Hypochromic Anemias Iron Deficiency Anemia

Most anemias are hypochromic. Their usual cause is iron deficiency from various causes (Fig.44). To distinguish quickly between real iron deficiency and an iron distribution disorder, iron and ferritin levels should be determined.

Hypochromic Anemias 129

Iron Deficiency Anemia Ferritin Below
Fig. 44 The most important reasons for iron deficiency (according to Begemann)
Table 22 Diagnostic findings and work-up for the most important disorders of the red cell series

Clinical

Hb MCH

Erythro-

Reti

Leuko-

Seg

Lym-

Other cells

Throm-

findings

cyte mor-

culo

cytes

mented

pho-

bocytes

phology

cytes

nuclei

cytes

(%)

(%)

Fatigue,

1 1

Ring-shaped

I

n

n

n

n/t

pallor

erythrocytes,

(dysphagia)

anisocytosis

Possibly

1 1

Anisocytosis,

I

n//

n

n

Possibly

n

fever, weight

poikilocytosis

eosinophils

loss

f

monocytes f

left shift

Diffuse

1 I/n//

All sizes,

I

n/I

n

n

n/I

symptoms

dimorphic

Acute

I n

n

n

n

/t)

I)

n/I //

hemorrhage

Subjaundice

I n

n or pathol.,

//

nI

n

n

Possibly nor-

n/I

possibly

moblasts

spherocytes

Spleen f

I I

Target cells

/

n

n

n

Possibly nor-

n

moblasts

Paller

I n

n

II

I

I

/

Possibly

II

possibly

monocytes f

infections

and bleeding

tendency

Pallor

I/

Macrocytes,

I

I

I

/

Possibly

I/n

possibly

megalocytes

hyperseg-

alcohol his-

mented

tory

granulocytes,

possibly nor-

moblasts

Plethora,

/n

n

n

n/t

n

n

n//

possibly

spleen

Acute bleed-

In

n

//)

n

n

n

II

ing tendency

Diagnostic steps proceed from left to right. I The next step is usually unnecessary;. the next step is optional; ^ the next step is obligatory. n = normal value, | =lowerthannormal, f = elevated, () = test not relevant, BSG = erythrocyte sedimentation rate. Theml, Color Atlas of Hematology © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license.

Diagnostic steps proceed from left to right. I The next step is usually unnecessary;. the next step is optional; ^ the next step is obligatory. n = normal value, | =lowerthannormal, f = elevated, () = test not relevant, BSG = erythrocyte sedimentation rate. Theml, Color Atlas of Hematology © 2004 Thieme All rights reserved. Usage subject to terms and conditions of license.

Hypochromic Anemias 131

BSG Elec- Iron Ferritin Trans- Tentative tro- and ferrin diagnosis pho- others resis

Evidence/ Bone marrow Ref. further diag- page nostics

1

Iron deficiency anemia

Determine source of bleeding; check iron absorption

Erythropoiesis f p. 132 sideroblasts |, iron in macrophages |

Yf n/f

Acquired/secondary anemia (infectious/ toxic, paraneoplastic)

Search for trigger

Erythropoiesis p. 134 sideroblasts | iron in macrophages f

n n / n/f /

Sideroachrestic anemia, myelodysplasia

-> Erythropoiesis f, p. 106

ring sideroblasts present

n n n// - nf

Anemia due to hemorrhaging

Search for source and reason for hemorrhages

(Erythropoiesis p. 140 f)

n n n Hapto-globulin //

Hemolytic anemia

Especially: thalassemia

Osmotic resistance, Coombs test,

Hb electro-phoresis and further tests

(Erythropoiesis p. 140 f , rightshift) increased storage of iron p. 138

f n f/(n) nf ///n)

