Athenia feels tired

Athenia feels tired

1. Demographics: Athenia, 65 years old

2. Erythropoietin and hemopoiesis

   • Hemopoiesis

3. Hemoglobin (Synthesis & Structure)

   • The Synthetic Pathway of Heme
     • Globin Chains
       • Iron Metabolism

4. RBC Morphology

   • Microcytic RBC
     • seen in : Iron deficiency anemia Thalassemia sideroblastic anemia anemia of chronic disorders.
   • Macrocytic RBC
     • seen in : Liver diseases hypothyroidism megaloblastic anemia
   • Variation in color
     • Hypochromic
       • seen in : Iron deficiency anemia anemia of chronic diseases thalassemia
     • Polychromic
       • reticulocytes
   • Poikilocytosis
     • Target cells: Red cells have an area of increased staining which appears in the area of central pallor.
       • seen in : severe Iron deficiency anemia obstructive liver disease thalassemia
     • Elliptocytes: The RBCs are oval or elliptical in shape.
       • seen in : megaloblastic anemia IDA thalassemia
     • Sickle cells: These are sickle-shaped Red Blood Cells.
       • seen in : sickle cell anemia
     • Spherocytes: RBCs lacks the biconcave shape and becomes more spherical, no central pallor is present with increased hemoglobin content.
       • seen in : hereditary spherocytosis hemolytic anemia
     • Stomatocytes: Red cells with a central linear slit or stoma. Seen as mouth shaped form in peripheral smear
       • seen in : excess alcoholism alcoholic liver disease
     • Burr cells: Red cells with uniformly spaced pointed projections on their surface.
       • seen in : hemolytic anemia Uremia megaloblastic anemia

5. classification of anemia

   • Classification of anemia depending on the size of RBCs
     • Microcytic MCV below 80 fL
       • Iron deficiency Anaemia of chronic disease (some cases) Sideroblastic anaemia Thalassaemia
     • Normocytic MCV between 80 & 100 fL
       • Many haemolytic anaemias Anaemia of chronic disease (some cases) After acute blood loss Renal disease BM failure, post chemotherapy
     • Macrocytic MCV more than 100 fL
       • Megaloblastic:Vitamin B12, or Folate deficiency, Prenicious anemia Non-megaloblastic: alcohol, liver disease, aplastic anaemia
   • Classification depending on the cause of anemia
     • de-creased production
       • Renal disease , BM failure, post chemotherapy Iron deficiency Folate and B12 deficiency anemia
     • In-creased destruction (hemolytic)
       • Intracorpuscular defects Hemoglobinopathies: (Thalassemias, sickle cell) Defects in the red cell membrane : Hereditary spherocytosis Enzyme defects: G6PD deficiency Paroxysmal nocturnal hemoglobinuria
       • Extracorpuscular defects Immune hemolytic anemia Infections Chemicals and toxins Physical agents Microangiopathic and macroangiopathic hemolytic anemias Splenic sequestration (sickle cell)
     • Blood loss
       • acute :trauma
       • Chronic : menstruation, inflammatory bowel diseases

6. iron deficiency anemia

   • Causes
     • Increased iron requirements
       • Blood loss . Blood donation. Worm infection. Pregnancy and lactation
     • Inadequate iron supply
       • Insufficient dietary iron (malnutrition) Impaired iron absorption, Gastric surgery(gastric bypass) ,Intestinal malabsorption ,Celiac disease
   • Pathogenesis
     • Decreased Iron stores
       • Decreased Hb Synthesis
         • Delayed maturation of erythroblasts (cytoplasmic)
           • Decreased cytoplasm, more division (microcytes)
             • Decreased Hb content (hypochromia)
               • Anemia

7. Histology OF Hematopoietic Organs

   • Bone marrow
     • Bone marrow smear
       • Lymph node
   • Spleen
     • Tonsil
       • Peyer’s patch

8. Lymph node examination

9. History Taking

   • Present History:
     • weakness, tiredness, dyspnea, fatigue and postural dizziness ,Bleeding (gastrointestinal,menstrual),Easy bruising (purport), Recurrent infections, fever or jaundice, Lymph gland enlargement, Bone pain ,Paraesthesia, Skin rash, Weight loss
   • past history
     • A history of gastric surgery or malabsorption previous blood transfusions venesections Drug History: Iron supplements, B12 injections. Anti-inflammatory, anticoagulants drugs
   • How to Reach a Diagnosis ??
   • family and social history
     • Family History: Family members with these same complaints ? Social History: Racial origin, Mediterranian or southern Asian origin? vegetarian ?

10. tests and investigations

    • hemoglobin test: normal is 13.5 to 17.5 grams per deciliter For men and 12.0 to 15.5 grams per deciliter For women.
      • White blood cell count : normal is (3,500 to 10,500 cells/mcL)
        • Platelet count : normal is (150,000 to 450,000/mcL)
          • Red blood cell count : normal for males (4.32-5.72 million cells/mcL) for females (3.90-5.03 million cells/mcL)
            • iron saturation : normal is 15%-50%
              • ferritin: normal is 10-120 microg/L
                • Red cell folate: normal is 317-1422 mol/L packed cells
          • Packed cell volume (PCV) In males        = 40 to 45%. In females     = 38 to 42%
            • Electrophoresis : Is a technique used in laboratories in order to separate macromolecules based on size. The technique applies a negative charge so proteins move towards a positive charge. This is used for both DNA and RNA analysis
            • serum iron : normal is 9-30 micro mol\L
              • transferrin : normal is 2-4 g/L
                • serum vitamin B12: normal is 148-616 micromol/L
        • Mean Corpuscular Volume (MCV) 80-100 Fl

11. Pharmacokinetics of Haematinics

    • A hematinic is a nutrient required for the formation of blood cells in the process of hematopoiesis. The main hematinics are iron, vitamin B12, and folate. Deficiency in hematinics can lead to anaemia.
      • Iron : For Iron deficiency anemias the Treatment is Oral or parenteral iron preparations
      • Vitamin B12: Absorption, transport and storage
        • In the stomach, dietary vitamin B12 complexes with intrinsic factor, a peptide secreted by the parietal cells. The intrinsic factor-vitamin B12 complex is absorbed by active transport in the distal ileum. Vitamin B12 is transported in the plasma bound to the protein transcobalamin II and is taken up by and stored in hepatocytes.
          • in case of deficiency Parenteral administration of vitamin B12 is standard Uncorrectable malabsorption requires life-long treatment. Improvement in hemoglobin concentration appears in 7 days and normalizes in 1—2 months.
      • Folic acid