APLASTIC ANEMIA

1 ABOUT THE PATIENT

CASE
A 24-year-old female went to check-up with her physician with
complaints of recurrent epistaxis, progressive weakness, and shortness of
breath with minimal physical effort. She has experienced recurrent fever
reaching 38.2℃. There’s no lymphadenopathy or hepatosplenomegaly.
The patient denies sinus congestion, throat pain, cough, nausea, emesis,
melena, or hematuria. She has no past medical history, and there’s no
family history of hematological disorders. Laboratory tests were ordered
on check-up.

3
CHIEF COMPLAINT

“Recurrent epistaxis,
progressive weakness,
and shortness of
breath with minimal
physical effort”

4
RISK FACTORS

- Age = Gender = Race

- Exposure to toxins

- Certain viruses

- Certain medicines

5
HISTORY OF PRESENT ILLNESS
For the past 3 months, after
resigning from being an
industrial worker, patient’s
family physician has been
following her recovery from viral
hepatitis. Her recovery was
uneventful. Her liver enzyme
levels returned to normal within
two months.
6
Review of Systems

7
2 DIAGNOSIS
Physical Examination
General Appearance:
General Survey
▫ Patient is awake Conscious and Coherent
▫ Oriented to time, place and person
▫ GCS 15

9
Physical Examination
SKIN
▫ Pallor
▫ Petechiae spots

HEAD
▫ The hair is black, thick, and evenly distributed.
Clean Scalp, normocephalic, mo mass or
tenderness; temporal arteries not visible
10
Physical Examination
EYES
▫ Visual acuity 20/20. Extraocular muscles are intact, and the
fundi appears to be normal including optic disc and vessels. No
signs of nystagmus. Eyelids appears normal without swelling or
lesions

EARS
▫ External ear and ear canal are non tender. Canal is clear without
discharge. Tympanic membrane and its landmarks appear to be
normal with a visible cone of light. Intact hearing

11
Physical Examination
NOSE
▫ Recurrent epistaxis
NECK
▫ Normal size, symmetrical, no visible mass, normal
muscle tone, no tenderness, full ROM, trachea in
midline, thyroid gland not visible or palpable

12
Physical Examination
THORAX AND LUNGS
▫ Bilateral decreased air entry upon auscultation

ABDOMEN
▫ Protuberant with active bowel sounds; soft and
non tender; no palpable mass, no
hepatosplenomegaly

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Physical Examination
Extremities
▫ Able to do range of motion exercises without
difficulty

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Complete Blood Count (CBC)
RESULTS REFERENCE VALUE

RBC 3.32 x 10^12/L 4.7 - 6.1 x 10^12/L

Hb 5.2 g/dL 13.0 - 18.0 g/dL

HCT 14.8% 40 - 52%

MCV 96 fl 80 - 97 fl

MCH 28 pg 27 - 31 pg

MCHC 33.6 g/dL 32 - 36 g/dL

WBC 1200/uL 4.5 - 11/uL

Neutrophil 570/mm^3 1500 - 8000/mm^3

Plt 5000/uL 150 - 400 x 10^3/uL

Reticulocytes 0.2 0.5 - 1.5

Reticulocyte count 30,000 50,000 - 150,000

15
Laboratory Findings:
Usually two of the following three blood parameters:
1. Hgb less than 100g/L
2. Granulocyte count less than 1.5 x 10^9/L
3. Platelet count less than 50 x 10^9/L

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Blood Smear

Normochromic (⅓ of the cell), normocytic RBCs

Pancytopenia and reticulocytopenia
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Bone Marrow Biopsy

▫ Hypocellular with increased fat cells

▫ Severely reduced hematopoietic stem cell precursors
▫ Bone marrow cellularity is <20%
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Clinical Lab Tests
Bone marrow biopsy
▫ Taken from the hip bone
▫ Using special biopsy needles: liquid bone marrow (aspirate) and a tiny core of bone
marrow tissue (trepine).
▫ It will show an empty or sparse marrow which usually contains fat cells.
▫ A bone marrow biopsy is done for two main reasons:
▫ To confirm a diagnosis of aplastic anemia
▫ To understand how well or poorly your bone marrow is making blood cells

The bone marrow test shows:

● The quantity (cellularity) of your bone marrow occupied by different cells
● Exactly what types and amounts of cells your bone marrow is making
● Increased, decreased, or normal levels of iron in your bone marrow
● Chromosomal (DNA) abnormalities
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20
Clinical Lab Tests
Full blood count
▫ This is a routine blood test which measures the number of red
cells, different types of white cells and platelets in the blood.

