LabMed
Low Hemoglobin or Hematocrit
Differential Diagnosis
Iron deficiency anemia
Thalassemia
Anemia of chronic disease
Acute blood loss
Lead poisoning
Anemia from folate or vitamin B12 deficiency
Sickle cell anemia
Hereditary spherocytosis or elliptocytosis
Hemoglobinopathies other than sickle cell disease
Autoimmune hemolytic anemia
Hemolytic disease of the newborn
Microangiopathic hemolytic anemia
Glucose-6-phosphate dehydrogenase (GGPD) deficiency
Pyruvate kinase deficiency
Paroxysmal nocturnal hemoglobinuria (PNH)
Sideroblastic anemia
Aplastic anemia
Don't Miss - Dangerous Situations
Acute blood loss resulting in a rapid decrease in hemoglobin or hematocrit can be life-threatening. If not promptly treated, many of the listed disorders in the list can result in clinically severe and possibly lethal outcomes.
Commonly Encountered Situations
More commonly encountered anemias
Iron deficiency anemia
Beta thalassemia minor
Anemia of chronic disease
Suggested Additional Lab Testing
Obtain hematocrit or hemoglobin measurement or RBC number to determine RBC mass.
Initial studies to assist in the evaluation of the type of anemia:
MCV (indicates cell size)
Peripheral blood smear examination
For the individual types of anemia, certain other tests are valuable in the diagnosis. These are listed in conjunction to the type of anemia.
Iron deficiency anemia
Microcytic hypochromic RBC with elliptocytes with a low reticulocyte production
Bone marrow deficient in iron is not usually needed to establish the diagnosis
Low serum ferritin, low serum iron, and elevated total iron binding capacity (TIBC) is typical.
Elevated RBC distribution width
Thalassemias
Microcytic RBCs with a variety of abnormalities on the peripheral smear, depending on the type of thalassemia and the clinical severity of the disease
Hemoglobin analysis may be abnormal and indicative of a certain type of thalassemia.
Patients with thalassemia often have normal to high serum ferritin, normal to low TIBC, normal to high serum iron, and normal RBC distribution width.
Anemia of chronic disease
RBCs are microcytic or normocytic, with an increase in size and shape variation.
Typical case: normal to elevated serum ferritin, low serum iron, low TIBC, increased sed rate
Anemia from acute blood loss
Reticulocyte production index is high.
RBC size and hemoglobin content reflect RBC status prior to the acute blood loss.
Anemia from folate or vitamin B12 deficiency
RBCs are macrocytic with macro-ovalocytes and low reticulocyte production.
For folate deficiency specifically, there is low or normal serum folate with low RBC folate and hypersegmented PMNs in peripheral blood smear.
For vitamin B12 deficiency, along with low serum vitamin B12, there may be elevated homocysteine and methylmalonic acid (MMA) levels indicative of pernicious anemia.
Anti-parietal cell antibodies and/or anti-intrinsic factor antibodies may be present in cases with pernicious anemia; hypersegmented PMNs can be found in the peripheral blood smear.
Sickle cell anemia
Sickle cells are found in sickle cell disease but not in sickle cell trait (under normal oxygen conditions).
Signs of hemolysis are found, including low haptoglobin, elevated unconjugated bilirubin, and increased LDH.
Hemoglobin analysis shows hemoglobin SS for sickle cell disease and hemoglobin AS for sickle cell trait.
Screening tests for the presence of sickle hemoglobin, usually based on the altered solubility of sickle hemoglobin, are positive in both sickle cell disease and sickle cell trait.
Anemias from hereditary spherocytosis or elliptocytosis
Reticulocyte production is high with the presence of spherocytes or elliptocytes and a prominent hemolytic component for hereditary spherocytosis in particular.
In hereditary spherocytosis, there is increased osmotic fragility of RBCs in the presence of a negative direct antiglobulin test.
Anemias from hemoglobinopathies other than sickle cell disease
There are hundreds of common and uncommon hemoglobin variants.
Hemoglobin electrophoresis can identify most of the clinically significant abnormal hemoglobins.
Hemolytic disease of the newborn
Reticulocyte production index is high with a prominent hemolytic component: low haptoglobin, elevated unconjugated bilirubin, and elevated LDH.
Mother tests Rh negative and baby tests Rh positive, with a positive direct antiglobulin test on the RBCs of the baby and an antibody to offspring RBCs in the mother's blood.
Microangiopathic hemolytic anemia
Peripheral smear shows fragmented RBCs (schistocytes) with prominent signs of hemolysis.
G6PD deficiency
Reticulocyte production index is high, with a prominent hemolytic component.
Test for RBC G6PD shows a deficiency.
Heinz bodies in the RBCs can be identified on the peripheral smear.
Pyruvate kinase deficiency
Reticulocyte production index is high, with a prominent hemolytic component.
An assay to quantitate RBC pyruvate kinase reveals the deficiency.
PNH
Prominent hemolytic component, with low platelet and WBC (especially granulocyte) counts
Flow cytometry of granulocytes and RBC showed decreased CD 55 and CD 59.
RBC populations in sideroblastic anemia are normochromic and hypochromic.
Increase in ringed sideroblasts in a normoblast population on bone marrow biopsy
Elevated serum ferritin
Aplastic anemia
Reticulocyte production index is low, with a hypocellular bone marrow from a production failure in all blood cell lines
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