Hemolytic anemia differential diagnosis: Difference between revisions

Latest revision as of 20:55, 26 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shyam Patel [2]

Overview

The differential diagnosis for hemolytic anemia is broad and includes a variety of conditions that affect red blood cells. Nutritional deficiencies and thalassemias are important components of the differentiation. Certain laboratory tests and physical exam features can help to distinguish these conditions. The treatment of these conditions are quite different, so it is important to distinguish hemolytic anemia from other causes of anemia or other conditions that present similarly.

Differentiating Hemolytic anemia from other Diseases

Characterisitc/Parameter	Etiology	Physical examination	Mean corpuscular volume	Laboratory abnormalities	Treatment	Other associated abnormalities
Hemolytic anemia^[1]	Drug-induced Immune-mediated Non-immune-mediated Infections Rheumatologic disease	Pallor Jaundice	Normocytic	Indirect hyperbilirubinemia Reticulocytosis Low haptoglobin Elevated LDH	Removal of offending agent Steroids Alternative immunosuppression	HELLP syndrome TTP CLL
Sideroblastic anemia^[2]	Alcoholism Lead poisoning Vitamin B6 deficiency Isoniazid Chloramphenicol	Pallor Weakness	Microcytic Normocytic	Ringed sideroblasts in bone marrow Low vitamin B6 level High lead level	Removal of offending medication High-dose vitamin B6 (up to 200mg daily) Avoidance of splenectomy Symptomatic transfusion support with iron chelation as needed	Myelodysplastic syndrome Myeloproliferative neoplasm Iron overload
Anemia of chronic disease^[3]	Chronic kidney disease Rheumatologic disease Cancer HIV Chronic infection; excess release of IL-1 and IL-6	Pallor Weakness	Normocytic	Elevated ESR and CRP Elevated hepcidin Low serum iron Low transferrin Elevated ferritin	Treatment of the underlying cause; erythropoiesis-stimulating agents Supportive red blood cell transfusions	Inflammatory bowel disease
Thalassemia^[4]	Genetic defect with alpha- or beta-globin production	Irritability Growth retardation Jaundice Hepatomegaly Splenomegaly	Microcytic	Abnormal hemoglobin electrophoresis (in beta-thalassemia)	Transfusion support Iron chelation Gene therapy if available	Extramedullary hematopoiesis
Iron deficiency anemia^[5]	Loss of iron from gastrointestinal blood loss or menstrual blood loss	Pallor Weakness Positive occult blood testing (if GI bleeding)	Microcytic	Low serum iron Elevated transferrin Low transferrin saturation Low ferritin	Intravenous or oral iron supplementation	Chronic blood loss
Erythropoietin deficiency^[6]	Chronic kidney disease or other renal dysfunction	Pallor Weakness Signs of chronic kidney disease	Normocytic	Low erythropoietin level	Epoetin alfa 50-100 units/kg 3 times weekly Darbepoietin 0.45 mcg/kg weekly or 0.75 mcg/kg every 2 weeks^[7]	Dialysis dependence Myelodysplastic syndrome
Vitamin B12 or folate deficiency^[8]	Pernicious anemia Diphyllobothrium latum infection Nutritional deficiency Crohn's disease of terminal ileum	Numbness Weakness Tingling Paresthesias	Macrocytic	Low vitamin B12 or folate level Megaloblastic anemia with hypersegmented neutrophils	Vitamin B12 1000mcg daily Folate 1mg daily	Neuropathy

Table legend: HELLP, hemolysis/elevated liver enzymes/low platelets; TTP, thrombotic thrombocytopenic purpura; CLL, chronic lymphocytic leukemia

