Hemat

ology(
Midt
erm)
VI
TAMINB12ANDFOLI CACI
DDEFI
CIENCY reser ves tor e( met hylcobal ami n)
ofB12.
Megal
obl
ast
icanemi a o Trans cobal ami nI II(CI I
I)–al s
o
 Propos edear lyi n1960’ sast he anal pha- globul inandmayact
met hyl folat et r ap asadef encebydepr iving
 Char act eriz edbydef ect i
ves ynthes isin pat hogensofB12.
DNA  TwoMechani s ms
 Res ultf rom l ackoff ol i
caci dorVi t.B12 o Act ive( 75%) -requi r est he
 Macr ocyt i
canemi a( l
ar geRBCsi nt he pres enceofi ntrins i
cf actor(a
ci
rcul ation) glycopr oteinpr oducedbyt he
 Ass ociat edwi thi nef fect ive mucos a).
erythr opoi es is o Pas sive–occur sbydi f f
usion
 MCV>100f lbutnor malMCHC andwor kswhen
 Macr ocyt i
cornor mochr omi c phar macol ogi caldos esof
vitami nB12ar einges ted.
 Pres enceofmegal obl as tinBMand
macr ocyt ic  Stor
agesites
o Duet ot hedef ect iveDNA o Tot alamountofvi tami nint he
synt hes is bodyi s2- 5mg
 Vi tB12( cobal ami nand o Maj ors i
te:liver
fol atedef iciency o Excr et edt hrought hebi l
eand
sheddi ngofi ntes tinalepi thelial
 Vitami nB12
cells
o Es s ent ialnut r ientcons i
s ti
ngof
o Mos tex cret edVi t.B12i sagain
tet rapyr rol e(cor rin)r ing
abs or bedbyt hei nt est i
ne.
cont aini ngcobal t.
(ent erohepat iccircul at i
on)
o Tr ans f erofmet hylgr oupf rom 5
-met hylTHFt ohomocys teine  Si
gnsandSympt oms
o Sour ces o fatigue
 Di ar ypr oduct (fish,eggs ,
meat )
 NoVi t.B12i spr es enti n
veget abl es
 Folicaci dorf ol at e
o Us edf oranyf or m ofvi tami n
fol icaci d
o Synt het icf or mi ns uppl ement
andf or tifiedf ood
o Pl aysasani mpor tantr olei n
met abol ism ofami noaci dsand
nucl eot ides
o Ci rcul atei nt hebl oodasmet hyl
fol at e
o mus cl eweaknes s
o Sour ce:gr eenveget abl es,yeas t
o l os sofappet i
te/
weightloss
andcer eal s
o di arrhea
 VitB12Abs or pt ion
o naus ea
o Vi tB12t rans por ti smedi at edby
o f asthear t
beat
thr eedi f fer entbi ndi ngpr ot ein
o s moot hort endertongue
thatar ecapbl eofvi ndi ngt he
o t inglingi nhandsandf eet
vitami nati tsr equi red
o numbnes sinex t
remit
ies
phys iol ogi calcon’ c
Causes/Indivi
dualsatRi skofMegal obl
astic
 I nt rins icf act or(IF)f or ms
Anemi a
apr ot ect ivecompl ex
 Age
wi thB12t hati s
o - Olderpeopl e>60
trans por tedi nt heGI
tract  Fami l
yHi stor y
o Tr ans cobal ami nI I( TCII)-abet a  Di etaryHabi ts
-gl obul inpr oducedbyt hel i
ver  St ri
ctveget arianwhodoes n’
teatany
andt hedomi nantcar ri
erof animalordai rypr oductsanddoes n’
t
B12af terabs or pt ion.Al sot he takeavi tami nB12s upplement
mai nagentf orr api dt r
ans por t  Al coholics
ofVi t.B12. LaboratoryDiagnos is
o R( rapi d)Pr ot eins /R-bi nder s  Scr eeningTes ts
o Tr ans cobal ami nI( TCI I
)-an o Compl eteBl oodCount
alpha-gl obul inpr oduceby  ↓Hb,Hct ,
RBCs ,WBCs,
gr anul ocyt es.Aci rcul at i
n Platelets
 ↑MCV,MCH(nor malMCHC)

