HAEMOLYTIC

ANAEMIA

www.similima.com 1
HAEMOLYTIC ANAEMIA
 Haemolytic Anaemias are defined as
anaemias resulting from an increase in the
rate of red cell destruction.

 Normal life span of RBC is 90-120 days.

 Lysis: within the cells of RE system in the

spleen and elsewhere(extravascular
haemolysis).

www.similima.com 2
 Premature destruction
of red cells
in HA

Intravascular Extravascular
Haemolysis Haemolysis

www.similima.com 3
 Intravascular HA: Red cells undergo
lysis in circulation and release their
contents into plasma.Plasma Hb rises and
part of it may be excreted in
urine(hemoglobinuria).

Extravascular HA: Red cells are taken

by cells of RE system where they are
destroyed and digested.Plasma Hb is
barely raised.It is more common.

www.similima.com 4
 CLASSIFICATION
1. ACQUIRED (EXTRACORPUSCULAR)

A.Antibody: Immunohaemolytic anaemias

1. Autoimmune haemolytic anaemia (AIHA)

i. Warm antibody AIHA
ii. Cold antibody AIHA

2. Drug-induced immunohaemolytic anaemia

3. Isoimmune haemolytic anaemia

www.similima.com 5
B.Mechanical trauma: Microangiopathic
haemolytic anaemia

C.Direct toxic effect: Malaria, bacterial, infection

and other agents

D.Acquired red cell membrane abnormalities:

paroxysmal nocturnal haemoglobinuria
(PNH)

E.Splenomegaly
www.similima.com 6
2. HEREDITARY (INTRACORPUSCULAR)

A. Abnormalities of red cell membrane

1. Hereditary spherocytosis

2. Hereditary elliptocytosis (hereditary

ovalocytosis)

3. Hereditary stomatocytosis

www.similima.com 7
B.Disorders of red cell interior
1. Red cell enzymes defects

i. Defects in the hexose monophosphate

shunt: G6PD deficiency
ii. Defects in the Embden-Meyerhof (or
glycolytic) pathway: pyruvate kinase
deficiency

2. Disorders of haemoglobin
i. Structurally abnormal haemoglobins
(haemoglobinopathies): sickle
syndromes, other haemoglobinopathies
ii. Reduced globin chain synthesis:
thalassaemias
www.similima.com 8
www.similima.com 9
 GENERAL CLINICAL FEATURES

 Pallor of mucous membrane

 Positive family history
 Mild fluctuating jaundice due to hyperbilirubinaemia
 Dark urine due to excess of urobilinogen
 Splenomegaly in chronic HA, both congenital and
acquired
 Pigment gallstones in some cases.

www.similima.com 10
 LABORATORY EVALUATION
 AIM
 Evidence of haemolysis
 Type of haemolytic mechanism
 Diagnosis
1.Tests of increased cell breakdown
 Serum bilirubin –unconjugated is raised
 Urine urobilinogen – raised

 Faecal stercobilinogen – raised

 Plasma lactic dehydrogenase – raised

 Evidence of intravascular haemolysis – in the form

of haemoglobinaemia or haemoglobinuria.
www.similima.com 11
2.Tests of increased red cell production
 Reticulocyte count – raised
 Routine blood film – macrocytosis, and
normoblasts
 Bone marrow – erythroid hyperplasia

 X-ray of bones – evidence of expansion of marrow

space

www.similima.com 12
3.Tests of damage to red cells

Routine blood film – abnormal morphological

appearances of red cells
Osmotic fragility – increased
Autohaemolysis test
Coombs’ antiglobulin test
Electrophoresis for abnormal haemoglobins

www.similima.com 13
 Tests for sickling
Estimation of HbA2
Screening test for G6PD deficiency and other
enzymes

4.Tests for shortened red cell life-span

51Cr labelling method – Normal 120 days,
Moderate haemolysis – 20-40 days, Severe
haemolysis – 5-20 days.

