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45 yo man. Anemia, lethargy for last few months (RBC production defect…

- - - - Aplastic anemia
        ~Infection (sepsis, pneumonia, UTI), clonal evolution
        ~pri: Fanconi anemia
        ~sec: drugs (chemo, carbimazole), toxins (benzene), radiation, viruses (parvovirus, hepatitis, HIV - cause transient pancytopenia)
      - Malignant/pre-malignant
        ~bone marrow infiltration by leukemia, myeloma (hyperCa, renal impairment, anemia, bone pain), myelofibrosis
        ~constitutional symptoms, hepatosplenomegaly
    - - Renal dz (insufficient erythropoietin synthesized)
      - Pure RBC aplasia
      - Anemia of Chronic Dz (AoCD) (inadequate erythropoiesis & dec RBC survival)
        ~chronic inflammatory state (infection, RA, cancer)
      - Myelodysplastic syndrome
  - - - Causes:
        
        Pernicious anemia (autoimmune destruction of parietal cell)
        ~Intrinsic factor/parietal cell autoAb
        
        Drug - methotrexate, phenytoin, trimethoprim
        
        GIT surgery:
        ~Gastrectomy, Ileal resection
        
        Dietary deficiency (vegans)
      - Types:
        
        B12 deficiency:
        ~neurological symptoms (loss of vibration/proprioception sense, +ve Romberg), long latency before symptoms
        ~classic pic: premature gray person, north european descent, lemon-colored skin (anemia + jaundice), mentally sluggish, shiny tongue (glossitis), shuffling broad-based gait
        
        Folate deficiency:
        ~Classic pic: alcohol/drug abuser, poor dietary intake, rare neuro symptoms, acute presentation of sym (4-5months)
    - - Hypothyroid
      - Liver dz, alcoholism, drugs (azathioprine)
      - Leukemia
  - - - Blood loss: NSAID usage, GIT malignancy, menorrhagia)
      - Poor absorption: GIT surgery
      - Poor intake/malnourished
- - - - G6PD deficiency
        ~acute hemolytic episodes (sudden onset jaundice, pallor, dark urine, abdo/back pain), precipitated by infection, drugs (antimalarials, Abx, analgesics), fava beans. blood count normal between episodes
      - Hereditary spherocytosis
        ~jaundice (mild), splenomegaly, aplstic anemia (parvovirus B19/other virus infection), bilirubin gallstone
        ~spherocytes on PBF, +ve osmotic fragility test
      - Sickle cell anemia
        ~low O2, high altitude, acidosis precipitates sickling
        ~'crew-cut' skull XR, chronic pain, neurological deficits/seizure/stroke, chronic leg ulcers, retinopathy, pulmonary complications (asthma, sleep diordered breathing, pulmonary fibrosis, pulm HTN)
    - - Autoimmune hemolytic anemia (AIHA)
        ~+ve direct Coomb's test
        ~acute anemia triggered by cold -> RBC agglutinins -> painful blue fingers and toes
        
        Infective:
        ~Mycoplasma- cold agglutinins
        ~CMV, EBV
        
        Inflammatory (e.g. SLE, RA, scelroderma) - do ANA
        
        Neoplastic - lymphoma, CLL
        
        Drugs - high does penicillin, mefenamic acid
      - Microangiopathic hemolytic anemia
        ~schistocytes, -ve Coomb's test (i.e. non-immune), inc LDH, indirect bilirubin, low haptoglobin
        ~can be caused intra-vascular heart device
      - Mechanical hemolysis - prosthetic valves
      - Fragile RBCs - B12 deficiency
      - Malaria
        ~fever, travel hx, use of prophylaxis. tachcardia, tachypnea, chills, diaphoresis, N/V, diarrhoea
      - Hypersplenism
  - - - Acute - Hb & HCt normal (bcos whole blood including plasma is lost)
      - Subacute (hrs) - dec HCt as lost plasma is replaced
      - Compensated - inc reticulocytes
      - Chronic blood loss - dec reticulocytes