2. Non- hemolytic anemias 3. Normocytic Normochromic Normocytic Normochromic Blood loss. (MCV<80 fl) (MCV fl) (MCV>100 fl)

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1 Definition of Anaemia of Anaemias Approach for diagnosis of Red cell disorders any condition resulting from a significant decrease in the total body erythrocyte mass due to decrease of Hb and or RBCs Hemoglobin (Child: g/dl) Morphological (size & color of RBC) Red cell indices Etiology 1. Microcytic Normochromic Microcytic Hypochromic 1. Hemolytic anemia 2. Microcytic Hypochromic (MCV<80 fl) 2. Non- hemolytic anemias 3. Normocytic Normochromic Normocytic Normochromic Blood loss 4. Macrocytic Normochromic (MCV fl) Nutritional anemia Macrocytic Normochromic Hypoproliferative anemia (MCV>100 fl) (Bone marrow failure) Definition Prevalence Symptoms Confirmation of hemolysis Hemolytic Anaemias Anemia due to premature destruction of RBCs (shortened red cell life span: 120 days) beyond the capacity of BM G6pD enzyme deficiency is the most common Immune hemolytic anemia is common hemolytic anemia( 4%) Sickle cell and spherocytosis are not common Beta thalassemia ( gene frequency 5 7%) 1. Pallor + Jaundice 2. Dark urine 3. Enlarged spleen 4. Fatigue 5. Rapid heart rate 6. Shortness of breath 1. Reticulocytosis 2. Indirect hyperbilirubinemia 3. Blood smear (Review by expert) 4. Decreased Haptoglobin 5. Decreased Hemopoxin 6. Increase LDH 7. Increased urinary Hemosiderin 8. Increased urinary urobilinogen 9. Increased urinary hemoglobin (intravascular hemolysis) Causes Congenital (Intracorpuscular causes) Acquired (Extracorpuscular causes) 1. Hemoglobin defect (Thalassemia, Sickle cell anemia) 2. Enzymes 3. Memberane Acute 1. G6pD enzyme deficiency 2. Post transfusion immune hemolytic anemia 3. Drug induced hemolytic anemias 1. Immune 2. Non immune 3. Hypersplenism Chronic 1. Thalassemia 2. Congenital spherocytosis Mean Corpuscular Volume (MCV) Mean cell volume MCV is average size of RBC!"#!!" MCV =!"# (!"##"$%&) If fl, normal range, RBCs considered normocytic If < 80 fl are microcytic If > 100 fl are macrocytic Not reliable when have marked anisocytosis Mean Corpuscular Hemoglobin (MCH) MCH is average weight of hemoglobin per RBC. MCH =!"#!!"!"# (!"##"$%&) RBC Indices Mean Corpuscular Hemoglobin Concentration (MCHC) MCHC is average hemoglobin concentration per RBC!"#!!"" MCHC =!"# (%) If MCHC is normal, cell described as normochromic If MCHC is less than normal, cell described as hypochromic There are no hyperchromic RBCs RBC Distribution Width (RDW) Most automated instruments now provide an RBC Distribution Width (RDW) An index of RBC size variation May be used to quantitate the amount of anisocytosis on peripheral blood smear Normal range is up to 14.5% for both men and women Component Normal Ranges Component Normal Ranges WBC x 10 3 /μl MCH pg RBC Male x 10 6 ; Female x 10 6 /μl MCHC 32-36% Hgb Male g/dl; Female g/dl RDW % Hct Male 42-52%; Female 37-47% Plt 150, ,000/μL MCV fl Retic %

2 Hemoglobin Definition Presentation Subtypes diagnosis of Beta thalassemia major Molecular diagnosis of Thalassemia diagnosis of Thalassemia carriers Multi- subunit protein (tetramer) *2 α and 2 β subunits Heme *One per subunit *Has an iron atom *Carries O 2 Thalassemia In red blood cells Inherited, autosomal recessive, chronic hemolytic anemia, due to globin chain imbalance According to the type of globin chain that is produced at reduced rate: A. Alpha thalassemia B. Beta thalassemia β- thalassemia α- Thalassemia β- thalassemia (Decreased β- chain prodction) α- Thalassemia (Decrease α- chain production) Other variants CBC BM 9-12 months (the time of globin chain switch) 1. Hb- Barts (Intrauterine) 2. Hb- H (Postnatal) Minor (Hb- A2 =>3.5%) Major (Hb- F =>90%) Intermedia( increased Hb- F) Carrier ( At birth Hb- Barts 5-20%) Hb- H (Hb- H) Hb- Barts (Hb- Barts) Hb MCV, MCH, RDW Frequent target RBCs Frequent schistocytes (fragmented RBCs ) May be leucocytosis, thrombocytosis Normoblastemia Reticulocyte (Inappropriate ) Intense erythroid hyperplasia with marked ineffective erythropoiesis Hb electrophoresis HbF (10-90%) Definitive test Quantitation of HbF Molecular characterization of globin gene mutation MCV, MCH Hb- H Hemoglobin H inclusion bodies in retics (incubation for 60 min). Hb- electrophresis Hb- H band faster than Hb- A The definitive diagnosis The only way in Case of alpha thalassemia carrier Important prenatal preimplantation diagnosis MCV, MCH normal RDW Basophilic stippling β- thalassemia carrier *Hb A2 3.5 α- Thalassemia: *Hb Barts 1-5% in cord blood *Definitive diagnosis by DNA study Congenital Spherocytosis Autosomal recessive hemolytic anemia Due to abnormality in membrane cytoskeleton Red Cell deformability Presentation at neonatal, adult or even old age CBC Normal MCV, MCH, and MCHC (>36g/L) Spherocytes in blood smear (> 15%) Osmotic fragility (specific tests) Marked in retics ( up to 80%) Corrected by splenectomy

