Presented by-1166
1167
1168
1169
1170
ANAEMIA

Definition and Classification ofanaemia andiron
deficiency anaemia

Definition
 Anaemia is present when the hemoglobin PCV
hematocrit RBC count level is more than 2SD below
the mean
for child’s age and sex.
 Cut offs for hemoglobin and hematocrit proposed by the
WHO to define anaemia-----Age group Hemoglobin(g/dl) Hematocrit %
Children,6 mo to 5 yr <11.0 <33
Children, 5-11 yr <11.5 <34
Children,12-13 yr <12.0 <36
Non pregnant
women
<12.0 <36
Men <13.0 <39
Acc. To National family health survey(NFHS3) 79%
of Indian children have anaemia including 71% of
urban children and 84% those in rural areas

 Clinical disturbances occur until the Hb level falls
below 7-8 g/dl below this level pallor becomes
evident in the skin and mucous membrane.
 PHYSIOLOGICAL ADAPTATIONS—
 Increased cardiac output
 Shunting of blood towards vital organs and tissue
 The conc. Of 2,3 diphosphoglycerate increases

Classification Of Anaemia--
 Pathophysiological
 Due to increased blood loss – Acute and chronic
Anaemia due to impaired red cell production– Cytoplasmic maturation
defects (deficient haem and globin synthesis)
-- Nuclear maturation defects (Vitamin B12 and folic acid deficiency)
 Defect in stem cell proliferation and differentiation
--Aplastic anaemia
--Pure red cell aplasia
 Anaemia of chronic disorders
 Bone marrow infiltration.
 Congenital anaemia
 Anaemia due to increased red cell destruction– Intra corpuscular &
Extra corpuscular

 Morphological
 Microcytic hypochromic
 Normocytic normochromic
 Macrocytic normochromic
Iron Deficiency anaemia
 Iron is essential for multiple metabolic processes.
 Iron deficiency occurs when decrease in total iron
body content is severe enough to diminish
erythropoiesis and cause anaemia
 The body of new born infant contains about 0.5g of
iron whereas adult content is 5g to make up for this
discrepancy the average of 0.8mg of iron must be
absorbed each day during the first 15 years of life .

Iron metabolism
 Most of the iron in the food is in the form of ferric ion
but it is ferrous form that is absorbed in the proximal
small intestine.To maintain positive iron balance in
childhood about 1mg of iron must be absorbed .About
20% of iron is absorbed from the diet so a diet
containin 8-10mg of iron must be absorbed each day.
 Ferric ion coverts into ferrous by ferric reductase.
 All the iron absorption occur in the
duodenum,transport of ferrous into enterocytes by
divalent metal transporter(DMT1)
 Some of iron is stored in ferritin and remaining is
transported out of the enterocytes by ferroprotien1, a
protien called hephaesitin is associated with it present
on the basolateral side.
 In plasma ferrous is converted to ferric and
transported by transferrin protien.

Source of Iron
 Healthy new born have body iron stores of250mg
or app.80parts per million..
 Human milk is a best source of iron than cow
milk.
 Infant consuming cow milk are more likely to have
iron deficiency anaemia because---- cow milk has
a higher concentration of calcium that competes
with absorption,lower bioavailability of iron and
due to GI blood loss with cow milk allergy..
 Infants breast fed exclusively should receive iron
supplementation at the age of 4months.

ETIOLOGY
 Low birth weight and perinatal haemorrhage
 Causes of chronic iron deficiency anaemia are:
 Lesions of GI tract(peptic ulcer,Meckel diverticulum,polyps,
hemangioma,inflammatory bowel diseases..
 Hookworm infestations.
 Pulmonary hemosiderosis
 MILK ALLERGY-due to lactase deficiency.
 Histological abnormalities of mucosa of GI tract.

CLINICAL MANIFESTATIONS
 Clinical findings are related to severity and rate of
development of anaemia.
 Pallor is the most important sign of iron deficiency.
 Irritability and anorexia usually precede
weakness,fatigue,lag cramps,breathlessness and
tachycardia.it occures when Hb level falls below 5g/dl
 Congestive cardiac failure,splenomegaly may occure
with severe untreated anaemia.
 Angular stomatitis.glossitis,koilonychiaand platynychia
are noted in severe cases.
 In some children ingestion of lead leads to
PLUMBISM.
 Iron def.anaemia may have effects on neurological
and intellectual function

MANAGEMENT
 INVESTIGATION-
 Acareful dietary history is important,including the type of
milk and weaning foods in infants and the use of
supplements.
 Peripheral blood smear reveals microcytic hypochromic
red cells,with anisocytosis and poikilocytosis and
increased red cell distribution width..
 MCV and MCH are reduced.total serum iron and ferritin
are reduced while the total iron binding capacity is
increased.
 Saturation of transferrin is reduced to less than16%..

