Hemolytic , Macrocytic, Aplastic Anemia

Dr . Yenny Dian Andayani SpPD -KHOM

Division Hematologic Oncology Medic

Dept Internal Medicine Moh Hoesin General Hospital /
Faculty of Medicine Sriwijaya University
Palembang
 Morphological classification of anemias

Anemia - Morfologi
MCV, MCH , MCHC nilai normal ?
1. Microcytic, hypochromic anemia
( decreased MCV < 80 dan MCH 27 pg )
2. Normocytic, normochromic anemia
( normal MCV 80 -95 fl dan MCH 27-34 pg)
3. Macrocytic, normochromic anemia
( increased MCV > 95 pg )
 Basic Blood Test
Routine blood
consist of : WBC, RBC, Hb, Hct, Red blood cell
indices , Platelet count.
CBC ( Complete Blood Count )
consist of routine blood + MCV, MCH, MCHC,
Peripheral Blood smear, RDW, Diff count WBC.
 Etiology of anemia
Production : anemia aplastic
Destruction : anemia hemolytic
Loss of blood : anemia cause hemorrhagic
Disturbance metabolism : anemia chronic
disease
 HEMOLYTIC ANEMIA
Anemia of increased destruction
- Normochromic, normochromic anemia
Shortened RBC survival
Reticulocytosis - Response to increased RBC
destruction
Increased indirect bilirubin
Increased LDH
 Classification of Hemolytic Anemia

Intracorpuscular factor
Extracorpuscular factor
 Causes of HEMOLYTIC ANEMIA

INTRACORPUSCULAR HEMOLYSIS
Membrane Abnormalities
Metabolic Abnormalities
Hemoglobinopathies
EXTRACORPUSCULAR HEMOLYSIS
Nonimmune
Immune
1. Intracorpuscular factor
Red cell abnormality
A. Hereditary
1. Membrane defect (spherocytosis, elliptocytosis)
2. Metabolic defect (Glucoze-6-Phosphate-Dehydrogenaze (G6PD)
deficiency, Pyruvate kinase (PK) deficiency)
3. Hemoglobinopathies (unstable hemoglobins,
thalassemias, sickle cell anemia )

B. Acquired
1. Membrane abnormality-paroxysmal nocturnal hemoglobinuria (PNH)
Mechanisms of hemolysis /
Pathogenesis:

1. Intra vascular
2. Extra vascular
 Hemolysis - RBC destruction

Extravascular Hemolysis Intravascular Hemolysis

Ingested by RE cell ( spleen Hgb liberated in

& liver) blood vessel

Serum
Heme Globin Hgb + haptoglobin
haptoglobin

Reutilized + hemalbumin
Hgb + albumin
Iron Protoporphyrin & plasma Hgb

Hgb excreted +
Reutilized bilirubin in urine hemoglobinuria
& hemosidenuria
Intravascular hemolysis :

- Red cells destruction occurs in vascular space

- Clinical states associated with Intravascular hemolysis:
Acute hemolytic transfusion reactions
Severe and extensive burns
Paroxysmal nocturnal hemoglobinuria (PNH)
Severe microangiopathic hemolysis
Physical trauma
Bacterial infections and parasitic infections (sepsis)
- Laboratory signs of intravascular hemolysis:
Indirect hyperbilirubinemia
Erythroid hyperplasia
Hemoglobinemia
Methemoalbuminemia
Hemoglobinuria
Absence or reduced of free serum haptoglobin
Hemosiderinuria
 Extravascular hemolysis :
- Red cells destruction occurs in reticuloendothelial system
(RES)
- Clinical states associated with extravascular hemolysis :
Autoimmune hemolysis
Delayed hemolytic transfusion reactions
Hemoglobinopathies
Hereditary spherocytosis
Hypersplenism
Hemolysis with liver disease

- Laboratory signs of extravascular hemolysis:

