HAEMOLYTIC ANAEMIAS

BY
Dr. S.O. AKIB
MB ChB, DCP, PGDHM, MPH, PGDE
APRIL 2020
 TOPICS
 INTRODUCTION
 CYTOPLASMIC DISORDERS
o ABNORMALITIES OF THE ENZYMES
 G6PD DEFICIENCY
 PK DEFICIENCY
 MEMBRANE DISORDERS
o ACQUIRED DISORDERS
 PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA
 INTRODUCTION
 Haemolytic anaemias that arise from corpuscular
defects are problems arising primarily from within the
cell.
 They can be divided into:

o Cytoplasmic disorders:
• Abnormalities of the enzymes (Red cell enzymopathy)
• Abnormalities of the Hb (Haemoglobinopathies)

o Membrane disorders:
• Inherited disorders
• Acquired disorders
 CYTOPLASMIC DISORDERS:
ABNORMALITIES OF THE ENZYMES
(RED CELL ENZYMOPATHY)
G6PD DEFICIENCY

GENETICS
PATHOPHYSIOLOGY
INDUCERS OF HAEMOLYSIS
CLINICAL FEATURES
LABORATORY INVESTIGATIONS
TREATMENT
 GENETICS
 Glucose-6-phosphate dehydrogenase deficiency (G6PD
deficiency) is an X-linked genetic deficiency
characterized by abnormally low levels of glucose-6-
phosphate dehydrogenase, a metabolic enzyme involved
in the pentose phosphate pathway, especially important
in RBC metabolism.
 Female carriers can be clinically affected due to
unfavorable lyonization, where random inactivation of an
X-chromosome in certain cells creates a population of
G6PD-deficient RBCs coexisting with normal red cells.
o A typical female with one affected X chromosome will
show the deficiency in approximately half of her red
blood cells.
o However, in rare cases, including double X deficiency,
the ratio can be much more than half, making the
individual almost as sensitive as a male to haemolysis.
 GENETICS contd
 All mutations that cause G6PD deficiency are found on
the long arm of the X chromosome.
 There are more than 140 different isomer variants
o G6PD-A (+), G6PD-A(-), G6PD - B, G6PD- Mediterranean,
G6PD-Orlando G6PD.
o G6PD-B is the commonest and found all over the world.
o G6PD A− is the commonest in Africa.
o G6PD Mediterranean is prevalent in the Middle East
(Spaniards, Italians, Greeks, Armenians, and Jews).
 PATHOPHYSIOLOGY
 G6PD deficiency is the most common abnormality of the
RBC.
o It is an enzyme needed in the pentose phosphate
pathway (HMP shunt pathway), and is the rate-limiting
enzyme for this metabolic pathway.
o It converts glucose-6-phosphate into 6-
phosphogluconate with the loss of 2 hydrogen atoms
which are picked up by 1 molecule of NADP to form of
NADPH.
o The NADPH represents the reducing energy of the cell
because it maintains the supply of reduced glutathione
in the cells that is used to mop up free radicals that
cause oxidative damage.
o The role of RBCs as oxygen carriers puts them at
substantial risk of damage from oxidizing free radicals.
 PATHOPHYSIOLOGY contd
o When all remaining reduced glutathione is consumed,
enzymes and other proteins (including Hb) are
subsequently damaged by the oxidants, leading to
electrolyte imbalance, cross-bonding and protein
deposition on the RBC membranes.
o Damaged RBCs are phagocytosed and sequestered in
the spleen.
o Hb is metabolized to bilirubin (causing jaundice)
o The RBCs rarely disintegrate in the circulation, so Hb is
rarely excreted directly by the kidney, but this can occur
in severe cases, causing acute renal failure.
 INDUCERS OF HAEMOLYSIS
 Haemolysis due to G6PD deficiency can be spontaneous
or induced.
o Some substances are known as inducers as they cause
oxidative stress with the release of free radicals.
o If an individual is G6PD deficient, free radicals are
released and the person is not protected from oxidative
damage.
 Some inducers are:
o Exposure to fava beans (favism)
• A disorder characterized by a haemolytic reaction after
ingestion of fava or broad beans, which contain high
levels of vicine, divicine, convicine and isouramil, all of
which are oxidants.
o Drugs
• Antimalarial drugs - Primaquine, chloroquine
 INDUCERS OF HAEMOLYSIS contd
• Nalidixic acid, nitrofurantoin, isoniazid, dapsone
o Chemicals
• Methylene blue
• Naphthalene
• Henna
o Infections
• Due to WBC producing a lot of free radicals while trying
to engulf bacteria.
• This leads to chronic haemolysis
o Stress
 CLINICAL FEATURES
 Most individuals with G6PD deficiency are
asymptomatic.
 Symptomatic patients are usually male.
o Patients can present with hypoxic features of anaemia.
o In addition they may present with the following:
o Dark coloured urine
o Jaundice
o In the newborn there can be neonatal jaundice, leading
to kernicterus
 LABORATORY INVESTIGATIONS
 Full blood count
o ↓ HB ↓ PCV ↓ RCC
o → ↑ WBC (T) (if infection)
o → ↑Diff (if infection)
o → ↑ PLT count
o ↑ retic count.
 RCI
o MCV → MCHC → MCH →

