1. ANEMIAS
4/27/2017
Dr. Alka Stoelinga

2. Hemolysis
4/27/2017
Dr. Alka Stoelinga

3. Hemolysis Evidences of hemolysis High colored urine High colored stool
Anemia maybe +/-
Jaundice may be +/-
Excess urobilinogen in urine
High reticulocyte and normoblastic count
High lDH
High uric acid
Low haptoglobulin
Low hemopexin
Chr- Hemosideronuria
4/27/2017
Dr. Alka Stoelinga

4. Intravascular hemolysis
Rapid cell destruction
Free Hb released in plasma
Haptoglobin produced by liver
Binds with free Hb and is degraded in liver
Once Haptoglobins (Are reduced) are saturated,
Free Hb is oxidised
Methemoglobin + Albumin
Methemalbumin- degraded
Any Free Hb is bound to Haemopexin
If all of these mechanisms are saturated/ overloaded, Free Hb urine
When fulminant black urine (Falci. malaria)
In smaller amt Renal tubular cells absorb Hb, degrade it and store iron as hemosiderin
Subsequently tubular cells- sloughed- urine- hemosideriuria
4/27/2017
Dr. Alka Stoelinga

5. Extravascular hemolysis
Physiological Red cell destruction in RE cells in liver, spleen
Haptoglobulins are normal or slightly reduced
4/27/2017
Dr. Alka Stoelinga

6. Features of Hemolysis Blood film Spherocytosis No Spherocytosis
Fragmentation
Hereditary
Enzymopathies
DCT+
DCT-
Microangiopathic
Traumatic
Autoimmune hemolysis
Malaria
Clostridium
H. spherocytosis
4/27/2017
Dr. Alka Stoelinga

7. Congenital hemolysis
RBC membrane defects (hereditary spherocytosis/ Elliptocytosis)
G6PD deficiency
Hemoglobinopathies
4/27/2017
Dr. Alka Stoelinga

8. Red cell membrane defect
Defect in cytoskeleton
Usually due to quantitative or functional deficiency of one or more proteins in cytoskeleton
Cells loose their normal elasticity
Each time they pass through spleen, they lose membrane relative to their cell volume
 Raised MCHC
Abnormal shape
Reduced cell survival (EVH)
4/27/2017
Dr. Alka Stoelinga

9. Hereditary Spherocytosis
Autosomal dominant trait
25% have no family history
Abnormalities in Beta spectrin and ankyrin
 Hemolytic crisis- when severity of hemolysis increases
 Megaloblastic crisis- follows folate deficiency
 Aplastic crisis- Parvovirus infection
Presents with severe anemia and low reticulocyte counts
4/27/2017
Dr. Alka Stoelinga

10. Investigations Blood picture- presence of spherocytes DCT –ve
Osmotic fragility test- Increased sensitivity to lysis in hypotonic saline solution
Treatment
Folic acid prophylaxis 5mg once weekly
Blood transfusion after cross matching
Consider splenectomy
Growth retardation in children
Recurrent severe crisis
Death of a family member from the disease
Symptomatic cholecystitis
4/27/2017
Dr. Alka Stoelinga

11. G6PD deficiency HMP shunt
NADPH – protects red cells against oxidative stress
G6PD deficiency Impairs production of NADPH
Affects male; females are carriers
Clinical Features:
Acute drug induced hemolysis
Chronic compensated hemolysis
Infection or acute illnesses
Neonatal jaundice
Favism (Vicia fava/ broad beans)
4/27/2017
Dr. Alka Stoelinga

12. Evidence of nonspherocytic intravascular hemolysis
Investigations
Evidence of nonspherocytic intravascular hemolysis
Bite cells, blister cells, irregular small cells
Polychromasia reflecting reticulocytosis
If stained with methyl violet- denaturated Hb is visible as Heinz bodies within RBC cytoplasm
G6PD levels- low
Treatment
Stop precipitating drugs
Acute transfusion support- life saver
4/27/2017
Dr. Alka Stoelinga

