Chapter 40

Standard textbooks of hematology and UpToDate® were used as general reference materials. Recent advances in hematology were accessed on PubMed.

Anemia is defined as the reduction in circulating erythrocytes as compared to age- and sex-adjusted ranges of normal. These ranges were developed since the advent of automated blood cell analysis which has allowed clinical laboratories, large and small, to screen large amounts of blood samples. However, these quantitative results must be combined with the results of an accurate history and physical examination, review of the peripheral blood smear and other, more specific, laboratory tests so that an accurate diagnosis for the cause of anemia is found. Once the diagnosis is made, then an appropriate treatment plan can be instituted so that the anemia is corrected and, ultimately, the patient’s clinical condition is improved.

In both the inpatient and outpatient settings, anemia is one of the more commonly encountered clinical conditions affecting both children and adults. With respect to the ages at which anemia is encountered, differential diagnoses are often disparate. By and large, anemia in a child is generally because of congenital causes, whereas in adults, anemia is caused by an acquired etiology. In this chapter, we will evaluate some of the more common explanations of anemia, along with their treatments, as well as examine how laboratory measurements may facilitate the diagnosis and subsequent evaluation of therapies.

Signs and symptoms of anemia may be nonspecific, such as the noting of fatigue or dyspnea on exertion, or quite specific, such as koilonychia (“spoon nail deformity”) or the presence of blood in stools. In general, all aspects of a detailed history and physical examination are important to understanding the cause of anemia. On review of systems, fatigue, shortness of breath or dyspnea on exertion, hematemesis, hemoptysis, hematochezia, and reduced mental concentration, among others, may be associated with an underlying deficiency in erythrocytes and oxygen delivery. Medical or surgical histories may point to a diagnosis (e.g., diabetes mellitus and subsequent decreased renal production of erythropoietin or a history of gastric or intestinal resection). For women who are premenopausal, noting the frequency and severity of menstruation can be helpful. Dietary factors, such as veganism or sprue, may be associated with nutritional deficiencies that lead to the development of anemia. Family history is invaluable in the evaluation of children with anemia, as congenital causes dominate the diagnoses in this age group. Occupational and recreational exposures may point to a toxin (e.g., lead) or infectious agents (e.g., mononucleosis or HIV) that result in anemia. Along with this, an accurate list of prescribed and over-the-counter medications may provide clues as well.

On physical examination, pallor of the skin or mucosal membranes is very common, although nonspecific. Likewise, tachycardia and/or systolic ejection murmurs may be present, although nondiagnostic (unless there is a history of valvular replacement). More specific findings may be related to an underlying etiology, such as koilonychia or angular cheilitis ...

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