Red cell
indices
birth 0.5-2yr 6-12yr 12-
18yr(girl
s)
12-18
yr(boys)
MCV 108 78 86 90 88
MCH 34 27 29 30 30
MCHC 33 33 34 34 34
RDW 12.8+_1.
2%
- - - -
SERUM
IRON
10-
30umol/l
- - - -
SERUM
FERRITI
N
15-
300ng/m
l(boys)1
5-
200ng/m
l(girls)
-
- - -
TOTAL
IRON
BINDIN
G
CAPACI
TY
250-
400ug/m
l
- - - -

 High free erythroprotoporphyrin…
 Reticulocyte count can be increased or
decreased,normal RC is 2-6%in newborns and
0.5-2% in children.RC should be corrected for
degree of anaemia..
 Corrected RC=RC X Actual hematocrit/normal
hematocrit
 LOWRC
 -Congenital or acquired anaemia,aplastic or
hypoplastic anaemia.
 Pure red cell aplasia
 Parvovirus B19 infection
 HIGH RC
 Hemolysis, hemorrhage,iron def. sepsis

 Peripheral smear

TREATMENT
 Oral therapy-
 Patients with iron def. anaemia should receive 3-
6mg/kg per day of elemental iron in 3 divided
doses. Ferrous salts (sulphates
,fumarates,gluconate)
 Absorption is better when taken on an empty
stomach or in between meals
 About 10-20 % patients develop gastrointestinal
side effects such as nausea,epigastric
discomfort,vomiting,constipation and diarrhea.
 Enteric –coated preparations have fewer side
effects but are less efficacious and more
expensive

 Parenteral therapy—
 Indications–
 Intolerance to oral iron
 Malabsorption on going blood loss at a rate
where oral replacement cannot match iron loss.
 IV Iron sucrose is safe and effective and is
commonly used for children IBD and end stage
renal disease
 The dose is 1-3mg/kg diluted in 150ml of NS and
given as slow infusion over 30-90 min.
 Total dose of parenteral iron can be calculated as
–
iron required(mg)=wt./kg x 2.3x(15-hb in g/dl) +
500-100mg

 Blood transfusions—
 Red cell transfusions are needed in emergency
situations such as acute severe
hemorrhage,severe anaemia and cogestive
cardiac failure but should be given at a very slow
rate with hemodynamic monitoring
 Differential diagnosis—
 Iron deficiency anaemia must be differentiated
from other causes of microcytic hypochromic
anaemia—
 Thalassemia (α&β)
 Other Hb pathies
 Anaemia of chronic disorders
 Lead poisoning

Thank you

MEGALOBLASTIC
ANAEMIA

Definition: Macrocytic Anemia
 MCV>100fL
 Impaired DNA formation due to lack of:
 B12 or folate in ultimately active form
 use of antimetabolite drugs
 Macrocytosis also caused by
 Liver disease with inadequate cholesterol esterification
 Alcohol abuse independent of folate (MCV 100-105)
 Myelodysplasia
 Post-splenectomy
 HIV drugs
 Dilantin

Vitamin B12: Cobalamin
 Meat and dairy products only
 Minimum daily requirement 6-9 mcg/d
 Total body store 2-5 mg (half in liver)
 Helps to synthesize thiamine, thus deficiency leads
to problems with DNA replication

B12: Cobalamin absorption
 Initially bound to protein in
diet, liberated by acid and
pepsin, then binds to R factors
in saliva and gastric acids
 Freed from R factors by
pancreatic proteases them
binds to Intrinsic Factor
secreted by gastric parietal cells
 Absorbed together (Cbl + IF) in
ileum
 Released from IF in ileal cell
then exocytosed bound to
trans-Cbl II
 Cbl bound to transcobalamin II
binds to cell surface receptors
and is endocytosed

Actions of Cobalamin & Folate

Causes of B12 Deficiency:
Pernicious Anemia
 Autoantibody to Intrinsic Factor detectable in <70%
 Highly specific, but insensitive
 2 types of anti-IF antibody
 Blocks attachment of Cbl to IF
 Blocks attachment of Cbl-IF complex to ileal receptors
 Chronic atrophic gastritis
 Autoantibody against parietal cells (H-K-ATPase) though
pathology indicates destruction by CD4+ T cells
 Increased risk of gastric cancer (carcinoid and intestinal-
type)

Causes of B12 Deficiency:
Growing Older
 Usually mild and subclinical
 Age >65 approx 5%
 Age >75 approx 10%+, up to 40% in institutionalized
patients
 Unclear mechanism
 gastric atrophy
 inadequate intake
 Achlorhydria

Causes of B12 Deficiency:
Surgery, Medication, Worms, Etc.
 Gastrectomy/Bariatric surgery
 Ileal resection or bypass
 Ileal disease (TB, lymphoma, amyloid, post-radiation, Crohn’s)
 Enteropathies (protein losing, chronic diarrhea, celiac sprue)
 Fish tapeworm (Diphyllobothrium latum) infection
 Bacterial overgrowth
 HIV infection
 Chronic alcoholism
 Sjogren’s syndrome
 Pancreatic Exocrine Insufficiency
 Strict vegetarian diet
 Inherited
 Trans-Cbl II or IF deficiency
 decreased uptake of IF-Cbl (Imerslun-Grasbeck’s or juvenile megaloblastic anemia) - also presents
with proteinuria
 Homocysteinuria, severe abnormalities of methionone synthesis, abnormal lysosomal exporter
 Decreased absorption from medication
 Neomycin
 Metformin (biguanides) up to 10-25%
 PPI
 Nitric oxide (inhibits methionine synthase)

