Common causes of macrocytic (or megaloblastic) anemias include chemotherapy and vitamin B12 and
folate deficiency; a less common cause is marrow malignancy. Rarely, inherited defects in DNA synthesis
or vitamin metabolism may be the cause. The peripheral blood changes include macro-ovalocytes,
neutropenia with hypersegmented neutrophils, and thrombocytopenia with large platelets.16 Levels of
serum vitamin B12, serum folate, and red cell folate should be measured. The differential diagnosis is
represented by the mnemonic “BIG FAT RED CELLS.”

B: Vitamin B12 (cobalamin) deficiency.16,17 Patients may present with weakness, fatigue, dyspnea,
paresthesias, and mental clouding. Physical signs include edema, pallor, jaundice, smooth tongue,
decreased vibratory and position sensation, peripheral neuropathy, and long tract findings.18

In the US, inadequate B12 intake usually occurs only in strict vegans. However, about 70% of cases of
vitamin B12 deficiency are caused by pernicious anemia—in which inadequate intrinsic factor or other
conditions result in B12 malabsorption. This diagnosis is confirmed by the presence of anti–intrinsic factor
antibodies or by positive results on the Schilling test.19

I: Inherited disorders (eg, orotic aciduria, Lesch-Nyhan syndrome, Di Guglielmo’s syndrome). These are
rare.18
Anemia, Platt Page 7

G: Gastrointestinal disease or surgery. Small bowel disease, nontropical sprue, regional enteritis, ileal
resection, celiac disease, fish tapeworm, or bacterial overgrowth all may block absorption of vitamin B12.

F: Folic acid deficiency.16 Patient history may reveal anemia symptoms, alcoholism, or a diet lacking in
fresh, uncooked fruits and vegetables (folates are rapidly destroyed by heat). Physical examination may
show stigmata of alcoholic liver disease.

The minimum daily requirement of folic acid is 50 µg; the average diet contains 700 µg, of which 10% is
absorbed. Pregnant women, patients with hemolytic anemia, and those undergoing dialysis have
increased folic acid requirements.

A: Alcoholism (chronic).17,19

T: Thiamine-responsive anemia. This rare, unexplained condition is correctable with thiamine.

R: Reticulocytes in large numbers may inflate the MCV, because they are larger than mature red cells.19

E: Endocrine disturbances (hypothyroidism).19

D: Dietary deficiencies, particularly folate, vitamin B12, protein, or lipids.16

C: Chemotherapeutic drugs, including methotrexate and 5-fluorouracil.20

E: Erythroleukemia. Circulating abnormal immature erythrocytes are larger than normal mature cells,
inflating the MCV.

L: Liver disease.17 Chronic hepatitis, alcoholism, and cirrhosis may increase MCV by altering the red cell
membrane lipid composition.

L: Lesch-Nyhan syndrome.21 This rare hereditary deficiency of hypoxanthine-guanine

phosphoribosyltransferase activity is manifested by hyperuricemia, self-mutilation, mental retardation,
spasticity, and choreoathetosis.

S: Splenectomy. Loss of splenic filtration function results in larger erythrocytes with increased membrane,
nucleated red blood cells (nRBCs), and nuclear fragments (Howell-Jolly bodies).22

Hemolytic Anemias
Hemolytic anemias, which result from increased rate in destruction of red cells, will be discussed
in some depth. Medical history, The CBC, Reticulocyte count, Chemistry profile with indirect and direct
bilirubin, and LDH, urinalysis, and haptoglobin levels are most useful in diagnosing hemolysis. The past
medical and family history, direct Coombs' test, and blood smear are most useful in establishing the
cause once hemolysis is proven.
The hallmark of hemolysis is the presence of an elevated reticulocyte count, with a stable or
falling hemoglobin. Other findings include:
-Elevated indirect bilirubin -
-Elevated serum lactate dehydrogenase (LDH)-
- Decreased Haptoglobin levels
-Hemoglobinemia and hemoglobinuria -
-Erythroid hyperplasia in bone marrow -
The diagnostic tests that are very helpful in establishing the etiology of hemolysis are the clinical
history, the direct antiglobulin (Coombs') test, Specific tests, such as hemoglobin electrophoresis, Heinz
body stain, osmotic fragility will prove the diagnosis suggested by the history, blood smear and negative
direct Coomb's test.

