Tutorial for my friends:

R3 Medicine
Kannadit Prayongratana, M.D.
 Anemia
The condition in which the hemoglobin concentration
is below the normal value
WHOs normal Hb/Hct value

Categories Hb (g/dl) Hct (%)

Child -4 yr 11.0 33
Children 5-7 years 11.5 35
Children 8-11 years 12.0 36
Female 12.0 36
Male 13.0 40
 Sign and symptoms of anemia
Related to anemia
Pallor
Palpitation, tachycardia
Dyspnea, congestive heart failure
Fainting, syncope
Orthostatic hypotension
Shock
 Sign and symptoms of anemia
Related to underlying causes
GA : Jaundice, edema
Skin : Rash, oral ulcer, koilonychia, premature
grey hair
Gastrointestinal : Glossitis, odynophagia, Pica,
dyspepsia, melena, hematochezia,
organomegaly, mass lesion
 Classification of anemia
Onset : Acute, Subacute, Chronic
Red cell size :
Microcytic anemia (MCV<80 fl)
Normocytic anemia (MCV 80-100 fl)
Macrocytic anemia (MCV >100 fl)
Causes : Hypoproliferative, overutilization
 Classification by size
Thalassemia, Hemoglobinopathies 40
Iron deficiency anemia
Sideroblastic anemia

Microcytic
Lead poisoning 60
HS
Anemia of chronic inflammation
Anemia of chronic kidney disease 80
G-6-PD deficiency

Normo-
Aplastic anemia

cytic
Reticulocytosis
Autoimmune hemolytic anemia 100

Macro-
Liver disease

cytic
MDS, Megaloblastic anemia
120
 Hypoproliferative anemia
Marrow erythroid hypoproliferation
Pure red cell aplasia
Aplastic anemia
Iron deficency and anemia of inflammation
Bone marrow suppressant : drugs, radiations
Infiltrative marrow : tumors, infections
Myelofibrosis
Ineffective hematopoiesis
 Hypoproliferative anemia
Marrow erythroid hypoproliferation
Ineffective hematopoiesis
Megaloblastic anemia
Sideroblastic anemia
Myelodysplastic syndrome
 Overutilization anemia
Blood loss
Hemolysis
Intracorpuscular defects
Hereditary:
Membrane defects: HS, HE, SAO, HPP
Enzymopathy: G-6-PD, Pyruvate kinase
deficiency
Acquired : Paroxysmal nocturnal hemoglobinuria
Extracorpuscular defects
 Overutilization anemia
Blood loss
Hemolysis
Intracorpuscular defects
Extracorpuscular defects
Immune mediated: AIHA, HDN, HTR
Infections: malaria, clostridial infection
Mechanical: TTP, HUS, Cardiac hemolysis
Drugs or chemical: Pb poisoning
 Tools for classification
Reticulocyte count
Corrected reticulocyte count (%)
= Reticulocyte count x Hct
45
Reticulocyte production index (RPI)
= Corrected reticulocyte count
Maturation time
Hematocrit Correction factor
(Maturation days)
39 - 44.1 1.0
34 38.1 1.5
24 33.1 2.0
15 23.1 2.5
<15 3.0
Temple of Poseidon, Sunion, Greece
 Pure red cell aplasia
Characterized by
Anemia; NCNC
Reticulocytopenia (<1%, typical<0.1%)
Absent or rare erythroid precursor cells in
the bone marrow (marrow erythroid<5%)
 Classification of PRCA
Self-limited
Transient erythroblastopenia of childhood
Transient aplastic crisis of hemolysis (acute B19 parvovirus
infection)
Fetal red blood cell aplasia
Nonimmune hydrops fetalis (in utero B19 parvovirus infection)
Hereditary pure red cell aplasia
Congenital pure red cell aplasia Virus
(Diamond-Blackfan syndrome) Chronic Parvovirus B-19, hepatitis,
Acquired pure red cell aplasia HTLV, EBV
Thymoma and malignancy Pregnancy
Lymphoid malignancies Drugs
(and more rarely other Phenytoin
hematologic diseases) Azathioprine
Paraneoplastic to solid tumors Chloramphenicol
Connective tissue disorders with Procaineamide
immunologic abnormalities Isoniazid
SLE, JRA, RA,PGA Idiopathic
 Parvovirus B19
Underlying RBC survival Ability to Outcome Inves-
clear tigation
infection