References

↑ Hill QA (October 2015). "Autoimmune hemolytic anemia". Hematology. 20 (9): 553–4. doi:10.1179/1024533215Z.000000000401. PMID 26447931.
↑ Bottomley SS, Fleming MD (August 2014). "Sideroblastic anemia: diagnosis and management". Hematol. Oncol. Clin. North Am. 28 (4): 653–70, v. doi:10.1016/j.hoc.2014.04.008. PMID 25064706.
↑ Roy CN (2010). "Anemia of inflammation". Hematology Am Soc Hematol Educ Program. 2010: 276–80. doi:10.1182/asheducation-2010.1.276. PMID 21239806.
↑ Zainal NZ, Alauddin H, Ahmad S, Hussin NH (December 2014). "α-Thalassemia with Haemoglobin Adana mutation: prenatal diagnosis". Malays J Pathol. 36 (3): 207–11. PMID 25500521.
↑ Camaschella C (May 2015). "Iron-deficiency anemia". N. Engl. J. Med. 372 (19): 1832–43. doi:10.1056/NEJMra1401038. PMID 25946282.
↑ Yamazaki S, Souma T, Hirano I, Pan X, Minegishi N, Suzuki N, Yamamoto M (2013). "A mouse model of adult-onset anaemia due to erythropoietin deficiency". Nat Commun. 4: 1950. doi:10.1038/ncomms2950. PMID 23727690.
↑ Platzbecker U, Symeonidis A, Oliva EN, Goede JS, Delforge M, Mayer J; et al. (2017). "A phase 3 randomized placebo-controlled trial of darbepoetin alfa in patients with anemia and lower-risk myelodysplastic syndromes". Leukemia. 31 (9): 1944–1950. doi:10.1038/leu.2017.192. PMC 5596208. PMID 28626220.
↑ Hunt A, Harrington D, Robinson S (September 2014). "Vitamin B12 deficiency". BMJ. 349: g5226. PMID 25189324.

Template:WS Template:WH

[pmid26447931-1] Hill QA (October 2015). "Autoimmune hemolytic anemia". Hematology. 20 (9): 553–4. doi:10.1179/1024533215Z.000000000401. PMID 26447931.

[pmid25064706-2] Bottomley SS, Fleming MD (August 2014). "Sideroblastic anemia: diagnosis and management". Hematol. Oncol. Clin. North Am. 28 (4): 653–70, v. doi:10.1016/j.hoc.2014.04.008. PMID 25064706.

[pmid21239806-3] Roy CN (2010). "Anemia of inflammation". Hematology Am Soc Hematol Educ Program. 2010: 276–80. doi:10.1182/asheducation-2010.1.276. PMID 21239806.

[pmid25500521-4] Zainal NZ, Alauddin H, Ahmad S, Hussin NH (December 2014). "α-Thalassemia with Haemoglobin Adana mutation: prenatal diagnosis". Malays J Pathol. 36 (3): 207–11. PMID 25500521.

[pmid25946282-5] Camaschella C (May 2015). "Iron-deficiency anemia". N. Engl. J. Med. 372 (19): 1832–43. doi:10.1056/NEJMra1401038. PMID 25946282.

[pmid23727690-6] Yamazaki S, Souma T, Hirano I, Pan X, Minegishi N, Suzuki N, Yamamoto M (2013). "A mouse model of adult-onset anaemia due to erythropoietin deficiency". Nat Commun. 4: 1950. doi:10.1038/ncomms2950. PMID 23727690.

[pmid28626220-7] Platzbecker U, Symeonidis A, Oliva EN, Goede JS, Delforge M, Mayer J; et al. (2017). "A phase 3 randomized placebo-controlled trial of darbepoetin alfa in patients with anemia and lower-risk myelodysplastic syndromes". Leukemia. 31 (9): 1944–1950. doi:10.1038/leu.2017.192. PMC 5596208. PMID 28626220.

[pmid25189324-8] Hunt A, Harrington D, Robinson S (September 2014). "Vitamin B12 deficiency". BMJ. 349: g5226. PMID 25189324.

