Microcytic hypochromic anemia- iron deficiency, anemia of chronic disease, thalassemia minor, sideroblastic anemia

1. MICROCYTIC
ANEMIA
Presented by- Dr. Monika Nema
Dr. Monika Nema

2.  Anemia is the collection of signs and
symptoms of reduced oxygen delivery to
tissues as a result of a reduction in the
number of red cells and/or reduction in
blood concentration of hemoglobin below the
level that is expected for healthy person of
same age and sex.
Dr. Monika Nema

3.  The world health organization (WHO) has
defined anemia as Hb<13.0 g/dl for men and
<12g/dl for women.
Dr. Monika Nema

4. Hb ( g/dl ) Ht(%) MCV (fl)
Adult men 13-17 39-49 80-100
Adult
women
12-15 33-43 80-100
Children
6-12 yr
11.5-12.5 37-46 77-95
6m-6yr 11-14 36-42 74-87
2m-6m 9.5-14 32-42 76-84
Dr. Monika Nema

5.  Most common hematologic disorder by far
 It is a clinical sign of disease
 It is not a single disease by itself.
Dr. Monika Nema

6. Dr. Monika Nema

7.  Average volume of a single red cell.
 Normal : 83-101 femtolitre
 Calculated as
 MCV= Packed cell volume x 10
Red cell count
Dr. Monika Nema

8.  Average amount of haemoglobin in each red
cells.
 Normal: 27-32 picogram.
 MCH= Hemoglobin concentration x 10
Red cell count
Dr. Monika Nema

9.  Represents the average concentration of
haemoglobin in a given volume of packed
cells.
 Normal : 31.5-34.5 g/dl.
 MCHC= Hemoglobin concentration x 100
Packed cell volume
Dr. Monika Nema

10.  It is a measure of degree of variation in red
cell size(anisocytosis) in a blood sample.
 Normal :
 As coefficient of variation(CV)- 11.6-14 %
 As Standard deviation(SD) – 39-46%
Dr. Monika Nema

11. Dr. Monika Nema

12.  Normocytic Normochromic
 Microcytic Hypochromic
 Macrocytic
Dr. Monika Nema

13. Dr. Monika Nema

14.  A patient presented with fatigue, shortness
of breath, weakness, irritability, reduced
work concentration to the physician.
 Doctor examined and found pallor.
 He simply ordered a complete blood count.
Dr. Monika Nema

15. Dr. Monika Nema

16.  When the average cell size (MCV) is reduced,
the anemia is classified as MICROCYTIC
ANEMIA.
Usually associated with hypochromia
It is very common in all age groups.
Dr. Monika Nema

17. Dr. Monika Nema

18. Dr. Monika Nema

19.  Disorders of iron metabolism
- Iron deficiency anemia.
- Anemia of chronic disorder.
 Disorder of globin synthesis
- Alpha and Beta Thalassemia.
Dr. Monika Nema

20.  Sideroblastic anemia
- Hereditary.
- Acquired.
- Reversible Acquired.
 Lead Intoxication.
Dr. Monika Nema

21. Dr. Monika Nema

22. •Shortness of breath
•Palpitation
•Decreased work or exercise
tolerance
•Fatigue
•Weakness
Dr. Monika Nema

23. Pica ( Abnormal eating
pattern ) is striking symptom
of iron deficiency anemia.
Dr. Monika Nema

24.  Iron deficiency usually arises from chronic
blood loss.
 The major cause in younger women is
menstruation.
 In non menstruating women and in men, the
most common source is gastrointestinal
hemorrhage.
(esophageal varices,hiatus hernia, peptic
ulcer,gastritis,neoplasm ,hook worm
infestation)
Dr. Monika Nema

25.  Inadequate dietary intake of iron
 Defective absorption of iron (Achlorhydriya, Gastric
surgery, Celiac disease, Duodenal bypass, Drugs,
Tannins, Phytate, Bran)
Dr. Monika Nema

