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Anemia

Definition of Anemia:
- has a broad differential diagnosis

why? because it could be a primary hematological problem or secondary to something else

(another disease)

- Loss of Red blood cell mass

- low hemoglobin level

Hb level < 120 g/L for women (12g/dL)

Hb level< 140 g/L for men (14 g/dL)

- low hematocrit level 

Hct level<35 % for women

Hct level< 38% for men

To diagnose a patient anemic:

Hb< 12 g/dL

Hct< 35%

Note: clinically, you can have a completely healthy asymptomatic patient with a Hb of 10 g/dL
and they are still considered anemic. 

How to diagnose a patient with anemia?

you can only measure hemoglobin (Hb) and Hematocrit (Hct)

Why do we use hemoglobin and Hematocrit to define anemia?

Red blood cells (RBC) are entirely almost made up of hemoglobin

By measuring the amount of Hb in the blood, you are indirectly measuring how much of the
blood is made up of red blood cells

Hematocrit level is the volume of blood occupied by RBCs

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Hematocrit is just the ratio of Volume of red blood cells/ Volume of blood

So, by measuring hematocrit volume which is just a %, you get an idea of how many red blood
cells are in the blood.

40% of your blood is Red blood cells

Note: Blood contains RBCs/ WBC/ Platelets/ and Plasma 

Classification of Anemia
- Different types of Anemia are classified based on Mean Corpuscular Volume (MCV)
- MCV: a lab test to measure the average size of red blood cells (measured in microns)
- How big or small red blood cells are

A. Microcytic Anemia (MCV < 80 fl)

 Small red blood cell (size of red blood cell is small)

B. Normocytic Anemia (Hemolytic and Non-Hemolytic Anemia) (MCV 80- 95

fl)

 Normal size of red blood cell

C. Macrocytic Anemia (Megaloblastic Anemia and Non-Megaloblastic Anemia)

(MCV> 95fl)

 Size of red blood cell mass is larger than normal (MCV> 95 fl)

STEM Question: An anemic patient….

1. The first thing I have to look at is Hb level and Hematocrit level (Hb and hematocrit level
lab tests)
2. Second thing is MCV (Mean Corpuscular Volume)

 Help you narrow down your differential diagnosis

A. Microcytic Anemia/ Hemoglobin Affected (FAST or TAIL)

F= Fe iron deficiency

A= Anemia of chronic Disease

S= Sideroblastic Anemia/ Lead poisoning

T= Thalassemia (alpha or beta)

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Microcytic Anemia:

- When RBC becomes smaller (remember that RBC are almost entirely made up of Hb)

What is the problem then?

Hemoglobin problem

A1. Defective in globin synthesis:

Thalassemia alpha and beta

A2. Defective in heme synthesis:

1. Iron deficiency
2. Sideroblastic Anemia (Lead poisoning)
3. Anemia of chronic disease

B. Macrocytic Anemia: Red blood cells are released from bone marrow too LARGE

Macrocytic Anemia (refers to the size of red blood cells = size of RBC is too large)

- two types (Megaloblastic vs Non-Megaloblastic Anemia)

- Megaloblastic Anemia (BLAST= IMMATURE RED BLOOD CELLS)
- Nonmegaloblastic Anemia (Mature red blood cells)

A. Megaloblastic Anemia

I. Defective in DNA synthesis

1. Folate deficiency
2. Vitamin B12 deficiency (Cobalt Amin Deficiency)
3. Orotic Aciduria

II. Defective in DNA repair

1. Fanconi Anemia

B. Non- Megaloblastic Anemia ( low yield )

1. Liver disease
2. Alcoholism
3. Diamond- Blackfan Anemia
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Anemia:

1. Microcytic Anemia (affect hemoglobin synthesis either globin chains synthesis or

heme synthesis)
2. Macrocytic Anemia (affect prematurity of red blood cells)
3. Normocytic Anemia (has different etiology affecting many different things)

 Classified whether it stimulates Red blood cells production or NOT

C. Normocytic Anemia

I. NonHemolytic Anemia (Non-destructive Anemia) RI< or equal to 2%

The problem is in the production of RBCs; therefore, the reticulocyte count will be low
(which cannot stimulate red blood cells production)

1. Early Iron deficiency

2. Anemia of chronic disease (starts as Normocytic Anemia but can progress to
microcytic Anemia/ NO destruction of Red blood cells/ RBCs will shrink
3. Chronic Kidney disease
4. Aplastic Anemia (result in the decrease of the number of RBCs because the body
cannot produce red blood cells (Either Bone Marrow is aplastic or the kidney has
failed to produce erythropoietin)

