1. Approach To A Patient With Anemia
Dr. Mohammad Usman Shaikh
Assistant Professor,
Aga Khan University Hospital.

2. Hematology
• Study of blood forming tissue and circulating blood
component
• Clotting factors
• Blood groups
• CBC and smear examination regardless of specialty
• Accessible, close proximity to tissues, often provide
some information
• Important for accurate diagnosis and therapeutics
choices

3. Manual Versus Automation
Feasibility:
Workload:
• Depend on number of samples per day
• Less than 20 samples, prefer manual method
• Tertiary care hospital setting in western hospitals,
CBC is mandatory for consultation.
• Rapid analysis
• Require only an appropriate blood sample.
• Measure 8-25 variables, no equivalent manually.

4. Principles of Automation
• Electrical Impedance
• Light scattering

5. Electrical Impedance
Detection & measurement of changes in
electrical resistance produced by cells as
they passes via a small aperture
Electrical resistance between two electrodes,
or impedance in current leads to the formation of
pulses

6. A stream of cells passes through aperture across which
electrical current is applied. Each cell that passes alters
electrical impedance and can thus be counted and
sized.
Good Pulse
Diluent stream

7. Sensing Zone
Red Blood
Cells
Electrical Impedance
Oscilloscope
Oscilloscope
Each time a cell passes a
pulse is produced.
The pulse height is
proportional to Cell
volume
Animation by M.A.Ghauri

8. Light Scattering
O-3 deg
(relative size)
Light Scatter estimates relative
cell size based on forward
scatter - that is a measurement
of cross-sectional diameter
Laser

9. Hemogram/ Histogram
• Visual representation of what was counted at the
aperture.
• Verify a count that has a typical pattern according to
the reference ranges
• Alert for possible interfering particles and
abnormalities

11. Hematological Variables on Automation
RBC
Hb, HCT, MCV, MCH, MCHC, RBC count, RDW
WBC
Total count, differential and absolute count
Platelet
Total count
Others: Nucleated RBC, reticulocyte count
flags

12. Anemia
– Definition: low Hemoglobin and hematocrit
– Results from a wide variety of disorders

13. Anemia
• Laboratory data is more informative when
considered in the context of history and physical
examination

14. Approach to Anemia
• History:
– Family history– inherited causes such as
thalassemia, sickle cell anemia, G6PD deficiency
and hereditary spherocytosis.
– In most of these cases morphological findings of
smear are diagnostic
• B symptoms
• Systemic or other chronic disorders

15. History
• Drug history:
• History of blood loss
• Clinically: Degree of pallor, with or without
icterus, angular stomatitis and
glossitis, koilonychia, lymphadenophathy and
hepatoslenomegaly

16. Koilonychia
Physical Examination:
helps to direct the
clinician to the cause of
anemia
Iron deficiency:
koilonychia, glossitis, ang
ular stomatitis.

17. Glossitis
B12 deficiency: decrease
vibration and postural
sense
Folate deficiency:
glossitis, sign of
malabsorption, alcohol
abuse and pregnancy

18. Angular stomatitis
Angular stomatitis:
non specific, can be
seen in iron
deficiency, B12 and
folate deficiency

19. Lymphadenophathy
• Bone marrow
failure/infiltration: fever,
Petechiae,
lymphadenophathy,
splenomegaly and sternal
tenderness

20. Splenomegaly
• Bone marrow
failure/infiltration:
splenomegaly

21. Normal RBC

22. Normal RBC

23. WBC Morphology

24. Classification of Anemia on the Basis of MCV
Less than 76fl --- microcytic
Iron deficiency
Thalassemia
Anemia of chronic disease
Sideroblastic anemia and lead poisoning
MCV between 76 to 96 fl
Anemia of chronic disease
Acute blood loss
Chronic renal failure
Anemia due to infiltration
Aplastic anemia

