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Acquired Anemia


Microcytic anemia: DDx TICS: thalassemia, iron deficiency, chronic inflammation, sideroblastic
Macrocytic anemia suggests: folate or B12 deficiency
Anemia: RBC production problem (vs destruction problem) distinguished by: Retic count; hypoproliferative = retic low (<2); hyper = retic high (>3)
Causes of Fe deficiency anemia Poor diet/intake; decreased absorption (atrophic gastritis, GI surg, sprue, achlorhydria); increased loss (GI bleed, menorrhagia, neoplasm); increased requirements (PG, lactation)
Anemia of chronic dz: lab pattern Likely microcytic. Low Fe, low ferritin, high TIBC. Low erythropoietin
Glossitis, peripheral neuropathy (stocking-glove paresthesias); MCV 110-140; low retic, hyperseg PMNs, high methylmalonic acid = B12 def
Triad: anemia, splenomegaly and jaundice = Hereditary spherocytosis
Fe deficiency anemia tx ferrous sulfate 325mg tid
pernicious anemia tx lifelong B12 supplementation
Hx HTN, nephrotic syndrome, CRF or Renal insufficiency; do CBC: Anemia
PICA, Pregnant & fatigue, Menstruation; cheilosis: Fe Deficiency Anemia
Anemia after colectomy, partial gastrectomy; glossitis, decreased vibratory sensation = B12 or Pernicious anemia
G6PD + Quinidine, Nitrofurantoin, Sulfa, fava beans => Hemolytic anemia
Fatigue, weakness, low fever, purpura, pallor, gingival bleeding; low retic; no HSM = Aplastic anemia
folate def is ______ anemia; erythropoeisis is due to lack of: megaloblastic anemia; lack of methylation
sideroblastic anemia tx: pts do not respond to: EPO; tx underlying cause, poss txn/ chelation
sideroblastic anemia causes myelodysplasia, chronic EtOH, Pb tox
N/N anemia pathophysiology hepcidin upregulation in response to inflammatory mediators
N/N anemia etiology organ fail d/t systemic dz (renal, endo, thy, liver), or impaired marrow fn (2/2 chronic infxn, aplastic anemia, PRCA)
macro anemia 2/2 folate def: S/S glossitis, no neuro sx
macrocytic anemia 2/2 B12 def S/S glossitis, pale icterus, GI sxs; neuro sxs (posn, vib sense, stocking-glove paresthesia, ataxia)
B12 def causes No. 1 pernicious anemia; veganism, blind loop syndrome, gastric surg, panc insuff, Crohn dz
Most common cause of anemia worldwide Fe def anemia
HYPOproliferative anemia due to: Marrow damage, Fe def, dec'd stimulation
HYPERproliferative anemia due to: BM failure to compensate for blood loss or RBC destruction
Enzyme disorder: adequate Fe but can't get it into Hgb; Fe accumulates in ? Sideroblastic anemia; in RBC mitochondria
Causes of B12 def Diet (vegans); malabsorption: inadequate intrinsic factor prodn (70%), terminal ileum dz (sprue, Crohns), tapeworm, drugs
B12 def vs folic acid def B12: meat/dairy; to 5000 mcg in liver (3 yrs); Folic acid: fruit/veg; 5-20 mg stored (few mos)
Acquired stem cell disorder making RBC membrane prone to lysis by complement PNH
In PNH, there is increased risk of: leukemia/myelofibrosis
Acquired hemolytic anemia due to IgM autoantibody Cold agglutinin dz
Evans syndrome (immune thrombocytopenia) AIHA
Anemia: morphology relative to MCV <80 = microcytic; 80-100 = normo; >100 = macro
Anemia: RBC production problem (vs destruction prob) distinguished by: Retic count; hypoproliferative = retic low (<2); hyper = retic high (>3)
Hypoproliferative anemia due to: Marrow damage, Fe deficiency, decreased stimulation
Hyperproliferative anemia due to: BM failure to compensate for blood loss or RBC destruction
Most common cause of anemia worldwide Fe deficiency anemia
Macrocytic anemias Folic acid def; B12 def
Tx B12 def Replacement tx: IV B12; frontload dose
B12 def vs folic acid def B12: meat/dairy; to 5000 mcg in liver (3 yrs); Folic acid: fruit/veg; 5-20 mg stored (few mos)
Causes folic acid def Inadeq intake (ETOH, teens, elder); inc’d req: PG, malignancy, anemias, hemodialysis; Malabsorption [sprue, drugs (phenytoin, barbituates)]; Impaired metabolism (ETOH, methotrexate)
Folic acid def findings Malnourished; glossitis, cheilitis; NO neuro S/S; RBC folate <150 ng/mL
