Transcript Iron deficiency anaemia

Appraoch to a child with
anaemia
Dr. Pushpa Raj Sharma
Professor of Child
Health
Institute of Medicine
13.11.2060
Definition of anaemia
• The condition of having too few red blood
cells.
• It is a reduction of the red cell volume or
hemoglobin concentration below -2SD for
age, race and sex.
• Microscopic:
normocytic,microcytic,normochromic
macrocytic or specific abnormalities
(spherocyte,sickle cell,target cell)
Case
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Nine months old “Rai” female, single child
Recurrent fever
Mass in abdomen with pallor
No history of rash, bleeding, persistent
diarrhoea, drug, jaundice, pica,
Had blood transfusion 2 days back
No consanguity of marriage
No family history of gall stones, jaundice.
No loss of weight, exclusive breast feeding
Summary of examination
finding
• 9 Kg.
• Mild pallor
• No purpuric rash, lymphadenopathy,
abnormal facies,
• Gross spleenomegaly
Diagnostic Approach-History
• Age : Iron def rare without blood loss
before 6mo in term infants.
• Family Hist & Genetics:
(1)X-linked: G6PD def
(2)Aut dominant: Spherocytosis
(3)Aut recessive: Sickle cell,Fanconi
anemia
(4)Family member with early age of
cholecystectomy/splenectomy
(5)Ethnicity: Thalassemia; G6PD def
Diagnostic Approach-History
• Diarrhoea:
-Malabsorption of VitB12/E/Fe.
Inflammatory bowel disease and anemia of
chronic disease with or without blood loss.
-Milk protein intolerance induced blood loss
-Intestinal resection: Vit B12 def
• Infection:
- Giardia: iron malabsorption
-Intestinal bacterial overgrowth: VitB12def
-EBV,CMV,Parvovirus: BM suppression
-Mycoplasma,Malaria: hemolysis
-Hepatitis: aplastic anaemia
-Endocarditis, HIV
Diagnostic Approach-History
• Nutrition:
(1)Cows milk diet:iron def.
(2)Strict vegetarian:Vit B12 def.
(3)Goats milk: Folate def.
(4)Pica: Plumbism,Iron def.
(5)Cholestasis,malabsorption:VitE def
• Drugs: (1)G6PD:oxidants(sulfa, primaquine, henna)
(2)Immune mediated hemolysis (penicillin)
(3)Bone marrow suppression (chemotherapy)
• (4)Phenytoin increase folate requirement
Physical exam reveals presence
and potential causes of anaemia
• Fever-acute infection,intravascular disease,collagen
vascular disease
• Jaundice suggests hemolysis
• Petechia&Purpura—bleeding tendency
• Hypertension&oedema-renal disease
• Hepatosplenomegaly and lymphadenopathy—
infiltrative disease
• Growth failure or poor wt. gain—Anemia of chronic
disease or organ failure
• Examine stool for blood; urine for hemoglobinuria
Physical Findings in Anaemia
• Skin:Hyperpigmentation,café au lait spotsFanconi anemia
-Jaundice-hemolysis
-Petechia&purpura- BMinfiltration,
autoimmune hemolysis&thrombocytopenia
-Erythematous rash- Parvovirus,EBvirus
-Butterfly rash-SLE; Vitiligo-VitB12def
• Head:Frontal bossing-Thalassemia major
-Microcephaly-Fanconi anemia
Physical Findings in Anaemia
– Eyes: Microphthalmia-Fanconi anemia
-Retinopathy-Sickle cell disease
-Optic atrophy-Osteopetrosis
-KF ring-Wilson disease
– Ears: Deafness-Osteopetrosis
– Mouth: Glossitis-B12 def,iron def
-Angular stomatitis-Iron def
-Pigmentation-Peutz Jeghers syndrome
-Telangiectasia-Osler Weber Rendu
syndrome
Physical Findings in Anaemia
• Chest: Cardiac murmurEndocarditis,prosthetic valve hemolysis
• Abdomen: Hepatomegaly-hemolysis,
infiltrative tumour,chronic disease,
hemangioma,cholecystitis
-Splenomegaly -hemolysis,sickle cell
disease,thalassemia,malaria,EBvirus, portal
hypertension
-Kidney anomaly-pelvic/absent kidney
Physical Findings in Anaemia
• Extremities:Absent thumb-Fanconi
anemia -Spoon nails-Iron deficiency
-Dystrophic nails-Dyskeratosis
congenita
• CNS-Irritable,apathy-Iron def.
