Anemia

Anemia - Chronic

 

Definition  

A decrease in the circulating red blood cell mass to below age-specific and gender-specific limits (usually a Hct of less than 40% [Hgb less than 13.5 g/dL] in men or less than 37% [Hgb less than 12 g/dL] in women)

 

Medical History  

* Megaloblastic anemia due to gastrectomy

* Enteritis

* Pregnancy

* Vegan diet

* Breast-fed babies of vegan mothers

* Alcohol Abuse

* Folic Acid Antagonist use

* Anticonvulsant use

* Disease of liver

* Kidney disease

* Family history of Pernicious anemia

 

Findings  

* Tachyarrhythmia

* Tachypnea

* Altered bowel function

* Altered mental status

* Atrophy of tongue papillae

* Beefy red tongue

* Dry skin

* Dyspnea on exertion

* Ecchymosis

* Excessive and frequent menstruation

* Fatigue

* Heart murmur - Chronic

* Hemangioma of skin

* Jaundice

* Koilonychia

* Loss of appetite

* Neuropathy

* Pallor

* Paresthesia

* Petechiae

* Pica

* Splenomegaly

* Telangiectasia

* Ulcer of lower extremity - Chronic

* Urine looks dark

 

Tests  

 

A CBC with a WBC differential is required to diagnose an anemia.  

* Complete blood count with white cell differential, manual

 

All patients with a megaloblastic anemia should have a RBC folate level drawn to determine if a folate deficiency is present.  

* Folic acid measurement, RBC

 

Anemia  

* Peripheral blood smear examination, light microscopy: Blood smear examination is indicated in the initial evaluation of suspected or unexplained anemia .

 

Hemolytic anemia will often cause total and unconjugated bilirubin to be elevated.  

* Serum total bilirubin measurement

 

Screening for iron deficiency anemia  

* Measurement of total hemoglobin concentration: Two Hgb values below the accepted threshold are presumptive for iron-deficiency anemia. The diagnosis can be confirmed if hgb values rise to 1 g/dL or greater after 4 weeks of iron supplementation therapy .

 

Serum folate measurement may help in diagnosing folate deficiency, but RBC folate levels are more sensitive and specific for folate deficiencies.  

* Folic acid measurement, serum

 

Suspected anemia  

* Hematocrit determination: Very mild anemias are associated with few or no clinical signs or symptoms; therefore, a mild anemia usually is first detected from a screening measurement of Hgb or HCT.

 

Suspected autoimmune hemolytic anemia  

* Direct Coombs test: A positive direct Coombs test requires further analysis of IgG or complement on red blood cells to determine the hemolytic mechanism .

 

Suspected iron deficiency anemia  

* Erythrocyte mean corpuscular volume determination: A low mean corpuscular volume (< 80 fL), together with a low RBC count and high red cell distribution width, favors the diagnosis of iron deficiency .

 

Suspected iron deficiency anemia  

* Serum ferritin measurement: A ferritin level of 15 mcg/L or less is a marker of depleted or absent iron stores, and confirms iron deficiency anemia in the presence of low Hgb or HCT .

 

Suspected iron-deficiency anemia  

* Total iron binding capacity measurement: Total iron binding capacity is a useful test in evaluating iron-deficiency anemia, but only in conjunction with other iron studies .

 

Suspected iron deficiency  

* Serum iron measurement: Low serum iron in the presence of elevated total iron-binding capacity and low serum ferritin is considered diagnostic for iron deficiency .

 

Suspected or known anemia  

* Reticulocyte count: The reticulocyte count is essential for differentiating between anemias arising from nonfunctional versus functional bone marrow .

 

Suspected vitamin B12 (cobalamin) deficiency secondary to pernicous anemia  

* Serum vitamin B12 measurement: Serum cobalamin levels below 74 pmol/L indicate a probable cobalamin deficiency .