II. Hemolytic Anemia (Destructive Anemia) RI > 2%

The problem is in the destruction of RBC (if the body is destroying red blood cells as the
cause of anemia, the body will try to compensate by producing new red blood cells to
replace them (this will increase the reticulocyte index)

A. Intrinsic (Hemolysis of RBCs depends on internal factors structurally or functionally

will result in a break of RBCs)

1. Enzyme deficiency

G6PD deficiency/ Pyruvate kinase deficiency

2. Membrane defects

Paroxysmal nocturnal hemoglobinuria / Hereditary spherocytosis

3. Hemoglobinopathy

Sickle cell Anemia (Hb S)/ HbC disease

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B. Extrinsic (Hemolysis of RBCs depends on external outside factors will result in a

break of RBCs)

1. Autoimmune
2. Infections will result in hemolysis
3. Macroangiopathic Anemia
4. Microangiopathic Anemia

Flash Quiz: what are the different lab values that we can attribute to different types of Anemia?

Anemia Labs

Folate deficiency ( Macrocytic and Hb low/ Hct low (Hb<12g/ Hct <35% / High MCV >95 fl
Megaloblastic Anemia)
Problem in the prematurity of red blood cells

Beta thalassemia ( Microcytic Anemia) Hb low/ Hct low (Hb<12g/ Hct <35% / Low MCV <80 fl /

-Defect in the production of Globin chain Synthesis

Paroxysmal Nocturnal Hemoglobinuria
(Normocytic Hemolytic Anemia)
( Normocytic Intrinsic Hemolytic Anemia)
Hb low/ Hct low (Hb<12g/ Hct <35% / Normal MCV between
80-95 fl/ RI > 2%
- Destruction of RBCs depends on internal factors
- Defect in membrane

Iron Deficiency Anemia
(Normocytic NON-Hemolytic Anemia
And it can progress into Microcytic Anemia
Hb low/ Hct low (Hb<12g/ Hct <35% / MCV <80 fl / Defect
in the Heme Synthesis (Microcytic Anemia)
Or
Hb low/ Hct low ( Hb<12g/ Hct <35% / MCV 80-95 fl /
RI<2%)
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Reticulocyte Production Index

Stem Question: A 24 years old woman has a low Hb level of 5 mg/dl and low hematocrit of 20%
and she does really need a blood transfusion

Probably this is really bad iron deficiency Anemia

you order more labs and you find your MCV comes back normal around 90 fl

you calculate the reticulocyte production index

Normally you should expect that in Iron deficiency anemia (non-hemolytic Anemia)

 RI is should be low< less than 2%

BUT, you calculate the reticulocyte index in this woman and you find it high

A reticulocyte production index is a powerful tool that will give you a lot of additional
information at no additional cost or time

I. Explain the clinical value of Reticulocyte index (RI)

1. How red blood cells are made?

Erythropoiesis (the process of creating red blood cells from a common precursor =
erythrocyte precursors)

Erythroblast (precursor of Red Blood Cells)

Reticulocytes (LAST Immature red blood cells present in the bone marrow)

Erythrocytes (Red blood cells in the blood)

- In the bone marrow, red blood cell precursors (Erythroblast) pump out Immature red blood
cells (Reticulocyte) which then go on and make erythrocytes (MRC) in the blood.

-Anemia however is the loss of red blood cell

- This loss is in two forms (either destruction or production problems)

- Production Problem (Bone marrow is NOT working / BM failed to produce RBCs no matter
how much the body wants to)

- Destruction Problem (Red Blood Cells get destructed in the blood by either bleeding or
hemolysis depending on intrinsic and extrinsic factors)
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-To judge the function of the bone marrow, you have to look at Reticulocyte Production Index

- CBC (complete blood count):

* Hb level/ Hct level

* MCV

* Reticulocyte Count (to judge the function of Bone marrow to check whether it is a destruction
or production problem)

* Reticulocyte Count is a ratio, is not a count

* Reticulocyte Count= Reticulocyte number/ Total number of RBCs * 100

* Reticulocyte Index (also called corrected Reticulocyte Count) =

Reticulocyte Count * Patient Hct/ Normal Hct of a person (45%)

Reticulocyte Productive Index

NORMOCYTIC NORMOCHROMIC ANEMIA

Normocytic Anemia= Anemia that has a normal size of RBC (80-95fl)