1
Hemat ol
ogy( Mi dt er m)
o Mor phol ogy PERNICIOUSANEMI A
 Hyper s egment edNeut rophi l
s,  autoi
mmunedi sorder
ovalmacr ocyt es ,  gastr
icat r
ophyofpar i
etalcel
ls
ani socyt es ,poi kilocyt es,  Reduceds ecreti
onofIF( i
ntri
ns i
cfact
or)
RBCi ncl us ions( Howel l  vit
aminB12def i
ciency
J olly,CabotRi ngs , Eti
ology
Bas ophi l
icSt i
ppl ing)  ImpairedRBCpr oductioncaus edby:
 Abs ol ut er eticul ocyt ec ount  Cobalami ndefi
ciencymayr esultfr
om
 decr eas ed thefollowing:
 Gas tr i
cAs say o Inadequat ediet
aryint
ake
 Forachl or hydi a o Atrophyorl ossofgastri
c
(inabi lityt opr oduce mucosa
HCl )t husdi et aryB12 o Funct i
onallyabnormalIF
can’ tbes par ated o Bact er
ialovergr
owt hi
n
f rom t hepr ot eini n i
nt esti
ne
f ood.
Specif
icTes t
BoneMar r owExami nat ion Mor
phol
ogyandclas
sif
icat
ion
 As ynchr onyofNucl eusandcyt opl as m  Macrocyti
cAnemi a
 Hyper c ellul ar,↑er yt hroppoi et i
cAct ivi
ty,  Impr operbl
oodcel
l
Giantmet amyel ocyt e f
ormat
ion
Chemi str y  I mpai redDNAsynt hesis
 Tet sf ors er um B12ors er um f ol ateor  Vit.B12defi
ciency
RBCf olat e  Lackofi nt
rinsicfactor
Compet itivePr ot ei n-Bi ndi ngRadi oas say  I nadequat ediet
forB12andFol at e  Los sofgast ri
cmucosa
 Pat i
ent sB12andf ol atei ns er um  I lealdysfunction
compet ewi thCo- label edcobal ami n Pat
hogenes
is
andI -label edf ol icaci d  Genet i
cfact
or
 B12bi nder :HogI F o Commonbl oodgr oupA
TheSchilli
ngTes t o Ancestry(Nor thernEur opean,
 Meas ur evi abl eI Fandabs or pt i
onof AseanAncest
ry)
B12 o Eyecol
or(
blue)
,whi
teski
n
 Ur i
nar yex cr et i
onofco- l
abel edf olic compl
exi
on
acid  Aut
oimmunefactor
 Tot es tt heabs or pt ionofr adi olabel ed o Pre-exi
sti
ngaut
oimmune
B12i nt heabs enceandpr es enceof di
sease
orallyadmi ni s ter edI F o Abagai ns tpar i
et alcell
s&I F
 I FDef iciencyi f2ndt es ti snor mal ,B12 ThreetypesofAnt i
bodi es
mal abs or pt ioni fbot het es t sar e  Type1-bl ocksvi taminB12andI F
abnor mal . binding
 Nor mal ly7% i sex cr et edoft he  Type2-pr eventsbi ndingofI F-B12
admi nis ter eddos eofCo- B12.3% f or compl exwi t
hi l
ealr ecept or
s
Per niciousAnemi a  Type3-agai nsts pecifi
cs tr
ucturesin
 Speci f i
cTes t thepar i
et alcell.
DeoxyuridineSuppr es sionTes t Cli
nicalSigns&Sympt oms
o Ver ys ens itive  Macr ocyticanemi a
o Def ecti nt hymi dines ynt hes is  Gl ossiti
s
eit herb12orf ol at edef iciency  Pal enessoft hes kin
UrinaryExcr etionofMet hyl mal oni c Aci d  Fat igue
o Speci fict es t:becaus eonl yB12  Shor t
nes sofbr eat h
toget herwi thas peci fi
cenz yme  Per ipheralneur opat hy
conver tsmet hyl mal oni cCoAt o  degener ationofs pi
nalcor d
succi nylCoA
 Par esthes ia
X-rayorEndos copi cSt udi es
o Ti ngl i
ngs ensationduet o
o Thi sf ors us pect edPer ni cious
 ner vedys function
Anemi a( PA)
Screening&Conf i
rmat oryTes t
 BoneMar r owChanges
 Abagai ns tpar i
et alcell
s&I F
o Mar kedl yhyper cel lular
 Endos copy
o Myel oid:er yt hroi dr atio
decr eaes edorr ever sed  Ser um B12l evel -<160ng/ L
o Er yt ropoi es is:MEGALOBLASTI C  CBCCount
 MCV->100f L
 Bonemar r owex ami nation

2
Hematol
ogy(Midterm)
 Schi l
li
ngTes t  BM-Megal oblast
Howisthetestisper for
med?  Ir
ondeficiency
o I ncludesf ourdi f
ferents tages  Eti
ologyandMor phol ogy
 St ageI:twodosesofvi t.B12 - devel opswhent heintakeof
 Fi rs
tdos e:radioact i
vef orm i
roni snotenought omeett he
ofVi t.
B12( mout h) standardl evel
 Seconddos e:largerdos eby -i mpai redabs orpti
on
shot1hrl at er -t hereisachr oniclossof
 Ur i
necol l
ect i
onovert he hemogl obi nint hebody
next24hr s - gas trointestinaltr
act
 Abnor mal : abnor maliti
es
i nabi li
tyofPCt os ecreteIF
 St ageIi sdone3-7daysl at
er I
RONDEFI CI ENCYANEMI A
 St ageII  ischar act eri
z edbyvar i
abledegr eesof
 Fi r
s tdose:Radioact ive mi cr ocytos is( MCV<80f l)and
VitB12w/I F hypochr omi a( MCHC<32g/ dl)whi ch
o Abnor mal :Proceedt oSt ageIII resul tsinwi deni ngoft hecent ralpal or
 St ageII
I account ingf or>1/ 3oft het otalRBC
 Doneaf tertakingAnt ibioti
cs diamet er.
for2weeks  Thevar iat i
oni ncel ls i
zer esultsinhi gher
o Maycaus eduet oVi tB12 RDW r eflectingt hef actt hatir on
consumpt
ionbybact
eri
a def iciencyi sacqui r
eddi sorderwi th
 StageIV differ entl evel sofhemogl obinpr oduct i
on
 Pancr eaticenz ymef or3days inr edcel ls.
 Followedbyr adi oact i
vedos eof Pat
hogenes is
VitB12  Hemogl obi ns ynt hes i
si simpai redasa
 NormalRes ul ts cons equenceofr educedi r
ons upply.
o Anor malr esul twoul dr equir
e  Ther eadef ecti ncel l
ularpr oliferati
on.
urinatingei ghtt o40per centof  Sur vivalofer ythr oid
ther adiolabel ledvitami nB12 precur sorsand
within24hour s. eryt hrocytesi sr educed
 AbnormalRes ults
o Abnor mals tageoneandnor mal
staget wo  i
ndi cat esthes tomach
i
sunabl et omakei ntrinsic
factor.
 BM- Megaloblas t
spr es ent
 PS-Macrocyt esar eobs erved
o 6- lobedpol ymor phonucl ear
l
eukocyt eispr esent

NON-
MEGALOBLASTI CMACROCYTI CANEMI A
 Macr ocytos i
s -duet otheex ces sRBC
membr aneoccur si npat ientwi th
chronicdi seas es .
Si
gnsandSympt oms
o MCVofabout100- 105f L
 Fati
gueandot hernonspeci
fi
c
 canoccurwi thchr onical coholus e
sympt oms
 Thesear edi sor der sinwhi cht he
 Epit
hel i
altis
s ue
macrocyt os i
si snotpr imar i
lyduet o
 Immuni tyandi nfect
ion
vit
ami nB12 orf oli
caci ddef iciency
 Pica
 Heret hemacr ocyt esar e“ ROUND”
 Genitourinarys ys
tem
 Relatedt ochangesowi ngt odi sruption
 Skeletalsystem
ofthechol es ter ol-to-phos pholipid
rati
o
 Diagnos i
s
Scr
eeni
ngandconf i
rmat orytestusedt o
- CBC,RBCi ndi ces,r eti
culocyte
det
ermi
nethetypeofanemi a
count , andper i
pher alsmear
 Scr
eening
- Hemat ocritandHemogl obin
- Somet imesbonemar r
ow  Routi
neCBC
exami nation o I fCBCf indingsshowa
- Abs enceofhyper s egment ed hypochr omic,microcyti
canemia
neut rophi lsand withanel evatedRDW butno
macr ooval ocyt es cons i
stentshapechangest othe
RBCspat i
entissuspectedIr
on
 PS-s tomat ocyt es ,reticulocyt es
defici
ency

