2 anemias - visão geral
DESCRIPTION
Anemias - Visão Geral Aula 2 da Disciplina de Hematologia Curso de Medicina Faculdades IngáTRANSCRIPT
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HEMATOLOGIA - AULA 2:
ANEMIAS(VISÃO GERAL)
Dr Francismar Prestes Leal
Hematologista
Uningá
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O que é Anemia?
• Não é doença
• É sinal / sintoma de doença
• Necessário buscar a causa
• O diagnóstico final nem sempre é fácil
• Tratamento também depende da causa
• Muito frequente e importante na prática
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Definição de Anemia
• Redução da quantidade de Hb / Hemácias circulantes (massa) e do transporte de O2
• Mais comum das desordens hematológicas
• Quase sempre secundária
• Fundamental:
– Avaliar, buscar causa e tratar
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Medula Óssea
• Esterno, bacia, ossos longos, vértebras
• Células pluripotentes
• Relação E/L é de 1/3
• Gordura medular
www.drsarma.in
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Eritropoese
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Hemácias Normais
• Discos bicôncavos
• Sem núcleo
• Citoplasma róseo (Hb)
• Palidez central (1/3)
• Cerca de 7,5 / 2,5 µm
• 100-120 dias de vida
• “Viaja” 250 km
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Hemoglobina (Hb)
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Passos da Abordagem
• História e Exame Físico
• Hemograma:
– Hb, Ht, Hemácias: Quantidade
– VCM, HCM, CHCM: Tamanho, Cor
– RDW: Índice de Anisocitose
• Reticulócitos:
– Contagem/ Índice de Produção (IPR)
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Passos da Abordagem• Exame do sangue periférico (Extensão)
– Microcitose: Ferritina, IST (TIBC)• Eletroforese de Hemoglobina?
– Macrocitose: Vitaminas B12 e B9
– Normocitose: Doença Crônica?
– Hemólise: Estudos Adicionais
– Presença de inclusões, parasitas etc.
• Estudo da Medula Óssea?
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História da Anemia
• O que está sentindo?
• Há quanto tempo?
– Aguda ou Crônica?• Pistas:– Evidência de sangramento– Estabilidade hemodinâmica (SV)– Hemogramas prévios
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Dados Clínicos Importantes
www.drsarma.in
Avaliar Sempre
Palidez cutâneo-mucosa
Pele seca, descamativa
Macroglossia, glossite, língua lisa
Úlceras orais ou retais
Icterícia, púrpura, telangiectasias
Adenopatia, organomegalia
Taquipnéia, dispnéia
Taquicardia, sopros
Sangramentos evidentes ou ocultos
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Anemia?Documente
www.drsarma.in
• Composição do sangue:
– Plasma (57%)
– Leucócitos (Buffy Coat; 1%)
– Hemácias/Hematócrito (42%)
– Hemoglobina (Hb; g/dL)– EUA <13,5/12,5» OMS <12,5/11,5 » Índia <12/11
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Anemia?Documente
www.drsarma.in
• Hemácias 3,5 a 5,5 milhões/mm3 (A)
• Hemoglobina 11/12 a 17/18 g/dL (B)
• Hematócrito 36/38 a 50/52% (C)
Regras: A x 3 = B; B x 3 = C
VCM C ÷ A x 10 = 80-100 fL
HCM B ÷ A x 10 = 28-32 pg
CHCM B ÷ C x 100 = 31-35%
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Tipos/Causas de AnemiaRedução da Produção de Hemácias
(Hipoprodução)Hipoproliferação
Aumento da Destruição de Hemácias(Redução da Sobrevida de Hemácias)
Hemólise
Perda de Hemácias(Aguda ou Crônica)
Sangramento
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Anemia HipoproliferativaFalha
Maturação
Nuclear Citoplasmática
Anemia Megaloblástica
Falha Síntese de DNA
Deficiência Folato/B12 Heme Globina
Outra
TalassemiaFe Porfiria
Anemia
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Anemia: Reticulócitos?
