CHAPTER 18

ANEMIAS:
Red Blood Cell Morphology
and Approach to Diagnosis
TESHAUNA ESCOBAR

Background

Red blood cells (RBCs)

perform the vital physiologic function of oxygen delivery to the tissues.

The term anemia is derived from the Greek word anaimia, meaning
without blood.

A decrease in the number of RBCs, or the amount of hemoglobin in the

RBCs, results in:

decreased oxygen delivery and;

subsequent tissue hypoxia.

It is a commonly encountered condition affecting an estimated 1.62 billion

people worldwide.

DEFINITION OF ANEMIA

Functional definition:

a decrease in the oxygen carrying capacity of the blood.

can arise if there is insufficient hemoglobin or the hemoglobin is

nonfunctional.

Operational definition:

a reduction, from the baseline value, in the total number of RBCs, amount of
circulating hemoglobin, and RBC mass for a particular patient.

Conventional definition:

a decrease in RBCs, hemoglobin, and hematocrit below the reference range for
healthy individuals of the same age, sex, and race, under similar environmental
conditions.

CLINICAL FINDINGS

The classic symptoms:

fatigue and shortness of breath.

iron deficiency which can lead to an interesting symptom called pica

Certain features to be evaluated closely during the physical

examination to provide clues to hematologic disorders:

skin (for pallor, jaundice, petechiae), eyes (for hemorrhage), and mouth (for mucosal
bleeding).

sternal tenderness, lymphadenopathy, cardiac murmurs, splenomegaly, and

hepatomegaly.

Jaundice because it may be due to increased RBC destruction, which suggests a

hemolytic component to the anemia.

vital signs

rapid fall in hemoglobin concentration; tachycardia (fast heart rate)

PHYSIOLOGIC ADAPTATIONS

Reduced delivery of oxygen to tissues caused by reduced hemoglobin causes an increase in

erythropoietin secretion by the kidneys.

Erythropoietin stimulates the RBC precursors in the bone marrow, which leads to the release of
more RBCs into the circulation.

With persistent anemia, the body implements physiologic adaptations to increase the
oxygen-carrying capacity of a reduced amount of hemoglobin.

Heart rate, respiratory rate, and cardiac output are increased.

The tissue hypoxia triggers an increase in RBC bisphosphoglycerate that results in increased
delivery of oxygen to tissues.

MECHANISMS OF ANEMIA

The life span of the RBC in the circulation is about 120 days.

In a healthy individual with no anemia, each day approximately 1% of the RBCs are removed from circulation due to
senescence, but the bone marrow continuously produces RBC to replace those lost.

Hematopoietic stem cells develop into erythroid precursor cells, and the bone marrow
appropriately releases reticulocytes that mature into RBCs in the peripheral circulation.

Adequate RBC production requires several nutritional factors:

such as iron, vitamin B12, and folate.

Globin synthesis also must function normally.

In conditions with excessive bleeding or hemolysis:

the bone marrow must increase RBC production to compensate for the increased RBC loss.

The maintenance of a stable hemoglobin concentration requires the production of functionally normal.

RBCs in sufficient numbers to replace the amount lost.

Ineffective and Insufficient

Erythropoies

Erythropoiesis - the term used for marrow erythroid proliferative activity.

Normal erythropoiesis occurs in the bone marrow.

Effective erythropoiesis - the bone marrow is able to produce functional RBCs that
leave the marrow and supply the peripheral circulation with adequate numbers of cells.

Ineffective erythropoiesis - production of erythroid progenitor cells that are defective.

Defective progenitors

often destroyed in the bone marrow before maturation and released into the peripheral
circulation.

Characteristics of ineffective erythropoiesis:

Megaloblastic anemia

Thalassemia

Sideroblastic anemia

Ineffective and Insufficient

Erythropoies

Insufficient erythropoiesis

a decrease in the number of erythroid precursors in the bone marrow.

Several factors can lead to:

decreased RBC production,

including a deficiency of iron (inadequateintake, malabsorption,

excessive loss from chronic bleeding);

deficiency of erythropoietin,

the hormone thatstimulates erythroid precursor proliferation and

maturation (renal disease);

loss of the erythroid precursors due to an autoimmune reaction (aplastic anemia,

acquired pure red cellaplasia) or infection (parvovirus B19);

suppression of the erythroid precursors due to infiltration of the bone marrow with
granulomas (sarcoidosis) or malignant cells (acute leukemia).w, resulting in decreased RBC
production and anemia.

Acute Blood Loss and Hemolysis

Anemia can also develop as a result of acute blood loss (such as

traumatic injury) or premature hemolysis resulting in a shortened
RBC life span.

With acute blood loss and excessive hemolysis, the bone marrow is able to increase
production of RBCs, but the level of response is inadequate to compensate for the
excessive RBC loss.

