33

CHAPTER

Anemia

earning Objectives Pregnant wornen: 110 g/dt.

rommon hiood Men/adult boys: 130 g/dl.
Itis a condition in which bod In troplcal and developing countries
healthy red blood cellsto carry adequate anemia is seen in 50% or more of preschool
okygen to bady's tissues, resulting in fatigue children and in pregnant women, it is mod
erate or severe. The main causes of anemia
Its own cause Tuneeach with incdudes malnutritlon, protein deficiency
upon morphology of red cells and upon the folate defciency, parasitic, bacterial and viral
etiology of disorder are discussed In this infections, or it may be inherited
Othernathologlcaloa associated ICLASSIFICATION
with each t n eahemla
ees
and Schilling test
is mentioned here. Anenias may be classified in rwo ways:
1. Basedupon morphology of red cell or
Keywords
Normochromic normocytic anemla, Hypochro 2. Upon the etiology, Le. the cause of anemia.
mic mlcrocytic anenla, Normochromiemsrto
cytic anenia, Normochromic microcytic
anemia, Based upon Morphological
Aplastic anemia, Iron defclency anemia, Per Classification
anemla SitehytiC anemia, Slckde cal
emia, Thalassemia. Seh It is based on mean corpuscular volume
ling test Vita nB (MCV), mean corpuscularhernoglobin (MCH).
mean corpuscular hemoglobin concentration
(MCHC) and the red cell morphology on
Worldwide anemia is the most commonred cell blood smear.
disorder. Anemia lead to a decreased amount
of hemoglobin concentration, red cell count Normochromic Normocytic Anemia
and PCV value. The anemia is present when In this type of anemia, RBCs are normnal in
Hb concentration falls below in the following size and color, but reduced in number. The
.Newborn infants: 14 g/dl.
packed cell volume is reduced. MCH, MCV
Child 6 months to 4years: 11 g/d. and MCHC are normal. Nornocytic normo
Child 5 to 1l years: l1.5 g/dl. chromic anemia may be found in acute blood
Child 12 to 14 years: 12.0 p/d.
loss, anemia of chronic disease aplastic
"Non-pregnant women: 12.0 g/dL. anemia.
 Capter 33 Atema201
Hypochromic Microcytic Anemia reagents like insecticides, streptomycin, lon
zing radiation, ete Usually, IBCs are thurmal
The red cells are sEnall and pale. Dectease in
total RBC count, low Hb and PCV, reduced u omenmeoorpoiocytosis
MCV, MCH and MCHC; hypochronic nicto reased platelets, bleeding time is
yc nemia is found in irun deficiency ane increase.
bone marrow is aplastic, rapid ESIL aplastie
anemia may terminate as leukemia
Normochromic Macrocytic Anemia tron Deficiency Anemio
The red cells are larger in size with no central
pale portion. RBC are reduced in numberwith The normal adult body contains 4000 mg cf
low Hib, elevated MCV and MCH and normal on.0u u in he
MCHC. Normochromic macrocytic anemiais
in the liver and reticuloendothelial colls of
found in pernicious anenia, anemia of folic bone marrow. When iron is being utilized
iciency and in somne
cases of aplastic anermia by the RBC at a faster rate and the dietury
intake of iron is insufficient to keep up with
Normochromic Microcytic Anemia the increased use, the iron stored in the body
The RBC are small in size with low Hb, re When the iron stotes become exhausted iren
duced MCV, MCH and normal MCHC, This deiciency anemia results.
type of anemia is found in some of the ane Microcytosis, hypochromia and poialocy
mias of chronic infections (Fig. 33.1) tosis are associated with iran deficiency ane
mia. Reticulocyte countis norrmal, serumiton
Etiological Classification is decreased. It is commonly seen in early
Based upon the cause of anemia, following stages of life and during pregnancy
types of anemia are found. Pernicious Anemia
i Acense is caused by
Aplastic Anemia asease
Teiole actorr. whic
vitamin B

It may occur due to congenital defect, Le.. for the absorption of vitarminB. is not s
chromosomal abnormalities in RBC ot
exposure to various physical and chemical ised generally
by the gastric rnucosa, This type of anemía
found in patients abave age of
60 years. It is associated vwith weakness and
shortness ofbreath, abdominal pain, diarhea,
nausea, pale and sore tongue. The laboratory
indings are macrocytic normochromic RHc
moderate to marked anisocytosis and poililo
cytosis serum biliubin may be increased