Normal Normal Yes No anemia IgM

Hemolytic Decreased Yes Aplastic crisis IgM

anemia

HIV Normal or No PRCA PCR

 PRCA treatment
Treat the underlying causes
Autoimmune: corticosteroid
Parvo B-19:
Acute: self-limited, transfusion if necessary
Chronic: IVIG, IFN+Ribavirin
Thymoma: Thymectomy
Lymphoma: Combination CMT according to
WHO category
Parthenon, Athens
 Aplastic anemia
Pancytopenia with bone marrow hypocellularity.
 Inherited aplastic anemia or
Fanconis anemia
Autosomal recessive disease rusults in fragility
of chromosome leads to multiple congenital
malformations and pancytopenia.
Syndrome: short stature, microcephaly, multiple
bony abnormality (poly/oligo dactyly, single
kidney, horse shoe kidney, mental retardation
10%
Diagnosis: chromosome fragility to mitomycin C
or diepoxybutane (DEB)
Fanconis anemia
Fanconis anemia
 Fanconis anemia

Cytogenetic after treated with DEB

 Fanconis anemia
Treatment:
oxymethalone 2.5 mg/kg with good response.
Curative strategies: match sibling allogeneic
transplantation with reduce dose of conditioning
regimen.
 Acquired aplastic anemia
Acquired bone marrow failure due to immune
destruction via cytotoxic T-cell.
Sign and symptoms: anemic symptoms,
neutropenic fever, thrombocytopenic bleeding.
CBC: Pancytopenia with low reticulocyte count
(corrected retic count<1%) and relative
lymphocytosis.
PBS: Normochromic, normocytic anemia, low
WBC with relative lymphocytosis, low platelet
count, no abnormal cell.
Acquired aplastic anemia
 Acquired aplastic anemia
BM: Severe hypocellular BM due to trilineage
hypoplasia with relative lymphocytosis.
Acquired aplastic anemia
 Severe aplastic anemia
(SAA)
At least two of these three PBS criteria and BM
cellularity<30%:
Corrected reticulocyte count < 1% or absolute
retic count < 60,000/l.
Absolute neutrophil count < 500/l.
Platelet count < 20,000/l.
Non-severe (moderate) AA: less severe and
incompatible with SAA.
Very severe AA(VSAA): ANC<200/l extreme
increases infectious risk.
 Potential causes of AA
Currently licensed drugs reported to have a rare association with aplastic
anemia.

Antibiotics Chloramphenicol*, Sulphonamides

Anti-rheumatics Gold, Penicillamine
Anti-inflammatory Phenylbutazone, Indomethacin,
Diclofenac, Naproxen, Piroxicam
Anti-convulsants Phenytoin, Carbamazepine
Anti-thyroids Carbimazole, Thiouracil
Anti-depressants Dothiepin, Phenothiazines
Anti-diabetics Chlorpropamide
Anti-malarials Chloroquine
*There is no evidence for an association between chloramphenicol eye drops
and aplastic anemia More likely to cause neutropenia.

Baumelou et al, Blood 1993, 81, 14711478.

Issaragrisil et al, Blood,1997, 89, 40344039.
Kauffmann et al, 1996, Eur J Haematol, 57(Suppl.),2330.
Treatment in aplastic anemia
AA
Severity

