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Alinity hq

Microcytic Hypochromic Anemia


This patient presented with normal WBC, platelet and RBC counts; however, hemoglobin, hematocrit and MCV were below the reference range. MCH and MCHC were low and the RDW was normal.


Peripheral smear examination revealed uniformly small RBC with increased central pallor, moderate number of target cells and few ovalocytes. There was no evidence of an increase in polychromasia, which correlates with the reticulocyte count of 1.98 %.


These findings are consistent with a diagnosis of microcytic hypochromic anemia.


The microcytic anemias are a group of anemias with different etiologies. However, all are characterized by the presence of smaller sized red blood cells (microcytes). The normal MCV is 80-100 fL. RBC smaller than 80 fL are described as microcytic while larger cells (>100 fL) are called macrocytic.


In microcytic anemia, the red blood cells are most often also hypochromic. These cells appear paler than usual because of decreased intracellular hemoglobin. This is usually reflected by a lower than normal MCHC (normal range: 320-360 g/L or 32-36 g/dL). Thus, this type of anemia is described as “microcytic, hypochromic anemia.”


The most common cause of microcytic hypochromic anemia is iron deficiency, but in this case the presence of a moderate number of target cells makes beta thalassemia a possible differential diagnosis. Anemia of chronic disease/inflammation (ACD) should also be considered, although ACD is usually normocytic to mildly microcytic (MCV: 75-85 fL). Patients with iron deficiency anemia most often present with low RBC count; however, not in this case.

Numerical Results

WBC 6.98 10e3/μL
NEU 4.49 10e3/μL 64.4 %
LYM 1.75 10e3/μL 25.1 %
MONO .462 10e3/μL 6.62 %
EOS .221 10e3/μL 3.16 %
BASO .054 10e3/μL 0.78 %
IG 0.01 10e3/μL .012 %
NRBC 0.68 10e3/μL
NR/W 0.97

RBC 5.06 10e6/μL
HGB 10.3 g/dL
HCT 34.2 %
MCV 67.4 fL
MCH 20.4 pg
MCHC 30.2 g/dL
RDW 8.24 %

RETIC 100. 10e3/μL 1.98 %
IRF .382
MCHr 20.2 pg

PLT 316. 10e3/μL
MPV 7.35 fL
%rP 3.23 %

FIGURE 1. CHC x Volume (RBC):
Cellular hemoglobin concentration vs. RBC volume plot
This scatterplot shows that the microcytic hypochromic RBC population falls toward the lower left corner of the square that defines RBC size: 60-120 fL, and hemoglobin content: 28-41 g/dL. The position of RBC is consistent with an MCV of 66 fL and MCHC of 31 g/dL. The compact nature of the RBC population along the y-axis correlates with an RDW of 8.2% and normal level of anisocytosis. Normocytic (MCV: 80-100 fL) and normochromic (MCHC: 32-36 g/dL) RBC population would be positioned near the center of this square.
Intermediate angles of light scatter plot
This scatterplot shows the separation of the PLT and the RBC populations based on two angles of intermediate light scatter (IAS2 vs. IAS3). RBC (red) smaller in size are positioned near the platelet cluster (yellow); however, differences in the internal complexity of RBC and PLT enables differentiation between them. This suggests that the platelet count is not affected by the presence of microcytic RBC. In patients with normocytic RBC, there is a wider separation between the RBC and PLT populations due to differences in both size and internal complexity.
FIGURE 3. Volume (RBC):
RBC volume histogram plot
The peak (MCV) is skewed towards the left inner hash mark along the x-axis, due to the MCV of 66 fL. A normal sized population of RBC would be centered between the left and right hash marks. The small area under the peak along the x-axis represents a normal RDW and small degree of anisocytosis.
Alinity hq casebook. Microcytic Hypochromic Anemia. ADD-00061876-v2 2019. p.20-21

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