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Hb electro-
phoresis and
further tests
" n "/(n) n/" (!/n) Aplastic ane-
mia or bone
marrow carci-
Search for trig-
ger or tumor
Hypoplasia of all
cell series, or car-
cinoma cells
p. 146,
148, 150
n n n/" Vitamin
folic acid
(!) Megaloblastic
of antibodies,
Schilling test
p. 152
n/! n ! " " Polyeythemia,
DD: hypergam-
ALP, progress-
Erythropoiesis" p. 162
n n ! duration
– Thrombocyto-
penic purpura
Search for trig-
gers, possibly
also for anti-
Elevated mega-
karyocyte count
p. 166
Hypochromic Anemias
Table 23 Normal ranges for physiological iron and its transport proteins
Old units SI units
Serum iron
Newborns 150–200µg/dl 27–36µmol/l
Female 60–140µg/dl 11–25µmol/l
Male 80–150µg/dl 14–27µmol/l
TIBC 300–350µg/dl 54–63µmol/l
Transferrin 250–450µg/dl 2.5–4.5 g/l
Serum ferritin 30–300µg/l
(15–160µg/l premenopausal)
TIBC = Total iron binding capacity.
Erythrocyte and Thrombocyte Abnormalities
This usually renders determination of transferrin and total iron binding
capacity (TIBC) unnecessary. If samples are being sent away to a labora-
tory, it is preferable to send serum produced by low-speed centrifugation,
since the erythrocytes in whole blood can becomemechanically damaged
during shipment and may then release iron. Table 23 shows the variation
of serum iron values according to gender and age.
It is important to note that acute blood loss causes normochromic ane-
mia. Only chronic bleeding or earlier serious acute blood loss leads to iron
deficiency manifested as hypochromic anemia.
Iron Deficiency and Blood Cell Analysis Focusing on the erythrocyte mor-
phology is the quickest andmost efficientway to investigate hypochromic
anemia when the serum iron has dropped below normal values. In hypo-
chromic anemia with iron and hemoglobin deficiency (whether due to in-
sufficient iron intake or an increased physiological iron requirement),
erythrocyte size and shape does not usually varymuch (see Fig.45). Only in
advanced anemias (from approx. 11 g/dl, equivalent to 6.27mmol/l Hb)
are relatively small erythrocytes (microcytes) with reduced MCV and
MCH and grayish stained basophilic erythrocytes (polychromatic eryth-
rocytes) seen, indicating inadequate hemoglobin content. Cells with the
appearance of relatively large polychromatic erythrocytes are reticulo-
cytes. The details of theirmorphology can be seen after supravital staining
(p. 141). A few target cells (p. 139) will be seen in conditions of severe iron
In severe hemoglobin deficiency (! 8g/dl, equivalent to 4.96mmol/l)
the residual hemoglobin is found mostly at the peripheral edge of the
erythrocyte, giving the appearance of a ring-shaped erythrocyte.
Small, hemoglobin-poor erythrocytes indicate iron deficiency
Fig. 45 Iron deficiency anemia. a and b Erythrocyte morphology in iron deficien-
cy anemia: ring-shaped erythrocytes (1), microcytes (2) faintly visible target cells
(3), and a lymphocyte (4) for size comparison. Normal-sized erythrocytes (5) after
transfusion. c Bone marrow cytology in iron deficiency anemia shows only in-
creased hematopoiesis and left shift to basophilic erythroblasts (1). d Absence of
iron deposits after iron staining (Prussian blue reaction). Megakaryocyte (1).
134 Erythrocyte and Thrombocyte Abnormalities
Hypochromic Infectious or Toxic Anemia
(Secondary Anemia)
Among the various causes of lack of iron for erythropoiesis (see Fig.44,
p. 129), a special situation is represented by the internal iron shift caused
by “iron pull” of the reticuloendothelial system (RES) during infections,
toxic processes, autoimmune diseases, and tumors. Since this anemia re-
sults from another disorder, it is also called secondary anemia. TheMCH is
hypochromic, or in rare instances, normochromic, and therefore erythro-
cytemorphology is particularly important to diagnosis. In contrast to exo-
genous iron deficiency anemias, the following phenomena are often ob-
served, depending on the severity of the underlying condition:
" Anisocytosis, i.e., strong variations in the size of the erythrocytes, be-
yond the normal distribution. The result is that in almost every field
view, some erythrocytes are either half the size or twice the size of their
" Poikilocytosis, i.e., variations in the shape of the erythrocytes. In addi-
tion to the normal round shape, numbers of oval, or pear, or tear shaped
cells are seen.
" Polychromophilia, the third phenomenon in this series of nonspecific
indicators of disturbed erythrocyte maturation, refers to light gray-
blue staining of the erythrocytes, indicating severely diminished
hemoglobin content of these immature cells.
" Basophilic cytoplasmic stippling in erythrocytes is a sign of irregular re-
generation and often occurs nonspecifically in secondary anemia.
The reticulocyte count is usually reduced in infectious or toxic anemia, un-
less there is concomitant hemolysis or acute blood loss.
Bone marrow analysis in secondary anemia usually shows reduced
erythropoiesis and granulopoiesiswith a spectrumof immature cells (“in-
fectious/toxic bone marrow”). The information is so nonspecific that usu-
ally bone marrow aspiration is not performed. So long as all other labora-
tory methods are employed, bone marrow cytology is very rarely needed
in cases of hypochromic anemia.
a b
Hypochromic erythrocytes of very variable morphology indicate
secondary anemia, usually in cases of infectious disease or
Fig. 46 Secondary anemia. a and b Erythrocyte morphology in secondary hypo-
chromic anemia: the erythrocytes vary greatly in size (anisocytosis) and shape (1)
(poikilocytosis), and show basophilic stippling (2). Burr cell (3), which has no spe-
cific diagnostic significance. Occasionally, the erythrocytes stain a soft gray–blue
(4) (polychromasia). c Bone marrow cell overview in secondary anemia. Cell
counts in the white cell series are elevated (promyelocytes = 1), eosinophils (2),
and plasma cells (3); erythropoiesis is reduced (4).
136 Erythrocyte and Thrombocyte Abnormalities
Bone Marrow Cytology in the Diagnosis of Hypochromic
So long as all other laboratory methods are employed, bone marrow cy-
tology is very rarely needed in cases of hypochromic anemia.
Bone marrow cytology is rarely strictly indicated after all other available
diagnostic methods have been exhausted (Table 22, p. 130). However, in
doubtful cases it can usually at least help to rule out malignant disease.
In iron deficiency anemias of themost various etiologies, erythropoiesis
is stimulated in a compensatory fashion, and the distribution of the
markers shows the expected increase in red cell precursors. The erythro-
poiesis to granulopoiesis ratio increases in favor of erythropoiesis from
1:3 to 1:2, but rarely further. The red cell series shows a left shift, i.e.,
there are more immature red cell precursors (erythroblasts and proeryth-
roblasts) (for normal values, see Table 4). Usually, these red cell precursors
do not show any clearly atypical morphology, but the cytoplasm is ba-
sophilic even in normoblasts, accordingwith the poor hemoglobinization.
Iron staining of the bonemarrow shows no sideroblasts (normoblasts con-
taining iron granules), or only very few (!10%, norm 30–40%). A constant
finding in anemia stemming from exogenous iron deficiency is absence of
iron in the macrophages of the bone marrow reticulum.
Megakaryocyte counts are almost always increased in iron deficiency
due to chronic hemorrhaging, but can also show increased