1 / 35

13.11.2060

Appraoch to a child with anaemia. Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine. 13.11.2060. Definition of anaemia. The condition of having too few red blood cells.

JasminFlorian
Télécharger la présentation

13.11.2060

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Appraoch to a child with anaemia Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine 13.11.2060

  2. Definition of anaemia • The condition of having too few red blood cells. • It is a reduction of the red cell volume or hemoglobin concentration below -2SD for age, race and sex. • Microscopic: normocytic,microcytic,normochromic macrocytic or specific abnormalities (spherocyte,sickle cell,target cell)

  3. Case • Nine months old “Rai” female, single child • Recurrent fever • Mass in abdomen with pallor • No history of rash, bleeding, persistent diarrhoea, drug, jaundice, pica, • Had blood transfusion 2 days back • No consanguity of marriage • No family history of gall stones, jaundice. • No loss of weight, exclusive breast feeding

  4. Summary of examination finding • 9 Kg. • Mild pallor • No purpuric rash, lymphadenopathy, abnormal facies, • Gross spleenomegaly

  5. Diagnostic Approach-History • Age : Iron def rare without blood loss before 6mo in term infants. • Family Hist & Genetics: (1)X-linked: G6PD def (2)Aut dominant: Spherocytosis (3)Aut recessive: Sickle cell,Fanconi anemia (4)Family member with early age of cholecystectomy/splenectomy (5)Ethnicity: Thalassemia; G6PD def

  6. Diagnostic Approach-History • Diarrhoea: -Malabsorption of VitB12/E/Fe. Inflammatory bowel disease and anemia of chronic disease with or without blood loss. -Milk protein intolerance induced blood loss -Intestinal resection: Vit B12 def • Infection: - Giardia: iron malabsorption -Intestinal bacterial overgrowth: VitB12def -EBV,CMV,Parvovirus: BM suppression -Mycoplasma,Malaria: hemolysis -Hepatitis: aplastic anaemia -Endocarditis, HIV

  7. Diagnostic Approach-History • Nutrition: (1)Cows milk diet:iron def. (2)Strict vegetarian:Vit B12 def. (3)Goats milk: Folate def. (4)Pica: Plumbism,Iron def. (5)Cholestasis,malabsorption:VitE def • Drugs: (1)G6PD:oxidants(sulfa, primaquine, henna) (2)Immune mediated hemolysis (penicillin) (3)Bone marrow suppression (chemotherapy) • (4)Phenytoin increase folate requirement

  8. Physical exam reveals presence and potential causes of anaemia • Fever-acute infection,intravascular disease,collagen vascular disease • Jaundice suggests hemolysis • Petechia&Purpura—bleeding tendency • Hypertension&oedema-renal disease • Hepatosplenomegaly and lymphadenopathy—infiltrative disease • Growth failure or poor wt. gain—Anemia of chronic disease or organ failure • Examine stool for blood; urine for hemoglobinuria

  9. Physical Findings in Anaemia • Skin:Hyperpigmentation,café au lait spots- Fanconi anemia -Jaundice-hemolysis -Petechia&purpura- BMinfiltration, autoimmune hemolysis&thrombocytopenia -Erythematous rash- Parvovirus,EBvirus -Butterfly rash-SLE; Vitiligo-VitB12def • Head:Frontal bossing-Thalassemia major -Microcephaly-Fanconi anemia

  10. Physical Findings in Anaemia • Eyes: Microphthalmia-Fanconi anemia -Retinopathy-Sickle cell disease -Optic atrophy-Osteopetrosis -KF ring-Wilson disease • Ears: Deafness-Osteopetrosis • Mouth: Glossitis-B12 def,iron def - Angular stomatitis-Iron def -Pigmentation-Peutz Jeghers syndrome -Telangiectasia-Osler Weber Rendu syndrome

