Systematic Approach in Anemia Evaluation

Systematic Approach in Anemia Evaluation and Review of Peripheral Smears
By:Jun W. Kim, MD
Family Medicine Residency
Dewitt Army Community Hospital

Objective
* Recognize abnormal peripheral blood smear
* Review differentials through systematic approach

Approach to Dx
Basic Labs to Start
Reticulocyte count
Reticulocyte Correction
Reticulocyte Production Index
- Hemolytic disease
- Hemoglobinopathy (including thalassemia)
Peripheral smear
* Optimal area for review
* RBC morphology, WBC differential, PLT (clumping?)
RBC morphology
Basophilic stippling
Burr cells
Elliptocytes/ovalocytes
Howell Jolly body
Schistocyte/helmet cells
Sickle cells
NRBC
Spherocyte
Stomatocyte
Target cells
Tear drop cells
Differentials
MCV/smear
Micro
Normo
Macro
Iron panel
Retic
Iron/B12/Folate
*Occult Blood Loss
Bone Marrow Bx
Anemia of Chronic Dis.
Anemia Differential Dx by Flow Chart
First use size (MCV) to sort the Differential Dx
Microcytic anemia
Iron def. Anemia
Thalassemia
Alpha-thalassemia
Beta-thalassemia
Sideroblastic anemia
Sample questions
Macrocytic anemia
Megaloblastic Anemia
B12
Folate
Aplastic Anemia
Occult Blood Loss?
Hemolytic Anemia
Other Lab Characteristics
* RBC morphology
* Serum haptoglobin
* Serum LDH
* Unconjugated bilirubin
* Hemoglobinuria
* Hemosiderinuria

Coombs’ positive with Spherocytes Autoimmune hemolytic anemia
Warm AIHA
Cold AIHA
Coombs’ positive with Spherocytes Other immune hemolytic anemia
Alloantibody hemolytic anemia
* Transfusion reaction
* Feto-maternal incompatibility (Kleihauer-Betke test)

Drug related Hemolytic anemia
* Toxic immune complex (drug+Ab+C3)
- Quinine, Quinidine, Rifampin, INH, Sulfonamides,
* Hapten formation (anti-IgG)
- PCN, methicillin, ampicillin

Coombs’ Negative Hemolytic anemia
Membrane Defects
Spherocytosis
Elliptocytosis
Coombs’ Negative Hemolytic Anemia Deficiency of RBC Enzymes
Pyruvate Kinase Def.
Coombs’ Negative Hemolytic Anemia Hemoglobinopathy
HbS disease
HbC disease
HbSC disease
Coombs’ Negative Hemolytic Anemia Paroxysmal Nocturnal Hemoglobinuria
Coombs’ Negative Hemolytic Anemia Fragmented RBC’s & Thrombocytopenia
Normocytic Anemia

Anemia Evaluation.ppt