Numerous causes of hemolysis:

intrinsic defects in the RBC membrane, enzyme systems, or

hemoglobin

extrinsic causes such as antibody-mediated processes, mechanical

fragmentation, or infection-related destruction if the level of response
is inadequate to compensate for the excessive RBC loss.

LABORATORY DIAGNOSIS OF
ANEMIA

Complete Blood Cell Count with Red Blood Cell Indices:

To detect the presence of anemia,

the medical laboratory professional performs a complete blood count using an automated hematology analyzer to
determine the RBC count, hemoglobin concentration, hematocrit, RBC indices, whiteblood cell (WBC) count,
and platelet count.

The RBC indices include the mean cell volume (MCV), mean cell hemoglobin (MCH), and mean cell hemoglobin concentration (MCHC)

MCV (Mean Cell Volume)

Most important of these indices

a measure of the average RBC volume in femtoliters (fL).

Automated hematology analyzers also provide an RBC histogram and the red blood cell distribution width (RDW).

Relative and absolute reticulocyte count should be:

performed for every patient when anemia is found.

Automated analyzers perform reticulocyte counts with greater accuracy and precision than manual counting methods.

RBC histogram

RBC volume frequency distribution curve with the relative number of cells plotted on the ordinate and RBC volume in
femtoliters on the abscissa.

LABORATORY DIAGNOSIS OF
ANEMIA

Complete Blood Cell Count with Red Blood Cell Indices:

Abnormalities include:

shift in the curve to the left (microcytosis) or to the right (macrocytosis)

widening of the curve caused by a greater variation of RBC volume about the mean or by the presence
of two populations of RBCs with different volumes (anisocytosis)

The histogram complements the peripheral blood film examination in identifying variant RBC populations.

The RDW is the coefficient of variation of RBC volume expressed as a percentage

Indicates variation in RBC volume within the population measured and correlates with anisocytosis on
the peripheral blood film.

Automated analyzers calculate the RDW by dividing the standard deviation of the RBC volume by the
MCV and then multiplying by 100 to convert to a percentage.

Reticulocyte Count

The reticulocyte count is an important tool to assess the bone marrows

ability to increase RBC production in response to an anemia.

Reticulocytes - young RBCs that lack a nucleus but still contain residual ribonucleic acid
(RNA).

Circulate peripherally for only 1 day while completing their development.

The adult reference range is 0.5% to 1.5% expressed as a percentage of the total number
of RBCs.

The newborn reference range is 1.5% to 5.8%, but these values change to approximately
those of an adult within a few weeks after birth.

An absolute reticulocyte count - determined by multiplying the percent

reticulocytes by the RBC count.

Reticulocyte Count

Peripheral Blood Film

Examination

An important component in the evaluation of an anemia - examination of the peripheral

blood film, with particular attention to RBC diameter, shape, color, and inclusions .

The peripheral blood film also serves as a quality control to verify the results produced by automated analyzers.

Normal RBCs on a Wright-stained blood film are nearly uniform, ranging from 6 to 8 m in diameter.

Small or microcytic cells are less than 6 m in diameter, and large or macrocytic RBCs are greater than 8 m in
diameter.

Examples:

sickle cells

Spherocytes

Schistocytes

oval macrocytes

RBC inclusions:

Ex: malarial parasites, basophilic stippling, and Howell-Jolly bodies

detected only by studying the RBCs on a peripheral blood film

Bone Marrow Examination

The cause of many anemias can be determined from the history, physical examination, and
results of laboratory tests on peripheral blood.

bone marrow aspiration and biopsy may help in establishing the cause of anemia

bone marrow examinations is indicated for a patient with an unexplained anemia associated
with or without other cytopenias, fever of unknown origin, or suspected hematologic malignancy.

bone marrow examinations evaluate hematopoiesis

determine if there is abnormal infiltration of the marrow.

Important findings in the marrow that point to the underlying cause of the anemia include
abnormal cellularity of the marrow

Example: hypocellularity in aplastic anemia

Evidence of ineffective erythropoiesis and megaloblastic chages

Ex: vitamin B12 deficiency or (myelodysplastic syndrome) lack of iron on iron stains of the bone
marrow (the gold standard for diagnosis of iron deficiency)

Presence of granuloma, fibrosis, infectious agents, and tumor cells that may be inhibiting normal
erythropoiesis.

Other Laboratory Tests

Routine urinalysis

(to detect hemoglobinuriaor an increase in urobilinogen)

To detect hematuria or hemosiderin an

Analysis of stool

To detect occult blood or intestinal parasites). Also, certin

Other Chemistry studies useful:

Renal and hepatic function tests

After the completion of hematologic laboratory studies the anemia may be classified based on reticulocyte count,
MCV, and peripheral blood film findings.

