Hafizuddin Mohamed Fauzi P-UM0037/10

A reduction in the blood count of all major cell lines red cells, white cells and platelets Severe pancytopenia is defined as:
Reticulocyte count < 1% Granulocytes < 0.5 X 109/L

Platelet < 20 X 109/L

Causes
Pancytopenia
Increased peripheral destruction

Decrease BM function

Sequestration

Causes

Decreased bone marrow function Aplasia Acute Leukaemia, myelodysplasia, myeloma Infiltration by lymphoma, solid tumours, tuberculosis Drugs Viral infection Megaloblastic anaemia Paroxysmal Nocturnal Haemoglobinuria Myelofibrosis(rare) Haemophagocytic syndrome

Causes

Increased peripheral destruction Infection Immune-mediated damage eg. SLE

Sequestration Splenomegaly (pooling effect e.g: portal hypertension)

Causes

Decreased bone marrow function Aplasia Acute Leukaemia, Myelodysplasia, myeloma Infiltration by lymphoma, solid tumours, tuberculosis Drugs Viral infection Megaloblastic anaemia Paroxysmal Nocturnal Haemoglobinuria Myelofibrosis(rare) Haemophagocytic syndrome

Aplastic Anaemia

Aplastic anemia (AA) is a rare disorder characterized by pancytopenia and hypocellular bone marrow due to injury to or loss of pleuripotent hematopoietic stem cells in which normal haemopoietic marrow is replaced by fat cells

The diagnosis of aplastic anaemia requires at least two of the following in addition to a hypocellular marrow:

(i) haemoglobin < 10 g/dL (ii) platelet count < 100 x 109/L (iii) neutrophil count < 1.5 x 109/L

Abnormal cells are not found in either the peripheral blood or the bone marrow. Dx is based on absence of cells, not on presence of any charaterictis feature

 Marrow aplasia is thought to arise from genetic

alteration in hematopoietic stem cells, either spontaneous mutations or mutations caused by an extrinsic insult ( drug,toxin,viral) stem cells capacity for proliferation & differentiation or indirectly affect hematopoiesis which introduce new antigens on the stem cell and its progeny , which trigger immune destruction via cytotoxic T cell.

Genetic damage may either directly impair the

Causes:
Primary

Fanconi Congenital Non-Fanconi

Idiopathic acquired
Aplastic anaemia Ionizing radiation Chemicals Secondary Drugs Viruses

Aplastic Anaemia
Primary Congenital
Fanconi types Non-Fanconi types Dyskeratosis congenita (DC) ShwachmanDiamond syndrome (SDS)

Idiopathic Acquired

Secondary Ionizing radiation Chemicals Drugs Viruses

Fanconi Anaemia
First described by Fanconi, 1927 Best characterised of the congenital causes of BM failure AR disorder .Incidence 3 per 1 million births a/w - growth retardation

- cong defects of skeleton (microcephaly, absent radii or thumbs) - cong defects of renal tract (pelvic/horse-shoe kidney) - skin (areas of hypo- and hyperpigmentation) - mental retardation

Pathogenesis: Involve defect in one or another components of multiprotein complex that play a role in DNA repair

FAND1 gene encoded proteins cooperate in a common cellular pathway involved in DNA repair abnormal spontaneous chromosomal breakage by DNA cross-linking agents

Diagnostic test:
Elevated chromosomal breakage after incubation of peripheral blood lymphocytes with diepoxybutane (DEB)

Presentation:

At birth the blood count is usually normal. Pancytopenia develops insidiously and presents in most cases between the ages of 5 and 10 years (median age 7 years). However, in some cases the pancytopenia develops in adolescence or even in adult life. Sx of pancytopenia: - platelet = bruising, epistaxis - anaemia - granulocytes

As the pancytopenia develops, the BM becomes progressively hypocellular. BM failure leading to fatal haemorrhage or infection is the main cause of death in FA patients. FA is associated with an increased risk of leukaemia (AML) ~10 % & other malignancies (hepatic tumours, GIT cancer and squamous cells carcinoma). In some cases, leukaemia may be the initial event leading to the diagnosis of FA. Prolonged remission - SCT

Dysmorphic features of FA

Rudimentary (dangling) thumbs

Aplastic Anaemia
Primary Congenital
Fanconi types Non-Fanconi types Dyskeratosis congenita (DC) ShwachmanDiamond syndrome (SDS)

Idiopathic Acquired

Secondary Ionizing radiation Chemicals Drugs Viruses

First description in 1906 by Zinsser Rare X-linked recessive disorder, AR, AD Characterized by the triad of abnormal skin pigmentation, nail dystrophy and mucosal leucoplakia

Very heterogeneous disorder, both clinically and genetically. Clinical manifestations in DC often appear during childhood. BM failure usually develops below the age of 20 years.