-Peripheral neuropathy-lead poisoning
-Ataxia,post.column signs-Vit B12def
- Stroke-Sickle cell anemia
• Short stature-Fanconi anemia,
Malnutrition
COMPLETE BLOOD COUNT
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Hb Conc
(g/dl)
Hematocrit(PCV)
MCV
(fl)
MCH
(pg)
MCHC (detects red cell dehydration)
RBC Count
(…x10 )
WbC Count
(…x10 )
Platelet Count
(…x10 )
Reticulocyte Count ( % )
Normal values
AGE
Hgb
Mean/ (-2SD)
HCT%
Mean/ (-2SD)
MCV
Mean/ (-2SD)
Newborn
16.5 (13.5)
51 (42)
108 (96)
1 Month
13.9 (10.7)
44 (33)
101 (91)
2 Months
11.2 (9.4)
35 (28)
95 (84)
6 Months
12.6 (11.0)
36 (31)
76 (68)
> 6 Months
12.5 (11.0)
36 (33)
Adult
Male
Female
15.5 (13.5)
14.0 (12.0)
47 (40)
41 (36)
81 (70+ age per yr)
90 (80)
90 (80)
Harriet Lane Handbook, The John Hopkins Hospital,15th edition
Reticulocyte Production Index
• RPI corrects the retics for the degree of
anaemia
• RPI indicates whether bone marrow is
responding appropriately to anaemia
• RPI= Retic x Hb(o) x 0.5 divided by Hb(n)
• RPI > 3 increased production (hemolysis or
blood loss)
• RPI < 2 decreased production or
ineffective production for the degree of
anaemia
• Reticulocytopenia—acute onset of anaemia,
antibody mediated destruction, BMdisease
AETIOLOGY
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(1) Inadequate response RPI < 2
A. Hypochromic microcyctic
B. Normochromic Normocytic
C. Macrocytic
(2)Adequate response RPI > 3 R/O
blood loss---Includes Hemolytic
disorders
Microcytic Anaemia
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TEST
Iron def ThalMin
S.Iron
- low
normal
S.Ferritin
- low
N/H
Marrow iron - low
N/H
Hb A2or F - N
H=Bthal
N=Athal
MCV ÷ RBC - >13
< 13
Sickle/B-thal – Hb S > Hb A
Absence of microcytosis in both parents excludes
B-thal or Sickle/B-thal but not A-thal
Macrocytic anaemia
• Vit.B12 def.- (1) pernicious anaemia
(2) ileal resection (3) abnomal
intestinal transport
• Folate def.- (1) malnutrition
(2) malabsorption (3) chronic
hemolysis (4)drugs - phenytoin,
sulfa
• Hypothyroidism
• Chronic liver disease
• Marrow failure-Fanconi
anaemia,Aplastic A
13.11.2060
Haemolytic anaemia
• Hemoglobinopathy– Hb
SS,SC,S-B thal
• Enzymopathy--G6PD def, PK
def
• Membranopathy—Hereditary
spherocytosis, elliptocytosis
• Extrinsic factors—
DIC,HUS,Abetalipoproteinemia,
Wilsons disease,Vit E def
• Immune hemolytic anaemiaAutoimmune,Isoimmune,Drug
induced
13.11.2060
THALASSEMIA-Lab
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Thal trait:Hb 9-10 g/dl
HbH disease:Hb 6-7 g/dl
Thal intermedia:Hb 7-8 g/dl
Thal major:Hb less than 5 g/dl
Peripheral smear:hypochromic,microcytic,
anisopoikilocytosis,target cells
• Hb electrophoresis: (1)Thal trait-HbF 15%, HbA2 3.5-8%,rest HbA
(2)Thal
major- HbF 20-100%,HbA2 2-7%,HbA 060%
Pure Red Cell Aplasia:
Reticulocytopenia + Absent marrow erythroid precursors
Congenital
(Blackfan-Diamond)
- 1st year of life
- congenital anomalies
- defective erythroid stem cell
- high MCV
- treatment: prednisone
blood transfusion
- life long
.
Acquired
(Transient Erythroblastopenia of
Childhood-TEC)
- healthy child
- mean age dx: 25 mo.
- serum inhibitor of erythropoiesis (?
virus)
- normocytic
- treatment: transfusion PRBC’s (no
steroids)
- recovery is rule
Aplastic anaemia
• Severe reduction
in platelets and
granulocyte
series
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Anaemia of chronic disease
Normal morphology
Chronic inflammatory disease—
(1)infection (2)collagen vascular disease
(3)inflammatory bowel disease
Recent blood loss
Malignancy/Marrow infiltration
Chronic renal failure
Transient erythroblastopenia of chidhood
Marrow aplasia/hypoplasia
HIV infection
Hemophagocytic syndrome
13.11.2060
Haemolytic anaemia
• Polychromasia
(Wright-Geimsa).
