Normochromic anemia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Normocytic anemia is a common issue that occurs for men and women typically over 85 years old. Its prevalence increases with age, reaching 44 percent in men older than 85 years.^[1] Normocytic anemia is the most frequently encountered type of anemia.^[1]

Causes

The issue is thought of as representing any of the following:

a decreased production of normal-sized red blood cells (e.g., anemia of chronic disease, aplastic anemia);
an increased destruction or loss of red blood cells (e.g., hemolysis, posthemorrhagic anemia);
an uncompensated increase in plasma volume (e.g., pregnancy, fluid overload);
or a mixture of conditions producing microcytic and macrocytic anemia.^[1]

Differentiating Normochromic Anemia from Other Diseases

To review the differential diagnosis of anemia, click here.

Disease	Genetics	Clinical manifestation					Lab findings
		History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Iron studies					Specific finding on blood smear
		History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Serum iron	Serum Tfr level	Transferrin or TIBC	Ferritin	Transferrin saturation	Specific finding on blood smear
Iron deficiency anemia (early phase)^[2]	−	Pica Glossitis Cheilosis	Fatigue Headache	Koilonychia Conjunctival pallor Dry skin	−	−	Normochromic	Normocytic	↑	↓	Nl	Nl	↓	↑	↑	↓	↓	Pencil cells Elliptocytosis Hypochromasia
G6pd deficiency^[3]	Defect in G6PD enzyme X-Linked recessive	History of using Sulfa drugs Antimalarials Fava Beans Infections	Back pain Hemoglobinuria	Back pain	+	Intrinsic	Normochromic	Normocytic	↑	↑ but usually causes resolution within 4-7 days	↓	↓	Nl to ↑	Nl	↑	↑	↑	RBC with Heinz bodies Bite cells Blister cells
Pyruvate kinase deficiency^[4]	Mutation in the PKLR and PKM gene Autosomal recessive	Gallstones	Hydrops fetalis Neonatal hyperbilirubinemia Iron overload Perinatal complications	Skin ulcers Splenomegaly	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↑	Nl	Nl	↑	−	Prickle cells Polychromatophilic erythrocytes
Disease	Genetics	History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Serum iron	Serum Tfr level	IBC	Ferritin	Transferrin saturation	Specific finding on blood smear
Sickle cell anemia^[5]	Hbs point mutation causes a single amino acid replacement in β chain	High altitude Low Oxygen Acidosis African-American race Parvovirus B19 infection	Painful crisis Dactylitis Priapism Acute chest syndrome Avascular Necrosis Stroke Autosplenectomy Salmonella osteomyelitis	Dactylitis Priapism	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl or moderately ↑	Nl	Nl	Nl or moderately ↑	↓	Nl	Increased erythropoiesis Howell-Jolly bodies Anisocytosis
HbC disease^[6]	Glutamic acid–to-lysine mutation in β-globin	Gallstone	Joint pains Increased risk of infections	Splenomegaly Cholelithiasis Avascular necrosis of the femoral head	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	Nl	Nl	Nl	↓	−	Hemoglobin crystals inside RBCs Target cells
Paroxysmal nocturnal hemoglobinuria^[7]^[8]	PIGA gene mutations Impaired synthesis of GPI anchor for decay-accelerating factor	Associated with aplastic anemia Thrombosis	Fatigue Chest pain Dyspnea on exertion Headache	Chronic hemolysis Hepatomegaly Ascites Papilledema Skin nodules	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↓	Nl	↑	↓	−	NA
Hereditary spherocytosis^[9]	Mutations in Ankyrin, Band 3, Protein 4.2, and spectrin	Associated with parvovirus B19 Cholelithiasis Megaloblastic crisis	Aplastic crisis	Splenomegaly	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↓	Nl	↑	Nl	−	Small, round RBCs with less surface area and no central pallor
Disease	Genetics	History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Serum iron	Serum Tfr level	IBC	Ferritin	Transferrin saturation	Specific finding on blood smear
Microangiopathic hemolytic anemia^[10]^[11]	−	Associated with DIC TTP HUS SLE HELLP syndrome Hypertensive emergency	Purpura Confusion Aphasia Diplopia	Numbness of an arm or hand Jaundice Pale conjunctiva	+	Extrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↓	Nl	−	↑	−	Helmet cells
Macroangiopathic hemolytic anemia^[12]	Autoimmune	Associated with Prosthetic heart valves Aortic stenosis	Pallor Fatigue	Signs of anemia Complications of hemolysis Decreased vascular volume	+	Extrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↓	Nl	−	−	−	Spherocytes or schistocytes
Autoimmune hemolytic anemia^[13]	−	Associated with: SLE CLL Mycoplasma pneumonia	Painful blue fingers and toes on exposure to cold temperature Chest pain Chills Dizziness Tachycardia Headache Fatigue	Painful, blue fingers and toes with cold weather	+	Extrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↓	Nl	−	−	−	RBC agglutination
Disease	Genetics	History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Serum iron	Serum Tfr level	IBC	Ferritin	Transferrin saturation	Specific finding on blood smear
Aplastic anemia^[14]	Constitutive expression of Tbet Mutations in the perforin gene Mutations in SAP gene	Exposure to Radiation Drugs like Benzene, chloramphenicol, alkylating agents Viral infections like EBV, HIV, Hepatitis Fanconi anemia Idiopathic like Immune mediated, primary stem cell defect	Symptoms based on underlying condition	Short stature Cafe-au-lait spots Thumb defects Radial defects	−	−	Normochromic	Normocytic	↑	↓	Nl	Nl	↓	↓	Nl	↑	↓	Pancytopenia Fatty infiltration
Infections^[15]	−	Associated with Malaria Babesia	Fever	Fever Signs of shock Headache	+	Extrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	Nl	Nl	−	−	−	Trophozoite Maltese crosses
Chronic kidney disease^[16]	−	Pericarditis Encephalopathy Rectal incontinence Decreased libido Restless leg syndrome	Polyuria Hematuria Edema	Hypertension	−	−	Normochromic	Normocytic	↑	Nl/↑	Nl	↑	↓	−	↓	↑	↓	Nl

