Hemolytic Hemolytic AnemiasAnemias Due Due to to IntrnisicIntrnisic

Abnormalities of the Abnormalities of the Abnormalities of the Abnormalities of the Red Cell Membrane Red Cell Membrane

Hereditary Hereditary SpherocytosisSpherocytosis

Defects due to abnormalities in Defects due to abnormalities in membrane proteins or lipidsmembrane proteins or lipids

Defects alter membrane’s stability, Defects alter membrane’s stability, shape, deformability and shape, deformability and shape, deformability and shape, deformability and permeabilitypermeability

Hemolysis occurs Hemolysis occurs extravascularlyextravascularly

Etiology:Etiology:

There is an inherited abnormality of one of There is an inherited abnormality of one of proteins forming the skeleton of RBC proteins forming the skeleton of RBC resulting in resulting in

11-- Permeability of the affected cells to Permeability of the affected cells to 11-- Permeability of the affected cells to Permeability of the affected cells to sodium and water sodium and water concentration of intro concentration of intro cellular sodium cellular sodium utilization of ATP utilization of ATP Premature senescence of RBCs Premature senescence of RBCs destruction. destruction.

22-- Loss of plasticity of RBCs Loss of plasticity of RBCs rigid rigid Spherocytes Spherocytes difficulty in passage difficulty in passage through microvasculature of the splenic through microvasculature of the splenic cords and sincerest cords and sincerest destruction in the destruction in the spleen. spleen.

Clinical Picture:Clinical Picture:

All general manifestation of chronic All general manifestation of chronic hemolytic anemia hemolytic anemia

Onset may be very early in the Onset may be very early in the Onset may be very early in the Onset may be very early in the neonatal period. Some patients may neonatal period. Some patients may remain arymptomatic into adulthood. remain arymptomatic into adulthood.

Varies in severityVaries in severity

Compensated hemolytic diseaseCompensated hemolytic disease

AnemiaAnemia-- varies with severityvaries with severity

Intermittent jaundiceIntermittent jaundice Intermittent jaundiceIntermittent jaundice

SplenomegalySplenomegaly

CholelithiasisCholelithiasis: : pigment bile stones pigment bile stones from increased bilirubin breakdownfrom increased bilirubin breakdown

Investigation:Investigation:

General laboratory manifestation:General laboratory manifestation:

As previous.As previous.

Special laboratory manifestation:Special laboratory manifestation:

Peripheral blood smear : Peripheral blood smear : Peripheral blood smear : Peripheral blood smear :

Osmotic fragility test:Osmotic fragility test:

.. Osmotic fragility Osmotic fragility -- ↑↑

Cells are incubated in decreasing Cells are incubated in decreasing concentrations of concentrations of NaClNaCl. . SpherocytesSpherocytes lyse lyse sooner than normal red cells.sooner than normal red cells.

AutohemolysisAutohemolysis testtest

Red cells are incubated at Red cells are incubated at 3737 ̊̊ C for C for 48 48 hours. Degree of hemolysis is increased hours. Degree of hemolysis is increased when when spherocytesspherocytes are present. are present. when when spherocytesspherocytes are present. are present.

Red cell membrane studiesRed cell membrane studies

Membrane proteins are analyzed using Membrane proteins are analyzed using gel electrophoresis.gel electrophoresis.

Treatment:Treatment:--

If HB > If HB > 1010g/dl & reticulocytic count g/dl & reticulocytic count < < 1010% %

No III except folic and therapy No III except folic and therapy No III except folic and therapy No III except folic and therapy

If HB < If HB < 1010g/dl, & reticulocytic count g/dl, & reticulocytic count > > 1010%%

Blood transfusion & folic acid Blood transfusion & folic acid therapy and splenectomy when the therapy and splenectomy when the patient > patient > 6 6 year. year.

Hereditary ElliptocytosisHereditary Elliptocytosis

It is inherited as autosomal dominant It is inherited as autosomal dominant trait. Clinically it is similar to trait. Clinically it is similar to spherocytosis in all aspects. spherocytosis in all aspects.

It is less common. It is less common. It is less common. It is less common.

Blood smears show the characteristic Blood smears show the characteristic elliptical (oval) RBCs. elliptical (oval) RBCs.

ttt: ttt: as same as hereditary as same as hereditary spherocytosis. spherocytosis.