  11. Physical Findings in Anaemia • Chest: Cardiac murmur-Endocarditis,prosthetic valve hemolysis • Abdomen: Hepatomegaly-hemolysis, infiltrative tumour,chronic disease, hemangioma,cholecystitis -Splenomegaly -hemolysis,sickle cell disease,thalassemia,malaria,EBvirus, portal hypertension -Kidney anomaly-pelvic/absent kidney

  12. Physical Findings in Anaemia • Extremities:Absent thumb-Fanconi anemia -Spoon nails-Iron deficiency -Dystrophic nails-Dyskeratosis congenita • CNS-Irritable,apathy-Iron def. -Peripheral neuropathy-lead poisoning -Ataxia,post.column signs-Vit B12def - Stroke-Sickle cell anemia • Short stature-Fanconi anemia, Malnutrition

  13. COMPLETE BLOOD COUNT • Hb Conc (g/dl) • Hematocrit(PCV) • MCV (fl) • MCH (pg) • MCHC (detects red cell dehydration) • RBC Count (…x10 ) • WbC Count (…x10 ) • Platelet Count (…x10 ) • Reticulocyte Count ( % )

  14. Normal values Harriet Lane Handbook, The John Hopkins Hospital,15th edition

  15. Reticulocyte Production Index • RPI corrects the retics for the degree of anaemia • RPI indicates whether bone marrow is responding appropriately to anaemia • RPI= Retic x Hb(o) x 0.5 divided by Hb(n) • RPI > 3 increased production (hemolysis or blood loss) • RPI < 2 decreased production or ineffective production for the degree of anaemia • Reticulocytopenia—acute onset of anaemia, antibody mediated destruction, BMdisease

  16. AETIOLOGY • (1) Inadequate response RPI < 2 • A. Hypochromic microcyctic • B. Normochromic Normocytic • C. Macrocytic • (2)Adequate response RPI > 3 R/O blood loss---Includes Hemolytic disorders

  17. Microcytic Anaemia • TEST Iron def ThalMin • S.Iron - low normal • S.Ferritin - low N/H • Marrow iron - low N/H • Hb A2or F - N H=Bthal • N=Athal • MCV ÷ RBC - >13< 13 • Sickle/B-thal – Hb S > Hb A • Absence of microcytosis in both parents excludes B-thal or Sickle/B-thal but not A-thal

  18. Macrocytic anaemia • Vit.B12 def.- (1) pernicious anaemia (2) ileal resection (3) abnomal intestinal transport • Folate def.- (1) malnutrition (2) malabsorption (3) chronic hemolysis (4)drugs - phenytoin, sulfa • Hypothyroidism • Chronic liver disease • Marrow failure-Fanconi anaemia,Aplastic A 13.11.2060

  19. Haemolytic anaemia • Hemoglobinopathy– Hb SS,SC,S-B thal • Enzymopathy--G6PD def, PK def • Membranopathy—Hereditary spherocytosis, elliptocytosis • Extrinsic factors—DIC,HUS,Abetalipoproteinemia,Wilsons disease,Vit E def • Immune hemolytic anaemia-Autoimmune,Isoimmune,Drug induced 13.11.2060

  20. THALASSEMIA-Lab • Thal trait:Hb 9-10 g/dl • HbH disease:Hb 6-7 g/dl • Thal intermedia:Hb 7-8 g/dl • Thal major:Hb less than 5 g/dl • Peripheral smear:hypochromic,microcytic, anisopoikilocytosis,target cells • Hb electrophoresis: (1)Thal trait-HbF 1-5%, HbA2 3.5-8%,rest HbA (2)Thal major- HbF 20-100%,HbA2 2-7%,HbA 0-60%

  21. Pure Red Cell Aplasia:Reticulocytopenia + Absent marrow erythroid precursors.

  22. Aplastic anaemia • Severe reduction in platelets and granulocyte series 13.11.2060

  23. Anaemia of chronic disease Normal morphology Chronic inflammatory disease—(1)infection (2)collagen vascular disease (3)inflammatory bowel disease Recent blood loss Malignancy/Marrow infiltration Chronic renal failure Transient erythroblastopenia of chidhood Marrow aplasia/hypoplasia HIV infection Hemophagocytic syndrome 13.11.2060