www.similima.com 14
2. HEREDITARY (INTRACORPUSCULAR)

A. Abnormalities of red cell membrane

1. Hereditary spherocytosis

2. Hereditary elliptocytosis ( ovalocytosis)

3. Hereditary stomatocytosis

www.similima.com 15
B.Disorders of red cell interior
1. Red cell enzymes defects

i. Defects in the hexose monophosphate

shunt: G6PD deficiency
2. Disorders of haemoglobin

i. Structurally abnormal haemoglobins

(haemoglobinopathies): sickle
syndromes, other haemoglobinopathies
ii. Defects in the Embden-Meyerhof (or
glycolytic) pathway: pyruvate kinase
deficiency
iii. Reduced globin chain synthesis:
thalassaemias
www.similima.com 16
HEREDITARY SPHEROCYTOSIS

 Common type,autosomal dominant

 Defect in proteins which anchor the lipid
bilayer to the underling cytoskeleton.

1. Spectrin deficiency –
 Almost all cases have deficiency of this structural
protein of red cell membrane
 Spectrin deficiency correlates with the severity of
anaemia
 Mutation in spectrin by recessive inheritance called α-
spectrin causes more severe anaemia
 Mutation by dominant inheritance forming β-spectrin
results in mild form of disease

www.similima.com 17
2.Ankyrin abnormality –
• About half of the cases have defect in
ankyrin, protein which binds protein 3
and spectrin
• Homozygous state with recessive
inheritance pattern have severe
anaemia
• While heterozygotes with more common
dominant inheritance pattern have
milder anaemia
www.similima.com 18
 Normal RBC biconcave and normal size

Mutation in membrane protein - α-spectrin, β-

spectrin and ankyrin

Defect in anchoring of lipid bilayer

Spherical contour and small size, not flexible rigid cells

Microspherocytes

Passage through Spleen lose their cell membrane further

Produces hyperspheroidal red cells which is

destroyed in spleen.
www.similima.com 19
 CLINICAL FEATURES
• All age groups, Equal sex incidence
• Family history
• Anaemia – mild to moderate
• Splenomegaly
• Jaundice
• Pigment gallstones due to increased bile
pigment production.

www.similima.com 20
 LABORATORY FINDINGS

• Anaemia – mild to
moderate
• Reticulocytosis
• Blood film –
microspherocytosis
• MCV – normal or
decreased
• MCHC – increased
• Osmotic fragility –
increased

www.similima.com 21
HEREDITARY ELLIPTOCYTOSIS
(HEREDITARY OVALOCYTOSIS)

• Autosomal dominant
disorder involving red
cell membrane
protein – spectrin

• Defect in erythrocyte
membrane protein 4.1
that interconnects
spectrin with actin.

www.similima.com 22
• Similar to hereditory spherocytosis in all
respects except blood film shows oval or
elliptical red cells and clinically milder
disorder than hereditory spherocytosis.

• Acquired causes – Iron deficiency and

myeloproliferative disorders

www.similima.com 23
 HEREDITORY STOMATOCYTOSIS
• Stomatocytes – cup-shaped RBCs, one surface
concave & one convex.

• Defect in membrane protein – stomatin

• Stomatocytes are swollen red cells

(overhydrated red cells) due to increased
permeability to sodium and potassium.

• Mild anaemia and splenomegaly.

www.similima.com 24
B. Disorders of red cell interior

1. Red cell enzymes defects

i. Defects in the hexose monophosphate shunt: G6PD
deficiency
ii. Defects in the Embden-Meyerhor (or glycolytic)
pathway: pyruvate kinase deficiency

2. Disorders of haemoglobin
i. Structurally abnormal haemoglobins
(haemoglobinopathies): sickle syndromes, other
haemoglobinopathies
ii. Reduced globin chain synthesis: thalassaemias

www.similima.com 25
 G6PD DEFICIENCY

 Most common defect in hexose

monophosphate shunt.

