Transcript Presentation

Haematology Group C
Wedyan Meshreky
Helen Naguib
Sharon Naguib
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A 25 year old female was referred for evaluation of
recently discovered anaemia. She had never been
pregnant and had noted no change in menstrual flow & no
intermenstrual bleeding. Her diet was normal and she took
no medications. She denied any change in bowel habit or
symptoms of GI/urinary blood loss.
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There were no abnormal physical findings.
Blood film – hypochromic, microcytic cells. There was
marked anisocytosis with moderate numbers of pencil and
target cells. An occasional Howell-Jolly body and
moderate numbers of hypersegmented neutrophils were
noted.
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Hb:65 g/L (115-165)
MCV:74 fL (80-100)
WCC:4.5X 109/L (4.0-11.0 X109/L)
WCC differential Normal
Platelets: 500 X109/L (150-400 X109/L)
Iron deficiency anaemia is suspected. Is the MCV
result consistent with a diagnosis of iron
deficiency - explain?
Microcytosis
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Presence of smaller than normal RBC,
possessing a variable central pallor
(hypochromic)
Normal RBC are 7-8m, but microcytic
cells are <7m in diameter
Normal vs Microcytic RBC
MCV
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MCV: average volume of a single RBC
Reference interval: 80-100fL
An MCV below this range indicates
microcytosis
Causes
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Commonly caused by iron deficiency
anaemia, thalassaemia and anaemia of
chronic disease
Rare: lead poisoning, sideroblastic anaemia
and Haemoglobin E
This px’s MCV=74fL therefore consistent
with diagnosis of iron deficiency anaemia
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Blood film: hypochromic, microcytic cells,
marked anisocytosis and moderate numbers
of pencil and target cells
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Hypochromia characterised by the presence
of a central pallor in the RBC
Anisocytosis
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Variation in the size of RBCs, without a
change in cell shape.
Anisocytosis..
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Mainly associated with 2 conditions:
- young RBC or polychromatophils
or - smaller RBC such as microcytes
It is a feature of many anaemias and other
blood conditions but does not have much
diagnostic value
Anisocytosis..
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The red cell distribution width (RDW) is a
qualitative measure of the degree of
anisocytosis
Useful in the differential diagnosis of
microcytic anaemia.
Most cases of iron deficiency anaemia have
a raised RDW, whereas in thalassaemia
RDW is normal
Anisocytosis is often due to low Vit. B12,
folic acid and iron
Blood film –
There was a moderate numbers of
pencil and target cells and an
occasional Howell-Jolly body
PENCIL/CIGAR CELLS
•Morphology:
Red cells shaped like a cigar
or pencil
•Found in:
Iron deficiency Anaemia
TARGET CELLS
Morphology:
Abnormal red blood cells (discoid shaped) resembling
targets
TARGET CELLS (2)
Found in:
 Chronic disease including
- liver disease
- obstructive jaundice
- certain endocrinopathies
- iron deficiency anaemia
- post-splenectomy
- thalassemia (hemoglobinopath)
HOWELL-JOLLY BODY
Morphology:
Round, purple staining nuclear fragments of
DNA in the RBC, due to abnormal cell
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division.
HOWELL-JOLLY BODY
Single Howell-Jolly Body:
- Haemolytic anemia.
- Post splenectomy,
- Splenic atrophy.
Multiple Howell-Jolly Bodies:
- Megaloblastic anemia
Causes of Iron Deficiency
Anaemia
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Increased iron demand (growth or pregnancy)
Blood loss (peptic ulcers, hookworms,
haemorrhoids, menstruation etc)
Inadequate intake of Folate & B12 & Iron
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Iron, B12 and folate are needed for Hb synthesis and
RBC production & maturation
Chronic diseases,bone marrow disorders etc
Does this patient also have B12 or
Folate deficiency?
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Results:
Hb
MCV
6 5 g /L
1 1 5 -1 6 5
7 4 fL
8 0 -1 0 0
S e r u m F e r r itin 5 u g /L
1 0 -2 3 0
S eru m B 12
2 2 0 p m o l/ L
1 2 0 -6 8 0
S e r u m F o la te
2 n m o l/ L
7 -4 5
R e d C e l l F o l a t e 1 0 0 n m o l/ L
P la te le ts
5 0 0 x 1 0 * 9 /L
3 6 0 -1 4 0 0
1 5 0 -4 0 0 x 1 0 * 9
Folate
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Body stores very little (4 weeks supply)
Maintenance of folate stores is dependent
on dietary intake.
Absorbed in small bowel and circulates in
free form or loosely bound to albumin.
Essential for DNA synthesis and aa
metabolism.
Folate Deficiency
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May be due to:
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Dietary folate deficiency
Coeliac disease
Alcoholism
Pregnancy
Hypothyroidism
Drugs (eg. Phenytoin, trimethoprim)
Liver disease
Vitamin B12
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In contrast to folate, the body stores large
amounts (2-6yrs supply)
Anaemia due to B12 deficiency takes ~2yrs
to develop due to large stores in liver
Deficiency of B12 or folate impairs
Thymidine Synthase function, hence
interupts DNA synthesis  
megaloblastic anaemia
Serum Ferritin
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Most specific biochemical test that
correlates with total iron stores in the body
Low levels ( <15ug/L) reflect depleted iron
stores.
Data is typical of Iron deficiency
Anaemia
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Microcytic (MCV < 80fL)
Low Hb (65g/L)
Raised Platelets (500x10*9/L)
Low Serum Ferritin (5ug/L)
Hypochromic cells on blood film
Folate deficiency (2nmol/L)
Treatment
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Establish cause of anaemia and treat
underlying cause.
Iron supplementation.
Increase dietary intake of Iron, Folate &
B12.