3 Complication Diagnosis Sickle cell Anemia Due to amino acid substitution in β globin chain( β6- glutamine valine Autosomal recessive Carrier has ββs ( one β globin chain affected) Disease has βsβs (2 β globin chain affected) Carrier are symptom free Patient suffer from many type of crises Hemolytic, occlusive, aplastic, sequesteration) Infection :Overwhelming post- splenectomy infection Stroke Leg ulcers Bone osteomyelitis (bacterial infection), aspetic necrosis Kidney (Acute papillary necrosis, Renal failure) During pregnancy, intrauterine growth retardation, spontaneous abortion, and pre- eclampsia. In eyes, background retinopathy, proliferative retinopathy, vitreous haemorrhages and retinal detachments, resulting in blindness Gallstone 1. CBC: Normocytic normochromic anemia, 2. osmotie fragilily 3. Definitive Diagnosis by hemoglobin electropresis Hb (< 50% in carrier, > 50% disease). 4. Sickling test : Positive 5. Solubility test : Positive WHO G6PD genetic variants diagnosis Red Cell enzymes (Enzymopathy) The red cell enzymes are important in the RBCs for either 1. Energy production 2. Protection of RBCs from oxidant stress (G6PD). 1. G6PD enzyme deficiency The most common hemolytic anemia Presention neonatal or infancy period Enzyme correction may occur at 14 ys in more than 90% of cases In between attacks the child is completely normal. Precipitating agents of hemolytic crisis: 1. Drugs 2. Infection 3. Acidosis 4. Fave beans or their pollens Class I mutation: Severe deficiency <5% activity with chronic (nonspherocytic) hemolytic anemia Class II mutation: Severe deficiency <10% activity with intermittent hemolysis Class III: Mild deficiency 10-60% activity hemolysis with stressors only (present in Egypt) Class VI,V: Non- deficient variant no clinical sequelae Increased enzyme activity, no clinical sequelae 1. Hb level (usually 3-5 g/dl) normocytic normochromic 2. WBCs count. 3. Platelet 4. Reticulocytosis 5. Specific test: Assay for G6PD enzyme activity. 2. Pyruvate kinase deficiency Congenital autosomal recessive nonspherocytic hemolytie anemia Hb usually 7-10 g/dl. Blood smear no characteristic changes Autohemolysis test is poorly corrected by glucose Definitive diagnosis: Determination of pyruvate kinase enzyme activity

4 Definition Types Autoimmune hemolytic anemia Prenatal screening At birth Etiology findings Hypersplenism Extracorpuscular causes of hemolytic anemia I - Immune hemolytic anemia Red cell destruction by the effect of antibodies Alloimmune (Isoimmune) According to the source of antibody (Ab) According to Ab reaction Warm Cold Paroxysmal cold hemoglobinuria The Ab from outside the body eg * Hemolytic transfusion reaction * Fetomaternal incompatibility Autoimmune The Ab is produced by subject against self antigen Warm Ab react at 37 c Cold Ab react at temp less than31 c Biphasic attach to antigen at low temperature and get its effect at 37 c Idiopathic Seconrdary : lymphoma, leukemia, infectious mononucleosis, systemic lupus erythromatosis (SLE) Idiopathic Secondary: mycoplasma penuomeniae, lymphoproliferative neoplasms, Idiopathic Secondary to viral illness, syphilis Hemolytic disease of newborn Due Alloimmunization to the following antigens ABO ( only when the mother O and the baby A,B,AB) Rh system antigens (D,c, E) Other minor blood groups: Kell, Lewis, duffy Screening for alloantibodies titre in maternal blood by indirect coombs test Amniocentesis is more reliable than anti- D titer (measurement of bilirubin reflecting hemolysis) determine Cord blood hemoglobin Belarusian Coombs test (direct for baby and indirect for mothers) Blood film for nucleated RBCs Typing of blood groups of the baby II - Non immune Hemolytic anemia Disseminated intravascular coagulation Thrombotic thrombocytopenic purpura TTP Hemolytic uremic syndrome Post transplantation liver or kidney ized vasclautis associated with immundisorders eg SLE., scleroderm 1- Microangiopathic hemolytic anemia 3.- Infection Intravascaular hemolysis caused by Malaria fragmentation of normal red cells passing Bartonellosis through abnormal arteries. Clostridium 2- chemical or physical agent hydredi Babesiosis Arsenic 4- Traumatic anemia Lead- Copper Cardiac Chlorate March Retics count Coagulaton factors V, VIII fibrin degradation product platelets 1- Decrease one or more of cellular component 2- Splenomegaly 3- Hyperactive Bone marrow 4- Correction of Cytopenia after splenectomy