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 LABORATORY INVESTIGATIONS contd
 Peripheral blood film
o There is anisocytosis and poikilocytosis
o RBCs are normchromic and normocytic, fragmented
cells, Heinz bodies, polychromatic cells
o WBCs- normal or increased on film
o PLTS – normal or increased on film.
 LABORATORY INVESTIGATIONS contd
 Bone marrow examination
o Erythroid hyperplasia
o Myeloid : Erythroid 1:2
 Biochemical tests and other tests
o LFT
o E/U/Cr
o Haemoglobinaemia
o Haemoglobinuria
o Haemosiderinuria
o Decreased serum haptoglobin
o Hyperbilirubinaemia
o Hyperbilirubinuria In severe haemolysis
 LABORATORY INVESTIGATIONS contd
o "Beutler fluorescent spot test"
• The Beutler fluorescent spot test is a rapid and
inexpensive test that visually identifies NADPH produced
by G6PD under ultraviolet light.
• When the blood spot does not fluoresce, the test is
positive; it can be falsely negative in patients who are
actively haemolysing.
• It should therefore only be done 2–3 weeks after a
haemolytic episode.
o G6PD assay.
• Direct DNA testing and/or sequencing of the G6PD gene.
 TREATMENT
 This is usually conservative
o Avoiding contact with the precipitating agent
o Treat the underlying infection
o Rehydration to improve renal function
o Administration of steroids
o Blood transfusion
o BMT
A JAUNDICED INFANT RECEIVING
PHOTOTHERAPY.
 CYTOPLASMIC DISORDERS:
ABNORMALITIES OF THE ENZYMES
(RED CELL ENZYMOPATHY)
PK DEFICIENCY