DIFFERENTIAL DIAGNOSIS : "HEMATOLOGIST".

Anemia, Platt Page 8

H: Hemoglobinopathies, with sickle cell disease among the most common (Type SS, SC, S-Beta
Thalassemia, SS increased fetal) Most common feature is pain crisis from hypoxia, dehydration,
infection. Children should be on Penicillin from birth to age 6. Consider hydroxyurea to prevent crisis

Paroxysmal Nocturnal Hemoglobinuria.2 Manifestations include episodic intravascular hemolysis,

thrombotic episodes, and increased infections.10 Diagnosis is based on flow cytometry for loss of
antibodies CD55 and CD59.26

E: Enzyme deficiency (eg, inherited pyruvate kinase deficiency, pyrimidine-5'-nucleotidase deficiency).27,28

M: Medications, including sulfonamides, high-dose IV penicillin, quinine, quinidine, and

chlorpromazine.29,30

A: Antibodies. In immune (Coombs’-positive) acquired hemolytic anemias, hemolysis is caused by an

antigen that triggers antibody- or complement-mediated red cell destruction. Immune hemolytic anemia
may be alloimmune (related to transfusion), autoimmune, or drug induced.10,31

Immunoglobulin G (IgG): Warm reacting antibody anemia32 occurs secondary to lymphoproliferative

syndrome (in 30% of cases), collagen vascular diseases (20%), and other tumors (20%), or it can be
idiopathic (20%). Laboratory findings are those of anemia with an increased reticulocyte count and
detection of microspherocytes on the blood smear. Direct Coombs’ testing is positive for IgG or IgG and
C3.33 IgM: Cold reacting antibody anemia32 occurs secondary to viral and mycoplasmal infections, with
lymphoproliferative disease, and as idiopathic disorders in the elderly.

T: Trauma to the red cells, as from an abnormal endothelium.10

O: Ovalocytosis is an autosomal dominant disorder seen in Southeast Asians.34

L: Liver disease, when severe, may lead to abnormal lipid loading in erythrocyte membranes, inducing
formation of spur cells with shortened red cell survival.35

O: Osmotic fragility occurs with hereditary spherocytosis and hereditary elliptocytosis.36 The former is
caused by autosomal dominant or recessive membrane protein abnormalities that result in sphere
formation, membrane budding, and increased permeability to sodium. Hereditary elliptocytosis is caused
by a defective red cell membrane, resulting from abnormal structural proteins. A finding of numerous
elliptocytes on the blood smear is diagnostic.

G: Glucose-6-phosphate dehydrogenase (G6PD) deficiency. Inherited G6PD deficiency is linked to the X

chromosome, fully affecting homozygous females and males who inherit the deficient gene. Drugs or
other substances cause increased oxidant stress within the red cell, triggering precipitation of hemoglobin
into Heinz bodies and thereby causing hemolysis (most effectively identified by Heinz bodies on methyl
violet stain). G6PD deficiency can be confirmed by molecular techniques or enzyme assay after two to
three months. Patients should be advised to avoid antimalarials, high-dose aspirin, sulfa drugs, and fava
beans.27,37

I: Infection. Intra-erythrocytic parasites (eg, malaria, babesiosis) lyse emerging red cells.10 They may be
identified on examination of a thick smear slide for parasites. Clostridium infections and ß-hemolytic
streptococcal septicemia may cause massive hemolysis.

