Haemolytic

anaemias are caused by increased destruction of red cells Red cell normally survives about 120 days
haemolytic anaemias, the red cell survival times are considerably shortened Breakdown of normal red cells occurs in the macrophages of the bone marrow, liver and spleen
In

 Hemolytic

anemias share the following

features: Premature destruction of red cells and a shortened red cell life span Elevated erythropoietin levels and a compensatory increase in erythropoiesis Accumulation of hemoglobin degradation products released by red cell breakdown derived from hemoglobin

of red cell survival does not always cause anaemia as there is a compensatory increase in red cell production by the bone marrow Compensated Haemolytic Disease: If red cell loss can be contained within the marrows capacity for increased output, then a haemolytic state can exist without anaemia Erythroid Hyperplasia: Bone marrow can increase its output by six to eight times by increasing the proportion of cells committed to erythropoiesis and by expanding the volume of active marrow
Shortening

addition, immature red cells (reticulocytes) are released prematurely These cells are larger than mature cells and stain with a light blue tinge on a peripheral blood film
In

Red cell destruction causes a modest rise in unconjugated bilirubin in blood and mild jaundice. Increased reabsorption of urobilinogen from the gut results in an increase in urinary urobilinogen Red cell destruction releases LDH into serum. The bone marrow compensation results in a reticulocytosis, and nucleated red cell precursors may also appear in the blood. Activation of the bone marrow can result in a neutrophilia and immature granulocytes appearing in the blood to cause a leuco-erythroblastic blood film.

Appearances of red cells may give an indication of the likely cause of the haemolysis

Spherocytes are small, dark red cells which suggest autoimmune haemolysis or hereditary spherocytosis Sickle cells suggest haemoglobinopathy Red cell fragments indicate microangiopathic haemolysis

Spherocytes

Laboratory features and classification of the causes of haemolysis

 Extravascular

haemolysis

In most haemolytic conditions red cell destruction is extravascular. The red cells are removed from the circulation by macrophages in the reticuloendothelial system, particularly the spleen
Intravascular

haemolysis

can be classified as congenital or acquired Inherited red cell abnormalities resulting in chronic haemolytic anaemia may arise from pathologies of
These

Red cell membrane (hereditary spherocytosis or elliptocytosis), Hemoglobin (haemoglobinopathies) or Protective enzymes which prevent cellular oxidative damage, such as glucose-6-phosphate dehydrogenase (G6PD)

 Acquired

causes include Auto- and Allo-antibody-mediated destruction of red blood cells and other Mechanical, Toxic and Infective causes

structure is a cytoskeleton 'stapled' on to the lipid bilayer by special protein complexes. This structure ensures great deformability and elasticity
Basic

cell diameter is 8 m but the narrowest capillaries measures just 2 m in diameter When normal red cell structure is disturbed, cells lose their elasticity Each time such cells pass through spleen, they lose membrane relative to their cell volume. This results in an increase in mean cell haemoglobin concentration (MCHC), abnormal cell shape and reduced red cell survival due to extravascular haemolysis
Red

to intrinsic defect in red cell membrane skeleton that makes red cells spheroid, less deformable, and vulnerable to splenic sequestration and destruction Autosomal dominant condition 25% of cases have no family history and represent new mutations The incidence is approximately 1:5000 in developed countries The most common abnormalities are deficiencies of beta spectrin or ankyrin
Due

 The

characteristic clinical features are anemia, splenomegaly, and jaundice The severity of HS varies greatly In a small minority HS presents at birth with marked jaundice and requires exchange transfusions. In 20% to 30% of patients the disease is mild and virtually asymptomatic; here the decreased red cell survival is readily compensated for by increased erythropoiesis

 Most

cases are asymptomatic with compensated chronic hemolytic state with spherocytes present on the blood film, a reticulocytosis and mild hyperbilirubinaemia. Pigment gallstones are present in up to 50% of patients and may cause symptomatic cholecystitis

 The

clinical course may be complicated by crises: Haemolytic crisis occurs when severity of haemolysis increases; this is rare, and usually associated with infection. Megaloblastic crisis follows development of folate deficiency. It may occur in pregnancy. Aplastic crisis occurs in association with erythro (parvo) virus infection. It directly invades red cell precursors and temporarily switches off red cell production.

