Hemolytic anemia

Hemolytic Hemolytic anemiaanemia

Rakesh Biswas

MD, Professor, Department of Medicine, People's College of Medical Sciences,

Bhanpur, Bhopal, India

Young man of 19

Complains of giddiness weakness, pallor

Examination reveals a spleenmild lemon yellow sclera

How shall you investigate to find out the cause of the problem?

Laboratory investigations:

Severe normochromic, normocytic anemia (hemoglobin level of 6.4 g/dL

Reticulocyte count of 12.2%.

Blood film:

Bilirubin level of 2.5 mg/dL,

Lactate dehydrogenase (LDH) of 2140 IU/L,

Haptoglobin below 7 mg/dL

Introduction

Mean life span of a RBC-120daysMean life span of a RBC-120daysRemoved Extravascularly by- Macrophages Removed Extravascularly by- Macrophages

of RE system of RE system

Hemolytic Anemia

Definition:Definition:Those anemias which result from an increase Those anemias which result from an increase

in RBC destructionin RBC destruction

Classification:Classification:Congenital / HereditaryCongenital / HereditaryAcquiredAcquired

Laboratory Evaluation of HemolysisExtravascular Intravascular  

HEMATOLOGIC

Routine blood filmReticulocyte countBone marrow examination

Polychromatophilia

Erythroid hyperplasia

Polychromatophilia

Erythroid hyperplasia

PLASMA OR SERUM

BilirubinHaptoglobinPlasma hemoglobinLactate dehydrogenase

Unconjugated , Absent N/ (Variable)

UnconjugatedAbsent (Variable)

URINE

BilirubinHemosiderinHemoglobin

000

0++ severe cases

Hemoglobinuria

Classification of Hemolytic Anemias

Hereditary 1. Abnormalities of RBC interior a.Enzyme defects: G-6-PD def,PK def b.Hemoglobinopathies 2. RBC membrane abnormalities a. Hereditary spherocytosis etc. b. PNH

Acquired c. Spur cell anemia3. Extrinsic factors a. Hypersplenism b. Antibody: immune hemolysis c. Mechanical trauma: MAHA d. Infections, toxins, etc

Ref : Harrison’s

Features of HEMOLYSISBilirubinBilirubin

LDHLDHReticulocytes, n-RBCReticulocytes, n-RBC

HaptoglobulinsHaptoglobulins+ve Urinary hemosiderin, Urobilinogen+ve Urinary hemosiderin, Urobilinogen

Blood FilmBlood Film

Spherocytes No spherocytes FragmentationSpherocytes No spherocytes Fragmentation

DCT +ve DCT –veDCT +ve DCT –ve

AI Hemolysis H. Sherocytosis Malaria, AI Hemolysis H. Sherocytosis Malaria, Clostidium Clostidium Hereditery enzymopathies Microangiopathic, Hereditery enzymopathies Microangiopathic,

Traumatic Traumatic

Red Cell Membrane Defects

1.Hereditary SpherocytosisUsually inherited as AD disorderUsually inherited as AD disorderDefect: Deficiency of Beta Spectrin or Ankyrin Defect: Deficiency of Beta Spectrin or Ankyrin

Loss of membrane in Spleen & RES Loss of membrane in Spleen & RES becomes more sphericalbecomes more spherical Destruction in Destruction in SpleenSpleen

RBC Membrane

C/F:C/F:AsymptomaticAsymptomaticFluctuating hemolysisFluctuating hemolysisSplenomegalySplenomegalyPigmented gall stones- 50%Pigmented gall stones- 50%

Complications

Clinical course may be complicated with Clinical course may be complicated with Crisis:Crisis:Hemolytic Crisis: associated with infection: associated with infectionAplastic crisis:: associated with Parvovirus associated with Parvovirus

infectioninfection

Inv:Inv:Test will confirm HemolysisTest will confirm HemolysisP Smear: SpherocytesP Smear: SpherocytesOsmotic Fragility: IncreasedOsmotic Fragility: Increased

Screen Family membersScreen Family members

Osmotic Fragility

Management:Management:Folic Acid 5mg weekly, prophylaxis life longFolic Acid 5mg weekly, prophylaxis life longSpleenectomySpleenectomyBlood transfusion in Ac, severe hemolytic crisisBlood transfusion in Ac, severe hemolytic crisis

2.Hereditary Elliptocytosis Equatorial Africa, SE AsiaEquatorial Africa, SE Asia AD / ARAD / AR Functional abnormality in one or more anchor Functional abnormality in one or more anchor

proteins in RBC membrane- Alpha spectrin , proteins in RBC membrane- Alpha spectrin , Protein 4.1Protein 4.1

