[醫如往常] Senior Clerkship Day 91: Lab Medicine: Anemia and RBC

林醫師 Anemia and RBC

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HTLV; human T-lymphotropic virus: ATLL; Adult T-Cell Leukemia/Lymphoma

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Needle shot 傳染率

HBV ~30%

HCV ~3%

HIV ~0.3%

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Myeloid

• Megakaryocytes
• Erythrocyte
• Neutrophil

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1. Proerythroblast
2. Erythroblast (basophilic->Polychromatic->Orthochromatic)
3. Normoblast(Orthochromatic)(NRBC) (Nucleated RBC): 正常周邊血不會有
4. Reticulocyte

Erythrocyte七天成熟, 壽命 120天

Erythropoietin: 90% kidney, 10% liver

Heme = Fe+ protoporphyrin

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History taking

• Exertional dyspnea
• Dizziness
• Fatigue

Etiology

• Age, gender
• Blood loss: MC, hemorrhoids, GI
• Diet, vegetarians, B12
• Operation, gastrectomy
• Thalassemia history α4% β2%
• Blood data

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Colon cancer, stool OB

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• B12; cobalamin: ileum
• B9
• Fe: duodenum

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Thalassemia

• Β homozygous severe
• α3 intermediate. HbH disease

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Lab data

• Hb, MCV, RBC
• RDW 紅血球變異度
• Reticulocyte
• PB smear

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RPI

Hematocrit (%)	Retic survival (days) = maturation correction
36-45	1.0
26-35	1.5
16-25	2.0
15 and below	2.5

https://en.wikipedia.org/wiki/Reticulocyte_production_index

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RPI<0.1%

• PRCA
• AA

RPI>3%

• Bleeding,
• hemolytic anemia

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MCV

>115

• Megaloblastic
• Chemotherapy
• MDS

100-115

• Hypothyroidism
• Alcoholism
• Ditto
• Reticulocytosis
• Bone marrow

80-100

• ACD chronic disease
• Renal failure
• Mixrf deficiency
• Bone marrow diz

<80

• IDA
• Thalassemia
• Sideroblastic anemia
• Pb intoxication
• ACD

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Small lymphocytes 8-9 um

RBC 7um

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IDA

• Microcytic hypochromic
• Central pale zone 正常應該1/3-1/4
• Anisocytosis 大小不一
• Poikilocytosis 形狀

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• MCV↓
• RBC↓
• High RDW
• High MCV/RBC. (DDx thalassemia RBC normal)
• Mild plt↑

• Ferritin low (Normal 20~300)
• TIBC high
• Iron/TIBC <16% (normal 33%)

(Ddx ACD HIGH ferritin, normal TIBC)

• Koilonychia
• Glossitis
• Angular celitis

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Thalassemia

• Target cell
• Poikilocytosis
• Hemolysis
• Normoblast

• HbA2>3.5%
• HbF>2%

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250cc blood transfusion 100mg Fe

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Megaloblastic anemia

• MCV↑
• Hypersegmented neutrophils.   (MDS 也會)
• Pancytopenia
• Hemolysis
• Tinnitus, neurological S/S
• Vegetarians
• Gastrectomy

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Pernicious anemia, antibody to IF Intrinsic factor

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林耘曲醫師 新竹分院 診斷B12

"台大醫院新竹分院血液腫瘤科醫師林耘曲表示，經抽血後發現，溫婦的白血球、血色素、血小板都偏低，進一步檢查才發現，溫婦是罹患典型的維生素B12缺乏症，一開始會出現食慾不振、體重減輕，甚至開始出現記憶力衰退等情形，長期下來恐導致骨髓衰竭及早年失智，所幸在幫溫婦注射維生素B12針劑後，溫婦情況大為好轉，脾氣也變好了。"
Normal 270~400

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Pancytopenia

P: PNH

A: Asplatic anemia

N: Neoplasm/ Near neoplasm (including MDS)

C: Cirrhosis/ Connective tissue disease

Y: Vit B12/ Folic acid

T: Toxin/ Drug

O: Overwhelming sepsis (Hemophagocytic

syndrome)/ Others

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Hemolytic anemia

• Reticulocytosis
• Indirect hyperbilirubinemia
• Increased LDH, very sensitive. (Lymphoma也敏感)
• Decreased haptoglobin (結合free form hemoglobin)
• Erythroid hyperplasia in marrow

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必考填空題

Vascular Hemolysis
Haptoglobin<30

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Extravascular Hemolysis: spleen

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Approach

Immune

• AIHA; autoimmune
• Drug-induced

Non-immune

• Microangiopathic TTP (Adamts 13 切割vWF), MAHA
• HUS
• DIC
• mechanical prosthetic heart valve
• Hypersplenism
• PNH
• Infection
• Congenital: G6PD, thalassemia, spherocytosis

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TTP

• LDH >1000
• Thrombocytopenia不能輸Platelets (有爭議)
• Plasmapheresis
• NTUH 一年2-3例
• Helmet cells

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Coombs' test

• Direct: RBC, 較有臨床意義， Anti- C3b,IgG
• Indirect: serum

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Cold AIHA

• IgM pentamer, cold agglutination
• Mycoplasma infection
• Lymphoma
• CAD

以前有個流浪漢寒流就送急診，肺癌

Warm

• MicroSpherocyte
• IgG帶到Spleen (extracellular)

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Comparison

• Multiple myeloma
• Linear agglutination (Rouleaux formation)