Indirect hyperbilirubinemia
Increased excretion of bilirubin by bile
Erythroid hyperplasia
Hemosiderosis
 Anamnesa
Fatigue
Pallor
Shortness of Breath
Bleeding/petechiae
Joint symptoms
Rash-eg malar
Family History
Medications
 Physical Exam Findings
Tachycardia
Tachypnea
Jaundice
Splenomegaly
Signs of congestive heart failure in rapidly
progressive anemia
Laboratory features:
Hematology test
1. Laboratory features
- Normocytic/macrocytic, hyperchromic anemia
- Reticulocytosis
- Increased serum iron
- Antiglobulin Coombs test is positive

2. Blood smear
- Anisopoikilocytosis, spherocytes
- Erythroblasts
- Schistocytes

3. Bone marrow smear

- Erythroid hyperplasia
 Extra corpuscular Factor
Autoimmune Hemolytic Anemia (AIHA)
* warm-reactive antibodies:
I. Primary
II. Secondary
1.Acute
- viral infections
- drugs ( -Methyldopa, Penicillin, Quinine,
Quinidine)
2. Chronic
- rheumatoid arthritis, systemic lupus
erythematosus
- lymphoproliferative disorders
(chronic lymphocytic leukemia, lymphomas,
Waldenstrms macroglobulinemia)
- miscellaneous (thyroid disease, malignancy )
 * cold-reactive antibodies:

I. Primary cold agglutinin disease

II. Secondary hemolysis:
- Mycoplasma infections
- Viral infections
- Lymphoproliferative disorders
III. Paroxysmal cold hemoglobinuria
Diagnosis
- Positive Coombs test (DAT)

Treatment:
- Steroids
- Splenectomy
- Immunosupressive agents
- Transfusion If needed
 Intracorpuscular FACTOR
A. Accquired :
Paroxysmal Nocturnal Hemoglobinuria (PNH)

1. Pathogenesis

- An acquired clonal disease, arising from a somatic mutation in

a
single abnormal stem cell
- Glycosyl-phosphatidyl- inositol (GPI) anchor abnormality
- Deficiency of the GPI anchored membrane proteins
(decay-accelerating factor =CD55 and a membrane inhibitor
of reactive lysis =CD59)
-Red cells are more sensitive to the lytic effect of complement
- Intravascular hemolysis

2. Symptoms
- Passage of dark brown urine in the morning
3. PNH laboratory features:

- Pancytopenia
- Chronic urinary iron loss
- Serum iron concentration decreased
- Hemoglobinuria
- Hemosiderinuria
 Lab Tests for PNH
Acidified serum lysis test (Hams test)
Sugar water (sucrose hemolysis) test
Flow cytometry: lack of CD59 on RBCs, or lack of
CD59 or CD55 on granulocytes
 Treatment
- Washed RBC transfusion
- Allogenic bone marrow transplantion
 Intracorpuscular Factor
B. Herediter ( defect)
Hemoglobinopathies
Sickle Cell Disease, Sickle cell trait, Hemoglobin
SC
Thallasemias
Unstable RBC Membrane
Hereditary spherocytosis
Metabolic Machinery
G6PD deficiency
Pyruvate kinase deficiency
 G6PD Deficiency
It is an X-Linked recessive inheheritance (
males usually affected and females are
carriers)
Risk factors : black, male, or having a family
history of G6PD deficiency
G6PD enzyme functions in the Pentose
Monophosphate shunt and in process,
catalyzes the reduction of NADP + to NADPH
required in triggering a cascade of events that
can detoxify the harmful oxidant H2O2
 Drugs that affect it
Drugs - can precipitate this reaction include :
Anti malaria agents, sulfonamide, aspirin
NSAIDs, nitrofurantoin, quinidine, quinine
Other :
exposure to certain chemicals such as those in
mothballs and flava beans
 What are the symptom ?
The most common symptoms :
- Abnormal palerness or lack of color of the skin
- jaundice, or yellow of the skin, eyes, and mouth
- dark color of urine
- Fever
-weakness
-Dizziness, confution
-Intolerance to physical activity
 Sign of anemia