13. Autoimmune Hemolytic Anemia
Red cell autoantibodies RBC destruction
IgG/ M, rarely IgE or A
CLASSIFICATION
Optimal temperature at which the antibody is active is used to classify AHA
1. Warm antibodies
bind best at 37⁰C
Majority are IgG
React against Rh antigens
80% of cases
2. Cold antibodies
Bind best at 4⁰C but can bind upto 37⁰C
Majority are IgM and bind compliment
20% of cases
4/27/2017
Dr. Alka Stoelinga

14. Warm autoimmune hemolysis
Middle aged females
Causes
Idiopathic (50%)
Others
Lymphoid neoplasia
Lymphoma; CLL; Myeloma
Solid tumors
Lung; Colon; Kidney; Ovary; thymoma
Connective tissue disease
SLE; RA
Drugs
Methyldopa; Mefenamic acid; Penicillin; Quinine
Miscellaneous
UC; HIV
4/27/2017
Dr. Alka Stoelinga

15. Investigations Hemolysis and spherocytes DCT/ Antiglobulin test
Treatment
Manage underlying condition
Stop offending drugs
Prednisolone 1mg/kg
Blood transfusion after cross matching
Splenectomy to be considered
Immunosuppressive therapy- Azathioprim/ Cyclophosphamide
4/27/2017
Dr. Alka Stoelinga

16. Cold Agglutinin disease
IgM binds red cells at 4⁰C and cause them to agglutinate
Low grade intravascular hemolysis- cold, painful, blue fingers, toes, ears, nose (acrocyanosis)
Blood film- red cell agglutination
MCV- raised
IgM
Treatment
Keep extremities warm during winter
Steroids
Cross matching and blood transfusion
4/27/2017
Dr. Alka Stoelinga

17. Complement proteins may subsequently bind to the bound antibodies.
The Direct Coombs test, is used to test for autoimmune hemolytic anemia.
In certain diseases or conditions an individual's blood may contain IgG antibodies that can specifically bind to antigens on the red blood cell (RBC) surface membrane, and their circulating red blood cells (RBCs) can become coated with IgG alloantibodies and/or IgG autoantibodies
Complement proteins may subsequently bind to the bound antibodies.
The direct Coombs test is used to detect these antibodies or complement proteins that are bound to the surface of red blood cells
Procedure:
A blood sample is taken and the RBCs are washed (removing the patient's own plasma) and then incubated with antihuman globulin (also known as "Coombs reagent"). If this produces agglutination of RBCs, the direct Coombs test is positive, a visual indication that antibodies (and/or complement proteins) are bound to the surface of red blood cells
4/27/2017
Dr. Alka Stoelinga

18. Hemoglobinopathies- Sickle cell anemia
4/27/2017
Dr. Alka Stoelinga

19. 4/27/2017
Dr. Alka Stoelinga

20. Each containing an iron containing porphyrin pigment called haem
Hemoglobin
Hb has 4 globin chains
Each containing an iron containing porphyrin pigment called haem
Globin chains- 2α + 2non α chains
Hb A ααββ (90-97%)
HbF ααγγ (Fetus, 1%)
HbA2 ααδδ (2%)
4/27/2017
Dr. Alka Stoelinga

21. Abnormalities
Alteration in the amino acid structure of polypeptide chains of globin fraction of Hb
E.g.: Hb S
Amino acid sequence is normal but polypeptide chain production is impaired or absent
E.g. Thalassaemias
4/27/2017
Dr. Alka Stoelinga

22. Inherited as autosomal recessive trait
Sickle cell anemia
Single glutamic acid Valine substitution at position 6 of beta globin polypeptide chain
Inherited as autosomal recessive trait
Homozygotes produce abnormal beta chains that make HbS/ SS
Results in clinical syndrome called Sickle cell disease
Heterozygotes produce a mixture of normal and abnormal beta chains that make HbA and HbS/ AS
Clinically asymptomatic sickle cell disease
4/27/2017
Dr. Alka Stoelinga

23. Polymerization is reversible when reoxygenated
Pathogenesis
When Hb S is deoxygenated, molecules of Hb polymerize to form pseudocrystalline structures called Tactoids
These distort the RC membrane and produce characteristic sickle-shaped cells
Polymerization is reversible when reoxygenated
Permanent Distortion leads to Irreversibly Sickled red cells
4/27/2017
Dr. Alka Stoelinga