26.  Increased requirements of iron
(Pregnancy, Infancy, Lactation)
 Inadequate presentation to erythroid precursors
(Atransferrinemia, Atransferrin receptor antibodies)
 Abnormal iron balance
(Aceruloplasminemia, Autosomal dominent
hemochromatosis due to mutation in ferroportin)
Dr. Monika Nema

27.  Is an inherited autosomal recessive blood disease
which results in reduced synthesis or no synthesis of
one of the globin chains that make up hemoglobin
causing the formation of abnormal hemoglobin
molecules leading to anemia.
 Thalassemia is a quantitative problem.
Dr. Monika Nema

28.  Thalassemia minor patients are usually
asymptomatic. Diagnosis is made through
evaluation of positive family history.
Dr. Monika Nema

29. These are group of disorders of varying
aetiology in which marrow shows marked
dyserythropoiesis & intra mitochondrial
accumulation of Fe in erythroid
precursors
Dr. Monika Nema

30.  In sideroblastic anemia, majority of patient
exhibits manifestations of iron overload.
 Abnormal glucose tolerance, cardiac
arrhythmia and congestive heart failure can
occur.
Dr. Monika Nema

31.  In case of Lead poisoning,
There can be occupational history of inhaling
fumes in industry.
Ingestion of lead based paint chips by
children.
Ingestion of contaminated herbs and food
supplements.
Gasoline sniffing in addicted person.
Dr. Monika Nema

32. A. Chronic inflammation
 Rheumatoid arthritis
 systemic lupus erythematosis
 Crohn’s disease
B. Chronic infection
 Tuberculosis
 Urinary tract disease
 HIV infection
 Bacterial endocarditis
 pneumonia
C. Neoplasm
 Carcinoma
 Lymphoma
 Myeloma
Dr. Monika Nema

33.  Anemia is related to decrease in release of iron
from macrophage to plasma
 Reduced RBC lifespan
 Inadequate erythropoietin response to anemia,
caused by effects of cytokine such IL-1, TNF on
erythropoiesis
 Hepcidin released by the liver in response to
inflammation.
 Hepcidin functions to regulate (inhibit) iron transport
across the gut mucosa, thereby preventing excess iron
absorption and maintaining normal iron levels within
the body. Hepcidin also inhibits transport of iron out
of macrophages (where iron is stored)
Dr. Monika Nema

34.  The clinical manifestation vary widely in
anemia of chronic disease because of its
association with so many diseases.
 Usually, the signs and symptoms of the
underlying disorder overshadow those of the
anemia.
Dr. Monika Nema

35. In the hands, the skin of
the palms first becomes
pale, but the creases
may retain their usual
pink color until the Hb
concentration is less
than 7 g/dl.
Is a sign of anemia.
The pallor associated with
anemia is best detected in
the mucus membrane of
mouth, the conjunctiva,
lips and the nail beds
Dr. Monika Nema

36. Site Findings
Nails Flattening, Koilonychia
Tongue Soreness, Mild papillary atrophy,
Absence of filiform papillae
Mouth Angular stomatitis
Hypopharynx Dysphagia,Esophageal varices
Stomach Achlorhydria,Gastritis
Koilonychia
Dr. Monika Nema

37. Gums in lead
poisoning.
Lead lines are shown
in gums of this patient
suffering from lead
poisoning
Dr. Monika Nema

38. Dr. Monika Nema

39.  Most microcytic anemia are due to deficient
hemoglobin synthesis often associated with
iron deficiency or impaired iron use.
Dr. Monika Nema

40. Erythrocytes:
 If symptoms of anemia are the presenting
complain, the blood hemoglobin is usually
8 g/dl or lower.
 MCV – decreased. (Microcytic)
 MCH- decreased. (Hypochromic)
 Anisocytosis- Important early sign . Leading
to raised Red Cell Distribution Width.
 Few pencil cells, few target cells can be
seen.
Dr. Monika Nema