HemolyticAnemia
Hemolytic anemias are characterized by afall
in hemoglobin, jaundice, dark urine, increas
ing reticulocytosis. It may be hereditary on
acquired. Red cells are usualy normochromic
Fig. 33.1: A8Cs in normochromic microgtic anemia. and microcytic.
appeayelow
(For color verslon See Calor Plate 8) due to increased bilirubin. Hemoglobin and
 202 Sectien 2: Hematolagy
hermatocrit varies from normal to extremely labeled with "Co within 24 hours, One-third
low levels Coomb's test is positive of absorbed labeled/radioactive vitamin B,
is lushed out in urine. Normal excretion is
Sickle Cell Anemia above 10% of oral dose. In anemic patients
iciency, patients excrete
In this
bemonled cells contain 90to 100 Jess that 5%. 1f the test is normal, no
associated with severe ah festing is necessary.
further
joint pain, enlarged spleen. Sickde cells ure If it is abnormal, repeat the said proce
found in blood. Reticulocytes and platelets are ofdure with simultaneous oral administration
intrinsic
increased Osmotic fragility of RBCis decreased. factor, Le. vitanin B, binding
protein, excretion increases, it implies lack
Sideroblastic Anemias some defert h
ie snot, then there in
puon. The test should be
Sideroblastic anemins may be hereditary or repeated after 48 hours,
acqured. In case of hereditary sideroblastic
infancv and u u n l a iescence.
ruring Signs and Symptoms of Anemia
RHBCs are hypochromie
creased serum iron level. moderate l Depending upon ype and severity, signs
tosts and poikilocytosis. In case of scquired weakness, shortness of breath. diziness
sideroblastic anemia, normochromic RBCs headache, cold hands and feet, pale skin,
but very few are hypochromic red cells It is hair loss, chest pain, irregular heartbeats and
found in adults above 50 years of age. difficulties with memory and concentration.
THALASSEMIA (C0OLEY'S ANEMIA) Diagnosis of Anemia
Itis a hereditary blood disease, widespread in Complete Blood Count (CBC) is often
Mediterranean countries, Asia and Africa, in used as a broad screening test to evaluate
which there is abnormality in the protein part overall health. It can be used to diagnose
ofhemoglobin molecule. Theaffected red cells various conditions incBuding anemia,
n not function normally, leading to anemia. infection, inflammation, bleeding
Symploms inciude enlargernent of the disorder or leukemia. CBC includes the
spleen a oTmalities of the bone marrow. following:
Individuals inherit from both White blood cells count, Red blood cell
parents are severelscase called
as thalassemla malor 1h his is (BC) count, hemoglobin, hematocrit,
e o n , ted blood cell indices(MCY
Singie parent are thalassemis m i n cel distribution idela
(RDWu
are usually symptom free, Patient with malor ulation of the variation in the
isease is treated with repeated blood transfu size of RBC)
sions. The disease can be detected by prenatal Reticulocyte count, iron studies (total
diagnosis including amniocentesis capacity of the blood to ransport iron and
the arnount of stored iron in
ISCHILLING TEST the body)
. Ferritin: This test is used to assess iron stores
in the body and is useful in
between iron deficiency distinguishing
Schilling test is a test for diagnosing vitamin
B,, deficiency. In this test, first give 1 mg un anemía and
labeled vitarnin B,. parentally, to the patient. anemia of chronic diseas
Ease.
" Vitamin B,, and folate
Then give l mg labeled vitamin B orally. Itis
Erythropoietin (EPO) level.
 34
CHAPTER

Leukemia

Learning Objectives Acute Leukemia

Leukemia isa cancer of the blood or bone Acute leukemia is a sudden onset generally
Leukemla can develond occurs in children under 1 yean d
with blood cell peoduction. It ususlly affects associated with
notmoeyt. Bleed
the leukocytes anemia, with decad white blood cell
This chapter has brief discussion ing times
e h a r e t o eukemia, its po1lakh cells/cu mm.
ennature and blast cells are present in pe
conditions associated with ripberal blood smear Acute leukemia is rapid
Acute and chronic leukemlas are compared progressive disease.
here

