Aplastic anaemia

Dr sandeep M R
Physician jayanagar general hospial
bangalore
 DEFINITION
• Aplastic anemia is pancytopenia with bone
marrow hypocellularity  in the absence of
abnormal infiltrate and with no increase in
reticulin.
 Epidemiology

• Incidence- 0.6-6/million population

• No race/age/ sex predilection 
• High incidence in Asia
• 50% of cases occur before 3rd decade
• Biphasic age peak- 1-25years and more than
60 years
• In India 6000-8000 patients/ year
 ETIOLOGY
Classification of Aplastic Anemia and Single
Cytopenias
Drugs and chemicals causing aplastic anaemia

Dose related-
• Alkylating agents(carboplatin)
• Antimetabolites(methotrexate)
• Benzene
• anibioitics (Chloramphenicol,sulfonamide)
• Inorganic arsenicals 
Idiosyncratic-
• aniepileptics (cbz,phenytoin)
• Antithyroid (methimazole,PTU)
• Chloramphenicol
• NSAIDS(indomethacin,Phenylbutazone)
• Organic arsenicals
• Penicillamine
• Gold salts
 Pathogenesis
two major etiologies
• an extrinsic, immune-mediated suppression
of marrow progenitors
• intrinsic abnormality of stem cells.

• autoreactive T cells play an important role.

 Cytogenetics
 
• By FISH karyotyping/ by Single nucleotide
polymorphism array (SNP-A) 19% patients show
chromosomal abnormalities
• Monosomy 7 (Most common) and Others: Trisomy 8,
5q deletion, deletion 20q, deletion 13q, trisomy 1.
• Trisomy 8 and del 13q herald good prognosis.
• Presence of cytogenetic abnormality does not rule
out the diagnosis of aplastic anemia.
 Next Generation Sequencing: 

• Somatic mutations commonly seen- TP53, ASXL-1,

DNMT3, RUNX1 (these cases are associated with
poor prognosis)
• Mutations in PIGA, BCOR and BCORL1 genes (these
cases are associated with good prognosis)
• Tests for specific mutation causing telomere
shortening. Done only if there is short telomere.
• Mutations typical of myeloid malignancies help to
differentiate aplastic anemia from hypocellular MDS. 
 MORPHOLOGY

• hypocellular bone marrow -devoid of

hematopoietic cells; often only fat cells,
fibrous stroma, and scattered lymphocytes
and plasma cells remain.
• dry tap
• aplasia is best appreciated in marrow biopsies
• granulocytopenia and thrombocytopenia
 History

• Petechiae and ecchymoses due to thrombocytopenia (most

common)
• Frequent infections due to granulocytopenia- Pneumonia and
septicemia are frequent cause of death
• Anemia- Fatigue, lassitude, shortness of breath, etc
• Systemic complaints and weight loss should point to other
etiologies of pancytopenia.
• Prior drug use, chemical exposure, and preceding viral illnesses
must often be elicited
• A family history of hematologic diseases or blood
abnormalities, of pulmonary or liver fibrosis should be asked.
 Physical Examination

• Petechiae and ecchymoses are typical, and retinal

hemorrhages may be present.
• Pallor of the skin and mucous membranes is common
• Infection on presentation is unusual but may occur if the
patient has been symptomatic for a few weeks.
• Lymphadenopathy and splenomegaly are highly atypical of
aplastic anemia.
• Cafe au lait spots and short stature suggest Fanconi anemia;
• peculiar nails and leukoplakia suggest dyskeratosis congenita;
• early graying of hair suggests a telomerase defect.
 Specific invesigations