Pathogenesis:
Mutations in DKC1 (dyskerin) or TERC (telomerase reverse transcriptase DNA template) Genes which are involved in the maintainance of telomere length abnormal chromosomes

Skin hyperpigmentation

Nail atrophy

Leukoplakia

AR Characterized by exocrine pancreatic insufficiency, bone marrow dysfunction (isolated neutropenia) and other somatic abnormalities (particularly involving the skeletal system). Metaphyseal dyschondroplasia, dwarfism, protuberant abdomen

The spectrum of haematological abnormalities includes neutropenia (~60%), other cytopenias (approximately 20% have pancytopenia), myelodysplasia and leukaemic transformation (~25%). Propensity to transform to myelodysplasia and AML NOT to be confused with Diamond Blackfan anemia!!!!!(closely parallel to acquared pure red cell anemia)

Aplastic Anaemia
Primary Congenital
Fanconi types Non-Fanconi types Dyskeratosis congenita (DC) ShwachmanDiamond syndrome (SDS)

Idiopathic Acquired

Secondary Ionizing radiation Chemicals Drugs Viruses

Most common type of AA 2/3 of acquired cases Pathogenesis 1:

Immune process dominated by oligoclonal cytotoxic T cells (IFN , TNF) target the haemopoietic tissue pancytopenia
Favourable response to antilymphocyte globulin (ALG)

Pathogenesis 2:
Mutations in the telomere repair complex unclear relevance

Aplastic Anaemia
Primary Congenital
Fanconi types Non-Fanconi types Dyskeratosis congenita (DC) ShwachmanDiamond syndrome (SDS)

Idiopathic Acquired

Secondary Ionizing radiation Chemicals Drugs Viruses

Ionizing radiation (radiotherapy, radioactive isotopes) direct damage to the haemopoietic marrow
Chemicals benzene
Carcinogens (used as a solvent) Chronic exposure pancytopenia a/w

hyperplastic/dysplastic marrow later become leukaemia or rarely AA

Drugs:
Cytotoxic drugs direct damage to haemopoietic marrow Antimetabolite drugs (eg. MTX) temporary aplasia
Mitotic inhibitors (eg. Daunorubicin) Alkylating agent (eg. Busulphan) chronic aplasia

Drugs:
Idiosyncratic acquired AA drugs that do not produce marrow failure in the great majority of persons exposed to these agents unpredictable onset prolonged course death usually occur

Viruses
Non-A, non-B, non-C hepatitis Rarely: hepatitis A, B or C HIV some cases pancytopenia with a hypocellular

marrow Parvovirus 19 pure red cell aplasia (specifically infects the BFU-E) does not normally produce true AA EBV neutropenia/pancytopenia rarely: true AA, transient, spont recovery 4-6 weeks

Causes

Decreased bone marrow function Aplasia Acute Leukaemia, myelodysplasia, myeloma Infiltration by lymphoma, solid tumours, tuberculosis Drugs Viral infection Megaloblastic anaemia Paroxysmal Nocturnal Haemoglobinuria Myelofibrosis(rare) Haemophagocytic syndrome

Acute leukaemia:
ALL May present as AA Not distinguishable from true AA on haematological grounds Some clinical observations that raise the possibility that the aplasia is a prodrome of ALL
Fever, documented infection, platelet tend to be relatively better preserved that neutrophil, enlarged spleen, aplasia usually lasts 3-6 weeks remission (spont/steroid-induced), ALL usually follows after a period of apparently normal haemopoiesis (1-3 months after recovery)

Acute leukaemia:
AML May present similar as ALL Much less common Increase suspicion:
Finding of occasional blasts on FBP or buffy coat prep, low NAP score, excess myeloblasts in the cells of remaining BM

Myelodysplasia:
Some ptn may present with hypoplastic BM
Remaining haemopoietic cells MDS changes

ineffective haemopoiesis Dysplastic changes:

Pelger-Huet Donut-shaped nucleus of neutrophils Hypogranular neutrophils Micromegakaryocytes Marked dyserythropoietic changes

Multiple myeloma:
Due to plasma cell accumulation in BM
BM suppression pancytopenia Normocytic normochromic or macrocytic anaemia Advanced disease Neutropenia Thrombocytopenia

Infiltration
Myelophthisis Most common cause is metastatic cancer ( breast , lung , prostate) Not only replace BM but activate fibroblast -> collagen deposition Reactive fibrosis distort microenvironment of BM & disrupting the hematopoietic cells leading a release of immature cells.FBP: shows tear drop cell , NRBC , immature granulocytes , clump of abnormal cell Myelophthisis also occur in leukemia/ lymphoma but the degree of fibrosis is less & FBP not the same as mentioned

