Haemolytic Anemias

Introduction to haemolytic
anaemias
• Anaemias that result from an increase in the rate of red cell
destruction.
• red cell lifespan is less than 30 days.

• Adult marrow produce red cells at 6 – 8 time the normal rate

• red cell destruction may be increased several - fold before

the patient becomes anaemic
 Intravascular and
extravascular haemolysis
• There are two mechanisms whereby red cells are destroyed
in haemolytic anaemia.

• There may be excessive removal of red cells by macrophages of

the RE system (extravascular haemolysis)

• or they maybe broken down directly in the circulation

(intravascular haemolysis)
 Intravascular haemolysis
• In intravascular haemolysis, free haemoglobin is released
which rapidly saturates plasma haptoglobins

• Excess free haemoglobin is filtered by the glomerulus

• free haemoglobin enters urine

• iron is released, the renal tubules become loaded with
haemosiderin
• Methaemalbumin is also formed
 Extravascular haemolysis
• Cells are removed extravascularly by the macrophages of the
reticuloendothelial (RE) system
• especially in the marrow but also in the liver and spleen

• The breakdown of haem from red cells liberates iron for

recirculation via plasma transferrin mainly to marrow
erythroblasts

• Protoporphyrin is broken down to bilirubin

 Clinical Manifestations in
Summary
• Onset may be acute or
insidious
• Symptoms and signs of anemia
• Jaundice
• Acholuric
• Without pruritus
• Symptoms and signs spesific to
the type of hemolytic anemia
• Symptoms related to the
underlying disease
• Splenomegaly
• Most congenital hem anemias except
sickle cell
• Some of the acquired hem. anemias
• Cholelithiasis (gall stones) symptoms
• Leg ulcers (sickle cell, spherocytosis)
• Skeletal abnormalities (thalassemia)
• Crises (chronic hemolytic disease)
• Aplastic crises (HPV-B19)
• Hemolytic
• Megaloblastic
 Laboratory findings
II-Increased bone marrow activity and RBC production

• Blood • Ferrokinetic
• Reticulocytosis • Increased plasma iron
• Macrocytosis turnover
• Polychromatophilia • Increased RBC iron
• Erythroblastosis turnover
• Leukocytosis and • Biochemical
thrombocytosis • Increased RBC creatine
• Bone marrow • Increased activity of
• Erythroid hyperplasia RBC enzymes eg:
hexokinase, etc
 Laboratory Evaluation of Hemolysis
Extravascular Intravascular
Hematologic
• Blood film Polychromatophilia Polychromatophilia
• Reticulocyte Increased Increased
• Bone marrow Erythroid hyperplasia
Erythroid hyperplasia
Plasma or serum
• Bilirubin unconjugated
unconjugated
absent
• Haptoglobin , absent
• Plasma free Hb N-
• LDH
Urine
• Bilirubin 0 0
• Hemosiderin 0 +
• Hemoglobin 0 + ( severe cases)
• Urobilinogen + +
 Morphologic abnormalities in hemolytic anemias

• Polychromasia : Reticulocytes
• Spherocyte : Her. Spherocytosis, immune hem. anemia,
burns, chemical injury to RBC
• Elliptocytes: Hereditary ovalocytosis,
• Stomatocytes: Hereditary stomatocytosis, alcoholism
• Acanthocytes: Spur cell anemia with liver disease,
abetalipoproteinemia
• Echinocytes: Pyruvate kinase deficiency, uremia
 Morphologic abnormalities in hemolytic
anemias
• Sickle cell: Sickle cell anemia
• Target cels: Thalassemia, HbC disease, liver disease,
splenectomy
• Schistocytes: Microangiopathic hem anemia, uremia, DIC,
malignant hypertesion, eclampsia,
disseminated vasculitis or malignancy,
• Agglutination: Cold agglutinin disease
• Heinz bodies: Unstable Hb, G6PD deficiency and oxidant stress
(a) Progressive urine
samples in an acute episode of
intravascular haemolysis
showing haemoglobinuria of
decreasing severity.

(b) Prussian blue - positive

deposits of haemosiderin
in a urine spun deposit (Perls
’stain)
 Classification of haemolytic
Hereditary anaemias.
• Anaemias are usually the result of ‘ intrinsic ’ red cell defects
• Hemoglobinopathies
• Enzymopathies
• Membrane cytoskeleton defects
Acquired
• Anaemias are usually the result of an ‘ extracorpuscular ’ or ‘
environmental ’ change
• Paraxysmal Nocturnal Hemoglobinuria
• Toxic drug
• Autoimunity
• Infection
 Membrane defects
• Hereditary spherocytosis
• Autosomal dominant with variable expression rarely it may
be autosomal recessive
• HS is usually caused by defects in the proteins involved in the
vertical interactions between the membrane skeleton and
the lipid bilayer of the red cell
• Ankyrin deficiency or abnormalities α - or β - spectrin
deficiency or abnormalities Band 3 abnormalities Pallidin
(protein 4.2) abnormalities
• Membrane and become increasingly spherical as they
circulate through the spleen and the rest of the RE system
RBC MEMBRANE
 Diagnosis
• Characteristic spherocytes in circulation