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@@ Line 1: / Line 1: @@
 __NOTOC__
-{{Hemolytic anemia}}
+[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Hemolytic_anemia]]
+{{CMG}}; {{AE}} {{shyam}}
-{{CMG}}
 ==Overview==
+The differential diagnosis for hemolytic anemia is broad and includes a variety of conditions that affect [[red blood cells]]. [[Nutritional deficiencies]] and [[Thalassemia|thalassemias]] are important components of the differentiation. Certain laboratory tests and physical exam features can help to distinguish these conditions. The treatment of these conditions are quite different, so it is important to distinguish hemolytic anemia from other causes of [[anemia]] or other conditions that present similarly.
 ==Differentiating Hemolytic anemia from other Diseases==
-*'''Ineffective hematopoiesis''' is sometimes misdiagnosed as hemolysis.
+{|
-** Clinically these conditions may share many features of hemolysis
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Characterisitc/Parameter
-** Red cell breakdown occurs before a fully developed red cell is released into the circulation.
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Etiology
-** Examples: [[thalassemia]], [[myelodysplastic syndrome]]
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical examination
-* [[Megaloblastic anemia]] due to deficiency in [[vitamin B12]] or [[folic acid]].
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Mean corpuscular volume
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Laboratory abnormalities
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Treatment
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other associated abnormalities
+|-
+! align="center" style="background:#DCDCDC;" |Hemolytic anemia<ref name="pmid26447931">{{cite journal |vauthors=Hill QA |title=Autoimmune hemolytic anemia |journal=Hematology |volume=20 |issue=9 |pages=553–4 |date=October 2015 |pmid=26447931 |doi=10.1179/1024533215Z.000000000401 |url=}}</ref>
+| align="left" style="background:#F5F5F5;" |
+* [[Drug-induced]]
+* [[Immune-mediated disease|Immune-mediated]]
+* Non-immune-mediated
+* [[Infections]]
+* [[Rheumatologic disease]]
+| align="left" style="background:#F5F5F5;" |
+* [[Pallor]]
+* [[Jaundice]]
+| align="left" style="background:#F5F5F5;" |
+* [[Normocytic anemia|Normocytic]]
+| align="left" style="background:#F5F5F5;" |
+* Indirect [[hyperbilirubinemia]]
+* [[Reticulocytosis]]
+* Low [[haptoglobin]]
+* Elevated [[LDH]]
+| align="left" style="background:#F5F5F5;" |
+* Removal of offending agent
+* [[Steroids]]
+* Alternative [[immunosuppression]]
+| align="left" style="background:#F5F5F5;" |
+* [[HELLP syndrome]]
+* [[TTP]]
+* [[Chronic lymphocytic leukemia|CLL]]
+|-
+! align="center" style="background:#DCDCDC;" |[[Sideroblastic anemia]]<ref name="pmid25064706">{{cite journal |vauthors=Bottomley SS, Fleming MD |title=Sideroblastic anemia: diagnosis and management |journal=Hematol. Oncol. Clin. North Am. |volume=28 |issue=4 |pages=653–70, v |date=August 2014 |pmid=25064706 |doi=10.1016/j.hoc.2014.04.008 |url=}}</ref>
+| align="left" style="background:#F5F5F5;" |
+* [[Alcoholism]]
+* [[Lead poisoning]]
+* [[Vitamin B6 deficiency]]
+* [[Isoniazid]]
+* [[Chloramphenicol]]
+| align="left" style="background:#F5F5F5;" |
+* [[Pallor]]
+* [[Muscle weakness|Weakness]]
+| align="left" style="background:#F5F5F5;" |
+* [[Microcytic anemia|Microcytic]]
+* [[Normocytic anemia|Normocytic]]
+| align="left" style="background:#F5F5F5;" |
+* Ringed sideroblasts in [[bone marrow]]
+* Low [[vitamin B6]] level
+* High [[lead]] level
+| align="left" style="background:#F5F5F5;" |
+* Removal of offending [[medication]]
+* High-dose [[vitamin B6]] (up to 200mg daily)
