Fast Five Quiz: Anemia

Emmanuel C. Besa, MD


February 20, 2019

The usefulness of skin pallor as a sign is limited by the color of the skin, the hemoglobin (Hgb) concentration, and the fluctuation of blood flow to the skin. The color of the palmar creases is a better indicator. If they are as pale as the surrounding skin, Hgb is usually less than 7 g/dL. Patients also may exhibit purpura, petechiae, and jaundice.

An acute drop in hemoglobin to a level of 7-8 g/dL is generally accepted to be symptomatic, whereas levels of 4-5 g/dL may be tolerated in chronic anemia, as the body is able to gradually replace the loss of intravascular volume. Physical findings mirror the underlying disease process and the duration from the onset. Patients with chronic anemia usually do not manifest typical physical findings associated with acute anemia.

Although iron-deficiency anemia is a laboratory diagnosis, a carefully obtained history can facilitate its recognition. The history can also be useful in establishing the etiology of the anemia and, perhaps, in estimating its duration. Iron-deficiency anemia often develops gradually, with small amounts of blood loss. Such persons may remain asymptomatic until their iron stores become sufficiently depleted to compromise red cell production and other tissues, at which point fatigue and other symptoms arise.

Clinical manifestations of hemolytic anemia may include:

  • In intravascular hemolysis, iron deficiency from chronic hemoglobinuria can exacerbate anemia and weakness

  • Tachycardia, dyspnea, angina, and weakness occur in patients with severe anemia, as cardiac function is sensitive to anoxia

  • Persistent hemolysis may result in the development of bilirubin gallstones; these patients may present with abdominal pain

  • Bronze skin color and diabetes occur in hematosiderosis; iron overload may occur in patients who have received multiple transfusions or have been administered iron therapy erroneously

  • Dark urine may result from hemoglobinuria

  • In addition to hemolysis, patients with TTP may experience fever, neurologic signs, renal failure, and thrombocytopenia

  • Leg ulcers may develop in patients with sickle cell anemia and other hemolytic disorders, as a result of decreased RBC deformability and endothelial changes

  • Venous thromboembolism occurs in 15% to 33% of adults with warm autoimmune hemolytic anemia, especially in the first few weeks after onset

Read more on the presentation of anemia.


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