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Aplastic Anaemia
Essential Haematology (7th Ed) p242-249
Myelodysplastic Syndrome
Essential Haematology (7th Ed) p177-185
Paroxysmal Nocturnal Haemoglobinuria
Essential Haematology (7th Ed) p247

Myelodysplastic Syndrome, Aplastic Anaemia and

Paroxysmal Nocturnal Haemglobinuria

Kate Leung

1 2

Diagnostic overlap Case 1

M/52
Worked in China (garment factory)
Non-smoker, social drinker
Good past health
Presented to China hospital with URI symptoms
P/E: unremarkable
Blood checking done (LRFT normal)
Paroxysmal
Hb 11.6 g/dL (13.4-17.1 g/dL)
nocturnal RBC 3.2 x 109/L (4.3-5.9 x 109/L )
haemoglobinuria
MCV 108.7 fL (82.0-97.0 fL)
WBC 7.0 x 109/L (3.7-9.2 x 109/L)
Plt 67 x 109/L (145-370 x 109/L )
USG abdomen: no hepatosplenomegaly

3 4

Brainstorm
PBS review: More information:
CBC indices persist after resolution of URI symptoms
Macrocytic anaemia Deny any drugs or herbs taken
WBC differential unremarkable
Thrombocytopenia confirmed Summary:
52 yo male, good past health, incidental finding of anaemia &
thrombocytopenia
Asymptomatic

What is your differential diagnosis?

Further investigations?
No?
Yes, what then?

5 6
Importance of PBS review Macrocytosis or macrocytic anaemia
CBC = complete blood count
Hb/RBC/MCV B12/folate deficiency
WBC Chronic liver disease
Platelet Common

Excess alcohol
Drugs
PBS = peripheral blood smear
Morphology
Medical haematological emergency (anaemia &
thrombocytopenia for this case): Hypothyroidism
Microangiopathic haemolytic anaemia (MAHA) red cell fragments or
schistocytes, polychromasia
Less Haemolysis
Myelodysplasia and other bone
Acute leukaemia or high grade myelodysplastic syndrome blasts,
dysplastic neutrophils
common marrow disorders

7 8

Thrombocytopenia Other blood tests

Repeat CBC and LRFT
Immune: autoimmune thrombocytopenic Lactate Dehydrogenase (LDH)
Increased purpura
Non-immune: DIC (disseminated
intravascular coagulation), TTP
Vitamin B12 and folate levels
destruction (thrombotic thrombocytopenic purpura) Thyroid function test (TFT)
Autoimmune marker
Direct antiglobulin test (DAT)
Bone marrow failure (inherited and Iron profile: iron, total iron binding capacity (TIBC),
Decreased acquired)
Myelodysplasia. leukaemia and other bone
ferritin
Haptoglobin
production
marrow disorders (such as myeloma)
Marrow infiltration by tumors or infection
Megaloblastic anaemia

9 10

Case 1 ( Bone Marrow Aspirate, 5/2015)

Case 1 (other blood tests):
Hb 10 g/dL 13.4-17.1 g/dL
MCV 112 fL 82-97 fL
WBC 4.9 x 109/L 3.7-9.2 x 109/L
Plt 28 x 109/L 145-370 x 109/L
Normocellular marrow
Bilirubin 24 umol/L 5-21 umol/L Active erythropoiesis with mild megaloblastoid changes
LDH 591U/L <248 U/L Active granulopoiesis and megakaryocytopoiesis
No dysplastic changes
Haptoglobin <0.08 g/L 0.14 - 2.58 g/L

Iron 47.2 umol/L 12.5 - 32.2 umol/L

TIBC <57.2 umol/L 44.8 - 76.0 umol/L
Ferritin 1734 pmol/L 53 - 739 pmol/L
11 12
 Case 1 (Trephine Biopsy, 5/2015) Cytopenia
One or two or three lineages
If all three lineages (Hb/WBC/Plt) pancytopenia