  24. Haemolytic anaemia • Polychromasia (Wright-Geimsa). 13.11.2060

  25. Leukaemias • Blast cells 13.11.2060

  26. Laboratory Evaluation • Hematology:Complete Blood Count, Retic count,Peripheral smear,ESR,G6PD Sickling(+/-inf),Hb electrophoresis,Group,DCT, Osmotic fragility test,BMaspiration • Biochemistry:LFT,UE,RFT,S.Ferrtin, S.Haptoglobin,Iron,VitB12,Folate,Ceruloplasmin • Serology:Heterophil antibody,ANA,Viral t • Urinalysis,microscopy,culture/sensitivity • Stool exam.for ova,parasites,occult blood • Endoscopy: upper and lower bowel • Imaging:US Abdomen,Skeletal radiographs, Tc pertechnetate scan for Meckels diverticulum • Tissue biopsy:skin,lymph node,liver

  27. Nine months old female, single child • Recurrent fever • Mass in abdomen with pallor • No rash, bleeding, persistent diarrhoea, drug • Had blood transfusion 2 days back • No consanguity of marriage • No loss of weight, exclusive breast feeding • 9 Kg. • Mild pallor Hb:9.4 g% • No purpuric rash, lymphadenopathy, abnormal facies, • Gross spleenomegaly • Blood report: • TLC: 9,600/ cmm: P: 44%: L: 56%; • Platelets: 30.000/cmm Anisocytosis, hypochromic, reticulocyte 0.8%, occasional NRC.

  28. The diagnosis • Reticulocyte production index = Retic x Hb(o) x 0.5 divided by Hb(n) = 0.3 RPI < 2 decreased production or ineffective production for the degree of anaemia • Metabolic • Malignancy • Further work up: • Bone marrow

  29. Normal values Cell Type Range %Myeloblasts 0-2 Promyelocytes 2-5 Myelocytes (neutrophilic)9-16 Metamyelocytes 7-23 Band forms 8-15 Neutrophils 4-10 Myelocytes (eosinophilic)0-2 Band 0-2 Mature 0-3 Monocytes/macrophages0-3 Basophils 0-1 Mast cell 0-2 Plasma cells 3-6  This patient Cell Type % Blast 10 Promyelocyte 1.5 Myelocyte 12 Metamyelocyte 18 Neutrophils 31 Bone marrow report

  30. Final diagnosis • Malignancy • Juvenile Chronic Myelogenous Leukemia

  31. The commonest cause • Iron def. is common in children 9mo-3yr • Iron def. anemia in a child over 3yr should prompt consideration of occult blood loss. • Infants less than 6months generally do not develop iron def.; the exception to this rule is premature infants,who are at risk of iron def.at 4mo, if iron supplementation is not given.

  32. Iron deficiency Anemia • Dietary iron def is the usual cause • Manifestations of anemia • CNS abnormalities:apathy,irritability,poor conc,cognitive deficits • Poor muscle endurance • GIT dysfunction • Impaired WBC and T-cell function

  33. Iron deficiency: hypochromic anaemia • Iron def.-(1)chronic blood loss (2)poor diet (3)cows milk protein intolerance • Chronic inflammatory disease 13.11.2060

  34. Differential Features of Iron Deficiency vs Acute and Chronic Inflammation

  35. Iron deficiency Anemia • Treatment:Response to oral iron includes 24-48hr-subjective improvement inCNS 48-72hr-reticulocytosis 4-30days-increase in Hb 1-3 mo-repletion of iron stores • Therapeutic dose:3-6 mg/Kg/day of elemental iron.---Induces an increase in Hb of 0.25-0.4 g/dl per day or 1%/day rise in hematocrit. • Failure of response after 2 weeks of oral iron requires reevaluation for ongoing blood losses,infection,poor compliance or other causes of microcytic anaemia.

More Related