5 Aplastic anemia Definition Pancytopenia in peripheral blood due to absence or marked reduction of stem cells in BM Inevitable TBI Chemotherapy e.g. high dose of busulphan Hereditary Fanconi s anemia Causes Idiosyncratic Chronic benzene exposure Drug induced but not dose related e.g gold, chloramphenicol phenylbutazon, ect. Post viral Parvovirus 19 infection Hepatitis A,B, CMV and EBV. Idiopathic most common cause. Defines highest risk group neutrophils <0.5 x 10 9 /L Severe platelets <20 x 10 3 /L Severity reticulocytes <0.1% Very severe neutrophils < 0.2 x 10 9 /L infection present feature of anemia Clinical feature of leucopenia (infection) feature of thrombocytopenea Pancytopenia Hematological Absent reticulocyts BM aspiration gross reduction in all hemopoietic tissues replaced by fat spaces. Complications Progression to more severe disease Transformation to acute leukemia occurs in 5-10% Aetiology Stages Diagnostic points Microcytic Hypochromic Anemias Iron Deficiency Anaemia Most common type of anemia worldwide Lack of dietary iron may be the cause in infancy and pregnancy. Blood loss the most common cause of iron deficiency (menstruation and GI blood loss) Decreased iron absorption(a partial gastrectomy or who have a malabsorption disorder.) 1. Iron depletion 2. Iron deficiency state 3. Iron deficiency anemia 1. Decreased hematocrit and hemoglobin 2. Hypochromic microcytic RBCs on peripheral smear 3. Decreased serum iron and increased total iron binding capacity (TIBC) 4. Decreased serum ferritin 5. Decreased bone marrow iron stores (Definitive test) Anemia of Chronic Disease Anemia associated with chronic liver, Kidney diseases and malignancy, chronic infection Microcytic hypochromic anemia Increased iron stores in Reticuloendothelial system and decresed iron in the Normoblasts Decreased serum iron, decreased TIBC and increased iron stores in the reticuloendothelial cells Sidroblastic Anaemia Due to accumalation of iron in the mitochondria The hereditary form is an X- linked recessive trait with variable expression. Most sideroblastic anemias are acquired associated with drugs (alcohol*, isoniazid, chloramphenicol, cytotoxic agents, and other Vit B6 antagonists) Heavy metals (lead) Various hematologic, neoplastic and inflammatory diseases

6 Pathophysiology Causes Differentiation between Folic acid and Vit B12 deficiencies Hematology Macrocytic anemia (Megaloblastic anemia ) Heterogenous group of disoreders with common entity which is Macrocytosis, neutrophil hypersegmentation and abnormal megakaryocytes that results from inhibition of DNA synthesis in red blood cell production. The molecular basis for megaloblastosis is a failure in the synthesis and assembly of DNA. The most common causes of megaloblastosis are cobalamin and folate deficiencies. Cobalamin metabolism and folate metabolism are intricately related, and abnormalities in these pathways are believed to lead to the attenuated production of DNA. 1. Vit B12 deficiency 2. Folate deficiency 3. Combined Vit B12 & Folate deficiency 4. Toxins & drugs like methotraxate 5. Inherited pyrmidine synthesis disorders (orotic aciduria) 6. Erythroleukemia A measurement of methylmalonic acid can provide an indirect method for partially differentiating B 12and folate deficiencies. The level of methylmalonic acid is not elevated in folic acid deficiency. Direct measurement of blood cobalamin remains the gold standard because the test for elevated methylmalonic acid is not specific enough. Hb WBCs MCV Platelets MCH LDH Retics Methyl malonic acid (Vit B12 def) Neutrophil Homocysteine (folic acid def)