Nonhemolytic= low amount of red blood cells but not because RBCs get destructed or lysed
(production problem/ either bone marrow is aplastic or Kidney failed to produce erythropoietin
or Defect in heme synthesis (deceases iron)

Hemolysis (loss of RBCs because of the destruction of RBCs)

you can order Reticulocyte Counter or Index to differentiate between hemolytic and non-
hemolytic anemia

In hemolytic anemia, High RI > 2% destruction problem, there is an appropriate response to

correct anemia, Bone marrow is stimulated to produce new Immature RBCs to compensate for
the loss of RBCs (Bone marrow reacts by pushing Immature red blood cells out of the bone
marrow to replace the old ones

(Reticulocyte production to compensate for the loss of RBCs)

you will see Immature red blood cells (RBCs containing nucleus which stain blue using Giemsa
stain)

High LDH (RBCs release lactate dehydrogenase enzymes when they lysed (1:1 ratio)
;..

Every RBC gonna release one LDH

High level of unconjugated Bilirubinemia (High level of urobilinogen)

-when RBCs are lysed they will release the Hb molecule

- The heme molecule in the Hb molecule will break down into unconjugated bilirubin (UCB
which is an unsolvable form of Bilirubin, so when it is in the bloodstream it has to bind
Albumin)

The goal of this bilirubin (it is a waste product so you want to get rid of it)

1. UCB has to go to the liver and has to be converted to a more soluble state

a. In the liver, UCB (unsoluble form) gets converted into CB (more soluble state)

b. CB will get converted to several UCB forms and have different fates:

- Fate 1: Excessive RBC lysed or excess amount of Bilirubin get stored into condensed stones in
the bladder (Black stones)

- Fate 2: CB gets converted into stercobilinogen and gets excreted into the feces (this gives the
stool brown color due to the destruction of RBCs)

- Fate 3: CB gets converted into urobilinogen and reabsorbed into the bloodstream and goes to
the kidney to get excreted into the urine

LAST: Pigment Gallstones (Black color) due to excessive RBCs destruction/ high amount of
bilirubin in blood lead to the formation of Black Pigment Gallstones in the gallbladder
(condensation and precipitation).

Gallbladder stones differ from cholesterol stones since they are black pigmented stones.

In Non-Hemolytic Anemia, none of these findings are observed.

IMPORTANT: so if a patient comes to your clinic has a low Hb level (Hb of 10 g/ dl) and
normal MCV (80 -100 fl)

ALWAYS CHECK FOR LDH or Reticulocyte Index (corrected reticulocyte count) to

differentiate whether the problem is a production problem or destruction problem.
;..

Hemolytic Anemia can be classified into two main groups

Immune-Mediated Vs Non-immune-mediated

A. Immune-Mediated: Immune system destroys RBCs for several reasons and causes

A1. Cold Agglutinin: Abs act best at low temperature

- Paroxysmal Nocturnal Hemoglobinuria (PNH)

- Post mycoplasmal hemolytic anemia

A2. Warm Agglutinin: Abs act best at 37 degrees Celsius

- Drug-induced
- Transfusion reaction
- Autoimmune hemolytic Anemia

B. Non- immune-mediated: Immune system did not act on RBCs/ problem is in RBC
structure itself (Intracorpuscular) vs problem is unrelated to RBC itself mainly in blood
vessels (Extra corpuscular)

B1. Intracorpuscular (problem is related to RBC itself)

Enzyme Deficiency; G6PD deficiency/pyruvate kinase deficiency

Membrane defect: Hereditary spherocytosis/ Paroxysmal Nocturnal Hemoglobinuria

Hemoglobinopathy: Sickle Cell disease or HbC disease

B2. Extra corpuscular (problem is unrelated to RBCs/ affect blood vessels)

B2.1 Macro circulatory (large vessels)

- Hypersplenism
- Extra Corporal Circulation
- March hemoglobinuria
- Mechanical valves

B2.2 Micro Circulatory (small vessels)

- Malignant Hypertension
- Sepsis
- DIC (Disseminated Intravascular coagulopathy)
- TTP (Thrombotic thrombocytopenia purpura)
- PNH (Paroxysmal Nocturnal Hemoglobinuria)
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Difference between Intravascular and Extravascular Hemolysis

Intravascular Hemolysis: Hemolysis that occurs in the blood vessel

Extravascular Hemolysis: Hemolysis that occurs in the spleen (in the red pulp in the
spleen