3
Hemat
ology( Midterm)
o el evat edRDW [ RBCdi st
ributi
on aredecr eas edi ni r
ondef iciencyanemi a,
wi dt h] as tatecal leds ideropeni a.
o RBCcount&hemat ocrit  Meas urement :Radioimmunoas says
decr eases  Ref er encer ange:
 Ast hehemogl obinl evelcont inuesto  Men:15- 200ug/ L
fall
,micr ocyt osi
sandhypochr omi a  Women:12- 150ug/ L
becomemor epr omi nent ,with ADDI
TIONALTEST
progres sivelydecl iningval uesformean  Fr eeer ythrocyt eprot opor phyr ini san
cellvolume( MCV) ,meancel l ear lyi ndicat orofani ronmet abol i
sm
hemogl obi n( MCH) ,andmeancel l dis order .
hemogl obi nconcent rati
on( MCHC) .  Meas urement :Hemat ofluoromet er
 Lowabs ol uter eticulocyt ecount --  Ref er enceRange:<50ug/ dL
diminishedr ateofef fective  Ther apeut ict ri
alofi r
onpr ovidesal ess
erythropoi es isbecaus ethi sisanon invas i
veandl essex pens ivedi agnos ti
c
regener ativeanemi a as ses sment
 Zincpr otopor phyrinisas sayed
Conf
irmat
or ytests
fluor omet rical l
y
o s erum ir
ont ot
ali
ron-
bindi
ng
 Per ipher albl oodf i
lmf rom apat ient
capaci t
y( TI
BC)
wi thhypochr omi c,mi crocyt i
c
 tr ansf
err i
ns at
urati
on
anemi a.(
X1000)
 s erum ferrit
in
 Irondef i
ciencyanaemi a:per ipher al
bloodf il
ms howi nghypochr omi c
 Ser um i r oni sameas ur eoft heamount mi cr ocyt es,el li
ptocyt es,penci lcel l
s
ofir onboundt ot r ans f erri
n( transpor t andf ragment edcel l
s.
prot ein)i nt hes er um.
 (x1000)
 Pr inci ple:Ser um f er r i
ci r
oni sf i
rst
 Bonemar r
owss mearf rom apat ient
removedf rom at tachmentt o
wi thi rondef ici
encyanemi a.(x1000)
trans fer rinbyt headdi tionofa
 Per l’sPr uss ianbl ues tains howi ng
chemi cals uchas0. 05Nhydr oc hloric
hemos i
derini naf ragmentofbone
acid.
mar row.( x
1000)
 Meas ur ement :Spect rophot omet ryat
562nm
ANEMI
AOFCHRONI
CDI
SEASE
 Ref erenceRange:50- 150ug/ dL
 Mal e- 125um/ dL  Anemi aiscommonl yas soci
atedwith
 Femal e-100um/ dL systemicdiseas es,includingchronic
TI
BC i
nflammat oryc ondi tionssuchas
 i sani ndirectmeas ureof rheumatoidar thr i
ti
s ,chronici
nfecti
ons
trans ferrinandt heavai labl e suchast ubercul osi
sorhuman
bindi ngs i
tesf ori roni nt hepl as ma. i
mmunodef i
ciencyvi rusinfecti
on,and
 Pr inci pl e:Theconcent rationof malignancies.
trans fer ringi smeas ur edi ndi rectlyby
meas ur ing t heabi lityofs er um o Cartwrightwast hefir
stto
trans fer ringt obindr ion. sugges tal
thought heunderlyi
ng
 Meas ur ement :Spect rophot omet ryat diseasesseem quitedispar
ate,
562nm theas soci
atedanemi amaybe
 Ref erenceRange:250- 450ug/ dL( adult
) from as i
nglecause,proposi
ng
 Tr ans fer rins atur at ionmayonl ybe theconc eptofanemi aof
obt ainedi fser um i ronandTI BCval ues chronicdisease.Theanemia
areavai labl eandcomput ed. representsthemos tcommon
 Pr inci ple:Theper centoft rans fer r
in anemi aamonghos pi
tali
zed
satur at edwi thi roncanbecal cul ated patients.
from t het otali r
onandt heTI BC:
o Anemi aofchroni
cinf
lammat i
on
 Tr ans f er ri
ns aturat ion=S erumi ronX
TIBC istheprefer
redtermsincenot
100 allchr
onicdiseas
esare
associ
atedwiththisf
orm of
 Ref
erenceRange:20-
55% s
atur
ati
on anemia.

 Serum f er
rit
inisaneas i
lyaccess i
ble  Cyt
omet
riccl
ass
ifi
cat
ion
surrogatefors t
ainablebonemar row
ir
on.Thei rons tudiesareus ed  Nor
mochromic,normocyt
icanemi
a
coll
ectivel
yt oas sesstheironst atusof (
normalMCHC,nor malMCV).
anindividual.Showst hat,asex pected, o Theseinclude:
serum ferri
ti
nands er
um ironval ues

4
Hemat
ology(
Midt
erm)
o anemiasofchr oni
cdiseas
e  Level sincreasedur i
ng
o Inf
ection(parvovi
rusB19) inf
lammat i
on
o anemiaofr enaldi
sease  Hor monepr oducedby
o aplas
ticanemi a hepat ocytest or egulate
o Myelophthisi
canemi a bodyi r
onl evels
 I nteractswi th
 Hypochr
omic,microcyt
icanemi
a(l
ow ferropor ti
n
MCHC,lowMCV) .  Whenbodyi ronl evels
o Thes
ei ncl
ude: decr ease,hepcidi n
product ionby
o ir
ondef i
ciencyanemia, enter ocytesdecr eas es
thalassemi a  Nons pecif
icdef ens e
o anemi aofchr oni
cdisease(
rar
e agains tinvadingbact eri
a.
cases)  SecondPhas
eAcut eReact ant
o SideroblasticAnemia
o Lact
oferrin
 Nor
mochromic,macr
ocyt
icanemi
a  I r
onbi ndingpr oteini
n
(
normalMCHC,highMCV). thegr anulesof
o Theseincl
ude: neutrophi l
s .
 Gr eateravi dityiniron
 Vitami nB12def i
ciency thant ransferrin
 Apl as t
icAnemi a  Ar ei mpor tant
 Myel odysplasti
cs yndrome i
nt r
acel l
ularl
y
 Eryt hroluekemi a  Rel easedi npl asma
 Chr oni cLiverdisease duringi nfl
ammat ion
 folatedef iciencyands omedr
ugs
B.Et
iol
ogy  Thi
rdAcut
ePhas
eReact
ant

