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Anemia, 30314, Spherocytes, Schistocytes, 838, download, images (1),…

- - - - Hypochromic red cells are common in iron deficiency
      - Eliptocytes are a common finding in iron deficiency, and are sometimes referred to as penicillate cells
      - Widely spaced red cells = anemia
      - Iron Studies
        
        Serum iron: A snapshot of what the iron level is right now, the serum iron level is dependent on daily activities and therefore can be variable day to day. A normal serum iron level does not exclude a diagnosis of iron deficiency, however a low iron level is more specific for iron deficiency
        
        Total Iron Binding Capacity (TIBC): The amount of protein available to bind iron. Elevated in times of low iron in order to maximize iron transportation; however, TIBC is typically decreased in anemia of chronic disease.
        
        % iron saturation: What percentage of the proteins which have the ability to transport iron currently have iron bound (low iron states will have low %saturation)
        
        Ferritin: A protein made by almost all cells in response to increased iron. The ferritin level reflects the total body iron. It will be low when there is iron deficiency and high when there is an excess of iron in the body. It is also an acute phase reactant.
        
        Transferrin receptor: Directly measures the level of transferrin in the blood, the principle protein that transports iron. The level depends upon liver function and a person’s nutritional status. Transferrin is a protein that may decrease during any inflammatory process.
  - - - unexplained, new microcytic anemia should evaluate iron studies
        
        Serum iron studies may not be picture perfect for iron deficiency, but at least one of the measures should be characteristic.
        
        The peripheral blood morphology may be normal or may show subtle changes seen in iron deficiency
    - - Loss of globin gene function through deletion or mutation
        
        In beta thalassemia there is loss of function of one of the two beta globin genes leading to relative excess of alpha globin production which leads to increased proportion of the minor hemoglobins (Hgb A2 and Hgb F).
        
        Beta thalassemia trait: One of the genes is affected genotype of ß/ß0 or ß/ß+
        
        Beta thalassemia major: both beta globin genes are involved, leading to a severe anemia (transfusion dependent)
        
        In alpha thalassemia there is loss of fuction of one or more of the four alpha genes
        
        αα / αα (normal)
        
        αα/α- (silent carrier) no abnormal lab values except at birth when there would be Hgb Barts (γ tetrad) due to relatively fewer alpha per gamma. Predominant hemoglobin in newborns: HgbF (α2γ2)
        
        αα/-- OR α-/α- (α-thalassemia trait) mildly abnormal lab values and usually asymptomatic
        
        α-/-- (HbH disease/α-thalassemia intermedia) moderate microcytic anemia
        
        --/-- (hydrops fetalis)
      - Target shaped red cells are often present in thalassemias and are due to increased surface to volume ratio (the red cells aren't filled as well with hemoglobin since the production is diminished)
        
        Target cells can also be seen in liver disease (increased cholesterol in red cell membranes) and post splenecotomy
    - - Variant hemoglobin production: SA, SS, SC,CC, CE, AC etc.
        
        These variant hemoglobin molecules are often unstable and : precipitate in the red cells, deforming them and leading to early destruction
        
        In some cases there is sickling of the red cells. Sickle cells can be seen in HbSC, HbSS, HbSD, HbSE, and HgBS with thalassemia
    - - Small fragmented red cells lead to lower MCV
    - - Check and trend CRP and ESR
        
        Iron is required for many microorganisms to grow. When infection is present, the body "hides away" its iron, making it less accessible to microorganisms. A similar response occurs in the setting of chronic inflammatory disease (such as osteoarthritis, chronic kidney disease, inflammatory bowel disease, cancer, and autoimmune disease), resulting in decreased iron availability not only to potential microbes but also to the body's own cells. Compare and contrast iron deficiency anemia to anemia of chronic disease in the iron studies table.
    - - Rare in the US, but children who live in households at or below the federal poverty level and those who live in housing built before 1978 are at the greatest risk of lead exposure. (The U.S. government banned lead-based house paint in 1978.) Also, communities of color are at higher risk of lead exposure because they may not have access to safe, affordable housing or face discrimination when trying to find a safe, healthy place to live.
- - - - Increased reticulocytes by morphology shows increased polychromasia (bigger purpler red cells)
      - Make sure to look in the background of the blood smear for why there might be increased reticulocytes (i.e. red cell fragments)
  - - - Symptoms include tongue swelling, mouth sores, hair and nail issues, migraines, fatigue, stunted growth/development
      - Folate is stored in the liver and taken up by proliferating cells. Folate is important in DNA synthesis and amino acid synthesis. Folate deficiency is easily corrected by dietary inta
        Serum folate fluctuates rapidly with intake. Red cell folate is a measure of folate storage and is a better test for evaluating folate deficiency
    - - Symptoms include cognitive decline (dementia), depression, low energy, numbness and tingling REMEMBER B12 shows neurologic deficits
      - B12 (Cobalimin) is required for DNA synthesis and hemoglobin synthesis
      - Rarely due to dietary deficiency. Seen in malabsorption, alcohol abuse, pernicious anemia, gastric bypass, and pancreatic insufficiency. Test for cobalamin level
- - - - Drugs (i.e. cyclosporin, sulfa medication, etc)
      - Obstetric complications (preeclampsia, eclampsia, HELLP, Sheehan postpartum pituitary necrosis)
      - Mechanical (prosthetic valves, crush injury, march hemoglobinuria, burns, dialysis)
      - Microangiopathic (eg DIC, TTP, HUS)
      - Alloimmune (eg transfusion reaction)
      - Autoimmune (eg drug or lymphoid disorder associated)
  - - - Vitamin deficiencies (B12)
      - Thalassemia
      - Hemoglobinopathies (eg sickle cell disease)
      - Enzymopathies (eg glucose-6-phosphate dehydrogenase deficiency)
      - Membranopathies (eg hereditary spherocytosis)