APPROACH TO HEMOLYTIC ANEMIA
Guide : Dr MANOJ GUPTA
Candidate: Dr SARATH MENON.R
HEMATOLOGY DIVISION.DEPT.MEDICINE,
MGM MEDICAL COLLEGE,INDORE
OBJECTIVES
Lab indication of hemolysis
Intravascular v/s extravascular hemolysis
D/D of hemolytic anemia
Diagnose hemo.anemia with peripheral smear &
ancillary lab tests
HEMOLYTIC ANEMIA
Definition: Those anemias which result from an increase in
RBC destruction coupled with increased erythropoiesis
Classification: Congenital / Hereditary Acquired
CLASSIFICATION OF HEMOLYTIC ANEMIAS
INTRACORPUSCULAR DEFECTS
EXTRACORPUSCULAR FACTORS
HEREDITARY •HEMOGLOBINOPATHIES
•ENZYMOPATHIES
•MEMBRANE-CYTOSKELETAL DEFECTS
•FAMILIAL HEMOLYTIC UREMIC SYNDROME
ACQUIRED •PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
•MECHANICAL DESTRUCTION [MICROANGIOPATHIC] •TOXIC AGENTS•DRUGS•INFECTIOUS•AUTOIMMUNE
CLASSIFICATION
MAHA Transfusion rx PNH Infections Snake bite
Hemoglobinopathies Enzymopathies Membrane defects AIHA
Intravascular hemolysisExtravascular hemolysis
HOW IS HEMOLYTIC ANEMIA DIAGNOSED?
Two main principles
One is to confirm that it is hemolysis
Two is to determine the etiology
HOW TO DIAGNOSE HEMOLYTIC ANEMIA
New onset pallor or anemia
Jaundice
Splenomegaly
Gall stones
Dark colored urine
Leg ulcers
GENERAL FEATURES
OF HEMOLYTIC DISORDERS
GENERAL EXAMINATION - JAUNDICE, PALLOR
BOSSING OF SKULL
PHYSICAL FINDINGS - ENLARGED SPLEEN
HEMOGLOBIN - FROM NORMAL TO SEVERELY REDUCED
MCV - USUALLY INCREASED
RETICULOCYTES - INCREASED
BILIRUBIN - INCREASED[MOSTLY UNCONJUGATED]
LDH - INCREASED
HAPTOGLOBULIN - REDUCED TO ABSENT
HEMOLYTIC FACIES- CHIPMUNK FACIES
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
+00
+++ severe cases
POLYCHROMATOPHILIC CELLS
THE KEY TO THE ETIOLOGY OF HEMOLYTIC ANEMIA
The history
The peripheral blood film
PATIENT HISTORY
Acute or chronic
Medication/Drug precipitants
G6PD
AIHA
Family history
Concomitant medical illnesses
Clinical presentation
CASE 1
3 yr old male child presenting with pallor,jaundice,
Severe pain of long bones, fever CBC-anemia,reticulocytosis,increased WBC LAB - LDH -600 (normal upto 200) S.bilirubin- 5mg%
PERIPHERAL SMEAR
WHAT IS THE DIAGNOSIS ?
SICKLE CELL ANEMIA
DIAGNOSIS – OTHER TESTS
Hemoglobin electrophoresis -HbS >80% -HbF -1-20% -HbA2 -2- 4.5% Sickling test POSITIVE
SICKLE CELL DISEASE
Mutn .beta globin-6 Glu Val. Deoxy HbS (polymerised)
Ca influx, K leakage
stiff,viscous sickle cell
venocclusion dec.RBC survival
microinfarctions,isch.pains anemia,jaundice,
autoinfarct.spleen gallstones,leg ulcers
CLINICAL MANIFESTATIONS
Hemo.anemia,reticulocytosis,granulocytosis Vasoocclusion-protean Painful crises Splenic sequestration crises Hand foot syndrome Acute chest syndrome
DIAGNOSIS?
SICKLE THALASSEMIA`
CLINICAL FEATURES OF SICKLE HEMOGLOBINOPATHIES
Condition Clinical abnorm
Hb level g% MCV,fl Hb electropho
Sickle cell trait
None,rare painlss hematuria
normal normal HbS/A: 40/60
Sickle cell anemia
Vasocclusive crises,AVN,gallstones, priapism
7-10 80-100 HbS/A:100/0HbF;2-25%
S/beta0thalasssemia
VasoocclusiveCrises,AVN
7-10 60-80 HbS/A-100/0HbF; 1-10%
S/beta+ thalassemia
Rare crises,AVN
10-14 70-80 HbS/A:60/40
HbSC --do--, retinopathy
10-14 80-100 HbS/A;50/0HbC;50%
CASE 2
6 yr old child presenting with severe pallor,jaundice growth delay
Abnormal facies,hepatosplenomegaly+ h/o recurrent blood transfusions CBC-Hb -3gm%, MCV-58FL(Nl-86-98), -MCH- 19pg (nl-28-33) P.S- MICROCYTIC,HYPOCHROMIA with target cells +
DIAGNOSIS?