PRCA is contracted: Acquired or idiopathic
Autoimmune dx mediated by T lymphocytes or (rarely) IgG antibody against erythroid precursors PRCA (pure red cell aplasia)
Poss causes include thymoma, solid tumors, SLE, RA, HIV/hep, phenytoin PRCA
PRCA findings Normal lab except low retic; severe anemia S/S
PRCA Tx Stop all meds; poss thymoma resection; IV Ig
Due to BM failure (injury or suppression); pancytopenia Aplastic anemia
Causes of aplastic anemia Idiopathic (50-65% ; likely autoimmune); Phenytoin, sulfonamides; chemotherapy, radiotherapy; benzene, solvents, insecticides; hep, HIV, EBV; PG, SLE, GVHD; Hereditary (rare): Fanconi’s anemia
Aplastic anemia findings NO hepatosplenomegaly; pancytopenia (purpura, pallor, petechiae); low retic; hypocellular BM
Aplastic anemia: diff dx from: 1-MDS; 2-hairy cell; 3-normo 1=abn cells; 2=splenomegaly & abn lymph cells; 3=SLE, hypersplenism, dissem'd infxn
Aplastic anemia tx Family HLA typing; supportive tx (txn/infxn); immunosuppn; GF; BM txplant
Aplastic anemia prognosis Untx'd = fatal; HLA matched txplant: 60-90% cure; ATG tx: partial remission 60-80% (1/3 relapse & 20-50% MDS)
Hemolytic anemias: intrinsic vs extrinsic Intrinsic = prob w/membrane, z defects, hgb (usu hereditary); Extrinstic = autoimmune, drugs or mechanical trauma (often acquired)
Hemolytic anemia lab findings Low haptoglobin; high LDH, indirect bili (not >4-5mg/dL unless underlying liver dz), retic; hemoglobinuria; stable or falling hgb
Workup to distinguish etiology of Hemolysis Clinical & FH; Direct Coombs; Peripheral blood smear; morpho (Heinz bodies, sickle cells, parasites); Hgb electrophoresis
Acquired stem cell disorder making RBC membrane prone to lysis by complement PNH
PNH findings Episodic hemolytic anemia; Venous thrombosis; Deficient hematopoiesis -> pancytopenia; reddish-brown urine; Hemoglobinuria, esp. first morning urine
Episodic hemolytic anemia; Venous thrombosis; Deficient hematopoiesis -> pancytopenia ... indicate: PNH
In PNH, increased risk of: leukemia/myelofibrosis
PNH tx Tx Fe def; prednisone for hemolysis; BM txp if severe
Acquired disorder which IgG autoantibody formed that binds to RBC membrane AIHA (autoimmune hemo anemia)
AIHA: ___% are idiopathic; seen in ___ 50% ; lupus, NHL, CLL
AIHA findings Pos coombs test; severe anemia (6-10); high retic & ind bili; spherocytes & NRBC; Evans syndrome (immune thrombocytopenia)
AIHA tx Prednisone 1 mg/kg/d; splenectomy if fail; Rituximab, Danazol, IVIG if fail; avoid txn
Acquired hemolytic anemia due to IgM autoantibody Cold agglutinin dz
Cold agglutinin dz causes Idiopathic or neoplasm or post-infxn (Monoclonal gammopathy, mono, mycoplasma)
Cold agglutinin dz findings Mottled/numb fingers/toes; anemia is rarely severe; mild reticulocytosis; spherocytes; Pos Coombs for complement; Pos cold agglutinin test; Chilled blood will look clumped on slide
Cold agglutinin dz tx Symptomatic, avoid cold; poss Rituximab or immunosupp or plasmapheresis; no splenectomy/steroid
Evans syndrome (immune thrombocytopenia) AIHA
Neutropenia findings Stomatitis; fever; poss septicemia, pneumonia and cellulitis
Neutropenia tx DC potl causative agents; tx infxns; poss GF (G-CSF) for severe
Anemia: no hepatosplenomegaly aplastic anemia
Anemia without neuro Sx/Sx suggest: Folic acid def
Aplastic anemia sx/sx do not include: hepatosplenomegaly
Dark blue-gray line along gingival border may be sx of: lead poisoning
most common anemia of hospitalized patients = anemia of chronic disease
Anemia of chronic disease etiologies Chronic inflammatory conditions: infection, IBD, RA, malignancy. CKD
Macrocytic anemia etiologies (PALER) Pernicious anemia. Lung (COPD). EtOH (AST > ALT 2x, increased GGT). Rx (antiseizure meds, methotrexate)
Elevated retic count may be due to: Hemolytic anemia; acute blood loss; response to therapy (within 5-7days)
Low or Normal retic count may be due to: All other forms of anemia (other than hemolytic or acute blood loss)
Created by: Abarnard
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