 Patient

and other family members should be screened for features of compensated hemolysis Haemoglobin levels are variable, depending on the degree of compensation. HS red cells also have an increased mean cell hemoglobin concentration The blood film will show spherocytes

 Direct

Coombs test is negative, excluding immune hemolysis. An osmotic fragility test may show increased sensitivity to lysis in hypotonic saline solutions but is limited by lack of sensitivity and specificity. More specific flow cytometric tests, detecting binding of eosin-5-maleimide to red cells, are recommended in borderline cases.

acid prophylaxis, 5 mg once weekly, should be given for life. Splenectomy, improves but does not normalise red cell survival. Potential indications include moderate to severe haemolysis with complications (anaemia and gallstones) It should be delayed until after 6 years of age in view of the risk of sepsis
Folic

severe hemolytic crises require transfusion support But blood must be cross-matched carefully and transfused slowly as hemolytic transfusion reactions may occur
Acute,

It is a heterogeneous group of disorders that produce an increase in elliptocytic red cells on the blood film and a variable degree of haemolysis It is caused primarily by defects in one or more of the proteins that make up the two-dimensional membrane skeletal network Inheritance may be autosomal dominant or recessive It is less common than hereditary spherocytosis in Western countries, with an incidence of 1/10 000, but is more common in equatorial Africa and parts of South-east Asia

 The

clinical course is variable and depends upon the degree of membrane defects Most cases are asymptomatic but in occasional cases haemolysis results Management is the same as for hereditary spherocytosis.

Elliptocytes

must produce energy via ATP to maintain a normal internal environment and cell volume It should also protect itself from oxidative stress presented by oxygen carriage. Anaerobic glycolysis via the EmbdenMeyerhof pathway generates ATP, and the hexose monophosphate shunt produces NADPH and glutathione to protect against oxidative stress
RBCs

 The

impact of functional or quantitative defects in the enzymes in these pathways depends upon the importance of the steps affected and the presence of alternative pathways. In general, defects in the HMP shunt pathway result in periodic haemolysis induced by oxidative stress, whilst those in the EmbdenMeyerhof pathway result in shortened red cell survival and chronic haemolysis

 Glucose-6-phosphate

dehydrogenase (G6PD) deficiency reduce the ability of red cells to protect themselves against oxidative injuries and lead to hemolysis Most common human enzymopathy, affecting 10% of population, with a geographical distribution which parallels the malaria belt G6PD deficiency is a recessive X-linked trait, placing males at higher risk for symptomatic disease while females acts as carriers

or muscle weakness Jaundice or pallor Dyspnea Dark urine Pain (especially abdominal) Splenomegaly
Fatigue

 Broad

beans (favism)

Fava beans, bell beans, fever beans, hava beans, pigeon beans, horse beans, tick beans, silkworm beans, English dwarf beans

Antimalarials (primaquine, quinine, chloroquine, pyrimethamine) NSAIDs (aspirin, ibuprofen, phenacetin) Antibiotics (sulfonamides, Nitrofurantoin ciprofloxacin) Miscellaneous: quinidine, probenecid, vitamin K, dapsone

 Henna

primarily infants and pregnant women Naphthlene (moth balls) regular exposure

The blood film will show Bite cells (red cells with a 'bite' of membrane missing) Blister cells (red cells with surface blistering of the membrane) Irregularly shaped small cells Polychromasia reflecting the reticulocytosis Denatured haemoglobin visible as Heinz bodies within the red cell cytoplasm

Red cells with precipitates of denatured globin (Heinz bodies)

Bite cells

any precipitant drugs and treat any underlying infection. Acute transfusion support may be life-saving.
Stop

 This

is the second most common red cell enzyme defect. It results in deficiency of ATP production and a chronic haemolytic anaemia. It is inherited as an autosomal recessive trait.

 The

extent of anaemia is variable Blood film shows characteristic 'prickle cells' which resemble holly leaves. Enzyme activity is only 5-20% of normal. Transfusion support may be necessary.

