Confusing Hemolytic Anemia

[tyagee]

A 40-year-old man came to see his primary care doctor as he had been feeling very fatigued of late. He stated that he was tired all the time, had difficulty walking the distance that he could only a month or so ago, and he also noticed some swelling of his feet, usually at the end of the day. Physical examination revealed a medium-built well-nourished man with conjunctival pallor. The sclera appeared mildly icteric. His temperature was 98.6F (37.0C), pulse 88/min regular, respirations 18/min, and his blood pressure was 120/86 mm Hg. Oxygen saturation using room air was 90%.
His lungs were clear to auscultation, bilaterally; he had a soft murmur in the precordial area without a thrill, and no gallops or rubs were noted. The abdomen was soft to palpation, and he had mild tenderness without guarding or rigidity in the right upper quadrant. No organomegaly was noted, and bowel sounds were present in all four quadrants. A complete blood count revealed a low hematocrit and a corrected reticulocyte count of greater than 3%. Which one of the following
changes in serum levels also would most likely occur?

(A) Conjugated bilirubin, haptoglobin, and lactic acid dehydrogenase levels would all be elevated
(B) Conjugated bilirubin would be elevated; haptoglobin and lactic acid dehydrogenase levels would be decreased
(C) Unconjugated bilirubin and haptoglobin levels would decrease; the lactic acid dehydrogenase level would increase
(D) Unconjugated bilirubin, haptoglobin, and lactic acid dehydrogenase levels would all increase
(E) Only the haptoglobin level would increase

[achistikbenny]

i dont know which ans to pick bcos in hemolytic anemia there is elevated indirect bilirubin,reticulocytosis,increase LDH and haptoglobulin in addition to low hematocrit. none of the ans choices show s that.

[jahn77]

What about B? Increased production and conjugation of bilirubin, and decrease of haptoglobin?

[achistikbenny]

Sorry i made a mistake in my post. there is decrease haptoglobulin in hemolytic anemia.

[Master shifu]

Originally Posted by achistikbenny

Sorry i made a mistake in my post. there is decrease haptoglobulin in hemolytic anemia.

That's the point!!!!bro...i was really wondering when i first saw the options stated there.......... thinking that how could i possibly miss that...
I Haemolysis.......occuring intravascularly....there would be obviously increased.......unconjugated billirubin,increased LDH level....but decreased Haptoglobin level.....Isn't that right?????

[tyagee]

ans in qbank is c
do you guys agree?

[achistikbenny]

Intravascular Hemolysis
The RBCs are lysed within the blood vessel such as by mechanical damage of a heart valve, or because of complement fixation as in paroxysmal nocturnal hemoglobinuria.
The hemoglobin is released into the blood and immediately bound by haptoglobin for clearance in the liver.
If the hemolysis is too much, haptoglobin get consumed and extra hemoglobin set free in the circulation (that's why hemoglobinemia).
This free hemoglobin reaches the kidney and get's filtered and then reabsorbed in the form of Iron.
Again if hemolysis is beyond the reabsorptive capacity of the renal tubules, hemoglobin will appear in the urine (hemoglobinuria, and urinary hemosiderin appears).
Because the fact that RBSs are lysed in the blood, its LDH is released into the circulation raising it's levels. (recall that LDH is mainly a cytoplasmic enzyme that's why it's available in the nucleus-free mitochondria-free RBC).
Schitiocytes are essentially broken up and fragmented RBCs.

Extravascular Hemolysis
RBCs are coated with antibodies or have abnormal shape of membrane or abnormal inclusion (such as Heinz bodies in G6PD) and so they are attacked prematurely by the liver and spleen phagocytes.
The engulfed hemoglobin is converted into iron for recycling and the globine portion becomes billirubin later.
So as no hemoglobin is released into the circulation, no haptoglobin is consumed and no hemoglobinemia or uria is observed.
As the RBC is not lysed in the circulation, no LDH is elevated.
Sometimes, the phagocytes spit up the RBCs back again after chewing up some membrane and therefore we may see spherocytes in the peripheral blood smear. Differentiate the two main cause of spherocytosis by doing osmotic fagility (positive in congenital spherocytosis) and DCT (positive in AutoImmune Hemolytic Anemia).

[achistikbenny]

With this explanation i dont know why C should be the ans.

[tyagee]

haptoglobin level is also APR. so its level can be high. this what the book said. i am taking this q & a wrong.

if any1 can explain, come and help..

[Dr.Lacune]

Originally Posted by tyagee

haptoglobin level is also APR. so its level can be high. this what the book said. i am taking this q & a wrong.

if any1 can explain, come and help..

in my opinion;
this is Iron deficiency anemia.or I should say chronic blood loss with normal reacting bone marrow(to be more accurate). Haptoglobin is elevated.retic may be elevated .

[mbbs2010]

Originally Posted by Dr.Lacune

in my opinion;
this is Iron deficiency anemia.or I should say chronic blood loss with normal reacting bone marrow(to be more accurate). Haptoglobin is elevated.retic may be elevated .

it is a hemolytic anemia (high retic count)

yes haptoglobin can be high -- if it is extravascular hemolysis. (increased as an APR)

if it is intravascular hemolysis --- the haptoglobin shud be low.

unconjugated bilirubin will be high in both cases

[nancynaguib]

the answer is c as haptoglobin decreases as it binds with free hemoglobin released into circulation but the LDH increases

[zainsyed]

haptoglobin should be decreased and LDH should be increased but why are the levels of unconjugated bilirubin decreased???

[bashir]

The answer to this question is wrong.

Hemolytic anemias:
1. reticulocyte count increased
2. Haptoglobin decreased
3. Indirect bilirubin increases
4. LDH increases.

[prabin]

....as haemolysis cause inc in ldh n decrease in hephoglobulin..also inc in indirect bilirubin...no options for it

[slamdunk]

Originally Posted by tyagee

A 40-year-old man came to see his primary care doctor as he had been feeling very fatigued of late. He stated that he was tired all the time, had difficulty walking the distance that he could only a month or so ago, and he also noticed some swelling of his feet, usually at the end of the day. Physical examination revealed a medium-built well-nourished man with conjunctival pallor. The sclera appeared mildly icteric. His temperature was 98.6F (37.0C), pulse 88/min regular, respirations 18/min, and his blood pressure was 120/86 mm Hg. Oxygen saturation using room air was 90%.
His lungs were clear to auscultation, bilaterally; he had a soft murmur in the precordial area without a thrill, and no gallops or rubs were noted. The abdomen was soft to palpation, and he had mild tenderness without guarding or rigidity in the right upper quadrant. No organomegaly was noted, and bowel sounds were present in all four quadrants. A complete blood count revealed a low hematocrit and a corrected reticulocyte count of greater than 3%. Which one of the following
changes in serum levels also would most likely occur?

(A) Conjugated bilirubin, haptoglobin, and lactic acid dehydrogenase levels would all be elevated
(B) Conjugated bilirubin would be elevated; haptoglobin and lactic acid dehydrogenase levels would be decreased
(C) Unconjugated bilirubin and haptoglobin levels would decrease; the lactic acid dehydrogenase level would increase
(D) Unconjugated bilirubin, haptoglobin, and lactic acid dehydrogenase levels would all increase
(E) Only the haptoglobin level would increase

i think its C