Difference between Intrinsic and Extrinsic Hemolysis

Intrinsic Hemolysis: Hemolysis that depends on internal factors (Enzyme deficiency

G6PD deficiency/ pyruvate kinase deficiency)/ Membrane defect/ Hemoglobinopathy

Extrinsic Hemolysis: Hemolysis that depends on external factors (Autoimmune

hemolysis/ Infections/ Macroangiopathic and Microangiopathic hemolytic Anemia

1. Intravascular Hemolysis: Hemolysis that occurs in the blood vessel (DECREASE

FREE HAPTOGLOBIN)

Few causes:

- Macro angiopathic hemolytic Anemia (Very large prosthetic valves)

As the blood is traveling to the heart there is a big prosthetic valve in the way which is
literally tearing red blood cells as they pass through them

- Microangiopathicic hemolytic Anemia (small blood vessel)

As the red blood vessels pass through a small blood vessel containing a small clock larger
than normal, they get lysed or deformed.

- So you might get Schistocytes (little broken fragments of red blood cells)
- Few pathologies where u can see Schistocytes:

TTP

DIC

PNH

Which lab does all intravascular hemolysis have in common?

Low free Haptoglobin (Haptoglobin binds to Extracellular Hb)

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Haptoglobin is a protein made up by the liver

Haptoglobin binds to Extracellular Hemoglobin circulating in the bloodstream

Some Hemoglobin is circulating in the bloodstream, but mostly all hemoglobin is present
in Red blood cells to transport oxygen and nutrient to the rest of the tissues in the body.

- When RBC gets lysed, it gonna release Hb molecules

- Haptoglobin will bind to these Hb molecules
- Therefore, there is a sudden decrease in the free Haptoglobin available because it gets
bind to Hb molecules

Which test can be used to differentiate between Intravascular and Extravascular

Hemolysis? How to differentiate whether the RBCs get destructed in the blood vessels or
outside the blood vessels?

Intravascular Hemolysis (DECREASE FREE HAPTOGLOBIN)

Extravascular Hemolysis (NORMAL FREE HAPTOGLOBIN)

Which other test can be used?

Hemoglobin in the urine

Because some of the Hb floating in the bloodstream will get filtered through the nephron
and get excreted in the urine.

What happens when Red Blood Cells are lysed outside the blood vessels (Extravascular =
in the spleen)?

- Extravascular Hemolysis happens in the spleen

- Normal Free Haptoglobin ( NO INTRAVASCULAR HEMOLYSIS)
- NO hemosidinuria/ NO hemoglobinuria

What is the function of the spleen to maintain RBCs homeostasis?

- To catch old or lysed or damaged RBCs

- Then, it phagocytosed them using splenic macrophages
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What are the causes of extravascular Hemolysis?

- Hereditary spherocytosis
- Autoimmune Hemolytic Anemia

In these two disorders, you will have the abnormal shape of red blood cells coated by Ab,
and those Abs are going to bind to RBCs caught in the spleen

Where splenic macrophages will go and break them down thus causing Hemolysis

Also in these patients you will not have Hb in the urine because Hb get break down in the
macrophage

Heriditary Spherocytosis ( Autosomal Dominant)

with RBCs unable to keep its original form

originally RBCS have a biconcave shape ( Biconcave on both sides of Red blood cells ( similar
to dumbells)

however, in hereditary spherocytosis the RBCs end up round and forming a sphere

why? bcse of genetic defect in a few of proteins

namely ankyrin, spectrin, protein 4.2 and band 3

Thes proteins normally hold the exoskeleton of RBCS into this biconcave shape

defect in these proteins result in the sphere shape/ also more condensed and smaller

As a consequence, these RBCs will filter through the spleen and they will get sequestered and
broken down by splenic macrophages

in the spleen what is the name of the system that filters RED BLOOD CELLS?

the reticuloendothelial system which filters the red blood cells but only ALLOW NORMAL
RBCs to get through then go to the circulation

Everything abnormal will end up eaten by splenic macrophages

This is a form of extravascular hemolysis because RBCs get broken down outside the blood
vessel  ( in the spleen)
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because of this the patients with hereditary spherocytosis will have symptoms of hemolytic
anemia:

Tired ( fatigue)

Pallor or jaundice becaus of high biliribin that will be circulating in their blood.

Because of splenic sequestration of red blood cells the spleen might enlarge and the patient
might have splenomegaly ( Abdominal discomfort or abdominal fullness)

Complications associated with Hereditary Spherocytosis:

if a pateint get a parvovirus B19 infection, they might have actually an aplastic crisis.

