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1. TYPES OF ANEMIAS
Hematology | Types of Anemias Medical Editor: Dr. Ana Guerra
OUTLINE Table 1-2. Types of anemia according to their morphology
[LabPedia.net].
I) OVERVIEW Microcytic Normocytic Macrocytic
II) IRON DEFICIENCY ANEMIA hypochromic normochromic
III) PERNICIOUS ANEMIA MCV <80 fl 80-95 fl >95 fl
IV) HEREDITARY SPHEROCYTOSIS
V) G6PDH MCH <27 pg >27 pg ↑/ N
VI) SICKLE CELL ANEMIA MCHC <32% N N
VII) HEMORRAGIC ANEMIA Hemolytic Vit B12
VIII) APLASTIC Iron
anemias deficiency
IX) THALASSEMIA deficiency
Thalassemia Acute blood Folic acid
X) APPENDIX loss deficiency
Sideroblastic
XI) REVIEW QUESTIONS E.g. Bone marrow Aplastic
anemia
XII) REFERENCES failure anemia
Chronic
diseases Renal
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diseases
I) OVERVIEW
poisoning
(A) DEFINITION
Anemia is defined as a low carrying capacity condition due (C) COMMON CLINICAL PRESENTATION
to decrease in hemoglobin concentration.
Table 1. Diagnostic criteria for anemia in males and females
[LabPedia.net].
RBCs values Male Female
Hemoglobin 13.5-17.5 g/dL 11.5-15.5 g/dL
Hct % 36-48%
Hematocrit (D) DIFFERENTIAL DIAGNOSIS STUDIES
40-52%
PCV
(i) Red cell distribution width (RDW)
Packed cell volume
MCV 80-95 fL Helps in the differential diagnosis of iron deficiency
80-95 fL anemia and thalassemia.
Mean cell volume
MCH 27-34 pg (ii) Serum iron
27-34 pg
Mean cell hemoglobin
Helps differentiating between hemochromatosis and
MCHC % 30-37%
hemosiderosis.
Mean cell hemoglobin 30-37%
concentration (iii) Transferrin
Reticulocytes count 0.5-1.5% 0.5-1.5%
Cand help in diagnosis of anemia of chronic disease and
differential diagnose with iron deficiency anemia.
(B) CLASSIFICATION
(iv) Transferrin saturation
There are several types of classifications for anemia, but
two of the widely accepted are based on: Cand help in diagnosis of anemia of chronic disease and
differential diagnose with iron deficiency anemia.
(v) Ferritin
It correlates with total body iron stores.
(i) Classification based on etiology
Increased RBC’s destruction (hemolysis).
(vi) Total Iron binding capacity (TIBC)
Increased blood loss, which may be acute or chronic. Always done along serum iron levels.
Defective maturation of erythropoiesis.
(vii) Peripheral blood smear
Informs abnormalities of the RBC shape, size and
(ii) Morphological classification
inclusions.
Normochromic and normocytic anemia (normal MCV
and MCHC). (viii) Bone marrow examination
Hypochromic and microcytic anemia (low MCV, MHC Helpful study when there are signs and symptoms of
and MCHC). aplastic anemia.
Normochromic and macrocytic (high MCV, normal or
increase MHC and normal MCHC). (ix) Coombs test
Very useful to differentiate between hereditary
spherocytosis and autoimmune hemolytic anemia.
TYPES OF ANEMIAS HEMATOLOGY: Note #1. 1 of 7
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II) IRON DEFICIENCY ANEMA III) PERNICIOUS ANEMIA
(1) Etiology (1) Etiology
Excessive bleeding. Autoimmune.
Menorrhagia. Deficiency in diet.
Iron deficiency in diet (common in vegetarians).
(2) Pathogenesis
Increased demand by the body
o Infancy, pregnancy, lactation. (i) B12 deficiency
Autoimmune condition where the body creates antibodies
against Intrinsic Factor.
(2) Pathogenesis
Absence of iron: In order to be absorbed, B12 binds to intrinsic factor
o Protoporphyrin can’t form heme inside the GI tract.
Dysfunctional hemoglobin.
• Erythrocyte volume decrease:
Figure 1. Pathogenesis of iron deficiency anemia.
(3) Specific symptoms
Koilonychia: Spoon-shaped nails.
Hair loss.
Pica: Some patients may like to eat clay, ice and starch.
Glossitis (smooth, red tongue).
Stomatitis.
