‫كلية التقنيات الصحية والطبية‬

‫قسم تقنيات التحليالت المرضية‬

3rd Stage

Blood Banking
Lecture 10

Dr. Hussam S. Aziz

MD, MSc. Medical Genetics
Hemolytic Anemias (HA)
• Group of diseases characterized by increased
destruction (hemolysis) of red blood cells
• Classification: Hemolytic anemias can be
classified according to:
– Onset: Acute or Chronic
– Site of hemolysis: Intravascular or Extravascular
– Cause: Hereditary or Acquired
– Cause: Intrinsic or Extrinsic

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Acute Versus Chronic HA
• Acute Hemolytic Anemia:
– Develops within hours or days
– Clinical features are more severe than chronic HA
– e.g. incompatible blood transfusion; infections
• Chronic Hemolytic Anemia:
– Gradual onset, might be lifelong
– The body adapts to low level of hemoglobin
clinical features are less severe than acute hemolysis
– e.g. hereditary spherocytosis; sickle cell anemia

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Extravascular Versus Intravascular HA
• Extravascular Hemolysis:
– Occurs in the macrophages of reticulo-endothelial
system (spleen, bone marrow, liver)
• Intravascular Hemolysis:
– Hemolysis occurs inside the blood vessels
– Hemoglobin is released in the circulation and free
hemoglobin can be detected by investigations
(hemoglobinemia)
– Free hemoglobin binds to haptoglobins and the complex
is removed by the reticulo-endothelial cells
– Hemoglobin is also excreted by kidneys, and can be
detected in urine (hemoglobinuria)
– In renal tubules, some iron is released from
hemoglobin hemosiderinuria
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Hereditary Versus Acquired HA
• Hereditary Hemolytic Anemia:
– Genetic cause, inherited from parents
– e.g. sickle cell anemia; G6PD-deficiency
• Acquired Hemolytic Anemia:
– The cause is acquired during life and can be
transient
– e.g. immune mediated HA; infection; drugs

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 Intrinsic Versus Extrinsic Cause
• Intrinsic causes of HA: Defect in RBCs
components, including:
– Hemoglobinopathies: e.g. sickle cell anemia, Hb C, etc.
– Cell membrane defect: e.g. hereditary spherocytosis;
hereditary elliptocytosis
– Enzyme defect: e.g. G6PD deficiency; pyruvate
deficiency
• Extrinsic causes of HA: the cause came from
outside the RBCs; e.g. immune-mediated HA,
infections, drugs, microangiopathic HA, etc.

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Clinical Features of HA
• Pallor of mucous membranes
• Jaundice
• Splenomegaly
• Increased urinary urobilinogen (dark color
urine)
• Pigment (bilirubin) gallstones
• Hemoglobinuria in acute, intravascular
hemolysis (might cause renal failure in severe
cases)
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Laboratory Findings
• Features of increased RBC breakdown:
– Blood film: microspherocytes, fragmented cells, etc.
– Increased serum bilirubin (unconjugated and bound to
albumin) in both, intravascular and extravascular
hemolysis
– Absent haptoglobins in intravascular hemolysis
– Increased urine urobilinogen, hemoglobinuria,
hemosiderinuria
• Features of increased RBC production:
– Reticulocytosis
– Bone marrow erythroid hyperplasia (normally,
myeloid:erythroid ration is 2:1 to 12:1, reduced to 1:1 or
reversed in HA)
• Specific tests: e.g. enzyme assay, DNA tests, osmotic
fragility test, etc. 9
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Immune Hemolytic Anemias
• Autoimmune hemolytic anemia:
– Caused by antibody production by the body against its
own red cells
– Characterized by positive direct antiglobulin test (DAT);
also known as Coomb’s test
– Autoimmune HA is divided into warm and cold types
according to whether the antibodies react more strongly
with red cells at 37°C or 4°C
• Alloimmune hemolytic anemias:
– Individual body forms antibodies against red blood cells
of another person; e.g. incompatible blood transfusion
and hemolytic disease of new born
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Classification & Causes of Immune HA

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Warm Autoimmune HA
• RBCs are coated with immunoglobulin (Ig),
usually IgG alone or with complement
• Antibodies react with RBCs best at 37°C
• Therefore RBCs are taken by the reticulo-
endothelial macrophages that have receptors
for the Ig Fc fragment
• Part of the coated membrane is lost, so the cells
become progressively spherical to maintain the
same volume; and is ultimately prematurely
destroyed, predominantly in the spleen
(extravascular hemolysis)
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Mechanism of Hemolysis in Warm AIHA

