ASPEK KLINIS ANEMIA

DAN HEMOLISIS

dr Erlina Marfianti, MSc, SpPD

Dept Ilmu Penyakit Dalam FK UII

DEFINITION
Normally defined as haemoglobin concent less than :
13. g/dl in adult male
12. g/dl in adult female
11. g/dl in pregnance women
Children : Newborn Hb 15-21 g/dl
3 month Hb 9.5-12.5 g/dl
1 year-puberty Hb 11.0-13.5 g/dl

Subtances needed for

erythropoiesis
Metal : Fe, Mg, Co
Vitamins : B1, B6, B12,
riboflavin, panthothenic
acid, Folate, Vit C, Vit E
Amino acids
Hormones: erythropoietin,
androgens, thyroxine

Main function Hb :
Carry oxygen the
tissue
Return carbon dioxide
(CO2) from the tissue
to the lung.

A. Classification of anemia based on

functional defect / Pathofisiologic :

I. Hemorrhage (Blood loss):

a. acute post acute
hemorrhage hipovolemia
b. chronic Iron
DeficiencyAnemia

II. Increase destruction RBC

1. Hemolytic Intrinsic Anemia /Intracorpuscular

a. Herediter:
Defect of red cell cytosceleton
membranhereditary spherocytosis
,eliptocytosis
metabolic defect /enzyme deficiency
G6PD, Piruvat Kinase deficiency
Defect of globin synthesis/globin
struc. abnormality :thalassemia,
hemoglobinopathi: sickle cell
anemia,HbC, HbE,

2. Ekstracorpuscular/Hemolytic Extrinsic
Anemia.
a. Immun Hemolytic Anemia
Iso/Allo Immun Hemolytic:
- HDN (Hemolytic Disease of The Newborn),
- hemolytic transfusion reaction
Auto immun Hemolytic Anemia (AIHA)
Drug Induced Immun Hemolytic Anemia
viral infection : mycoplasma, mononucl inf
b. Non Immun Hemolytic Anemia
mechanical: artificial valve dysfunction,
MAHA (Microangiopathic Hemolytic Anemia)
chemical, burn
parasitic infection : malaria

III. Failure in RBC production /

hipoproliferatif:
1. EPO production / response to EPO
chronic inflamation and renal disease,
endocrin disease.
2. Marrow damage
Stem cell proliferation & differentiation
failure hipoplastic, aplastic
3. Bone marrow replacement:
* fibrosis,
* infiltration (lekemia, limfoma),
* metastatic neoplasm

IV. Maturation defect/maturation

disorder
1. Cytoplasmic maturation defect
Abnormal globin development
thalassemia
Abnormal iron metabolism: Iron def An,
ACD
Abn porphyrin synthesis An.
sideroblastik
2. Abnormal nuclear development :
Vit B12 deficiency
folic acid deficiency

Klasifikasi morfologi

A. mikrositik hipokromik
A. normositik normokromik
A. Makrositik

Anemia
Defek fungsional
Destruksi
Hemolitik

Defek maturasi
Blood Loss:
Kronik
Akut

Inti : A. Megaloblastik
Sitoplasma :
- Fe : A..Def Besi
- Heme:A.Sideroblastik
- Globin:
* Thalassemia
* Hb Pati

Extrapusculer
Intracorpusculer

Herediter
Imun
HDN
Reaksi
transfusi
AIHA
Drug induce
Infeksi virus

Non Imun
H.mekanis:
disfungsi
katub, MAHA
Bahan kimia,
luka bakar
Inf.parasit:
malaria

Defek struktur globin:

-Kuantitas: thalassemia
-Kualitas:
sickle cell,
Hb-pati
Defek membran:
sferositosis hered,
elliptositosis hered.
Defek enzim: def.G6PD,
piruvat kinase

Hipoproliferatif
- Peny. Ss tulang
Intrinsik : aplastik
Infiltasi: lekemia
-Peny. Kronis
-Peny. Endokrin
-Peny. Ginjal

Didapat
Defek
membran
erits: PNH

Classification of anaemia

MORPHOLOGY
Morphologic classification of anemia according to RBC
count, size & Hb content.

