Classification and IDA

Classification and Iron deficiency
anemia.
Dr. Manasa GC
Assistant professor
Dept of Pathology
“The only person who never makes a mistake is a person who never does anything”
- Theodore Roosevelt
Classification
A. PATHOPHYSIOLOGIC
• I. Anaemia due to increased blood loss
– a) Acute post-haemorrhagic anaemia
– b) Chronic blood loss
• II. Anaemias due to increased red cell destruction
(Haemolytic anaemias)
– A. Extrinsic (extracorpuscular)
– B. Intrinsic (intracorpuscular) red cell abnormalities
• III. Anaemias due to impaired red cell production
– Inherited genetic defects
• Defects leading to stem cell depletion: Fanconi anemia, telomerase
defects
• Defects affecting erythroblast maturation :Thalassemia syndromes
– Nutritional deficiencies
• Deficiencies affecting DNA synthesis :B12 and folate deficiencies
• Deficiencies affecting hemoglobin synthesis: Iron deficiency anemia
– Erythropoietin deficiency: Renal failure, anemia of chronic disease
– Immune-mediated injury of progenitors Aplastic anemia, pure red cell
aplasia
– Inflammation-mediated iron sequestration Anemia of chronic disease
– Primary hematopoietic neoplasms Acute leukemia, myelodysplasia,
myeloproliferative disorders
– Space-occupying marrow lesions Metastatic neoplasms, granulomatous
disease
– Infections of red cell progenitors Parvovirus B19 infection Unknown
mechanisms Endocrine disorders, hepatocellular liver disase
B. MORPHOLOGIC
• I. Microcytic, hypochromic
– iron deficiency anaemia, sideroblastic anaemia,
Thalassaemia, anaemia of chronic disorders
• II. Normocytic, normochromic
– acute blood loss, haemolytic anaemias, bone
marrow failure, anaemia of chronic disorders
• III. Macrocytic, normochromic
– deficiency of vitamin B12 or folic acid
IRON DEFICIENCY ANAEMIA
Iron metabolism
ABSORPTION
Ferric reductase
Ferric--------------------------------->Ferrous
1. Haem
DMT1
2. Non-haem
FERRIC
medicinal
ascorbicantacids,
acid
milk,citric
pancreatic
acid,
secretions,
amino acids,
phytates,
sugars, gastric
phosphates,
secretions FERRITIN FERROPORTIN
ethylene
and diamine AND
tetra-acetic
hydrochloric
acid HEPHAESTIN
(EDTA)
acid.
and
tannates contained
in tea.`
TRANSFERRIN
Transferrin
 Transport Protein For Iron In Blood

 Fully Saturated Transferrin = TIBC
300 - 350ug/dl Fe
 Normal Transferrin - 1/3 Filled With Iron
100 - 120ug/dl Fe (Serum Iron)

DISTRIBUTION
FERRITIN AND
HAEMOSIDERIN
30%
TRANSFERRIN
BOUND IRON HEMOGLOBIN
0.5% 65%
HAEM AND NON
HAEM ENZYMES
0.5%
MYOGLOBIN
4%
Etiopathogenesis
1. Increased blood loss
2. Increased requirements
3. Inadequate dietary intake
4. Decreased intestinal absorption.
Etiology
I. INCREASED BLOOD LOSS
1. Uterine e.g. excessive menstruation in reproductive years, repeated
miscarriages, at onset of menarche, post-menopausal uterine bleeding.
2. Gastrointestinal e.g. peptic ulcer, haemorrhoids, hookworm infestation,

cancer of stomach and large bowel, oesophageal varices, hiatus hernia,
chronic aspirin ingestion, ulcerative colitis, diverticulosis.
3. Renal tract e.g. haematuria, haemoglobinuria.
4. Nose e.g. repeated epistaxis.
5. Lungs e.g. haemoptysis.

II. INCREASED REQUIREMENTS
1. Spurts of growth in infancy, childhood and adolescence.
2. Prematurity.
3. Pregnancy and lactation.
III. INADEQUATE DIETARY INTAKE

1. Poor economic status.
2. Anorexia e.g. in pregnancy.
3. Elderly individuals due to poor dentition, apathy and
financial constraints.
IV. DECREASED ABSORPTION

1. Partial or total gastrectomy
2. Achlorhydria
3. Intestinal malabsorption such as in coeliac disease.
Sequence of events
1. Depletion of iron stores
– Iron absorption is increased
– serumiron level is still normal, although the serum ferritin will
have already fallen.
2. Iron - deficient erythropoiesis