Aplastic Crisis: is a crisis in which you have a selective aplasia of your entire blood cell lineage

they will have a sudden drop in red blood cells and their anemia will significantly worsen

This may lead to tissue Hypoxia and high output heart failure ( because the heart will try to
compensate for the lack of oxygen delivery to the periphereal tissue 

what another disease you would see aplastic crisis with parvovirus B19?

Sickle cell disease

what do you expect to see normal blood cell on a periphereal blood smear?

Red blood cells with central pallor

why?

because the exoskeleton holds it in such a way that majority of Hb is concetrated on the
periphery of the cell and creates a ring structure like this

when you have hereditary spherocytosis and you lose this exoskeleton, there is no way to
differentiate or limit the Hb from being disbursed evenly through out the whole red blood cell  

therefore there is NO CENTRAL PALLOR in these spherical cells

therefore the Hb will actually concentrate more evenly.

on a blood smear, you will see spherocytes ring structures with NO central clearing

the blood smear is characterisitc of Autoimmune hemolytic anemia

More tests to diagnose hereditary spherocytosis:

;..

Osmotic Fragility test:

RBC are placed into hypotonic fluid

what happen to the cells when they are placed in hypotonic fluid?

when the cells are placed in hypotonic fluids, the cells will swell and expands.( bcse water will
enter the cell)

Normal red blood cell can expand without any kind of damage to the cell because of its
exoskeleton so it can withstand the osmotic fragility test

In a spherocyte, because it does not have any kind of exoskeleton, when you place this spherical
cell in hypotonic fluid, it will actually start to burst. 

EMA TEST( Eosin 5 maleimide binding test)

this molecule binds to band three

In hereditary spherocytosis, they don't have this band 3 to bind to EMA, the EMA test will
obviously be low

How to treat hereditary spherocytosis?

Splenectomy

by getting rid of the spleen you remove all the pathology.

there is no hemolysis if there is no spleen

These patients with Hereditary spherocytosis

will live completely normal lives for the most part of their lives even though they have very
abnormal red blood cells floating through their bloodstream

The only concern of a patient who has splenectomy is a certain type of infection.

Patients who have splenectomy or functional asplenia will get?

High likehood to get infected with encapsulated bacteria like strep puneumonia

G6PD deficiency ( X linked condition )

;..

inherited defect in the enzyme G6PD deficiency

( glucose 6 phosphate dehydrogenase)

More common in Mediterranean populations like greeks , turks, persians

what chemical pathway is the  G6PD enzyme part of?

pentose phosphate pathway

G6PD enzyme works will oxidise NADP to become NADPH

NADPH will reduce glutathione through glutathione reductase

so glutathione will form into its reduced form

then reduced glutathione is used to break down free radicals or oxidative molecules such as
hyrogen peroxide.

GOAL of pentose phosphate pathway:

to fight off free radical or oxidative damage

if G6PD enzyme is dysfunctional you will not be able to fight oxidative stress in these RBCs.

Therefore these patients are suceptible to oxidative stress and they are exposed to source 0f
oxidative stress like fava beans, sulfa drugs, chloroquine..

Heinz bodies in RBCs ( these little blue inclusions bodies are actually precipitated Hb

Hb that have been damaged and precipitated by free radical damage  

these inclusion bodies will also do somthing very unique:

Macrophages will see them and then take a bite directly out of them

Macrophages phagocyte this abnormal area of RBC resulting in a bite cell

Bite cells have a very unstable structure

Bite cells can actually lyse there in the bloodstream or when they end up in the spleen's
reticuloendothelial system

or splenic macrophages can take them 

( Intravascular or Extravascular Hemolysis)

;..

Vignette Question: Patient X has a UT infection and is given a drug like TMP SMX

few days later they end up feeling fatigued , they feel pale, they have yellow eyes and they have
back pain and the urine is dark

( the reason they have a dark urine and back pain is because of a consequence of the hemolysis is
the prodsuction of Hemoglobinuria

Patient who have large Hemoglobinuria in these oxidative attacks and it causes kidney
inflammation

Treatment of a patient with G6PD deficiency

- supportive care ( bcse G6PD defciency attacks in bursts, it attacks when they are exposed to
sources of oxidative stress

IT IS NOT ALWAYS AFFECTING THE PATIENT

By providing supporting care, you can help them get over these episodes

- AVOID OXIDANT STRESS IN THE FUTURE

( THESE PATIENTS WILL BE LISTED AS ALLERGIC TO SULFA DRUGS. 