Enzymatic Defects of Enzymatic Defects of the Red blood cells the Red blood cells

Glucose Glucose ––66-- phosphate phosphate Dehydrogenase (G Dehydrogenase (G 6 6

PD) Enzyme deficiencyPD) Enzyme deficiency

A A 14 14 years old boy was admitted to years old boy was admitted to our University Hospital complaining our University Hospital complaining of dark urine, He complained of of dark urine, He complained of weakness and abdominal and back weakness and abdominal and back weakness and abdominal and back weakness and abdominal and back pain. His pain. His scleraesclerae were yellow. Past were yellow. Past history of green fava bean history of green fava bean ingestion.Theingestion.The treating doctor treating doctor requested the following laboratory requested the following laboratory investigations on admission and investigations on admission and 10 10 days later:days later:

Definition:Definition:

It is XIt is X--linked disorder, affecting linked disorder, affecting males and much less commonly males and much less commonly females. It results from deficiency of females. It results from deficiency of females. It results from deficiency of females. It results from deficiency of glucose glucose 6 6 phosphatase phosphatase dehydrogenate enzyme. dehydrogenate enzyme.

is the most common human enzyme is the most common human enzyme deficiency in the world; it affects an deficiency in the world; it affects an estimated estimated 400 400 million people. Gmillion people. G66PD PD deficiency is also known as "deficiency is also known as "favismfavism," ," deficiency is also known as "deficiency is also known as "favismfavism," ," since Gsince G66PD deficient individuals are PD deficient individuals are also sometimes allergic to fava also sometimes allergic to fava beans. Gbeans. G66PD deficiency is an allelic PD deficiency is an allelic abnormality which is inherited in an abnormality which is inherited in an XX--linked recessive fashion linked recessive fashion

When someone has GWhen someone has G66PD deficiency, PD deficiency, complications can arise; hemolytic complications can arise; hemolytic anemia and prolonged neonatal anemia and prolonged neonatal jaundice are the two major jaundice are the two major pathologies associated with Gpathologies associated with G66PD PD deficiency.deficiency.

Both of these conditions are directly Both of these conditions are directly Both of these conditions are directly Both of these conditions are directly related to the inability of specific cell related to the inability of specific cell types to regenerate reduced types to regenerate reduced nicotinamidenicotinamide adenine dinucleotide adenine dinucleotide phosphate (NADPH); this reaction is phosphate (NADPH); this reaction is normally catalyzed by the Gnormally catalyzed by the G66PD PD enzymeenzyme

Pathogensis:Pathogensis:

Deficiency of GDeficiency of G66PD enzyme resulting PD enzyme resulting in decrease activity of hexose in decrease activity of hexose monophosphate pathway. monophosphate pathway. monophosphate pathway. monophosphate pathway.

This pathway is essential for This pathway is essential for production of reduced NADPHproduction of reduced NADPH22, , which is essential for conversion of which is essential for conversion of oxidized glutathione to reduced oxidized glutathione to reduced glutathione that protects the RBCs glutathione that protects the RBCs against oxidizing agents. against oxidizing agents.

Hemolysis occurs in GHemolysis occurs in G66PD patient if PD patient if exposed to oxidizing agents such as:exposed to oxidizing agents such as:--

Fava beans & its derivatives (Anemia Fava beans & its derivatives (Anemia following in take of fava beans is called following in take of fava beans is called favismfavism).).

SalicglatesSalicglates --NovaglagineNovaglagine

Antimalarial drugs Antimalarial drugs SulphonamidesSulphonamidesSulphonamidesSulphonamides

ChloramephincolChloramephincol -- Nitro Nitro furantionfurantion

Para amino salicylic acid Para amino salicylic acid -- NaphNaphthalenethalene

Synthetic Synthetic VitVit .K..K. -- Benzene Benzene SufectiousSufectious as hepatitis, influenza as hepatitis, influenza

Clinical pictures Clinical pictures

The The hemolysishemolysis occurs about occurs about 24 24 -- 48 48 h. after ingestion oxidizing agent. h. after ingestion oxidizing agent.

Acute onset of pallor, Jaundices red Acute onset of pallor, Jaundices red urine (urine (HemoglobinuriaHemoglobinuria), abdominal ), abdominal urine (urine (HemoglobinuriaHemoglobinuria), abdominal ), abdominal pain, nausea, vomiting.pain, nausea, vomiting.