 

Anemia  

* Bone marrow biopsy, needle or trocar: Bone marrow biopsies allow for analysis of bone marrow contents and cellularity to aid in diagnosis of bone marrow disorders .

 

Abdominal CT scans are often needed to evaluate patients with lymphoma associated with aplastic anemia.  

 

* CT of abdomen

 

Abdominal ultrasound may reveal lymphoma or splenomegaly associated with aplastic and hemolytic anemia. It is also useful in the evaluation of patients with Fanconi anemia.  

* Abdominal ultrasound

 

A chest x-ray may be useful in diagnosing carcinoma or lymphoma associated with aplastic anemia, anemia of chronic disease, hemolytic anemia, and acute sickle cell chest syndrome.  

 

* Plain chest X-ray

 

Differential Diagnosis  

* Leukemia

* Hemorrhage

* Hypersplenism

* Hemorrhage

* Nutritional deficiency

* Malabsorption syndrome

* Alcoholism

* Hemolysis

* Hypervolemia

* Myelodysplastic syndrome - Chronic

* Multiple myeloma - Chronic

* Cancer

* Leukemia

* Malignant lymphoma

* Sickle cell anemia - Chronic

* Hypersplenism

* Hypothyroidism - Chronic

* Renal failure

* Heart failure

* Glucose-6-phosphate dehydrogenase deficiency anemia

* Hemolytic anemia

* Aplastic anemia - Acute

* Sickle cell anemia - Acute

* Iron deficiency anemia - Chronic

* Anemia of chronic disease - Chronic

* Thalassemia - Chronic

* Sideroblastic anemia

* Megaloblastic anemia due to vitamin B12 deficiency - Chronic

* Megaloblastic anemia due to folate deficiency - Chronic

* Hemolytic anemia - Chronic

* Hereditary spherocytosis

* Paroxysmal nocturnal hemoglobinuria

* Glucose-6-phosphate dehydrogenase deficiency anemia

* Sickle cell anemia - Chronic

* Autoimmune hemolytic anemia

* Cold autoimmune hemolytic anemia

* Microangiopathic hemolytic anemia

* Aplastic anemia

 

Treatment  

 

Drug Therapy  

 

Hereditary spherocytosis  

 

FOLIC ACID  

Adults: 1 mg orally once daily; lifetime use required

 

 

Paroxysmal nocturnal hemoglobinuria  

 

PREDNISONE  

Adults: Initial therapy: 1 mg/kg/day orally for 7 days; Prolonged therapy: 15 to 40 mg orally every other day

 

IRON (Related toxicological information in IRON)  

Adults: 350 mg orally 3 times daily

 

 

Sideroblastic anemia  

 

PYRIDOXINE (Related toxicological information in PYRIDOXINE)  

Adults: 200 mg orally once daily

 

 

Thalassemia major  

 

FOLIC ACID  

Adults: 1 mg orally daily

 

Procedural Therapy  

 

Anemia  

* Transfusion of packed red blood cells: Patients with a HCT >30% rarely require RBC transfusion; patients with acute anemia and a HCT <21% typically require transfusion .

 

Hereditary spherocytosis  

* Splenectomy

 

Sickle cell anemia  

* Pneumococcal vaccination

* Meningococcus vaccination

* Haemophilus influenzae type b vaccination

 

Sideroblastic anemia due to lead poisoning  

* Chelation therapy

 

Splenectomy may be necessary in patients with hereditary spherocytosis and warm antibody autoimmune hemolytic anemia who do not respond to initial therapy or moderate doses of prednisone. Splenectomy may also be required in sickle cell patients to prevent recurrent sequestration crises, or to reduce the high transfusion rate in patients with beta-thalassemia major.  

* Splenectomy

 

Anemia  

* Oxygen therapy

 

Paroxysmal nocturnal hemoglobinuria  

* Bone marrow transplant

 

Thalassemia major  

Splenectomy

 

Non-Procedural Therapy  

 

Anemia  

* Lifestyle measures