+* Avoidance of [[splenectomy]]
+* Symptomatic [[Blood transfusion|transfusion]] support with [[iron]] [[chelation]] as needed
+| align="left" style="background:#F5F5F5;" |
+* [[Myelodysplastic syndrome]]
+* [[Myeloproliferative neoplasm]]
+* [[Iron overload]]
+|-
+! align="center" style="background:#DCDCDC;" |[[Anemia of chronic disease]]<ref name="pmid21239806">{{cite journal |vauthors=Roy CN |title=Anemia of inflammation |journal=Hematology Am Soc Hematol Educ Program |volume=2010 |issue= |pages=276–80 |date=2010 |pmid=21239806 |doi=10.1182/asheducation-2010.1.276 |url=}}</ref>
+| align="left" style="background:#F5F5F5;" |
+* [[Chronic kidney disease]]
+* [[Rheumatologic disease]]
+* [[Cancer]]
+* [[HIV]]
+* Chronic infection; excess release of [[IL-1]] and [[IL-6]]
+| align="left" style="background:#F5F5F5;" |
+* [[Pallor]]
+* [[Weakness]]
+| align="left" style="background:#F5F5F5;" |
+* [[Normocytic anemia|Normocytic]]
+| align="left" style="background:#F5F5F5;" |
+* Elevated [[ESR]] and [[CRP]]
+* Elevated [[hepcidin]]
+* Low serum [[iron]]
+* Low [[transferrin]]
+* Elevated [[ferritin]]
+| align="left" style="background:#F5F5F5;" |
+* Treatment of the underlying cause; [[erythropoiesis]]-stimulating agents
+* Supportive [[Red blood cell transfusion|red blood cell transfusions]]
+| align="left" style="background:#F5F5F5;" |
+* [[Inflammatory bowel disease]]
+|-
+! align="center" style="background:#DCDCDC;" |[[Thalassemia]]<ref name="pmid25500521">{{cite journal |vauthors=Zainal NZ, Alauddin H, Ahmad S, Hussin NH |title=α-Thalassemia with Haemoglobin Adana mutation: prenatal diagnosis |journal=Malays J Pathol |volume=36 |issue=3 |pages=207–11 |date=December 2014 |pmid=25500521 |doi= |url=}}</ref>
+| align="left" style="background:#F5F5F5;" |
+* [[Genetic defect]] with alpha- or [[beta-globin]] production
+| align="left" style="background:#F5F5F5;" |
+* [[Irritability]]
+* [[Growth retardation]]
+* [[Jaundice]]
+* [[Hepatomegaly]]
+* [[Splenomegaly]]
+| align="left" style="background:#F5F5F5;" |
+* [[Microcytic]]
+| align="left" style="background:#F5F5F5;" |
+* Abnormal [[hemoglobin]] [[electrophoresis]] (in [[beta-thalassemia]])
+| align="left" style="background:#F5F5F5;" |
+* [[Blood transfusion|Transfusion]] support
+* [[Iron]] chelation
+* [[Gene therapy]] if available
+| align="left" style="background:#F5F5F5;" |
+* [[Extramedullary hematopoiesis]]
+|-
+! align="center" style="background:#DCDCDC;" |[[Iron deficiency anemia]]<ref name="pmid25946282">{{cite journal |vauthors=Camaschella C |title=Iron-deficiency anemia |journal=N. Engl. J. Med. |volume=372 |issue=19 |pages=1832–43 |date=May 2015 |pmid=25946282 |doi=10.1056/NEJMra1401038 |url=}}</ref>
+| align="left" style="background:#F5F5F5;" |
+* Loss of [[iron]] from [[gastrointestinal]] blood loss or [[menstrual]] [[blood loss]]
+| align="left" style="background:#F5F5F5;" |
+* [[Pallor]]
+* [[Weakness]]
+* Positive [[occult blood]] testing (if [[Gastrointestinal bleeding|GI bleeding]])
+| align="left" style="background:#F5F5F5;" |
+* [[Microcytic]]
+| align="left" style="background:#F5F5F5;" |
+* Low serum [[iron]]
+* Elevated [[transferrin]]
+* Low [[transferrin saturation]]
+* Low [[ferritin]]
+| align="left" style="background:#F5F5F5;" |
+* Intravenous or oral iron supplementation
+| align="left" style="background:#F5F5F5;" |
+* [[Blood loss|Chronic blood loss]]
+|-
+! align="center" style="background:#DCDCDC;" |[[Erythropoietin]] deficiency<ref name="pmid23727690">{{cite journal |vauthors=Yamazaki S, Souma T, Hirano I, Pan X, Minegishi N, Suzuki N, Yamamoto M |title=A mouse model of adult-onset anaemia due to erythropoietin deficiency |journal=Nat Commun |volume=4 |issue= |pages=1950 |date=2013 |pmid=23727690 |doi=10.1038/ncomms2950 |url=}}</ref>