References

↑ ^1.0 ^1.1 ^1.2 http://www.aafp.org/afp/20001115/2255.html
↑ De Andrade Cairo RC, Rodrigues Silva L, Carneiro Bustani N, Ferreira Marques CD (June 2014). “Iron deficiency anemia in adolescents; a literature review”. Nutr Hosp. 29 (6): 1240–9. doi:10.3305/nh.2014.29.6.7245. PMID 24972460.
↑ Luzzatto L, Seneca E (February 2014). “G6PD deficiency: a classic example of pharmacogenetics with on-going clinical implications”. Br. J. Haematol. 164 (4): 469–80. doi:10.1111/bjh.12665. PMC 4153881. PMID 24372186.
↑ Grace RF, Zanella A, Neufeld EJ, Morton DH, Eber S, Yaish H, Glader B (September 2015). “Erythrocyte pyruvate kinase deficiency: 2015 status report”. Am. J. Hematol. 90 (9): 825–30. doi:10.1002/ajh.24088. PMC 5053227. PMID 26087744.
↑ Singh PC, Ballas SK (March 2015). “Emerging drugs for sickle cell anemia”. Expert Opin Emerg Drugs. 20 (1): 47–61. doi:10.1517/14728214.2015.985587. PMID 25431087.
↑ Lemonne N, Billaud M, Waltz X, Romana M, Hierso R, Etienne-Julan M, Connes P (2016). “Rheology of red blood cells in patients with HbC disease”. Clin. Hemorheol. Microcirc. 61 (4): 571–7. doi:10.3233/CH-141906. PMID 25335812.
↑ Bunyaratvej A, Butthep P (January 1992). “Cytometric analysis of paroxysmal nocturnal hemoglobinuria erythrocytes”. J Med Assoc Thai. 75 Suppl 1: 237–42. PMID 1402472.
↑ Kahng J, Kim Y, Kim JO, Koh K, Lee JW, Han K (January 2015). “A novel marker for screening paroxysmal nocturnal hemoglobinuria using routine complete blood count and cell population data”. Ann Lab Med. 35 (1): 35–40. doi:10.3343/alm.2015.35.1.35. PMC 4272963. PMID 25553278.
↑ Da Costa L, Galimand J, Fenneteau O, Mohandas N (July 2013). “Hereditary spherocytosis, elliptocytosis, and other red cell membrane disorders”. Blood Rev. 27 (4): 167–78. doi:10.1016/j.blre.2013.04.003. PMID 23664421.
↑ Morishita E (July 2015). “[Diagnosis and treatment of microangiopathic hemolytic anemia]”. Rinsho Ketsueki (in Japanese). 56 (7): 795–806. doi:10.11406/rinketsu.56.795. PMID 26251142.
↑ George JN, Charania RS (March 2013). “Evaluation of patients with microangiopathic hemolytic anemia and thrombocytopenia”. Semin. Thromb. Hemost. 39 (2): 153–60. doi:10.1055/s-0032-1333538. PMID 23390027.
↑ Westphal RG, Azen EA (May 1971). “Macroangiopathic hemolytic anemia due to congenital cardiovascular anomalies”. JAMA. 216 (9): 1477–8. PMID 5108522.
↑ Hill QA (October 2015). “Autoimmune hemolytic anemia”. Hematology. 20 (9): 553–4. doi:10.1179/1024533215Z.000000000401. PMID 26447931.
↑ Dolberg OJ, Levy Y (2014). “Idiopathic aplastic anemia: diagnosis and classification”. Autoimmun Rev. 13 (4–5): 569–73. doi:10.1016/j.autrev.2014.01.014. PMID 24424170.
↑ Bustinduy AL, Parraga IM, Thomas CL, Mungai PL, Mutuku F, Muchiri EM, Kitron U, King CH (March 2013). “Impact of polyparasitic infections on anemia and undernutrition among Kenyan children living in a Schistosoma haematobium-endemic area”. Am. J. Trop. Med. Hyg. 88 (3): 433–40. doi:10.4269/ajtmh.12-0552. PMC 3592521. PMID 23324217.
↑ Drawz P, Rahman M (June 2015). “Chronic kidney disease”. Ann. Intern. Med. 162 (11): ITC1–16. doi:10.7326/AITC201506020. PMID 26030647.

