Hemolytic

anemia

Young man of 19
Complains of giddiness
weakness, pallor

How shall you investigate to find

out the cause of the problem?

Laboratory investigations:
Severe normochromic, normocytic
anemia (hemoglobin level of 6.4 g/dL
Reticulocyte count of 12.2%.

Bilirubin level of 2.5 mg/dL,

Lactate dehydrogenase (LDH) of
2140 IU/L,
Haptoglobin below 7 mg/dL

Introduction
Mean

life span of a RBC-120days

Removed Extravascularly by- Macrophages
of RE system

Hemolytic Anemia
Definition:
Those

anemias which result from an increase

in RBC destruction

Classification:
Congenital
Acquired

/ Hereditary

Laboratory Evaluation of Hemolysis

Extravascular Intravascular

HEMATOLOGIC

Routine blood film

Reticulocyte count
Bone marrow
examination

Polychromatophilia

Polychromatophilia

Erythroid
hyperplasia

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

Hemoglobinuria

Hereditary

Acquired

Classification of Hemolytic Anemias

1. Abnormalities of RBC interior
a.Enzyme defects: G-6-PD def,PK def
b.Hemoglobinopathies
2. RBC membrane abnormalities
a. Hereditary spherocytosis etc.
b. PNH

c. Spur cell anemia

3. Extrinsic factors
a. Hypersplenism

Ref : Harrisons

Features of HEMOLYSIS
Bilirubin
LDH
Reticulocytes, n-RBC
Haptoglobulins
+ve Urinary hemosiderin, Urobilinogen
Blood Film
Spherocytes
DCT +ve
AI Hemolysis

No spherocytes

Fragmentation

DCT ve
H. Sherocytosis

Malaria,
Clostidium
Hereditery enzymopathies Microangiopathic,

Red Cell Membrane Defects

1.Hereditary Spherocytosis
Usually

inherited as AD disorder
Defect: Deficiency of Beta Spectrin or Ankyrin
Loss of membrane in Spleen & RES
becomes more spherical Destruction in
Spleen

RBC Membrane

C/F:
Asymptomatic
Fluctuating

hemolysis
Splenomegaly
Pigmented gall stones- 50%

Complications
Clinical

course may be complicated with

Crisis:
Hemolytic

Crisis: associated with infection

Aplastic crisis: associated with Parvovirus
infection

 Inv:
Test

will confirm Hemolysis

P Smear: Spherocytes
Osmotic Fragility: Increased

Screen Family members

Osmotic Fragility

 Management:
Folic Acid

5mg weekly, prophylaxis life long

Spleenectomy
Blood transfusion in Ac, severe hemolytic crisis

2.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

Elliptocytosis

Red Cell Enzymopathies

Physiology:
EM

pathway: ATP production

HMP shunt pathway: NADPH & Glutathione
production

1. Glucose-6-Phosphate Dehydrogenase
( G6PD ) Deficiency
Pivotal

enzyme in HMP Shunt & produces

NADPH to protect RBC against oxidative
stress

Most

common enzymopathy -10%

worlds population
Protection against Malaria
X-linked

(Reduced form)

(Oxidised form)

 Clinical
Acute

Features:
drug induced hemolysis:

Aspirin,

primaquine, quinine, chloroquine,

dapsone.

Chronic

compensated hemolysis
Infection/acute illness
Neonatal jaundice
Favism

 Inv:
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

2. Pyruvate Kinase Deficiency

AR
Deficient ATP production,

Chronic

hemolytic anemia
Inv;
P. Smear: Prickle cells
Decreased enzyme activity
Treatment:
Transfusion may be required

Hemolobinopathies

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

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.Misc: UC, HIV

MACROCYTE
SPHEROCYTE

IMMUNOHEMOLYTIC ANEMIA

complement

Direct antiglobulin test

demonstrating the presence of autoantibodies (shown
here) or complement on the surface of the red blood
cell.

 Inv:
e/o

hemolysis, MCV
P Smear: Microspherocytosis, n-RBC
Confirmation: Coombs Test / Antiglobulin test
Treatment
Correct

the underlying cause

Prednisolone 1mg/kg po until Hb reaches
10mg/dl then taper slowly and stop
Transfusion: for life threatening problems
If no response to steroids Spleenectomy or,
Immunosuppressive: Azathioprine,
Cyclophosphamide

2. Cold AI Hemolysis
Usually Ig M
Acute or Chronic form
Chronic:
C/F:
Elderly

patients
Cold , painful & often blue fingers, toes,
ears, or nose ( Acrocyanosis)
Inv:
e/o

hemolysis
P Smear: Microspherocytosis
Ig M with specificity to I or I Ag

 Other

causes of Cold Agglutination:

Infection:

Mycoplasma pneumonia, Infec

Mononucleosis
PCH : Rare cause seen in children in
association with cong syphilis

 Treatment:
Treatment

of the underlying cause

Keep extremities warm
Steroids treatment
Blood transfusion

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

TRAUMATIC HEMOLYSIS

Acquired hemolysis
2.Infection
F. malaria: intravascular hemolysis: severe
called Blackwater fever
Cl. perfringens septicemia
3.Chemical/Drugs: oxidant denaturation of
hemoglobin
Eg: Dapsone, sulphasalazine, Arsenic
gas, Cu, Nitrates & Nitrobenzene

The direct antiglobulin test was

positive for complement (C3d) (++),
and IgG (++-).
Also was positive for agglutinins of
IgM type and had a titer of 1:1024.

Serologies for human

immunodeficiency virus, hepatitis B
and C viruses, and Mycoplasma
pneumoniae were negative.
Rheumatoid factor and antinuclear
antibodies were undetectable.

Prednisone therapy was started at

a dose of 1 mg/kg intravenously,
daily. Hemoglobin level rose to
11 g/dL, concomitantly with the
improvement of hemolytic signs.

A reduction of positivity of both

direct and indirect antiglobulin tests
(polyvalent serum + ; C3d + ;
IgG+ ), as well as a reduction of
cold agglutinin titers (1:128), was
observed 8 weeks after
corticosteroid therapy.

Three months later, corticosteroids

were tapered to a maintenance
dose of 25 mg daily.
Hemolysis recurred again with the
fall of hemoglobin to 7 g/dL.

The direct antiglobulin test recurred

positive for polyvalent serum (+++),
complement (+++), and IgG (+++),
while cold agglutinin titers again
became strongly positive (1:256).

Immunophenotyping of bone
marrow cells showed that 10% of
all the cells were CD20 and CD19
positive.

CD20 is widely expressed on Bcells.

CD20 could play a role in Ca2+
influx across plasma membranes,
maintaining intracellular Ca2+

Rituximab is a monoclonal
antibody that binds to CD 20
Rituximab was started at the dose
of 375 mg/mq once weekly, for a
total of 4 doses

Hemoglobin value reached

13.5 g/dL just before the third dose,
although biochemical signs of
hemolysis remained substantially
unaltered.

At the end of therapy, the hemolytic

signs disappeared, the direct and
indirect antiglobulin tests became
negative, and cold agglutinin titers
fell to 1:32
Immunophenotyping of bone

Summary of lecture
Learning points