Archive for the ‘ L2-Patho Anemia ’ Category

L2- Pathology of Anaemia

BLOOD

Composition:

Suspension of cells in a complex liquid (Plasma).

Plasma:

•H2O+ Organic molecules + Mineral Salls.

•After coagulation (- Fibrinogen)= Serum

Blood Cells:

•R.B.C

•W.B.C

•Platelets

Origin:

Site:

•In the embryo (liver, Spleen, Bone marrow)

•After birth (only in the Bone marrow)

•Lymmphoid tissues (B.M. , L.N., Spleen , Payer`s Patches)

EXAMINATION OF THE BLOOD

COMPLETE BLOOD PICTURE(C.B.C)

A.Quantitative Examination:

1- Quantitative Exam. Of the RBCs with its constituents:

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A- R.B.Cs no./mm:

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B- Hematocrite 😦 Relative Volume of R.B.Cs in the blood)

– By centrifugation of a small column of blood in a standard tube:

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C- Hb. Content of 100 cc blood

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D- mean Corpuscular Volume:

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Normal : 85-95 N

•If <   97 indicates Macrocytosis

•If >   83  indicates Macrocytosis

E- Mean Corpuscular Hb. Conc.:

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Normal: 0.32 – 0.36 (32%-36%)  (Normochromic)

•If >   32  indicates Hypochomic

•If <   36 Hyperchromic ( error)

F- Reticulocytic count

-normal life  span of RBCs=120 days

-Reticulocytes are the newly fabricated RBCs within the 1st 24 hrs (still counting cytoplasmic organells) i.e. by special stain- counting the no. of RBCs containing such organells amoong 100 RBCs in%

-Absolute no. of reticulocytes := RBCs count X reticulocytic %.

-Normal 25.000———–100.000/mm3    (1-2%)

for Hb. Content within the normal range.

-Within anaemia increase in no. of the reticulocytes, if there is a normal ability of the B.M. to synthesis RBCs.,

i.e, if Hb > =8 gm in regenerative anaemia ( e.g, haemolytic or post Hgic)—reticulocytic count must be < 100.000. if > 100.000 this means aregnerative. i.e. (Hypoplastic or apastic ) anaemia.

2-Quantitive Exam. Of WBCs

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N.B. In adults .

•<   11.000 indicates leucocytosis

•>   4.000 indicates leucopenia.

3- Quantitative Estimation of Platelets:

Normal : 15.0.000-040.000/ mm3

>  150.000 indicates thrombocytopenia

< 450.000 indicates thrombocytosis.

B- Morphologic Examination

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1- Morphological exam. Of RBCs

Normaly : RBCs are of :

•Same form

•Same colour

•Same diameter

Any abnormality : Pathological Condiation:

•In size: anisocytosis

•In form: Poikilocytosis

2- Differential white cell count

The absolute no more important than the %

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Anemia

Def :

Reduction in the concentration Of HB in the peripheral blood below the normal for the age and sex of the patient:

•<13 gm. /100 ml for adult male

•<11.5 gm./100 ml for adult female & infant

• <14 gm. /100 ml for new born

True or False Anemia

HB concentration

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Classification

Depends on:

1-  Aetiology.

2- morphology of RBCs

both are complementary

A- According to the  Aetiology:

I- Anemia due to excess red cell loss (RBC lost):

a) Post- haemorrhagic anemia

– Acute haemorrhagic Anemia

– Chronic Haemorrhagic Anemia

b) Haemolytic anemia

– corpuscular defect

– Extra corpuscular defect

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II- Anemia due to impaired red cell formation (RBC low):

a)Deficiency of substances essential for erythropoiesis (raw low):

– Substance essential for HB synthesis:

  1. – Iron deficiency anemia
  2. – Protein deficiency

– Substance necessary for DNA synthesis :

  1. – Folic acid
  2. – B12

b)disturbance of B.M. function (mecha broken)

  1. -due to B.M. infiltration
  2. -Aplastic Anemia

III- Anemia due to other causes :

1- endocrine disorders

2- renal failure

3- Infections

4- liver disease

5- malignant disease

6- collagen diseases

B- According to RBCs Morphology

•1-Microcytic and/or Hypochromic Anemias

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•2- Normocytic Normochromic Anemias

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•3- Macrocytic Anemias

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Clinical Picture

The symptoms and signs are due to:

I:  The anemia itself.

II: The disorder causing the anemia.

