Chapter 22

### Introduction

There's never none of these demure boys come to any proof; for their drink doth so over cool their blood, and making many fish-meals, that they fall into a kind of male green-sickness.

William Shakespeare (1564–1616), King Henry IV

Anaemia is a label, not a specific diagnosis. Anaemia is defined as a reduction in red blood cell numbers or a haemoglobin (Hb) level below the normal reference level for the age and sex of that individual.

The WHO defines anaemia as haemoglobin <130 g/L for men, <120 g/L for women and <110 g/L in pregnant women and school-aged children.

##### Anaemia: a masquerade

Anaemia is regarded as a masquerade because the problem can develop surreptitiously and the patient may present with many seemingly undifferentiated symptoms before the anaemia is detected. Once identified, a cause must be found.

Key facts and checkpoints

• In Australia, most people with anaemia will have iron deficiency ranging from up to 5% for children to 20% for menstruating females.1

• The remainder will mainly have anaemia of chronic disorders.

• The incidence of haemoglobinopathy traits, especially thalassaemia, is increasing in multicultural Western societies.

• If a patient presents with precipitation or aggravation of myocardial ischaemia, heart failure or intermittent claudication, consider the possibility of anaemia.

• The serum ferritin level, which is low in cases of iron-deficiency anaemia, is probably the best test to monitor iron-deficiency anaemia as its level reflects the amount of stored iron.

• Normal reference values for peripheral blood are presented in Table 22.1.

Table 22.1

Normal reference values for peripheral blood: adults

DxT fatigue + palpitations + exertional dyspnoea ➜ anaemia

Clinical features

Patients with anaemia may be asymptomatic. When symptoms develop they are usually nonspecific. Symptoms can include:

• tiredness/fatigue

• muscle weakness

• headache and tinnitus

• lack of concentration

• faintness/dizziness

• dyspnoea on exertion

• palpitations

• angina on effort

• intermittent claudication

• pica—usually brittle and crunchy food, e.g. ice (iron-deficiency anaemia)

Signs

Non-specific signs include pallor, tachycardia, systolic flow murmur and angular cheilosis.

If severe, signs can include ankle oedema and cardiac failure.

Specific signs include jaundice—haemolytic anaemia, and koilonychias (spoon-shaped nails)—iron-deficiency anaemia.

History

The history may indicate the nature of the problem:

• iron deficiency: inadequate diet, pregnancy, GIT loss, menorrhagia, NSAID and anticoagulant ingestion

• folate deficiency: ...

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