• Hemogram
– Pancytopenia
– Normocytic normochromic RBCs. Mild
macrocytosis is usually observed
– Leucopenia especially neutropenia
– No abnormal cells are seen
– Platelets – Reduced counts, usually small in size
– Absolute reiculocyte count= <25*109 /l, Corrected
count - <1%
• Bone marrow aspiration
– Can be dry tap and fragments are usually easily obtained
and they are hypocellular.
– Erythropoiesis is suppressed. Marked dyserythropoiesis is
common. So this alone does make the diagnosis of MDS.
– Granulocytes and megakaryocytes are decreased or absent.
Presence of dysplasia in them indicates diagnosis of
hypocellular MDS.
– Residual lymphocytes, plasma cells, mast cells and
macrophages are seen.
– Marrow lymphocytes >75% correlates with poor prognosis
• Trephine biopsy
– Should be minimum 2cm long and avoid tangential
biopsies
– Hypocellular marrow
• <30% in age <60 years and <20% in age >60years
– Empty marrow spaces populated by fat cells, fibrous
stroma and scattered lymphocytes and plasma cells.
– Very few precursor cells are seen (<25%)
– Megakaryocytes are usually absent
– Hot spots
– Sometimes lymphoid aggregates insystemic autoimmune
disorder such as SLE /RA
– In a bone marrow of aplastic anemia, always look for
hypocellular MDS, hypocellular AML, hairy cell leukemia,
lymphoma, myelofibrosis and mycobacterial infection
Non specific findings
• ESR – Elevated
• Serum erythropoietin level –Elevated
• Hemoglobin electrophoresis: Hb F content is
increased up to 1.5g/dL
• Serum iron content – Increased
 TO RULE OUT OTHER DISEASES

• Cytogenetics
• NEXT GENERATION SEQUENCING:  
• Vitamin B12 levels and folate levels: As some
megaloblastic anemia can present with
hypocellular bone marrow
• Abdominal USG- Enlarged lymph nodes and
splenomegaly indicate possibility of malignant
hematological disorder
 FOR ETIOLOGY
• Chromosome breakage study using diepoxybutane, or mitomycin C
(stress cytogenetics)-Positive in Fanconi’s anemia
• Serological tests for HIV, EBV, CMV, hepatitis (A/B/C), parvovirus B19
• Measurement of peripheral blood leucocyte telomere length- By
PCR or flow FISH methods
• LFT: To detect antecedent hepatitis
• ANA and anti-DsDNA
• DCT and ICT
• Chest X ray: To exclude infections and for comparison with
subsequent films
• X ray radii- In young patients, to exclude Fanconi anemia 
• HLA typing- To identify potential donor, especially in case of young
patient
• Criteria for Diagnosis:
• Bone marrow - <25% cellularity without
presence of abnormal cells or fibrosis
and any two of following findings
–Granulocytes - <1.5x109/L or absolute
neutrophil count  <0.5x109/L
–Platelet - <50x109/L
–Corrected retic count - <1%
–Hb<10g/dL 
 Prognosis:
• Untreated patients: 70% die within 5 years of diagnosis
• 20% patients spontaneously recover with supportive
therapy
• With immunosuppressive therapy- 5 year survival rate
is 75%
• With bone marrow transplant from matched donor- 5
year survival is>90%
• Those due to exposure to toxin, have better prognosis
than idiopathic ones.
• Major causes of death: Infections, Bleeding
– In BMT patients: GVHD, toxicity from conditioning regimen
– In immunosuppressant responders: PNH, MDS, Leukemia
 Grading of severity: (Camitta criteria)

• Severe aplastic anemia: Bone marrow

cellularity<25% with at least two of following 3
criteria
–Absolute neutrophil count <500cells/cmm
–Platelet count <20,000/cmm
–Reticulocyte count <20,000/cmm or <1%
• Very severe aplastic anemia: Same as severe aplastic
anemia but absolute neutrophil count is <200/cmm
• Non severe aplastic anemia: Aplastic anemia not
fulfilling criteria of severe/ very severe aplastic
anemia
 TREATMENT

NON SEVERE APLASTIC ANAEMIA

• IF Non transfusion dependant on prc/platelets- observe
• If transfusion dependent-ATG+CSA
• IF responds taper cyclosporine A and maintain
• If doesnt responds repeat 2 nd dose at 6 months, again if no response –
BMT ,OXYMETHALONE
 
SEVERE APLASTIC ANAEMIA  
• Preferred treatment if donor available,good performance scores,age <50-
60 yrs-BMT 
• IF BMT not possible - ATG+CSA+Eltrombopag
 
Poor patients who cannot afford ATG
• Cyclosporine A + Danazol +/- Eltrombopag
 Response Criteria:

 
• Complete response:
– Hemoglobin concentration normal for age and gender
– Neutrophil count- >1500/cmm
– Platelet count- >1,50,000/cmm
• Partial response:
– Transfusion independence
– No longer meet the criteria of severe aplastic anemia