 G6PD gene is located on the X chromosome,

and it’s deficiency mainly affects males

 Females are carriers and are asymptomatic

www.similima.com 26
CLINICAL FEATURES

Clinical manifestations of acute haemolytic

anaemia.
Self-limiting as affects the older red cells only
Hb level return to normal when the older
population of red cells has been destroyed and
only younger cells remain
Darkening of urine
Jaundice

www.similima.com 27
 LABORATORY FINDINGS
1. During the period of
acute haemolysis,
– Features of intravascular
haemolysis like
• Rise in plasma
haemoglobin
• Haemoglobinuria
• Rise in unconjugated
bilirubin
• Fall in plasma
haptoglobin

2. Between the crises

– Patient generally has no
anaemia
– Red cell survival is
shortened
www.similima.com 28
PYRUVATE KINASE DEFICIENCY
• Only significant enzymopathy of the Embden-
Meyerhof glycolytic pathway.

• Heterozygote state is entirely asymptomatic

• Homozygous presents anaemia, jaundice and

splenomegaly in childhood.

www.similima.com 29
 ABNORMAL HAEMOGLOBINS
(HAEMOGLOBINOPATHIES)
• SICKLE SYNDROMES (HbS)
– Red cells with HbS develop ‘sickling’ when exposed
to low oxygen tension
– Highest frequency in black race and in Central
Africa where falciparum malaria is endemic
– Presents in 3 forms –
• As hererozygous state for HbS: sickle cell trait(AS)
• As homozygous state for HbS: sickle cell anaemia(SS)
• As double hererozygous states e.g. sickle β-thalassaemia,
sickle-C disease (SC), sickle-D disease(SD)

www.similima.com 30
 HETEROZYGOUS STATE:
SICKLE CELL TRAIT
 Benign heterozygous state of HbS with one abnormal
gene

 Patients have no significant clinical problems except

when they become severely hypoxic.

 Patients have no anaemia and normal red cells

 Only in hypoxic crises, sickle cell crises develop.

www.similima.com 31
 HOMOZYGOUS STATE

SICKLE CELL ANAEMIA

Sickle cell anaemia (SS) is a homozygous state of HbS in

which abnormal gene is inherited from each parent. SS is a
severely malignant disorder with decreased life expectancy.

www.similima.com 32
 PATHOGENESIS
 Basic molecular lesion :
 Basic genetic defect is the single point mutation in one
amino acid out of 146 in haemoglobin molecule
 There is substitution of valine for glutamic acid at the 6

residue position of the β-globin producing Hb α2β2s

www.similima.com 33
www.similima.com 34
• Mechanism of sickling :
• During deoxygenation red cell
containing HbS change from biconcave
disc shape to elongated crescent-
shaped or sickle-shaped cell.
• Deoxygenation of HbS which
aggregates to form elongated rod-like
polymers.
• These elongated fibres align and distort
the red cell into classical sickle cells.

www.similima.com 35
www.similima.com 36
 – Reversible-irreversible
sickling :
• Oxygen dependent
sickling is reversible

• Damage to red cell

membrane leads to
formation of irreversible
sickle cell even after
exposed to normal
oxygen tension.

www.similima.com 37
 CLINICAL FEATURES

 Anaemia
 Vaso-occlusive phenomena
 Recurrent vaso-occlusive episodes due to
obsturction to capillary blood flow by sickled
red cells.
 Vaso-obstruction causes 2 types of infarcts
 Microinfarcts affecting mainly the abdomen, chest,
back and joints.
 Macroinfarcts involving most commonly

www.similima.com 38
  Bone marrow – pains
 Spleen – splenic sequestration

 Bones – aseptic necrosis, osteomyelitis

 Lungs – pulmonary infections

 Kidneys – renal cortical necrosis

 CNS – stroke

 Retina – damage

 Skin – ulcers

 Constitutional symptoms – impaired growth

and development, increased susceptibility to
infections due to impaired splenic functions

www.similima.com 39
Persons with sickle cell
trait:
* Generally have no symptoms
* Live normal lives
* Can pass the sickle cell gene on to
their children.

www.similima.com 40
 DOUBLE HETEROZYGOUS STATES
• Combination of HbS with other
haemoglobinopathies.

