Anemia: Overview

00:01 This is an overview that you want to pay attention to when you're dealing with anemia.

00:06 Our doing here is the overview.

00:08 And what we will do later on is then divide and dive into each one of these categories of different types of anemias.

00:16 Is that clear? So for example, under microcytic anemia, which we will take on at first.

00:21 First and foremost, you pay attention to MCV being less than 80.

00:25 And under microcytic anemia, we will then walk through the differentials that you see here.

00:29 And these include your iron deficiency, anemia of chronic disease, sideroblastic, and also your thalassemia.

00:36 And I will tell you how to approach this when the time is right, because really, what you're doing here is hemoglobin.

00:43 And so therefore, you divide for pathologic purposes, to make your life easier with diseases.

00:48 You'll divide into heme and globin.

00:50 Do that for me, and you'll be in good shape.

00:52 And when we deal with heme, there are a lot of things that we need to talk about there with biochemistry.

00:56 Biochemistry, is you should be thinking about the porphyria pathway.

01:00 And if you're not familiar with it, perhaps it would be a good time for you to take a look at the porphyria pathway with heme synthesis.

01:05 Whereas, your globin would then be the genes.

01:08 You don't have control over genes, that's something that you're given.

01:10 And we'll talk about the alpha, beta, gamma, and delta, and such.

01:14 Under macrocytic, we'll divide this into megaloblastic and nonmegaloblastic.

01:21 And that becomes really important for us.

01:23 So for example, the megaloblastic here that are often tested, in folate deficiency and vitamin B12 deficiency.

01:32 There are a couple others that we have to address as well under megaloblastic.

01:35 And those include Lesch-Nyhan syndrome.

01:37 And then you also have Orotic aciduria.

01:39 Alright, so those are things that are have shown up are showing up, and will show up.

01:44 Stick with me here, and I will constantly feed you current information constantly.

01:50 But what I'm saying is, "Dr. Raj, I thought megaloblastic was always macrocytic." That is true. Okay.

01:55 But the macrocytic don't always doesn't have to be megaloblastic.

01:58 Really? I thought they were interchangeable.

02:00 No, they're not. Please pay attention.

02:04 So you can have macrocytic megaloblastic.

02:06 or you can have macrocytic, nonmegaloblastic.

02:09 Is that clear? So what's the difference? The difference is the following: What you're measuring here with macrocytic is going to be for the most part, the size of that RBC in serum.

02:19 Is that clear? That to you means a circulation.

02:22 So therefore, if you're thinking about folate and vitamin B12 deficiency, then don't you need that for proper DNA synthesis? Either pyrimidine or purine? Sure.

02:32 So if you don't have proper folate and B12 available, how in the world can you properly form normal RBCs? You cannot.

02:41 Not only can you not form proper RBCs, you have, many, many, many, many other issues, including your WBCs and such as well.

02:48 Would you please tell me what an immature cell is called in your bone marrow? Oh, I see what you're getting at.

02:57 That's a blast, isn't it? There you go.

02:59 So whenever you have a blast this to you should mean that you have a problem in the bone marrow.

03:04 Is that clear? Whereas, if you take a look at the category of nonmegaloblastic, it's still macrocytic. So what does that mean? MCV greater than 100.

03:15 Now you can be more technical in terms of dividing megaloblastic and nonmegaloblastic with 110 femtoliters, but that's a bit much right now.

03:22 But the under nonmegaloblastic though, this would mean that from the bone marrow, there was no problem.

03:27 Not B12. Not folate deficiency.

03:29 Under nonmegaloblastic you have things like liver disease, alcohol use disorder, and reticulocytosis.

03:36 Alright, so, there was a things that I will mention, but in terms of going in detail, if I were you, I'd be paying attention to alcohol.

03:44 Alcohol does a lot of things.

03:45 "Dr. Raj, I thought alcohol would then consume your folate." Yes, it does. So be smart, though.

03:51 So if your alcoholic has megaloblastic anemia, it most likely was due to? There you go, folate deficiency.

03:58 See what I'm getting at? What else could alcohol do? We'll talk.

04:03 Alcohol could also result in a very common form of acquired type of a sideroblastic anemia.

04:08 And what's sideroblastic anemia? Take a look.

04:11 Microcytic.