Reticulócitos– Hemácias jovens (0,5-2% das Hemácias)
– Resposta medular• Baixa (<0,5%): Hipoproliferação• Alta (>2%): Hemólise ou Sangramento
– Restos nucleares /organelas
(RNA pode ser corado)
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Anemia: Reticulócitos
Supravital Leishman
www.drsarma.in
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Anemia: Reticulócitos
Reticulócitos
• Cerca de 10 µm
• Sem núcleo definido
• Retículo de RNA de
Cor Azul Escura
• Citoplasma Azul Claro
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Índice de Produção de Reticulócitos (IPR)
Exemplo de Cálculo:
• Hb 7,5 g/dL (g%) e Reticulócitos 9%
• Correção para a anemia:
9 x (7,5 ÷ 15) = 9 x 0,5 = 4,5%
• Correção para a meia-vida:
4,5 ÷ 2 = 2,25% (IPR)
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Índice de Produção de Reticulócitos (IPR)
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Próximo Passo:Caracterizar Hemácias
• VCM
Tamanho das Hemácias
• HCM/CHCM
Conteúdo Hb das Hemácias
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Próximo Passo:Caracterizar Hemácias
Microcítico
< 80 fL
VCM
Normocítico Macrocítico
80 - 100 fL > 100 fL
< 6,5 µm 6,5 - 9 µm > 9 µm
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Próximo Passo:Caracterizar Hemácias
Microcitose Normocitose Macrocitose
Ferropenia Doença Crônica Megaloblástica
Talassemia Policarência Hepatopatia
Doença Crônica Doença Medular Tireoidopatia
Doença Medular Hemólise SMD
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Próximo Passo:Avaliação do SP
1. Qual é o tamanho das hemácias?
2. Quais são as formas das hemácias?
3. Qual é a cor das hemácias?
4. Há variação de cores?
5. Há alguma inclusão nas hemácias?
6. Há algum parasita?
7. Como estão leucócitos e plaquetas?
www.drsarma.in
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HemogramaAnemia Ferropênica
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SPMicrocitose/Hipocromia
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SPHipocromia
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Anemia Microcítica/Hipocrômica
FERRITINA SÉRICA (mg/dL)
< 20 20-100 > 100
IST (%)
< 20 > 20
FERRO MEDULAR
BAIXO NORMAL /ALTO
FERROPÊNICA OUTRA
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Anemia Ferropênica
• Microcítica VCM < 80 fL (Hemácias < 6,5 µm)
• Hipocrômica HCM < 27 pg / CHCM < 30%
• RDW Aumentado (Anisocitose)
• IPR < 2 (Reticulócitos podem ser > 2%)
• Ferritina Baixa (< 20 mg/dL)
• Índice de Saturação da Transferrina < 20%
• Ferro Medular Baixo ou Ausente
• Ótima Resposta à Ferroterapia
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Anemia MicrocíticaDiferencial
VCM < 80 fL Ferritina ISTFerro
Medular
Anemia Ferropênica ↓↓ ↓↓ 0
Doença Crônica N ↑ N ↓ + +
Talassemia ↑↑ N ↑ + + +
Hemoglobinopatia N ↑ N ↑ + +
Intoxicação por Chumbo
N N + +
Sideroblástica ↑↑ N ↑ + + + +
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Sideroblastos, Anel (SMD)(MO; Azul da Prússia)
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Anemias Macrocíticas
• Megaloblástica: Falta de B12 e/ou Folatos
• Não-Megaloblástica:
– Hepatopatia/Etilismo
– Hipotireoidismo/Outras Endocrinopatias
– Mielodisplasia/Outras Mielopatias
– Reticulocitose (Hemólise, Sangramento)
– Drogas (Citotóxicos, Imunossupressores, Anticonvulsivantes, AZT etc.)
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Anemias Macrocíticas
• VCM >110 fL
– Quase Sempre MEGALOBLÁSTICA
• VCM 100-110 fL
– Investigar Outras Possíveis Causas
• Podem ser assintomáticas até atingir valores muito baixos de Hb
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Macrocitose do Etilismo
• 25-96% dos Alcoólatras
• VCM até 110 fL
• Macrócitos “Redondos” (Não Ovais)
• Sem Neutrófilos “Hipersegmentados”
• Anemia Habitualmente Discreta
• Tabagismo Aumenta Massa Eritrocitária
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Anemia Megaloblástica
• Insuficiência Medular:
– Falha na síntese de ADN; Hematopoese Ineficaz; Pancitopenia
– Megaloblastose (Precursores Gigantes)
– Maturação Assincrônica Núcleo-Citoplasmática; Macrovalócitos e Neutrófilos Hipersegmentados
– Quase sempre por carência de B12/B9
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Anemia Perniciosa
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Anemia Megaloblástica
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Anemia Megaloblástica
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Macrocitose/Anisocitose
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Neutrófilo Hipersegmentado
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Pontilhado Basofílico(AMB; Saturnismo)
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Megalócitos
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Megaloblastos (MO)
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Megaloblastose (MO)
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MegaloblastoseDéficit de Folatos
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Anemias Normocíticas
• Fase Inicial da Anemia Ferropênica
• Doenças Crônicas
• Policarências
• Hemoglobinopatias
• Hemólise
• Desordens Primárias da Medula Óssea
• Iatrogenia (UTI)
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Anemia de Doença Crônica
• Neoplasias
• Doenças Tireoideanas
• Doenças do Colágeno (LES, AR, PAN, Polimiosite etc.)