24. Sickling is precipitated by:
Note
Sickling is precipitated by:
Hypoxia
Acidosis
Dehydration
Infection
Irreversibly sickled cells have shortened survival
Plugs the vessels in microcirculation
This results in a no. of acute syndromes called crisis and chronic organ damage
4/27/2017
Dr. Alka Stoelinga

25. Vaso Occlusive crisis (Most common) Acute severe bony pain
Clinical Features
Vaso Occlusive crisis (Most common)
Acute severe bony pain
Affects areas of active marrow
Hands and feet in children
Femora, humeri, ribs, pelvis and vertebrae in adults
Systemic response:
Tachycardia
Sweating
Fever
4/27/2017
Dr. Alka Stoelinga

26. Sickle chest syndrome: Follow vaso-occlusive crisis
Clinical Features
Sickle chest syndrome:
Follow vaso-occlusive crisis
Most common cause of death in Adult sickle cell disease
Bone marrow infarction leads to fat emboli to lungs
Ventilatory failure
4/27/2017
Dr. Alka Stoelinga

27. Clinical Features Sequestration crisis
Thrombosis of venous outflow from organ
Loss of function
Acute pain
Spleen (Children)
Massive Splenomegaly severe anemia circulatory collapse death
Recurrent Sickling in spleen in children infarction
In adults No functional spleen
Capsular stretching Liver sequestration Severe pain
4/27/2017
Dr. Alka Stoelinga

28. Infection in adult sicklers with Parvovirus B19
Clinical Features
Aplastic crisis
Infection in adult sicklers with Parvovirus B19
Results in severe but self limiting red cell aplasia
Very low Hb
Heart failure
Reticulocytes- “low”
4/27/2017
Dr. Alka Stoelinga

29. Blood film- sickled cells with target cells Features of hyposplenism
Investigations
Hb- low (6-8g/dl)
Blood film- sickled cells with target cells
Features of hyposplenism
Reticulocytosis
HbS (Na dithionite)
Hb electrophoresis
No Hb A
2-20% Hb F
Predominance of Hb S
4/27/2017
Dr. Alka Stoelinga

30. Prophylactic folic acid supplementation Penicillin V
Treatment
Prophylactic folic acid supplementation
Penicillin V
Pneumococcal, Haemophilus, hep B vaccination
Vaso-occlusive crisis
Aggressive rehydration O2
Analgesics
Antibiotics
Blood transfusion- full genotyped
Hydroxyurea
4/27/2017
Dr. Alka Stoelinga

31. Hemoglobinopathies- Thalassaemia
4/27/2017
Dr. Alka Stoelinga

32. 4/27/2017
Dr. Alka Stoelinga

33. 4/27/2017
Dr. Alka Stoelinga

34. Thalassaemias
Thalassaemia is an inherited impairment of hemoglobin production, in which there is partial or complete failure to synthesize a specific type of globin chain
In Thalassaemia the genetic defect, which could be either mutation or deletion, results in reduced rate of synthesis or no synthesis of one of the globin chains that make up hemoglobin.
This can cause the formation of abnormal hemoglobin molecules, thus causing anemia, the characteristic presenting symptom of the Thalassaemias.
TYPES
α Thalassaemia
β Thalassaemia
Homozygous- Beta Thalassaemia major
β⁰- no β gene
β⁺- few β gene
Heterozygous- Beta Thalassaemia minor
4/27/2017
Dr. Alka Stoelinga

35. Pathophysiology
Normal hemoglobin is composed of two chains each of α and β globin.
Thalassemia patients produce a deficiency of either α or β globin, unlike sickle-cell disease which produces a specific mutant form of β globin.
The thalassemias are classified according to which chain of the hemoglobin molecule is affected.
In α thalassemias, production of the α globin chain is affected
In β thalassemia production of the β globin chain is affected.
β globin chains are encoded by a single gene on chromosome 11
α globin chains are encoded by two closely linked genes on chromosome 16.
Thus in a normal person with two copies of each chromosome, there are two loci encoding the β chain, and four loci encoding the α chain.
Deletion of one of the α loci has a high prevalence in people of African or Asian descent, making them more likely to develop α thalassemias.
β thalassemias are common in Africans, but also in Greeks and Italians.
4/27/2017
Dr. Alka Stoelinga