INTRODUCTION
PATHOPHYSIOLOGY
CLINICAL FEATURES
LABORATORY INVESTIGATIONS
TREATMENT
 INTRODUCTION
 Pyruvate kinase (PK) deficiency, also called erythrocyte
pyruvate kinase deficiency is an inherited metabolic
disorder of the enzyme pyruvate kinase which affects
the survival of red blood cells and causes them to
deform into echinocytes ("burr cells") on peripheral
blood smears.
o Both autosomal dominant and recessive inheritance
have been observed with the disorder.
o Classically the more common one is autosomal
recessive.
o Pyruvate kinase deficiency is the second most common
cause of enzyme-deficient haemolytic anemia, following
G6PD deficiency.
 PATHOPHYSIOLOGY
 PK is an enzyme involved in RBC metabolism, in the
conversion of glucose with the formation of high energy
substances-ATP .
o PK catalyses the last step of glycolysis
(phosphoenolpyruvate converted to pyruvate), with the
formation of ATP.
o ATP is responsible for maintaining the function Na+/K+-
ATPase and other ATP-dependent processes.
o Absence of ATP impairs the Na+/K+-ATPase and other
ATP-dependent processes, leading to a cellular loss of
K+ and water and an intracellular accumulation of Na+.
o This cellular swelling is comparable to ischemic changes
in which cells denied of O2 sufferfrom anATP deficien c
y.
o This swelling causes rigidity of the RBC and eventually
splenic haemolysis from an inability to pass through
splenic sinusoids.
 PATHOPHYSIOLOGY contd
 The buildup of reaction intermediates can also increase
the level of 2,3-bisphosphoglycerate (2,3 BPG) in the
cells and affect tissue oxygenation.
o This will cause a "right shift" in the haemoglobin oxygen
saturation curve, implying a decreased oxygen affinity for
the haemoglobin and earlier oxygen unloading than
under normal conditions.
o As a result, individuals with PK deficiency may have a
greater capacity for physical activity than others with
similarly low haemoglobin levels.
 CLINICAL FEATURES
 Similar to G6PD deficiency
o With jaundice , gall stones, frontal bossing and
splenomegally.
 LABORATORY INVESTIGATIONS
 Similar to G6PD deficiency
o PK assay.
 TREATMENT
 Most affected individuals do not require treatment.
o Treatment can include blood transfusion.
o Splenectomy can be done in those who require frequent
blood transfusion.
 MEMBRANE DISORDERS:
ACQUIRED DISORDERS
PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA
(PNH)
INTRODUCTION
GENETICS
PATHOGENESIS
CLINICAL FEATURES
COMPLICATIONS
LABORATORY INVESTIGATIONS
TREATMENT
PROGNOSIS
 INTRODUCTION
 Paroxysmal nocturnal haemoglobinuria (PNH),
previously called Marchiafava–Micheli syndrome, is a
rare, genetically acquired, life-threatening disease of the
blood characterized by destruction of RBCs by the
complement system.
o There is an annual rate of 1 to 10 cases per million
population.
o Many of the cases develop in people who have
previously been diagnosed with aplastic anaemia or
myelodysplastic syndrome.
o PNH is a descriptive term for the clinical manifestation
of RBC breakdown with release of Hb into the urine that
is manifested most prominently by dark-colored urine in
the morning.
o The term ‘‘nocturnal’’ refers to the belief that haemolysis
is triggered by acidosis during sleep and activates
 INTRODUCTION contd
o However, this observation was later disproved.
o Haemolysis has been shown to occur throughout the day
and is not actually paroxysmal, but the urine
concentrated overnight produces the dramatic change in
color.
o Only a minority (26%) have the telltale red urine in the
morning that originally gave the condition its name.
o It is most common among men in their 20s, but can
occur in both sexes and at any age.
 PATHOGENESIS
 PNH is the only haemolytic anemia caused by an acquired
(rather than inherited) intrinsic defect in the cell
membrane It results in a membrane defect in stem cells
and their progeny, including RBCs, WBCs, and platelets.
o It results from a mutation in the X chromosome gene
coding for phosphatidylinositol glycan A (PIGA) which is
responsible for the formation of an enzyme called N-
acetylglucosaminyl transferase which is important in the
generation of phospholipid on the surface of cell
membranes.
o The phospholipid is called glycosyl- phosphatidylinositol
(GPI) and it serves as a carrier for certain vital proteins
responsible for neutralising the effect of complement on
the cell membrane that can lead to chronic haemolysis.
o As a result, RBCs break down too early and leak Hb into
the blood, this passes into the urine.
 PATHOGENESIS contd
o This can happen at any time, but is more likely to occur
during the night or early morning and it may occur
everyday in severe cases, more frequently in episodes
lasting 3-10 days, or, in some cases, not at all.
 Some of these vital proteins that protect RBCs from
destruction are:
o Decay-accelerating factor (DAF/CD55)
o Protectin or membrane inhibitor of reactive lysis (MIRL)
(CD59)
o Glucoside alkaline phosphatase (GAP)
o Urokinase type plasminogen activator (U-PA)
o All the above are absent from the surface of cells of all
the cells lines in patients with PNH.
 CLINICAL FEATURES
 The haemolysis that occurs can be acute or chronic and
is usually intravascular.
 Clinical features are those due to hypoxia caused by the
anaemia
 Others are:
o Repeated infections due to leukopaenia
o Passing dark urine
o Splenomegaly
o Difficulty swallowing and pain during swallowing
o Erectile dysfunction in males
• This occurs mainly when the breakdown of RBCs is rapid,
and is attributable to spasm of smooth muscle due to
RBC breakdown products.
 CLINICAL FEATURES contd
o Easy bruising or bleeding of mucous membranes due to
thrombocytopaenia.
o Thrombosis of the veins usually manifests as a sudden
catastrophic complication and may be due to a lack of
CD59 on platelet membranes that induces platelet
aggregation and is highly thrombogenic. It can occur:
• In liver - Hepatic vein thrombosis (Budd-Chiari syndrome)
• In liver - Portal vein (portal vein thrombosis)
• In CNS- Cerebral venous thrombosis an uncommon form
of stroke
• In eyes-Blurred vision
• In kidney-Renal papillary necrosis
• In respiratory system-ARDS
 CLINICAL FEATURES contd
• In abdomen-intermittent abdominal pain due to the
superior or inferior mesenteric vein ischaemia.
• In legs –Deep venous thrombosis