41. Dr. Monika Nema

42. Leukocytes:
 Usually normal in number.
 Mild graulocytopenia is seen in long standing
cases.
 Recent large volume hemorrhage leads to
Neutrophilic Leukocytosis.
 Due to parasitic infestation, Eosinophilia can
be seen.
Thrombocytes:
 Thrombocytosis is usually seen.
Dr. Monika Nema

43. Dr. Monika Nema

44. The normal film shows little
variation in red cell size
The iron deficient cells shows
variations in size (anisocytosis) and
shape (poikilocytosis), as well as
microcytosis (low average cell size)
and hypochromia (increased central
pallor).
Dr. Monika Nema

45.  Usually normocytic normochromic anemia is
seen.
 Hypochromia is more common than
microcytosis.
 Microcytosis in anemia of chronic disease is
usually not as striking as that commonly
associated with iron deficiency anemia.
Dr. Monika Nema

46.  In iron deficiency anemia, hypochromia
follows microcytosis.
 Whereas in anemia of chronic disease,
hypochromia preceeds microcytosis.
Dr. Monika Nema

47. Normocytic picture
Microcytic picture
Dr. Monika Nema

48. Dr. Monika Nema

49.  It is a measure of amount of iron bound to
transferrin.
 Shows diurnal variation
Highest in morning and lowest in evening.
 Influenced by recent ingestion and
absorption of iron medication.
 Normal value : 0.6-1.7 microgram/L.
Dr. Monika Nema

50.  The principal source of iron for hemoglobin
production is that carried by transferrin, the
iron transport protein in plasma.
 When transferrin saturation with iron is less
than 16%, RBC production rate decreases and
hypochromic,microcytic cells are
manufactured. This state is known as iron
deficient erythropoiesis.
 Normal transferrin saturation is 16-50%.
Dr. Monika Nema

51.  It is indirect measurement of transferrin in
terms of amount of iron it will bind.
 Shows slight fluctuation.
 Normal value : 2.5-4.0 microgram/L.
Dr. Monika Nema

52.  Disulphide linked transmembrane protein
that facilitates entry of transferrin bound
iron into cells.
Dr. Monika Nema

53.  Ferritin is chiefly intracellular iron storage
protein.
 Serum ferritin is glycosylated and contains
little or no iron.
 In most circumstances, Serum ferritin is
proportional to total body iron stores.
 Not influenced by recent iron therapy.
 Normal :
Male – 15-300 microgram/L.
Female – 15-200 microgram/L.
Dr. Monika Nema

54.  Ferritin levels are the single best serum
measure of storage iron.
 Serum ferritin level in patient with anemia of
chronic diseases may increase
dispropotinately relative to increase in iron
stores, probably because ferritin is an Acute
phase reactant.
 This phenomenon complicates diagnosis of
Iron deficiency anemia when it co-exists with
inflammatory disease.
Dr. Monika Nema

55. Dr. Monika Nema

56.  Total iron binding capacity –
Increased in iron deficiency anemia
Decreased in anemia of chronic disease.
 Erythrocyte sedimentation rate is found to
be elevated in anemia of chronic disease
owing to its inflammatory etiology.
Dr. Monika Nema

57.  Cellularity – increased
 Erythroid hyperplasia
 Micronormoblastic reaction
 Normoblast are smaller
 Late micronormoblast demonstrates persistent
basophilia and fraying of cytoplasmic borders
indicating lack of complete hemoglobinization
 Myelopoiesis – Normal
 Megakaryopoiesis – Normal
 Depleted bone marrow iron
Dr. Monika Nema

58. Dr. Monika Nema

59. Bone marrow aspirate
demonstrating
increased iron staining in a
fragment representing
increased marrow iron
stores. . This finding is
present in a patient with
anemia of chronic
disease.
Normal iron staining in
histiocytes is shown for
comparison
Dr. Monika Nema