Aplastic anemia or bone marrow carci-nosia

Search fortrig- Hypoplasia of all p. 146, geror tumor cell series, or car- 148,150 cinoma cells

folic acid

/

Megaloblastic anemia

Gastroscopy, determination of antibodies, possibly Schilling test

Erythropoietic p. 152 megaloblasts

n// n / f f

Polyeythemia, DD: hypergam-maglobuline-mia

ALP, progression

Erythropoiesis f p. 162

n n / duration -of hemorrhaging ff

PTTn

Thrombocyto-penic purpura (ITP)

Search fortrig- Elevated mega- p. 166 gers, possibly karyocyte count also foranti-bodies

Table 23 Normal ranges for physiological iron and its transport proteins

Old units

SI units

Serum iron

Newborns

150-200 [xg/dl

27-36 xmol/l

Adults

Female

60-140 [g/dl

11-25 xmol/l

Male

80-150 [g/dl

14-27 xmol/l

TIBC

300-350 [g/dl

54-63 xmol/l

Transferrin

250-450 [g/dl

2.5-4.5 g/l

Serum ferritin

30-300xg/l

(15-160 xg/l premenopausal)

TIBC = Total iron binding capacity.

TIBC = Total iron binding capacity.

This usually renders determination of transferrin and total iron binding capacity (TIBC) unnecessary. If samples are being sent away to a laboratory, it is preferable to send serum produced by low-speed centrifugation, since the erythrocytes in whole blood can become mechanically damaged during shipment and may then release iron. Table 23 shows the variation of serum iron values according to gender and age.

It is important to note that acute blood loss causes normochromic anemia. Only chronic bleeding or earlier serious acute blood loss leads to iron deficiency manifested as hypochromic anemia.

Iron Deficiency and Blood Cell Analysis Focusing on the erythrocyte morphology is the quickest and most efficient way to investigate hypochromic anemia when the serum iron has dropped below normal values. In hypo-chromic anemia with iron and hemoglobin deficiency (whether due to insufficient iron intake or an increased physiological iron requirement), erythrocyte size and shape does not usually vary much (see Fig. 45). Only in advanced anemias (from approx. 11 g/dl, equivalent to6.27mmol/lHb) are relatively small erythrocytes (microcytes) with reduced MCV and MCH and grayish stained basophilic erythrocytes (polychromatic eryth-rocytes) seen, indicating inadequate hemoglobin content. Cells with the appearance of relatively large polychromatic erythrocytes are reticulo-cytes. The details of their morphology can be seen after supravital staining (p. 141). A few target cells (p. 139) will be seen in conditions of severe iron deficiency.

In severe hemoglobin deficiency (< 8 g/dl, equivalent to4.96 mmol/l) the residual hemoglobin is found mostly at the peripheral edge of the erythrocyte, giving the appearance of a ring-shaped erythrocyte.

Small, hemoglobin-poor erythrocytes indicate iron deficiency a c

Anemia Ring

Fig. 45 Iron deficiency anemia. a and b Erythrocyte morphology in iron deficiency anemia: ring-shaped erythrocytes (1), microcytes (2) faintly visible target cells (3), and a lymphocyte (4) for size comparison. Normal-sized erythrocytes (5) after transfusion. c Bone marrow cytology in iron deficiency anemia shows only increased hematopoiesis and left shift to basophilic erythroblasts (1). d Absence of iron deposits after iron staining (Prussian blue reaction). Megakaryocyte (1).

Fig. 45 Iron deficiency anemia. a and b Erythrocyte morphology in iron deficiency anemia: ring-shaped erythrocytes (1), microcytes (2) faintly visible target cells (3), and a lymphocyte (4) for size comparison. Normal-sized erythrocytes (5) after transfusion. c Bone marrow cytology in iron deficiency anemia shows only increased hematopoiesis and left shift to basophilic erythroblasts (1). d Absence of iron deposits after iron staining (Prussian blue reaction). Megakaryocyte (1).

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  • samuel
    How iron deficiency anemia works?
    7 years ago

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