Transcript Patients Blood Film

FULL BLOOD COUNT
PRESENTATION
Clinical Practice A
GROUP C
Iron Deficiency Anaemia



Caused by a lack of adequate iron to synthesize
haemoglobin and meet body demands in such as
during periods of rapid growth and pregnancy
Usually due to a diet insufficient in iron or from blood
loss
Diagnosis includes
- Often, the platelet count is elevated
(>450,000X109/L)
- WBC is usually within reference ranges
Iron Deficiency



blood loss:
o uterine e.g. menorrhagia
o gastrointestinal
o malignancy
increased demands:
o pregnancy
o prematurity
o growth
others:
o malabsorption e.g. gastrectomy, coeliac disease
o dietary iron deficiency
Investigation and Diagnosis
Biochemistry:
 decreased serum ferritin - best biochemical
marker
 increased total iron binding capacity (TIBC)
 decreased TIBC saturation - less than 30%;
often the best parameter with which to
monitor treatment
 decreased serum iron
Investigation and Diagnosis
Haematology:
 microcytic, hypochromic anaemia
 blood film shows occasional target cells and pencilshaped poikilocytes
 platelet count may be at or above the upper limit of
normal if there is persistent bleeding
 The best proof of iron deficiency anaemia is that the
anaemia is cured by administration of iron.
Microcytosis


Defined as a reduced mean cell volume –
average volume of a single red cell - of less
than 80 femtolitres in adults (norm range 80100 fl)
Characterized by the presence of microcytes
(abnormally small red blood cells) in the
blood.
Causes






iron deficiency anaemia - the commonest
cause
Vit A, C, copper deficiency
sideroblastic anaemia
thalassaemias
anaemia of chronic disease
lead poisoning
Clinical Features







Possible symptoms:
pallor
fatigue
dyspnoea
anorexia
headache
bowel disturbance
Investigation



to investigate microcytic anaemia , patient has a
blood film, then serum iron levels are measured.
blood film - iron deficiency anaemia has a microcytic,
hypochromic blood film showing anisocytosis and
poikilocytosis
serum iron, ferritin and total iron binding capacity:
- iron deficiency anaemia - low serum iron, low
serum ferritin, raised TIBC
- other causes are iron loading conditions
characterised by raised serum iron, raised ferritin,
low total iron binding capacity
Patient Investigation

FBC
Hb
65 g/L
115-165
MCV
Platelets
Serum ferritin
74 fL
500 X 109/L
5ug/L
80-100
150-400 X 109/L
10-230
Serum B12
220pmol/L
120-680
Serum folate
Red cell folate
2.0nmol/L
100nmol/L
7-45
360-1400
Case History











25 year old female
Suspected iron deficiency anaemia
Never been pregnant, no change in menstrual flow
Normal diet/No medications
No GIT problems
Low MCV
High platelets
Normal Serum B12
Low Serum Folate
Low Red Cell Folate
Low haemoglobin
Is the MCV result consistent with a
diagnosis of iron deficiency?

Yes in iron deficiency anaemia, MCV is low,
however microcytosis is not always caused
by iron deficiency anaemia

WHY?
Because…

In the majority of cases, microcytosis is the
result of impaired hemoglobin synthesis.
Disorders of iron metabolism and of
porphyrin and heme synthesis, as well as
impaired globin synthesis, lead to defective
hemoglobin production and to the generation
of microcytosis.
Could this patient also have associated B12
or folate deficiency?
Serum folate, RBC folate and Vitamin B12
levels differentiate between folate and B12
deficiency
 The patient:
 Low haemaglobin: anaemia
 Serum B12: Normal
 Serum folate and RBC folate: LOW
Thus there is a folate deficiency

Folate Deficiency

Low folate levels can cause macrocytic
anaemia – indicated by high MCV

The patient has a low MCV - indicates
microcytic anaemia due to iron deficiency
Anisocytosis

However, blood film showed anisocytosis:
RBC are of unequal size (large and small)
Patient can have both
 iron deficiency anaemia: small size RBC
 folate deficiency anaemia: large size RBC

Main causes of folate deficiency
Dietary – inadequate intake (Common)
 Blood loss
 Increase physiological requirements eg infant growth
or pregnancy
 Malabsorption due to GIT problems eg Coeliac
disease, Crohn’s disease
 Other: Drugs eg Phenytoin, Trimethoprim,
Methotrexate, Oral Contraceptives
 Patient doesn’t display any of these factors

Is the data typical for patient’s with
iron deficiency anaemia?


Data is normal as in iron deficiency anaemia,
patients display low MCV and low serum
ferritin levels
Folate levels are not normally low in iron
deficiency anaemia. Thus the levels must be
investigated for other possible causes.
Patients Blood Film
Shows:
 Hypochromic, Microcytic Cells
 Marked Anisocytosis
 Piokilocytosis
- Pencil Cells
- Target Cells
 Occasional Howell-Jolly Bodies
 Hypersegmented Neutrophils
Anisocytosis


RBC show abnormal size
variation
Normal RBC diameter = 6-8
µm. Grades 14 depending
on % of abnormality

Normal RDW (Red cell
Distribution Width) is 11.5 14.5. Increased RDW
suggest anisocytosis

Significance: Sign of many
anaemias - Iron deficiency, Vit
B12 deficiency
Target Cells

Target cells AKA Codocytes

Characterised by thin “bullseye” shape and an increase in
the surface membrane area to
volume ratio due to a decrease
in Hb

Significance: A sign of Iron
Deficiency Anaemia, Vit B12
deficiency Anaemia and other
disorders eg Liver Disorders,
Thalassemia,
Pencil Cells

Oval to elongated, ellipsoid
shape with central area of
pallor and hemoglobin at
both ends of cell

Significance: Iron deficiency
anaemia (Elongated cells),
Vitamin B12 deficiency
anaemia (Oval Cells), can also
be Inherited, where by >25%
elliptocytes are oval.
Howell-Jolly Bodies

Smooth, round nuclear
fragments made up of
DNA

Observed when
erythropoiesis is active

>3% is significant and
indicates Megaloblastic
Anaemia
Hypersegmented Neutrophils

Neutrophils with five or
more lobes

Significance: an
important clue to the
presence of deficiency
of vitamin B12 or folic
acid
Conclusion

Patient FBC and Blood film suggest:
Iron Deficiency Anaemia
AND
Folate Deficiency Anaemia
As evidenced by Low MCV and Low Folate
combined with the presence of Hypochromic,
Microcytic Cells, Marked Anisocytosis, Howell-Jolly
Bodies, Hypersegmented Neutrophils