o ThreePathogeni
cMechani
sm o Fer
rit
in
toexpl
ainthedevel
opmentof  I ncreasedlevelsint he
anemiaduri
ngill
nes
s: plasmabi ndt os ome
i
r on
a.
1Impai
redmobi l
izat i
onofi ron  Unavai lablefor
i
ncor porationinto
 Lows erum i ronl evel
hemogl obin
 Decr easedi roni nmar rower ythroid
 Ef f
ects:abundanti n
precur sor
bonemar row
 Nor malori ncreas edironi nthemar r
ow
macr ophages
store
 r
eleaset o
a.
2.I
mpair
edmar rowr espons et oanemi a
developinger ythrocyt
e
 Def i
ciencyi ner ythropoiet i
nl evel i
ss lowed
 Res pons eofer ythroidmar rowt o
erythropoi etinmayber educed  Di
mini
shederyt
hropoi
esi
sanda
 a. 3.Shor teningofr edcel lsurvival bl
unt
edresponsetoer
ythr
opoi
eti
n
 Mi l
dr educt ioni nRBC’ sl ifespanasa
resultofex trac orpuscul arfact ors I
V.Def
ini
ti
veSi
gnsandSympt
oms
i
ncl udingover act i
vehis tiocyte
des tr
uct i
onofr edcel l
s. o Anemiaofchroni
cdiseas
eis
oft
enmild.Youmaynotnotice
o Factor
sthatCont
ribut
etot
he anysymptoms.
AnemiaofChroni
c o Whens y
mpt omsoccur,t
hey
Inf
lammation mayincl
ude:

 I
mpai
redFer
roki
net
ics  Feeli
ngweakort i
red
 Headache
 Di
mi ni
shed
 Paleness
er
ythropoi
esisanda
 Shortnessofbr
eath
bl
untedresponseto
er
ythropoi
eti
n

I
II
.Mechani
sm orpat
hogenes
isoft
heanemi
a

 Impai
redFerr
oki
neti
cs
 Fir
stAcut
ePhaseReactant
o RoleofHepci
din

5
Hemat
ology(
Midt
erm)
AnemiaofChr
oni
c
V.Screeni
ngandConfi
rmatoryTes
tst
o I
nflammati
on
deter
mi nethet
ypeofanemia
Ser
um f
err
iti
n I
ncr
eas
ed/
nor
mal
 Per
ipheralbloodpicture
o Mi l
danemi a Ser
um i
ron Decr
eas
e
o Hemogl obi
nconcent r
ati
on-9t
o TI
BC Decr
eas
e
11g/dL
o Wi thoutreti
culocyt
osis Tr
ans
fer
rins
atur
tion Decr
eas
e/nor
mal

 Cell
sarenor mocyti
cand FEP/
ZPP I
ncr
eas
e
normochr omic
o Mi crocytos
isandhypochromi
a BMi r
on(Prus
sianbl
ue
I
ncr
eas
e/nor
mal
developinaboutonethir
dof react
ion)
pat i
ents Si
der
obl
ast
sinBM None/
ver
yfew
 Leukoc
yt osisandThrombocyt
osis
Specif
ict
est
sfor
Si
deroblasticandRef ractoryAnemi a Ot
hers
peci
alt
est
s inf
lammator
ydis
order
sor
Si
deroblasticanemi as cancer
 ar ei ron- ut il
izati
on anemi as t hatar e
us ual ly par t of a myel odys plasti
c typicall
y s evere i n
s yndr ome, presentation.
 caus ing a nor mocyt i
c- normochr omic Acquir
edcl onals ider oblas ti
canemi a
anemi a wi th hi gh RBC di s
t ribut i
on  Cl onals ider oblasti
canemi asfallunder
wi dt h or a mi crocytic-hypochr omic the br oader category of
anemi a, par ti
cularly wi t
h i ncr eased myel odys plasti
cs yndromes( MDS).
s erum i ronandf erri
tinandt r
ans ferri
n Threefor
msexi standi nclude
s atur ation.  r ef r
act ory anemi a wi th r inged
 af or m ofanemi ai n whi ch t hebone sider oblas t
s( RARS) ,
mar row pr oduces r inged s ider obl ast
s  r ef r
act ory anemi a wi th r inged
rat her t han heal t
hy r ed bl ood cel l
s sider oblas t
sandt hr ombocyt osi
s(RARS
(eryt hr ocyt es ). -T) ,
 I ns ider obl asticanemi a,t hebodyhas  r efractor ycyt openi awithmul t
il
ineage
ironav ailabl ebutcannoti ncorpor at eit dys plas i
a and r i
nged s ideroblas
ts
intohemogl obin,whi chr edbl oodcel l
s (RCMD- RS) . Thes e anemi as ar e
needt ot r ans portox ygenef f
icient ly. as sociated wi t h increased r isk for
Cl
assif
ication leukemi cevol ution.
Congenitals i
der oblas ticanemi a
 Her edi tarys i
der oblastic anemi as ar e Acquiredrever s i
bles i
deroblas ti
canemi a
us ual lys mal l(mi crocytic)andofpoor  Caus esi nclude ex ces si
ve alcoholus e
col or( hypochr omi c)andt husmus tbe (the mos t common caus e of
di stingui shedf r
om i rondef i
ciencyand sider obl astic anemi a), pyr i
dox ine
thal as semi a. def iciency,l eadpoi soning,andcopper
def iciency.
- X- l
inked s ider obl ast
ic  Ex ces s z i
nc can i ndirectly caus e
anemi a: sider obl astic anemi a by decr easing
 mos t common congeni tal caus e of abs or pt i
onandi ncr eas i
ngex cretionof
sideroblastic anemi a and i nvol ves a copper .
defecti nALAS2,whi chi sinvol vedi n  Ant imi crobials t hat may l ead t o
the f i
rsts tep of heme s ynt hesi
s. sider obl asticanemi ai ncludei soni azid,
Although X- l
inked,appr ox i
mat elyone chl orampheni col, cycl oseri
ne, and
third ofpat i
ent sar e women due t o li
nez olid.
skewedX- inactivation. Pathogenesis
 Aut osomal r eces si
ve s ider obl ast
ic  The pr ocess begi ns i n t he
anemi a mi tochondr i
on wit ht hecondens ation
 involves mut ations i nt he SLC25A38 ofgl ycine and s ucci nyl-CoA t of orm
gene.\ del ta- ami no l evul i
ni c aci d ( ALA) .
 itisinvolvedinmi tochondr i
alt rans port Pyr idox alphos phat ei sacof actori nt he
ofgl yci
ne. react ion. ALA t hen moves t o t he
o Gl yci
ne cyt opl asm wher e s everal addi ti
onal
 i sas ubstratef orALAS2 enz ymat ic t ransfor mat ions pr oduce
andneces s ar
yf orheme copr opor phyrinogen I I
I.Thi smol ecul e
synthes i
s.Theaut os omal ent er s t he mi tochondr i
on wher e
reces si
ve for m is addi t i
onalmodi fi
cat ions ,includingt he