S: Splenic destruction in hypersplenism can occur with splenomegaly, portal hypertension secondary to
infections, infiltration with leukemia or lymphoma, and collagen vascular diseases.22

T: Transfusion. Hemolysis may occur in a patient with antibodies directed against an antigen on the
transfused red cells.31 The patient may experience an immediate acute transfusion reaction, or more
commonly, a reaction that is delayed for five to 14 days. Additionally, thalassemia must be considered in
a patient with hemolytic anemia and a low MCV.
Anemia, Platt Page 9

What causes polycythemia or too many red cells

1. Primary or Polycythemia vera.
2. Secondary Polycythemia
a. High altitude. People ascending to altitudes above 2000 meters (6500 feet)
b. Chronic lung disease with arterial hypoxemia.
c. Cardiovascular right-to-left shunt.
d. High-oxygen-affinity hemoglobinopathies. Erythrocytosis results from impaired release of oxygen to
the tissues.
e. Carboxyhemoglobinemia ("smokers erythrocytosis"). Erythrocytosis results from a functional anemia
and left shift of the oxyhemoglobin dissociation curve caused by binding of carbon monoxide to
hemoglobin
f. Congenital decreased erythrocyte 2,3-DPG.
g. Tumors producing erythropoietin or other erythropoietic substances neoplasm.
h. Renal disease. These disorders lead to regional renal hypoxia, presumably affecting the tissue
oxygen sensor and resulting in increased erythropoietin production.
i. Adrenal cortical hypersecretion. Increased red cell mass may result from the production of adrenal
androgens.

General References
Platt A. Differential Diagnosis Mnemonics.and the Medical History 3nd Edition. Palm book at
http://www.EmoryPA.org

Eckman J, Platt A. Problem Oriented Management of Sickle Syndromes.

National Maternal and Child Health Clearing House. 1991 and 2000. Available online
http://www.SCInfo.org.

Platt A, Eckman J, Diagnosing Anemia, Clinician Reviews Vol 16 No 12 December 2006 p 43 – 50. Web
http://www.clinicianreviews.com/print.asp?page=courses/105417/lesson.htm

Wintrobe's Clinical Hematology by Author(s): John P Greer MD; John Foerster MD, FRCP(C); John N
Lukens MD; George M Rodgers MD, PhD; Frixos Paraskevas MD; Bertil E Glader MD, PhD
11th edition (2003) Lippincott, Williams & Wilkins

References
1. Adams PF, Hendershot GE. Current estimates from the National Health Interview Survey 1996. Vital and Health Statistics. Series 10,
no. 200. Hyattsville, Md: National Center for Health Statistics; 1999.
2. Brill JR, Baumgardner DJ. Normocytic anemia. Am Fam Physician. 2000;62:2255-2264.
3. Ania BJ, Suman VJ, Fairbanks VF, Melton LJ 3rd. Prevalence of anemia in medical practice: community versus referral patients. Mayo
Clin Proc. 1994;69:730-735.
4. Cheng CK, Chan J, Cembrowski GS, van Assendelft OW. Complete blood count reference interval diagrams derived from NHANES III:
stratification by age, sex, and race. Lab Hematol. 2004;10:42-53.
5. Segel CB, Palis J. Hematology of the newborn. In: Lichtman MA, Beutler E, Seligsohn U, et al, eds. Williams Hematology. 7th ed. New
York, NY: McGraw-Hill Professional; 2005:81-100.
6. Andrews NC. Disorders of iron metabolism. N Engl J Med. 1999;341:1986-1995.
7. Goodnough LT, Skikne B, Brugnara C. Erythropoietin, iron, and erythropoiesis. Blood. 2000;96:823-833.
8. Beutler E. Production of erythrocytes. In: Lichtman MA, Beutler E, Seligsohn U, et al, eds. Williams Hematology. 7th ed. New York, NY:
McGraw-Hill Professional; 2005:393-404.
9. Massey AC. Microcytic anemia: differential diagnosis and management of iron deficiency anemia. Med Clin North Am. 1992;76:549-
566.
10. Dhaliwal G, Cornett PA, Tierney LM Jr. Hemolytic anemia. Am Fam Physician. 2004;69:2599-2606.
11. Beutler E, Hoffbrand AV, Cook JD. Iron deficiency and overload. Hematology Am Soc Hematol Educ Program. 2003;40-61.
12. Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med. 2005;352:1011-1023.
13. Means RT Jr. Recent developments in the anemia of chronic disease. Curr Hematol Rep. 2003;2:116-121.
14. Sharp RA, Lowe JG, Johnston RN. Anti-tuberculous drugs and sideroblastic anaemia. Br J Clin Pract. 1990;44:706-707.
15. Pegues DA, Hughes BJ, Woernle CH. Elevated blood lead levels associated with illegally distilled alcohol. Arch Intern Med.
1993;153:1501-1504.
16. Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a guide for the primary care physician. Arch Intern Med.
1999;159:1289-1298.
17. Savage DG, Ogundipe A, Allen RH, et al. Etiology and diagnostic evaluation of macrocytosis. Am J Med Sci. 2000;319:343-352.
18. Babior BM. Folate, cobalamin, and megaloblastic anemias. In: Lichtman MA, Beutler E, Seligsohn U, et al, eds. Williams Hematology.
7th ed. New York, NY: McGraw-Hill Professional; 2005:477-510.
Anemia, Platt Page 10