TARGET CELLS
THALASSEMIA
Other diagnosis test-Hb electrophoresis DNA analysis for mutations Alpha thalassemia & beta thalassemia Beta thalassemia- major - intermedia - minor
BETA THALASSEMIA
Mutn. Beta globin expression
M.C- derange splicing of m-RNA
HYPOCHROMIA ,MICROCYTIC anemia
BETA THALASSEMIA MAJOR Severe homozygous Childhood, growth delay Severe anemia,hepatosplenomegaly,r/r transfusion Iron overload-endo.dysfnct
P.Smear- severe microcytosis,target cells
Hb electro- HbF - 90-96 % HbA2- 3.5 %- 5.5% HbA - 0 %
BETA THALASSEMIA INTERMEDIA
Similar stigmata like major Survive without c/c transfusion Less severe than major Moderate anemia,microcytosis,hypochromia Hb electrophor- HbF - 20-100% HbA2 -3.5%-5.5% HbA – 0-30%
BETA THALASSEMIA MINOR
Profound microcytosis,target cells Minimal anemia Similar bld picture of iron def.anemia Lab inv: MCV<75,Hct <30-33% Hb electr: HbA2-3.5-7.5%,HbA-80-95%,HbF-1-
5%
ALPHA THALASSEMIAS
disease Hb A %
HbH % Hb , % MCV,fl
normal 97 0 15 90
Thalassemia traits
90-95 rare 12-13 70-80
HbH (b4) 70-95 5-30 6-10 60-70
Hb Bart(hydrops fetalis)
0 5-10 Fatal inutero or at birth
CASE 3
45 yr old male came to opd in a remote PHC with burning micturition
Urine R/M shows numerous pus cells++++ UTI diagnosed & medical officer gave
cotrimoxazole 2 bd X 5days 1 wk later,pt developed severe
pallor,palpitation,jaundice Lab- increased LDH, S.BILIRUBIN,RETIC
COUNT P.S- shows irreg cells like
BLISTER CELLS
HEINZ BODIES
DIAGNOSIS?
G-6PD DEFICIENCY INVESTIGATION- Peripheral smear- bite cells,heinz bodies, - polychromasia
G-6PD LEVEL
BEUTLER FLUORESCENT SPOT TEST- Positive-if blood spot fails to flouresce in U
V
Clinical Features:
Acute hemolysis:
Drugs,infections,asso with diabetic acidosis
Favism
Neonatal jaundice
Congenital nonspherocytic hemolytic anemia
Definitive risk Possible risk Doubtful risk
antimalarials PrimaquineDapsonecholrproguanil
chloroquine quinine
Sulphonamides/sulphones
SulphametoxazoleDapsone
SulfasalazineSulfadimidine
SulfisoxazoleSulfadiazine
Antibacterials/Antibiotics
Cotrimoxazole Nalidixic acidNitrofurantoin
CiprofloxacinNorfloxacin
Cholramphenicolp-Aminosalicylic acid
Antipyretic/Analgesics
Acetanilide Phenazopyridine [pyridium]
Acetylsalicylic acid High dose[>3g/d]
Acetylsalicylic acid [<3g/d]Acetaminophen
2. Pyruvate Kinase DeficiencyARDeficient ATP production, Chronic
hemolytic anemiaClinical features
o hydrops fetalis
o neonatal jaundice
o compensated hemolytic anemia Inv;
P. Smear: PRICKLE CELLS ( Contracted rbc with
spicules)
Decreased enzyme activity
PRICKLE CELL
CASE 4
14 YR old female present with anemia, jaundice
Rt hypochondrial pain o/e- vitals
stable.pallor+,icterus+,splenomegaly + Usg- cholilithiasis Lab; elevated ,LDH, S.Bilirubin Peripheral smear shows-
DIFFERENTIAL DIAGNOSIS
Hereditary spherocytosis
Autoimmune hemolytic anemia
Other diagnostic tests- osmotic fragility - coombs test
RED CELL MEMBRANE DEFECTS
1.Hereditary Spherocytosis
Usually inherited as AD disorder
Defect: Deficiency of Beta Spectrin or Ankyrin Loss of
membrane surface area becomes more spherical
Destruction in Spleen
C/F:PallorJaundiceSplenomegalyPigmented gall stones- 50%
COMPLICATIONS
Clinical course may be complicated with
Crisis:
Hemolytic Crisis: associated with infection
Aplastic crisis: associated with Parvovirus
infection
Inv:
Test will confirm Hemolysis
