Hemolytic anemia –

Pathophysiology and diagnostic

approach

Debdatta Basu
Department of Pathology
JIPMER
Pondicherry
 Hemoglobin structure

Hb A = 2 2 - 95-97%
Hb F = 2 2 - < 1%
Hb A2 = 2 2 - < 3%
Senescent Red Cells Broken down to Amino
 Acids

RE Cells Haemoglobin releasd Haem + Globin

In RE Cells and
of Spleen broken down

In Plasma Iron + Protoporphyrin

Carried to iron stores Biliverdin

like Bone Marrow

Bilirubin (unconjugated)
Iron deposited in
Conjugated in Liver
Marrrow
 
Bilirubin excreted in bile

Bilirubin acted upon by
Bacterial enzymes in intestine

Enterohepatic  absorbed  Urobilinogen /
stercobilinogen
Circulation 
 Fecal stercobilinogen
Kidney

Urobilinogen in urine
(2-4 mg / day)
Hemolytic anemia

• Hemolysis

• Compensated hemolytic state

• Hemolytic anemia
Sites of destruction
• Extravascular
– RE cells in spleen and BM
– Life span less than 120 days
– Inherent defect of RBC

• Intravascular
– Circulating blood
– Extrinsic factors
– RBC essentially normal
Extravascular hemolysis
• RE cells
•  unconjugated Bilirubin
•  stercobilinogen
•  urinary urobilinogen - dark urine
•  iron stores
• Diseases like thalassemia, hereditary
spherocytosis
Intravascular hemolysis
• In circulating blood
• Hemoglobinemia
•  serum haptoglobin
• Hemoglobinuria
• Hemosiderinuria
•  LDH
• Malaria, fragmentation syndromes,
G6PD deficiency
Compensatory mechanisms

• Vigorous blood regeneration

• Erythroid hyperplasia

• Reticulocytosis
Clinical features
• Anemia

• Jaundice

• Splenomegaly
Clinical features (contd)
• Gall stones
– pigment stones

• Leg ulcers
– Bilateral
– medial or lateral
malleolus
Skeletal abnormalities
Acquired hemolytic anemia

• Anemia
• Jaundice
• Fever
• Chills and rigors
• Abdominal pain
Classification of HA

• Intrinsic defect
– Inherited
– Morphological abnormality, target cell

• Extrinsic defect
– Acquired
– Morphologically normal, fragmentation
Hereditary spherocytosis

• Deficiency of
spectrin

• Membrane instability

• Spherocytes
Disorders of globin chain

• Thalassemia
– Quantitaive deficiency
– Alpha or Beta
• Hemoglobinopathy
– Qualitative defect
– Hb S, Hb E, Hb D Punjab, Hb C
Thalassemia
Beta thalassemia
• Deficiency/Absence of beta chains
• Decreased Hb A - anemia
• Excess alpha chains precipitate -
erythroid cells destroyed in marrow -
anemia
• Hb F increase
• Iron overload
Electrophoresis at pH 8.6
Thalassemia trait
• Heterozygotes, asymptomatic
• Genetic counselling
• Near normal Hb with micro hypo RBC
• Increased Hb A2
• Column chromatography
• HPLC
Hemoglobinopathy
• Sickle cell disease
• Africa, Mediterranean, Central India
• Valine for Glutamine at 6th position of
Beta chain
• Sickling phenomenon
• Autosplenectomy
• Crises
Extracorpuscular defects
• Immune mediated
– Alloimmune hemolytic anemia
• Mismatched transfusion
• Hemolytic disease of newborn
– Autoimmune hemolytic anemia
• Infections - falciparum malaria
• Fragmentation syndrome - Mechanical
– Cardiac
– MAHA - DIC, TTP, HUS
Infections causing HA
• Malaria
– Plasmodium falciparum
– Black water fever

• Babesiosis
• Clostridial sepsis
Hemolytic disease of newborn

• Rh incompatibilty

• Rarely ABO
incompatibilty
 Autoimmune haemolytic
anaemia AIHA
Warm antibody type: antibodies react
with RBC at 37oc
• Idiopathic - 35-45 % of cases
• Secondary - 55- 65% of cases are
associated with
–autoimmune disease like SLE,rheumatoid
arthritis, ulcerative colitis
–CLL and Non-Hodgkin’s lymphoma
–drugs like M-DOPA, Procainamide,
Levodopa
Autoimmune haemolytic
anaemia AIHA (contd.)
Cold antibody type: Antibodies react with
RBCs at lower temperature < 370 c
• Idiopathic-Cold agglutinin disease
• Secondary
– Paroxysmal cold haemoglobinuria PCH
– Infectious mononucleosis
– M.Pneumonia infection
Causes of Red Cell Fragmentation

A. Cardiac Haemolytic Anaemia

– Valvular prosthesis
– Aortic Stenosis
– Mitral valve disease
– Coarctation aorta
B. Microangiopathic Haemolytic anaemia-MAHA
– Haemolytic uremic syndrome(HUS)
– Thrombotic thrombocytopenic purpura(TTP)
– DIC
c. March Haemoglobinuria
Drug induced HA
• Hapten type mechanism
– Penicillins and cephalosporins
• Imune complex ( Innocent bystander)
– Quinine, Quinidine, Isoniazid
• Auto immune type
– Alpha methyl dopa, Procainamide,
Ibuprofen
Paroxysmal Nocturnal
Hemoglobinuria
• Acquired intrinsic defect
• Stem cell disorder
• Susceptibility to complement mediated
lysis
• Mutations in PIG-A gene leads to
defective anchorage of certain proteins
like DAF
• Intravascular hemolysis
Approach to Hemolytic Anemia
• Establish hemolysis
– Signs of increased RBC destruction
– Signs of accelerated erythropoiesis
• Establish cause of hemolysis
– History and examination
– Peripheral blood examination
– Specific tests