B12 Deficiency Symptoms
 Atrophic glossitis (shiny
tongue)
 Shuffling broad gait
 Anemia and related sx
 Vaginal atrophy
 Malabsorption
 Jaundice
 Personality changes
 Hyperhomocysteinemia
 Neurologic symptoms (next
slide)
 Copper deficiency can
cause similar neurologic
symptoms

B12 Symptoms: Neurologic
 Paresthesias
 Memory loss
 Numbness
 Weakness
 Loss of dexterity due to loss
of vibration and position
sense
 Symmetric neuropathy
legs>arms
 Severe weakness, spasticity,
clonus, paraplegia and
incontinence
 Subacute combined
degeneration of the dorsal
(posterior) and lateral spinal
columns
 Due to a defect in
myelination
 NOT ALL PATIENTS WITH B12
DEFICIENCY RELATED
NEUROLOGIC
ABNORMALITIES ARE
ANEMIA OR MACROCYTOSIS

Subacute
Combined
Degeneration
Degeneration and demyelination of the
dorsal (posterior) and lateral spinal
columns

B12 Lab findings
 Macroovalocytic anemia
with elevated serum bili
and LDH
 Increased red cell
breakdown due to
ineffective hematopoiesis
 Reticulocytes, WBC &
platelets normal to low
 Hypersegmented
neurophils
 Also occur in renal failure,
iron deficiency, inherited

Bone Marrow
 Hypercellular marrow
 Megaloblastic erythroid
hyperplasia
 Giant metamyelocytes
Due to slowing of DNA
synthesis and delayed
nuclear maturation
Methionine deficiency may
play a central role

Folate
 SOURCE:Animal products (liver), yeast and leafy
vegetables
 Normal requirement 400mcg/day
 Pregnancy/Lactation: 500-800mcg/day
 Increased requirement in hemolytic anemia and
exfoliateive skin disease
 Body stores: 5-10mg

Folate Metabolism
 Binds to folate
receptor, becomes
polyglutamated
intracellularly
 Many drugs
(trimethoprim,
methotrexate,
pyrimethamine)
inhibit dihydrofolate
reductase

Causes of Folate Deficiency
 Malnutrition: Destroyed by heat during cooking
 Alcoholism (decreased in 2-4 days): impairs
enterohepatic cycle and inhibits absorption
 Increased requirement in hemolytic anemia,
pregnancy, exfoliative skin disease
 IBD, celiac sprue
 Drugs
 Trimethoprim, Methotrexate, Primethamine (inhib DHFR)
 Phenytoin: blocks FA absorption, increases utilization
(mech unknown)

Folate deficiency symptoms
 Similar symptoms as B12 except for neurologic
symptoms
 Presentation is different classically:
 Alcoholic
 Very poor dietary intake
 Older
 Depressed
 Living alone

Whom should you test for B12 or Folate deficiency?
 MCV >100 with or without anemia
 Hypersegmented neutrophils
 Pancytopenia of uncertain cause
 Unexplained neurologic symptoms
 Alcoholics
 Malnourished, particularly the elderly
 Diabetics on metformin with new onset neuropathy

Lab testing for diagnosis
Serum B12 Serum
Folate
MMA Homocystein
e
Normal >300 >4 70-270 5-14
Deficiency <200 <2
Confirm B12 200-300 High High
Confirm folate 2-4 Normal High
High amount of seaweed in the diet can interfere with the B12 assay as
can a single meal. It is best to add-on tests to blood already in the lab,
particularly for inpatients due to the variability of the test.
Intrisic factor antibody assay can be falsely positive if pt has recently
received a B12 shot with B12 >800, thus important to add-on.

Shilling Test
1. PART 1: Oral labeled B12 and
IM unlabeled B12 at the same
time to saturate tissue stores
2. 24h urine to assess absorption
>5% normal
<5% impaired
3. PART 2: Repeat w/oral IF
if now normal =PA
if abnormal = malabsorption
4. Can continue with antibiotics to
look for bacterial overgrowth,
pancreatic enzymes for
exocrine insufficiency
Part 1 test result Part 2 test result Diagnosis
Normal -
Normal
or vitamin B12
deficiency
Low Normal
Pernicious
anemia
Low Low Malabsorption

B12 Deficiency: Treatment
 IM B12 1000mcg daily x 1 wk
 then 1000mcg weekly x 1 month
 Then 1000mcg monthly for life for PA
 Oral high dose 1-2 mg daily
 As effective but less reliable than IM
 Currently only recommended after
full parenteral repletion
 Sublingual, nasal spray and gel formulations
available

Vegan B12 Recommendations
 Daily multivitamin with10mcg/d
 Available in a few specific commercial nutritional
yeasts most of which contain B12 from
Pseudomonas sp., Propionibacterium sp. or
Streptomyces sp.
 Probiotics are NOT sufficient to provide
adequate B12
 Keep supplements in the fridge and out of light