• A rapid fluorescent flow analysis of eosin

• maleimide bound to red cells is used as a test for HS and
membrane band 3 protein deficiency

• osmotic fragility test

• HS cells excessively fragile in dilute saline solution.
Blood film in hereditary spherocytosis. The spherocytes are deeply
staining and of small diameter. Larger polychromatic cells are
reticulocytes
 Hereditary elliptocytosis
• The basic defect is a failure of spectrin heterodimers to self -
associate into heterotetramers
• α - or β - spectrin mutants leading to defective spectrin
dimer formation
• α - or β - spectrin mutants leading to defective spectrin –
ankyrin associations
• Protein 4.1 deficiency or abnormality
 Clinical features
• Patients with homozygous or doubly heterozygous
elliptocytosis present with a severe haemolytic anaemia

• microspherocytes, poikilocytes and splenomegaly (hereditary

pyropoikilocytosis)

• Occasional patients require splenectomy

Blood film inhereditary elliptocytosis.
 South - East Asian o
valocytosis
• This is common in Melanesia, Malaysia, Indonesia and the
Philippines

• Caused by a nine amino acid deletion at the junction of the

cytoplasmic and transmembrane domains of the band 3
protein.

• The cells are rigid and resist invasion by malarial parasites.

 Acanthocytosis-
• seen in patients with abetalipoproteinemia (congenital
absence of apolipoprotein)
• complication of severe cirrhosis or pancreatitis.
• It results from accumulation of nonesterified cholesterol or
sphingomyelin on the outer layer of the lipid membrane.

• This distorts the membrane configuration and produces a

characteristic spiculatedspur shape of the acanthocyte
The characteristic spiculated shape of
the red blood cells is typical Of
acanthocytosis,
 Stomatocytosis
• seen in patients with cirrhosis, neoplasms, cardiovascular
diseases,
• inherited defect characterized by marked reduction in the
expression of Rh antigen on the cell membrane.
• Congenital stomatocytosis has been associated with
vasoocclusive events, especially pulmonary hypertension.
• Osmotic fragility is increased, reflecting a loss of red cell
membrane
Stomatocytes, cells with a
mouth-shaped concavity
 Defective red cell
metabolism
Glucose – 6 - phosphate dehydrogenase deficiency
• Glucose - 6 - phosphate dehydrogenase (G6PD) functions to
reduce nicotinamide adenine dinucleotide phosphate (NADP).
• It is the only source of NADPH that is needed for the
production of reduced glutathione.
• Deficiency of G6PD renders the red cell susceptible to oxidant
stress
• The inheritance is sex - linked, affecting males, and carried by
females who show approximately half the normal red cell
G6PD values
 Clinical features
• Acute haemolytic anaemia in response to oxidant stress, e.g.
drugs, fava beans or infections
• The acute haemolytic anaemia is caused by rapidly
developing intravascular haemolysis with
• haemoglobinuria
• The anaemia may be self - limiting as new young red cells are
made with near normal enzyme levels.
• Neonatal jaundice.
 Diagnosis
• The enzyme deficiency is detected direct enzyme
assay on red cells.

• blood film may show contracted and fragmented cells,

‘ bite ’ cells and ‘ blister ’cells

• Heinz bodies (oxidized, denatured haemoglobin) may

be seen in the reticulocyte
Blood fi lm in G6PD
deficiency with acute haemolysis
after an oxidant stress. Some of
the cells show loss of cytoplasm
with separation of remaining
haemoglobin from the cell
membrane ( ‘ blister ’ cells).

There are also numerous contracted

and deeply staining cells. Supravital
staining (as for
reticulocytes) showed the
presence of Heinz bodies
Heinz bodies-refractile intracellular
hemoglobin G6PD deficiency.
 Defective red cell metabolism
• Glutathione deficiency and other syndromes
• Other defects in the pentose phosphate pathway leading to
similar syndromes to G6PD deficiencyhave been described –
particularly glutathione deficiency.

• denatured hemoglobin precipitates on the inner surface of

the red blood cell membrane , resulting in membrane
damage and hemolysis
 Defective red cell metabolism
Glycolytic (Embden – Meyerhof) pathway defects

• The Embden-Meyerhoff pathway ( nonoxidative or anaerobic

pathway) is responsible for the generation of the ATP
• necessary for membrane function and the maintenance of cell
shape and fexibility
• Defects in anaerobic glycolysis are associated with increased
cell rigidity and decreased survival, which produces a
hemolytic anemia
 Defective red cell metabolism
Pyruvate kinase deficiency

• This is inherited as an autosomal recessive, the affected

patients being homozygous

• The red cells become rigid as a result of reduced

adenosine triphosphate (ATP) formation