HEMOLYTIC ANEMIA

DR.SAGAR
PROFESSOR
DEPT. OF PATHOLOGY
ARMCH&RC, KUMBHARI
 Hemolytic Anemia
General Features Of Hemolysis
 Def- Group of anemias of differing etiology that all
are characterised by abnormal destruction of red
cells.
 Hallmark of these disorders is
1) reduced life span of red cells rather than
underproduction by the bone marrow
2) Accumulation of products of hemoglobin
catabolism.
3) A marked increased in erythropoiesis within
bone marrow
 Classification of hemolytic
anemia
1. Mode of acquisition of the disease
-inherited disorder or
-acquired in later life
2. Location of abnormality
-within red cell (intrinsic), or
-outside it (extrinsic)
3. Site of red cell destruction
-prematurely destroyed in blood stream
(intravascular hemolysis)
-or outside it in the spleen and liver
(extravascular hemolysis)
 Classification
 Inherited disorders ( Intracorpuscular)
Red cell membrane- Hereditary spherocytosis and hereditary
elliptocytosis .
Hemoglobin - Thalassaemia syndrome and sickling
disorders.
Metabolic pathways – G6PD and pyruvate kinase deficiency

 Acquired disorders (Extracorpuscular)

Immune - Warm and cold autoimmune hemolytic
anemia .
Isoimmune - Rh and ABO incompability.
Non immune and trauma-
valve prosthesis,microangiopathy,infection,
drugs, hypersplenism
HAEMOLYTIC ANAEMIAS
 Intravascular hemolysis is manifested by
1) Hemoglobinemia 2) Hemoglobinuria
3) Methemalbuminemia 4) Jaundice
5) Hemosiderinuria
 Extravascular hemolysis

1) Jaundice 2) Splenomegaly
 Clinical manifestation
 Pallor
 Jaundice
 Splenomegaly
 Gall stones
 Skeletal abnormalities
 Leg ulcers
 Compensatory mechanisms to
hemolysis
 Bone marrow erythroid hyperplsia
- normablastic
- reversal of ME ratio
 Reticulocytosis
 Peripheral blood findings

 Polychromasia
 Nucleated RBCS
 Neutrophilia with shift to left
 Thrombocytosis
 Morphologic red cell abnormalities
Spherocyte, sickle cell, target cell schistocytes,
acanthocytes
Polychromasia - Hemolytic An.
 A 39-year-old woman who presented with increasing fatigue
and muscle weakness is found have a microcytic and
hypochromic anemia.
 Which of the following is the most likely cause of her anemia?
 A. Folate deficiency
 B. Iron deficiency
 C. Viral infection
 D. Vitamin B12
 deficiency
 E. Vitamin C deficiency
 Which of the following autoantibodies is most likely to be
present in a patient with pernicious anemia?
 A. Anticentromere antibodies

 B. Antigliadin antibodies

 C. Anti-intrinsic factor antibodies

 D. Antimitochondrial antibodies

 E. Antismooth muscle antibodies


 61-year-old woman with pancytopenia, mild jaundice, and
peripheral neuropathy is found to have decreased serum levels
of vitamin B12
 Which of the following abnormal cell morphologies is most
likely to be present in a smear made from her peripheral
blood?
 A. Hypersegmented PMNs
 B. Large granular lymphocytes
 C. Oval microcytes
 D. Pelger-Huët neutrophils
 E. Plasmacytoid lymphocytes
 Low Hb=Anemia
MCV

Low Normal High

microcytic normocytic macrocytic

Measure Ferritin Measure B12 + folate

Low Normal/high Normal Low

Megaloblastic
Anemia of anemia
Iron def
chronic disease/
Anemia
Congenital Hb dis.
Reticulocyte count

