Anaemia

Anaemia: Anemia is defined as a reduction in hemoglobin concentration below the
level, which is expected for healthy persons of same age and sex, and in the same
environment.
Normal range:
• Adult males: 13.0-17.0 gm/dl.
• Adult females (non-pregnant): 12.0-15.0 gm/dl.
• Adult females (pregnant): 11.0-14.0 gm/dl.
• Children, 6-12 years: 11.5-15.5 gm/dl.
• Children, 6 months to 6 years: 11.0-14.0 gm/dl.
• Infants, 2-6 months: 9.5-14.0 gm/dl.
• At birth (full term): 13.6-19.6 gm/dl.
Plan of Investigation for Anaemia - In order to confirm or deny the presence of anaemia, its
type and its cause, the following plan of investigations is generally followed:
I. Screening tests: A. Haemoglobin estimation B. Peripheral blood film examination C.
Red cell indices D. Leucocyte and platelet count E. Reticulocyte count
II. Confirmatory tests: A. Bone marrow examination B. Biochemical tests
PERIPHERAL BLOOD FILM EXAMINATION - The haemoglobin estimation is invariably
followed by examination of a peripheral blood film for morphologic features after staining it
with the Romanowsky dyes (e.g. Leishman’s stain, May-Grunwald-Giemsa’s stain,
JennerGiemsa’s stain, etc). The blood smear is evaluated in an where there is neither rouleaux
formation nor so thin as to cause red cell distortion. Such an area can usually be found towards
the tail of the film, but not actually at the tail
PBF in Microcytic Hypochromic Anaemia (Iron Deficiency Anaemia) The degree of anaemia
in iron deficiency varies. It is usually mild to moderate but occasionally it may be marked due to
persistent and severe blood loss. The salient haematological findings in these cases are as under:
1. Haemoglobin. The essential feature is a fall in haemoglobin concentration up to a
variable degree.
2. Red cells. The red cells in the blood film are hypochromic and microcytic, and there is
anisocytosis and poikilocytosis. Hypochromia generally precedes microcytosis.
Hypochromia is due to poor filling of the red cells with haemoglobin so that there is
increased central pallor. In severe cases, red cells reveal only a thin rim of haemoglobin
at the periphery (ring or pessary cell). Target cells, elliptical forms and polychromatic
cells are often present. Normoblasts are uncommon. RBC count is below normal but is
generally not proportionate to the fall in haemoglobin value. When iron deficiency is
associated with severe folate or vitamin B12 deficiency, a dimorphic blood picture occurs
with dual population of red cells, macrocytic as well as microcytic-hypochromic.
3. Reticulocyte count. The reticulocyte count is normal or reduced but may be slightly
raised (2-5%) in cases after haemorrhage.
4. Absolute values. The red cell indices reveal a diminished MCV (below 80 fl), diminished
MCH (below 25 pg) and diminished MCHC (below 27 g/dl).
5. Leucocytes. The total and differential white cell counts are usually normal. However, in
cases in which iron deficiency is due to parasitic infestations such as hookworm
infestation, there may be associated eosinophilia.
6. Platelets. Platelet count is usually normal but may be slightly to moderately raised in
patients who have had recent bleeding.
PBF in Macrocytic Anaemia (Megaloblastic Anaemia)
The investigations of a suspected case of megaloblastic anaemia are aimed at 2 aspects:
A. General laboratory investigations of anaemia which include blood picture, red cell indices,
bone marrow findings, and biochemical tests
B. Special tests to establish the cause of megaloblastic anaemia as to know whether it is due
to deficiency of vitamin B12 or folate. The estimation of haemoglobin, examination of a
blood film and evaluation of absolute values are essential preliminary investigations.
1. Haemoglobin. The haemoglobin estimation reveals values below the normal range. The
fall in haemoglobin concentration may be of a variable degree.
2. Red cells. The red blood cell morphology in a blood film shows the characteristic
macrocytosis. However, macrocytosis can also be seen in several other disorders such as:
haemolysis, liver disease, alcoholism, hypothyroidism, aplastic anaemia, myeloproliferative
disorders and reticulocytosis. In addition, the blood smear demonstrates marked anisocytosis,
poikilocytosis and presence of macro-ovalocytes. Basophilic stippling, Howell-Jolly bodies,
Cabot ring and occasional normoblast may also be seen.
3. Reticulocyte count. The reticulocyte count is generally low to normal in untreated cases.
4. Absolute values. The red cell indices reveal an elevated MCV (above 120 fl) proportionate
to the severity of macrocytosis, elevated MCH (above 50 pg).
5. Leucocytes. The total white blood cell count may be reduced. Presence of characteristic
hypersegmented neutrophils (5% neutrophils having more than 5 nuclear lobes) in the blood
film should raise the suspicion of megaloblastic anaemia. An occasional myelocyte may also
be seen.
6. Platelets. Platelet count may be moderately reduced in severely anaemic patients. Bizarre
forms of platelets may be seen.

Anaemia

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Anaemia: Anemia is defined as a reduction in hemoglobin concentration below the

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