...and you thought Anemia is just Paleness!
NATIONAL JOURNAL OF HOMOEOPATHY 2001 Jul / Aug VOL III NO 4.
Dr C H Asrani

Wake up and join me to know the minimum a Primary Care Physician (that is us!) has to know about Anemia!

Anemia refers to a condition wherein there is a reduction in the circulating red cell mass. As a result both the hemoglobin concentration and hematocrit (Packed Cell Volume) are reduced.

Classification: Causative

1. Anemia from blood loss
   1. Acute - bleed from a gastric/ duodenal ulcer
   2. Chronic - hookworm infestation, Menorrhagia, piles etc
2. Excessive RBC destruction or diminished synthesis of Hb
   1. Infections - malaria, bacterial infections
   2. Effects of chemicals, drugs, radiation
   3. Misc - cirrhosis of liver, splenic vein thrombosis, chronic renal failure, malignancies
3. Deficiency Anemia
   1. Iron
   2. B12, Folate
   3. Protein
   4. Misc - copper, Vit C and Vit E
4. Bone marrow failure
   1. Aplastic anemia
   2. Infections
   3. Malignancy
   4. Collagen disorders etc

1. MCV (Mean Corpuscular Volume) PCV X 10/ RBC in millions
2. MCH (Mean Corpuscular Hemoglobin) Hb in gm X 10 / RBC in million per cc
3. MCHC (Mean Corpuscular Hemoglobin Concentration) Hb in gm X 100/ PCV %

Normal ranges of Complete blood count in children

Clinical Features (General)
Symptoms of Anemia depend on the rate at which Anemia develops, severity of Anemia and change in the blood volume. Features of Anemia are mostly due to "oxygen lack". Resulting adjustment leads to increased rate of blood flow and transfer of blood to more vital areas. The cardiac output increases proportionately to degree of Anemia. Pulse rate and volume are increased. Viscosity of blood, peripheral resistance and diastolic blood pressure are decreased. These physiological adjustments occur when Hb falls below 7 Gm%. While these symptoms are common to all Anemias, symptoms due to cause will vary. Clinical symptoms get more pronounced when Cardio Vascular System is affected.

In majority of cases in our practice, the development of Anemia is so gradual that the body adapts itself to the lowered oxygen supply that the patient hardly complains of any symptoms until the Hb levels have fallen very low.

The general symptoms common to all Anemias are

• weakness
• easy fatigability
• loss of weight and appetite
• vague gastro intestinal symptoms
• frequent respiratory and/or skin infections

As a result of oxygen lack, dyspnoea on exertion, tachypnoea and palpitations may be present. Very late, symptoms of cardiac failure may also appear (Hb less than 5 Gm%). Females may get amenorrhoea. Children may present with arrest of growth and wound healing is delayed.

Diagnosis
Pallor is NOT synonymous with Anemia. Diagnosis of Anemia, its cause and severity must be established by blood tests. Adequate thought is to be given to blood loss (hook worm, menorrhagia) while taking history as also to the adequacy of diet. Unexplained anemia in children should bring up the suspicion of Thalassemia (discussed elsewhere in this issue).

As a first step, ask for - Complete Blood Count with Indices - insist on a cell counter reporting against manual wherever possible. Study of a peripheral smear for morphology of RBCs and demonstration of parasites is a must. WBC count may indicate infections or malignancy. Simultaneous reduction in Platelet count may signal bone marrow involvement. Stool test for occult blood and a Gynec examination in females, where required, to rule out uterine pathology may be indicated.

If Anemia is not responding to treatment, one may have to go in for Serum Iron, Serum Transferrin and Total Iron Binding Capacity.

Ready Reckoner:

1. Normally Packed Cell Volume is 3 times the Hb level. (Hb: 11.8 Gm% will have PCV of 35.4)In acute blood loss Haematocrit will be less than 3 times Hb as it takes time for Hb levels to fall but Packed Cell Volume is affected immediately. If Packed Cell Volume is more than 3 times the Hb, suspect megaloblastic anemia as with larger RBCs the PCV is higher.
2. Microcytosis - indicates Iron deficiency anemia. If the size too small as compared to Hb levels suspect Thalassemia.
3. Macrocytosis - suspect B₁₂ or folate deficiency. Serum B₁₂ and Serum Foilc acid levels are helpful
4. Poikilocytosis and Anisocytosis means that bone marrow is throwing out immature cells.
5. In hemolytic anemia (commonest being in Malaria) the serum will be Icteric and more of indirect bilirubin than direct bilirubin confirms the diagnosis.

Deficiency anemias need supplementation of the deficient factor and Hemolytic anemias need careful recognition of the cause and therapy thereof.

A good physician pre-empts the need of increased iron and supplements it eg in pregnancy, lactation and in a case of malaria.

Follow-Up: Hb levels should not be measured earlier than 2 mths unless clinically indicated by deteriorating clinical condition. Expected rise in Hb level is 1 Gm% in a month.

Quiz
A female patient comes to your clinic and you have to clinically assess her for Anemia. Difficulty is that she has mehndi on her hands; dark red color on her nails, kajal smeared in her eyes and her gums, tongue and cheeks are stained with years and years of chewing pan and tobacco. How will you ascertain her paleness?

Answer on page: (be honest to yourself)

Reference:

1. Pediatric Hematology PCNA Vol 43 No 3 June 96
   Interpretation of CBC By Mark Walters, MD and Herbert Abelson, MD
2. Dacie and Lewis - Practical Haematology
3. Jacques Wallach- Synposis of Lab Medicine

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