P Smear: Spherocytes
Osmotic Fragility: Increased
Screen family members
AUTOIMMUNE HEMOLYTIC ANEMIA
Result from RBC destruction due to RBC autoantibodies: Ig G, M, E, A
Most commonly-idiopathic Classification
Warm AI hemolysis:Ab binds at 37degree Celsius Cold AI Hemolysis: Ab binds at 4 degree Celsius
1.Warm AI Hemolysis: Can occurs at all age groups F > M Causes:
50% IdiopathicRest - secondary causes:
1.Lymphoid neoplasm: CLL, Lymphoma, Myeloma
2.Solid Tumors: Lung, Colon, Kidney, Ovary, Thymoma
3.CTD: SLE,RA4.Drugs: Alpha methyl DOPA, Penicillin , Quinine, Chloroquine
5. UC, HIV
Inv:
hemolysis, MCV decreased
P Smear: microspherocytosis,
Confirmation: Direct Coomb’s Test / Antiglobulin test
• 2. Cold AI Hemolysis Usually Ig M directed at the RBC I antigen
Infection: Mycoplasma pneumonia, Infec MononucleosisNeoplasms : waldenstrom macroglobulinemia ,
lymphoma,CLL,kaposi sarcoma, myeloma. C/F:
Elderly patientsExacerbations in the winter Cold , painful & often blue fingers, toes, ears, or nose ( Acrocyanosis)
Inv: e/o hemolysis
P Smear: Microspherocytosis
DAT positive with polyspecific and anticompliment
antisera
CASE 5
32 yr old presented 4 days history of distention of abdomen and rt hypochondrial pain and has h/o passage of dark colored urine at night for weeks
On USG- hepatomegaly,gross ascites,hepatic vein
thrombosis Lab : Hb – 7gm%. WBC- 2200, PLC- 80,000 LDH- 600, S.BR- 4 mg% urine bile pigment +,heme dip
stick++
What is the diagnosis?
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
Acquired chronic H.A Persistent intra vascular hemolysis Pancytopenia Lab :hburia,hemosiderinuria,increased
LDH,bilirubin Risk of venous thrombosis C/F – hemoglobinuria during night P.S – polychromatophilia, normoblasts B.M – normoblastic hyperplasia Def.diagnosis-flow cytometry CD59-,CD55-
RBC,WBC - Hams’ acidified serum test
CASE 6
25 yr old male with RHD – severe MR done MVR,after 10 days presented with pallor, palpitation,jaundice
CBC shows Hb – 7.5 gm %, Hct -22 % Lab : S.bilirubin -4.5mg% LDH -600 Retic count 10%
Peripheral smear –
MICROANGIOPATHIC HEMOLYTIC ANEMIA
NON-IMMUNE ACQUIRED HEMOLYTIC ANEMIA1. Mechanical Trauma
A). Mechanical heart valves, Arterial grafts: cause shear stress damage
B).March hemoglobinuria: Red cell damage in capillaries of feet
C). Thermal injury: burnsD). Microangiopathic hemolytic anemia (MAHA): by
passage of RBC through fibrin strands deposited in small vessels disruption of RBC eg: DIC,PIH, Malignant HTN,TTP,HUS
MICROANGIOPATHIC HEMOLYTIC ANEMIA(MAHA)
Other findings - leukocytosis -
thrombocytopenia(DIC,TTP) - hemoglobinuria - deranged RFT - PT,APTT prolonged (DIC,TTP)
ACQUIRED HEMOLYSIS
InfectionF. malaria: intravascular hemolysis: severe called ‘Blackwater fever’Cl. perfringens septicemia
Chemical/Drugs: oxidant denaturation of hemoglobinEg: Dapsone, sulphasalazine, Arsenic gas, Cu, Nitrates & Nitrobenzene
PERIPHERAL BLOOD SMEARSpherocytes
AIHA, hereditary spherocytosis
Schistocytes
With thrombocytopenia-Familial HUS TTP or DIC
Without thrombocytopenia- heart valve hemolysis
Blister Cells
oxidative damage- G6PD Sickle cells
sickle cell anemia Heinz bodies
Alpha thalassemia
G6PD deficiency
CONCLUSION
Hemolytic anemia can be recogised by clinical picture-
- history & physical
- lab test to confirm hemolysis
- peripheral smear to guide further
tests
THANK YOU