[AAFP-1] 1.0 ^1.1 ^1.2 http://www.aafp.org/afp/20001115/2255.html

[pmid24972460-2] De Andrade Cairo RC, Rodrigues Silva L, Carneiro Bustani N, Ferreira Marques CD (June 2014). “Iron deficiency anemia in adolescents; a literature review”. Nutr Hosp. 29 (6): 1240–9. doi:10.3305/nh.2014.29.6.7245. PMID 24972460.

[pmid24372186-3] Luzzatto L, Seneca E (February 2014). “G6PD deficiency: a classic example of pharmacogenetics with on-going clinical implications”. Br. J. Haematol. 164 (4): 469–80. doi:10.1111/bjh.12665. PMC 4153881. PMID 24372186.

[pmid26087744-4] Grace RF, Zanella A, Neufeld EJ, Morton DH, Eber S, Yaish H, Glader B (September 2015). “Erythrocyte pyruvate kinase deficiency: 2015 status report”. Am. J. Hematol. 90 (9): 825–30. doi:10.1002/ajh.24088. PMC 5053227. PMID 26087744.

[pmid25431087-5] Singh PC, Ballas SK (March 2015). “Emerging drugs for sickle cell anemia”. Expert Opin Emerg Drugs. 20 (1): 47–61. doi:10.1517/14728214.2015.985587. PMID 25431087.

[pmid25335812-6] Lemonne N, Billaud M, Waltz X, Romana M, Hierso R, Etienne-Julan M, Connes P (2016). “Rheology of red blood cells in patients with HbC disease”. Clin. Hemorheol. Microcirc. 61 (4): 571–7. doi:10.3233/CH-141906. PMID 25335812.

[pmid1402472-7] Bunyaratvej A, Butthep P (January 1992). “Cytometric analysis of paroxysmal nocturnal hemoglobinuria erythrocytes”. J Med Assoc Thai. 75 Suppl 1: 237–42. PMID 1402472.

[pmid25553278-8] Kahng J, Kim Y, Kim JO, Koh K, Lee JW, Han K (January 2015). “A novel marker for screening paroxysmal nocturnal hemoglobinuria using routine complete blood count and cell population data”. Ann Lab Med. 35 (1): 35–40. doi:10.3343/alm.2015.35.1.35. PMC 4272963. PMID 25553278.

[pmid23664421-9] Da Costa L, Galimand J, Fenneteau O, Mohandas N (July 2013). “Hereditary spherocytosis, elliptocytosis, and other red cell membrane disorders”. Blood Rev. 27 (4): 167–78. doi:10.1016/j.blre.2013.04.003. PMID 23664421.

[pmid26251142-10] Morishita E (July 2015). “[Diagnosis and treatment of microangiopathic hemolytic anemia]”. Rinsho Ketsueki (in Japanese). 56 (7): 795–806. doi:10.11406/rinketsu.56.795. PMID 26251142.

[pmid23390027-11] George JN, Charania RS (March 2013). “Evaluation of patients with microangiopathic hemolytic anemia and thrombocytopenia”. Semin. Thromb. Hemost. 39 (2): 153–60. doi:10.1055/s-0032-1333538. PMID 23390027.

[pmid5108522-12] Westphal RG, Azen EA (May 1971). “Macroangiopathic hemolytic anemia due to congenital cardiovascular anomalies”. JAMA. 216 (9): 1477–8. PMID 5108522.

[pmid26447931-13] Hill QA (October 2015). “Autoimmune hemolytic anemia”. Hematology. 20 (9): 553–4. doi:10.1179/1024533215Z.000000000401. PMID 26447931.

[pmid24424170-14] Dolberg OJ, Levy Y (2014). “Idiopathic aplastic anemia: diagnosis and classification”. Autoimmun Rev. 13 (4–5): 569–73. doi:10.1016/j.autrev.2014.01.014. PMID 24424170.

[pmid23324217-15] Bustinduy AL, Parraga IM, Thomas CL, Mungai PL, Mutuku F, Muchiri EM, Kitron U, King CH (March 2013). “Impact of polyparasitic infections on anemia and undernutrition among Kenyan children living in a Schistosoma haematobium-endemic area”. Am. J. Trop. Med. Hyg. 88 (3): 433–40. doi:10.4269/ajtmh.12-0552. PMC 3592521. PMID 23324217.

[pmid26030647-16] Drawz P, Rahman M (June 2015). “Chronic kidney disease”. Ann. Intern. Med. 162 (11): ITC1–16. doi:10.7326/AITC201506020. PMID 26030647.

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