Anemia: Initial approach

Acute or chronic? Acute severe haemolysis e.g. due to bartonellosis, haemolytic-uraemic syndrome, sickle cell crisis, G6PD-deficiency with a triggering factor or blackwater fever (hyperhaemolysis as a complication with Plasmodium falciparum). Acute internal blood loss is sometimes not immediately obvious (e.g. rupture of the spleen, ruptured ectopic pregnancy, pelvic fracture). If there has not been sufficient time for fluid redistribution, the extent of blood loss can easily be underestimated.

Transfusion necessary or not? Blood should be regarded as a potentially dangerous medicament. It is important to be aware of the (non) safety of a blood transfusion (hepatitis B, C, D, malaria, treponematosis, HIV, Chagas’ disease).

Further work up

The physical examination should also pay attention to the following points:

• Fever or afebrile?

• Koilonychia, icterus (jaundice), rhagades, glossitis, dysphagia (e.g. due to a Plummer-Vinson oesophageal web. This is however rare).

• Splenomegaly? Hypersplenism in kala azar, portal hypertension or tropical splenomegaly syndrome can cause anaemia or pancytopenia.

In cases of haemolytic anaemia one should suspect , among other things:

• malaria (frequent)

• mononucleosis can be accompanied by acute haemolysis, usually limited in severity.

• Genetically determined haemolytic diseases. G6PD deficiency can induce severe haemolysis when a predisposing factor is present. This situation is frequent in individuals originating from the Mediterranean. Children with beta-thalassaemia major have a very pronounced anaemia with gross splenomegaly. Diagnosis of sickle cell anaemia will usually present no problems. Hereditary spherocytosis can cause enlargement of the spleen, gallstones and chronic haemolysis .

• Autoimmune haemolytic anaemia. This can be due to certain medications (e.g. quinine, alpha-methyldopa).

• Paroxysmal cold haemoglobinuria is a very rare disease described as complication of tertiary syphilis.

• Bartonellosis (rare)

• Babesiosis (rare)

• Certain types of snake venom

• Rarely due to spider bites such as Loxosceles sp, brown recluse spider. Nausea, vomiting, fever, general malaise, local irritation or cutaneous necrosis and haemolytic anaemia can occur. There can be severe consequences in children.

• Hypersplenism

• Haemophagocytosis

Category: Pathology Notes