Vlad The Impaler

Affixed to the wall of 15A Grafton Street in England’s capital is one of London’s nearly 1,000 blue historical plaques, this one noting that Sir Henry Irving lived there between 1872 and 1899. Irving was a prominent actor and theater owner, a celebrity of the latter part of the nineteenth century. 

Just over two miles west, at 19 St. Leonard’s Terrace, another plaque commemorates the London residence of Bram Stoker, Irving’s assistant, and the author of the most famous Gothic horror novel of them all, Dracula. Purportedly the story was based on the exploits of Vlad the III, otherwise known as Vlad the Impaler, given his penchant for placing the heads of those who displeased him on spikes for all to see. As far as we know, however, he did not suck blood from necks, did not feel dead on his feet, sleep in a coffin, or avoid garlic! But from all the movies, one would have to live in the wilds of Transylvania not to know that Dracula’s victims displayed all the symptoms of anemia, the topic of today’s narrative.

Anemia originates from the Greek word anaimi, which literally means “lack of blood.” Circulating blood contains various components and performs several functions; leukocytes or “white blood cells” fight disease, platelets help clotting, serum contains various chemicals, and erythrocytes or “red blood cells” deliver oxygen picked up in the lungs and dump carbon dioxide to be exhaled. These cells contain hemoglobin, the clever substance that manages gas transport. Anemia is said to occur if there are either not enough cells, insufficient hemoglobin, or the hemoglobin present is not working properly.

If red cells are scarce that will be due to inadequate production, destruction inside the body, or losing blood – which is rather careless, frankly!

Failure to produce red cells may result from malfunctioning bone marrow in diseases, including the various leukemias. I always enjoy silly doctor jokes and telling someone that having iron deficiency does not mean their clothes are creased; in fact, it is one of the most common dietary causes of anemia. Other common production deficit causes are deficiencies of vitamin B12 – although that is most often due to an issue with absorption rather than intake – and lack of folate. Other elements needed to make red cells include protein, vitamin C, and many others, so severe malnutrition or adopting bizarre fad diets can cause problems. Pregnancy and breastfeeding induce anemia due to the demands of growing and nourishing a new AOPA member, so women should consider dietary supplements.

Various chronic diseases affecting gut, kidneys, or liver also impair production, as does cancer or inflammatory conditions like rheumatoid arthritis.

If hemoglobin is compromised, anemia may result. Sickle cell disease is so-called because an aberrant form of hemoglobin causes red cells to adopt a crescent shape instead of their more usual biconcave disc. In addition to anemia, these cells get stuck in small blood vessels, damaging organs, bones, and joints and causing immense pain in the process. Thalassemia is a group of inherited illnesses that cause anemia. The term is derived from the Greek word thalassa meaning “sea,” as it was first described in people from the Mediterranean, although it is a global issue.

Red cells may be destroyed internally because of various conditions where they are inappropriately "tagged" as foreign invaders such as in idiopathic thrombocytopenic purpura... now you know why we call it ITP! Certain medications may induce this kind of hemolytic anemia, meaning anemia caused by blood destruction, and include various antibiotics in the cephalosporin class, some anti-Parkinson's disease drugs, and a host of others.

Red cells may also be attacked by infections such as hepatitis, cytomegalovirus, and Babesiosis, a nasty tick-borne disease commonly found in the American Northeast and Midwest. This is another good reason to wear suitable clothing when walking in the woods, apply DEET or permethrin-containing anti-insect sprays, and perform a thorough tick-check after exposure.

As above, one can also misplace red cells, most obviously with trauma, which can lead to acute anemia. Blood can also be lost if the clotting mechanism is defective due to diseases like hemophilia or drugs that interfere with clotting such as aspirin and non-steroidal anti-inflammatory agents like ibuprofen, or due to ailments that lead to reduced platelet counts, which can make even minor afflictions like a nosebleed into a life-threatening event.

Chronic bleeding from the gut can be from multiple causes such as varices, swollen veins caused by liver disease, as well as from ulcers, tumors, aberrant blood vessels, hemorrhoids, and many others. The urinary system can also bleed from the kidney, bladder, or tubes in between and blood in the urine is always obvious and alarming. Women can lose larger than usual amounts of blood during menstruation from benign or malignant tumors in the uterus.

The word iatrogenic means “originating from a doctor” and refers to problems we cause directly. While significant blood loss can occur during surgery, it is very uncommon; most operations are almost totally bloodless contrary to media depictions. However, as has been noted, certain drugs can cause anemia and some surgical procedures lead to anemia, such as removal of the stomach for disease, or operations to address morbid obesity.

In addition to the effects of whatever is inducing anemia, symptoms may be very subtle such as fatigue, poor sleep, breathlessness, or even chest pain as the heart works hard to oxygenate the body with the little blood available to it. On examination a physician may see pale membranes inside the eyelids or mouth, detect a faster heart rate, hear a murmur, and find signs of the underlying cause.

You know the old joke “Why did Dracula break up with his girlfriend after she had a blood test – she wasn’t his type!” Investigations will include blood tests to measure the amount of hemoglobin, number, size, and shape of red cells and evaluations of the sort of precipitating circumstances described above, perhaps including a bone marrow biopsy or various scans.

Treatment will depend on the cause, but might include dietary supplementation, suppression of the immune system, drugs such as erythropoietin that stimulate red cell production, or even blood transfusion. And as a side note, please consider helping Dracula and give blood – becoming a blood donor can truly save a life and we need all we can get!

There are rare causes of anemia, and one described in the medical literature by a dear friend of mine concerned a prison inmate who was escorted to his hospital emergency room with profound anemia and melena, blood in his feces. It turns out this fellow had stolen medical syringe needles, would surreptitiously drain blood from his veins…and drink it, a condition called auto vampirism.

Seeing blood in the stool or urine, having frequent or persistent nosebleeds, noticing a tendency to bruise easily, or finding red spots on the skin, as well as feeling generally unwell should all lead to a doctor’s appointment. Anytime a pilot feels unwell, flight should not be an option; self-ground until fully recovered. If you are diagnosed with anemia, the implications for operating as a pilot will obviously depend on causation, but always put your health first and be sure to document the medical interactions in your report prior to an AME visit.

So, an aviator visits his doctor and says, “I keep seeing a vampire with fangs and a black cloak.” The doctor replies, “Have you seen a psychiatrist?” And our perplexed pilot responds, “No, just a vampire!” Don’t be faint of heart. If you think you are anemic see a doctor who can stake out the problem and deliver a silver bullet!

You can send your questions and comments to Dr. Sackier via email: [email protected] and listen to his weekly podcasts at:

Jonathan Sackier

Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

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