Folate Deficiency Treatment
 Oral folate 1mg daily for 4 months or until
hematologic recovery
 Rule out B12 deficiency prior to treament as folic
acid will not prevent progression of neurologic
manifestations of B12 deficiency
 Repeat testing for B12 deficiency may be
reasonable for those on long-term folic acid
therapy if hematologic (macrocytosis or ↑LDH) or
neurologic sx persist

Thank you

HAEMOLYTIC ANAEMIA
 It is defined as
1) Premature destruction of red cells and a shortened red cell life span
below normal 120 days
2) Elevated erythropoietin levels and a compensatory increase in
erythropoiesis
3) Accumulation of hemoglobin degradation products released by red
cell breakdown derived from haemoglobin

CLASSIFICATION

ACQUIRED HAEMOLYTIC ANAEMIA
 IMMUNE HAEMOLYTIC ANAEMIA
 These can be subdivided into:
a) Autoimmune
b) Alloimmune
c) Drug-induced

AUTOIMMUNE HAEMOLYTIC ANAEMIA
Caused by antibodies produced by patient’s own
immune system
Classified according to thermal properties of antibodies:
 warm antibodies bind to RBC most avidly at 370C
 cold antibodies bind best below 320C

Warm AIHA:
 Antibody usually IgG, but may be IgM or IgA
 Usually facilitate sequestration of sensitized RBCs in
spleen
 May be primary or secondary –
 autoimmune disorders, HIV,
 chronic lymphocytic leukaemia (CLL),
 non-Hodgkin's lymphoma (NHL)
Most common type

Incidence:
 Occurs in either sex but female preponderance
reported esp. primary
 Occurs in all ages
 Higher incidence of secondary noted in patients > 45
years

Clinical Features:
 Hemolytic anaemia of varying severity
 Tends to remit and relapse
 Symptoms of anaemia
 Jaundice
 Splenomegaly
 Symptoms of underlying disorder (if 20

Laboratory Features:
 Variable anaemia
 Blood film: polychromasia, microspherocytes
 Severe cases: nucleated RBCs, RBC fragments
 Mild neutrophilia, normal platelet count
 Evan’s syndrome: association with ITP
 Bone marrow: erythroid hyperplasia; underlying
lymphoproliferative disorder
 Unconjugated hyperbilirubinaemia
 Haptoglobin levels low
 Urinary urobilinogen usually increased; haemoglobinuria
uncommon

Serological Features
 Direct antiglobulin test (DAT; Coomb's test) usually
positive
 DAT: rabbit antiserum to human IgG or complement
(Coomb's reagent) added to suspensions of washed
RBCs. Agglutination signifies presence of surface IgG
or complement
 RBC may be coated with
IgG alone
IgG and complement
complement only
 Rarely anti-IgA and anti-IgM encountered

Treatment:
 Remove/treat underlying cause
 Corticosteroids - high doses then tapering when PCV stabilizes
 Splenectomy:
 patients who fail to respond to steroids
 unacceptably high doses of steroids to maintain adequate PCV
 unacceptable side-effects
 Transfusion
 Immunosuppressive Drugs:
 Azathioprine
 Cyclophosphamide (CTX)
 Others:
 plasmapheresis
 Intravenous immunoglobulin (IVIG)
 Androgens e.g. danazol

Cold AIHA:
• Two major types of cold antibody:
1) Cold agglutinins
2) Donath-Landsteiner antibodies
 Causes either immediate intravascular destruction of
sensitized RBCs by complement-mediated mechanisms
or sequestration by liver (C3 coated RBCs preferentially
removed here)

Cold Agglutinins:
 IgM autoantibodies that agglutinate RBCs optimally
between 0 to 50C. Complement fixation occurs at
higher temperatures
 Primary - Cold Haemagglutinin Disease (CHAD) or
secondary (usually due to infections)
 Peak incidence for CHAD > 50 years
 Primary usually monoclonal;
 secondary usually polyclonal

Pathogenesis:
 Specificity usually against I/i antigens
 Varying severity depending on:
 titre of antibody in serum
 affinity for RBCs
 ability to bind complement
 thermal amplitude
 Bind red cells in peripheral circulation impeding capillary
flow, producing acrocyanosis

Clinical Features:
 Chronic haemolysis; episodes of acute haemolysis can
occur on chilling
 Acrocyanosis frequent; skin ulceration and necrosis
uncommon
 Mild jaundice and splenomegaly
 Secondary cases e.g. Mycoplasma, self-limited

Laboratory Features:
 Anaemia- mild to moderate
 Blood film:
a) agglutination,
b) spherocytosis less marked than warm AIHA
 DAT +ve: complement only
 Anti-I: idiopathic disease, mycoplasma, some
lymphomas
 Anti-i: infectious mono, lymphomas

Treatment:
 Keep patient warm
 Treat underlying cause
 Alkylating agents: chlorambucil, CTX
 Splenectomy and steroids generally not helpful
 Plasmapheresis- temporary relief
 Transfusion- washed packed cells

Paroxysmal Cold Haemoglobinuria
 Rare form of haemolytic anaemia
 Characterized by recurrent haemolysis following
exposure to cold
 Formerly, more common due to association with syphilis
 Self-limited form occurs in children following viral
infections
 Antibodies usually IgG with specificity for P antigen
 Biphasic:
a) binds to red cells at low temperatures,
b) lysis with complement occurs at 37C