Condition 3: Pyruvate Kinase deficiency

Autosomal recessive condition

which pathway does the pyruvate kinase takes in?

Pyruvate kinase is used in glycolysis

what is the job of a kinase enzyme>?

it is used to move around phosphate groups ( phosphorylates a substance)

which specific step in glycolysis that use pyruvate kinase?

;..

PEP into pyruvate and ATP using pyruvate kinase

In pyruvate kinase deficiency we have a decrease in ATP production within the red blood cells

Remember: when it comes to red blood cells

red blood cells can not use aerobic respiration

when there is defciency in Pyruvate kinase, RBCs run very dangerously in ATP

What is a major function of ATP in a Red blood cell?

one major function of ATP in RBC is to maintain homeostasis of the sodium potassium pump.

when you loose ATP you are no longer able to properly function the sodium/ potassium pump.

As a consequence these cause the RBCs to swell

VERY MUCH LIKE IN HERDITARY SPHEROCYTOSIS

These swollen cells end up caught by spenic macrophages in the spleen's reticucloendothelial net
and there they get broken down by splenic macrophages

As a result we have a form of extravascular hemolysis

Patient with pyruvate kinase deficiency have increase level of 2, 3 BPG in the glycolysis
pathway.

what does increased 2,3 BPG have to do with our respiratory physiology?

it affects our oxygen affinity for Hb

In which direction does it change oxygen affinity to HB?

it lowers oxygen affinity to Hb

How does this affect the Hb- Oxygen dissociation curve?

it shifts it to the right

COndition 4: PNH

- NOT an inherited condition

;..

it does not have an inheritance pattern

this is an acquired defciency

a NORMAL RBC has the ability to protect itself

from complement proteins in the blood stream

- this is an acquired deficiency because comlement protein does not have any kind of specificity
to it and it can just attack anything that it comes across

- It is important for not just RBCs but every single cell in our blood stream to be able to protect
itself from a complement

and our RBC do this through two membrane proteins DAF(CD55) and MIRL(CD59)

What is the function of DAF and MIRL?

to turn off activated complement ( oval)

DAF and MIRL are expressed on the surface of RBC because they are anchored by GPI anchor

GPI anchor ( glycosylphosphatidylinositol anchor is produced from PIGA gene which is made in
red blood cell precursors

and in PNH we have acquired mutation in PIGA gene

so our PIGA gene gets knocked out and as a result these patients don't have any DAF and MIRL
on their RBC.

Now these cells are suceptible to complement attack

so complement will come and attack these RBCs therfore the RBC will lyse

Let's talk about these patients clinically:

the name of the disorder is paroxysmal meaning sometimes/ nocturnal meaning at night
hemoglobinuria meaning Hb in the urine.

Patients who have this condition

will wake up

and they will have dark urine

;..

Clinical Manifestations;

- Episodic dark urine when the patient walk up in the morning

why this happen?

the reason this happens is because when we sleep at night

we breathe a little bit more shallow

this causes more carbon dioxide retention

this actually causes a respiratory acidosis

this acidosis will turn on complement in the blood stream

Now in patients who have Proxysmal Nocturnal Hemoglobinuria

their PIGA gene gets knocked out

they don;t have GPI anchor

meaning that DAF and MIRL are no longer

protecting them against complement

- when complement activates  it will attack RBCs

one major complication is thrombosis

DAF and MIRL are present on all types of bloods cells ( RBCs , WBCs, platelets,..)

when complement gets activated it breaks down platelets

even though these patients are thrombocytopenic, the platelets when they break down will
release pro-coagulation granules

this will be release into the blood stream and trigger coagulation

Classical triad with patient who has PNH:

- venous thrombosis like Budd Chiari Syndrome

- pancytopenia because of the lysis of RBCs platelets and white blood cells
;..

- anemia that is not reactive to Coomb's test.

Diagnosis: by flow cytometry 

where the clot is located in Budd Chiari Syndrome?

located within the hepatic veins

What is Coombs test looking for?

Coombs test looks to see if RBCs lysis occurs because of Ab or Not. 

So to diagnose a patient with PNH

we can just do flow cytometry to see if RBCs have CD55 and CD59 on them.

