Anaemia II

Dr Afshan Sumera
Haematopathologist
Session outcomes
 You should be able to
◦ Describe major types & pathogenesis of haemolytic
anaemia
◦ Interpret the investigations of haemolytic anaemia
Classification of Anaemia according to
Underlying Mechanism
◦ Decreased Production

◦ Increased Destruction (Haemolysis)

◦ G6PD deficiency
◦ Thalassaemia syndromes,
◦ Sickle cell disease
◦ Transfusion reactions
◦ Drugs
◦ Infections

◦ Blood Loss
Haemolytic Anaemia
 Premature destruction of red cells & shortened
red cell life span below the normal 120 days
 Elevated erythropoietin levels and a
compensatory increase in erythropoiesis
 Accumulation of hemoglobin degradation
products released by red cell breakdown
derived from hemoglobin
Types of haemolysis
 Extravascular

◦ Extravascular haemolysis is generally caused by

alterations that render the red cell less deformable
◦ Extreme changes in shape are required for red cells
to navigate the splenic sinusoids successfully

◦ Principal clinical features of extravascular

haemolysis are
◦ (1) anaemia
(2) splenomegaly
(3) jaundice
Types
 Intravascular
◦ Caused by mechanical injury, complement fixation,
intracellular parasites (e.g., falciparum malaria) or
exogenous toxic factors

◦ Manifested by
◦ (1) anaemia
◦ (2) haemoglobinemia
◦ (3) haemoglobinuria
◦ (4) haemosiderinuria
◦ (5) jaundice
HAEMOLYTIC ANAEMIA- INTRACORPUSCULAR DEFECTS

 Hereditary
◦ Red cell membrane disorders: Spherocytosis,
Elliptocytosis
◦ Red cell Enzyme deficiency: G6PD, Pyruvate
Kinase, Hexokinase
◦ Disorders of Hb Synthesis: Thalassemia, Sickle
cell anaemia, other haemoglobinopathies

 Acquired
◦ Paroxysmal nocturnal haemoglobinuria
Haemolytic Anaemia- Extracorpuscular Defects
 Antibody mediated RBC lysis
◦ Idiopathic
◦ Transfusion reactions
◦ SLE
◦ drugs
◦ Infections
◦ Malignancies
 Mechanical trauma
◦ Microangiopathic HA,
◦ TTP, Disseminated Intravascular haemolysis,
Cardiac
 Infections, Chemicals, Hypersplenism
Morphology
 Anemia and lowered tissue oxygen tension
erythropoietin erythroid differentiation
erythroid precursors (normoblasts) in the marrow

 Compensatory increases in erythropoiesis result in

a prominent reticulocytosis in the peripheral blood
Glucose-6-Phosphate
Dehydrogenase Deficiency (G6PD)
 Hereditary deficiency of glucose-6-phosphate
dehydrogenase (G6PD) activity

 Reduce the ability of red cells to protect

themselves against oxidative injuries and lead
to haemolysis
Role of glucose-6-phosphate dehydrogenase (G6PD) in defense against oxidant injury
G6PD deficiency
 Recessive X-linked trait
 Males at higher risk for symptomatic disease

 Two variants, designated G6PD- and G6PD

Mediterranean, cause most of the clinically
significant haemolytic anaemias
 Episodic haemolysis, characteristic of G6PD deficiency
is caused by exposures that generate oxidant stress
 Most common triggers
Infections (oxygen-derived free radicals are produced by
activated leukocytes)
Viral hepatitis, pneumonia, typhoid fever

Drugs  
Foods (fava beans)
G6PD deficiency: effects of oxidant drug exposure 
Sickle Cell Disease

 Sickle cell disease is a common hereditary

haemoglobinopathy that occurs primarily in
individuals of African descent
Sickle Cell Disease
 Caused by a point mutation in the sixth codon
of β-globin that leads to the replacement of a
glutamate residue with a valine residue
Sickle Cell Disease
 Abnormal physiochemical properties of the resulting

sickle hemoglobin (HbS) are responsible for the disease

 Asymptomatic condition known as sickle cell trait

.
Pathophysiology
Morphology
Clinical Features
 Sickle cell disease causes a moderately severe
haemolytic anemia (haematocrit 18% to 30%)
and the presence of irreversibly sickled cells
 Aplastic crises stem from the infection of red
cell progenitors by parvovirus B19, which
causes a transient cessation of erythropoiesis
and a sudden worsening of the anaemia.
Diagnosis
 Clinical findings and the presence of
irreversibly sickled red cells

 Metabisulfite Test, induces sickling of red

cells if HbS is present

 Hemoglobin electrophoresis is also used to

demonstrate the presence of HbS
 Haemolytic Anaemia-
Laboratory Investigations
Laboratory investigations
 Complete blood count
◦ Reticulocyte count & Index

 Peripheral blood smear

◦ polychromasia, macrocytosis: increased red cell
production
◦ spherocytosis: hereditary spherocytosis
◦ elliptocytosis: hereditary elliptocytosis
◦ sickle cells
Laboratory investigations
 Bilirubin –
◦ increased in unconjugated bilirubin if there is increased
red cell destruction
◦ increased urinary urobilinogen and reduced haptoglobin

 LDH: increased if red cell destruction

 Urine:
◦ urobilinogen: high if increased RBC destruction
◦ haemoglobinuria, haemosiderinuria: present in
intravascular causes of RBC destruction
Laboratory investigations
 Other tests
◦ Coomb's test - tests for autoimmune cause of
haemolytic anaemia
Coomb’s test
◦ Direct coombs test: Autoantibodies that
have formed a complex with the RBC are
identified

◦ Indirect coombs test: Autoantibodies that

are still circulating in the blood, that have
not yet formed any complexes with RBC are
detected
Basis of Coomb’s test

http://www.youtube.com/watch?v=JWXC8yXe9
dE
Direct Coomb’s
Test

Indirect Coomb’s
Test
Questions