SAA Non-SAA
age Supportive treatment

Less than 40 years More than 40 years

ISD
ANC 200-500/l VSAA
ISD Transplantation

Supportive Rx = Anabolic steroids, transfusion, antibiotics

ISD = Antithymocyte/antilymphocyte globulin (ATG/ALG) +
Cyclosporin A (CSA)
If transplant donor unavailable try ISD
Hydra island, Greece
 Cobalamine deficiency
Disorder which all of the hematopoietic cell are
unusually enlarged results from deficiency of
folate or cobalamine
Disorder caused by impaired DNA synthesis
Presents of Megaloblastic cell is the hallmark of
the disease
Normal development of Hb synthesis of
cytoplasm in contrast to delayed nuclear
development results in Nucleocytoplasmic
asynchrony
Cobalamines journey
Megaloblastic anemia :
Pathogenesis
Cobalamine deficiency: Causes
Decreased intake : Vegans
Impaired absorption
Gastric causes
Pernicious anemia
Gastrectomy
Zollinger-Ellison syndrome
Prolonged use of proton pump inhibitors
Intestinal causes
Ileal resection or disease
Blind loop syndrome
Diphyllobotrium latum (Fish tapeworm)
 Cobalamine deficiency :
Clinical manifestation
Fatigue
Palpitation
Light-headness
Shortness of breathing
Markedly pale
Mild jaundice
Sore tongue; beefy glossitis
Premature graying
(Pernicious anemia)
Neurologic manifestation:
Numbness, Posterolateral syndrome (SCD)
 Cobalamine deficiency :
Clinical manifestation
Neurologic symptoms and signs: in cobalamine
deficiency
Could be preceeding megaloblastic anemia
Begin with paresthesia due to peripheral nuropathy
together with disturbance of propioceptive and vibratory
senses (loss of position
sense of 2nd toe &
loss of vibration (256 Hz)
If untreated may progress to
Subacute combined degeneration
Cobalamine deficiency : Therapy
Most result from poor absorption or more than 3-
5 year totally deficient diet.
If neurologic defect developed; initiation with
intensive replacement to prevent further deficit
with cobalamine 1,000 g IM daily for 2 weeks
then every week until Hct is normalized
1,000 g every month life-long except vegans:
supplemented with oral form.
1,000 g every 2 wk for 6 mo in patient presented
with neurological deficit.
No therapeutic diagnosis!!!!
Notre Dame, Reims, France
Myelodysplastic syndromes
Heterogeneous group of disorders characterized
by inadequate and dysmorphic hematopoiesis.
Central to consideration is the fact that they
are clonal hematopoietic disorders.
The progeny of a single dysplastic stem cells are
able to dominate BM to the exclusion of their
normal progeny.
The dysplastic clone is inability to maintain
effective circulating cell populations.
 Clinical manifestation
Study Mean M:F Incidence
age
Anemia Thrombo Neutrop Splenome
cytopenia enia galy

BJH,1983 70 100:0 83 28 36 25

Hemonc,1985 72 - 93 25 31 18

BJH,1985 73 51:49 67 38 39 -

AJH,1984 59 65:35 - - - -

Blood,1989 68 53:47 82 45 24 12

BJH,1985 62 58:42 45 32 24 -

BJH,1987 73 50:50 85 - - -

Cancer,1985 68 52:48 - - - 12

Cancer,1983 - 54:46 - - - 21
 Diagnosis
CBC: anemia, thrombocytopenia, leukopenia
PBS: present of dysplastic features.
LDH, Indirect hyperbilirubinemia, AST
BM: dysplastic feature, elevated blast but less
than 20%.
BM Prussian blue: ringed sideroblast.
 Hematologic findings
RED CELLS
Macrocytosis
Dimorphism
Punctate basophilia
Nucleated red cell
Polychromatophilia
Erythroblast
 Hematologic findings
WHITE CELLS
Hypogranulation
Pseudo Pelger-Huet anomaly
Hypersegmentation
Ringed Neutrophil
Dohle bodies
Myeloblast
Immature cells
 Hematologic findings
PLATELETS
Giant platelets
Hypogranulation
Megakaryocyte fragments
 Bone marrow findings
CELLULARITY
Increased or normal cellularity is the most
common finding (81-100%) supporting ineffective
hematopoiesis.
Hypocellular marrow
found in 0-19% without
significance
(clinical & prognosis)
Fibrosis 20-25%
 Bone marrow findings
DYSERTYTHROPOIESIS 73-100%
Multinuclearity
Intranuclear bridging
Nuclear fragment and budding
Megaloblastic change
Vacuolation
Ringed sideroblast
Maturation arrest
 Bone marrow findings
DYSERTYTHROPOIESIS
 Bone marrow Prussian blue
RINGED SIDEROBLAST
Abnormal iron storage in mitochondria of
erythroid around the nucleus.
Defined as 1/3 or more erythroid nucleus is
encircled by 10 or more siderotic granules.
 Bone marrow pathology
RINGED SIDEROBLAST
 Bone marrow findings
DYSMYELOPOIESIS 37-88%
Giant primary granules.
Decreased primary granules.
Auer rods.
Decreased secondary granules.
Fragmented or abnormal nuclei.
Maturation arrest.
Abnormal localization of immature precursors
(ALIPS).
 Bone marrow findings
DYSMYELOPOIESIS
 Bone marrow pathology
Abnormal localization of immature precursors
(ALIPS)
 Bone marrow pathology
Abnormal localization of immature precursors
(ALIPS)
The anatomic interrelations between
hematopoietic precursors and the bone marrow
stroma.
Interface between marrow and bone, may be
disordered in patients with MDS.
Such relations regulate the normal
hematopoiesis.
 Bone marrow pathology
Abnormal localization of immature precursors
(ALIPS)
Stromal cells are important source of various
growth and inhibitory factors.
Specific binding to stromal matrix proteins may
also control the local concentration of growth
factors.
 Bone marrow pathology
Abnormal localization of immature precursors
(ALIPS)
Myeloblasts and other immature forms are
normally localized along the endosteal surface.
In many patients they form clusters (ALIPs)
that are not contiguous with bony trabeculae.
 Bone marrow pathology
DYSMEGAKARYOPOIESIS 50-87%
Micromegakaryocytes
Decreased nuclear polyploidy
Separated nuclei
Le Chteau de Chantilly, France
Vardiman JW : Blood 2002 :100(7) :2297
 FAB and WHO
FAB WHO
RA RA
5q- syndrome
RCMD
RARS RARS
RCMD/RS
RAEB RAEB-1
RAEB-2
RAEB-t AML
CMML MDS/MPD
Impact of WHO classification