Usually asymptomaticUsually asymptomatic Mx: Similar to H. spherocytosisMx: Similar to H. spherocytosis Variant:Variant:

3.SE-Asian ovalocytosis:Common in Malaysia , Indonesia…Common in Malaysia , Indonesia…Asymptomatic-usuallyAsymptomatic-usuallyCells oval , rigid ,resist invasion by malarial Cells oval , rigid ,resist invasion by malarial

parasitesparasites

ElliptocytosisElliptocytosis

Red Cell Enzymopathies

Physiology:Physiology:EM pathway: ATP productionEM pathway: ATP productionHMP shunt pathway: NADPH & Glutathione HMP shunt pathway: NADPH & Glutathione

productionproduction

1. Glucose-6-Phosphate Dehydrogenase ( G6PD ) DeficiencyPivotal enzyme in HMP Shunt & produces Pivotal enzyme in HMP Shunt & produces

NADPH to protect RBC against oxidative NADPH to protect RBC against oxidative stressstress

Most common enzymopathy -10% Most common enzymopathy -10% world’s populationworld’s population

Protection against MalariaProtection against MalariaX-linkedX-linked

(Oxidised form)(Reduced form)

Clinical Features:Clinical Features:Acute drug induced hemolysis:Acute drug induced hemolysis:

Aspirin, primaquine, quinine, chloroquine, Aspirin, primaquine, quinine, chloroquine, dapsone….dapsone….

Chronic compensated hemolysisChronic compensated hemolysis Infection/acute illnessInfection/acute illnessNeonatal jaundiceNeonatal jaundiceFavismFavism

Inv:Inv:e/o non-spherocytic intravascular e/o non-spherocytic intravascular

hemolyishemolyisP. Smear: Bite cells, blister cells, P. Smear: Bite cells, blister cells,

irregular small cells, Heinz bodies, irregular small cells, Heinz bodies, polychromasiapolychromasia

G-6-PD levelG-6-PD level

Treatment: Treatment: Stop the precipitating drug or treat the Stop the precipitating drug or treat the

infectioninfectionAcute transfusions if requiredAcute transfusions if required

2. Pyruvate Kinase DeficiencyARARDeficient ATP production, Chronic Deficient ATP production, Chronic

hemolytic anemiahemolytic anemiaInv;Inv;

P. Smear: Prickle cellsP. Smear: Prickle cellsDecreased enzyme activityDecreased enzyme activity

Treatment: Treatment: Transfusion may be requiredTransfusion may be required

Hemolobinopathies…Hemolobinopathies…

Autoimmune Hemolytic Anemia

Result from RBC destruction due to RBC Result from RBC destruction due to RBC autoantibodies: Ig G, M, E, Aautoantibodies: Ig G, M, E, A

Most commonly-idiopathicMost commonly-idiopathicClassificationClassification

Warm AI hemolysis:Ab binds at 37degree Warm AI hemolysis:Ab binds at 37degree CelsiusCelsius

Cold AI Hemolysis: Ab binds at 4 degree Cold AI Hemolysis: Ab binds at 4 degree CelsiusCelsius

1.Warm AI Hemolysis:Can occurs at all age groupsCan occurs at all age groupsF > MF > MCauses:Causes:

50% Idiopathic50% IdiopathicRest - secondary causes:Rest - secondary causes:

1.Lymphoid neoplasm: CLL, Lymphoma, 1.Lymphoid neoplasm: CLL, Lymphoma, MyelomaMyeloma

2.Solid Tumors: Lung, Colon, Kidney, Ovary, 2.Solid Tumors: Lung, Colon, Kidney, Ovary, ThymomaThymoma

3.CTD: SLE,RA3.CTD: SLE,RA4.Drugs: Alpha methyl DOPA, Penicillin , 4.Drugs: Alpha methyl DOPA, Penicillin ,

Quinine, ChloroquineQuinine, Chloroquine5.Misc: UC, HIV5.Misc: UC, HIV

IMMUNOHEMOLYTIC ANEMIA

MACROCYTE

SPHEROCYTE

Direct antiglobulin test demonstrating the presence of autoantibodies (shown here) or complement on the surface of the red blood cell.

complement

Inv:Inv:e/o hemolysis, MCV e/o hemolysis, MCV P Smear: Microspherocytosis, n-RBCP Smear: Microspherocytosis, n-RBCConfirmation: Coomb’s Test / Antiglobulin testConfirmation: Coomb’s Test / Antiglobulin test

TreatmentTreatmentCorrect the underlying causeCorrect the underlying causePrednisolone 1mg/kg po until Hb reaches Prednisolone 1mg/kg po until Hb reaches