6
Hematology( Mi dter m)
inser ti
on of i ron into the
prot opor phyr i
n IX ring by
ferrochel at ase,pr oduceheme.Def ect s
in t he cyt opl asmi cs teps of heme
bios ynt hes i
s caus e var i
ous f orms of
por phyr ia.Funct i
onalabnor mal itiesof
the enz yme por phobi linogen
deami nas e,f ori ns tance,pr oduc eacut e
intermi t tentpor phyr ia.
 I n cont r as t,def ect si nt he s teps of
heme bi os ynt hes ist hatoccurwi t
hin
the mitochondr ion pr oduce
sider obl as tic anemi as . For i ns tance,
per turbat ionsoft heenz ymat icact ivi
t y
ofdel ta- ami nol evul i
ni caci ds ynt hase
(ALAS)pr oduc es ider oblast i
c anemi a.
The X- linked her editarys ider obl astic
anemi asr esul tf rom mut at i
onsi nt he
geneencodi ngALA- S.
 Def initiveSi gnsandSypt oms
- Ski n pal enes s, Fat i
gue,
Di z zi
nes s,Enl argeds pleen
andl iver
Scr
eeningandConf irmat or yTes ts
 Rout i
nel abor ator yt es ti
ngmaybeus ed
todi s coveri nci dent aldi seas e.
 Genet i
ct es ti
ngpr ovidesconf irmat ion
oft hedi agnos isf ormos tpat ient swi th
heredi tar yhemochr omat os i
s.
 Li verbi ops ywi th as s essmentofi ron
staininganddegr eeofs carringi nl i
ver
speci mensi ses s ent i
alt odet er mi ning
thedegr eeofor gandamage.

Bl
oodPi
ctur
e
o Peri
pher albl oods mears howing
manyhypochr omi cand
microcy t
iccel ls.
o Bonemar rows mears howi ng
eryt
hr oidhyperpl asi
a,
eryt
hr oblas t
swi thdefective
hemogl obi ni
z ationand
eryt
hr oblas t
scont aini
ng
multiplePappenhei merbodi es
andmos teryt hroidpr ecursors
arerings iderobl as t
s.

7
Hemat ology(Midt erm)
PORPHYRI AS
-dis
easeschar acterizedbyi mpairedpr oducti
onof HEMOCHROMATOSI SandHEMOSI DEROSIS
heme.  Hemos iderosi
s- i
sfocaldeposi
tionofir
onthat
-maybe: doesnotcaus et is
suedamage.
 Acqui redPor phyria–LeadPoi soning *Trans f
usi
on- relatedhemochromatosi
s¬-
 I nher i
tedPor phyr i
a–deficiencyinenzymes whent herei sarepeatedtr
ansfusi
onfor
int heproduct ionofhemepat hway anemi cpatients,andtheir
onf r
om theRBC
-cancaus eSideroblas ti
cAnemi a( defi
ciencyin wil
lbeaddedt othenormal1mg/ daythat
theenz ymeAmi nolevuli
nicAcid( ALA) wil
lbes toredi nthebody.
Synthethas e,
ALAdehydr at
ase,Fer r
ochelatase.
 Hemochr omatosi
s(i
ronoverl
oad)
-isa
typi
cal
lysystemi
cprocessinwhi
chir
on
deposi
tioncancauseti
ssuedamage.

Pat
hogenes is
1.For mat ionofHemos iderin
-inactivemet aboliteandar esul
tof
degener ationoff erri
tininsidethecel l
2.Accumul ationofFr eeIron( Ferrous)
-Fer r
ousi nt hepr esenceofox ygenwi ll
reactt of orm Super ox i
desandFr ee
-
Cli
nicalSignandSympt oms :
radicals
 Por tWi neRedUr ine(porphyrininur i
ne)
3.Per oxidat i
onofAl lki
ndsofMembr anes
 Ski ni sverysensi
tivetolight,especiall
y
¬- Super oxidesandFr eeradicalswill
directsunlight(f
luorescentproduct so
breakdownmembr anes( Cellmembr ane,
 Eyesmayal sobes ensiti
vetobr i
ght
l
ys osomalmembr ane,Mi tochondr i
al
sunlight
membr ane,et c.
)leadingt ot hedeathof
 Ski nmayt akelongertohealaf terinjuryor
thecel ls.
blisteri
ng
 Anemi a
Cl
ini
calSignsandSympt oms
 Spl enomegal y
 Gol denColorSkin-hemos i
deri
ndepos i
ti
on
 Cirrhosis
-inducedJaundiceintheLi ver-
somet imesitcouldleadtocancer
 Bronz ediabetes-
Hemochr omatosisin
diabeticpati
ents(pancreasisaf
fected)
 Conges ti
veHear tFail
ure