Hemolytic anemia or high low Anemia of chronic disease

blood loss Renal failure
Marrow failure
 A 70-year-old Jewish man presents to his primary care
physician with weakness. Physical examination reveals pallor
and hepatosplenomegaly. A bone
 marrow aspiration and a biopsy are performed to evaluate the
cause of his anemia. Histiocytes that appear enlarged with
“wrinkled tissue paper” cytoplasm
 are noted in the bone marrow.
 ◆What is the most likely diagnosis?
 ◆What is the underlying etiology of this condition?
 ◆What are the other clinical features of this disease?
 Inherited disorders
Disorders of red cell membrane
Hereditary Spherocytosis
-Inherited hemolytic anemia resulting from red
cell membrane defect leading to
microspherocytosis, splenomegaly and
intermittent jaundice.
-Increased osmotic fragility
-Severity of disease is diminished following
splenectomy
Normal red cell membrane
Molecular defect
 Hereditary Spherocytosis

Shear forces
in circulation
 membrane membrane
stability loss

Chronic
hemolytic M
anemia
splenomegaly spherocyte
 Lab findings
 Anaemia mild to moderate degree; Reticulocytosis
(5-20%)

 Microspherocytes

 MCV: Normal

 MCHC: increased

 Osmotic fragility is Increased

Her. Spherocytosis:
Hereditary Elliptocytosis:
 Inherted disorders
Abnormalities of red cell metabolism
 Red cell has metabolic pathway to generate energy
and also to protect it from oxidant stress
 Deficiency of any enzyme of the pathway will affect
red cell metabolism
 Enzymes of HMP pathway – G6PD deficiency
 Enzymes of glycolytic pathway- Pyruvate kinase
deficiency
 Miscellaneous- pyrimidine-5 nucleotidase deficiency
 G6PD Deficincy
 G6PD is necessary enzyme in generation of
reduced glutathion which protect red cell from
oxidant stress.
 Sex linked- affecting male, females are carrier
 Increased oxidant stress leads to severe
hemolytic anemia (intravascular destruction)
 Common trigger- fava beans (vicia faba) ,
drugs( antimalerial, analgesic) and infection
 Confers protection against malaria.
 G6PD Deficiency

O- glutathione
*GSH +
hydrogen peroxide

Hemoglobin precipitates
(Heinz bodies)

- plucked out by spleen - bite cells

(RBCs phagocytized in spleen)
Hemoglobin Precipitates (Special Stain)
Bite Cell - G6PD Deficiency
 C/F
 Can not withstand oxidant stress (due to viral,
bacterial, drug)
 Acute haemolytic anaemia
 Self –limiting condition
 Haemoglobinuria (darkening of urine)

Lab findings:
 Rapid fall in haematocrit by 25-30%
 Haemoglobinuria

 Heinz bodies formation (oxidation & precipitation of

Hb within in the red cells)
 Rise in unconjugated Bilirubin
 Rise in plasma Haemoglobin

 Direct enzyme assay in red cells clinches the

diagnosis
 ACQUIRED DISORDERS
Autoimmune hemolytic anemia
 Interaction of autoantibody with patient’s own red
cell antigen is dependent on the temperature.
 ‘ Warm’ antibody AIHA in which autoantibodies
are reactive at body temperature (37 0C)
IgG type and do not fix complement
 ‘Cold’ antibody AIHA in which autoantibodies react
better with patient’s own red cells at 4 0C
IgM type, fix complement and result in intravascular
hemolysis or sensitised RBCS are lysed by RE
system of liver and spleen.
 Warm antibody AIHA
 Chronic anaemia
 Splenomegly : major site of red cell
destruction
 Antibodies reactive at body temperature
 IgG antibodies
 Associated with SLE, Lymphocytic leukaemia,
Lymphomas , Drugs like M-DOPA,
procainamide, levodopa
 Idiopathic (35-40%)
 LAB FINDINGS OF WARM
ANTIBODY
 Mild to moderate chronic anaemia

 Reticulicytosis

 Spherocytosis in PBF

 Positive Direct Coomb’s test (antiglobulin) at

37 0C

 Indirect hyperbilirubiraemia

COLD
0
Antibodies reactive at 4 C
AIHA
 Etiology not known (IDIOPATHIC)
 Seen with mycoplasma pneumonia, Infectious mononucleosis,
Lymphomas, paroxysmal cold haemoglobinuria
C/F: chronic anaemia worsened by exposure to cold
 Raynaud’s phenomenon