+| align="left" style="background:#F5F5F5;" |
+* [[Chronic kidney disease]] or other [[renal dysfunction]]
+| align="left" style="background:#F5F5F5;" |
+* [[Pallor]]
+* [[Weakness]]
+* Signs of [[chronic kidney disease]]
+| align="left" style="background:#F5F5F5;" |
+* [[Normocytic anemia|Normocytic]]
+| align="left" style="background:#F5F5F5;" |
+* Low [[Erythropoietin|erythropoietin level]]
+| align="left" style="background:#F5F5F5;" |
+* [[Epoetin alfa]] 50-100 units/kg 3 times weekly
+* Darbepoietin 0.45 mcg/kg weekly or 0.75 mcg/kg every 2 weeks<ref name="pmid28626220">{{cite journal| author=Platzbecker U, Symeonidis A, Oliva EN, Goede JS, Delforge M, Mayer J et al.| title=A phase 3 randomized placebo-controlled trial of darbepoetin alfa in patients with anemia and lower-risk myelodysplastic syndromes. | journal=Leukemia | year= 2017 | volume= 31 | issue= 9 | pages= 1944-1950 | pmid=28626220 | doi=10.1038/leu.2017.192 | pmc=5596208 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28626220  }} </ref>
+| align="left" style="background:#F5F5F5;" |
+* [[Dialysis]] dependence
+* [[Myelodysplastic syndrome]]
+|-
+! align="center" style="background:#DCDCDC;" |[[Vitamin B12 deficiency|Vitamin B12]] or [[folate deficiency]]<ref name="pmid25189324">{{cite journal |vauthors=Hunt A, Harrington D, Robinson S |title=Vitamin B12 deficiency |journal=BMJ |volume=349 |issue= |pages=g5226 |date=September 2014 |pmid=25189324 |doi= |url=}}</ref>
+| align="left" style="background:#F5F5F5;" |
+* [[Pernicious anemia]]
+* [[Diphyllobothrium latum infection]]
+* [[Nutritional deficiency]]
+* [[Crohn's disease|Crohn's disease of terminal ileum]]
+| align="left" style="background:#F5F5F5;" |
+* [[Numbness]]
+* [[Weakness]]
+* [[Tingling]]
+* [[Paresthesias]]
+| align="left" style="background:#F5F5F5;" |
+* [[Macrocytic anemia|Macrocytic]]
+| align="left" style="background:#F5F5F5;" |
+* Low vitamin B12 or folate level
+* [[Megaloblastic anemia]] with  hypersegmented [[neutrophils]]
+| align="left" style="background:#F5F5F5;" |
+* [[Vitamin B12]] 1000mcg daily
+* [[Folate]] 1mg daily
+| align="left" style="background:#F5F5F5;" |
+* [[Neuropathy]]
+|}
-===Differentiating Drug-Induced Autoimmune Hemolytic Anemia from other Diseases===
+'''Table legend:''' [[HELLP]], hemolysis/elevated liver enzymes/low platelets; '''TTP''', thrombotic thrombocytopenic purpura; '''CLL''', [[chronic lymphocytic leukemia]]
-[[Penicillin]] in high doses can induce immune mediated [[hemolysis]]<ref name="pmid10815791">{{cite journal |author=Stroncek D, Procter JL, Johnson J |title=Drug-induced hemolysis: cefotetan-dependent hemolytic anemia mimicking an acute intravascular immune transfusion reaction |journal=Am. J. Hematol. |volume=64 |issue=1 |pages=67–70 |year=2000 |month=May |pmid=10815791 |doi= |url=http://dx.doi.org/10.1002/(SICI)1096-8652(200005)64:1<67::AID-AJH12>3.0.CO;2-Z}}</ref> via the [[hapten]] mechanism in which antibodies are targeted against the combination of [[penicillin]] in association with [[red blood cell]]s. Complement is activated by the attached antibody leading to the removal of [[red blood cell]]s by the spleen.
-The drug itself can be targeted by the [[immune system]], e.g. by [[IgE]] in a [[Type I hypersensitivity reaction]] to [[penicillin]], rarely leading to [[anaphylaxis]].
 ==References==
 {{Reflist|2}}
+[[Category:Hematology]]
+{{WS}}
+{{WH}}

Hemolytic anemia differential diagnosis: Difference between revisions

Latest revision as of 20:55, 26 February 2019

Overview

Differentiating Hemolytic anemia from other Diseases

References

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