Manual /
Automatic Cell
Counter
Direct examination of red
cell morphology in a
stained blood film

The components of the CBC

also help in the classification
of anemia. Microcytic is
reflected by a lower than
normal MCV (<80), whereas
high values (>100) reflect
macrocytic. The MCH and
MCHC reflect defects in
hemoglobin synthesis
(hypochromia).

Measurement of :
Hb, RBC count, Hct , MCV,MCH,MCHC

MCV : Mean Corpuscular Volume: Is the average

volume of the RBC, ex pressed in FL (10-15/L) &
calculated as follows
Hct (%)
MCV =

x 10 (Normal 81-100 fL/m3)

RBC count (x 106/L)

MCH : Mean Corpuscular Haemoglobin: is the average

weight of Hb in an each RBC, expressed in
picogram/10-12g
Hb (gm/dl)
MCH =

x 10 (Normal 26-34 pg)

RBC count (x 106/L)

MCHC : Mean Corpusc Haemoglobin Conctr

is the average concentration of Hb
Hb (gm/dl)
MCHC =
x 100% (Normal 31- 36%)
Hmt (%)

MACROCYTIC NORMOCHROMIC ANEMIA

RBC size > 8 m
normal Hb content
RBC count relatively low compared to Hb
MCV & MCH, normal MCHC.
* Macrocytosis associated with a megaloblastic
marrow
(marrow erythroid precursor with morphologic
abnormality, increase in size )
vit B12, folic acid deficiensy + reticulocytosis
* Macrocytosis associated with a normoblastic
marrow:
* hemorrhagic & hemolysis
*def. folic acid/vit B12

ANEMIA NORMOCYTIC NORMOCHROMIC

- Low Hb
- Normal MCV / MCH/ MCHC
- Acute hemorrhage
Anemia with appropriate
marrow response
- Hemolytic anemia
- Disturbed iron utilization

Anemia of chronic disorders (ADC)

- B.Marrow disease:Intrinsic or infiltration
Aplastic An., metastatic,
lekemia, lymphoma, myeloma
- Decreased erythropoietin drive

- chronic renal failure

- endocrin disorders

Anemia with
inadequate
marrow
response

ANEMIA MIKROCYTIC HYPOCHROMIC

Inadequat Hb formation
RBC count relatively high compare with [Hb]
low MCV & MCH, MCHC
Blood film : Impaired Hb content
RBC size <6 um & increased pallor areal :

- Iron deficiency Anemia

- Hereditary defect of Hb synthesis : Thalassemia & Hb pathi
ACD & Renal Failure
-Sideroblastic Anemia

Normal Blood

Normocytic - normochromic

CLINICAL PRESENTATION OF
ANEMIA
1. Mild
2. Moderate
3. Several

Table 61-1. Laboratory Tests in Anemia

Diagnosis
I. Complete blood count (CBC)
A. Red blood cell count
1. Hemoglobin
2. Hematocrit
B. Red blood cell indices
1. Mean cell volume (MCV)
2. Mean cell hemoglobin (MCH)
3. Mean cell hemoglobin concentration
(MCHC)
4. Red cell distribution width (RDW)
C. White blood cell count
1. Cell differential
2. Nuclear segmentation of neutrophils
D. Platelet count

E. Cell morphology
1. Cell size
2. Hemoglobin content
3. Anisocytosis
4. Poikilocytosis
5. Polychromasia

II. Reticulocyte count

III. Iron supply studies

1. Serum iron
2. Total iron-binding capacity
3. Serum ferritin, marrow iron stain

IV. Marrow examination

A. Aspirate
1. E/G ratioa
2. Cell morphology
3. Iron stain
B. Biopsy
1. Cellularity
2. Morphology

Approach to the Patient

Sign and Simptoms
Such as bleeding
Fatique
Malaiese
Fever
Weight loss
Sistemic symptoms
blood in the stool,
lymphadenopathy,
splenomegaly
petechiae.