Blood film examination

▫ In many patients with acquired AA, the number of red blood
cells, neutrophils and platelets are decreased; however, the
number of lymphocytes are usually normal.

21
Blood Tests
Complete Blood Count (CBC)
▫ Low RBC, WBC and platelets
▫ Low Hgb and Hct level

Reticulocyte Count
▫ A reticulocyte count measures the number of young red blood cells in your blood. The test
shows whether your bone marrow is making red blood cells at the correct rate. People who
have aplastic anemia have low reticulocyte levels.

EPO level
▫ A low EPO level may indicate a problem other than aplastic anemia, or it may make anemia
worse in people who have MDS.

Iron level
Vitamin B12 and folate levels

22
Clinical Lab Tests
Tests for gene mutations
▫ Blood or bone marrow tests may be performed to check for mutations to
exclude inherited AA and also somatic (acquired) mutations related to the
patient’s external causes.
▫ In acquired AA, the most common somatic mutations can be found in the
following genes:
▫ PIGA (phosphatidylinositol glycan class A)
▫ ASXL1 (additional sex combs like 1)
▫ BCOR (BCL6 corepressor)
▫ DNMT3A (DNA [cytosine-5]-methyltransferase 3 alpha)

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STAGING
Staging of aplastic anemia is based on the criteria of the International Aplastic Anemia Study Group (IAASG),
also known as modified Camitta criteria.

Severe aplastic anemia (SAA) is defined as marrow cellularity < 25% (or 25–50% with < 30% residual
hematopoietic cells), plus at least two of the following peripheral blood findings:
● Neutrophils less than 0.5 × 10 9
● Platelets less than 20 × 10 9/L
● Reticulocytes less than 20 × 10 9/L

Very severe aplastic anemia (VSAA) is defined as as marrow cellularity < 25% (or 25–50% with < 30% residual
hematopoietic cells), plus at least two of the following peripheral blood findings:
● Neutrophils less than 0.2 × 10 9/L
● Platelets less than 20 × 10 9/L
● Reticulocytes less than 20 × 10 9/L

Non-severe aplastic anemia (NSAA) is defined as aplastic anemia not fulfilling the criteria for SAA or VSAA.

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RADIOGRAPHIC FEATURES

MRI
▫ focal low-signal (both TI and T2) areas (likely representing
islands of active hematopoietic cells) interspersed with
high-SI areas in the marrow of the spine
▫ diffuse high-signal marrow without focal abnormalities in the
pelvis and proximal femoral regions

25
Other Tests
▫ X ray, computed tomography (CT) scan, or an ultrasound imaging test
▫ These tests can show enlarged lymph nodes in your abdomen. Enlarged lymph nodes may be a
sign of blood cancer. Doctors also may use these tests to look at the kidneys and the bones in the
arms and hands, which are sometimes abnormal in young people who have Fanconi anemia. This
type of anemia can lead to aplastic anemia.

▫ Chest x ray. This test creates pictures of the structures inside your chest, such as your
heart, lungs, and blood vessels. A chest x ray may be used to rule out infections.

▫ Liver tests and viral studies. These tests are used to check for liver diseases and viruses.

▫ Tests that check vitamin B12 and folate levels in the blood. These tests can help rule out
anemia caused by vitamin deficiency.

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3 TREATMENT
TREATMENT AND MANAGEMENT
▫ The classification of acquired AA into non-severe,
severe or very severe is used as a general guide for
treatment choice.
▫ For all acquired aplastic anemia, suspected cause
should be removed immediately (e.g. drugs,
fertilizers, pesticides, benzene)

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TREATMENT AND MANAGEMENT
OBJECTIVES
▫ Replacing or renewing the depleted stem cell pool (such as
with stem cell transplantation)
▫ Controlling the damage to bone marrow stem cells
(immunosuppressive and antithymocyte therapy)
▫ Stimulating the remaining bone marrow stem cells
▫ Providing supportive treatment for anaemia, bleeding or
infections

