Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

CASE STUDY
(Aplastic Anemia)

Coleen Angelique Q. Montenegro

BSM- 4A (Group 1)

Dr. Jennifer Tam, RN, MAN, PhD

Clinical Instructor
 APLASTIC ANEMIA

Aplastic anemia (AA) is a severe hematologic condition in which the body fails to make blood
cells in sufficient numbers. Aplastic anemia is associated with cancer and various cancer syndromes.
Blood cells are produced in the bone marrow by stem cells that reside there. Aplastic anemia causes a
deficiency of all blood cell types: red blood cells, white blood cells, and platelets.
It occurs most frequently in people in their teens and twenties but is also common among the elderly.
It can be caused by heredity, immune disease, or exposure to chemicals, drugs, or radiation. However,
in about half of cases, the cause is unknown.
Aplastic anemia can be definitively diagnosed by bone marrow biopsy. Normal bone marrow has 30–
70% blood stem cells, but in aplastic anemia, these cells are mostly gone and are replaced by fat.
First-line treatment for aplastic anemia consists of immunosuppressive drugs—typically either anti-
lymphocyte globulin or anti-thymocyte globulin—combined with corticosteroids, chemotherapy,
and ciclosporin. Hematopoietic stem cell transplantation is also used, especially for patients under 30
years of age with a related, matched marrow donor.
Aplastic anemia is known to have caused the deaths of Eleanor Roosevelt, Luana Reyes, Molly
Holzschlag, and Marie Curie.

HOW COMMON IS THIS DISEASE OR CONDITION?

 Each year, 300 to 900 people in the United States receive an aplastic anemia diagnosis.
Studies show aplastic anemia affects 2 in 1 million people in Europe. Anyone can develop
aplastic anemia, but it typically affects people ages 15 to 25 and age 60 and older.
 Anyone can get aplastic anemia, but it's more likely to happen to people in their late teens and
early 20s, and the elderly. Males and females have about an equal chance of getting it. It is
more common in developing countries.

WHAT ARE THE SYMPTOMS OF APLASTIC ANEMIA?

 Aplastic anemia can develop suddenly or slowly. It can be mild or severe. The symptoms of
aplastic anemia can include:

 Fatigue
 Weakness
 Dizziness
 Shortness of Breath
 Easy Bruising or Bleeding
WHAT OTHER PROBLEMS CAN APLASTIC ANEMIA CAUSE?

 Aplastic anemia can be caused by immune disease or exposure to certain chemicals, drugs,
radiation, or infection; in about half the cases, a definitive cause is unknown. It is not
a hereditary condition, nor is it contagious.

Aplastic anemia is also sometimes associated with exposure to toxins such as benzene or with
the use of certain drugs,
including chloramphenicol, carbamazepine, felbamate, phenytoin, quinine,
and phenylbutazone. However, the probability that these drugs will lead to aplastic anemia in
a given patient is very low. Chloramphenicol treatment is associated with aplasia in less than
one in 40,000 treatment courses, and carbamazepine aplasia is even rarer.

Exposure to ionizing radiation from radioactive materials or radiation-producing devices is

also associated with the development of aplastic anemia. Marie Curie, famous for her
pioneering work in the field of radioactivity, died of aplastic anemia after working
unprotected with radioactive materials for a long period of time; the damaging effects of
ionizing radiation were not then known.

Aplastic anemia is present in up to 2% of patients with acute viral hepatitis.

One known cause is an autoimmune disorder in which white blood cells attack the bone
marrow. Acquired aplastic anemia is a T-cell mediated autoimmune disease, in
which regulatory T cells are decreased and T-bet, a transcription factor and key regulator of
Th1 development and function, is upregulated in affected T-cells. As a result of active
transcription of the interferon gamma (IFN-gamma) gene by T-bet, IFN-gamma levels are
increased, which reduces colony formation of hematopoietic progenitor cells in vitro by
inducing apoptosis of CD34+ cells in the bone marrow.

Short-lived aplastic anemia can also be a result of parvovirus infection. In humans, the P
antigen (also known as globoside), one of many cellular receptors that contribute to a
person's blood type, is the cellular receptor for parvovirus B19, which causes erythema
infectiosum (fifth disease) in children. Because it infects red blood cells as a result of the
affinity for the P antigen, parvovirus causes complete cessation of red blood cell production.
In most cases, this goes unnoticed, as red blood cells live on average 120 days, and the drop
in production does not significantly affect the total number of circulating cells. However, in
people with conditions where the cells die early (such as sickle cell disease), parvovirus
infection can lead to severe anemia.

More frequently, parvovirus B19 is associated with aplastic crisis, which involves only red
blood cells (despite the name). Aplastic anemia involves all cell lines. Other viruses that have
been linked to the development of aplastic anemia include hepatitis, Epstein-
Barr, cytomegalovirus, and HIV.

