Version 2.0 Anaemia 4/07/2012
Defined as [Hbsea level] <125-130g/L (M) or <110-120g/L (F). It may be due to a low red cell mass
(e.g. ↓production or loss of RBC), or ↑plasma volume (e.g. in pregnancy) and has many causes.
Presentation
History
Fatigue, dyspnoea, syncope, palpitations, headache, worsening IHD/CCF/COPD if pre-existing.
Symptoms suggestive of underlying cause.
Examination
Pallor (look at conjunctivae, skin creases), hyperdynamic circulation (e.g. tachycardia, murmurs
and cardiac enlargement±HF), Signs of underlying cause e.g. dysphagia due to oesophageal web
with chronic iron deficiency (=Plummer-Vinson Syndrome – has association with oesophageal Ca).
Koilonychia/angular cheilitis (Fe-def), glossitis (Vit B12 def)
Classification
One classification is based on MCV:
Microcytic (MCV<80fl)
• Iron-deficiency anaemia (most common cause).
• Thalassaemia (may have disproportionately low MCV for Hb, normal RDW & ↑RCC,)
• Congenital sideroblastic anaemia (very rare).
• Lead poisoning
• Multiple myeloma
• Chronic systemic illness
Normocytic (MCV 80-100fl)
• Chronic disease (chronic inflammation, infection, connective tissue disease, cancer, etc.)
• Renal failure
• Hypothyroidism (or macrocytic)
• Bone marrow failure
• Haemolysis (or macrocytic)
• Pregnancy
• Congenital (Fanconi’s, Diamond-Blackfan)
• Early stages of most anaemias
Macrocytic (MCV>100fl)
• B12 or folate deficiency (esp if MCV>115fl)
• Chronic EtOH
• Liver disease
• Hypothyroidism
• Myelodysplastic syndromes
• Marrow infiltration /Aplastic anaemia
• Reticulocytosis (>2% e.g. haemolysis)
• Antifolate drugs (e.g. phenytoin)
• Cytotoxics (e.g. hydroxyurea)
• Congenital cyanotic heart disease
Management
Depends on underlying cause (see below). Transfusion may be considered if symptomatic and
Hb<7, or Hb<10 and IHD or risk of haemorrhage ± frusemide 10-40mg PO/IV if CCF.
, ↓MCV Iron Deficiency Anaemia
Ave. adult diet = 15mg/d, abs. ~10%. Losses M 1mg/d, F 1.5mg/d. Common. Often asymptomatic.
Causes
• Blood loss – GIT (NSAID, GORD, PUD, Ca, Angiodysplasia, haemorrhoids, varices), GUT
(menstruation), chronic haemolysis, excessive donation
• Malabsorption – Drugs (tetracyclines), IBD, coeliac, post-gastrectomy.
• Pregnancy (↑demand)
• Dietary - childhood (often milk-related), vegetarians with poor diet, high phytate diet
(cereals, nuts, seeds & legumes – impairs Fe absorption), calcium.
Management
Investigate for underlying cause:
• Urine: U/A for RBC.
• Blood: FBC, iron studies (Ferritin low, serum iron low), film (anisocytosis [variation in RBC
size] and poikilocytosis [abnormally shaped RBC]), coeliac screen.
• Other: Gastro-/colonoscopy, stool
Iron replacement:
Ferrous sulphate 325mg od (child Ferro-liquid 0.5ml/kg od) (SE: Constipation/diarrhoea, black
stools, heartburn, nausea, abdo pain), diet advice. Rpt FBC in 1/12 cont Rx until Hb ok for 3 /12.
↓↑MCV Sideroblastic Anaemia
Abnormal ringed RBC precursors (sideroblasts) + non-haem Fe granules in bone marrow aspirate.
Causes:
• Congenital (rare, X-linked)
• Acquired
o Myelodysplastic syndromes
o 2° to myeloproliferative disorders (myeloma, Polycythaemia ruba vera, leukaemias)
o Drugs & toxins – lead, alcohol, chloramphenicol, isoniazid, linezolid, pyrazinamide
o Other 2° causes: SLE, RA, myxoedema, pregnancy
o Idiopathic
Management
Investigate for underlying cause:
• Blood: FBC (↓MCV in cong, may ↑in aquired), iron studies (serum iron high & ferritin high)
• Other: BMA (sideroblasts)
Treatment:
• Supportive. Transfusion if symptomatic (may need iron chelation if multiple).