Anemic H. F. may occur in severe Anemic H. F. may occur in severe cases cases

It may occur during neonatal period It may occur during neonatal period and cause Jaundice or may lead to and cause Jaundice or may lead to KernicterusKernicterus..

Investigation: Investigation:

––Low Hb%, low RBC count.Low Hb%, low RBC count.

––High reticulocytic count. High reticulocytic count.

–– Unconjugated bilirubinemia Unconjugated bilirubinemia

––HemoglobinuriaHemoglobinuria––HemoglobinuriaHemoglobinuria

––Diagnosis is confirmed by estimation of Diagnosis is confirmed by estimation of enzyme activity. The test better to enzyme activity. The test better to deferred for deferred for 44weeks, weeks,

Screening: Screening:

Qualitative assessment of GQualitative assessment of G66PD PD enzymatic activityenzymatic activity

Confirmatory test: Confirmatory test:

Quantitative measurement of GQuantitative measurement of G66PD PD Quantitative measurement of GQuantitative measurement of G66PD PD enzymatic activityenzymatic activity

Molecular test: Molecular test:

Detection of GDetection of G66PD gene mutationPD gene mutation

Prophylaxis:Prophylaxis:--

––Avoid precipitating agents in susceptible Avoid precipitating agents in susceptible persons. persons.

––Give Give paracetamolparacetamol in fever. in fever. ––Give Give paracetamolparacetamol in fever. in fever.

Treatment:Treatment:--

––Mild cases,Mild cases, observationobservation

––Sever cases,Sever cases, packed RBCs. Transfusion packed RBCs. Transfusion & I.V. fluid.& I.V. fluid.

ThalassemiasThalassemias

Beta Beta thalassemiathalassemia

DefinitionDefinition: :

It is the most common cause of It is the most common cause of Thalassemias are a heterogeneous Thalassemias are a heterogeneous group of inherited disorders; group of inherited disorders; characterized by hypochromic characterized by hypochromic characterized by hypochromic characterized by hypochromic anemia caused by deficient synthesis anemia caused by deficient synthesis of one or more of the polypeptide of one or more of the polypeptide chain.chain.

PathogensisPathogensis::

The normal hemoglobin molecule consists of two alpha The normal hemoglobin molecule consists of two alpha chains and two beta chain. chains and two beta chain.

In BetaThalassemiaIn BetaThalassemia , there is decrease in beta chain , there is decrease in beta chain compensatory increase compensatory increase

of alpha chain which aggregate and precipitate to form in of alpha chain which aggregate and precipitate to form in soluble inclusion bodies inside RBCs soluble inclusion bodies inside RBCs red cell damage and red cell damage and soluble inclusion bodies inside RBCs soluble inclusion bodies inside RBCs red cell damage and red cell damage and hemolysis hemolysis

Since there are Since there are 2 2 genes responsible for controlling genes responsible for controlling synthesis of Beta chain in erythropoietic cells. synthesis of Beta chain in erythropoietic cells.

If abnormality affect one gene (heterozygous) If abnormality affect one gene (heterozygous) Beta Beta thalassemia minor thalassemia minor

If abnormality affect If abnormality affect 2 2 genes (Homozygous) genes (Homozygous) Beta Beta thalassmia major or intermedia.thalassmia major or intermedia.

According to the degree of beta chain According to the degree of beta chain deficiency, beta thalassemia can be deficiency, beta thalassemia can be subdivided into: subdivided into:

Beta Beta 00: : No beta chain synthesisNo beta chain synthesisBeta Beta 00: : No beta chain synthesisNo beta chain synthesis

Beta +: Beta +: Little beta chain synthesis Little beta chain synthesis

Clinical picture:Clinical picture:

––Occurs in the Occurs in the 22nd half of the nd half of the 11st year of st year of life + General manifestation of chronic life + General manifestation of chronic

hemolytic anemia as beforehemolytic anemia as beforehemolytic anemia as beforehemolytic anemia as before

Laboratory manifestations: Laboratory manifestations:

––General laboratory manifestation as General laboratory manifestation as before hypochromic microcytic anemia. before hypochromic microcytic anemia.

––HB electrophonesis:HB electrophonesis:

level of HBF and Hb Alevel of HBF and Hb A22 level of HBF and Hb Alevel of HBF and Hb A22

––Alkaline denaturation test: Shows Alkaline denaturation test: Shows resistance of hemoglobin to alkali as resistance of hemoglobin to alkali as

NaoH.NaoH.

