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}} {{shyam}}
+{{CMG}}; {{AE}} {{shyam}}
 ==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==
-{| class="wikitable"
+{|
-! scope="col" | Characteristic/Parameter
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Characterisitc/Parameter
-! scope="col" | '''Hemolytic anemia'''
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Etiology
-! scope="col" | '''Sideroblastic anemia'''
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical examination
-! scope="col" | '''Anemia of chronic disease'''
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Mean corpuscular volume
-! scope="col" | '''Thalassemia'''
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Laboratory abnormalities
-! scope="col" | '''Iron-deficiency anemia'''
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Treatment
-! scope="col" | '''Erythropoietin deficiency'''
+! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other associated abnormalities
-! scope="col" | '''Vitamin B12 or folate deficiency'''
 |-
-! scope="row" | Etiology
+! 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>
-| Drug-induced, immune-mediated, non-immune-mediated, infections, rheumatologic disease
+| align="left" style="background:#F5F5F5;" |
-| Alcoholism, lead poisoning, vitamin B6 deficiency, isoniazid, chloramphenicol
+* [[Drug-induced]]
-| Chronic kidney disease, rheumatologic disease, cancer, HIV, chronic infection; excess release of IL-1 and IL-6
+* [[Immune-mediated disease|Immune-mediated]]
-| Genetic defect with alpha- or beta-globin production
+* Non-immune-mediated
-| Loss of iron from gastrointestinal blood loss or menstrual blood loss
+* [[Infections]]
-| Chronic kidney disease or other renal dysfunction
+* [[Rheumatologic disease]]
-| Pernicious anemia, Diphyllobothrium latum infection, nutritional deficiency, Crohn's disease of terminal ileum
+| 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]]
 |-
-! scope="row" | Mean corpuscular volume
+! 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>
-| Normocytic (80-100 femtoliter)
+| align="left" style="background:#F5F5F5;" |
-| Microcytic (<80 femtoliter) or normocytic (80-100 femtoliter)
+* [[Alcoholism]]
-| Normocytic (80-100 femtoliter)
+* [[Lead poisoning]]
-| Microcytic (<80 femtoliter)
+* [[Vitamin B6 deficiency]]
-| Microcytic (<80 femtoliter)
+* [[Isoniazid]]
-| Normocytic (80-100 femtoliter)
+* [[Chloramphenicol]]
-| Macrocytic (>100 femtoliter)
+| 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]]
 |-
-! scope="row" | Laboratory abnormalities
+! 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>
-| Indirect hyperbilirubinemia, reticulocytosis, low haptoglobin, elevated LDH
+| align="left" style="background:#F5F5F5;" |
-| Ringed sideroblasts in bone marrow; low vitamin B6 level, high lead level
+* [[Chronic kidney disease]]
-| Elevated ESR and CRP, elevated hepcidin, low serum iron, low transferrin, elevated ferritin
+* [[Rheumatologic disease]]
-| Abnormal hemoglobin electrophoresis (in beta-thalassemia)
+* [[Cancer]]
-| Low serum iron, elevated transferrin, low transferrin saturation, low ferritin
+* [[HIV]]
-| Low erythropoietin level
+* Chronic infection; excess release of [[IL-1]] and [[IL-6]]
-| Low vitamin B12 or folate level, megaloblastic anemia and hypersegmented neutrophils
+| 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]]
 |-
-! scope="row" | Physical exam
+! 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>
-| Pallor, jaundice
+| align="left" style="background:#F5F5F5;" |
-| Pallor, weakness
+* [[Genetic defect]] with alpha- or [[beta-globin]] production
-| Pallor, weakness
+| align="left" style="background:#F5F5F5;" |
-| Irritability, growth retardation, jaundice, hepatomegaly, splenomegaly
+* [[Irritability]]
-| Pallor, weakness, positive occult blood testing (if GI bleeding)
+* [[Growth retardation]]
-| Pallor, weakness, signs of chronic kidney disease
+* [[Jaundice]]
-| Numbness, weakness, tingling, paresthesias
+* [[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]]
 |-
-! scope="row" | Treatment
+! 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>
-| Removal of offending agent, steroids, alternative immunosuppression
+| align="left" style="background:#F5F5F5;" |
-| Removal of offending medication, high-dose vitamin B6 (up to 200mg daily), avoidance of splenectomy, symptomatic transfusion support with iron chelation as needed
+* Loss of [[iron]] from [[gastrointestinal]] blood loss or [[menstrual]] [[blood loss]]
-| Treatment of the underlying cause; erythropoiesis-stimulating agents, supportive red blood cell transfusions
+| align="left" style="background:#F5F5F5;" |
-| Transfusion support, iron chelation, gene therapy if available
+* [[Pallor]]
-| Intravenous or oral iron supplementation
+* [[Weakness]]
-| Epoetin alfa 50-100 units/kg 3 times weekly, darbepoietin 0.45 mcg/kg weekly or 0.75 mcg/kg every 2 weeks
+* Positive [[occult blood]] testing (if [[Gastrointestinal bleeding|GI bleeding]])
-| Vitamin B12 1000mcg daily, folate 1mg daily
+| 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]]
 |-
-! scope="row" | Other associated abnormalities
+! 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>
-| HELLP syndrome, TTP, CLL
+| align="left" style="background:#F5F5F5;" |
-| Myelodysplastic syndrome, myeloproliferative neoplasm, iron overload
+* [[Chronic kidney disease]] or other [[renal dysfunction]]
-| Inflammatory bowel disease
+| align="left" style="background:#F5F5F5;" |
-| Extramedullary hematopoiesis
+* [[Pallor]]
-| Chronic blood loss
+* [[Weakness]]
-| Dialysis dependence, myelodysplastic syndrome
+* Signs of [[chronic kidney disease]]
-| Neuropathy
+| 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]]
 |}
+'''Table legend:''' [[HELLP]], hemolysis/elevated liver enzymes/low platelets; '''TTP''', thrombotic thrombocytopenic purpura; '''CLL''', [[chronic lymphocytic leukemia]]
 ==References==

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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