Howe RB : Blood. 2004;103:3265-3270

 Managements in MDS
FACTORS TO BE CONSIDER
Age
IPSS risk
Performance status
Comorbid underlying diseases
Availability of matched sibling or unrelated
donor
 Managements in MDS
THERAPEUTIC CHOICES
Low intensity
to improve cytopenias
Consider first in low risk IPSS.
High intensity
to change natural course of disease (Leukemic
transformation)
Consider earlily in high risk IPSS.
Managements in MDS

Gotlib J, Greenberg P. Leukemia,7th Edition.; 2002:562.

Eiffels Tower, Paris
 G-6-PD deficiency
Defect in RBC enzymes results in hemolysis
triggered by oxidative stress
Clinical manifestation:
Hemolytic crisis; intravascular is predominant
response to fever, drugs, favism
Neonatal jaundice(NNJ) 20-30% of male NNJ
Chronic nonspherocytic hemolytic anemia
(CNSHA); mimic Hereditary spherocytosis
Hemoglobinemia Hemoglobinuria
G-6-PD deficiency: Therapy
Avoid fever and drugs
If hemolysis occurs hyperkalemia and renal
failure due to hemoglobinuria must be
concern, IV fluid replacement is mandatory
Oxidative agents: Acetanilide,Chloroquine,
Dapsone, Methylene blue, Nalidixic acid,
Naphthalene, Nitrofurantoin, Primaquine,
Sulfa, Sulfone, Sulfonylureas, Toluidine blue,
Urate oxidase
Grand Place, Brussels, Belgium
 Hereditary spherocytosis
Hereditary defect in RBC membrane constituent.
Largely Autosomal dominant inherited pattern
Spectrin is the most common protein loss but
largely secondary loss.
Ankyrin is the most common primary loss.
The loss of primary protein results in loss of
normal architecture and secondary loss
Chronic extravascular hemolysis in spleen is the
most common pathologic basis
 HS: Clinical manifestation
Neonatal jaundice
Asymptomatic, Jaundice without anemia
(compensated hemolysis)
The severity of anemia severity of hemolysis
and spleen size.
Splenomegaly
Gallstone with complication in the young
Aplastic crisis: Parvovirus B-19 infection
 HS: Laboratory findings
Anemia with MCV, MCHC, RDW
Reticulocytosis
Blood smear: spherocytes
Direct Coombs test: negative
Increased Osmotic fragility
Osmotic fragility test

control

patient
 HS: Therapy
In mild case therapy may not required.
Folate supplement is necessary in moderate to
severe case
Splenectomy is the definite treatment but this
must pay cost of infectious risk
Indications:
Symptomatic gallstone (with cholecystectomy)
Frequent hemolytic crisis
Failure to thrives
Patient desire
 HS: Therapy
Special considerations:
Presplenectomize vaccination
at least 2 weeks before splenectomy.
Polyvalent pneumococcal vaccine
Hib vaccine
Meningococcal vaccine
Postsplenectomy prophylactic antibiotics
for 2-5 years
 HS: Therapy