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CLASSIFICATION OF APLASTIC ANEMIA
NON-SEVERE
At least 2 of the ff:
▫ Haemoglobin <100g/L
▫ Platelets <50g/L
▫ Neutrophils <1.5g/L
▫ Bone marrow with few
cells (hypocellular), but
no abnormal cells or
fibrosis.
Hypocellular bone marrow
(as in low cell number) is
defined as:
▫ Bone marrow cells
<25% or
▫ Bone marrow cells
between 25% and 50%,
with less than 30% of
stem cells
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CLASSIFICATION OF APLASTIC ANEMIA
SEVERE VERY SEVERE
A hypocellular bone marrow and A hypocellular bone marrow
any 2 of the following criteria: and any two of the following
▫ A low platelet count (less criteria:
than 20x109/L) ▫ A low platelet count (less
▫ A reticulocyte count less than 20x109/L)
than 60x109/L ▫ A reticulocyte count less
▫ A neutrophil count less than than 60x109/L
0.5x109/L ▫ A neutrophil count less
than 0.2x109/L 31
NON-SEVERE
▫ May not require any treatment initially
▫ Watch and wait approach is often recommended at
first
▫ Regular check-ups and blood tests
▫ Maintaining a healthy lifestyle

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SUPPORTIVE CARE: Blood Product Support
1.Transfusion of red blood cells
2. Transfusion of platelets
3. Granulocyte transfusions
4. Use of irradiated cellular blood components for AA
patients
5. CMV tested blood products
6. Iron chelation therapy

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SUPPORTIVE CARE: Prevention of Infections
▫ Infections remain the major cause of death in AA (Marsh &
Kulasekararaj, 2013)
▫ When neutrophil counts are 0.5x109/L
▫ prophylactic antibiotics and antifungal drugs are often given to
reduce the risk of infection
▫ 2 non-absorbables (e.g. colistin and neomycin) or quinolones
(e.g. ciprofloxacin)
▫ → mould (aspergillus) active azole, preferably itraconazole or
posaconazole

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SUPPORTIVE CARE: Prevention of Infections
▫ When receiving immunosuppressive therapy, patients with
acquired AA should also receive anti-viral drugs
▫ Antiviral prophylaxis with aciclovir or valaciclovir during and after
ATG therapy
▫ Regular mouth care: antiseptic mouthwash (e.g. chlorhexidine or
saline) and food of low bacterial content

35
SUPPORTIVE CARE: Treatment of Infections
▫ Empiric anti-fungal therapy for patients with clinically suspected
IFIs
▫ Granulocyte transfusions for severe sepsis

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Immunosuppressive therapy
- Current standard first line IST
- Combination of horse ATG and CSA
- For NSAA patients who are transfusion dependent,
bleeding, encoutering infections or for lifestyle.
- SAA/VSAA patients in absence of an
HLA-matched sibling
- SAA/VSAA patients > 35-50 years old.

37
Prior to starting ATG
- Patient should be clinically stable and
afebrile
- Platelet count increment studies should be
performed to exclude platelet refrectoriness
- Prophylactic antiviral, antibiotic and
antifungal drugs should be administered
according to local policy
- Test dose must be given due to risk of
anaphylaxis 38
Administration of ATG (Antithymocyte
globulin)
- Must be given as an in-patient. Must be given
in centers that are familiar with using the
drug and it side effects
- Powerful immunosuppressive agent
- Dose of horse ATG is 40 mg/kg/d for 4 days,
given intravenous infusion over 12-18 hours.

39
Side effects of ATG
I. Early reactions
- Fever, rash, rigors, hypo/hypertension,
fluid retention, rarely acute pulmonary
edema,adult respiratory distress
syndrome and anaphylaxis
II. Late reactions
- Serum sickness on day 7/14 from start of
ATG, most commonly with arthralgio,
myalgia, rash, fever 40
41
Haemopoietic stem cell transplant
- Current indication are based on EBMT
SAAWP guidelines. Patients should be
managed by JACIE [Joint accreditation
Committee-International Society for Cellular
Therapy (ISCT) and EBMT]
- Survival is age-dependent

