Dr Sarath Menon presents an approach to diagnosing and classifying hemolytic anemia. Hemolytic anemia results from increased red blood cell destruction and bone marrow compensation. It can be congenital/hereditary or acquired. Classification includes intracorpuscular defects like hemoglobinopathies and enzymopathies, and extracorpuscular factors like mechanical destruction, toxic agents, infections, and autoimmune causes. Diagnosis involves confirming hemolysis and determining the etiology through history, physical exam, peripheral smear, and ancillary lab tests. Common etiologies discussed in detail include sickle cell disease, thalassemia, G6PD deficiency, membrane defects like hereditary spherocytosis, and autoimmune

1. APPROACH TO HEMOLYTIC ANEMIA
Candidate: Dr SARATH MENON.R
K.B.ILLAVA HEMATOLOGY DIVISION
DEPT.MEDICINE,
MGM MEDICAL COLLEGE,INDORE

2. OBJECTIVES
 Lab indication of hemolysis
 Intravascular v/s extravascular hemolysis
 D/D of hemolytic anemia
 Diagnose hemo.anemia with peripheral smear &
ancillary lab tests

3. HEMOLYTIC ANEMIA
 Definition:
 Those anemias which result from an increase in RBC
destruction coupled with increased erythropoiesis
 Classification:
 Congenital / Hereditary
 Acquired

4. 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

5. CLASSIFICATION
 MAHA
 Transfusion rx
 PNH
 Infections
 Snake bite
 Hemoglobinopathies
 Enzymopathies
 Membrane defects
 AIHA
Intravascular hemolysis Extravascular hemolysis

6. HOW IS HEMOLYTIC ANEMIA DIAGNOSED?
Two main principles
 One is to confirm that it is hemolysis
 Two is to determine the etiology

7. HOW TO DIAGNOSE HEMOLYTIC ANEMIA
 New onset pallor or anemia
 Jaundice
 Splenomegaly
 Gall stones
 Dark colored urine
 Leg ulcers

8. 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

9. HEMOLYTIC FACIES- CHIPMUNK FACIES

10. 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
+
+
+ severe cases

11. POLYCHROMATOPHILIC CELLS

12. THE KEY TO THE ETIOLOGY OF
HEMOLYTIC ANEMIA
The history
The peripheral blood film

13. PATIENT HISTORY
 Acute or chronic
 Medication/Drug precipitants
G6PD
AIHA
 Family history
 Concomitant medical illnesses
 Clinical presentation

14. 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%

15. PERIPHERAL SMEAR

16. WHAT IS THE DIAGNOSIS ?
 SICKLE CELL ANEMIA

17. DIAGNOSIS – OTHER TESTS
 Hemoglobin electrophoresis
-HbS >80%
-HbF -1-20%
-HbA2 -2- 4.5%
 Sickling test POSITIVE

18. 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

19. CLINICAL MANIFESTATIONS
 Hemo.anemia,reticulocytosis,granulocytosis
 Vasoocclusion-protean
 Painful crises
 Splenic sequestration crises
 Hand foot syndrome
 Acute chest syndrome

20. DIAGNOSIS?
SICKLE THALASSEMIA`

21. 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,gal
lstones,
priapism
7-10 80-100 HbS/A:100/0
HbF;2-25%
S/beta0
thalasssemia
Vasoocclusive
Crises,AVN
7-10 60-80 HbS/A-100/0
HbF; 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;50/0
HbC;50%

22. 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 +

23. DIAGNOSIS?

24. TARGET CELLS

25. THALASSEMIA
 Other diagnosis test-Hb electrophoresis
 DNA analysis for mutations
 Alpha thalassemia & beta thalassemia
 Beta thalassemia- major
- intermedia
- minor

26. BETA THALASSEMIA
 Mutn. Beta globin expression
 M.C- derange splicing of m-RNA
 HYPOCHROMIA ,MICROCYTIC anemia

27. 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 %

28. 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%

29. 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%

30. 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

31. 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

32. BLISTER CELLS

33. HEINZ BODIES

34. 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

35.  Clinical Features:
 Acute hemolysis:
Drugs,infections,asso with diabetic acidosis
 Favism
 Neonatal jaundice
 Congenital nonspherocytic hemolytic anemia