Increased Immune: autoimmune disease

Non-immune: splenomegaly
destruction
Bone marrow failure (inherited and acquired)
Decreased Myelodysplasia. leukaemia and other bone
marrow disorders (such as myeloma)
Normocellular marrow with
adequate trilineage production Marrow infiltration by tumors or infection
Megaloblastic anaemia (vitamin B12 or folate
deficiency)
haemopoiesis

13 14

Cytopenia Aplastic anaemia

One or two or three lineages Characterized
If all three lineages (Hb/WBC/Plt) pancytopenia pancytopenia with
hypoplastic bone marrow
Causes: primary (inherited
Increased Immune: autoimmune disease
Non-immune: splenomegaly vs acquired) or secondary
destruction
Bone marrow failure (inherited and acquired)
Decreased Myelodysplasia. leukaemia and other bone
marrow disorders (such as myeloma)

production Marrow infiltration by tumors or infection

Megaloblastic anaemia (vitamin B12 or folate
deficiency)

15 16 Essential Haematology 7th Ed (p243)

Aetiology of aplastic anaemia Aplastic anaemia (primary, congenital)

Idiopathic (~70%): vast majority Also termed Inherited bone marrow failure syndrome
Secondary (~10-15%): Multi-lineage:
Inevitable: ionizing radiation, cytotoxic drugs
Fanconis anaemia
Idiosyncratic: idiopathic, drug induced, viral, commercial
solvents Dyskeratosis congenita
Industrial: benzene Single lineage:
Infections: viruses (EBV, hepatitis, HIV) Diamond Blackfan anaemia
Immune diseases: SLE,
Shwachman-Diamond syndrome
Inherited (~10%)
Congenital amegakaryocytic thrombocytopenia with absent
Fanconis anaemia (AR): spontaneous chromosomal
breakage, also predispose to leukaemia radii
Dyskeratosis congenita (X linked recessive mainly, some AR Some cases may progress to complete bone marrow failure
& AD)

17 18
Clues to inherited BMF syndromes
Fanconis anaemia
Dyskeratosis congenita
19
Fanconis anaemia
Diamond Blackfan
Autosomal recessive (most) or X linked recessive
anaemia Heterogeneous with multiple genes involved
FA cells are genomic instable, increase chromosomal breakage and
hypersensitivity to DNA cross-linking agents such as diepoxybutane
(DEB)
Progressive BM failure and increased predisposition to
malignancy
90% developed BM failure at 40 years old
Congenital thrombocytopenia 10% progress to acute myeloid leukaemia (AML)
with absent radii Associated with growth retardation and other somatic
abnormalities:
Skin (caf au lait spots or hypo-/hyper-pigmentation)
Skeletal (absent thumbs, radial hypoplasia, scoliosis)
Genitourinary (underdeveloped gonads, horseshoe kidneys)
1/3 have no physical abnormalities
Hoffman (2005) 20

Dyskeratosis congenita Diamond Blackfan Anaemia

Most are X-linked recessive Present in infancy or less than one year of age as pure red cell
aplasia (pallor or failure to thrive)
Present in childhood Macrocytic anaemia
Mucocutaneous triad of abnormal skin pigmentation, nail Reticulocytopenia
dystrophy and mucosal leukoplakia BM: absent erythropoiesis
Pulmonary fibrosis
Like FA, associated with bone marrow failure and increased
risks of malignancy
80 % BM failure before age of 20 May have other physical abnormalities such as short stature,
Defective telomere maintenance with shortened craniofacial, cardiac and urogenital malformations
telomere lengths Think of acquired causes (transient or chronic pure red cell
aplasia)
Management: supportive treatment
21 22