• Most common are –

– Sickle-β-thalassaemia
– Sickle-C disease (SC)
– Sickle D disease (SD)

• All these disorders behave like mild form of

sickle cell diseases

www.similima.com 41
LABORATORY FINDING

1.Hb – decreased(6-9 g/dl)

2.Sickle cells in peripheral smear

3.Positive sickling test

4.Hb electrophoresis show predominance of HbS

www.similima.com 42
 THALASSAEMIA
 The thalassaemias are hereditory disorders in which there is
reduce rate of synthesis of one or more of the globin
polypeptide chains.

 Quantitative abnormalities of polypeptide globin chain

synthesis; where as haemoglobinopathies are qualitative
disorders.

 First described in people of Mediterranean countries (North

Africa, Southern Europe) known as Mediterranean anaemia.

 The word ‘thalassa’ in Greek means ‘the sea’ since the

condition was found commonly in regions around
Mediterranean countries.
www.similima.com 43
 CLASSIFICATION
Normally, an individual inherits two β-globin genes located
one each on two chromosomes 11, and two α-globin
genes one each on two chromosomes 16, from each
parent i.e. α2β2
Depending upon the genetic defect or deletion of α- or β-
globin chain genes thalassaemia are classified into -
1.α-thalassaemia
 Heterozygous (α-thalassaemia minor or trait)
 Homogygous state (α-thalassaemia major)
2.β-thalassaemia
 Heterozygous (β-thalassaemia minor or trait)
 Homogygous (β-thalassaemia major)

www.similima.com 44
 α-THALASSAEMIA
 There is defective synthesis of α-globin chains resulting
in depressed production of haemoglobins that contain α-
chains .

 α-thalassaemias are most common due to deletion of

one or more of the α-chain genes located on short arm
of chromosome 16.

 Clinical manifestations of α-thalassaemia depend upon

the number of genes deleted.

 According to this α-thalassaemia may be classified into 4

types –
 Four α-gene deletion : Hb Bart’s hydrops foetalis
 Three α-gene deletion : HbH disease
 Two α-gene deletion : α-thalassaemia trait
 One α-gene deletion : α-thalassaemia trait (carrier)
www.similima.com 45
1. Hb Bart’s Hydrops Foetalis

 Deletion of all four α-chain genes results in total

suppression of α-globin chain synthesis causing
the most severe form of α-thalassaemia.
 Hb Bart’s Hydorps Foetalis is incompatible with
life due to severe tissue hypoxia.
 The condition is either fatal in utero or the infant
dies shortly after birth.
 If born alive, severe Rh haemolytic disease are
present.

www.similima.com 46
2.HbH Disease
Deletion of three α-chain genes produces
HbH and markedly impaired α-chain
synthesis.
Presents with moderate haemolytic anaemia
and fluctuating anaemia.

3.α-Thalassaemia Trait
Deletion of two or one α-chain genes.
α-thalassaemia trait due to two α-chain gene
deletion is asymptomatic.
One gene deletion α-thalassaemia triat is
silent carrier state.
www.similima.com 47
 β-THALASSAEMIA
 Decreased rate of β-chain synthesis resulting in
reduced formation of HbA in red cells.

 Arises from different types of mutations of β-

globin gene resulting from single base change.

