good presentation

1. HEMOLYTIC ANEMIA
Hemolytic anemia = reduced red-cell life
span
By Dr Abeer ELHadidi
Ass.Prof of Clinical Pathology

2. Hemolytic anemia
• Decreased levels of erythrocytes in
circulating blood (anemia) because of
their acclerated destruction
(hemolysis)
• A red blood cell survives 90 to 120
days (on average) in the circulation,
therefore about 1% of human red
blood cells break down each day.

3. • The spleen (part of the reticulo-endothelial
system) is the main organ which removes old
and damaged RBCs from the circulation.
• In health, the breakdown and removal of RBCs
from the circulation is matched by the
production of new RBCs in the bone marrow.

4. • When the rate of breakdown
increases, the body compensates by
producing more RBCs, but if
compensation is inadequate clinical
problems can appear and so anemia
can develop.

5. • The breakdown products of
hemoglobin will accumulate in the
blood causing jaundice and be
excreted in the urine causing the
urine to become dark brown in
colour.

6. Signs of hemolytic anemia: History
• Onset/ duration (hereditary versus
acquired)
• History of fatigue or jaundice
• Abdomen pain (chronic hemolysis)
• Medications or food /ie fava bean/(may
exacerbate enzyme deficiencies)

7. • Travel (consider infection)
• Blood loss or sequestration (increases
reticulocytes in the absence of
hemolysis)
• Discolored urine (intravascular
haemolysis)
• Complete family history (jaundice,
gallbladder disease, splenectomy)

8. Signs of hemolytic anemia: Physical
• Symptoms of anemia
• Jaundice
• Pallor
• Splenomegaly / hepatosplenomegaly

9. Laboratory findings:
Peripheral blood smear microscopy:
• Fragments of the red blood cells
("schistocytes") can be present
• Spherocytes
• Increased reticulocytes
• Normoblasts can be present.
• The level of unconjugated bilirubin in
the blood is elevated.
• The level of lactate dehydrogenase
(LDH) in the blood is elevated

10. Laboratory findings(2)
• Haptoglobin, hemopexin levels are
decreased
• Iron level in the blood is elevated.
• The direct Coombs test is positive, if
hemolysis is caused by an immune
process.
• Free hemoglobin, methemalbumin
elevated level in the blood.
• hemosiderin in the urine indicates
chronic intravascular hemolysis.

11. Classification of hemolytic anemias
•Causes of hemolytic anemis can
be either genetic or acquired.

12. Classification of hemolytic anemia
===Genetic===
Genetic conditions of RBC membrane
• Hereditary spherocytosis
• Hereditary elliptocytosis
Genetic conditions of RBC metabolism
(enzyme defects)
• G-6-P-D def
• Pyruvate kinase deficiency
Genetic conditions of hemoglobin
• Sickle cell anemia
• Thalassaemia

13. Classification of hemolytic anemias
===Acquired===
• ''Immune mediated hemolytic anemia''' (direct
Coombs test is positive)
Autoimmune hemolytic anemia
• Warm antibody autoimmune hemolytic anemia
(Ab binds at 37degree Celsius)
▫ Idiopathic
▫ Systemic lupus erythematosus (SLE)
▫ Evans' syndrome (antiplatelet antibodies
and hemolytic antibodies)

14. • Cold antibody autoimmune hemolytic
anemia
(Ab binds at 4degree Celsius)
▫ Idiopathic cold hemagglutinin syndrome
▫ Infectious mononucleosis and
mycoplasma ( atypical) pneumonia
▫ Paroxysmal cold hemoglobinuria.
(Rare cause seen in children in association with cong
syphilis)

15. Classification of hemolytic anemia
===Acquired===
'
• Alloimmune hemolytic anemia
• Hemolytic disease of the newborn (HDN)
▫ Rh disease (Rh D)
▫ ABO hemolytic disease of the newborn
▫ Anti-Kell hemolytic disease of the newborn
▫ Rhesus c hemolytic disease of the newborn
▫ Other blood group incompatibility (RhC,
Rhe, RhE, Kidd antigen system, Duffy
antigen, MN, P and others)

16. • Alloimmune hemolytic blood transfusion
reactions (ie from a non-compatible blood type)
• Drug induced immune mediated
hemolytic anemia
• Penicillin (high dose)
• Methyldopa

17. Coombs Test
• Typical screening is with broad
spectrum reagent.
• Contains antibodies directed at both
human immunoglobulin and
complement components

19. Direct Coomb’s test
Indirect Coomb’s test

20. Classification of hemolytic anemia
===Acquired===
• Drugs (i.e., some drugs lead to
hemolysis by direct action on RBCs)
• Toxins (e.g., snake venom)
• Trauma Mechanical (heart valves,
extensive vascular surgery,
microvascular disease)
• Microangiopathic hemolytic
anemia (e.g. TTP, HUS, DIC)