– serum ferritin below 15 μ g/L and
– serum transferrin saturation to less than 15%,
– Increasing concentrations of serum transferrin receptor and red
cell protoporphyrin.
– haemoglobin, MCV and MCH may still be within the reference
range.
3. Iron deficiency anaemia
– red cells become obviously microcytic and
hypochromic
– MCV and MCH are reduced,
– reticulocyte count is low.
– The serum TIBC rises and the serum iron
falls, percentage saturation of Transferrin is usually
less than 10%.
Clinical features
• weakness, fatigue, dyspnoea on exertion, palpitations and
pallor of the skin, mucous membranes and sclerae.
• Older patients may develop angina and congestive cardiac

failure.
• koilonychia or spoon-shaped nails
• Atrophic glossitis
• Angular stomatitis
• dysphagia from development of thin, membranous webs at

the postcricoid area
Angular cheilitis
Angular cheilitis
Angular cheilitis & Glossitis
…Why?
Koilonychia in Iron def.
…Why?
Laboratory Findings
1.BLOOD PICTURE AND RED CELL INDICES.
2.BONE MARROW FINDINGS.
3.BIOCHEMICAL FINDINGS.
i) Haemoglobin.
ii) Red cells: hypochromic and microcytic, and there is

anisocytosis and poikilocytosis
Target cells, elliptical forms and polychromatic cells
iii) Reticulocyte count: normal or reduced but may be

slightly raised (2-5%) in cases after haemorrhage.
iv) Red cell indices:MCV (below 50 fl), MCH (below 15 pg), and
MCHC (below 20 g/dl).
v) Leucocytes. The total and differential white cell counts are

usually normal.
vi) Platelets. Platelet count is usually normal but may be slightly

to moderately raised in patients who have had recent
bleeding.
i) Marrow cellularity: increased due to erythroid hyperplasia
(myeloid-erythroid ratio decreased).
ii)Erythropoiesis:
– normoblastic erythropoiesis with predominance of small
polychromatic normoblasts (micronormoblasts).
– The cytoplasmic maturation lags behind so that the late
normoblasts have pyknotic nucleus but persisting
polychromatic cytoplasm
iii) Other cells. Myeloid, lymphoid and megakaryocytic cells are
normal in number and morphology.
iv) Marrow iron. Iron staining (Prussian blue reaction) carried

out on bone marrow aspirate smear shows deficient
reticuloendothelial iron stores and absence of siderotic iron
granules from developing normoblasts.
i) Serum iron (normal 40-140 ug/dl)
it is often under 50 ug/dl.
When below 15 ug/dl, marrow iron stores are absent.
ii) Total iron binding capacity (TIBC) (normal 250- 450 ug/dl)
rises to give less than 10% saturation (normal 33%).
iii) Serum ferritin (normal 30-250 ng/ml)
low indicating poor tissue iron stores.
iv) Red cell protoporphyrin (normal 20-40 ug/dl)
is very low as a result of insufficient iron supply to form haem.
v) Serum transferrin receptor protein (normal level 4-9 ug/L ).
which is normally present on developing erythroid cells and
reflects total red cell mass, is raised in iron deficiency due to
its release in circulation
Treatment
• 2 essential principles:
– correction of disorder causing the anaemia, and
– correction of iron deficiency.
• Oral iron therapy
– to correct the anaemia and to replenish the body
iron stores.
– The response to oral iron therapy is observed by
reticulocytosis which begins to appear in 3-4 days
with a peak in about 10 days.
• ii) Parenteral therapy.
– intolerant to oral iron therapy,
– The haematological response to parenteral iron
therapy is no faster than the administration of
adequate dose of oral iron but the stores are
replenished much faster.
– The adverse effects with iron dextran include
hypersensitivity or anaphylactoid reactions,
haemolysis, hypotension, circulatory collapse,
vomiting and muscle pain.

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Classification and Iron deficiency

 Transport Protein For Iron In Blood

100 - 120ug/dl Fe (Serum Iron)

2. Gastrointestinal e.g. peptic ulcer, haemorrhoids, hookworm infestation,

3. Renal tract e.g. haematuria, haemoglobinuria.

4. Nose e.g. repeated epistaxis.

5. Lungs e.g. haemoptysis.

III. INADEQUATE DIETARY INTAKE

IV. DECREASED ABSORPTION

2. Iron - deficient erythropoiesis

• Older patients may develop angina and congestive cardiac

• koilonychia or spoon-shaped nails

• dysphagia from development of thin, membranous webs at

ii) Red cells: hypochromic and microcytic, and there is

iii) Reticulocyte count: normal or reduced but may be

v) Leucocytes. The total and differential white cell counts are

vi) Platelets. Platelet count is usually normal but may be slightly

iv) Marrow iron. Iron staining (Prussian blue reaction) carried

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