Dr Shwe Sin

FMHS
Universiti Tunku Abdul Rahman
By the end of the lesson, the students
should be able to :
Describe the definition and classification of
haemolytic anaemias.
Describe the pathogenesis, clinical features and
laboratory diagnosis of common haemolytic anaemia
(e.g Hereditary spherocytosis, G6PD deficiency etc).
State the general evidence of haemolysis.
Hemolytic Anaemia
Definiton:
Anaemia resulting from increase in the rate of red cell
destruction & shortening of red cell life span.
The life span of normal red cell is 100- 120 days; in
haemolytic anaemia it is shortened by varying degrees & in
very severe cases, may be only a few days
Characterized by (1) increased rate of red cell destruction
(2) a compensatory increased in erythropoiesis in bone
marrow that result in reticulocytosis (3) the retention by
the body of products of red cell destruction (including
iron)
Caused by either intracorpuscular defect or
extracorpuscular defect
Sites of hemolysis:

Intravascular Destruction within the vascular

compartment Release of free Hb Hburia

Extravascular Destruction within the cells of

mononuclear phagocyte (reticuloendothelial) system
increased serum bilirubin and no free Hb in plasma
Extravascular Vs Intravascular Haemolysis
CLASSIFICATION OF HAEMOLYTIC
ANAEMIAS
HEREDITARY:
(i) Membrane defects:
a. Hereditary spherocytosis
b. Hereditary elliptocytosis
(ii) Hemoglobin defects:
a. Hemoglobinopathies
Sickle cell anaemia
Other homozygous disorders (Hb C, Hb E,
Hb D etc)
Unstable Hb disease
 b.Thalassaemia:
thalassaemia
thalassaemia
c.Double heterozygous disorder
Sickle cell thalassaemia etc.
(iii) Metabolism:
i. Due to deficiency of pyruvate kinase enzymes
ii. Due to deficiency of G6PD (Glucose-6 phosphate
dehydrogenase) enzymes
ACQUIRED:
I. Immune mechanisms:
1. Auto -immune
a. Warm Antibody type
b. Cold Antibody type
2. Alloimmune
a. Hemolytic transfusion reaction
b. Haemolytic disease of the newborn
c. Allografts, especially stem cell transplantation
3. Drug associated hemolytic anaemia
II. Mechanical haemolytic anaemia:
a. Cardiac hemolysis
b. Arteriovenous malformations
c. Microangiopathic haemolytic anaemias (MAHA)
d. March haemoglobinuria
III. Infections: Malaria, Clostridia
IV. Chemical and physical agents: Especially drugs,
industrial/ domestic substances, burns
V. Secondary: Liver and renal disease
VI. Paroxysmal nocturnal haemoglobinuria (P.N.H)
 HEREDITARY HAEMOLYTIC
ANAEMIAS
MEMBRANE DEFECTS
HEREDITARY SPHEROCYTOSIS
It is congenital & example of membrane defect
Caused by deficiency of Ankyrin, or -Spectrin, Band 3
protein and Pallidin (protein 4.2) proteins of red cell
membrane
These proteins are responsible for the normal shape,
strength and flexibility of red cells
Reduced membrane stability and reduction in surface area
spherical in shape unable to pass through the splenic
circulation where they die prematurely in spleen (these
spherocytes are sequestered in the splenic cords and
destroyed by splenic macrophages)
Red cell membrane proteins
Clinical Features:
Anaemia
Splenomegaly
Jaundice
Cholelithiasis (Pigment gall stones) occurs in 4050 %
of patients
Haematological findings:
Hb %- reduced
Shape microspherocytes
Reticulocyte count increased usually 5- 20%
Investigations:
Osmotic fragility test -showed excessively fragile of
red cells in dilute saline solution resulting increased
osmotic fragility test
Treatment:
Splenectomy is beneficial but increased risk of infections
particularly in children
Osmotic Fragility Test

Normal

HS
HEREDITARY ELLIPTOCYTOSIS
Similar clinical and laboratory features to HS except
for the appearance of blood film (elliptocytes can be
seen)
Usually mild disorder

SOUTH EAST ASIAN OVALOCYTOSIS

Common in Melanesia, Malaysia, Indonesia and
Philippines
Most cases are asymptomatic
 Defective Red Cell Metabolism
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Sex-linked inheritance, so males are affected
Example of enzyme defect, some resistant to Falciparum malaria
G6PD needed to produce glutathione(GSH) and protect the cells
from oxidant stress
Reduced level of glutathione (GSH) leading to reduced the ability of
red cells to protect themselves from oxidative injury and resulting
haemolytic anaemia
Because of reduced GSH, oxidized Hb denatures and precipitate
forming intracellular inclusions called Heinz bodies which can
damage the red cell membrane and causing haemolysis
 There are > 400 variants
G6PD A+ - G6PD Mediterranean
G6PD A- - common in Africans
G6PD B+ - common in Western

Clinical features: G6PD deficiency produce no symptoms until

the patient exposed to an environmental factors.
(1) Acute haemolytic anaemia in response to oxidant stress e.g
drugs (primaquine, sulphonamides etc), fava beans or infections.
- darkening of urine (Haemoglobinuria)
(2) Neonatal jaundice
(3) Rarely, congenital non-spherocytic haemolytic anaemia
Haematological findings:
Between crisis : the blood count is normal
During haemolytic crisis contracted and fragmented cells,
bite cells and blister cells with Heinz bodies (oxidized
denatured Hb)
Laboratory detection:
Screening tests
Enzyme Assay
Diagnosis:
Clinically suspected, screening test if possible and enzyme
assay
G6PD deficiency
Heinz bodies