In some animals, aplastic anemia may have other causes. For example, in the ferret (Mustela
putorius furo), it is caused by estrogen toxicity, because female ferrets are induced ovulators,
so mating is required to bring the female out of heat. Intact females, if not mated, will remain
 in heat, and after some time the high levels of estrogen will cause the bone marrow to stop
producing red blood cells.

HOW IS APLASTIC ANEMIA DIAGNOSED?

 Aplastic anemia must be differentiated from pure red cell aplasia. In aplastic anemia,
the patient has pancytopenia (i.e., also leukopenia and thrombocytopenia) resulting in
a decrease of all formed elements. In contrast, pure red cell aplasia is characterized by
a reduction in red cells only. The diagnosis can only be confirmed with a bone
marrow examination.

Before this procedure is undertaken, a patient will generally have had other blood tests to find
diagnostic clues, including a complete blood count, renal function and electrolytes, liver
enzymes, thyroid function tests, vitamin B12 and folic acid levels.

Tests that may aid in determining an etiology for aplastic anemia include:

1. History of iatrogenic exposure to cytotoxic chemotherapy: transient bone marrow

suppression
2. Vitamin B12 and folate levels: vitamin deficiency
3. Liver tests: liver diseases
4. Viral studies: viral infections
5. Chest X-ray: infections
6. X-rays, computed tomography (CT) scans, or ultrasound imaging tests:
enlarged lymph nodes (sign of lymphoma), kidneys, and bones in arms and hands
(abnormal in Fanconi anemia)
7. Antibody test: immune competency
8. Blood tests for paroxysmal nocturnal hemoglobinuria
9. Bone marrow aspirate and biopsy: to rule out other causes of pancytopenia
(i.e., neoplastic infiltration or significant myelofibrosis).

PATHOGENESIS
 For many years, the cause of acquired aplastic anemia was not clear.
Now, autoimmune processes are considered to be responsible. The majority of cases are
hypothesized to be the result of T-cell-mediated autoimmunity and destruction of the bone
marrow, which leads to defective or nearly absent hematopoiesis. It is suggested that
unidentified antigens cause a polyclonal expansion of dysregulated CD4+ T cells and
overproduction of pro-inflammatory cytokines, such as interferon-γ and tumor necrosis
factor-α. Ex vivo bone marrow models show an expansion of dysregulated CD8+ T
cell populations. Activated T cells also induce apoptosis in hematopoietic stem cells.
Aplastic anemia is associated with increased levels of Th17 cells—which produce pro-
inflammatory cytokine IL-17—and interferon-γ-producing cells in the peripheral blood and
bone marrow. Th17 cell populations also negatively correlate with regulatory T-
cell populations, suppressing auto-reactivity to normal tissues, including the bone
marrow. Deep phenotyping of regulatory T-cells showed two subpopulations with
specific phenotypes, gene expression signatures, and functions.
Studies in patients who responded to immunosuppressive therapy found dominant
subpopulations characterized by higher expression of HLA‐DR2 and HLA‐DR15 (mean age
of two groups: 34 and 21 years), FOXP3, CD95, and CCR4; lower expression
of CD45RA (mean age: 45 years); and expression of the IL‐2/STAT5 pathway. Higher
frequency of HLA‐DR2 and HLA‐DR15 may cause augmented presentation of antigens to
CD4+ T-cells, resulting in immune‐mediated destruction of the stem cells. In addition, HLA‐
DR2-expressing cells augment the release of tumor necrosis factor-α, which plays a role in
disease pathology.
The hypothesis of aberrant, disordered T‐cell populations as the initiators of aplastic anemia
is supported by findings that immunosuppressive therapy for T-cells (for example, anti-
thymocyte globulin and ciclosporin) results in a response in up to 80% of severe aplastic
anemia patients.
CD34+ progenitor cells and lymphocytes in the bone marrow over-express the Fas receptor,
the main element in apoptotic signaling. A significant increase in the proportion of apoptotic
cells in the bone marrow of aplastic anemia patients has been demonstrated. This suggests
that cytokine‐induced and Fas‐mediated apoptosis play roles in bone marrow failure because
annihilation of CD34+ progenitor cells leads to hematopoietic stem cell deficiency.
 Frequently detected autoantibodies
A study of blood and bone marrow samples obtained from 18 aplastic anemia patients
revealed more than 30 potential specific candidate autoantigens after the serologic
screening of a fetal liver library with sera from 8 patients. The human fetal liver
cDNA library (chosen because of its high enrichment of CD34+ cells), compared
with peripheral blood or the bone marrow, significantly increased the likelihood of
detection of possible stem cell autoantigens.
ELISA and Western blot analysis revealed that an IgG antibody response to one of
the candidate autoantigens, kinectin, was present in a significant number of patients
(39%). In contrast, no antibody was detected in 35 healthy volunteers. Antibody was
detected in both transfused and transfusion-naive patients, suggesting that
antikinectin autoantibody development was not due to transfusion-related
alloreactivity. Negative sera from patients with other autoimmune diseases (systemic
lupus erythematosus, rheumatoid arthritis, and multiple sclerosis) showed a specific
association of antikinectin antibodies with aplastic anemia. These results support the
hypothesis that immune response to kinectin may be involved in the pathophysiology
of the disease.
Kinectin is a large molecule (1,300 amino acid residues) expressed by CD34+ cells.
Several kinectin-derived peptides can be processed and presented by HLA I and can
induce antigen-specific CD8+ T-cell responses.
 Bone marrow microenvironment
A critical factor for healthy stem cell production is the bone marrow
microenvironment. Important components are stromal cells, the extracellular matrix,
and local cytokine gradients. The hematopoietic and non-hematopoietic elements of
 the bone marrow closely interact with each other and sustain and maintain the balance
of hematopoiesis.
In addition to low numbers of hematopoietic stem cells, aplastic anemia patients have
altered hematopoietic niche:
 cytotoxic T-cells (polyclonal expansion of dysregulated CD4+ T-cells)
trigger apoptosis in bone marrow cells
 activated T-cells induce apoptosis in hematopoietic stem cells
 there is abnormal production of interferon-γ, tumor necrosis factor-α,
and transforming growth factor
 overexpression of Fas receptor leads to apoptosis of hematopoietic stem cells
 poor quality and quantity of regulatory T-cells means failure in suppressing
auto-reactivity, which leads to abnormal T-cell expansion
 due to higher amounts of interferon-γ, macrophages are more frequent in the
bone marrow of aplastic anemia patients; interferon-mediated loss of
hematopoietic stem cells occurs only in the presence of macrophages
 interferon-γ can cause direct exhaustion and depletion of hematopoietic stem
cells and indirect reduction of their functions through cells that are part of the
bone marrow microenvironment (e.g., macrophages and mesenchymal stem
cells)
 increased numbers of B cells produce autoantibodies against hematopoietic
stem cells
 increased numbers of adipocytes and decreased numbers of pericytes also
play a role in suppressing hematopoiesis

