Page 396 - Essential Haematology

382 / Chapter 28 Haematological changes in systemic disease

Anaemia of c hronic d isorders Malignant d iseases ( o ther t han
p rimary b one m arrow d iseases)
Many of the anaemias seen in clinical practice occur
in patients with systemic disorders and are the result
of a number of contributing factors. Th e anaemia Anaemia

of chronic disorders (also discussed on p. 46 ) is of Contributing factors include anaemia of chronic
central importance and occurs in patients with a disorders, blood loss and iron defi ciency, marrow
variety of chronic infl ammatory and malignant dis- infiltration (Fig. 28.1 ) often associated with a leuco-

eases (Table 28.1 ). Usually, both the erythrocyte erythroblastic blood film (see p. 118 ), folate defi -

sedimentation rate (ESR) and C - reactive protein ciency, haemolysis and marrow suppression from
(CRP) are raised. It may be complicated by addi- radiotherapy or chemotherapy (Table 28.2 ).
tional haematological changes caused by the disease. Microangiopathic haemolytic anaemia (see p.

The serum iron and total iron binding capacity 85 ) occurs with mucin - secreting adenocarcinoma
(transferrin) are both low; serum ferritin can be (Fig. 28.2 ), particularly of the stomach, lung and
normal or raised. Th e characteristic features are breast. Less common forms of anaemia with malig-
described in Chapter 3 . nant disease include autoimmune haemolytic
The pathogenesis of this anaemia appears to be anaemia with malignant lymphoma and rarely with

related to the decreased release of iron from macro- other tumours; primary red cell aplasia with
phages to plasma and so to erythroblasts, caused by thymoma or lymphoma; and myelodysplastic syn-
hepcidin, reduced red cell lifespan and an inade- dromes secondary to chemotherapy. There is also an

quate erythropoietin response to anaemia. Th e association of pernicious anaemia with carcinoma
plasma levels of various cytokines, especially of the stomach.
interleukin - 1 (IL - 1), IL - 6 and tumour necrosis The anaemia of malignant disease may respond

factor (TNF) are raised and reduce erythropoietin partly to erythropoietin but this may accelerate

secretion. The anaemia is corrected by the successful tumour growth. Folic acid should only be given if
treatment of the underlying disease. It does not there is definite megaloblastic anaemia caused by

respond to iron therapy despite the low serum iron. the deficiency; it might feed ’ the tumour.

‘
Responses to recombinant erythropoietin therapy
may be obtained (e.g. in rheumatoid arthritis or Polycythaemia
cancer). In many conditions the anaemia is compli-
cated by anaemia from other causes (e.g. iron or Secondary polycythaemia is occasionally associated

folate deficiency, renal failure, bone marrow infi ltra- with renal, hepatic, cerebellar and uterine tumours
tion, hypersplenism or endocrine abnormality). (see p. 208 ).
White c ell c hanges

Table 28.1 Causes of anaemia of chronic

disorders. Leukaemoid reactions (see p. 117 ) may occur with
tumours showing widespread necrosis and infl am-
Chronic infl ammatory diseases mation. Hodgkin lymphoma is associated with a
Infectious (e.g. pulmonary abscess, variety of white cell abnormalities including eosi-
tuberculosis, osteomyelitis, pneumonia, nophilia, monocytosis and leucopenia. In non -
bacterial endocarditis) Hodgkin lymphoma, malignant cells may circulate
Non - infectious (e.g. rheumatoid arthritis, in the blood (see p. 260 ).

systemic lupus erythematosus and other
connective tissue diseases, sarcoid, Crohn ’ s
disease, cirrhosis) Platelet and b lood c oagulation
a bnormalities
Malignant disease
(e.g. carcinoma, lymphoma, sarcoma, myeloma) Patients with malignant disease may show either
thrombocytosis or thrombocytopenia. Disseminated