Iron Deficiency Anaemia

microcytic hypochromic anaemia
Ferrum = a constituent of hemoglobin
The aims in treating iron deficiency
anaemia :
* To remove the cause
* To increase red cell mass by
giving iron

Causes of Iron Deficiency Anaemia

1. Chronic blood loss
* Gastrointestinal
- Disease of the GI tract (i.e. peptic ulcer,
carcinoma of the large bowel, intestinal
parasites)
- Drug induced ( i.e. aspirin , other NSAID)
- Menstrual (over 80 ml/cycle = 45 mg iron)
- Recurrent haemoptysis ( i.e. vascular
abnormalities, pulmonary haemosiderosis)

2. Increased requirements
Pregnancy
Treatment of
megaloblastic anaemia
3. Malabsorption
Malabsorption syndromes
Post gastrectomy
4. Dietary deficiency

Table 105-1. Body Iron Distribution

Hemoglobin

Iron Content, mg
Adult Male (80
Adult Female (60
kg)
kg)
2500
1700

Myoglobin/enzy
mes

500

300

Transferrin iron

600-1000

0-300

Iron stores

Table 105-4. Diagnosis of Microcytic Anemia

Tests

Iron
Inflammatio Thalassemia
Deficiency n

Sideroblastic
Anemia

Smear

Micro/hyp Normal
o
micro/hypo

Micro/hypo
with
targeting

Variable

SI

<30

<50

Normal to
high

Normal to
high

TIBC

>360

<300

Normal

Normal

Percent
saturation

<10

10-20

30-80

30-80

Ferritin (mg/L)

<15

30-200

50-300

50-300

Hemoglobin
pattern

Normal

Normal

Abnormal

Normal

NOTE: SI, serum iron; TIBC, total iron-binding capacity

TREATMENT:
1. Suplement Fe oral
2. Fe Parenteral

Megaloblastic Anemia

The cell proliferation are needed an adequate folate and vitamin B12.
Folate = efficient thymidilate synthesis and production of DNA.
B12 = incorporate circulating folic acid into developing RBCs and retaining the
folate in the RBC.
Lack of folate or B12 decreased dTTP synthesis a slowing of DNA
synthesis.

Anemia :
history and symptoms

Tired
pallor
infections
slow growth
pica (eating stones, mud, paper)
ask for:
diet (enough and good food?)
family history (hereditary disease?)

Etiology Megaloblastic anemia

Malabsorbsi
Gastrointestinal disease
Malnutrition
Inadekuat intake

What about the food?

Does it contain meat, fish, egg,
vegetables?
Contain iron

Does it contain fruit/juice?

Vit C doubles iron absorption

Does child drink tea often?

Tea halves iron absorption

Does child drink cows milk?

Can induce allergy and less resorption

Special attention points for

doctors :
General well being
nutritional status
sick or not? tachycardia?

pallor, icterus
icterus may point to hemolysis

spleen, liver
enlargement spleen: hemolysis?
enlargement spleen+liver: malignant?

lymph nodes
general enlargement: leukemia?

Nutritional anemia
Iron deficiency
microcytic
iron is needed for Hb production, so absence
causes low Hb and therefore small cells

Vit B12 or Folic acid

megaloblastic
B12 and F are needed for cell division, so
absence causes low Ery count and large cells

Screening tests
1. CBC :
MCV 100-150 fL range (>120 fL)
RDW
Morphologic: oval macrocytes and
hypersegmented neutrophils (the cause is
not understood)

The peripheral blood reveals a pancytopenia

(decreased RBCs, white cells, and platelets),
hypersegmented neutrophils (> five lobes), and
oval macrocytes.

Aplastic Anemia
bone marrow produces too few of all three types
of blood cells: red blood cells, white blood cells,
and platelets.