 Cyanosis: Tips of nose, ears, fingers, toes

 Haemoglobinuria occurs on expoture to cold

 Lab findings

1. Chronic anaemia

2. Low recticulocyte count since young red cells are affected more

3. Positive direct coomb’s test

 ISOIMMUNE (ALLOIMMUNE)
HEMOLYTIC ANEMIA
 Hemolytic transfusion reaction
ABO mismatch
 Hemolytic disease of new born
 Non immune acquired hemolytic
anemia
 Cardiac hemolytic anemia
- Valvular prosthesis
- Aortic stenosis
- Mitral valve stenosis
- Coarctation of aorta
 Microangiopathic hemolytic anemias Fragmentation syndrome

- Hemolytic uraemic syndrome

- Thrombotic thrombocytopenic purpura
- Pre eclamsia
- HELLP syndrome
 March hemogloburia
 Paroxysmal nocturnal hemoglobunuria
 Paroxysmal nocturnal hemoglobunuria
(PNH)
 Rare acquired clonal disorder of red cell membrane
 Chronic intravascular haemolysis
 Acquired hemolysis with intrinsic cell defect
 Mutation in hemopoietic stem cells, as a result RBCS,
WBCS, and platelets are affected
 Red cells are abnormally sensitive to lysis by complement

 Clinical & Lab findings

1. Haemolytic anaemia
2. Pancytopenia
3. Haemoglubinuria: passage of brown urine in the morning
4. Venous Thrombosis: common complication
5. Ham’s acidified serum test
HAEMOLYTIC ANAEMIA FROM
DIRECT TOXIC EFFECTS
 Malaria (black water fever) Direct parasitation red
cells

 Bartenellosis: infection of red cells

 Septicaemia: with CL. Welchii

 Extensive burns

 Snake & spider bites

 HAEMOLYTIC ANEMIA IN
SPLENOMEGALY
 Common in any splenic enlargment from any
cause

 Pancytopenia
 Inherited Disorders of hemoglobin
Hemoglobinopathies

 Quantative hemoglobinopathy (Thalassemias)

reduced synthesis of globin chain

 Qualitative disorders of Hb (Sickle cell syndrome)

Structurally abnormal hemoglobins i.e. HbS
 THE THALASSEMIAS
 Group of disorders which result from inherited
abnormality of globin chain synthesis
 Defects in the rate of synthesis of alpha or
beta chains
 Clinical and hematological features are due to
-reduced Hb production
-accumulation of one type alpha or beta
globin chains
 Thalassemia
 Absent or decreased Synthesis of Globin
Chains (Quantitative)
 Most Frequent in Mediterranean, African, or
Asian Populations
 β - Thalassemia - decreased β Chain
Synthesis (Gene Mutations)
 α - Thalassemia - decreased α Chain
Synthesis (1-3 of 4 Genes Deleted) (SE
Asians)
ALPHA THALASSEMIA
 - Thalassemia Minor

   chain
o 
 synthesis


+    chain
 synthesis

Mild or no anemia
  - Thalassemia Major

 No  Chain
o o
 Synthesis
Chromosome 11


+ +   Chain
 Synthesis
Severe Anemia
 Thalassemia major (Cooley’s
anemia)
 Anaemia due to premature red cell destruction due to
damage to erythrocyte membrane caused by the
precipitated - < globin chains