Tes
ts
*Er ythroblastwi l
lappearbr i
ghtr edi
n  Tr
ansfer
rinSatur
ati
on-Scr
eeningTes
t
fluorescencemi croscope  Genet
icTesti
ng-Confi
rmator
yTest
*Er li
ch’sTes tfort hedetectionofAcute
Intermi tt
entPor phyr i
awhi chusesEhrli
ch's *Ser
um Fer
rit
ini
sel
evat
edi
nhemochr
omat
osi
s
aldehyder eagentcons istsofp-dimethylamino
benz aldehydei naci dsoluti
on Tr
eatment
*RingedSi deroblas t
,Sideroblas
tandSiderocyt
es  Wi thdrawalofBl ood-f
orhereditary
i
spr esentint hebl oods mear. hemochr omat osispati
ents
 Ir
on- chelati
ngdr ugs(Desfer
rioxami ne)
-bindwi t
hex cessirontheneli
mi natedin
orderfort heirontonotaccumul ateinthe
plasma

8
Hemat
ology(
Midt
erm)
5.Hypox i
cenvi ronmentl ower spHwhi ch
decr easesox ygenaf finity,whi chf ur ther
promot essickli
ng
SI
CKLECELLANEMI
A 6.Occl usionofcapi ll
ariesandar teri
esby
sickledRBCsandi nfarct i
onofs urrounding
Hemogl obi nS( α2β26GluVal) tissues
-congeni talc hroni chemol ysis Cl
inicalSignsandSympt oms
-subst i
t utionofGl utamat et oVal i
nei nt he6th  Vas oocclusion- mainpr oblem
Ami noaci doft heBet aGl obi nChai n  Spl enomegal yduet os plenics eques trat
ion
-Glutamat ehasachar geof( - 1)andVal inehasa  Epi s odesofPai n
chargeof( +0) ,achangeof( +1)char ge,s ot hat ’
s  Acut eches ts yndrome( f
ever ,ches tpai n
whyHemogl obi nSmi gratet oot herar eai n andpr esenceofpul monar yinfiltr
at es
electrophor es is  Pul monar yhyper tens i
on- fatal
-Glutamat eispol ar(hydr ophi li
c),Valinei snon-
polar( Hydr ophobi c) Tes
ts
-hasaHbSpol ymert hati sl ongands l
ender  Per i
pher alBl oodSmear
-lowox ygent ens i
onl eadst opol ymer izationof *Wr ights taini sus edandt hepr esenceofa
Hemogl obi nS long,cur vedcel lwi thapoi ntateachendi s
SickleCel ls pres ent .
 Rever s ibleSi ckleCel ls-HbS- cont aining *Tar getcel lisal sopr es ent
eryt hrocyt est hatc hangei ns hapei n  Ol dScr eeni ngTes t
res pons et oox ygent ens i
on. *addi t
ionofs odi um met abi sulf
ite(a
-nor malbi concav ewhenox ygenat ed,and reduc i
ngagent )onas l
idewi thadr opof
changesi ns hapewhendeox ygenat ed blood,t hemi xtur ei sseal edundera
-caus esvas sooccl us ivecompl i
cat ion( can cover slip.Hemogl obini sr educedi ntoit
s
pas st hrought hemi crovas culat ure deox ygenat edf or m,t heni tpr omot e
becaus ei tisnor malbi concavewhen polymer izationofHbS( ifHbSi spresent)
,
oxygenat ed,andi twi llchanges hapei n themor phol ogyoft hecel lwi llchange,and
tissuesbecaus eitwi llbedeox ygenat ed) itisex ami nemi cros copi cal l
y.
 I rrever sibleSi ckleCel ls-donotchangei n  Hemogl obi nSol ubi l
ityTes t
shapewhet heri twi llbeox ygenat edornot . -reagentus ed:Saponi nandSodi um
-Elongat eds icklecel l
swi thapoi ntateach dithioni te
end *Saponi n- promot eslys edofRBC,
-removedbyt hes pl eenandt her ei sal ess releas i
ngHb
chancet hatitwi l
lent erthe *Di t
hi oni t
e- reactwi thHbconver ti
ngitto
mi croci rculationandcaus evas ooccl usions. itsdeox ygenat edf orm
-Deoxygenat edHbSi sins olubleand
Intracell
ularHydr at ion preci pitatesi nt hes olut ionwhi chcauses
-Poly meri
z eddeox yhemogl obi nactivat esPsickle turbidi ty.Nor malHbi scl ear
membr anechannelwhi chdecr easest heox ygen  Elect rophor esis
toles sthan50mm Hgandal lowingt hei nf
luxof *Cel luloseAcet ate- co-mi gr atewi t
hHbD
2+
Ca whi chwi llactivatesecondmembr anechannel andG
call
edGar dosChannel *Ci t
r ateAgar -mi grateal oneaf terHbC
-Gar doschannels timulatest heef fl
uxofK+andCl
-,wat ereffluxwi l
lt henfollowt omai ntain Treat
ment
equilibr
ium -Suppor
tiveTreat
ment
-Wat ereffluxcaus esdehy drationoft hecel l,  Neonat als
creening
therebyt heHbSc oncentrat i
oni shigher ,soasa  Chi l
hoodprophylacti
cpenici
ll
int
her
aphy
resultpolymer i
zationofHbSi sintens if
y  Bonemar r
owt ranspl
antat
ion
 Treatmentwi t
hhydr oxyur
ea
Pat
hogenes i
s
1.HbSi nRBCSi sl
es ssolubleforming *Si
ckl
ecellt
raiti
sresi
stanceagai
nsti
nfect
ion
tactoids/ l
iquidcrystalsthatcausessickli
ng wihPl
t asmodium f
alci
parum.
2.Bl oodbecomesmor eviscouswhens ickle
cell
sandpol ymersar eformed Hemogl obinC- Harl
em (C-Georgetown)
t
h
3.I ncreaseBl oodvi scositycausedecrease -doublesubs t
itut
ion,6 AA,Gl utamatet
oVal
ine,
bloodf low. rd
73 AA,As paragi
netoAs part
ate
4.I ncreasebl oodf l
owpr olongstheexpos ure -Pos i
ti
veinHemogl obi
nSol ubi
li
tyTest
ofHbS- containi
nger ythrocytestoa
hypox icenvi ronment . Hemogl
obi α2β26GluLys)
nC(