04:11 You see this, okay.

04:12 So these are things that I'll be doing you're setting up an overview.

04:15 I am spending a little bit of time here so that you keep these arms and branches of your anemias all well organized, shall we say? Okay, then what do we do? Divide our normocytic.

04:27 So, normocytics are going to be the largest of all of the anemias.

04:33 So, be careful, just because you find an MCV, take a look between 80-100 all it does is put you in the category of anemia.

04:43 Normocytic specifically.

04:45 And your patient is going to what? Come with? Fatigue and tiredness, right? That's all he or she knows.

04:51 And then you will then take the proper history, and then you will figure out and the way that you want to do this, ladies and gentlemen, all I'm doing here is setting up the organization pattern is divided into nonhemolytic and hemolytic.

05:03 So I would like for you to take a look at the category in the far left here.

05:07 And those are all nonhemolytics.

05:09 What does that mean? For the most part, as a rule of thumb, for example, let's say that you have a patient has Parvovirus B19.

05:17 Reflex.

05:18 Your thinking aplastic anemia, correct? Maybe your patient is taking chloramphenicol.

05:23 Maybe your patient is receiving chemotherapy.

05:26 Maybe, maybe, the kidneys got damaged.

05:29 What does all all these have in common? Kidneys got damaged, no erythropoietin.

05:34 No erythropoiesis. Oh, okay.

05:36 Next, chemotherapy.

05:37 Bone marrow shut down, suppression, oh...

05:40 no bone marrow function, okay.

05:41 Parvovirus B19.

05:43 It hits the bone marrow, what happens? Aplastic.

05:46 Okay. You see my point? If you're never able to properly form your RBCs from the bone marrow, how in the world can you possibly destroy them? You cannot.

05:57 So therefore, these are nonhemolytic.

05:58 Are we clear? Now, you tell me where the grave site is for an RBC.

06:03 The grave site for an RBC...

06:05 Good. The spleen.

06:06 And so therefore, all the two categories that you see here, the one in the middle, and the one on the right.

06:11 For you, those are all hemolytics.

06:14 And we walked through all of these in detail.

06:17 So all of these will at some point, then end up at the spleen, or maybe even perhaps intravascular.

06:22 But guaranteed, there's going to be destruction of that RBC because there was no problem with the bone marrow.

06:27 Hence, we call it hemolytic anemia.

06:30 Before I move on, there was one other concept that I have to introduce now.

06:34 And then we'll go into a greater detail when the time is right.

06:37 And that is going to be what's known as what current a practice called? Reticulocyte Production Index, or RPI.

06:42 It's a concept that you want to know.

06:44 And really, it comes down to what's known as corrected reticulocytes.

06:48 And luckily, now there is calculations and such, you can just plug it into your computer, or app, or whatever.

06:54 And they will tell you the proper RPI.

06:56 But before you go here though, you must understand what's happening.

06:59 Can I ask us something? If the bone marrow, which is the first column, or first category, normocytic here has been shut down, I'm not able to produce any RBCs, alright.

07:11 So, if you're not able to produce any RBCs, we're able to produce any type of reticulocytes.

07:19 What is a reticulocyte? We'll go into detail about reticulocyte.

07:22 It's the fact that it's an immature RBC.

07:24 The point is this, if you're bone marrow has been shut down, there is no way that you can produce any reticulocyte.

07:30 So what do you expect your RPI or corrected reticulocyte count to be? Know the concept first, decreased.

07:37 Good? So here, you're thinking less than 3%.

07:41 Whereas, the RBCs are being destroyed in mass by the spleen or intravascular.

07:48 So now what happens? Bone marrow has to turn turn turn turn, alright? You put it into overdrive.

07:54 Overdrive.

07:55 And what are you turning out? The bone marrow is spitting out reticulocytes.

08:01 Clear? So therefore, you'd expect there to be an increase in reticulocytes.

08:08 We call this greater.

08:10 We mean, actual value greater than 3%.

08:12 And that will be for any hemolytic.

08:14 So now, well, you ask more questions later on, but understand the concept.

08:18 So here's a nice little overview.

08:20 Not to worry.

08:21 Obviously, we're going to repeat, repeat, repeat, repeat everything that I said.

08:25 But hopefully, you have now developed a proper organization pattern.