A reduced number of red blood cells causes

hemoglobin to drop. A reduced number of white
blood cells makes the patient susceptible to
infection. And, a reduced number of platelets
causes the blood not to clot as easily.

Clinically and Diagnostic

pancytopenia - decreased numbers of
erythrocytes, leukocytes, and platelets in the
peripheral blood. anemia syndrome, infection,
hemorhage.

Aplasia must be confirmed by bone marrow

biopsy.
Other hematopoietic disorders can present with
pancytopenia and must be distinguished from
aplastic anemia. These include paroxysmal
nocturnal hemoglobinuria, myelodysplasia, and
acute leukemia.

Manajemen

Anemia in Systemic Diseases

1.
2.
3.
4.

Anemia of Chronic Disease

Anemia with Chronic Endocrine Disease
Anemia with Chronic Renal Disease
Anemia associated with Liver Disease

Anemia of Chronic
Disease
ACD is associated with an underlying disease
(usually inflammation, infection, or malignancy), but is
without apparent cause (not due to a lack of the
nutrients iron, vitamin B 12, or folic acid). ACD
resolves when the underlying disease resolves.
Anemia of chronic disease (ACD) is difficult to define
as its eitology and pathogenesis is not clear.

ACD is the most common anemia in hospitalized

patients.

Causes of
Anemia of
Chronic
Disease

Chronic inflammatory diseases

Infectious
Tuberculosis
Pulmonary infections,pneumonia
Pelvic inflammatory disease
Chronic fungal disease
Subacute bacterial endocarditis
Osteomyelitis
Meningitis
Non Infectious
Rheumatic arthritis
Thermal injury
Systemic lupus erythematosus
Malignant Disease

Carcinoma
Hodgkin Disease
Non-Hodgkin lymphoma
Leukemia
Multiple Myeloma

Pathophysiology
1.
2.
3.

Failure of erythropoiesis
Lack of iron for
hemoglobin synthesis
Decreased RBC survival

Anemia in Endocrine Disease

Anemia in DM patients:
ACD
Enteropathy poor absorption of iron,
vit B12, and folate.
Suffer from chronic blood loss and
chronic renal insufficiency

Anemia with chronic Renal Disease

Pathophysiology:
1. Decreased erythropoiesis EPO or
nonfunctional

2. Azotemia suppressed the bone marrow and

RBC survival
3. Chronic blood loss defects of plt and vessel
4. Folate and iron deff Chronic hemodialysis

Anemia in Liver Disease

The most common liver disease linked to anemia in
alcoholism
Anemia generall mild to moderate, but can periodically
become more severe
Pathophysiology:
1.Direct toxic effects of alcohol
2.Various nutritional deficiencies
3.RBC survival defects
4.Abnormal iron metabolism

Hemolytic Anemia
Classification
Extracorpucular Hemolytic Anemia
a. Immune Hemolytic Anemia
1. Alloimmune Hemolytic Anemia
2. Autoimmune Hemolytic Anemia (AIHA)
3. Drug induce immune Hemolytic Anemia

b. Non-immune Hemolytic Anemia

1. Mechannical: arterial valve dysfunction
- MAHA: TTP, HUS
2. Chemical, burn
3. Parasitic infection: malaria

Immune Hemolytic anemia

Alloimmune hemolytic anemia
Transfusion : ABO incompatibility
Hemolytic disease of the newborn (HDN)
ABO incompatibility
Rhesus incompatibility

Autoimmune hemolytic anemia

Warm-reactive antibodies
Cold-reactive antibodies

Drug induce

Donor nucleotides and immunodominant sugars responsible

for H, A and B antigen
Gene

Glycosyltransferase
(enzyme)

Immunodominant
Sugar

Antigen

-2-L-fucosyltransferase

L-fucose

-3-Nacetylgalactosaminyl
transferase

N-acetyl-Dgalactosamin

D-galactose

-3-Dgalactocylltransferase

ANTIGLOBULIN TEST ( COOMBS TEST )