• Doença Inflamatória Intestinal (RCU, DC)
• Doenças Renais Crônicas
• Infecções (TBC, Osteomielite etc.)
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Anemias Dimórficas
• Deficiência de Fe e Folatos (Alcoolismo)
• Deficiência de Fe e B12 (Perniciosa)
• Deficiência de Fe e Hemólise
• Deficiência de Folatos e Hemólise
• Talassemia + Anemia Megaloblástica
• RDW muito aumentado
• Exame do SP é fundamental
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AnemiaHemolítica
Anemia por aumento da destruição eritrocitária
• Meia-vida menor das hemácias
• Reticulocitose
• Normocítica, Normocrômica
• Geralmente assintomática até que a meia-vida eritrocitária seja menor que 20 dias
• MO compensa até 6 vezes
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Testes para DiagnosticarHemólise
1. Hemograma Seriado2. Contagem de Reticulócitos 3. Bilirrubinas Séricas4. DHL Sérica5. Haptoglobina Sérica6. Hemosiderinúria7. Hemoglobinúria
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AnemiaHemolítica
Reticulócitos e IPR Aumentados
Bilirrubina Total e Indireta Aumentadas
DHL Aumentada
Haptoglobina Diminuída
Hemoglobinúria Presente
Hemosiderinúria Presente
Urobilinogênio na Urina Aumentado
Meia-vida Hemácias Cr 51 Diminuída
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Testes para Definir aCausa da Hemólise
1. Eletroforese de Hemoglobina
2. Hemoglobina A2 (β-Talassemia)3. Autoimune: TAD e TAI (CD e CI)4. Crioaglutininas5. Fragilidade Osmótica (Esferocitose)6. Teste de HAM (HPN)7. Enzimopatia (G6PD, PK etc.)8. Coagulograma (CID, PTT, SHU)
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Anemia Hemolítica Microangiopática
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Anemia Hemolítica Microangiopática
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Anisocitose
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Poiquilocitose
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PolicromasiaEsferocitose
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Target Cells (Alvo)
– Talassemias–Hepatopatias–Asplenia– Esplenectomia
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Tear Drop Cells(Lágrima)
–Mielofibrose– Infiltração MO– Tumores MO– Talassemias
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Drepanócitos (SS)Falciforme
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AutoesplenectomiaFalciforme
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Normal 8-12 cm
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Corpúsculos deHowell-Jolly (Asplenia)
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Esferocitose
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Esferocitose Hereditária
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Eliptocitose(Com Déficit B12 e Folatos)
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Estomatocitose
• Hepatopatias
• Alcoolismo Agudo
• Hereditária
• Neoplasias
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Equinocitose> 10 Espículas
• Uremia
• DUP
• Câncer Gástrico
• Artefato
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Acantocitose
• Spur Cells
• 5-8 Espículas Irregulares
• Ocorre na AHA
• Artefato
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Esquizocitose
• Microangiopatia
• Valvopatia Cardíaca
• Uremia
• Hipertermia Maligna
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BMOAnemia Aplástica
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Mielofibrose
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Algoritmo para Diagnóstico
Anemia?