25. Classification of Anemia on the Basis of MCV
• MCV more than 96fl
– Macrocytic anemia
• Megaloblastic: B12 and folate deficiency
• Non megaloblastic:
– Hemolysis
– MDS
– Hypothyroidism
– Liver disease

26. Etiological Classification of Anemia:
• Increase destruction
1-Hemolytic anemia
inherited and acquired
• Impaired Production
2-Anemia due to bone marrow failure states
3-Nutritional deficiencies
4-Anemia due to infiltrative disorders
5-Anemia of chronic disorders

27. Hemoglobin: 3.5 gm/dl
HCT: 12%
MCV: 57 fl
MCH: 18 pg
TLC: 22,000
Platelets: 155,000

30. Hemoglobin: 4.5 gm/dl
HCT: 14%
MCV: 56 fl
MCH: 20 pg
TLC: 6,000
Platelets: 600,000

32. NORMOCYTIC NORMOCHROMIC ANEMIA
MCV between 76 to 96 fl
• Anemia of chronic disease
• Acute blood loss
• Chronic renal failure
• Anemia due to infiltration
• Aplastic anemia

33. Hemoglobin: 8 gm/dl
HCT: 25%
MCV: 84 fl
MCH: 27 pg
TLC: 5000
Platelets: 205,000

34. Sickle Cell

35. Sickle Cell Disease
• Rare in Pakistan (Balochistan), common in Middle
East, and up to 40% trait in Central Africa
• Qualitative globin chain defect; Homozygous inheritance
• Deoxy Hb S--- tendency to aggregate--- sickle cell
• Increase blood viscosity --- vascular stasis---tissue
damage + RBC membrane damage
• Sickling depend on Hb S concentration
• Hb S <50%, usually no symptoms
• Hb F---confer protection
• Hb: 5-11 g/dl, Normocytic normochromic, Target
cells, reticulocytosis, Increase WBC & Platelets

36. Hemoglobin: 7.0 gm/dl
HCT: 22%
MCV: 89 fl
MCH: 28 pg
TLC: 22,000
Platelets: 20,000

39. Acute Leukemia
• Presenting count
• Age
• Cytogenetics

40. Hemoglobin: 5.0 gm/dl
HCT: 16%
MCV: 93 fl
MCH: 26 pg
TLC: 500
Platelets: 11,000
Pancytopenia
Cellular Vs hypocellular

44. Chronic Leukemias
• Cytogenetics for CML
• CLL workup and staging

45. Hemoglobin: 5.0 gm/dl
HCT: 16%
MCV: 93 fl
MCH: 26 pg
TLC: 500
Platelets: 11,000
Pancytopenia
Cellular Vs hypocellular

46. Normal Marrow

47. Bone Biopsy

48. • Hemoglobin: 9.5 gm/dl
HCT: 30%
MCV: 99 fl
TLC: 2200
Platelets: 10,000
Blood culture: gram negative rods

49. Microangiopathy /DIC

50. Microangiopathy /DIC

51. Macrocytic Anemia
• MCV more than 96fl
– Macrocytic anemia
• Megaloblastic: B12 and folate deficiency
• Non megaloblastic:
– Hemolysis
– MDS
– Hypothyroidism
– Liver disease

52. Hemoglobin: 6.0 gm/dl
HCT: 19%
MCV: 110 fl
MCH: 36 pg
TLC: 2,800
Platelets: 45,000

54. Hemoglobin: 7.5 gm/dl
HCT: 23%
MCV: 100 fl
MCH: 28 pg
MCHC 36%
TLC: 5000
Platelets: 100,000

60. Reticulocyte
• Reticulocyte: larger than
normal RBC
• RNA and Golgi remnants,
Ribosome, maturation take
another 24 to 48 hours in
the blood circulation

63. Conclusions
• Peripheral blood smear examination and reporting is one
of the most important aspect of hematology.
• It is diagnostic in many hematological and non
hematological disorders.
• It is cost effective and non invasive and helps the
clinicians in further diagnostic workup