TREATMENT
 Treating immune-mediated aplastic anemia involves suppression of the immune system, an
effect achieved by daily medicine or, in more severe cases, a bone marrow transplant, a
potential cure.] The transplanted bone marrow replaces the failing bone marrow cells with
new ones from a matching donor. The multipotent stem cells in the bone marrow reconstitute
all three blood cell lines, giving the patient a new immune system, red blood cells,
and platelets. However, besides the risk of graft failure, there is also a risk that the newly
created white blood cells may attack the rest of the body ("graft-versus-host disease").
In young patients with an HLA-matched sibling donor, bone marrow transplant can be
considered as a first-line treatment. Patients lacking a matched sibling donor typically pursue
immunosuppression as a first-line treatment, and matched, unrelated donor transplants are
considered second-line therapy.
Treatment often includes a course of antithymocyte globulin (ATG) and several months of
treatment with ciclosporin to modulate the immune system. Chemotherapy with agents such
as cyclophosphamide may also be effective but is more toxic than ATG. Antibody therapy
such as ATG targets T cells, which are believed to attack the bone
marrow. Corticosteroids are generally ineffective, though they are used to ameliorate serum
sickness caused by ATG. Normally, success is judged by bone marrow biopsy six months
after initial treatment with ATG.
 One prospective study involving cyclophosphamide was terminated early due to a high
incidence of mortality from severe infections as a result of prolonged neutropenia.
Before the above treatments became available, patients with low leukocyte counts were often
confined to a sterile room or bubble (to reduce risk of infection), as in the case of Ted DeVita.

EPIDEMIOLOGY
 Aplastic anemia is a rare, noncancerous disorder in which the blood marrow is unable to
adequately produce blood cells required for survival. It is estimated that the incidence of
aplastic anemia is 0.7–4.1 cases per million people worldwide, with the prevalence between
men and women being approximately equal. The incidence rate of aplastic anemia in Asia is
2–3 times higher than it is in the West; the incidence in the United States is 300–900 cases per
year. The disease most commonly affects adults aged 15–25 and over the age of 60, but it can
be observed in all age groups.
The disease is usually acquired during life and not inherited.[43] Acquired cases are often
linked to environmental exposures such as chemicals, drugs, and infectious agents that
damage the bone marrow and compromise its ability to generate new blood cells. However, in
many instances the underlying cause for the disease is not found. This is referred to as
idiopathic aplastic anemia and accounts for 75% of cases. This compromises the effectiveness
of treatment since treatment of the disease is often aimed at the underlying cause.
Those with a higher risk for aplastic anemia include individuals who are exposed to high-dose
radiation or toxic chemicals, take certain prescription drugs, have pre-existing autoimmune
disorders or blood diseases, or are pregnant. No screening test currently exists for early
detection of aplastic anemia.

SOURCES:
https://en.wikipedia.org/wiki/Aplastic_anemia
https://www.nhlbi.nih.gov/health/anemia/aplastic-anemia#:~:text=Aplastic%20anemia%20is%20a%20rare,can%20be
%20mild%20or%20serious.
https://www.mayoclinic.org/diseases-conditions/aplastic-anemia/symptoms-causes/syc-20355015