História e EF Hb, Ht Diminuídos
RPI/Reticulócitos <2 RPI/Reticulócitos >2
Sgto ou Hemólise
Coombs D e I
Eletroforese Hb
Fragil. Osmótica
VCM, HCM, CHCM, SP
Microcítica/Hipocrômica Macrocítica
Megaloblástica NormoblásticaAnemia Ferropênica
Ferritina, IST, Fe MO
Talassemia, Hbpatia
Anemia Sideroblástica
Doença Crônica, Pb
Folatos
B12; Perniciosa
Identifique a Causa
Fígado, Álcool
Tireoidopatia
Drogas
Medulopatia
Teste de HAM
Crioaglutininas
CID, PTT, SHU
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Test Done Value Remarks
RBC 3.96 million/c mm Decreased
Hb% 9.7 g% Decreased
Hematocrit 23.9 % Decreasd
MCV 60.4 fl Microcytosis
MCH 24.6 pg/l Hypochromia
MCHC 40.5 % Not relevant
RC and RPI 4 %, 1.29 Not Hemolytic
Peripheral SmearMicrocytic hypochromic
DD of Microcytic
Serum Ferritin 46 pmol/l Boarderline
TIBC 390 µg/dl Elevated
BM Iron stain Absent Clinches IDA
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Test Done Value Remarks
RBC 3.86 million/c mm Decreased
Hb% 10.4 g% Decreased
Hematocrit 26.9 % Decreasd
MCV 69.7 fl Microcytosis
MCH 25.8 pg/l Hypochromia
MCHC 38.66 % Not relevant
RC and RPI 5 %, 1.73 Not Hemolytic
Peripheral SmearMicrocytic hypochromic
DD of Microcytic
Serum Ferritin 320 pmol/l High
TIBC 300 µg/dl Normal
BM Iron stain Ringed sideroblasts Clinches SBA
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Test Done Value Remarks
RBC 2.69 million/c mm Decreased
Hb% 10.6 g% Decreased
Hematocrit 31.6 % Decreasd
MCV 117.5 flMacrocytosis (Severe)
MCH 39.4 pg/l Hyperchromia
MCHC 33.5 % Normal
RC and RPI 5 %, 1.76 Not Hemolytic
Peripheral Smear
Macrocytic DD of Macrocytic
Serum Ferritin 240 pmol/lNormal (Not required)
TIBC 338 µg/dlNormal (Not required)
BM Exam Megaloblastic BMClinches MBA (F, B12)
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Test Done Value Remarks
RBC 3.09 million/c mm Decreased
Hb% 10.6 g% Decreased
Hematocrit 31.6 % Decreasd
MCV 102.3 flMacrocytosis (Moderate)
MCH 34.3 pg/l Hyperchromia
MCHC 33.5 % Normal
RC and RPI 3 %, 1.06 Not Hemolytic
Peripheral Smear
Macrocytic Hyperchromic
DD of Macrocytic
Serum Ferritin 240 pmol/lNormal (Not required)
TIBC 338 µg/dlNormal (Not required)
BM Exam Normoblastic BMClinches MCA (Chr D)
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Test Done Value Remarks
RBC 3.10 million/c mm Decreased
Hb% 9.3 g% Decreased
Hematocrit 27.9 % Decreasd
MCV 90 fl Normocytosis
MCH 30.0 pg/l Normochromia
MCHC 33.3 % Normal
RC and RPI 1.5 %, 0.47 Not Hemolytic
Peripheral Smear
Normocytic Normochromic
DD of Normocytic A
Serum Ferritin 240 pmol/lNormal (Not required)
TIBC 338 µg/dlNormal (Not required)
BM Exam Normoblastic BMCLD, ALD, CKD, Drugs
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Test Done Value Remarks
RBC 3.81 million/c mm Decreased
Hb% 11.1 g% Decreased
Hematocrit 33.3 % Decreasd
MCV 87.4 fl Normocytosis
MCH 29.2 pg/l Normochromia
MCHC 33.33 % Normal
RC and RPI 10 %, 3.70 Hemolytic
Peripheral Smear
Poikilo, Aniso, target cells
DD of Hemolytic Anemia
Serum Ferritin 240 pmol/lNormal (Not required)
TIBC 338 µg/dlNormal (Not required)
BM Exam E : G Ratio is 2 : 1Hypercellular marrow
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AnemiaResumo
• NÃO dê ferro sem investigar!• Olhe: Hemácias, Hb, Ht, VCM, HCM, CHCM• Olhe: Sangue Periférico (Formas, Cor etc.)• Peça “Reticulócitos” e calcule o IPR (<2>)• Se há Reticulocitose:– Procure por Sangramentos (Ocultos)– Investigue possível Hemólise
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AnemiaResumo
– Se Hipoproliferativa (Reticulocitopenia)• Microcítica–Ferropenia: Ferritina, IST, Fe MO
• Macrocítica–Megaloblástica: B12, Folatos–Normoblástica: MO
• Normocítica–Anemia de Doença Crônica
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Obrigado!
© L. A. Burden 2005