Aetiology of aplastic anaemia Aetiology of aplastic anaemia

Idiopathic (~70%): vast majority Idiopathic (~70%): vast majority
Secondary (~10-15%): Secondary (~10-15%):
Inevitable: ionizing radiation, cytotoxic drugs Radiation: predictable
Idiosyncratic: idiopathic, drug induced, viral, commercial
solvents Drugs: predictable or idiosyncratic
Industrial: benzene Viruses: idiosyncratic
Infections: viruses (EBV, hepatitis, HIV) Immune such as SLE
Immune diseases: SLE, Inherited (~10%)
Inherited (~10%) Fanconis anaemia (AR): spontaneous chromosomal
Fanconis anaemia (AR): spontaneous chromosomal breakage, also predispose to leukaemia
breakage, also predispose to leukaemia Dyskeratosis congenita (X linked recessive mainly, some AR
Dyskeratosis congenita (X linked recessive mainly, some AR & AD)
& AD)

23 24
Aplastic Anaemia (primary, acquired) Diagnosis
Most common type of aplastic anaemia are acquired Straightforward
Majority of acquired aplastic anaemia are idiopathic, though Cytopenia
believed to be immune-related Bone marrow: cellularity <25% (trephine biopsy)
Age of presentation: biphasic (10-25 and 60 years old) No other abnormal infiltrates
Pancytopenia (>2 lineages involved) + Hypocellular BM
Anaemia (normocytic or macrocytic, Hb <10 g/dL) Consider
Leucopenia (WBC <1.5 x 109/L)
Inherited bone marrow failure in younger patients
Thrombocytopenia (<50 x 109/L)
Hypoplastic myelodysplastic syndrome in older patients
Severity:
Severe (retic <20%, absolute neutrophil <0.5 x 109/L, plt <20 x 109/L)
Very severe (absolute neutrophil <0.2 x 109/L)
Non-severe (not so severe as above)

25 26

Pathogenesis of AA Pathogenesis of aplastic anaemia

Proliferation defect of precursor cells
Quantitative & qualitative stem cell defects
Immune reaction against haemopoietic tissue
T lymphocytes (CD8+)
Lymphokines (interferon & TNF)
? Abnormal sensitivity of AA precursor cells to these
inhibitory lymphokines
Stromal & haemopoietic growth factors (not likely)
Genetic factors: HLA-DR2 and HLA-DR15
( DRB1*1501 and 1502 alleles)
Role in antigen recognition

27 28 Clin & Expt Immuno (2015)

Treatment Cytopenia
Depends on severity One or two or three lineages
Supportive If all three lineages (Hb/WBC/Plt) pancytopenia
Transfusion
Prophylactic antibiotics
Increased Immune: autoimmune disease
Non-immune: splenomegaly
Curative destruction
Bone marrow failure (inherited and acquired)
Decreased Myelodysplasia, leukaemia and other bone
marrow disorders (such as myeloma)

production Marrow infiltration by tumors or infection

Megaloblastic anaemia (vitamin B12 or folate
deficiency)

29 30
Myelodysplastic syndromes (MDS) Myelodysplastic syndromes (MDS)
A group of clonal haemopoietic stem cell disorder Most cases are primary
characterized by dysplasia and ineffective haemopoiesis in May have history of benzene exposure, cigarette smoking or
one or more major myeloid cell line inherited syndromal disorders such as Fanconi anaemia
Some are secondary to chemotherapy or radiation
< 20% blasts in blood and bone marrow therapy given due to other malignancies (therapy-related
MDS)
Characterized pancytopenia with hypercellular bone
marrow Disease of elderly (median age of onset 70 years old)
Some MDS: pancytopenia with hypocellular bone marrow
hypoplastic MDS

31 32

Definition Dyserythropoiesis
Classification of MDS Nuclear budding
Dysplasia Inter-nuclear bridging
Single VS Multi-lineage
Karyorrhexis
% of ring sideroblasts
(erythroid dysplasia) Multinuclearity
% of blasts Megaloblastoid maturation
Vacuolation