36. α Thalassaemia
α thalassemias result in decreased alpha-globin production, therefore fewer alpha-globin chains are produced
Resulting in an excess of β chains in adults and excess γ chains in newborns.
The excess β chains form unstable tetramers (called Hemoglobin H or HbH of 4 beta chains)
SUMMARY
Reduced or absent production of alpha chain
Chromosome 16
2 alpha gene loci
Hence, 4 alpha genes
If 1 is deleted- No clinical effect
If 2 are deleted- mild hypochromic anemia
If 3 are deleted- Hb H disease
If all 4 are deleted- Stillborn (Hydropfetalis)
4/27/2017
Dr. Alka Stoelinga

37. Failure of production of hemoglobin alpha chains due to gene deletion
Alpha Thalassaemia
CAUSE
Failure of production of hemoglobin alpha chains due to gene deletion
AGE AND SEX
Both sexes from birth
GENETICS
2 alpha genes from each parent
PRESENTATION
Hydrops fetalis if all gene are deleted
Hb H disease if 3 genes are deleted
Mild hypochromic microcytic anemia if 2 genes are deleted
TREATMENT
Hydrops fetalis- none
Hb H- No specific therapy required; Avoid iron therapy; Folic acid if necessary
4/27/2017
Dr. Alka Stoelinga

38. Complications Hypersplenism Iron overload Due to transfusion therapy
Deposition in liver (Cirrhosis)
In Pancreas (Diabetes)
In skin (Bronze diabetes)
In gonads (Gonadal failure)
In heart (Cardiomyopathy Heart failure)
3. HBV/ HCV
4. HIV
4/27/2017
Dr. Alka Stoelinga

39. β Thalassaemia
Mutations are characterized as (βo or β thalassemia major) if they prevent any formation of β chains (which is the most severe form of β thalassemia)
They are characterized as (β+ or β thalassemia intermedia) if they allow some β chain formation to occur.
In either case there is a relative excess of α chains, but these do not form tetramers: rather, they bind to the red blood cell membranes, producing membrane damage, and at high concentrations they form toxic aggregates
SUMMARY
β Thalassaemia
Homozygous- Beta Thalassaemia major
Either unable to synthesize Hb A OR
Profound hypochromic anemia
β⁰- no β gene
β⁺- few β gene
Heterozygous- Beta Thalassaemia minor
Mild anemia
Little or no clinical disability
4/27/2017
Dr. Alka Stoelinga

40. Diagnostic features of Beta Thalassaemia MAJOR
Profound hypochromic anemia
Evidence of severe red cell dysplasia
Erythroblastosis
Absence or gross reduction of amount of Hb A
Raised levels of Hb F
Evidence that both parents have Thalassaemia minor
MINOR
Mild anemia
Microcytic hypochromic erythrocytes
Target cells
Punctate basophilia
Raised resistance of erythrocytes to osmotic lysis
Raised Hb A2 fraction
Evidence that one parent has Thalassaemia minor
4/27/2017
Dr. Alka Stoelinga

41. Treatment of Beta Thalassaemia PROBLEM TREATMENT
Erythropoietic failure
Allogenic bone marrow transplantation from HLA compatible antigen
Transfusion to maintain Hb> 10g/dl
Folic acid 5mg daily
Iron overload
Iron therapy is forbidden
Desferrioxamine therapy
Splenomegaly with mechanical problems, with increased requirement of transfusion
Splenectomy
4/27/2017
Dr. Alka Stoelinga

42. 4/27/2017
Dr. Alka Stoelinga

43. Delta (δ) thalassemia
As well as alpha and beta chains being present in hemoglobin about 3% of adult hemoglobin is made of alpha and delta chains.
As with beta thalassemia, mutations can occur which affect the ability of this gene to produce delta chains.
4/27/2017
Dr. Alka Stoelinga

44. Functions of spleen Red pulp Mechanical filtration of red blood cells
Reserve monocytes
White pulp
Active immune response through humoral and cell-mediated pathways.
4/27/2017
Dr. Alka Stoelinga

45. Hematological malignancies
4/27/2017
Dr. Alka Stoelinga