Age Penicillin V Amoxycillin Erythromycin

2 mo - 3yr 125 mg bid 125 mg bid 125 mg OD

Child > 3yr 250 mg bid 250 mg bid 250 mg OD

Adult 500 mg bid 500 md bid 250 mg OD

Brugges, Belgium
Paroxysmal nocturnal hemoglobinuria
Acquired hematologic disease occurring in adults
at a frequency of 1:100,000.
Phosphatidyl inositol glycan-A(PIG-A) gene
located on Xp22.1 encode the GPI.
Glycosylphosphatidyl-inositol (GPI) is the
transmembrane protein that act as the anchor
for the membrane protein.
The important examples of GPI linked protein
are CD55 or Decay accelerating factor (DAF)
and CD59 or Membrane inhibitor of reactive
lysis (MIRL).
Molecular pathogenesis of PNH
Paroxysmal nocturnal hemoglobinuria
CD55 and CD59 are complement regulatory
proteins important for self-protection from
complement.
Patients have a clonal population of RBC that are
highly sensitive to complement
Abnormal gene haboring multipotential
hematopoietic stem cells are long live.
This also occurred in wbc and platelet result in
bi- or pancytopenia in the patients.
 Clinical manifestation
Anemia due to chronic IVH.
Iron deficiency anemia may also occurred due to
renal iron loss.
Thrombosis may also occurred due to
Abnormal platelet microparticles activate coagulation
cascade
Impaired fibrinolysis due to impaired urokinase from
monocyte.
Dysphagia from NO2esophageal spasm
 Laboratory manifestation
CBC: Anemia, bicytopenia, pancytopenia Retic
count
PBS: Dimorphic anemia
LDH, Indirect hyperbilirubinemia, AST
Haptoglobin
Iron study may present IDA
Urine hemosiderin positive
Hams test (Acidify serum test) positive
Flow cytometry demonstrate the absent of
CD55, CD59: PNH-1, PNH-2, PNH-3.
Urine hemosiderin
Flow cytometry
 Treatment
Folic acid, Anabolic steroids, Iron supplement.
Prednisolone 1 mg/kg/d alternate day response
in ~30-50% of cases.
Transfusion
Eculizumab (monoclonal antibody to C5) in
severe case.(Not available in Thailand)
Allogeneic transplantation is curative tool
Eculizumab

Hillmen P, et al, N Engl J Med 2004;350:552-9.

Lean tower of Pisa, Italy
Thrombotic microangiopathy
Microvascular occlusive disorder due to
thrombus formation result in consumption of
platelet + coagulation factor and mechanical
trauma to the erythrocyte.
Red thrombi DIC
White thrombi TTP/HUS
Multiple organ dysfunction syndrome(MODS)
due to ischemia of the end-organ.
 Disseminated intravascular
coagulation
Pathophysiology
Syndrome results from microvascular
thrombosis due to certain stimuli
The thrombosis is wide spread and results in
consumption of coagulation factors
Classification
Acute DIC: usually uncompensated, bleeding
predominant
Chronic DIC: compensated, may be thrombosis
predominant
 Disseminated intravascular
coagulation
Etiology
Congenital: Kasabach-Merritt syndrome
Trauma: Giant hematoma, burn, aneurysm
Tumors: Acute DIC - APL
Chronic DIC - AdenoCA, others
Infection: Septicemia, Endotoxinemia,
Encapsulated bacteremia
Obstetric complications: Abruptio placentae,
Preeclampsia, HEELP syndrome, amniotic fluid embolism,
dead fetus in utero (DFIU)
Kasabach-Merritt syndrome
Acute Promyelocytic leukemia
 Disseminated intravascular
coagulation
Treatment
Acute DIC
Correct cause
Transfusion of component only serious bleeding
Chronic DIC:
Unfractionated or low molecular weight heparin
Correct cause
Thrombotic thrombocytopenic purpura
Hemolytic uremic syndrome
Thrombocytopenia (increased platelet
destruction) + MAHA (Microangiopathic
hemolytic anemia) + organ dysfunction (from
microvascular platelet thrombi)
Pathogenesis
Deficiency of vWF-cleaving metalloproteinase
(ADAMTS13) --> Unusually large vWF
multimers
Thrombotic thrombocytopenic purpura

N Eng J Med. 2002: 347: 8: 589-600.

Hemolytic uremic syndrome

N Eng J Med. 2002: 347: 8: 589-600.

Hemolytic uremic syndrome

N Eng J Med. 2002: 347: 8: 589-600.

 TTP/HUS
Clinical syndrome: Pentad
Fever
Anemia (Coombs neg. MAHA)
Thrombocytopenia
CNS : confusion, headache, focal deficit, coma
Renal dysfunction
Differential diagnosis:
Evans syndrome (ITP+AIHA), SLE ,
DIC, Infective endocarditis,
preeclampsia (in pregnant case) , disseminated
carcinoma
 TTP/HUS
Laboratory findings :
CBC, blood smear: MAHA picture
LDH
Urine exam
BUN Creatinine
Normal coagulogram
Direct Coombs test
D-dimer/FDP
 TTP/HUS
Plasma therapy
Plasma exchange
Plasma infusion : FFP , Cryosupernatant
Adjunctive therapies ( + )
Glucocorticoids
Relapse: Cyclophosphamide , Azathioprine,
Splenectomy
Refractory: Splenectomy,Vincristine, IVIg
Cyclosporin : case report
Platelet transfusion is Contraindicated!!


Kinderdijk, Netherlands
Tutorial for my friends:
R3 Medicine
Kannadit Prayongratana, M.D.


Fontana de Trevi, Rome