42
Haemopoietic stem cell transplant
HLA identical sibling donor Unrelated Donor
- Indicated for SAA in
young and adult
patients who have MSD
- Comorbidities should
be carefully assess to
determine fitness for
up-front
- transplantation
- Indicated for SAA after failure to
respond to one course of IST
- No strict upper age limit but
should be discussed on an
individual patient basis and
according to comorbidities.
- Donor should be 10/10- or 9/10-
matched based on HLA high
resolution typing for class I and II
antigens.
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Haemopoietic stem cell transplant

Alternative donor: cord blood and haploidentical

- If failure to respond to IST and in the absence of MSD
and suitable matched UD
- All donors should be screened for donor-directed HLA
antibodies, presence is associated with very high risk
graft rejection
Syngeneic donor
- Donor is an identical twin of the patient
- Simplest source of stem cells and least complicated
transplants because of no risk of rejection
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Timing of donor search/availability
- All newly diagnosed patients who may be potential transplant
candidates, HLA tissue typing should be performed at time of
diagnosis so that:
- MSD HSCT can proceed as soon as possible
- Potential availability of UD is established if there is no response
to ATG and CSA (ciclosporin)

Assessment for response to IST is usually made at 3, 6 months

45
Early post-transplant management
- Post-graft CSA is continued for 9 months followed by
tapering to 12 months to reduce risk of late graft failure
- Blood CSA trough level need to be maintained at higher
levels, between 300-350 ug/L.
- If renal function is compromised, a half dose of CSA
and half dose of MMF can be used
- Regular monitoring of unfractioned and lineage-specific
CD3 (T-cell) in peripheral blood and bone marrow is
recommended to detect early graft failure.

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RESPONSE AND MONITORING
Patients treated with immunosuppressive therapy (IST) for AA are
monitored regularly for response, toxicities, and evidence of clonal
progression
1. First 6 months:
▫ 2-4 weeks w/ stable blood counts
▫ Weekly/Biweekly for those w/ severe cytopenias for infection and
surveillance and transfusion support
▫ Complete blood count (CBC) and differential, reticulocyte count, electrolytes,
blood urea nitrogen and creatinine, liver transaminases, and cyclosporine (CsA)
levels

47
RESPONSE AND MONITORING
1. First 6 months:
▫ 3-6 months: Bone marrow examination
▫ Repeat bone marrow examination who have a partial response or if
blood counts decline unexpectedly to assess clonality or
evidence of a hematologic malignancy
2. Beyond 6 months:
▫ Interval can be increased between outpatient visits and laboratory
studies guided by the patient's clinical status
▫ Monthly: taking eltrombopag (EPAG) and/or CsA who are
transfusion-independent and have an absolute neutrophil count
(ANC) >500/microL
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RESPONSE AND MONITORING
2. Beyond 6 months:
▫ Upon discontinuance of all medications, the interval between visits
can be increased to every 3 months, then every 6 months for the first
two to three years, and then yearly.

49
REFERENCES
▫ Henry, J. B., McPherson, R. A., & Pincus, M. R. (2021). Henry's clinical diagnosis
and management by laboratory methods. 24th ed. Philadelphia, PA:
Elsevier/Saunders.
▫ Killick, S. B., Bown, N., Cavenagh, J., Dokal, I., Foukaneli, T., Hill, A., Hillmen, P.,
Ireland, R., Kulasekararaj, A., Mufti, G., Snowden, J. A., Samarasinghe, S., Wood, A.,
& Marsh, J. C. (2015). Guidelines for the diagnosis and management of adult
aplastic anaemia. British Journal of Haematology, 172(2), 187–207.
https://doi.org/10.1111/bjh.13853
▫ Kumar, V., Abbas, A. K., Aster, J. C., & Robbins, S. L. (2021). Robbins basic
pathology (10th ed.). Philadelphia, PA: Elsevier/Saunders.

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REFERENCES
▫ https://www.hoacny.com/patient-resources/blood-disorders/aplastic-anemi
a/how-aplastic-anemia-diagnosed-0
▫ https://jksronline.org/pdf/10.3348/jkrs.1999.40.2.347
▫ https://emedicine.medscape.com/article/198759-workup#c10

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TREATMENT AND MANAGEMENT
Bone Marrow Transplantation
Horse antilymphocyte globulin (ATG) and
cyclosporin A
Rabbit ATG
Androgens
Antibiotics
Single-donor platelets or platelets from
HLA-matched donors 52