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Adult with Hb 106 and MCV 72 - what kind of anemia?
Microcytic anemia
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Differential diagnosis of microcytic anemia? (10)
#1 Iron deficiency,thalassemias, chronic disease (rare, late stage), sideroblastic, lead, EtOH, drugs, Copper def, zinc poisoning, congenital
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#1 worldwide cause of iron deficiency anemia?
Hook worm
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Causes of macrocytic anemia?
Alcohol #1, B12 or folate, drugs (HIV anti-retrovirals, chemo/MTX, anti-epileptics), Myelodysplastic syndromes MDS, AML/ALL, liver disease, reticulocytosis (hemolysis, bleed, iron therapy), hyperlipidemia, congenital, thyroid, myeloma
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Clues about macrocytic anemia from the CBC?
RDW - Increased (B12, folate, AIHA, drugs) vs Normal (sick bone marrow - MDS, myeloma)
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Ancillary tests for work-up of macrocytic anemia
- #1 smear & retics - to r/o hemolysis and metabolic dz
- B12 level, RBC folate (or plasma folate), methylemalonate (confirmatory for B12 def), homocysteine level
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More ancillary tests for macrocytic anemia - rare
SPEP, UPEP, liver enzymes, TSH, coombs, haptoglobin, BM biopsy
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Normocytic anemia DDx
Chronic disease, Chronic kidney disease (Epo def), iron deficiency (early), endocrine causes, BM suppression (cancer, aplastic)
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Clues on CBC for normocytic anemia w/u
- RDW - Normal (Chronic disease)
- WBC/plts - if both low then pancytopenia (aplastic anemia)
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2 best ancillary tests for Normocytic anemia w/u
Start with smear and retics
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If smear and retics not helpful in normocytic workup, what next?
Do Cr to rule out CKD, but otherwise consult heme if going further
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Clues on CBC for Microcytic anemia
- RDW - increased (Fe def), Normal (thalassemia, chronic disease)
- Count - Increased (Thalass), Decreased (Fe def)
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Single best ancillary test for microcytic anemia
Ferritin! But increased in inflammatory process (more common with inpatients)
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How to interpret ferritin results?
- <10 - Dx for Fe deficiency, <30-40 (LR 11) very sense and spec for iron deficiency. If >100 then not Fe def (LR 0.1).
- So if between 40 and 100 then can't tell.
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If Ferritin is equivocal for microcytic anemia work-up?
- TIBC, Transferrin sat, Fe level (if ferritin between 40-100)
- Hb electrophoresis if suspect thalassemia, hemoglobinopathy
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When to be more hasty with tests in microcytic anemia?
If pregnant, want to Dx thalassemia or genetic Hb-opathy sooner than later, so do hb electrophoresis (SPEP) sooner.
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AAFP's approach to macrocytic anemia - 1st 3 tests to order?
If MCV > 100, order a smear, retic count and B12 (interpret in that order)
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Interpret smear in macrocytic anemia workup?
- If smear normal (not megaloblastic) - consider EtOh, drugs, thyroid, liver dz --> consider LFTs and TSH
- If smear ban (megaloblastic) - then move onto retic count
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Interpret retic count in macrocytic anemia with megaloblastic on smear?
- Retics > 2% = hemolysis (do hemolytic workup)
- Retics < 2% = Look at B12 level
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Interpret B12 level in macrocytic, megaloblastic anemia with N retic count?
- Vit B12 < 100 pg/ml --> B12 deficiency - treat
- Vit B12 100-400pg/ml (74 - 294 pM/L) - indeterminate
- Vit B12 >400 pg/ml (>294 pmol/L) - not B12 def… order RBC folate
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If indeterminate B12 level in megaloblastic anemia with N retics?
B/w 100-400 pg/ml - check MMA and homocysteine
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Clues to MMA and homocysteine interpretation?
- MMA HIGH (regardless of homocys)- Vit B12 def
- MMA N + N homocysteine - BM Biopsy
- MMA N + high homocysteine - Folate deficiency
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If smear megaloblastic, retics N, B12 > 400 pg/ml, what next?
RBC Folate level (if low treat), if normal - BM Bx?
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Which results suggest iron def anemia?
Increased RDW, low RBC count, low ferritin, low Fe, TIBC increased, transferrin sat decreased (only do last 3 if ferritin N)
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Which results suggest chronic disease anemia in microcytic workup?
Low Fe, TIBC low, Transferrin sat decreased with high ferritin
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If patient has mild normocytic anemia with N RDW, WBC/plts N, no abN cells on smear, no Sx and known chronic disease? If not?
Presumptive Dx of Anemia of CHronic Disease (ACD), if not - then repeat CBC and get corrected retic index (CRI)
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If normocytic anemia without obvious ACD and N or low CRI?
- Either BM cause, Fe def or ACD.
- Consider BM biopsy (if any of CRI<0.1%,low plts/WBC or leukoerythroblastic cells) or Ferritin.
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Thrombocytopenia workup - DDx
clumping, pregnancy, iron def (severe), hypersplenism (if drinker), ITP, malignancy, TTP/HUS, drugs, infection (HIV, malaria), HIT, HELLP
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CBC clues of thrombocytopenia
- MPV (mean platelet volume) - high with clumping, low with BM failure
- Other cell lines - ? pancytopenia
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Ancillary tests for thrombocytopenia
- Smear - fragments vs clumping vs other AbN cells
- if unsure after this… heme consult
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What is platelet clumping due to and how to prevent it?
2º to EDTA in medium. Repeat and order Non-EDTA on requisition.
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