9
Hematol
ogy( Mi
dterm)
-Hashemoglobi
nCCr ys t
al,als
oknownasgol
d Hemogl
obi
nD(α2β2121GluGln)
barcr
ystal
s(hexagonalcr ystal
s) Hemogl
obi
nG(α268AsnLysβ2)
-pr
oducemi l
dhemol yticanemi a Hemogl
obi
nO-
Ar ab( α2β2121GluLys)
26Gl
uLys
HemoglobinE(α2β2 )

10
Hemat
ology(
Midt
erm)

UNSTABLEHEMOGLOBI
NVARI
ANTS -
res
ult
sfr
om genet
icmut
ati
onst
ogl
obi
ngenes
11
Hemat ology(Midterm)
creatinghemogl obinpr oductsthatpr eci
pitat
ein
vivo,pr oduci
ngHei nzbodi escaus i
ngahemol yt
ic
anemi a. HEMOGLOBINSWITHI
NCREASEAND
-maj orityofthesevari
ant sareβchai nvariants DECREASEDOXYGENAFFI
NITY
-befor eitwascalledCongeni talnons pherocytic
hemol yti
canemi aorCongeni talHei nzbody Recal
l:
anemi a  Deoxygenat edHemogl obin
-
pr oper l
ycall
edUns tableHemogl obindisease -Tenseds tate
-allpat i
entsareheterozygousbecaus e -l
owaf f
init
yf orhemel i
gand:oxygen
homoz ygousisnots uit
ableforlife -highaffini
t yforBohrprotonsand2,3-
-mos tpr eval
entuns t
ablehemogl obinisHbKöl n BPG
 Oxygenat edHemogl obin
CausesofHemogl obinVariant s -Relaxeds tate
1.Subs tit
uti
onofachar gedforanuncharged -highaffini
t yforhemel i
gand:oxygen
aminoacidintheinter i
orofthemolecule -l
owaf f
init
yf orBohrprotonsand2,3- BPG
2.Subs tit
uti
onofapol arf oranonpolar
aminoacidinthehydr ophobicheme Hemogl obinswi t
hInceas edOxygenAf fi
nity
pocket -HbAbr uzzoandHbCr et e
3.Subs tit
uti
onofanami noacidintheαand -failedt oreleaseox ygenr esulti
ngt ohypox i
a
βchainsattheinter
s ubunitcont
actpoints -hypox i
at ri
ggerskidneyt or eleaseerythropoieti
n,
4.Repl acementofanami noacidwit
hpr ol
ine whi chl eadst ocompens ator yerythropoiesis
intheαhelixsect
ionofachai n -donotpr ecipi
tateinvi vot opr oducehemol ysi
s
5.Del eti
onorelongati
onoft hepri
mary -noabnor malRBCmor phol ogy
str
ucture -det ectedbyEl ectrophor esisus i
ngCi t
rateagar
(pH6. 0)orbygelel ectrophor esis.
Cl
ini
calSi
gnsandSympt oms -Ox ygenAf fi
nitymeas ur ementf ordefi
nitive
 Hemol yt
icAnemia diagnos i
s
 Jaundice -pat ientsareus uall
ynor malanddon’ trequire
 Splenomegaly treat ment
 DarkUr i
ne(cont
ainsdi
pyr
rol
e)
Hemogl obinwi thDecreas edOxygenAf finit
y
Tes
ts -HbKans as
 Per ipher alBl oodSmear -quickl
yr el
easeox y
gent ot heti
ssues,whi ch
-pr omi nentbas ophi l
ics tippl
ing result
sinnor maltodecr easedhemogl obin
-Supr avitalstainswouldhowHei nzbodies concent r
ationands l
ightanemi a
(l
ar gerandnumer ous ) -detectedbySt archgelelectrophoresis
,HPLC,or
 Elect rophor esis DNA- bas edglobingeneanal ysi
s
¬- notdet ectedbecaus eitmi grates
toget herwi thnor malAApat tern
 Isopr opanolPr ecipitationTes t THALASSEMI
A
-Isopr opanol@ 37degr eesCweakenst he -gr
oupofhet
erogeneousdisor
dersi
nwhichone
bondi ngf orcesoft hehemogl obin ormoregl
obi
nchainsarereducedorabs
ent
mol ecule.Ifuns t
ablehemogl obinsar e
pres ent ,rapidpr ecipi t
at i
onoccur sin5
mi nut es,heavyf locculat i
onoccur saft
er20
mi nut es.
*Nor malhemogl obindoesnotpr ecipi
tate
unt ilappr ox i
mat ely40mi nutes.
 Heatdenat urationTes t
-incubat i
on@ 50degr eesCf or1hour .
*Uns tablehemogl obi ns howaf l
occulent
preci pitation
*littleornopr ecipitationf ornormal
hemogl obin
 Hi ghPer formanceLi qui dChr omat ography
 DNA- bas edgl obi ngeneanal ysis

Treatment
*Inseverecas
es,Spl
eenmustber
emoveto
reducesequest
rat
ionandr
ateofr
emovalofRBCs

12
Hemat
ology(
Midt
erm)
o Sil
entCar rierStat e( βsilent/β)
-caus edbyonemut atedβgenet hat
producesas malldecr eas einβchai ns.
-nor malbl oodpi ctur e
o β-Thal assemi aMi nor
-mi l
d, asympt omat i
c,mi cr ocyti
c,
hypochr omi canemi a
-elevatedHbA2l evel
o β-Thal assemi aMaj or
-sever eanemi aleadi ngt ot rans
fusion
dependence
o β-Thal assemi aInt ermedi a
-mani festabnor mal iti
eswi thas everi
ty
bet weent hos eofβ- Thal assemiaMaj orand
β-Thal assemi aMi nor