Drug-induced Haemolytic Anaemia
 May cause immune haemolytic anaemia by three
different mechanisms:
1) Neoantigen type e.g. Quinidine
2) Autoimmune mechanism e.g.  - Methyldopa
3) Drug adsorption mechanism e.g. Penicillin

Drug adsorption mechanism
 Also known as hapten mechanism
1) Drug binds tightly to red cell membrane
2) Antibody attaches to drug without direct interaction
with RBC
 Usually seen in patients receiving high doses of
penicillin – substantial coating of RBC with drug
 Small proportion develop anti-penicillin antibody
binds to drug on RBC
 DAT +ve and haemolysis may ensue
 Occurs after 7-10 days of treatment
 Ceases few days to 2 weeks after drug stopped

Neoantigen type
 Formerly known as immune complex / innocent
bystander
 theory suggested drug formed immune complex with
anti-drug antibody
a) attached non-specifically to red cell
b) destruction by complement
 Above interaction required component of red cell
membrane to bind to antigen recognition site on antibody

Autoimmune mechanism
 Antibody binds to red cell membrane antigens
 Alpha-methyldopa responsible for most cases
 DAT becomes +ve in 8-36% of patients taking drug
 However, only 0.8% of patients develop clinical
haemolysis
 Induces auotimmune red cell antibodies by unknown
mechanisms

Non-immune haemolytic
anaemias:
 Non-immune haemolytic anaemias:
Paroxysmal nocturnal haemoglobinuria (PNH)
Red cell fragmentation syndromes
March haemoglobinuria
Infections
Chemical and physical agents
Secondary haemolytic anaemia

Paroxysmal nocturnal
haemoglobinuria (PNH)
 Acquired haemopoietic stem cell disorder
 Characterized by increased sensitivity of red
cells to haemolysis by complement

Pathogenesis:
 Arise as a clonal abnormality of stem cells
 Disorder a consequence of somatic mutations error in
synthesis of the glycosylphosphatidylinositol (GPI) anchor
 Results in deficiencies of several GPI-anchored membrane
proteins –
1) decay accelerating factor (DAF),
2) membrane inhibitor of reactive lysis (MIRL),
3) acetylcholine esterase, leukocyte alkaline phosphatase
(LAP)
 Some of these proteins involved in complement
degradation
 Absence of MIRL plays most critical role

Clinical Features:
 Haemoglobinuria occurs intermittently precipitated
by a variety of events
 Nocturnal haemoglobinuria uncommon
 Chronic haemolytic anaemia which may be severe
 Iron deficiency due to loss in urine
 Bleeding may occur secondary to thrombocytopenia
 Thrombosis a prominent feature

Laboratory Features:
 Pancytopenia
 Anaemia may be severe
 Macrocytosis may be present due to mild
reticulocytosis
 Hypochromic, microcytic due to iron deficiency
 Marrow: erythroid hyperplasia; may be aplastic
 Urine: haemosiderinuria constant feature;
haemoglobin sometimes present
 Ham’s (acidified serum lysis) test positive

Treatment:
 Transfusion of washed packed red cells
 Oral iron
 Folate supplements
 Steroids may be of benefit
 Anticoagulation for thrombotic complications

Red Cell Fragmentation
Syndromes
 Microangiopathic haemolytic anaemia (MAHA)
 Intravascular haemolysis due to fragmentation of normal red cells
passing through abnormal arterioles
 Deposition of platelets and fibrin most common cause of
microvascular lesions
 Red cells adhere to fibrin and are fragmented by force of blood flow
 Underlying disorders:
 Mucin-producing adenocarcinomas
 Complications of pregnancy:
a) Preeclampsia, eclampsia,
b) Haemolysis, Elevated Liver enzymes, Low Platelets (HELLP)
 Disseminated Intravascular Coagulation (DIC)
 Thrombotic Thrombocytopenic Purpura (TTP)/ Haemolytic
Uraemic Syndrome (HUS)
 Malignant hypertension

Laboratory Findings:
 Blood film:
1) schistocytes prominent,
2) spherocytes,
3) reticulocytes,
4) normoblasts
 Thrombocytopenia
 Coagulopathy in DIC

Treatment:
 Treat underlying cause
 2. Traumatic cardiac haemolytic anaemia
 Seen in patients with prosthetic heart valves, cardiac
valvular disorders esp. severe aortic stenosis
 Due to physical damage of red cells from turbulence
and high shear
 stresses
 Haemolytic anaemia usually mild and well
compensated

March Haemoglobinuria
 Due to damage to red cells between small bones of feet
 Usually during prolonged marching or running
 Blood film does not show fragments

Infections
 Cause haemolysis in a variety of ways
 Ppt acute haemolytic crisis in G6PD deficiency
 Cause MAHA e.g. meningococcus
 Direct invasion of red cells by infective organisms e.g.
malaria
 Elaboration of haemolytic toxins e.g. clostridium
 Production of red cell autoantibodies e.g. viral
infections