19. Davenport J. Macrocytic anemia. Am Fam Physician. 1996;53:155-162.

20. Groopman JE, Itri LM. Chemotherapy-induced anemia in adults: incidence and treatment. J Natl Cancer Inst. 1999;91:1616-1634.
21. McKeran RO. Factors in the pathogenesis of the brain damage and anaemia in the Lesch-Nyhan syndrome. Ciba Found Symp.
1977;48:83-96.
22. Erslev AJ. Hypersplenism and hyposplenism. In: Lichtman MA, Beutler E, Seligsohn U, et al, eds. Williams Hematology. 7th ed. New
York, NY: McGraw-Hill Professional; 2005:773-778.
23. Collins AJ, Ma JZ, Xia A, Ebben J. Trends in anemia treatment with erythropoietin usage and patient outcomes. Am J Kidney Dis.
1998;32(6 suppl 4):S133-S141.
24. Hosenpud JD, Thorning D, Greenberg G. Liposarcoma metastatic to bone marrow presenting as myelophthisic anemia: a case report.
Cancer. 1980;45:345-348.
25. Young NS. Acquired aplastic anemia [published correction appears in JAMA. 2000;283:57]. JAMA. 1999;281:271-278.
26. Hall SE, Rosse WF. The use of monoclonal antibodies and flow cytometry in the diagnosis of paroxysmal nocturnal hemoglobinuria.
Blood. 1996;87:5332-5340.
27. Jacobasch G, Rapoport SM. Hemolytic anemias due to erythrocyte enzyme deficiencies. Mol Aspects Med. 1996;17:143-170.
28. Marinaki AM, Escuredo E, Duley JA, et al. Genetic basis of hemolytic anemia caused by pyrimidine 5' nucleotidase deficiency. Blood.
2001;97:3327-3332.
29. Garratty G, Petz LD. Drug-induced immune hemolytic anemia. Am J Med. 1975;58:398-407.
30. Stein PB, Inwood MJ. Hemolytic anemia associated with chlorpromazine therapy. Can J Psychiatry. 1980;25:659-661.
31. Sallah S, Wan JY, Hanrahan LR. Future development of lymphoproliferative disorders in patients with autoimmune hemolytic anemia.
Clin Cancer Res. 2001;7: 791-794.
32. Rubin H. Autoimmune hemolytic anemias: warm and cold antibody types. Am J Clin Pathol. 1977;68(5 suppl):638-642.
33. Wheeler CA, Calhoun L, Blackall DP. Warm reactive autoantibodies: clinical and serologic correlations. Am J Clin Pathol.
2004;122:680-685.
34. Laosombat V, Dissaneevate S, Wongchanchailert M, Satayasevenaa B. Neonatal anemia associated with Southeast Asian
ovalocytosis. Int J Hematol. 2005;82:201-205.
35. Cooper RA. Anemia with spur cells: a red cell defect acquired in serum and modified in the circulation. J Clin Invest. 1969;48:1820-
1831.
36. Iolascon A, Miraglia del Giudice E, Camaschella C. Molecular pathology of inherited erythrocyte membrane disorders: hereditary
spherocytosis and elliptocytosis. Haematologica. 1992;77:60-72.
37. Frank JE. Diagnosis and management of G6PD deficiency. Am Fam Physician. 2005;72:1277-1282.