 25% of female cases of PNH are discovered during

pregnancy.
o This group has a high rate of thrombosis, and the risk of
death of both mother and child are significantly
increased (20% and 8% respectively)
 COMPLICATIONS
 Acute myelogenous leukemia
 Aplastic anemia
o Deficient haemopoiesis may occur due to diminished
blood cell production with a hypoplastic bone marrow so
patients have a 10-20% chance of developing aplastic
anemia in their course, and patients known to have
aplastic anemia eventually develop PNH in 5% of cases
 Iron deficiency anemia
o Patient keeps loosing Hb and the renal cells pick it up
and convert it to haemosiderin
 Myelodysplasia
 Death
 LABORATORY INVESTIGATIONS
 Full blood count
o ↓ HB ↓ PCV ↓ RCC
o ↓ WBC (T)
o ↓ Diff
o ↓ PLT count
o ↑ Retic count
o RCI
• MCV → MCHC → MCH →

34
 LABORATORY INVESTIGATIONS contd
 Peripheral blood film
o RBCs are normochromic and normocytic, polychromatic
cells
o WBCs- decreased on film
o PLTS –decreased on film

 Bone marrow examination

o Increased erythroid hyperactivity
o There is reduced activity in the myeloid, lymphoid or
megakaryocytic development.
 LABORATORY INVESTIGATIONS contd
 Biochemical tests and other tests
o LFT- ↑ bilirubin
o E/U/Cr-deranged
o ↑ LDH
o Haemoglobinuria
o Haemosiderinuria
o Decreased serum haptoglobin
o Hyperbilirubinaemia
o Hyperbilirubinuria

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 LABORATORY INVESTIGATIONS contd
 Screening tests
o Sucrose lysis test, in which a patient's RBCs are placed
in low-ionic-strength solution and observed for
haemolysis.
o Detection of haemosiderin in urine-constant
haemosiderin in urine whether or not person is
haemolysing.
 Confirmatory tests
o Ham's acid haemolysis test
o Flow cytometry to look for loss of expression of GPI-
linked proteins (CD55 and CD59) on RBCs and WBCs.
o Fluorescein-labeled proaerolysin (FLAER) test is being
used more frequently to diagnose PNH.
• FLAER binds selectively to the GPI anchor and is more
accurate in demonstrating a deficit than simply looking
 TREATMENT
 Treatment has been largely symptomatic
 Supportive measures include:
o Oral iron folate supplementation and sometimes
transfusions.
 Definitive
o Empiric use of corticosteroids e.g. prednisone
o Heparin followed by warfarin may be required for
thromboses.
o Erythropoietin therapy
o Eculizumab (Soliris )
• A new monoclonal antibody which is a terminal
complement inhibitor has remarkably changed the
course of the disorder, reducing transfusion
requirements, thromboembolism, and symptoms.
o BMT
 PROGNOSIS
 This varies:
o Most cases can be managed by these supportive
measures for years to decades.
o The prognosis without disease-modifying treatment is
10–20 years.
o Death can result from complications such as thrombosis
or bleeding.
o In rare cases, the abnormal cells may decrease over time.
THANKS FOR LISTENING

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