Chemical and physical agents
 Certain drugs cause oxidative damage in high doses
e.g. dapsone
 Acute haemolytic anaemia due to high levels of Cu e.g.
Wilson’s disease
 Chemical poisoning e.g. Pb, chlorate or arsine may
cause severe haemolysis
 Severe burns
 Snake / spider bites
 Hypophosphataemia

Secondary haemolytic anaemias
 Red survival shortened in many systemic disorders
 Renal failure – ‘burr’ cells
 Liver disease – acanthocytes, target cells
 Zieve’s syndrome – acute haemolytic anaemia with
intravascular haemolysis, hyperlipidaemia and
abdominal pain in alcoholics

Roha Shad
Roll no.-1169

HAEMOLYTIC ANEMIA
inherited acquired
Haemoglobinopathy Membrane
defects
Enzyme
deficiency
Hereditary
spherocytosis
Hereditary
elliptocytosis
Hereditary
stomatocytosis
G6PD
deficiency
PK
deficiency

Common type of
hereditary anemia
Autosomal dominant
inheritance

 Defect in the RBC membrane structural
proteins which anchor the lipid bilayer to the
underlying cytoskeleton.
Spectrin
abnormality
Ankyrin abnormality
α spectrin β spectrin
Severe
anemia
Mild
anemia

Mutation in spectrin and ankyrin result in
unstable RBC membrane
Spherical contour & small sized RBC’s
(microspherocyte)
Non deformable RBC’s, Unable to pass the spleen
Destroyed in spleen
Other structural changes include loss of
surface area and abnormal permeability

 ANEMIA –mild to moderate
 RETICULOCYTOSIS : 5-20%
 BLOOD FILM-presence of spherocytes
 MCV-normal or decreased
 MCHC-increased
 OSMOTIC FRAGILITY TEST-increased fragility
 Direct coomb’s test: negative
 Abnormal cytoskeletal protein analysis.

Anemia-mild to moderate
Splenomegaly-in 75%
patients
Jaundice - unconjugated
type
Pigment Gall stones

 If Hb >10gm/dl &reticulocyte count<10% = no
treatment
 If severe anemia , poor growth, aplastic crisis,age
<2 yrs, then
1. Blood transfusion
2. Folic acid =1-5mg/day
 Splenectomy-prefered when age >6 yrs,severe
hemolysis& high transfusion required.

Autosomal dominant disorder
Involves the
spectrin
Protein-
4.1
Glycophorin C
Clinical presentation – same as of
HS

 Lab tests –
 Blood film – elliptocytes
 RBC mildly heat sensitive
 Abnormal cytoskeletal protein
analysis

TREATMENT
mild type-no treatment
Chronic haemolysis-
transfusion + splenectomy
Folic acid-1mg/dl

 Autosomal dominant disorder
 PATHOGENESIS-
 Defect in membrane protein STOMATIN
 Swollen or hydrated cell(increased Na/K
permeability)
 Abnormal RBC cation and water content.
 CLINICAL FEATURES-mild anemia&
splenomegaly

 Stomatocyte in PBF
 TREATMENT: Folic acid-1mg qd
 Splenectomy ineffective

 X-linked recessive disease
 Cause disease in males and
females are carriers

Bite cells

 Jaundice
 Pallor
 Darkening of urine/
haemoglobinuria
 Spenomegaly
 Weakness
 Self limiting –as affects only old
RBC’s

 DURING PERIOD OF ACUTE HAEMOLYSIS;
 Fall in haematocrit by 25-30%
 Haemoglobinemia
 Decreased plasma level of heptoglobin and
haemopexin.
 PBF-bite cell and polychromasia
 Demonstration of HIENZ BODIES.
 Enzyme assays.

Bite cells

 Supportive care during crisis:
 Hydration
 Monitoring
 Transfusion if needed
 Counseling to avoid intake of
oxidative drugs(sulfonamides,
aspirin NSAIDs, dapsone etc.

 Autosomal recessive disorder
 EMP pathway enzyme-90% of glucose
metabolism.
 PATHOGENESIS-Inability to maintain ATP
Impaired cellular function
Decreased RBC life span

 Normocytic normochromic anemia
 Reticulocytosis
 Increased osmotic fragility
 Pyruvate kinase assay
 TREATMENT:
 If severe anemia with symptoms, poor growth
and age <2yrs=require transfusion
 Folic acid 1mg qd

Hemoglobinopathies
and
Thalassemia

Hemoglobinopathies
HEMOGLOBINOPATHY IS A KIND OF GENETIC DEFECT THAT
RESULTS IN ABNORMAL STRUCTURE OF ONE OF
THE GLOBIN CHAINS OF THE HEMOGLOBIN
MOLECULE. HEMOGLOBINOPATHIES ARE INHERITED SINGLE-
GENE DISORDERS

Hb-A Molecule. Hb-A is the major
adult hemoglobin.(97%)

Normal Human Haemoglobins
Haemoglobin Structural formula
Adult Hb-A 2 2 97%
Hb-A2 2 2 1.5-3.2%
Fetal Hb-F 2 2 0.5-1%
Hb-Bart’s 4
Embryonic Hb-Gower 1 2 2
Hb-Gower 2 2 2
Hb-Portland 2 2

Sickle Cell Disease
(HbS)
 sickle cell anemia is an autosomal recessive
disease that result from the substitution of valin for
glutamic acid at position 6 of beta-globulin chain.
 Patient who are homozygous for the HbS have
sickle cell disease
 Patient who are heterozygous for HbS gene have
sickle cell trait.