The antiglobulin test is based on the

principle that antihuman globulin (AHGs)
obtained from immunized nonhuman species
bind to human globulin such as
IgG or complement, either free in serum or
attached to antigens on RBCs

Serum COOMBS (ANTIHUMAN GLOBULIN)

Direct Antiglobulin Test /DAT

(Direct Coombs Test)

The DAT detects in vivo sensitization of RBCs with

IgG and/or complement components
Detects of incomplete antibody that has already
attached on RBCs
Clinical condition that can result in in vivo coating of
red cells with antibody an/or complement are:

Hemolytic disease of the newborn (HDN)

Hemolytic transfusion reaction
Autoimmune and drug induce hemolytic anemia (AIHA)

Normal catabolism
of aged RBCs

Intravascular
hemolytic
anemia

Removal of hemoglobin from blood plasma after intravascular hemolysis

Lysed RBC
In blood vessel

/ dimers

Kidney

Hemoglobinuria
Hemosiderinuria
Urobilinogenuria

Extravascular
hemolytic
anemia

Clinically Findings

Symptomp of Anemia
Icteric
Organomegali (splenomegali)
Hematopoesis ekstra meduller
Change in colour of urin

Laboratory findings indicating accelerated RBCs

destruction
Test sample
Serum

Anticoagulated
blood

Urine

Result of testing
increased unconjugated bilirubin
increased LDH activity
absence of haptoglobin
decreased glycosylated hb
increased free hb
increased methemalbumin
decreased hemopexin
decreased hematocrit
decreased hb
decreased RBCs
increased urobilinogen
positive free hb
positive methemoglobin

Laboratory findings indicating accelerated RBCs

production
Test sample

Anticoagulated
blood

Bone marrow
special studies

Result of testing

increased reticulocyte count

increased MCV
increase leukocytes
increased thrombocytes
presence of morphology specific to
hemolytic disorder (polychromasia, NRBCs)
presence of erythroid hyperplasia
increased plasma iron turnover
increased erythrocyte iron turnover
increased activity of certain erythrocyte
enzymes

Intravascular hemolytic anemia

Serum:
increased unconjugated &bilirubin
increased urobilinogen
increased LDH activity
absence of haptoglobin
decreased glycosylated hb
increased free hb
increased methemalbumin
decreased hemopexin

Urine
increased urobilinogen (urobilinogenuria)
positive free hb (hemoglobinuria)
positive methemoglobin
hemosiderinuria
Stools
Fecal urobilinogen
Coombs test : + (positive)

Extravascular hemolytic anemia

Serum:
increased unconjugated bilirubin
increased conjugated bilirubin
increased urobilinogen
Urine
increased urobilinogen

Stools
increased urobilinogen
Coombs test : + (positive)

ALLOIMMUNE HEMOLYTIC
ANEMIA
Hemolytic Transfusion Reactions

Hemolytic disease of the newborn (HDN)

Hemolytic Transfusion Reactions

Hemolytic transfusion reactions result from intravascular

breakdown, which is commonly due to an incompatibilty in the
ABO system or to destruction occuring in the macrophage
system
Two types reactions: immediate & delayed
Immediate

symptoms begin within minutes hours (chills, fever, urticaria,

tachycardia, nausea, vomiting, chest & back pain, shock,
anaphylaxis, pulmonary edema & congestive heart failure
The laboratory diagnosis:

Based on the evidence of hemolysis & a blood group incompatibility

Hemoglobinemia, hemoglobinuria
Bilirubin level is increased
The entire typing & crossmatch procedures should be repeated

Hemolytic Transfusion Reactions

Delayed

may occur days or weeks after transfusion

may result in jaundice and anemia due to hemolysis
development of undetected antibodies occurs 4-14 after
transfusion of apparently compatible blood
Patient has been alloimmunized by previous pregnancy or
transfusion
Antibody concentration at the time of transfusion was
below the level of serologic detection
DAT +