Iron studies (including serum iron, total iron-binding capacity, transferrin saturation, and
serum ferritin) are valuable if an inappropriately low reticulocyte count and a microcytic anemia are present.

Serum vitamin B12 and serum folate assays are helpful in investigating a macrocytic anemia with a low
reticulocyte count

Direct antiglobulin test can differentiate autoimmune hemolytic anemias from hemolytic anemias with other
causes.

Because of the numerous potential etiologies of anemia, the cause needs to be determined before initiation of therapy.

APPROACH TO EVALUATING
ANEMIAS

The approach to the patient with anemia begins with taking a complete
history and performing a physical examination.

New-onset fatigue and shortness of breath suggest an acute drop in

the hemoglobin concentration, whereas a lack of symptoms suggests a longstanding or congenital condition.

RBC count and comparison of these values with the reference range for healthy
individuals of the same age, sex, race, and environment.

Reticulocyte Count and Anemia

Classification

The absolute reticulocyte count is useful in initially classifying

anemias into the categories of decreased RBC production (decreased
reticulocyte count) and shortened RBC survival (increased reticulocyte
count).

When the reticulocyte count is decreased, the MCV can further classify
the anemia into three subgroups:

(1) normocytic anemias

(2) microcytic anemias

(3) macrocytic anemias

Reticulocyte Count and Anemia

Classification

Mean Cell Volume and Anemia

Classification

Microcytic anemia is characterized by an MCV of less than 80 fL with small RBCs (less than 6
m in diameter)

Hypochromia, characterized by an MCHC of less than 32 g/dL and increased central pallor in
the RBCs, may accompany the microcytosis.

Microcytic anemias are caused by conditions that result in reduced hemoglobin synthesis:

The most common microcytic anemia results from an iron level that is insufficient for
maintaining normal erythropoiesis

it is characterized by abnormal results on iron studies.

Macrocytic anemia is characterized by an MCV greater than 100 fL with large RBCs (greater
than 8 m in diameter).

iron deficiency, inability to utilize iron (chronic inflammatory states), globin synthesis defect
(thalassemia), and heme synthesis defect (sideroblastic anemia, lead poisoning)

Macrocytic anemias may be megaloblastic or nonmegaloblastic.

Megaloblastic anemias are caused by conditions that impair synthesis of deoxyribonucleic

acid (DNA), such as vitamin B12 and folate deficiency or myelodysplasia.

Mean Cell Volume and Anemia

Classification

Nuclear Maturation lags behind cytoplasmic development as a result of impaired DNA synthesis.

Pernicious anemia is one cause of vitamin B12 deficiency, whereas malabsorption secondary to
inflammatory bowel disease is one cause of folate deficiency

A megaloblastic anemia characterized by:

oval macrocytes and hypersegmented neutrophils in the peripheral blood and by megaloblasts or large
nucleated RBC precursors in the bone marrow.

The MCV in megaloblastic anemia can be markedly increased (up to 150 fL), but modest increases (100 to 115
fL) occur as well.

Non-megaloblastic forms of anemia are also characterized by large RBCs, but in contrast to
megaloblastic anemias,

Typically related to membrane changes owing to disruption of the cholesterol-to-phospholipid ratio.

These macrocytic cells are mostly round, and the marrow nucleated RBCs do not display the
egaloblastic maturation changes.

Macrocytic anemias are often seen in patients with chronic liver disease and bone marrow failure. It
is rare for the MCV to be greater than 115 fL in these nonmegaloblastic anemias.

Normocytic anemia is characterized by an MCV in the range of 80 to 100 fL.

Red Blood Cell Distribution

Width

To determine the cause of an anemia when used in conjunction with

the MCV.

Each of the three MCV categories mentioned previously (normocytic,

microcytic, macrocytic) can also be subclassified by the RDW as

homogeneous (normal RDW)

heterogeneous (increased or high RDW)

Red Blood Cell Distribution

Width

Red Blood Cell Distribution

Width

Red Blood Cell Distribution

Width

Hemolytic Anemias

Elevated reticulocyte count caused by shortened survival of RBCs, an

investigation for a hemolytic anemia is required.

Numerous intrinsic and extrinsic causes of hemolysis exist.

A direct ant globulin test helps differentiate immune-mediated destruction from the
other causes.

In the other hemolytic anemias, reviewing the peripheral blood film is vital for
determining the cause of the hemolysis.

Pathophysiologic Classification

Grouped by the mechanism causing the anemia

The anemias caused by decreased RBC production (e.g., disorders of DNA synthesis) are
distinguished from the anemias caused by increased RBC destruction or loss (intrinsic
and extrinsic abnormalities of RBCs.

END