Complication: Complication:

––Heart failure: due to anemia or Heart failure: due to anemia or myocardial siderosismyocardial siderosis

––Growth retardation.Growth retardation.

––HemosiderosisHemosiderosis––HemosiderosisHemosiderosis

–– Intercurrent infection Intercurrent infection

––HyperspelensimHyperspelensim

––Pathologic fracturePathologic fracture

––Complication of blood transfusionComplication of blood transfusion

Prevention:Prevention:--

In areas where the incidence is In areas where the incidence is high, prevention of thalassemia done high, prevention of thalassemia done either by: either by: either by: either by:

––Prospective genetic counseling to detect Prospective genetic counseling to detect the carriers.the carriers.

––Prenatal diagnosis in early pregnancy by Prenatal diagnosis in early pregnancy by taking chrorionic villous biopsy and taking chrorionic villous biopsy and followed by recombinant DNA followed by recombinant DNA

techniques.techniques.

Treatment:Treatment:--

Packed RBCs transfusion: Packed RBCs transfusion: 15 15 –– 20 20 ml/kg of packed cells every ml/kg of packed cells every 44--5 5 weeks to keep weeks to keep

hemoglobin level above hemoglobin level above 1010gm/dl (hyper transfusion) or gm/dl (hyper transfusion) or above above 12 12 gm/dl (super transfusion) gm/dl (super transfusion)

-- Advantages:Advantages:-- Permits normal activity and growth Permits normal activity and growth Permits normal activity and growth Permits normal activity and growth Minimizes marrow expansion so reduce the cosmetic Minimizes marrow expansion so reduce the cosmetic

problems. problems. Minimizes cardiac dilation and oestoprosis. Minimizes cardiac dilation and oestoprosis. N. B:N. B: Fresh packed RBCs are desirble. Fresh packed RBCs are desirble. Neocytes transfusions can reduce the frequency of blood Neocytes transfusions can reduce the frequency of blood

transfusiontransfusion

Iron Chelating therapy: Iron Chelating therapy:

The aim is to maintain serum The aim is to maintain serum ferritinferritinbelow below 1000 1000 mg/ml, to prevent mg/ml, to prevent hemosiderosishemosiderosis

DesferrioxamineDesferrioxamine ((DFO)DFO)DFO binds to iron molecules in the DFO binds to iron molecules in the

body and then releases them in body and then releases them in urineurine and stools.. and stools..

DFO is usually given through a pump DFO is usually given through a pump infusion that lasts infusion that lasts 1010--12 12 hours, five hours, five infusion that lasts infusion that lasts 1010--12 12 hours, five hours, five to six nights a week. to six nights a week.

It is common to develop pain, It is common to develop pain, swelling, itchiness and redness at the swelling, itchiness and redness at the site of the injection.site of the injection.

headacheheadache

nauseanausea

DeferiproneDeferiprone (DFP)(DFP)

DFP also binds to iron molecules in DFP also binds to iron molecules in the body and releases them in urine.the body and releases them in urine.

DFP is available in tablet or liquid DFP is available in tablet or liquid form, so isform, so is more convenient to take. more convenient to take. form, so isform, so is more convenient to take. more convenient to take. However, DFP is not usually as However, DFP is not usually as effective as DFO, particularly in effective as DFO, particularly in preventing liver damage, sopreventing liver damage, so is is normally used in combination with normally used in combination with DFO.DFO.

Common side effectsCommon side effects

nauseanausea

abdominal painabdominal pain

headacheheadache

vomitingvomitingvomitingvomiting

joint painjoint pain

diarrhoeadiarrhoea

fatiguefatigue

AgranulocytosisAgranulocytosis

DeferiproneDeferiprone;;

7575mg/kg/day orally in mg/kg/day orally in 3 3 divided divided dose as dose as amonotherapyamonotherapy or or incombinationincombination with with desferoxaminedesferoxamine..incombinationincombination with with desferoxaminedesferoxamine..

D D eferasiroxeferasirox

was licensed for use in the UK in was licensed for use in the UK in 20062006..

However, the use of DFX as an However, the use of DFX as an alternative to DFO is not usually alternative to DFO is not usually alternative to DFO is not usually alternative to DFO is not usually recommended in people with high recommended in people with high levels of iron in their heart.levels of iron in their heart.