60. Grade Criteria
0 No iron granules observed
1+ Small granules in reticulum cells, seen only in oil
immersion lens
2+ Few small granules seen with low power lens
3+ Numerous small granules in all marrow particles
4+ Large granules in small clumps
5+ Dense, large clumps of granules
6+ Very large granules, obscuring marrow details
Normal Marrow =1+ To 3+
Dr. Monika Nema

61.  Red cell count is increased.
 MCV –decreased.
 MCH- decreased.
 MCHC- normal or slightly decreased.
 Reticulocytes are generally increased to
twice the normal number and have been
found to correlate with hemoglobin level.
Dr. Monika Nema

62. Dr. Monika Nema

63. Target cells
Dr. Monika Nema

64. Basophilic
stippling in
thalassemia.
Dr. Monika Nema

65. Dr. Monika Nema

66. Findings Thalassemia minor Iron deficiency
anemia
Anisocytosis Mild or absent Early and prominent
finding
Microcytosis More severe Less severe
Dr. Monika Nema

67. Dr. Monika Nema

68.  Mentzer index=
Mean cell volume
Red cell count
Value greater than 14 is found in iron deficiency
anemia whereas value less than 12 is seen in
thalassemia trait disorder.
Value between 12-14 is considered
indeterminate.
Dr. Monika Nema

69.  Calculated as MCV x MCH
Red cell count
>371: normal
321-370: iron def.=> trial of iron for 1 mo.
251-320: Mixed iron def. & minor thalassemia => trial of
iron
& folate then check CBC & Hb elect
<250 : Minor thalassemia =>check Hb elect.
Sensitivity =99% , Specificity=86%
Dr. Monika Nema

70.  Calculated as MCV x MCH
Red cell count x MCHC
>13: Normal
10.5-13: Iron deficiency
8-10.5: Mixed iron def & minor thalassemia.
<8 : Minor thalassemia
Note : Sensitivity=99% , Specificity=93%
Dr. Monika Nema

71.  HbF
Electrophoresis
 High performance liquid chromatography
 DNA analysis
Dr. Monika Nema

72.  Hb A 2 ranges 3.5 to 7.0 %
 Hb F ranges 1 – 3 %
Dr. Monika Nema

73.  Hypercellular
 Erythroid hyperplasia
 M:E ratio 1:5
 Dyserythropoisis
 Myelopoisis and megakaryopoisis are normal
 Bone marrow iron increased
Dr. Monika Nema

74. Top and bottom panels show bone
marrow aspirate and
biopsy, respectively, from a case of
thalassemia trait.
The bone marrow has increased
numbers of erythroid precursors (a
low myeloid to erythroid ratio)
related to the increased peripheral
RBC destruction in this disease.
Dr. Monika Nema

75.  Peripheral smear: microcytic hypochromic
,anisopoiklocytosis ,few cell show basophilic
stippling,WBC and platelet normal.
 Serum iron and percent transferrin saturation
increased
 Bone marrow: hypercellular,normoblastic or
micronormoblastic reaction with vacuolation
in cytoplasm, sideroblast , megakaryopoisis
and normal myelopoisis.
Dr. Monika Nema

76. Sideroblastic anemia. Normocytic cells are present, along with
a minor population of microcytic, hypochromic
erythrocytes possessing a thin rim of cytoplasm. Occasional
teardrop cells are visible.
Dr. Monika Nema

77. Dr. Monika Nema

78. In Sideroblastic anemia.
Numerous ringed
sideroblasts are seen in
this marrow aspirate
smear stained for iron.
They are normoblasts
with ≥10 iron-containing
granules in the cytoplasm
encircling at least one-
third of the nucleus.
Dr. Monika Nema

79. Peripheral blood film
demonstrating coarse
basophilic stippling.
Normocytic or
microcytic anemia may
be present.
Dr. Monika Nema

80. Dr. Monika Nema

81. Dr. Monika Nema

82. PRESENTED BY :- DR.MONIKA
NEMA
Dr. Monika Nema