*HbLeporethalassemi
a
-her
editarypers
ist
enceoff
etal
hemoglobin

-r
esult
stohypochromi
c,micr
ocyti
canemi
aduet
o TESTS( forbot hαandβThal assemia)
decr
easedproduct
ionofhemoglobi
n o Compl eteBl oodCount
-hemogl obinandhemat ocri
taredecreased
ALPHATHALASSEMI A -l
owMCV,MCHC
-caus edbyadel etionofoneorbot hoft heα -RBCDi stri
but ionWi dth(RDW)i selevat
ed
genesonchr omos ome16,r esultingi nr educedor o Ret iculocyt eCount -elevated
abs entpr oduct ionofαchai ns o BoneMar rowExami nation
-tetramer sofγchai nsmaypr eci pitateasHbBar t o Os mot icFr agili
tyTest-decreased
inthef etusandnewbor n o Supr avitalSt ai
ning
-tetramer sofβchai nsmaypr ecipi tat
easHbHi n *HbHi nclus ion-gr
eeni s
hbl uebodies
theadul t o El ectrophor esis
-dividedi nto:
o Si lentcar ri
erα- thalass emi a
-res ultoft hedel eti
on,orr arelyanon APLASTICANEMIA
del etionalmut ati
on,ofoneoff ourαgenes -i
sararebutpot
ent
ial
lyf
atalbonemar
rowf
ail
ure
(-α/ αα)or( T
αα/ αα) syndr
ome.
-as soc iatedwi t hanor malRBCpr of i
leand
isas ympt omat ic
o α- Thal as semi ami nor
¬- resul toft hedel etionoft woαgenes( -α/
-α)or( - -/αα)
-mi ld, as ympt omat ic,mi crocyt ic,
hypochr omi canemi a,HbA2i snotel evated
o HbHdi s ease
-res ultoft hedel eti
onoft hr eeoft hef our
αgenes( --/-α)
-HbHi ncl usions( exces sβchai ns)
preci pit ateinol derci r
cul atingRBCs ,
caus ingahemol yticanemi a
-RBCsar emi cr ocyticandhypochr omi c,
simi lart oβ- t halassemi ai nt ermedi a
o HbBar thydr opsf et al
is
¬- resul toft hedel etionoff ouroft heα
genes( --/--)
-sever eanemi ai nut er
o
-incompat i
blewi thlife

BETATHALASSEMI A
-cl
ini
cal
lymani
fes
tedas
:

13
Hemat
ology(
Midt
erm)

AcquiredAplast
icAnemi a
-cl
assifi
edasidi
opathic(70%)whenthecauseis
unknownandass econdary(10%)whenthecause
i
sident i
fi
ed
-pancytopeni
aiscommon( decr
easebl
oodcell
s)

Inher
itedAplas
t i
cAnemia
-showmanifestati
onsofthedi
sor
deratanear
ly
ageandmayhavephys i
calmal
for
mati
ons.

o FanconiAnemi a
-Chr omos omei nstabili
tydi sorder
char act er
izedbyapl asticanemi a,physical
abnor malities,andcancers us ceptibil
it
y.
o Dys ker atosisCongeni ta-bonemar row
fai
lur e
o Shwachman- DiamondSyndr ome
-pancr eati
ci nsuf f
iciency ,cytopeni a,
skelet alabnor malit
ies ,anda
predi spos i
tionf orhemat ologic
malignanc ies.

14
Hemat ology(Midt erm)
PUREREDCELLAPLASI A
-isararedisorderofer ythropoies
ischaract
erized
byas electi
veands ever edecreaseInerythr
ocyt e MYELOPHTHI SI CANEMI A
precursorsinanot herwisenor malbonemar row. -inf
iltrationofabnor malcel lsintot hebone
-characteri
zedbys evereanemi a(normocytic), mar rowands ubs equentdes tr uctionand
reti
culocytopenia,andnor malRBCandpl at
elet replacementoft henor malhemat opoieticcel l
s .
count. -Cytoki nes ,growt hf actor s,andot hersubs tances
arer eleas esthats uppr esshemat opoies i
sor
Acquir
edPur eRedCel lApl asi
a destr oys tem,pr ogeni tor,ors tr
omalcel ls
,whi ch
¬-canbecat egoriz
edi nto: resultsinper ipher alcyt openi as.
 Pr imar yPRCA¬- maybei di
opathi cor -ifthei nfiltr
at i
onandpr oliferat i
onoft he
autoimmuner elated. abnor malcel l
sdi s ruptst henor malbonemar row
 Secondar yPRCA¬- mayoccuri n architect ure,pr emat urer eleas eofi mmat urecel ls
associati
onwi thanunder l
yingthymoma, from t hebonemar rowoccur s.
hemat ologi
cmal i
gnancy,solidtumor , -mildt omoder atewi thnor mocyt icer ythrocyt es
inf
ect i
on,chroni chemolyticanemi a, andr et i
cul ocytopeni a.
coll
agenvas culardi s
ease,orexpos ureto -pres enceoft ear droper ythr ocyt esandnucl eated
drugsorchemi cals. RBCs ,buti mmat ur emyel oidcel l
s
-i
nyoungchi l
drenitisal soknownasTr ansi
ent (l
eukoer ythrobl asticper ipher albl oodpi ct ure),
er
yht
obl
ast
openi
aofchi
ldhood megakar yocyt ef ragment s,andgi antpl atelet s
¬-
Trans
fuci
onsar
eini
ti
alt
her
apy alsomaybepr esent

Congeni talPureRedCel lAplasi

a:Diamond-
BlackfanAnemi a ANEMI AOFCHRONI CKIDNEYDI SEASES
-Ac ongenitaleryt
hroidhypoplasti
cdi sorderof -anemi aoccur sinmos tpatientswi thchronic
earlyinfancy kidneydi sease
-mut ati
onsingenest hatcodef orstructural -anemi acaus edbyi nadequatepr oductionof
ri
bos omepr oteins erythropoieti
nbyt hekidneys
-Mut ati
onsint heseri
bosomalpr oteinsdisrupt -anemi acanal sobecaus edbyUr emi ctoxins
ri
bos omebi ogenesisinDBA accumul ateint hebloodbecaus eoft hekidney
-macr ocyti
canemi awithreti
culocytopenia fail
ure,andt heyinhibiteryt
hr opoiesisand
-normalWBCandpl atel
ets shortent helifespanoft heRBCs
-treatmentisRBCt r
ansfusi
onandcor ti
cos t
eroi
ds -normocyt ic,normochr omicRedbl oodcel ls

CONGENI TALDYSERYTHROPOETI CANEMI A

(CDA)
-het erogeneousgr oupofr aredisorder s
char acterizedbyrefract
oryanemi a,r eti
cycl
openi
a,
hyper cellularbonemar r
owwi t
hmar kedly
ineffectiveer yt
hropoies
is,anddi st
inct i
ve
dys plasti
cchangesi nbonemar rower yt
hrobl
asts
.
-classifi
edi nto:
 CDAI
 CDAI I
 CDAI I
I

15