DFX is available in tablet form. DFX is available in tablet form. Common side effects include:Common side effects include:

nauseanausea

vomitingvomitingvomitingvomiting

diarrhoeadiarrhoea

abdominal painabdominal pain

skin rashskin rash

stomach ulcersstomach ulcers

Dose;Dose;2020-- 30 30 mg /kgmg /kg

Bone marrow transplantBone marrow transplant

The procedure involves replacing The procedure involves replacing affected bone marrow with new affected bone marrow with new bone marrow then begins producing bone marrow then begins producing healthy blood cells.healthy blood cells.healthy blood cells.healthy blood cells.

There are significant risks involved There are significant risks involved

GVHD. Symptoms of GVHD includeGVHD. Symptoms of GVHD include

Other risks related to bone marrow Other risks related to bone marrow transplants include an increased risk transplants include an increased risk of strokes, seizures and of strokes, seizures and tumourstumours

Cord blood transfusionCord blood transfusion

The advantage of cord blood The advantage of cord blood transfusions is that there is a lower transfusions is that there is a lower chance of GVHD occurring and the chance of GVHD occurring and the HLA match does not need to be as HLA match does not need to be as HLA match does not need to be as HLA match does not need to be as accurate as that needed for a bone accurate as that needed for a bone marrow marrow transplantransplan

splenectomysplenectomy

Indications: Indications: –– Massive splenomegalyMassive splenomegaly–– hypersplensim: hypersplensim:

Where transfusion requirement exceed Where transfusion requirement exceed 240 240 ml/kg/year of packed RBCs considered and ml/kg/year of packed RBCs considered and indication of splenectomy. indication of splenectomy. indication of splenectomy. indication of splenectomy.

Splenectomy must be deferred to age of Splenectomy must be deferred to age of 5 5 years years to prevent infection by organisms as to prevent infection by organisms as pneumococci and mennigococci. pneumococci and mennigococci.

Prophylaxis by pneumoccocal, meningo coccal Prophylaxis by pneumoccocal, meningo coccal polysacharile vaccine, hepatitis B vaccine, polysacharile vaccine, hepatitis B vaccine, hemophilus in fluency a B vaccine are give hemophilus in fluency a B vaccine are give 2 2 weeks before splenectomy and long acting weeks before splenectomy and long acting penicillin is given monthly after splenectomypenicillin is given monthly after splenectomy

Bone marrow transplantationBone marrow transplantation Gene therapy.Gene therapy...

B Thalassemia MinorB Thalassemia Minor

It is mild form of B thalassemia It is mild form of B thalassemia characterized by:characterized by:

Mild hypochremic microcytic anemia.Mild hypochremic microcytic anemia.

HB is more than HB is more than 9 9 g/dL.g/dL. HB is more than HB is more than 9 9 g/dL.g/dL.

Slight increase in HBF.Slight increase in HBF.

H B AH B A22 4 4 %.%.

It may be misdiagnosed as iron deficiency It may be misdiagnosed as iron deficiency anemia and differentiated by assessment anemia and differentiated by assessment of serum iron, iron binding capacity, of serum iron, iron binding capacity, serum ferritin.Itserum ferritin.It

B Thalassemia intermediaB Thalassemia intermedia

It characterized by intermediate It characterized by intermediate manifestation between thalassemia manifestation between thalassemia major and thalassemia minor hB major and thalassemia minor hB major and thalassemia minor hB major and thalassemia minor hB between between 77--10 10 g/dLg/dL

Alpha Thalassemia Alpha Thalassemia

It is Common in south east Asia but rare It is Common in south east Asia but rare in Egypt.in Egypt.

Characterized by decrease synthesis of Characterized by decrease synthesis of alpha chain alpha chain compensatory increase of compensatory increase of abnormal hemoglobin containing abnormal hemoglobin containing 4 4 no no abnormal hemoglobin containing abnormal hemoglobin containing 4 4 no no alpha chains as HBH (alpha chains as HBH (4 4 beta chains), or beta chains), or Bart & HB (Bart & HB (4 4 gamma chains). gamma chains).

As alpha chain is characterized by As alpha chain is characterized by 4 4 genes, so there are genes, so there are 4 4 grades of affection grades of affection according to number of abnormal genes according to number of abnormal genes ranging from silent carrier to sever ranging from silent carrier to sever anemia. anemia.