 Three types –
1. Homozygous form : β-thalassaemia major (severe
form)
2. β-Thalassaemia intermedia
3. Heterozygous form : β-thalassaemia minor (trait)

www.similima.com 48
 β-THALASSAEMIA MAJOR
• Mediterranean or Cooley’s anaemia
• Most commonest form congenital HA
• Types
1. Complete absence of β-chain synthesis – β0
thalassaemia
2. Small amount of β-chain synthesis – β+
thalassaemia
Results in excessive formation of alternate
haemoglobins, HbF (α2γ2) and HbA2 (α2δ2)

www.similima.com 49
 CLINICAL FEATURES

• Anaemia
• Hepatosplenomegaly
• Expansion of bones – thalassaemic facies and
malocclusion of the jaw
• Damage to endocrine organs resulting -
– slow rate of growth and development
– delayed puberty
– diabetes mellitus
– damage to the liver and heart

www.similima.com 50
www.similima.com 51
 LABORATORY FINDINGS
• Anaemia – severe
• Blood film –
– Microcytic hypochromic red cell
– Anisopoikilocytosis
– Basophilic stippling
– Normoblasts
• Serum bilirubin – raised
• Reticulocytosis
• MCV, MCH and MCHC – reduced
• WBC count – raised
• Platelet count – normal or reduced
www.similima.com 52
www.similima.com 53
 TREATMENT

• Mainly supportive
• Anaemia – blood transfusion
• Folic acid supplement
• Splenectomy
• Prevention and treatment of iron overload by
chelation therapy (desferrioxamine)
• Bone marrow transplantation

www.similima.com 54
 β-THALASSAEMIA MINOR

 Clinically, asymptomatic. Diagnosis is made when

investigate for mild chronic anaemia.

 Laboratory findings
 Mild anaemia
 Blood film show mild anisopikilocytosis, microcytosis and
hypochromia
 Serum bilirubin – normal or slightly raised
 Mild reticulocytosis
 MCV, MCH and MCHC may slight reduce

 Normal life expectancy

www.similima.com 55
 ACQUIRED(EXTRACORPUSCULAR)

1. AUTOIMMUNE HAEMOLYTIC
ANAEMIA (AIHA)-
formation of antibodies against
patient’s own red cells.
1. Warm antibody AIHA - autoantibodies are
reactive at body temp.(370C), IgG or IgA
antibodies
 Chronic anaemia
 Splenomegaly
 Occasionally hyperbilirubinaemia
www.similima.com 56
2.Cold antibody AIHA – autoantibodies react
better at 40C. IgM antibodies
 Chronic anaemia worse by exposure to cold
 Raynaud’s phenomenon
 Cynosis affecting the cold exposed region like tip
of nose, ears, fingers and toes
 Haemoglobinaemia and haemoglobinuria occur
on exposure to cold

www.similima.com 57
 LABORATORY FINDINGS
WARM ANTIBODT AIHA :
• Mild to moderate chronic anaemia
• Reticulocytosis
• Prominent spherocytosis
• Immune thrombocytopenia
• Haemoglobinaemia & haemoglobinuria
• Unconjugated hyperbilirubinaemia
COLD ANTIBODY AIHA
 Chronic anaemia
 Low reticulocyte count-young red cells are affected more
 Spherocytosis is less marked

www.similima.com 58
2.DRUG-INDUCED IMMUNOHAEMOLYTIC
ANAEMIA –
a. α-Methyl Dopa Type Antibodies
b. Penicillin-Induced Immunohaemolysis
In each type of drug-induced immunohaemolytic
anaemia, discontinuation of the drug results in
gradual disappearance of haemolysis.

3.ISOIMMUNE HAEMOLYTIC ANAEMIA –

 Caused by acquiring isoantibodies or alloantibodies
by blood transfusions, pregnancies and in
haemolytic disease of the newborn.
 These antibodies produced by one individual are
directed against red blood cells of the other.

www.similima.com 59
 Microangiopathic Haemolytic Anaemia
It is caused by abnormalities in the microvasculature which
is generally due to mechanical trauma to the red cells in
circulation and is characterised by red cell fragmentation.
This results by 3 ways -