Angular cheilitis.
Figure 1-2. Pathogenesis of pernicious anemia.
(4) Diagnosis
History of patient. (ii) Folic acid deficiency
Physical examination. Usually due to folic acid deficiency in diet.
Blood test with complete blood count (CBC).
Levels of serum ferritin, iron, TIBC and/or transferrin.
Folic acid is also needed for RBC to condense and
mature
Table 1-3. Useful tests in the diagnosis of iron deficiency
anemia [Hematología. La sangre y sus enfermedades]. (3) Diagnosis
RBC
Hg ↓↓↓↓
Table 1-4. Useful tests in the diagnosis of pernicious anemia
Hct [Hematología. La sangre y sus enfermedades].
MCV ↓ RBC
MCH ↓ Hg ↓↓↓↓
MCHC N Hct
Reticulocytes N/↑ MCV ↑
Leukocytes N/↓ MCH N
Hypochromic and MCHC N
Blood smear microcytic RBC, Reticulocytes N/↑
elliptocytes. Leukocytes ↓↓↓↓
Platelets N Macrocyte RBC,
Blood smear
Serum iron ↓ teardrop cells
Ferritin ↓ Platelets ↓↓↓↓
TIBC ↑
RDW ↑
(4) Treatment
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IV) HEREDITARY SPHEROCYTOSIS VI) SICKLE CELL ANEMIA
(1) Etiology (1) Etiology
Hereditary condition with mutations in membrane proteins Hereditary condition: Missense mutation
and erythrocyte cytoskeleton.
(2) Pathogenesis
Sickle cell anemia occurs due to a substitution on the
position 6 of the β chain of Hb A1
o Glutamine is substituted by valine
(2) Pathogenesis
Abnormal erythrocyte membrane due to proteins
mutations.
o They only take a sickle form when they’re not bound
to O2 → every time they get oxygenated, RBCs go
back to their normal structure.
o On their sickle form they can undergo hemolysis or
(3) Diagnosis
occlude blood vessels causing a vaso-occlusive
Table 1-5. Useful tests in the diagnosis of hereditary crisis
spherocytosis [Hematología. La sangre y sus enfermedades]. Priapism: Vessels of the penis get clogged with
RBC sickle cells, causing a painful erection.
Hg ↓↓↓↓ Splenomegaly due to the hemolysis
Hct
• In some cases splenectomy will be needed.
MCV ↓
MCH N/↑
MCHC N
Reticulocytes ↑↑↑↑
Blood smear Microspherocytes
Platelets N/↑
Coombs Test Negative
V) G6PDH Figure 1-3. Red blood cells: Normal form and sickle form
[MedlinePlus].
Glucose 6-phosphate Dehydrogenase deficiency
(1) Etiology Nice to know
Hereditary condition People with sickle cell anemia have been found to be resistant
to malaria.
(2) Pathogenesis
In order to obtain energy, RBC can only do glycolysis:
(3) Treatment
Glucose Transfusions.
Oxygen.
Glucose-6-phosphate
dehydrogenase 6-Phosoho- Opioids depending on the severity of the pain.
Glucose Fluids
6-phosphate glucanolactone
Hydroxy urea – helps producing fetal hemoglobin
GSSG
NADP NADPH (oxidized
glutathione) VII) HEMORRAGIC ANEMIA
(1) Etiology
GSH Peptic ulcers due to H. pylori or aspirin
AfraTafreeh.com (reduced Aneurisms
glutathione) Traumas
Erythrocytes generate energy. Cancer
The NADPH obtained thanks to the action of the G6PD Hemorrhoids
enzyme, reduce glutathione allowing it to catch free (2) Pathogenesis
radicals that are harmful for the RBC.
Excessive bleeding → ↓ RBC’s
(3) Treatment
Transfusions
Fluids
(3) Diagnosis
Surgery to stop bleeding
TYPES OF ANEMIAS HEMATOLOGY: Note #1. 3 of 7
VIII) APLASTIC ANEMIA IX) THALASSEMIA
(1) Etiology (1) Etiology
Idiopathic in 65% Hereditary condition where there is an absence of a
Drugs (e.g. chloramphenicol, benzenes, streptomycin, globin chain
etc.). o If there is an α-chain missing → α-thalassemia.
Viruses (CMV, EBV).
Radiation. o If there is a β-chain missing → β-thalassemia.
(2) Pathogenesis
Destruction of the myeloid stem cells
Nice to know
Hemoglobin is formed with two α-chains and two β-chains.