 Laboratory findings in HDN caused by ABO

incompatibility:
Anemia (anemia is milder than in HDN Rh
incompatibility)
Increased reticulocyte count
mikrospherocytosis
Direct Coombs test +
Slightly increased of unconjugated bilirubin

Laboratory findings in HDN caused by Rh

incompatibility:
Mild severe anemia
Reticulocyte count > 10%
NRBCs ++, polichromasia, leukocytosis,
thrombocytopenia
Unconjugated bilirubin is markedly increase
Direct Coombs test ++

Hemolytic disease of the newborn (HDN)

HDN caused by destruction of the RBCs of the fetus

by antibodies produced by the mother
Only antibodies of the IgG class are actively
transported across the placenta
The antibodies are directed against those antigens
on the fetal RBCs that were inherited from the father
ABO incompatibility

HDN

Rh incompatibility

HEMOLYTIC DISEASES OF NEWBORN / HDN

ABO INCOMPATIBILITY

Mother: group O, fetus: group A/B

Mothers antibodies (IgG) enter across the placenta
Promotes interaction of Ag-Ab
hemolysis

Anti A

lyse

Anti B

Mother, group O

Ag-Ab

Fetal circulation

Hemolytic Disease of
Newborn (HDN)

Mother Rh Fetus Rh +

AUTOIMMUNE HEMOLYTIC
ANEMIA
(AIHA)

Autoimmune Hemolytic Anemia (AIHA)

WARM

70-75% cases
37C
Ig G

>> autoimmune disease:

Lymphoproliferative ds
Systemic Lupus Erythematosus
(SLE)
Infections diseases
Non-lymphoid neoplasm
Colitis ulcerative
drugs
Extravascular hemolysis

COLD

16% cases
< 20C
Ig M

>> infectious diseases:

MYCOPLASMA
PNEUMONIAE
Infectious
mononucleosis (EBV)
Cytomegalovirus
HIV etc.
Intravascular hemolysis

Laboratory findings

Anemia
Increased reticulocyte count
Direct Coombs test +
Mikrospherocytosis (warm ab), clumping (cld
ab)
increased of unconjugated bilirubin
Accelerated of RBCs production
Accelerated of RBCs destruction

AIHA

Blood smear
Polychromasia
nucleated RBCs
Clumping (Cold-antibody)
Micro-spherocytes (warm-antibody)

clumping

Non-immunohemolytic anemia

Microangiopathic hemolytic anemia

Macrovascular hemolytic anemia
Hemolytic anemia caused by infection with
microorganism
Hemolytic anemia caused by chemicals,
drugs and venoms
Hemolytic anemia caused by thermal injury

 RBC abnormalities that repressent

diagnostic characteristic (sickle cell,
spherocytes, target, fragmentocytes)

Drugs and Chemicals

Drugs and Chemicals that Have Been Reported to Cause
Clinically Significant Hemolytic Anemia.
CHEMICALS
Aniline
Apiol
Dichlorprop (herbicide)
Formaldehyde
Hydroxylamines
Lysol
Mineral spirit
Nitrobenzene
Resorcin

DRUG:
Amyl nitrite
Mephenesin
Methylene bule
Omeprazole
Phenazopyridine (Pyridium)
Salicylazosulfapydine
Salicylazosulfapyridine (Azulfidine)

Oxygen:
Hemolytic anemia has developed inpatients
receiving hyperbaric oxygenation and in astronauts
exposed to 100% oxygen.
Insect and Arachined venoms
Severe hemolysis may occur in some patients
following bites by bees wasps, spiders, or scorpions
Snake bites are only rarely a caused of hemolysis
Heat
Patient with extensive burns may develop severe
hemolytic anemia apparently as a result of direct
damage to the red cells by heat

Hemolytic Anemia Resulting from Infectious

Agent
Mechanisms:
Hemolysis may be caused by:
Direct invasion by infecting organisms
(malaria)
Elaboraion of hemolytis toxins (Clostridium
perfringens)
Development of autoantibodies againt red
blood cell antigens (Mycoplasma pneumoniae)

Alhamdulillah