Keywords Chronic Leukemia

Acute leukemia, Chronic leukernia, Myelocytich Chronic leukemia is slow progressive disease,
Lymphoblastic, Metamyelocytes s White cell
anemia may ed and may go up to
0llhslun Blastcells are seen occasionally.
Leukemin is malignant disorders of white In between these two, subacute leukemia is
blood cells. Bone marrow is always involved
in this disease. The found in sone cases. It is quite sirnilar to
exact cause of leukemia is kemis Rut he total leukocyte count
acute
unknown, but hereditary or viral or exposure nay be normal, decreased or increased up to
to radiation may be suggested. The maior
symptons of leukemia include weight loss. 50,000.
fever and increased sweating. Liver, spleen and
lymph nodes are enlarged. Basal metabolic CLASSIFICATION
rate is also increased.
(Onthe Basis of Cell of Origin)
Leukemias are further classified on the basis
ICLASSIFICATION of the cell of origin, Le., whether myelocytic or
(On the Basis of Course of Disease) Iymphocytic as:
Based on the course of disease, leukemia is 1 Acute myelocytic leukemia (AML)
classified as acute and chronic. 2. Acute lymphocytic leukemia (ALL)
204 Setion 2 Hematology
3. Chronic myelocytic leukemia (CML)
4. Chronic lyinphocyuc leukemia (CLL)
Acute Myelocytic Leukemia
Acute myelocytic leukemia
(AML) ocCrs in all
age groups, butmore cammon in adults than in
Chidren. Itis also called as acute granulocytic
emma AGL). t is characterized by the
presen
m e r of myeloblasts
in the bone
appearance
n the peripberal hleheir
perrpheral blood mav ste in the
much as 95%. Many variants ofAMC have
been described depending upon the type
cell predominating in the peripheral blood.of Fig. 34.1: Acute lymnphoblastic leukemia.
nee couid be nyeloblasts, promyelocytes, (CGL). It is common in middle age group. It
r basts of both myeloid and is characterized by the presence of marked
be MC there is often increase in the cells of myelocytic series. The
inflammation of th
rectal ulceratlon. face m r m e t predominant cells are neutrophilic mvelocvtes
n y s Total leukocyte count is
nerny associated with normocromie
nomocytic anernia. AML 0s rapidy fatal with uL Symptoms due to hnerneth
most patients dying fromn
infection due to bone marrowhemorrhage
or cominon in chronic myelocytic leke
failure.
Anemla is normocytic normochromic. Plate
Jet count is usually increased. The abnormal
Acute Lymphoblastic Leukemia Philadelphis (Ph) chromosome is
the leukemic cells of more than 95% present
in
Acute
lynphoblastic leukemla (ALL) is more ofpatients
WinGhII. CMLmay develop into AML at later
Common in children than in aduire that to
in males than in females. It is less severe than Stages.
AMC and in many cases itis cured by intensive
and sustained treatment.AlLI,is the malignancy Chronic Lymphoblastic Leukemia
of the cells of lymphocytic series and it is Chronic lymphoblastic leukemia (CLL) is
characterized by the presence of increased more often found in older persons (over 60
number of lymphoblasts in bone marrow years) with men affected than women. It is
as well as in peripheral blood snear. Bone characterized by marked increase of mature
pain, fever, bleeding, purpura, thrombosis, lymphocytes (above 15,000 cells/uL), The
yand cental nervous system count may go very high and 80 to 90%
beween the diag sis of AMT. a
1o differentiate ook ike immature lymphocvtes
AL, several 08u0steaiy, patients of CLL may live
ytochemical stain irmmunological of thie A o u r treatment. Onset
markers can be used (Fig. 34.1). s10W ana in early stages
asynptomatie Most
bmnhnave weightloss
and develop
Chronic Myelocytic Leukemia ny, in later stages
of CLL, neutronenle ombocytopenia and
Chronic myelocytic leukemia (CML) is also the loss of normal functior
called as chronic granulocytic leukemia lead to inadequate oning lymphocytes
immune responses
 Capterj imkrnta 205
Laboratory Diagnosis
There are a number ol different tests that can
be used to diagnosn leukemin
determine the
numbers af RHCA, wBCs, and platelets.
Tissue blopsies can be taken fom the bone
marrow or ymnph nodes to look for evidence
of leukemia
Flow cytometry exarnines the DNA ofthe
cancer cells and determines their growth
Fig. 34.2: Chronic lymphoblastie leukenia,
(Forcolor vension Ser Color FSate &) " Cytochemistry In these types of test, cells
are put ona slide and stained with dyes that
resulting in various infections. Anemia also react only with some types ofleukemia cells.
develops in last stage (Fig. 34.2). These stains cause color changes that can
be seen under a microcope.
Consparison ofAcute and the cells are
Aute
Progress rapidly
ChronicLeukeml
Chron
Progress slowly
they start dividing.
Then he chromosomes are looked at under
a microscope to detect any changes.
Severely i Can be asymptomatic Fluorescent in situ hybridization (FISH):
Heals without complcation Compliçation atises This is another way to look at chromosomes
nmon in younger age man in oider age and genes. It uses special fluorescent dyes
orouos
its prominent Its mlld
that only artach to specificgenes or parts ef
Prognosis s predictable Prognosks P regular blood or bone marro samples
unpredictable
Normal growth factor Lower growthfactor . Polymerase chain reaction (PCR This is a
levets
very sensitive DNA test that can also find
eatndleveio certain gene and chromosome changes.
mmatory cytokinesprolnfarrator
cytokinesk
More than 30% blast cellsLess than 30N blast
in the borie marrowOicells in the bone
marrow