21. • Infections, Malaria (F. malaria: intravascular
hemolysis: severe called ‘Blackwater fever),
Babesiosis, Septicaemia
• Membrane disorders
Paroxysmal nocturnal hemoglobinuria
(rare acquired clonal disorder of red blood
cell surface proteins)
Liver disease
• Hypersplenism

22. TRAUMATIC HEMOLYSIS

23. Mechanisms of hemolysis:
- Intravascular
- extravascular

24. Intravascular hemolysis :
- red cells destruction occurs in vascular space
- Clinical states associated with Intravascular
hemolysis:
1)acute hemolytic transfusion reactions
2)severe and extensive burns
3)paroxysmal nocturnal hemoglobinuria
4)severe microangiopathic hemolysis
5)physical trauma
6)bacterial infections and parasitic infections
(sepsis)

25. Intravascular hemolysis
- laboratory signs of intravascular
hemolysis:
tests for hemolysis and additionally:
hemoglobinemia
methemalbuminemia
hemoglobinuria
hemosiderinuria

27. Extravascular hemolysis :
- red cells destruction occurs in reticuloendothelial
system
- clinical states associated with extravascular
hemolysis:
autoimmune hemolysis
delayed hemolytic transfusion reactions
hemoglobinopathies
hereditary spherocytosis
hypersplenism
hemolysis with liver disease

29. Lab Findings in Extravascular
Hemolysis:
• Anemia
• Unconjugated hyperbilirubinemia
• Increased reticulocytes
• Decreased haptoglobin
• Increased urobilinogen

30. Laboratory Evaluation of Hemolysis
Extravascular Intravascular
HEMATOLOGIC
Routine blood film
Reticulocyte count
Bone marrow
examination
Polychromatophilia
Erythroid
hyperplasia
Polychromatophilia
Erythroid
hyperplasia
PLASMA OR SERUM
Bilirubin
Haptoglobin
Plasma hemoglobin
Lactate dehydrogenase
Unconjugated
, Absent
N/
(Variable)
Unconjugated
Absent
(Variable)
URINE
Bilirubin
Hemosiderin
Hemoglobin
0
0
0
0
+
+ severe cases

31. Hemoglobinuria

32. Hemolytic anemia (complications)
• Clinical course may be complicated with
Crisis:
▫ Hemolytic Crisis: associated with
infection
▫ Aplastic crisis: associated with
Parvovirus infection

33. Differential diagnosis
* ''Ineffective hematopoiesis'' is sometimes
misdiagnosed as hemolysis.
• Clinically these conditions may share many features
of hemolysis
• Red cell breakdown occurs before a fully developed
red cell is released into the circulation.
• Examples: myelodysplastic syndrome, megaloblastic
anemia.

34. Hereditary Spherocytosis
1. Inherited as autosomal dominant
2. red cell membrane protein defects
(Deficiency of Beta Spectrin or Ankyrin)
3. Family history
4. Clinical features: jaundice,
gallstones, splenomegaly.

35. • 5. Laboratory features
- hemolytic anemia
- microspherocytes
- abnormal osmotic fragility test
- negative direct Coombs test
- increased MCHC

38. IMMUNOHEMOLYTIC ANEMIA
MACROCYTE
SPHEROCYTE

39. Hereditary Elliptocytosis
• Equatorial Africa, SE Asia
• AD / AR
• Functional abnormality in one or more anchor
proteins in RBC membrane- Alpha spectrin ,
Protein 4.1
• Usually asymptomatic
• Mx: Similar to H. spherocytosis
• Variant:
3.SE-Asian ovalocytosis:
 Common in Malaysia , Indonesia…
 Asymptomatic-usually
 Cells oval , rigid ,resist invasion by malarial parasites

40. Elliptocytosis

41. SICKLE CELL ANEMIA
Definition: chronic hemolytic anemia
characterized by sickle-shaped red
cells(RBCs) caused by homozygous
inheritance of Hemoglobin S

42. SICKLE CELL ANEMIA-pathogenesis
- In HbS, valine is substituted for glutamic acid in
the sixth amino acid of the ß chain.
- Deoxy-HbS is much less soluble than deoxy HbA;
it forms a gelatinous network of fibrous polymers that
cause RBCs to sickle at sites of low pO2.
- Hemolysis - because sickle RBCs are too fragile to
withstand the mechanical trauma of circulation
- Occlusion in microvascular circulation caused by
distorted, inflexible RBCs adhering to vascular
endothelium

43. SICKLE CELL ANEMIA-incidence
- Homozygous - about 0.3% of blacks
in the USA
(have sickle cell anemia)
- Heterozygotes 8-13% of blacks, (are
not anemic, but the sickling can be
demonstrated in vitro)

44. SICKLE CELL ANEMIA-clinical features
IN HOMOZYGOTES
1. Clinical complications due to severe hemolytic anaemia
- slow growth and development in children
- gall bladder stones
- aplastic crisis
- congestive heart failure from chronic anemia and
cardiac overload compensation
2. Consequences of vaso-occlusion of the microcirculations
(tissue ischemia and infarction)
- infarction of spleen, brain, kidney, lung, aseptic
necrosis, central nervous system and ophtalmic vascular
lesions