36. Definitive risk Possible risk Doubtful risk
antimalarials Primaquine
Dapsone
cholrproguanil
chloroquine quinine
Sulphonamides/
sulphones
Sulphametoxazole
Dapsone
Sulfasalazine
Sulfadimidine
Sulfisoxazole
Sulfadiazine
Antibacterials/
Antibiotics
Cotrimoxazole
Nalidixic acid
Nitrofurantoin
Ciprofloxacin
Norfloxacin
Cholramphenicol
p-Aminosalicylic
acid
Antipyretic/
Analgesics
Acetanilide
Phenazopyridine
[pyridium]
Acetylsalicylic acid
High dose[>3g/d]
Acetylsalicylic acid
[<3g/d]
Acetaminophen

37. 2. Pyruvate Kinase Deficiency
 AR
 Deficient ATP production, Chronic hemolytic
anemia
 Clinical features
o hydrops fetalis
o neonatal jaundice
o compensated hemolytic anemia
 Inv;
P. Smear: PRICKLE CELLS ( Contracted rbc with
spicules)
Decreased enzyme activity

38. PRICKLE CELL

39. 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-

41. DIFFERENTIAL DIAGNOSIS
 Hereditary spherocytosis
 Autoimmune hemolytic anemia
 Other diagnostic tests- osmotic fragility
- coombs test

42. 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

43.  C/F:
Pallor
Jaundice
Splenomegaly
Pigmented gall stones- 50%

44. COMPLICATIONS
 Clinical course may be complicated with Crisis:
 Hemolytic Crisis: associated with infection
 Aplastic crisis: associated with Parvovirus infection

45.  Inv:
 Test will confirm Hemolysis
 P Smear: Spherocytes
 Osmotic Fragility: Increased
 Screen family members

46. 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

47. 1.Warm AI Hemolysis:
 Can occurs at all age groups
 F > M
 Causes:
50% Idiopathic
Rest - secondary causes:
1.Lymphoid neoplasm: CLL, Lymphoma,
Myeloma
2.Solid Tumors: Lung, Colon, Kidney, Ovary,
Thymoma
3.CTD: SLE,RA
4.Drugs: Alpha methyl DOPA, Penicillin ,
Quinine, Chloroquine
5. UC, HIV

48.  Inv:
 hemolysis, MCV decreased
 P Smear: microspherocytosis,
 Confirmation: Direct Coomb’s Test / Antiglobulin test

50. • 2. Cold AI Hemolysis
Usually Ig M directed at the RBC I antigen
 Infection: Mycoplasma pneumonia, Infec Mononucleosis
 Neoplasms : waldenstrom macroglobulinemia ,
lymphoma,CLL,kaposi sarcoma, myeloma.
C/F:
Elderly patients
Exacerbations in the winter
Cold , painful & often blue fingers, toes,
ears, or nose ( Acrocyanosis)

51. Inv:
 e/o hemolysis
 P Smear: Microspherocytosis
 DAT positive with polyspecific and anticompliment antisera

52. 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?

54. 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

55. 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 –

56. MICROANGIOPATHIC HEMOLYTIC ANEMIA

57. NON-IMMUNE ACQUIRED HEMOLYTIC
ANEMIA
1. 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: burns
D). 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

58. MICROANGIOPATHIC HEMOLYTIC
ANEMIA(MAHA)
 Other findings - leukocytosis
- thrombocytopenia(DIC,TTP)
- hemoglobinuria
- deranged RFT
- PT,APTT prolonged
(DIC,TTP)

59. ACQUIRED HEMOLYSIS
Infection
F. malaria: intravascular hemolysis: severe called
‘Blackwater fever’
Cl. perfringens septicemia
Chemical/Drugs: oxidant denaturation of hemoglobin
Eg: Dapsone, sulphasalazine, Arsenic gas, Cu,
Nitrates & Nitrobenzene

60. PERIPHERAL BLOOD SMEAR
 Spherocytes
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

62. CONCLUSION
 Hemolytic anemia can be recogised by clinical
picture-
- history & physical
- lab test to confirm hemolysis
- peripheral smear to guide further
tests

63. THANK YOU