(2) Pathogenesis
Low functional hemoglobin due to its structure mutation
o MCV >90 ft
Microcytic anemia.
(3) Diagnosis
Figure 1-4. Aplastic anemia.
Table 1-7 Differential diagnosis of thalassemia and iron
deficiency anemia [Hematologïa. La sangre y sus
(3) Specific symptoms enfermedades].
Current infections due to leucopenia. Thalassemia Iron deficiency
Petechiae (↑ bruising). RDW N ↑
Bleeding.
AfraTafreeh.comSerum ferritin N/↑ ↓
(4) Diagnosis Serum iron N ↓
Transferrin ↑
N
Table 1-6. Useful tests in the diagnosis of aplastic anemia saturation
[Hematología. La sangre y sus enfermedades].
RBC
Hg ↓↓↓↓
Hct (4) Treatment
MCV N Transfusions.
MCH N Iron supplements.
Oxygen.
MCHC N
Bone stem cell transplant.
Reticulocytes N/↑
L: ↑
Leukocytes
N: ↓
Platelets ↓↓↓↓
Bone marrow
Hypocellularity
examination
(5) Treatment
Bone marrow transplant.
Transfusions.
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X) APPENDIX
Figure 5. Summary of types of anemias.
TYPES OF ANEMIAS HEMATOLOGY: Note #1. 5 of 7
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XII) REFRENCES
XI) REVIEW QUESTIONS
● Le T, Bhushan V, Sochat M, Chavda Y, Zureick A. First Aid for
1) A 31 year old woman is presented with history of the USMLE Step 1 2018. New York, NY: McGraw-Hill Medical; 2017
● Marieb EN, Hoehn K. Anatomy & Physiology. Hoboken, NJ:
fatigue, dizziness and headaches since three months Pearson; 2020.
ago. ● Boron WF, Boulpaep EL. Medical Physiology.; 2017.
● Urry LA, Cain ML, Wasserman SA, Minorsky PV, Orr RB,
A blood test was performed and results showed Hb Campbell NA. Campbell Biology. New York, NY: Pearson; 2020.
10 g/dL; Hct 40%; MCV 78 fl; MHC 25 pg and MCHC ● Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL,
30%. Loscalzo J. Harrison's Principles of Internal Medicine. New York
etc.: McGraw-Hill Education; 2018.
According to laboratory findings, how would you ● Sabatine MS. Pocket Medicine: the Massachusetts General
morphologically classify this type of anemia? Hospital Handbook of Internal Medicine. Philadelphia: Wolters
Kluwer; 2020.
a) Microcytic normochromic. ● Pérez, J.C. Hematología. La sangre y sus
b) Macrocytic hypochromic. enfermedades (4.a ed.). Editorial McGraw-Hill; 2015.
c) Microcytic hypochromic. ● Anemia: Part 1 - Anemia Classification, Diagnosis, and Routine
Work up. (2021, 1 junio). Labpedia.Net. https://labpedia.net/anemia-
d) Normochromic normocytic. part-1-anemia-classification-diagnosis-and-routine-workup/
2) The following test comes to be very useful in the
differential diagnosis of hereditary spherocytosis and AfraTafreeh.com
autoimmune hemolytic anemia:
a) RDW
b) Peripheral blood smear
c) TIBC
d) Coombs test
3) G6PDH deficiency is a condition where glucose can’t
turn into 6-phospho-glucanolactone due to lacking of
G6PDH, which leads damage to RBC’s membranes.
What is exactly the mechanism of this damage?
a) NADP can’t turn into NADPH so glutathione can’t be
oxidized, leading to increased free radicals.
b) NADP can’t turn into NADPH so glutathione can’t be
reduced, leading to increased free radicals.
c) NADPH can’t turn into NADP so glutathione can’t be
reduced, leading to increased free radicals.
d) NADPH can’t turn into NADP so glutathione can’t be
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oxidized, leading to increased free radicals.
4) If you’re suspecting of pernicious anemia on your
patient, which finding on a blood smear test would
support your diagnosis?
a) Teardrop cells.
b) Elliptocytes.
c) Heinz bodies.
d) Microspherocytes.
5) The followings are specific symptoms of iron
deficiency anemia EXCEPT for:
a) Pica.
b) Tachycardia.
c) Koilonychia.
d) Angular cheilitis.
CHECK YOUR ANSWERS
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