Sickle-Cell Disease
Pathophysiology
 Deoxygenation of heme moiety of sickle hemoglobin leads to
hydrophobic interaction between adjacent sickle hemoglobin
that aggregate into larger polymers.
 Sickle red blood cell are less deformable and obstruct the
microcirculation, resulting in hypoxia.
 These red blood cell have a life span of only 10-20 days.

CLINICAL MANIFESTATIONS
and treatment
 Fever and Bacteremia Fever in a child with sickle cell anemia
is a medical emergency, requiring prompt medical evaluation
and delivery of antibiotics due to the increased risk of
bacterial infection and concomitant high fatality rate with
infection
 Treatment antimicrobial therapy to administering a 3rd-
generation cephalosporin.

Dactylitis
Dactylitis , often referred to as hand-foot syndrome, is often the
first manifestation of pain in children with sickle cell anemia
occurring in 50% of children by their 2nd year Dactylitis often
manifests with symmetric or unilateral swelling of the hands
and/or feet.
Treatment Dactylitis requires palliation with pain medications,
such as acetaminophen with codeine, whereas osteomyelitis
requires at least 4-6 week of antibiotics
Splenic Sequestration Acute splenic sequestration is a life-
threatening complication. This is due to sickled cell that block
splenic outflow, leading to pooling of peripheral blood into the
spleen.
Treatment includes early intervention and maintenance of
hemodynamic stability using isotonic fluid or blood transfusions.

Pain The cardinal clinical feature of sickle cell anemia is pain,
that can occur in any part of the body but most often occurs in the
chest, abdomen, or extremities.
The exact etiology of pain is unknown, but the pathogenesis is
initiated when blood flow is disrupted in the microvasculature by
sickle cells, resulting in tissue ischemia. Precipitating causes of
painful episodes can include physical stress, infection,
dehydration, hypoxia, local or systemic acidosis, exposure to
cold.
 The majority of painful episodes in patients with sickle cell
anemia are managed at home with comfort measures, such as
heating blanket, relaxation techniques, massage, and pain
medication(acetaminophen or a nonsteroidal agent)
Lung Disease Lung disease in children with sickle cell anemia is the
second most common reason for admission to the hospital and a
common cause of death. ACS findings include a new radiodensity on
chest radiograph, fever, respiratory distress, and pain that occurs often in
the chest.

common pulmonary complications such as bronchiolitis, asthma,
and pneumonia
TREATMENT
Blood transfusion
Supplemental oxygen
Empirical antibiotics (cephalosporin and macrolide)
Bronchodilators and steroids for patients with asthma
Optimum pain control and fluid management.
Other complication includes.
Kidney Disease
Psychological Complications
Excessive Iron Stores
Neurologic Complications
Priapism
sickle cell retinopathy, delayed onset of puberty, avascular
necrosis of the femoral and humeral heads, and leg ulcers.

Laboratory Diagnosis
 In peripheral smear, sickle-shaped red blood cell are found.
 Anemia and thrombocytopenia
 Leukocytosis
 Rise in WBC count more than 20000
with a left shift indicative of infection
 If diagnosis of sickle cell anemia
Has not been made sickling test will
Establish the presence of sickle cell
Anemia.
 Hemoglobin electrophoresis can differentiate between
homozygous(80-90% HbSS) and heterozygous(35-40% HbSS)

Preventive care
 All children require prophylaxis with penicillin or amoxicillin up to 5 year of
age
 Immunization with pneumococcal, meningococcal and hemophillus
influenzae B vaccine
 Life long folate supplementation
 Regularly screening for development of gall stone
 Genetic counseling and testing should be offered to family.

Thalassemia Syndromes
• Hereditary disorders that can result in moderate to severe
anemia
• Basic defect is reduced production of selected globin chains
.

There are two basic groups of thalassaemia.
 thalassemia: There are four types categorized according to the
severity of their effects on persons with thalassemia.
ß thalassemia: There are 3 types categorized according to severity
 Thalassemia minor
 Thalassemia intermedia
 Thalassemia major
Types of Thalassemia

α-Thalassemia
 An absence or deficiency of α-chain synthesis due to deletion of α-genes.
 Predominant cause of alpha thalassemia is large number of gene deletions in
the α-globin genes on chromosome no. 16
 There are four clinical syndromes present in alpha thalassemia:
 Silent Carrier State
 Alpha Thalassemia Trait (Alpha Thalassemia Minor)
 Hemoglobin H Disease
 Bart's Hydrops Fetalis Syndrome

Variants of α-Thalassemia
Silent carrier
Deletion of single α-gene
Genotype α-/αα
Asymptomatic
Absence of RBC abnormality
Can only be detected by DNA studies.
Thalassemia trait
Also called Alpha Thalassemia Minor.
Deletion of 2 α-genes
Genotype --/αα or -/-
Asymptomatic, minimal or no anemia
Minimal RBC abnormalities