 Shortened life span of RBC

 Ineffective erythropoiesis

 Decreased rate of β - chain synthesis leading to reduced

formation of HbA in the red cells
 Contd…
 Most severe form of congenital haemolytic
anaemia
 Anaemia strats 1st 4-6 months of life
 Marked hepatosplenomagly
 Thalassaemic facies and Mal occlusion of the
Jaw
 Slow rate of growth and development
 Delayed puberty, diabetes mellitus
 Damage to the liver and heart
Pathophysiology
 CLINICAL FEATURES
 Age- present within 1 yr of life, but not before 1-2
months of life
 Pallor
 Splenomegaly
 Thalasemic facies- frontal bossing because of
thicking of cranial bones and overgrowth of
zygomatic bones makes the cheek bones prominent.
(mongoloid facies)
 Jaundice
 Bone changes
 C/F CONTINUE….
 Growth and development
 Infections
 Cardiac changes
 Hepatomegaly
 Endicrine changes – GH deficiency,
hypothyroidism , hypoparathyroidism, DM
 Hematological finding
 Severe anaemia

 PBF: MHA

 Marked anisocytosis & poikilocytosis

 Many target cells

 Tear drop cells

 Normoblast

 increased serum bilurubin

 Reticulocytosis

 MCV MCH, MCHC are reduced

 Osmotic fragility: resistant to saline haemolysis i.e. decreased osmotic fragility

Thalassemia Major
ß Thalassemia Major:
Thalassemia minor:
Special laboratory test for diagnosis
 Increased HbF
HbF levels are high 30-90%
HbF estimated by alkali denaturation method
acid elution method
 Hb electrophoresis
 Prenatal diagnosis- first by fetal blood
sampling and globin chain synthesis, later by
chorionic villos biopsy and fetal DNA analysis
 Management of Thalassemia major
 Blood transfusion
 Iron chelation
 Splenectomy
 Bone marrow transplantation

Causes of death – cardiac failure

transfusion transmitted diseases
pancytopenia resulting in infection
Prevention of Thalassemia major
 Blood Smear Interpretation:
A B C D

E F G H

I J
 Sickle cell disorder
Sickle syndrome are characterised by presence of HbS
which imparts sickle shape to red cell in a state of reduced
oxygen tension

Sickle syndrome occurs in 3 different forms

 As heterozygous state for Hbs: Sickle cell trait (AS)

 As homozygous state for Hbs: Sickle cell anaemia (SS)

 As double heterozygous states

-Sickle β – Thalassemia

-Sickle C – disease, sickle – D- disease

 Structure of Hemoglobin S
 Sickle mutation result in substitution of valine
in place of glutamic acid in the 6th position of
beta chain.
 This alters the solubility and characteristic of
Hb resulting in polymerization of HbS forming
tactoids
 Polymerisation of HbS is dependent on O2
tension and amount HbS in red cells
 Normal Vs. Sickle Red Cells
Normal Sickle
 Disc-Shaped  Sickle-Shaped
 Deformable  Rigid
 Life span of 120 days  Lives for 20 days or
less
Sickle Cell Disease
Sickle cell

Polymerization
of Hgb S
 Sickle Cell Pedigree

 Parents with sickle cell trait: hemoglobin AS

 Probability of child with hemoglobin AA: 25%
 Probability of child with sickle cell trait AS: 50%
 Probability of child with sickle cell disease SS: 25%
 Sickle cell anemia (Homozygous state ss)
Clinical features
 Age at presentation – 3 mths- 1 yr
 Growth and development
 Spleen
 Leg ulcers
 Hand foot syndrome
 Infections
 Cardiomegaly
 Hepatomegaly
 Gall stones
 Abdominal pains
 CNS involvement
 Priapism
 Crises in Sickling Syndrome
 Sickling crises (vaso-occlusive crises)
Acute ,painful recurrent crises precipitated by
fever, infection and dehydration
 Hemolytic crises
 Aplastic crises – aplasia of erythroid
precursors occures because of certain viral
infection.( parvovirus B19)
 Sequestration crises
 Hematological finding
 Anemia
 WBC and platelet count increased
 PS finding
 Reticulocytosis
 Serum haptoglobin decreased
 Urine urobilinogen increased
Sickle Cells
 Diagnostic test
 Sickling test –sickling is induced by adding a
reducing agent like 2% sodium metabisulphite
or sodium dithionite to blood
 Hb electrophoresis
 Hb F estimation
 Family studies
 Globin chain analysis
 HbS solubility test