Treatment;

we can treat this patient with a monclonal antibody drug called eculizumab

eculizumab target C5 complement protein and turns it off

Hemoglobinopathy

Sickle Cell Anemia:( VERY HIGH YIELD )

In sickle cell anemia, cells are similar to sickle ( menjal)

Sickle cell anemia cause occlusion of small blood vessels ( Sickle cell anemia occlude the whole
lumen of the red blood cell)

this occlusion of small blood vessels will cause ischemia and infarct of downstream tissue

Another consequence is that these RBCs take this weird form.

what happens when these sickle cells get caught by splenic macrophages in the
reticuloendothelial system in the spleen?

these sickle cells get phagocytosed

;..

and because they have unstable form in the bloodstream themselves they will also get lysed
within the vessels

Sickle cell Anemia cause both Intravascular and Extravascular Hemolysis

Basic Question: What is that's causing these red blood cells to sickle? Can you recall the specific
mutation in sickle cell anemia?

Conversion of Glutamic acid to Valine

Sickle Cell Anemia is an autosomal recessive condition that causes point mutation in the
hemoglobin B chain that coverts glutamic acid to valine 

what type of mutation is this?

this is a missense mutation ( it is a single amino acid chain)

so this abnormally structural Hb will actually participate when the Hb is in the deoxygenated
form or the tense form ( Hb-T).

So in a relaxed form, the RBCs will be normal

In a tense Form also mean deoxygenated , the RBC WILL BE sickled

This precipiatetion will happens within the entire red blood cell and it causes it to deform into
this pathomenomonic sickle shape

( you will not see the shape in any other pathology)

What are some things that will put a Hb in the tense form or deoxygenated form? what are the
things that will right shift hemoglobin?

- low oxygen in the blood

- low pH

- being in High altitude locations

Clinically, what we look for in a sickle cell patients is a high association with the African
population and these are the patients who become

-short of breath

- ending up having pain in their body( because of these episodes of sickling

;..

Now when it comes to sickle cell anemia

neonates or infants less than 6 months  are usually aysmptomatic

this is because they have a high preponderance of HbF

Hb F is not dysfunctional like Hb S in sickle cells anemia pattients

Hb F has higher affinity than Hb S

Tretment of Sickle cell Anemia:

Patients are given Hydroxyurea

which increases the amount of circulating Hemoglobin F in patients who are beyond the neonatal
age 

Symptoms that present in sickle cell patients;

when they are children is dactylitis ( Abnormal painful swelling of their fingers) this is because
vaso occlusive crisis that happens in their small vasculature of their hands.

young kids can also get splenic sequestration crisis, this happens when there is vaso occlusion
that blocks the vasculature within the spleen ( more specifically the veins within the spleen) that
prevents blood from leaving the spleen. this can result in hypovolemic shock and death 

As kids get older though, the spleen repeatedly infarcts and it results in functional asplenia

their spleen becomes completely fibrotic and shrunk to the point that it does not even work
anymore.

so what RBCs inclusions might you see in these patients?

you would see Howell Jolly bodies

Image asssociated with functional asplenia because the spleen is able to normally remove these
inclusion bodies

BUT in older patients with sickle cell anemia

they are no longer have a spleen so they ended up with Howell jolly bodies

And what kind of infections are they at a higher risk for?

;..

Encapsulated bacterial Infections organisms like Strep pneumonia

Speaking of Infections

-there is high yield association between  osteomuyelitis due to Salmonella in kids with sckle cell
disease

- Another infection that could happen is parvovirus B19

this is very dangerous in patients with sickle cell anemia because the virus infects erythrocyte
precursor cells  ( erythroblasts)

These kids have complete arrest of erthropoeisis they have a red blood cell aplasia

This is called aplastic crisis ( sudden drop off in their Hb and Hct and worsening anemia
symtpoms)

- Patients with sickle cell disease can get sickling in all sorts of organs not just their hands and
their extremities

but they can also get sickling in for example -their lungs which causes acute chest syndrome or
acute chest crisis

- their bones which caused avascular necrosis

- their brain which can cause stroke

- their kidney which can cause stroke also

what portion of their nephron do you think the cells are most likely to sickle?

in the renal medulla

and this bcse the renal medulla tends to be the lowest oxygenated portion of the whole nephron
( lowest partial pressure of oxygen)

- patients with sickle cell disease can also get papillary necrosis and hematuria

- To diagnose a patient with sickle cell disease

we use Hb Electrophoresis

so what banding pattern would you expect to see in Hemoglobin electrophoresis?

 you would expect to see a thick band

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where Hb S is and no band where Hb A is

What about the heterozygous form of the disease sickle cell traits?

you would see a thin band at S and then a thin band at A

LAST CONDITION:

Hb C disease

similar pathophysiologically to sickle cell disease

these patients have an inherited glutamic acid

to lysine point mutation in the B chain of Hb

This causes extravascular hemolysis

this is very similar to sickle cell disease

except instead of glutamic acid to valine

it is glutamic acid to lysine

High yield fact about this disorder is the difference in Hb electrophoresis

If the Hb C band is more or less positive than in Hb S or Hb A ?