10mg/dl then taper slowly and stop10mg/dl then taper slowly and stopTransfusion: for life threatening problemsTransfusion: for life threatening problems If no response to steroids If no response to steroids Spleenectomy or, Spleenectomy or, Immunosuppressive: Azathioprine, Immunosuppressive: Azathioprine,

CyclophosphamideCyclophosphamide

2. Cold AI HemolysisUsually Ig MUsually Ig MAcute or Chronic formAcute or Chronic formChronic:Chronic:

C/F:C/F:Elderly patients Elderly patients Cold , painful & often blue fingers, toes, Cold , painful & often blue fingers, toes,

ears, or nose ( Acrocyanosis) ears, or nose ( Acrocyanosis) Inv:Inv:

e/o hemolysise/o hemolysisP Smear: MicrospherocytosisP Smear: Microspherocytosis Ig M with specificity to I or I AgIg M with specificity to I or I Ag

Other causes of Cold Agglutination:Other causes of Cold Agglutination: Infection: Mycoplasma pneumonia, Infec Infection: Mycoplasma pneumonia, Infec

MononucleosisMononucleosisPCH : Rare cause seen in children in PCH : Rare cause seen in children in

association with cong syphilisassociation with cong syphilis

Treatment:Treatment:Treatment of the underlying causeTreatment of the underlying causeKeep extremities warmKeep extremities warmSteroids treatmentSteroids treatmentBlood transfusionBlood transfusion

Non-Immune Acquired Hemolytic Anemia

1. Mechanical TraumaA). Mechanical heart valves, Arterial grafts: A). Mechanical heart valves, Arterial grafts:

cause shear stress damagecause shear stress damage

B).March hemoglobinuria: Red cell damage in B).March hemoglobinuria: Red cell damage in capillaries of feetcapillaries of feet

C). Thermal injury: burnsC). Thermal injury: burns

D). Microangiopathic hemolytic anemia D). Microangiopathic hemolytic anemia (MAHA):(MAHA): by passage of RBC through fibrin strands by passage of RBC through fibrin strands deposited in small vessels deposited in small vessels disruption of disruption of RBC eg: DIC,PIH, Malignant HTN,TTP,HUSRBC eg: DIC,PIH, Malignant HTN,TTP,HUS

TRAUMATIC HEMOLYSIS

Acquired hemolysis

2.Infection

F. malaria: intravascular hemolysis: severe F. malaria: intravascular hemolysis: severe called called ‘Blackwater fever’

Cl. perfringens septicemiaCl. perfringens septicemia

3.Chemical/Drugs: oxidant denaturation of oxidant denaturation of hemoglobinhemoglobin

Eg: Dapsone, sulphasalazine, Arsenic Eg: Dapsone, sulphasalazine, Arsenic gas, Cu, Nitrates & Nitrobenzenegas, Cu, Nitrates & Nitrobenzene

The direct antiglobulin test was positive for complement (C3d) (++), and IgG (++-).

Also was positive for agglutinins of IgM type and had a titer of 1:1024.

Serologies for human immunodeficiency virus, hepatitis B and C viruses, and Mycoplasma pneumoniae were negative.

Rheumatoid factor and antinuclear antibodies were undetectable.

Prednisone therapy was started at a dose of 1 mg/kg intravenously, daily. Hemoglobin level rose to 11 g/dL, concomitantly with the

improvement of hemolytic signs.

A reduction of positivity of both direct and indirect antiglobulin tests (polyvalent serum + ; C3d + ; IgG+ ), as well as a reduction of cold agglutinin titers (1:128), was observed 8 weeks after corticosteroid therapy.

Three months later, corticosteroids were tapered to a maintenance dose of 25 mg daily.

Hemolysis recurred again with the fall of hemoglobin to 7 g/dL.

The direct antiglobulin test recurred positive for polyvalent serum (+++), complement (+++), and IgG (+++), while cold agglutinin titers again became strongly positive (1:256).

Immunophenotyping of bone marrow cells showed that 10% of all the cells were CD20 and CD19 positive.

CD20 is widely expressed on B-cells.

CD20 could play a role in Ca2+ influx across plasma membranes, maintaining intracellular Ca2+ concentration and allowing activation of B cells.

Rituximab is a monoclonal antibody that binds to CD 20

Rituximab was started at the dose of 375 mg/mq once weekly, for a total of 4 doses

Hemoglobin value reached 13.5 g/dL just before the third dose, although biochemical signs of hemolysis remained substantially unaltered.

At the end of therapy, the hemolytic signs disappeared, the direct and indirect antiglobulin tests became negative, and cold agglutinin titers

fell to 1:32

Immunophenotyping of bone marrow cells showed the absence

of CD20 and CD19 B cells.

Summary of lecture

Learning points