Causes

Decreased bone marrow function Aplasia Acute Leukaemia, myelodysplasia, myeloma Infiltration by lymphoma, solid tumours, tuberculosis Drugs Viral infection Megaloblastic anaemia Paroxysmal Nocturnal Haemoglobinuria Myelofibrosis(rare) Haemophagocytic syndrome

Megaloblastic anaemia:
Folate/B12 deficiency Macrocytic anaemia Neutropenia Thrombocytopenia

Severe disease

BM hypercellular with failure of nuclear maturation

ineffective haemopoiesis

PNH:
Mutation of X chromosome coding for PIG-A
Deficient synthesis of GPI anchor Failure of attachment of several surface protein

CD55 DAF CD59 MIRL

RBC, WBC, platelet sensitive to lysis by

complement Almost invariably a/w BM hypoplasia (often frank AA)

d/t selective pressure, possibly immune mediated against normal cells expansion of PNH clone

Myelofibrosis:
Progressive generalized reactive fibrosis of BM
Secondary to hyperplasia of abnormal

megakaryocytes PDGF + fibroblasts

Early: raised Anaemia is usual (N/) Later: reduced WBC Platelet

Haemophagocytic syndrome:
Can be:

Familia :Inherited AR (rare) Acquired (precipitated by viral EBV, Herpes; bacterial; fungal; or a/w tumours)
Presentation:

Fever, pancytopenia, splenomegaly, liver dysfunction

Aetiology: T-cell overstimulation that activate histiocytes Pancytopenia due to histiocytes in BM ingest RBC, WBC, platelet Histiocytes also secrete cytokines/chemokines that cause systemic inflamm.

State Lab findings- serum ferritin > 10000 microgram per L ( specific & sensitive for hemophagocytic syndrome)
Often fatal

History
Detailed presenting symptoms Drug history Occupational history Family history

Clinical features:
Anemia -> Pallor, tiredness, fatigue, puffiness of face,

edema, lassitude, effort intolerance Thrombocytopenia -> Mucocutaneous bleeding epistaxis, hematuria, GI bleeding, menorrhagia, ICB, retinal bleed Neutropenia -> Fever, sore throat, chest or soft tissue infection, sepsis Lymph nodes Organomegaly splenomegaly, hepatomegaly Hemoglobinuria

Lab investigations:
FBC/FBP Pancytopenia and morphological changes in peripheral blood RBC NNA or macrocytic anemia Retic markedly reduced or absent WBC Blast cells may be evident in BM of patients in whom pancytopenia is due to malignant infiltration Morphological changes in neutrophil (absent granulation, nuclear abnormalities) suggest preleukemic/MDS states Platelet Always present, in severe cases is < 20 x 109 /L

- Folate/B12 levels
- Hams test (Acidified Serum Lysis Test)
A test to see whether RBCs become more fragile when they are placed in mildly acidified serum (pH 6.5-7.0) Lowering of pH results in complement lysis of RBC with the PNH defect

Flowcytometry
Testing for CD55, CD59 deficiency

- BMA: Indicated in all cases of pancytopenia where underlying causes is not obvious Need to exclude leukemia or malignant infiltration BMA may have to be combined with trephine biopsy as BMA might yield dry/blood tap BMA shows:
Diminished cellularity with increased fat Relative increase in lymphocytes and plasma cells Megakaryocytes severely reduced/absent Elements of dyserythropoeisis (megaloblastosis, nuclear cytoplasmic asynchrony)

2 approaches:
General
Identify and remove cause Supportive care with PC, platelet transfusion
Blood products filtered to reduce risk of allo-immunization and to prevent transfusion induced GVHD

Anti fibrinolytic agent (eg: tranexamic acid) for patient with severe thrombocytopenia Prophylactic oral antibiotics (eg: ciprofloxacin/norfloxacin) to reduce incidence of gram negative sepsis Reverse barrier isolation

Specific
Tailored to the severity of illness and age of patient Severity assessed by reticulocytes, neutrophils and platelet

count and degree of marrow hypoplasia Some specific measures:

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Anti lymphocyte globulin (ALG) given with steroid to reduce side effects; effective in achieving remission in AA Ciclosporin effective in combo with ALG and steroids Androgens beneficial in patients with FA and acquired AA. Side effects : virilization and liver damage Stem cell transplantation (SCT) suitable for younger patients who have HLA-matched sibling donors, offer chance of permanent cure 80% Hemopoietic growth factors eg: G-CSF; produce minor response but does not lead to sustained improvement

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Essential Hematology, 5th edition, Hoffbrand et al, Blackwell Publication 2006 Postgraduate Hematology, 4th edition, Hoffbrand et al, Blackwell Haematology at a Glance, 3rd edition, Hoffbrand et al, Blackwell 2009 Hematologic Pathophysiology , 1st edition, H.Franklin Bunn, Lange.