• Drugs:
o Erythropoietin ± GCSF or Cyclosporin A in myelodysplastic syndrome
o Hereditary sideroblastic anaemia may respond to pyridoxine
• Stem cell transplantation
↓MCV Thalassaemia
See Haemoglobinopathies
Defined as [Hbsea level] <125-130g/L (M) or <110-120g/L (F). It may be due to a low red cell mass
(e.g. ↓production or loss of RBC), or ↑plasma volume (e.g. in pregnancy) and has many causes.
Presentation
History
Fatigue, dyspnoea, syncope, palpitations, headache, worsening IHD/CCF/COPD if pre-existing.
Symptoms suggestive of underlying cause.
Examination
Pallor (look at conjunctivae, skin creases), hyperdynamic circulation (e.g. tachycardia, murmurs
and cardiac enlargement±HF), Signs of underlying cause e.g. dysphagia due to oesophageal web
with chronic iron deficiency (=Plummer-Vinson Syndrome – has association with oesophageal Ca).
Koilonychia/angular cheilitis (Fe-def), glossitis (Vit B12 def)
Classification
One classification is based on MCV:
Microcytic (MCV<80fl)
• Iron-deficiency anaemia (most common cause).
• Thalassaemia (may have disproportionately low MCV for Hb, normal RDW & ↑RCC,)
• Congenital sideroblastic anaemia (very rare).
• Lead poisoning
• Multiple myeloma
• Chronic systemic illness
Normocytic (MCV 80-100fl)
• Chronic disease (chronic inflammation, infection, connective tissue disease, cancer, etc.)
• Renal failure
• Hypothyroidism (or macrocytic)
• Bone marrow failure
• Haemolysis (or macrocytic)
• Pregnancy
• Congenital (Fanconi’s, Diamond-Blackfan)
• Early stages of most anaemias
Macrocytic (MCV>100fl)
• B12 or folate deficiency (esp if MCV>115fl)
• Chronic EtOH
• Liver disease
• Hypothyroidism
• Myelodysplastic syndromes
• Marrow infiltration /Aplastic anaemia
• Reticulocytosis (>2% e.g. haemolysis)
• Antifolate drugs (e.g. phenytoin)
• Cytotoxics (e.g. hydroxyurea)
• Congenital cyanotic heart disease
Management
Depends on underlying cause (see below). Transfusion may be considered if symptomatic and
Hb<7, or Hb<10 and IHD or risk of haemorrhage ± frusemide 10-40mg PO/IV if CCF.
, ↓MCV Iron Deficiency Anaemia
Ave. adult diet = 15mg/d, abs. ~10%. Losses M 1mg/d, F 1.5mg/d. Common. Often asymptomatic.
Causes
• Blood loss – GIT (NSAID, GORD, PUD, Ca, Angiodysplasia, haemorrhoids, varices), GUT
(menstruation), chronic haemolysis, excessive donation
• Malabsorption – Drugs (tetracyclines), IBD, coeliac, post-gastrectomy.
• Pregnancy (↑demand)
• Dietary - childhood (often milk-related), vegetarians with poor diet, high phytate diet
(cereals, nuts, seeds & legumes – impairs Fe absorption), calcium.
Management
Investigate for underlying cause:
• Urine: U/A for RBC.
• Blood: FBC, iron studies (Ferritin low, serum iron low), film (anisocytosis [variation in RBC
size] and poikilocytosis [abnormally shaped RBC]), coeliac screen.
• Other: Gastro-/colonoscopy, stool
Iron replacement:
Ferrous sulphate 325mg od (child Ferro-liquid 0.5ml/kg od) (SE: Constipation/diarrhoea, black
stools, heartburn, nausea, abdo pain), diet advice. Rpt FBC in 1/12 cont Rx until Hb ok for 3 /12.
↓↑MCV Sideroblastic Anaemia
Abnormal ringed RBC precursors (sideroblasts) + non-haem Fe granules in bone marrow aspirate.
Causes:
• Congenital (rare, X-linked)
• Acquired
o Myelodysplastic syndromes
o 2° to myeloproliferative disorders (myeloma, Polycythaemia ruba vera, leukaemias)
o Drugs & toxins – lead, alcohol, chloramphenicol, isoniazid, linezolid, pyrazinamide
o Other 2° causes: SLE, RA, myxoedema, pregnancy
o Idiopathic
Management
Investigate for underlying cause:
• Blood: FBC (↓MCV in cong, may ↑in aquired), iron studies (serum iron high & ferritin high)
• Other: BMA (sideroblasts)
Treatment:
• Supportive. Transfusion if symptomatic (may need iron chelation if multiple).
• Drugs:
o Erythropoietin ± GCSF or Cyclosporin A in myelodysplastic syndrome
o Hereditary sideroblastic anaemia may respond to pyridoxine
• Stem cell transplantation
↓MCV Thalassaemia
See Haemoglobinopathies