Pale skin
Rapid pulse
Heart murmur
Enlarged spleen and liver
 Required test
Blood tests are taken to measure levels of :
- Red cells, assess size, shape of red cells
- Hb level
- Reticulocytes
Other Blood test :
- Combs test
- Heinz body presentation
 Treatment
Stopping use drug
For severe case
- corticosteroid
- Intravenous imunoglobulin
-Imunosupresive
Change in diet
Transfusion if needed
 MACROCYTIC ANEMIAS
Macrocytic anemias are characterized by
large RBCs with a normal hemoglobin
content.
Macrocytic anemias Megaloblastic or
non-Megaloblastic
Megaloblastic anemias are associated
with defective DNA synthesis and
therefore, abnormal RBC maturation in
the bone marrow (a nuclear
maturation defect).
 MEGALOBLASTIC ANEMIAS
The biochemical basis for this is as follows:
Megaloblastic dyspoiesis (abnormal synthesis)
occurs when the DNA synthesis in the hematopoietic
system is disrupted or slowed down.
Other rapidly proliferating cells in the body are also
affected.
Administration of drugs that interfere with DNA
metabolism can be the cause of a megaloblastic
anemia.
On rare occasions there is an inherited disorder that
affects DNA synthesis
DIFFERENTIAL DIAGNOSIS WITH A
HIGH MCV
NON-MEGALOBLASTIC MACROCYTIC ANEMIA

Note that the macrocytic RBCs are not

oval, but are round.
There are no hypersegmented
neutrophils or Howell-Jolly bodies
NON-MEGALOBLASTIC MACROCYTIC ANEMIA
 Megaloblastic anemia / Macrocytic
anemia
95% of cases of megaloblastic anemia are
- Deficiency of vitamin B12
- Deficiency of folic acid
Macrocytic blood picture
Megaloblastic erythropoesis.
 Vitamin B12 deficiency
Inadequate diet (no animal products!)
Malabsorption
Pernicious anemia (PA)
Partial or total gastrectomy
Blind loop syndrome
Fish tapeworm
Primary hypothyroidism
VITAMIN B12 ABSORPTION

Mucosal cell
Folate/B12 DNA Synthesis
 Clinical Feature
Sympton and sign Vit B12 Def :
Severe : anemia, neuropathy
Other symptom : sore mouth,loss of taste,
atropy mucosa of the tongue.
Disorder of the central nervous system :
paresthesias of the hands & feet, unsteadiness
of gait, memory loss etc.
 Folate deficiency
Reduced intake ( nutritional & malabsorpsi)
Increased utilisation (pregnancy, malignancy,
hyperthytoidsm)
Defective utilisation : drugs (anticonvulsant,
oral contraceptive), alcoholism.
Reduced hepatic stores
alcohosm, hepatoma
 Sypmtom & Sign folic acid def
Often go undiagnosed, especially alcoholic
who have a very poor diet and maintain blood
alcohol levels above 100 mg/dl enteropatic
cycle of folate supply to the intestine and
tissues impared.
Diagnosis is made difficult clinician must
be suspicious of the possibility of folate def. in
the alcoholic.
The peripheral blood smear Macrocytic
Anemia
oval macrocytes, anisocytosis,
poikilocytosis
Hypersegmental neutrophils (>5% with
more than five nuclear lobes)
Platelets bizarre in shape and size (giant
platelets)
Neutropenia
Thrombocytopenia (not as severe as in AA)
Low reticulocytosis
The bone marrow shows a megaloblastic
erythropoesis
 Bone marrow smear in Macrocytic
Anemi

Megaloblastic erythropoesis
Bone marrow rich in cells,
Giant metamyeolcytes
Giant bands
Many Howell-Jollyes bodies
Cabots rings
 Biochemical findings in MA
Serum indirect (unconjugated) bilirubin
Serum LDH (principally LDH-1)
Serum iron
(unless the anemia is complicated with iron
deficiency)
Vitamin B12 concentration
Folic acid concentration
The diagnosis of megaloblastic anemia
Serum vitamin B12 concentration
Serum folic acid concentration
If vitamin B12 and folate assays are within
normal limits, then the bone marrow
examination is performed (before blood
transfusion or vitaminB12, folate
administration).
Schilling test
 Diagnosis

Establised based on laboratory test.