1. External Impact
 Caused by direct external trauma to red cells
when they pass through microcirculation,
especially over the bony prominences during
various activities
 In prolonged marchers, joggers, karate players
etc.

www.similima.com 60
2.Cardiac Haemolysis
 In patients with prosthetic cardiac valves or artificial
grafts due to direct mechanical trauma to the red blood
cells from turbulent blood flow.
3.Fibrin deposit in microvasculature
 Fibrin deposit in small vessels causes physical
obstruction for red cell resulting fragmentation of cells.
 Fibrin deposit may occur due to
 Abnormalities of blood vessels e.g. hypertension, eclampsia
 Thrombotic thrombocytopenic purpura
 Haemolytic-uraemic syndrome
 Disseminated intravascular coagulation (DIC)
 Collagen diseases

www.similima.com 61
 HAEMOLYTIC ANAEMIA FROM DIRECT
TOXIC EFFECTS

1. Malaria by direct parasitisation of RBCs.

2. Septicaemia with clostridium welchii
3. Other microorganisms such as pneumococci,
staphylococci and E.coli.
4. Copper by direct haemolytic effect in Wilson’s disease.
5. Lead poisoning
6. Snake and spider bites
7. Extensive burns

www.similima.com 62
 PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA
(PNH)
 Rare acquired disorder of RBC membrane where there
is chronic intravascular haemolysis due to defective
synthesis of a RBC membran protein.
 This defect affects all the cells of myeloid progenitor
lineage (RBCs, WBCs, platlets) suggesting a deficient
haematopoiesis.

HAEMOLYTIC ANAEMIA IN SPLENOMEGALY

 Normally, spleen acts as filter and traps the damaged
RBCs, destroys them and the splenic macrophages
phagocytose the damaged red cells.
 But splenomegaly exaggerates the damaging effect to
which the red cells are exposed.
www.similima.com 63
 APLASTIC ANAEMIA
• It is defined as pancytopenia (anaemia
leucopenia,thrombocytopenia) resulting
from aplasia of bone marrow.

• Reduction in the no.of haematopoietic

pluripotent stem cells.

www.similima.com 64
CAUSES
A.PRIMARY APLASTIC ANAEMIA
1.Fanconi’s anaemia(congenital)
2.Immunologically mediated(acquired)
B.SECONDARY APLASTIC ANAEMIA
1. Drugs
2.Toxic chemicals-industrial,domestic
3.Infections- hepatitis,AIDS,other viral
4.Miscellaneous-therapeutic X-ray

www.similima.com 65
Fanconi’s anaemia
Autosomal recessive inheritance

Deformities:

Skeletal-hypoplastic or absent thumb

CNS-microcephaly,mental retardation

Skin-hyper pigmentation

CVS & Renal affection

www.similima.com 66
CLINICAL FEATURES

Anaemia,progressive weakness,fatigue
Haemorrhage from nose,
skin,gums,vagina,bowel&occ.CNS,retina
due to thrombocytopenia
Infections of mouth&throat
Lymphnodes,liver,spleen generally not
enlarged

www.similima.com 67
LABORATORY FINDINGS
1.Anaemia:Hb reduced
normocytic normochromic
reduced reticulocyte count
macrocytosis

2.Leucopenia:with relative lymphocytosis

3.Thrombocytopenia

4.Bone marrow aspiration:severe depression of myeloid

cells,megakaryocytes and erythroid cells so that marrow
chiefly consists of lymphocytes and plasma cells.

www.similima.com 68
www.similima.com 69
TREATMENT
A.General management
1.Identification & elimination of the
possible cause.
2.Supportive care consisting of blood
transfution,platelet concentrates,treatment
&prevention of infections.
B.Specific management
1.Marrow stimulating agents like androgen
may be administered orally.
www.similima.com 70
2. Immunosuppressive therapy

3.Bone marrow transplantation

Severe aplastic anaemia is a serious
disorder terminating in death within 6-12
months in

www.similima.com 71
Thank you

www.similima.com 72