One commonly used method for classifying anemia is to categorize the anemia by the size of the red blood cell as measured by the mean corpuscular volume (MCV). Microcytic anemias are associated with an MCV of 79 fL or lower and include iron-deficiency anemia, thalassemia, and anemia of chronic disease. Macrocytic anemias are associated with an MCV higher than 101 fL and include anemias related to vitamin B12 or folate deficiency, myelodysplasia, and liver disease. Most anemias are normocytic, meaning that the MCV is in the normal range. This category includes the following:
- Myelophthisic anemia (i.e., anemia due to neoplastic replacement of the bone marrow).
- Most chemotherapy-related anemias.
- Anemia due to renal or hepatic dysfunction.
- Hemolytic anemia.
- Aplastic anemia.
However, a mixed red blood cell population consisting of both microcytic and macrocytic cells (anisocytosis) may indicate a combined etiology, for example, chronic blood loss (microcytic) with resultant reticulocytosis (macrocytic). In this situation, the MCV may be in the normal range, but the red blood cell size distribution width would be elevated.
The peripheral blood smear examination, though often overlooked, remains an important step in the evaluation of anemia. For example, nucleated blood cells and teardrop-shaped red blood cells suggest myelophthisic anemia. Macro-ovalocytes and hypersegmented neutrophils often indicate megaloblastic anemia. Small target cells and basophilic stippling are associated with thalassemia.
Additional studies that are sometimes required to characterize anemia in a given patient include testing of vitamin B12 or folate levels; serum iron, transferrin, and ferritin levels; erythropoietin level, the direct and indirect Coombs test, and/or examination of a bone marrow aspirate and biopsy. In cancer patients, the underlying etiology is often multifactorial.
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