DD Macrocytosis
Dysplastic anemias,
Liver disease
Hemolysis exposure to the
chemotherapeutic agents.
 Treatment
Folic Acid and Vit B12 ( etiology must known
well)
Severe with anemias : PRC transfusion
 Aplastic anemia
Aplastic anemia is a severe, life threatening
syndrome in which production of erythrocytes,
WBCs, and platelets has failed.
Aplastic anemia may occur in all age groups and both
genders.
The disease is characterized by peripheral
pancytopenia and accompanied by a hypocellular
bone marrow.
 Aplastic anemia
Etiology
Acquired
Most cases of aplastic anemia are idiopathic and there is
no history of exposure to substances known to be
causative agents of the disease
Exposure to ionizing radiation hematopoietic cells are
especially susceptible to ionizing radiation. Whole body
radiation of 300-500 rads can completely wipe out the
bone marrow. With sublethal doses, the bone marrow
eventually recovers.
Chemical agents include chemical agents with a
benzene ring, chemotherapeutic agents, and certain
insecticides.
Idiosyncratic reactions to some commonly used drugs
such as chloramphenicol or quinacrine.
 Aplastic anemia
Infections viral and bacterial infections such as
infectious mononucleosis, infectious hepatitis,
cytomegalovirus infections, and miliary
tuberculosis occasionally lead to aplastic anemia
Pregnancy (rare)
Paroxysmal nocturnal hemoglobinuria this is a
stem cell disease in which the membranes of
RBCs, WBCs and platlets have an abnormality
making them susceptible to complement
mediated lysis.
Other diseases preleukemia and carcinoma
 Aplastic anemia
Congenital disorders
Fanconis anemia the disorder usually
becomes symptomatic ~ 5 years of age
and is associated with progressive bone
marrow hypoplasia. Congenital defects
such as skin hyperpigmentation and
small stature are also seen in affected
individuals.
Familial aplastic anemia a subset of
Fanconis anemia in which the congenital
defects are absent.
 Clinical features
Fatique
Heart palpitation
Palor
Infections
Ptchiae
Mucosal bleeding/gum bleeding
 Aplastic anemia
Pathophysiology:
The primary defect is a reduction in or depletion of
hematopoietic precursor stem cells with decreased
production of all cell lines. This is what leads to the
peripheral pancytopenia.
This may be due to quantitative or qualitative damage
to the pluripotential stem cell.
In rare instances it is the result of abnormal hormonal
stimulation of stem cell proliferation
or the result of a defective bone marrow
microenvironment
or from cellular or humoral immunosuppression of
hematopoiesis.
 Aplastic anemia
Lab findings
Severe pancytopenia with relative
lymphocytosis (lymphocytes live a long time
Normochromic, normocytic RBCs (may be
slightly macrocytic)
Mild to moderate anisocytosis and
poikilocytosis
Decreased reticulocyte count
Hypocellular bone marrow with > 70% yellow
marrow
Differential Diagnosis of pancytopenia and hypoplastic
marrow

1. Aplastic anemia
2. Hypoplastic myelodysplastic syndrome or
hypoplastis AML
3. PNH
4. Hypoplastic antecedent phase of acute
lymphocytic leukemia
5.Hypoplastic antecedent of hairy cell leukemia
6. Idiopathic myelofibrosis
7. Pure red cell aplasia
8. Agranulocytosis.
 Diagnosis Criteria for Severe AA

At least two of following

- Absolute neutrophil count < 0,5 x 10 9 /L
- Platelet count < 20 x 10 9/L
- Anemia with corrected reticulocyte count < 1 %.
One of the following
- Bone marrow cellularity <25 %
- Bone Marrow cellularity < 50 % with fewer the
30 % the neutrophil cell
 Treatment
Marrow tranplantation isI curative for < 40
years.
Only one third of patients have suitable
donor.
Immunosuppressive therapy : not curative
-ATG
-Cyclosporin
-Androgen
- Corticosteroids