Bone Marrow Erythroid Series

NORMOBLASTIC MEGALOBLASTIC SIDEROBLASTIC

Table 4-1 Table 6-24

Iron-deficiency anemia Infection Renal disease Malignancy

Connective tissue disorders Hemolytic anemia

Vitamin B12 deficiency Folic acid deficiency Miscellaneous

Congenital disorders in

DNA synthesis Acquired disorders in

DNA synthesis Drug induced

Mitochondrial defect Primary Secondary Congenital Acquired

Fig. 1-3. Causes of normoblastic, megaloblastic, and sideroblastic bone marrow morphology.

Table 1-4. Laboratory Studies Often Helpful in the Investigation of a Patient with Anemia

Usual initial studies

Hemoglobin and hematocrit determination

Erythrocyte count and red cell indices, including MCV and RDW Reticulocyte count Study of stained blood smear Leukocyte count and differential count Platelet count Suspected iron deficiency

Free erythrocyte protoporphyrin Serum ferritin levels Stool for occult blood

99mTc pertechnetate scan for Meckel's diverticulum—if indicated Endoscopy (upper and lower bowel)—if indicated Suspected vitamin B12 or folic acid deficiency Bone marrow Serum vitamin B12 level Serum folate level

Gastric analysis after histamine injection Vitamin B12 absorption test (radioactive cobalt) (Schilling test) Suspected hemolytic anemia Evidence of red cell breakdown Blood smear Serum bilirubin level Urinary urobilinogen Hemoglobinuria Serum haptoglobin Evidence of red cell regeneration Reticulocyte count Blood smear Skeletal radiographs Evidence of type of hemolytic anemia: corpuscular Membrane Blood smear Osmotic fragility test Autohemolysis test

Classification and Diagnosis of Anemia During Childhood 11 Table 1-4. (Continued)

Hemoglobin Sickle test

Hemoglobin electrophoresis Hemoglobin F determination Kleihauer-Betke smear Heat-stability test Enzymes

Enzyme assay Evidence of type of hemolytic anemia: extracorpuscular Immune

Antiglobulin test Acid serum lysis test Sucrose lysis test Donath-Landsteiner antibody ANA

Suspected aplastic anemia or leukemia

Bone marrow (aspiration and biopsy)—cytochemistry, immunologic markers, chromosome analysis Skeletal radiographs Other tests often used especially to diagnose the primary disease Viral serology, e.g., HIV ANA, complement, CH50

Blood urea, creatinine, T4, TSH Tissue biopsy (skin, lymph node, liver)

4. Bone marrow aspiration, if required, to examine erythroid, myeloid, and megakaryocytic morphology to determine whether normoblastic, megaloblastic, or sideroblastic erythropoiesis is present and to exclude marrow pathology (e.g., aplastic anemia, leukemia, and benign or malignant infiltration of the bone marrow) (Figure 1-3)

5. Determination of underlying cause of anemia by additional tests (Table 1-4).

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