 Second most severe form alpha thalassemia.
Deletion of 3 α-genes
Genotype --/- α
75% reduction of α-chain
Only 25% α-chain synthesis small amount of HbF, HbA, & HbA2
Fetus can survive
Severe anemia
Severe RBC abnormalities
RBCs are microcytic, hypochromic with marked poikilocytosis
Hemoglobin H Disease

Most severe form. Incompatible with life. Have no functioning α chain
genes (- -/- -).
Baby born with hydrops fetalis, which is edema and ascites caused by
accumulation serous fluid in fetal tissues as result of severe anemia. Also
we will see hepatosplenomegaly and cardiomegaly.
Bart’s Hydrops Fetalis Syndrome

β Thalassemia
 The molecular defects in β thalassemia result in the absence or
varying reduction (according to the type of mutation) in β chain
production.
 In individuals with beta thalassemia, there is either a complete
absence of β globin production ( β-thalassemia major) or a
partial reduction in β globin production ( β-thalassemia minor).
An absence or deficiency of β-chain synthesis of
adult HbA.

Silent carrier state - the mildest form of beta thalassemia.
Beta thalassemia minor - heterozygous disorder resulting in
mild hypochromic, microcytic hemolytic anemia.
Beta thalassemia intermedia - Severity lies between the
minor and major.
Beta thalassemia major - homozygous disorder resulting in
severe transfusion-dependent hemolytic anemia.

Beta Thalassemia Minor
 Caused by heterogeneous mutations that affect beta globin synthesis.
 Usually presents as mild, asymptomatic hemolytic anemia unless
patient in under stress such as infection or folic acid deficiency.
 Have one normal beta gene and one mutated beta gene.
 Anemia usually hypochromic and microcytic
 Normally require no treatment

Beta Thalassemia Intermedia
 Expression of disorder falls between thalassemia minor and
thalassemia major. May be either heterozygous for mutations
causing mild decrease in beta chain production, or may be
homozygous causing a more serious reduction in beta chain
production.
 Have varying symptoms of anemia, jaundice, splenomegaly and
hepatomegaly.
 Have significant increase in bilirubin levels.
 Anemia usually becomes worse with infections folic acid
deficiencies.

Beta Thalassemia Major
 Characterized by severe microcytic, hypochromic anemia.
 Detected early in childhood:
 Infants fail to thrive.
 Have pallor, variable degree of jaundice, abdominal enlargement, and
hepatosplenomegaly.
 Hemoglobin level between 4 and 8 gm/dL.
 Severe anemia causes marked bone changes due to expansion of marrow
space for increased erythropoiesis.
 Peripheral blood shows markedly hypochromic, microcytic erythrocytes
with extreme poikilocytosis

Laboratory study
 Complete blood count and peripheral blood film exam. Are usually
sufficient to confirm the diagnosis
 Hb level range from 2-8 gm/dL
 MCV and MCH are significantly low
 Reliculocyte count elevated 5-8%
 Leukocytosis
 In PBF marked hypochromasia & microcytosis, polychromatophillic cell,
nucleated red blood cell
 HPCL (high performance liquid chromatography) confirms the diagnosis

Complication
 Iron overload: People with thalassemia can get an overload of iron in their
bodies, either from the disease itself or from frequent blood transfusions.
Too much iron can result in damage to the heart, liver and endocrine
system, The damage is characterized by excessive deposits of iron.
Without adequate iron chelation therapy, almost all patients with beta-
thalassemia will accumulate potentially fatal iron levels.
 bone deformities: Thalassemia can make the bone marrow expand, which
causes bones to widen. This can result in abnormal bone structure,
especially in the face and skull. Bone marrow expansion also makes
bones thin and brittle, increasing the risk of broken bones

thalassemic facies (maxilla
hyperplasia, flat nasal
bridge, frontal bossing)
Hair on End Appearance
Bone deformities

Splenomegaly Thalassemia is often accompanied by the destruction of a
large number of red blood cells and the task of removing these cells causes the
spleen to enlarge. Splenomegaly can make anemia worse, and it can reduce
the life of transfused red blood cells. Severe enlargement of the spleen may
necessitate its removal.
•Slowed growth rates: anemia can cause a child's growth to slow. Puberty
also may be delayed in children with thalassemia.
•Heart problems: such as congestive heart failure and arrhythmias may be
associated with severe thalassemia.
• Infection
• Extra-medullary hematopoiesis
• Psychological complication

Management
 Hematopoietic stem cell transplantation- it is the only known treatment
for thalassemia, however this option is available only to a relatively small no.
of patient.
 Blood transfusion- blood transfusion should be initiated at an early age
attempt should made to keep Hb lavel to 9-10 g/dL
 Chelation therapy- to overcome iron overload and iron toxicity. The
optimal time for therapy is 1-2 year of transfusion when ferratin lavel is about
1000-1500 µg/L
Deferoxime a total dose of 40-60mg/kg/day is infused over 8-12 hrs over night for
5-6 day a week by mechanical pump.

Deferiporone 75mg/day may be used as oral chelating agent
Hydroxyurea in dose of 15-20 mg/kg/day used to increase HbF
production and reduce the need of transfusion support

Thank you