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Clinical Features of Warm AIHA
• Disease may occur at any age, in either sex and
present as hemolysis of varying severity
• Spleen is often enlarged
• Disease tends to remit and relapse
• It might occur alone or with other diseases like:
– Systemic Lupus Erythematosus (SLE)
– Chronic Lymphocytic Leukemia (CLL)
– Lymphoma
– Immune Thrombocytopenic Purpura (ITP) (Evan’s
syndrome) 17
Lab Findings
• Features of extravascular
hemolytic anemia (low Hb,
raised S. bilirubin, etc.)
• Spherocytosis prominent in
peripheral blood
• Coomb’s test is positive as
result of IgG +/-
complement, or IgA on the
cell surfaces
• Antibodies, both on cell
surface and free in serum,
are best detected at 37°C 18
Coomb’s Test
• Antiglobulin test (Coomb’s test): anti-human
globulin, extracted from cows serum after
injected with human globulin, is used to detect
the presence of Ig on RBC surfaces
• Presence of Ig on RBC
surfaces agglutination
of RBCs (Coomb’s test
positive)
• Coomb’s test can be:
– Direct
– Indirect
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Direct Coomb’s Test

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Indirect Coomb’s Test

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Interpretation of Coomb’s Test

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 Treatment of Warm AIHA
• Remove the underlying cause, e.g. methyldopa
• Corticosteroids: prednisolone is the usual first line of
treatment, 60 mg/day starting does in adults, then
should be tapered gradually
• Splenectomy if response to steroid is poor
• Immunosuppression may be tried if steroid and/or
splenectomy failed. e.g. azathioprine,
cyclophosphamide, ciclosporin, etc.
• Treat underlying disease, e.g. CLL, lymphoma
• Folic acid in severe cases
• Blood transfusion may be needed if anemia is severe
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Cold Autoimmune HA
• Antibodies, monoclonal or polyclonal, attach to
red cells, mainly in the peripheral circulation
where the blood temperature is cooled
• Antibodies are usually IgM and bind best at 4°C
• IgM is highly efficient at fixing complement
both intravascular and extravascular hemolysis
occur

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Clinical Features
• Patient might have chronic hemolytic anemia
aggravated by cold and often associated with
intravascular hemolysis hemoglobinuria
• Mild jaundice and splenomegaly might present
• Patient might develop acrocyanosis (purplish
skin discoloration) at the tip of nose, ears,
fingers and toes caused by agglutination of red
cells in small vessels

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Acrocyanosis

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Lab Findings
• Similar to those of warm AIHA, except that
spherocytosis is less marked
• Red cells agglutinate in cold
• Coomb’s test positive
• Serum shows a high titer
of cold autoantibodies to
red cells

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Treatment
• Keeping the patient warm
• Treating the underlying cause if present
• Splenectomy does not usually help unless
massive splenomegaly is present
• Steroids are not helpful

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ABO-Incompatible Blood Transfusion
• Antibodies in the recipient’s plasma react with
the donor’s red cells acute hemolysis

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Hemolytic (Rh) Disease of New Born
• Mother Rh –ve; fetus Rh +ve

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Drug-Induced Hemolytic Anemia
• Drugs cause hemolysis via 3 mechanisms
– Antibodies directed against drug-red cell membrane
complex; e.g. penicillin and ampicillin
– Deposition of complement via drug protein-
antibody complex onto RBC surface; e.g. quinidine,
and rifampicin
– True autoimmune reaction, in which the role of the
drug is unclear; e.g. methyldopa
• In each case, hemolysis gradually disappears
when the drug discontinued
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Drug-Induced Hemolytic Anemia

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Chemical Agents
• Some drugs, e.g. dapsone and salazopyrin, in
high does cause oxidative intravascular
hemolysis with Heinz body formation in normal
subjects
• Chemical poisoning, e.g. lead, chlorate or
arsine, can cause severe hemolysis (toxic effect
on RBCs)

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Infection-Induced Hemolysis
• Infection can cause hemolysis in variety of ways
– May precipitate an acute hemolytic crisis in sickle cell
anemia and G6PD deficiency
– Micro-angiopathic hemolytic anemia; e.g.
meningococcal and pneumococcal septicemia
– Malaria causes hemolysis by extravascular destruction
of parasitized red cells (by splenic macrophages), as well
as by direct intravascular lysis (black water fever is an
acute intravascular hemolysis accompanied by acute
renal failure caused by falciparum malaria)
– Clostridium perfringens septicemia can cause
intravascular hemolysis with marked spherocytosis
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Malaria

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Red Cell Fragmentation Syndrome
• Red cells destruction due to mechanical cause,
examples:
– Artificial heart valve
– Disseminated intravascular coagulation (DIA)
– Microangiopathic hemolytic anemia
– Vasculitis
– Malignant diseases
– Burns
• Blood film shows fragmented
cells (shistocytes)
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Blood Film: Fragmented RBCs

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March Hemoglobinuria
• Intravascular hemolysis following prolonged
marching or running hemoglobinuria
• Caused by damage of RBCs between the bones
of the feet
• Blood film does not show fragments

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Paroxysmal Nocturnal Hemoglobinuria
• Acquired intravascular hemolytic anemia
caused by acquired mutations in X chromosome
• Affect certain red blood cell membrane
proteins intravascular hemolysis

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