Ring sideroblast
PAS +ve

33 34

Dyserythropoiesis Dysgranulopoiesis
Small size
Nuclear hypolobulation
(pseudo-Pelger Heut)
Hypersegmentation

Hypogranularity
Pseudo-Chediak Higashi
granules

Ring sideroblasts: presence of 5 or more

iron granules encircling one third or more of
35 the nucleus 36
Blasts Dysmegakaryocytopoiesis
Hypolobulated micro-
megakaryocyte
Non-lobulated nuclei in
megakaryocyte of all sizes
Multiple, widely separated
nuclei

37 38

Classification of MDS
Dysplasia
Single VS Multi-lineage
% of ring sideroblasts
(erythroid dysplasia)
% of blasts High-risk MDS

Cytogenetic
abnormalities

Cytopenia generally
corresponding to the dysplasia
lineages
But may be discordance

39 Essential Haematology 7th Ed (p178) 40 Essential Haematology 7th Ed (p181 )

Risk group in MDS Progression to AML

IPSS (International prognostic scoring Low risk Vs High risk MDS

system)
Different treatment plan
Cytogenetic (very good to very
Supportive for low risk MDS or
poor karyotype)
elderly
% bone marrow blasts
More aggressive for high risk
Cytopenias: unilineage Vs (consider other co-morbids)
multilineage
41 42 JHO (2013)
Essential Haematology 7th Ed (p179 )
Diagnostic overlap Aplastic anaemia (AA)
Immune destruction of
haemopoietic stem cells
Increase apoptosis
Decrease proliferative
capacity
Bone marrow failure
Peripheral cytopenia
Paroxysmal Hypocellular bone marrow
nocturnal
haemoglobinuria
(aplasia)

43 44 Lancet (2005)

Paroxysmal nocturnal haemoglobinuria

(PNH) or Myelodysplastic syndrome (MDS)
Direct insult of
haemopoietic stem cells
Increase apoptosis
Clonal mutation and
expansion of abnormal
clone (ineffective
haematopoiesis)
Myelodysplastic
syndrome
Peripheral cytopenia
Hypercellular bone
marrow
AA/PNH/MDS
Immune attack of
haemopoietic stem cells
Increase apoptosis
Clonal mutation and
expansion of abnormal
clone (ineffective
haematopoiesis)
Myelodysplastic
syndrome
Peripheral cytopenia
Hypocellular bone marrow
(Hypoplastic MDS)

45 Lancet (2005) 46 Lancet (2005)

Diagnostic overlap Paroxysmal Nocturnal Haemoglobinuria

Very rare
Acquired clonal stem cell disorder
Deficient synthesis of glycosylphosphatidylinositol (GPI)
anchor
GPI attaches several surface proteins to the cell membrane
Mutations in the phosphatidylinositol glycan protein class A
Paroxysmal
(PIG - A) on chromosome X
nocturnal Direct damage VS immune attack (~ AA and MDS)
haemoglobinuria

47 48
GPI-linked proteins Pathogenesis of PNH
CD55 = decay activating
factor
CD59 = membrane
inhibitor of reactive lysis

49 Essential Haematology 7th Ed (p247 ) 50 Am J of Blood Res (2015)

Clinical presentation Case 1 (5/2015)

Classic: Hb 10 g/dL 13.4-17.1 g/dL
Haemolytic anaemia (complement-mediated, chronic MCV 112 fL 82-97 fL
intravacular haemolysis)
WBC 4.9 x 109/L 3.7-9.2 x 109/L
Thrombosis
Plt 28 x 109/L 145-370 x 109/L
Bone marrow failure
PNH associated with other bone marrow disorders
(aplastic anaemia, myelodyplastic syndromes or others) Bone marrow: normocellular marrow
May have haemolysis
Subclinical
May be a small clone in patients with AA or MDS
No haemolysis

51 52

Case 1 (PNH screen, 6/2015) Case 1 (12/2015)