Answer: Hb C is the most positive Hb disorder

so it travels the least toward the anode

it is the closest toward the cathode

Another high yield point

if you have Hb S and Hb C then you have Hb SC and this is a milder form of sickle cell anemia

Lastly, the blood smear in patients with Hb CC

we have a thick C band it shows crystal structures within the red blood cell which are made up of
Hb as well as target cells
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what is the inheritance pattern of these pathologies?

1. Hereditary Spherocytosis ( AD)

2. G6PD deficiency ( X linked recessive X-R)

3. Pyruvate kinase ( A-R)

4. Sickle cell anemia (A-R  point mutation )

5. PNH ( Acquired Not inherited)

MICROCYTIC HYPERCHROMIC Anemia video

Fatigue is one of the most common complaints

- whenever you see a patient with fatigue, you have to work them up for anemia

- Most common cause of Anemia which is iron deficiency Anemia

-Microcytic (cells are small/ measure of MCV less than 80) Hypochromic Anemia

( cells are pale low MCHC stands for mean corpuscular hemoglobin concetration )

Hemoglobin concetration that gives red blood cells their red color

MCHC is low ( cells will be pale).

Anemias:

Iron deficiency Anemia

Hemoglobin is made up of two major components:

It is made up of Globin chains ( made up of four different protens)

- also made up of the heme portions ( in the heme molecule, also contains iron that the oxygen
or the carbon dioxide will bind to)
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- if any of these components, the heme or the globin are dysfunctional

then the red blood cell will be unable to carry out its proper function.

- In iron deficiency anemia, patients are iron deficient and this causes their hemoglobin to
form incompletely.

they don't have iron that completes these small green little heme groups- this reduces their
size-because they don't have functional hemoglobin

hemoglobin is what gives red blood cells their size.

hemoglobin also gives red blood cells their color

this reduces the MCV and the MCHC

so we meet the criteria for a microcytic hyochromic anemia.

in a blood smear you will see reduced central pallor

this means when u see a red blood cell, the center is a little pale.

- In iron deficiency anemia, the central pallor end up of becoming wider and wider

-you will see a wide amount of paleness and a very thin rim of color.

what happens in patients with iron deficiency anemia?

-Iron is a major component of Hb

and Hb job is to carry oxygen and nutrients for the tissues in our bodies.

- if a patient does not have iron and their red blood cells are unable to carry nutrients and
oxygen, the most sensitive finding that you find in patients with anemia is fatigue

why? bcse they are not getting their oxygen ( Hb capacity is lower).

- the second important findings is conjunctival pallor

which is pretty much paleness under the rim of their eye, in their conjuctiva, and you also
generally see pallor on the skin

- Anemic patients also have what is called pica

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pica is when these patients have cravings and they eat things that are not foods

( they eat paper or they eat ice)

- Also, there are some rare symptoms such as Koilonychia, glossitis or colossus.

- A high yield association is

Plummer- Vinson syndrome

( this is a triad of iron deficiency anemia, esophageal webs, or web like structures that travel
down their esophagus and causes diffuculty of swallowing food (dysphagia).

- Causes of Iron deficiency anemia:

-most commonly due to chronic bleeding.

- if u think of iron deficiency anemia in an old person, then you should automatically think of
an occult GI bleed ( angiodysplasia or colon cancer)

- when you have anemia in an old person you should always consider colon cancer

- can also be due to malnutrution or malabsorption

- even increase in red blood cell demand such as in pregnancy.

Labs specific to anemia of iron deficiency:

- IRON IS LOW

- FeRRITN IS LOW ( structure that stores iron within cells is also gonna go down)

if we don't have enough iron to start with

why would you be storing it away.

- TIBC IS LOW ( TOTAL IRON BINDING CAPACITY= WHICH IS THE ABILITY OF

FREE ION TO BE BOUND IN THE BLOOD STREAM WILL GO UP.

Although, your iron is low, what little of that you have is being occupied by TIBC 

because this is carrying it around.

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