I- Clinical picture of Anemia Whatever the cause:

A)Symptoms:

-Generalized

-C.V.S

-CNS

b) Signs :

-Pallor

-C.V.S :

  1. Tachycardia
  2. Murmurs
  3. High C.O. state
  4. Congestive heart Failure

II- Clinical picture which may indicate the cause of anemia:-

1)History:

a) Present History:

-Age and sex

-Occupation

-Rate of onset

-History of blood loss

-History of bleeding tendency

-History suggestive of hemolysis

-History of drug intake

-G.I.T symptoms

-Bony pains

-C.N.S paraesethia

-Fever

-Diet

b) Social History

c) Menstrual and Gynecologic History

d) Family History

2)Examination:

a)General examination:

-Built

-Skin

-purpura, ecchymosis

-Conjunctiva

-Mouth

-Nails

-Blood pressure

-Bones

-Legs

B) C.V. examination :

– Hypertension

– Signs are usually secondary to anemia.

– Presence of organic heart disease may suggest rheumatic activity or  bacterial endocarditis

C) Abdominal examination :

-Splenomegaly

-Hepatomegaly

-Abdominal mass

3) Investigations :

I- Determination of the morphologic type :

– Microcytic and or hypochromic .

– Normochromic (Normocytic or microcytic).

– Macrocytic (Megaloblastic or  Normoblastic ).

According to :

a)MCV

b)MCHC

c)Reticulocytic count

II- Discovery of the cause :

From:-

-history.

-physical examination.

-blood film examination.

-Sometimes+ further special investigation.

A-Microcytic +/- hypochromic

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If iron deficiency anemia:

Search for a source of chronic blood loss:

1)In females:

-Abnormal uterine bleeding;menorrhagia or contra-

ceptive device.

-Gynaecologic examination for fibroids or tumours.

2)G.I.bleeding:

-Occult blood ,parasites.

-Barium meal or upper endoscopy.

-Colonoscopy or barium enema.

3)Less frequent causes:*Iron deficiency;malabsorption.

*Chronic epistaxis or hematuria.

B-Normochromic Anemia with Reticulocytosis

Reticulocytes  >120. 000/mm3

M.C.V. N. or slightly ↑

=Anemia with regeneration.

1) signs of acute heamorrhage

– epistaxis

– h.± melena

– hemoptysis

=Post hemorrhagic Anemia

2) If No evidence of He but signs of hemolysis

and/or :

↑ indirect bilirubin

↓ Haptoglobine

= Hemolytic Anemia

Search for the most commonacute  causes:

*Coomb’s test  *G6PD  *Blood culture (septicemia)*Malaria

If (1),(2) are negative

– repair of certain anemias

e.g tretment with B12 or folic

– stopage of toxins fore erythropoises.

e.g alcohol, chloramphenicol.

– Rcent unnoticed Hemorrhage.

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C-Aregenerative Non Microcytic Anemia:

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Indications of B.M aspiration

(In aregenerative non microcytic Anemias)

A- if no apparent cause

(No R.F, inflammation, Endocrinal manifestation)

and no cause of hemodilution

( huge splenomegaly; abn. Ig. Or oedema measure the red cell mass)

B- M.C.V. > 110N3

C- if + Neutropenia ±/ Thrombocytopenia, or if there is abnormal cells

Marrow aspiration: the following possibilities:

1- No erythroblasts

anerythroblastic anemia

2- megaloblasts .

megaloblastic anemia

3-abn. cells

B.M. infilteration

4- hypocellular marrow

5- Normal marrow

6-Malfornied erythroblasts:

Dyserythropoiesis

e.g.:

– Antimeitotic drugs

– Congenital

– Refractory anemia

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d) AREGENERATIVE MEGALOBLASTIC

1) Search for a cause of folic acid or B 12 deficiency:

-malnutrition  -malabsorption  -gastric resection.

-relative deficiency: multipara

chronic hemolytic anemias.

-defect in utilization:alcoholism

antifolic drugs.

For confirmation:

Measure folic acid & B12 serum

2) If no evident cause:

•Seach for pernicious anemia

•schilling test

•gastric acidity test + gastric endoscopy

•folic and B12 serum levels

•If low B12,normal folic acid,+ve schilling

= Pernicious anemia

•If not pernicious anemia:

we have the following possibilities:

–low B12, N. folic= may be diphylobothrium L –low folic acid—-> do malabsorption tests –N. B12 and folic—–>refractory anemia

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