13.11.2060
Leukaemias
• Blast cells
13.11.2060
Laboratory Evaluation
• Hematology:Complete Blood Count, Retic
count,Peripheral smear,ESR,G6PD
Sickling(+/-inf),Hb electrophoresis,Group,DCT,
Osmotic fragility test,BMaspiration
• Biochemistry:LFT,UE,RFT,S.Ferrtin,
S.Haptoglobin,Iron,VitB12,Folate,Ceruloplasmin
• Serology:Heterophil antibody,ANA,Viral t
• Urinalysis,microscopy,culture/sensitivity
• Stool exam.for ova,parasites,occult blood
• Endoscopy: upper and lower bowel
• Imaging:US Abdomen,Skeletal radiographs, Tc
pertechnetate scan for Meckels diverticulum
• Tissue biopsy:skin,lymph node,liver
•Nine months old female, single
child
•Recurrent fever
•Mass in abdomen with pallor
•No rash, bleeding, persistent
diarrhoea, drug
•Had blood transfusion 2 days
back
•No consanguity of marriage
•No loss of weight, exclusive
breast feeding
•9 Kg.
•Mild pallor Hb:9.4 g%
•No purpuric rash, lymphadenopathy, abnormal facies,
•Gross spleenomegaly
Blood report:
TLC: 9,600/ cmm: P: 44%: L: 56%;
Platelets: 30.000/cmm Anisocytosis, hypochromic,
reticulocyte 0.8%, occasional NRC.
The diagnosis
• Reticulocyte production index
= Retic x Hb(o) x 0.5 divided by Hb(n) = 0.3
RPI < 2 decreased production or ineffective
production for the degree of anaemia
– Metabolic
– Malignancy
– Further work up:
– Bone marrow
Bone marrow report
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Normal values
Cell Type
Range
%Myeloblasts
0-2
Promyelocytes
2-5
Myelocytes (neutrophilic)9-16
Metamyelocytes
7-23
Band forms
8-15
Neutrophils
4-10
Myelocytes (eosinophilic)0-2
Band
0-2
Mature
0-3
Monocytes/macrophages0-3
Basophils
0-1
Mast cell
0-2
Plasma cells
3-6
This patient
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Cell Type
Blast
Promyelocyte
Myelocyte
Metamyelocyte
Neutrophils
%
10
1.5
12
18
31
Final diagnosis
• Malignancy
– Juvenile Chronic Myelogenous Leukemia
The commonest cause
• Iron def. is common in children 9mo-3yr
• Iron def. anemia in a child over 3yr should
prompt consideration of occult blood loss.
• Infants less than 6months generally do
not develop iron def.; the exception to
this rule is premature infants,who are at
risk of iron def.at 4mo, if iron
supplementation is not given.
Iron deficiency Anemia
– Dietary iron def is the usual cause
– Manifestations of anemia
– CNS
abnormalities:apathy,irritability,poor
conc,cognitive deficits
– Poor muscle endurance
– GIT dysfunction
– Impaired WBC and T-cell function
Iron deficiency: hypochromic
anaemia
• Iron def.-(1)chronic
blood loss (2)poor
diet (3)cows milk
protein intolerance
• Chronic inflammatory
disease
13.11.2060
Differential Features of Iron Deficiency vs
Acute and Chronic Inflammation
Iron Deficiency
Anemia
Red Cell Indices
Blood Smear
Serum Iron
TIBC
Transferrin Saturation
S. Ferritin
B.M. Iron Stores
MCV,  MCH
Microcytic,
hypochromic
Decreased
Increased
Decrease (<7%)
Decreased (<12
mg/ml)
Acute and Chronic
Inflammation
MCV: N or , MCHC:
N or 
Normocytic/microcytic
Decreased
Normal or decreased
Decreased (<16%)
Normal or increased
Normal or increased
Iron deficiency Anemia
• Treatment:Response to oral iron includes
24-48hr-subjective improvement inCNS
48-72hr-reticulocytosis
4-30days-increase in Hb
1-3 mo-repletion of iron stores
• Therapeutic dose:3-6 mg/Kg/day of
elemental iron.---Induces an increase in Hb
of 0.25-0.4 g/dl per day or 1%/day rise in
hematocrit.
• Failure of response after 2 weeks of oral
iron requires reevaluation for ongoing
blood losses,infection,poor compliance or
other causes of microcytic anaemia.