Hb 6.6 g/dL 13.4-17.1 g/dL
MCV 87 fL 82-97 fL
WBC 4.3 x 109/L 3.7-9.2 x 109/L
Plt 12 x 109/L 145-370 x 109/L

Evolving into Aplastic Anaemia with PNH clone

PNH granulocyte & monocyte PNH Type 1/II/III red cells 80%/6%/14% Repeat Trephine Biopsy:
clone 64% and 60% - Adequate core of trephine biopsy
Notes: Type I = normal CD59 expression (i.e. normal red
53 cells) 54
Case 1 (Repeat Bone Marrow,12/2015) Case 1 (12/2015)
Treatment
Immunosuppressants
Anti-thymocyte globulin (ATG)
Cycloporin A
Prednisolone
Markedly hypocellular marrow Supportive transfusion
Reduced trilineage haemopoiesis
Red cell
No dysplastic changes
No increase in blasts Platelets

55 56

Case 2
F/26, presented with anaemic symptoms Case 2
Hb 6.6 g/dL 11.7-14.9 g/dL Summary:
WBC 4.8 x 109/L 3.7-9.2 x 109/L F/26
Plt 160 x 109/L 145-370 x 109/L Evidence of haemolysis: anaemia, raised LDH and bilirubin, low
haptoglobin
Bilirubin 44 umol/L 5-21 umol/L Direct antiglobulin test (DAT) negative
LDH 4192 U/L <248 U/L Iron deficiency anaemia with no underlying causes found
Haptoglobin <0.08 g/L 0.35-2.50 g/L Urine for haemosiderin: positive

Iron 32 umol/L 7-26 umol/L Subsequently developed abdominal pain (3 episodes in

TIBC 65% 15-50% one year)
Ferritin 48 ng/mL 7-283 ng/mL

57 58

PNH Screen Case 2

Diagnosis:
Classic paroxysmal nocturnal haemoglobinuria (PNH)
Presented with haemolytic anaemia (PNH granulocyte clone
>50%)

Treated with Eculizumab (humanized monoclonal

antibody against C5 that inhibits terminal complement
activation)

Developed inferior vena cava and portal vein thrombosis

PNH granulocyte & monocyte
clone 89% and 86%
59
during pregnancy despite anticoagulation given,
PNH Type 1/II/III red cells 70%/2%/28%
emergency caesarean section at 28 weeks of gestation
Notes: Type I = normal CD59 expression (i.e. normal
red cells)
60
Case 2 (after eculizumab) Diagnostic overlap
Hb 9.9 g/dL 11.7-14.9 g/dL Incidence in US
WBC 3.2 x 109/L 3.7-9.2 x 109/L PNH: 1 in million
Plt 111 x 109/L 145-370 x 109/L AA: 2 in million
MDS: 40 in million
Bilirubin 24 umol/L 5-21 umol/L
LDH 281 U/L <248 U/L All are rare disease
Haptoglobin <0.04 g/L 0.35-2.50 g/L Paroxysmal 50% of AA has PNH clone
nocturnal
haemoglobinuria 20% Hypocellular MDS has
Iron 18 umol/L 7-26 umol/L PNH clone
TIBC 32% 15-50% AA can evolve into MDS
Ferritin 189 ng/mL 7-283 ng/mL

61 62

Summary
Aplastic Anaemia
Cytopenia + Hypoplastic bone marrow (production defect)
Inherited VS Acquired causes
Myelodysplastic Syndrome
Cytopenia + Hypercellular bone marrow with dysplastic changes
(ineffective haematopoiesis)
Some: Cytopenia + Hypocellular bone marrow with dysplastic
changes
Rare cases with overlapping myeloproliferative features [Essential
Haematology (7th Ed) p184]
Paroxysmal Nocturnal Haemoglobinuria
Classic (Haemolyic anaemia + Thrombosis + Bone marrow failure)
PNH clones in association with AA, MDS or other myeloid disorders
(survival advantage or immune-related)
Subclinical

63