45. SICKLE CELL ANEMIA
laboratory findinges
1. Anemia-normocytic or slightly macrocytic
2. Leukocytosis (chronic neutrophilia)
3. Thrombocytosis - usually mild
4. Reticulocytosis
5. Peripheral smear: sickle shaped red cells,
polychromatophilia, Howell-Jolly bodies
6. Hb –electrophoresis or high-performance
liquid chromatography (HPLC)

46. Sickle Cell Disease
• Mutation in beta
globin
(6 Glu Val)
• Inherited as
autosomal recessive
• Protection against
malaria

47. Thalasemias
• Thalasemia result from gene (located on
chromosomes 11 and 16) deletion, abnormalities
in transcription and translation and instability of
the mRNA directing globin synthesis or of the
globin itself.
• Result: imbalanced synthesis of normal globin
chain. The unpaired chain accumulates in the
developing erythroid precursor cell, and toxicity
results – ineffective erythropoiesis, hemolysis
and anemia of variable degree.

48. Thalassemia: Impaired Globin
Gene Production
 globin  globin
 globin  globin
Hgb A tetramer

49. Different forms of thalassemia
• α thalassemia
• β thalasemia: major, minor (trait), intermedia
• δ/β thalassemia
• Hereditary persistentce of fetal hemoglobin
(HPFH)

50. Hemoglobin
 Chains Hgb (g/dl) MCV (fl) Analysis
/ Normal Normal Normal
/- 12-14 75-85 Normal
-/- or 11-13 70-75 Normal with Hgb
Barts (4);
--/ Hgb H (4)
--/- 7-10 50-60 Normal with Hgb
Barts (4);
Hgb H (4)
--/-- - - Not viable
Alpha Thalassemia: Laboratory Findings

51. Beta Thalassemia
Clinical Hgb
Syndrome Genotype Hgb (g/dl) Analysi
Minor (Trait) /+
or /° 10-13  Hgb
A2,  Hgb F
Intermedia +
/+
7-9  Hgb
A2,  Hgb F
Major(Cooleys) +
/° or °/° < 7  Hgb A2, 
Hgb F

52. Beta-Thalassemia major
(Cooley anemia)
• Usually homozygous condition
• Is the most severe variant no beta-chains are synthesized
• Clinical features: severe anemia that appears in the first
year of life; jaundice, hepatosplenomegaly (secondary
neutropenia and thrombocytopenia),
• skin pigmentation and chronic leg ulceration,
• expansions of the erythroid marrow with secondary
body changes (including retarded growth, bossing of
skull, expanded maxilla, widened diploe,
• gross skeletal deformities, spontaneous fractures, dental
problem), increased susceptibility to infection,
symptoms of iron overloading

53. Beta-Thalassemia major
laboratory features
• Severe anemia
• Blood film: anisopoikilocytosis, hypochromia,
target cells, basophilic stippling, reticulocytosis
• Bone marrow: marked erythroid hyperplasia,
increased sideroblasts
• Shortened red cell survival
• Fetal hemoglobin > 90%, HbA absent, HbA2
low/normal/high

54. Red Cell Enzymopathies
1. Glucose-6-Phosphate Dehydrogenase (
G6PD ) Deficiency
▫ Pivotal enzyme in HMP Shunt & produces
NADPH to protect RBC against oxidative
stress
▫ Most common enzymopathy -10% world’s
population
▫ Protection against Malaria
▫ X-linked

55. • Clinical Features:
▫ Acute drug induced hemolysis:
 Aspirin, primaquine, quinine, chloroquine,
dapsone….
▫ Chronic compensated hemolysis
▫ Infection/acute illness
▫ Neonatal jaundice
▫ Favism

56. • Investigation:
▫ e/o non-spherocytic intravascular
hemolyis
▫ P. Smear: Bite cells, blister cells,
irregular small cells, Heinz bodies,
polychromasia
▫ G-6-PD level
• Treatment:
▫ Stop the precipitating drug or treat the
infection
▫ Acute transfusions if required

57. 2. Pyruvate Kinase Deficiency
▫ AR
▫ Deficient ATP production, Chronic
hemolytic anemia
• Investigation:
 P. Smear: Prickle cells
 Decreased enzyme activity
▫ Treatment:
 Transfusion may be required

58. Features of HEMOLYSIS
Bilirubin
LDH
Reticulocytes, n-RBC
Haptoglobulins
+ve Urinary hemosiderin, Urobilinogen
Blood Film
Spherocytes No spherocytes Fragmentation
DCT +ve DCT –ve Hereditery enzymopathies
AI Hemolysis H. Sherocytosis Malaria,
Clostidium
Microangiopathic,
Traumatic