Bite Cell
Pyruvate kinase deficiency
Autosomal recessive
Relative mild symptoms
Anaemia, jaundice and gall stone frequent
Direct enzyme assay is needed
 ACQUIRED HAEMOLYTIC
ANAEMIAS
AUTOIMMUNE HEMOLYTIC ANAEMIA (AIHA)
Due to antibody production by the body against own
red cells (auto antibodies)
Characterized by positive antiglobulin test (Coombs
test)
Antibodies on red cell surface- Direct Coombs
(antiglobulin) test positive
Antibodies in serum Indirect Coombs (antiglobulin)
test positive
 I. Warm autoimmune haemolytic
anaemias
Red cells are coated with antibody IgG alone or with
complement and they are active at 37. C
Red cell destruction occurs more generally in RE
system
Causes:
Primary : Idiopathic
Secondary : B-cell lymphoid neoplasm (e.g CLL),
autoimmune disorders (e.g SLE), drugs (e.g
methyldopa, penicillin)
 II. Cold autoimmune haemolytic
anaemias
Due to autoantibody which attaches to red cells where
the blood temperature is cooled (4.C)
Antibody is usually IgM
Usual affected sites are ears, toes and hands
Causes:
Acute : Mycoplasma infection, infectious
mononucleosis
Chronic : Idiopathic, B-cell lymphoid neoplasm
 ALLOIMMUNE HAEMOLYTIC ANAEMIAS
Caused by antibody produced by on individual react
with red cell of another
Two important situations are ABO-incompatible blood
and Rh disease of newborn
Occur in allogenic transplantation due to production
of red cell antibody in the recipient by donor
lymphocytes
DRUG-INDUCED HEMOLYTIC ANAEMIAS
1. Antibody directed against a drug-red cell membrane
complex (Penicillin, Ampicillin)
2. Deposition of complement (Quinidine, Rifampicin)
3. A true autoimmune haemolytic anaemia
(Methyldopa)
Mechanical haemolytic anaemias
Results from mechanical trauma and physical damage to red
cells
Examples Cardiac haemolytic anaemia (caused by abnormal
surfaces e.g artificial heart valves, arteriovenous malformations
because of forming turbulent flow of blood)
- Microangiopathic haemolytic anaemia (MAHA) (seen in DIC,
malignant hypertension, SLE, thrombotic thrombocytopenic
purpura (TTP), haemolytic uraemic syndrome (HUS) and
disseminated cancer)
- March haemoglobinuria (caused by damage to red cells
between the small bones of the feet during prolong marching or
running)
Characteristically, morphologic alteration of injured red cells
(schistocytes) can be seen ; such as burr cells, helmet cells and
triangle cells
Mechanical haemolytic anaemias showing
schistocytes
HEMOLYTIC ANAEMIA DUE TO INFECTIONS
MALARIA
Caused by one of four types of protozoa
- Plasmodium falciparum
- Plasmodium vivax
- Plasmodium malariae
- Plasmodium ovale
The parasite destroys large numbers of red cells and
thus cause hemolytic anaemia
PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA
(PNH)
It is an acquired membrane defect secondary to a
mutation that affects myeloid stem cells
Rare disorder
Due to deficient synthesis of
Glycosylphosphatidylinositol (GPI) resulting absent of
GPI-linked proteins (CD55 and CD59) leading to
defect in red cell membrane causes Complement
mediated lysis because these CD55 and CD59 protects
cell lysis
Platelet and WBC functions are also affected
 GENERAL EVIDENCE OF
HAEMOLYSIS
I. EVIDENCE OF INCREASED Hb BREAKDOWN
1. Hyperbilirubinaemia & jaundice
2. Plasma haptoglobin- Reduced
Hb molecules are small and can pass through normal glomerulus
but when combine with haptoglobin (reduced glycoprotein)
becomes larger molecular size of complex and prevent passage.
3. Plasma hemopexin- Reduced
4. Plasma LDH: Moderately increased
5. Haeglobinaemia, Hemoglobinuria, hemosiderinuria
(Intravascular hemolysis)
6. Urinary and fecal urobilinogen- increased
II. EVIDENCE OF COMPENSATORY ERYTHROID
HYPERPLASIA
1. Reticulosis: It may be used as an index of RBC
production
2. Nucleated RBC (Normoblast)
3. Hyperplasia of bone marrow
4. Skeletal Radiological abnormalities- Occur due to
marrow hyperplasia
III. EVIDENCE OF RED CELL DAMAGE
1. Spherocytosis
2. Fragmentation (Schistocytes)- Seen in mechanical
haemolytic anaemia, cardiac haemolytic anemia and
microangiopathic haemolytic anaemia
3. Heinz bodies (denatured globin)- Seen as small
round inclusion beneath the cell membrane
IV. DEMONSTRATION OF SHORTENED RED CELL
LIFE SPAN
Can be done
 References
Essential Haematology (A.V Hoffbrand and P.A.H
Moss), 6th Edition
Robbins Basic Pathology, 9th Edition