 This

results from increased red cell destruction due to red cell autoantibodies. The antibodies may be IgG or M, or more rarely IgE or A. If an antibody avidly fixes complement, it will cause intravascular haemolysis, but if complement activation is weak, the haemolysis will be extravascular. Antibody-coated red cells lose membrane to macrophages in the spleen and hence spherocytes are present in the blood

 The

optimum temperature at which the antibody is active is used to classify immune haemolysis: Warm antibodies bind best at 37 C and account for 80% of cases. The majority are IgG and often react against Rhesus antigens. Cold antibodies bind best at 4 C but can bind up to 37 C in some cases. They are usually IgM and bind complement. They account for the other 20% of cases

 The

incidence is approximately 1/100 000 population per annum It occurs at all ages but is more common in middle age and in females. No underlying cause is identified in up to 50% of cases

 The

remainder are secondary to a wide variety of other conditions Lymphoid neoplasms: lymphoma, chronic lymphocytic leukaemia, myeloma Solid tumours: lung, colon, kidney, ovary, thymoma Connective tissue disease: SLE, rheumatoid arthritis Drugs: methyldopa, mefenamic acid, penicillin, quinidine Miscellaneous: ulcerative colitis, HIV.

 There

is evidence of haemolysis and spherocytes on the blood film. The diagnosis is confirmed by the direct Coombs or antiglobulin test There are two Coombs tests are the direct Coombs test and the indirect Coombs test Direct Coombs test, is used to test for autoimmune hemolytic anemia

Direct Coombs Test Patient's red cells are mixed with Coombs reagent It contains antibodies against human IgG/M/ complement If the red cells have been coated by antibody in vivo, the Coombs reagent will induce their agglutination and this can be detected visually. The relevant antibody can be eluted from the red cell surface and tested against a panel of typed red cells to determine against which red cell antigen it is directed

Coombs test is used in prenatal testing of pregnant women, and in testing blood prior to a blood transfusion. It detects antibodies against RBCs that are present unbound in the patient's serum. Here serum is extracted from the blood, and is incubated with RBCs of known antigenicity
Indirect

hemolysis is secondary to an underlying cause, it must be treated and any offending drugs stopped Patients initially treated with Prednisolone 1 mg/kg orally. Response is seen in 70-80% but may take up to 3 weeks Once the haemoglobin has normalised, the corticosteroid dose can be reduced slowly over about 10 weeks Corticosteroids work by decreasing macrophage destruction of antibody-coated red cells and reducing antibody production.
If

 Transfusion

support may be required for lifethreatening cases The least incompatible blood should be used but this may still give rise to transfusion reactions Splenectomy should be considered, if hemolysis fails to respond to corticosteroids or can only be stabilised by large doses If splenectomy is not appropriate, alternative immunosuppressive therapy with azathioprine or cyclophosphamide may be considered Anti-CD20 (B cell) monoclonal antibody, rituximab, has shown some success in difficult cases

 This

is due to antibodies, usually IgM, which bind to red cells at 4 C and cause them to agglutinate. It may cause intravascular haemolysis if complement fixation occurs. This can be Chronic when the antibody is monoclonal, or Acute or transient when the antibody is polyclonal

affects elderly patients and may be associated with an underlying low-grade B cell lymphoma. It causes a low-grade intravascular haemolysis with cold, painful and often blue fingers, toes, ears or nose (acrocyanosis) It is due to red cell agglutination in small vessels in these cold exposed areas The blood film shows red cell agglutination and MCV may be spuriously raised
It

 Treatment

is directed at any underlying lymphoma but if the disease is idiopathic, then patients must keep extremities warm, especially in winter. Some patients respond to corticosteroid therapy Blood transfusion may be considered, but the cross-match sample must be placed in a transport flask at a temperature of 37 C and blood administered via a blood-warmer.

 Cold

agglutination can occur in association with Mycoplasma pneumoniae or with infectious mononucleosis. Paroxysmal cold haemoglobinuria is a very rare cause seen in children in association with congenital syphilis

haemolytic anaemia is due to an antibody against non-self red cells. It has two main causes: Unmatched transfusion of red cells (haemolytic transfusion reaction) Maternal sensitisation to paternal antigens on fetal cells (haemolytic disease of the newborn)
Alloimmune

 These

can be due to

Physical

trauma Infection Chemicals or drugs Paroxysmal nocturnal haemoglobinuria (PNH)

 Physical

disruption of red cells may occur in a number of conditions and is characterised by the presence of red cell fragments on the blood film and markers of intravascular haemolysis: Mechanical heart valves March haemoglobinuria. Vigorous exercise can cause red cell damage in the capillaries in feet Thermal injury Severe burns cause thermal damage to red cells. Microangiopathic haemolytic anaemia. Fibrin deposition in capillaries can cause severe red cell disruption

 Infection

falciparum malaria may be associated with intravascular haemolysis; when severe, this is termed blackwater fever due to the associated haemoglobinuria. Clostridium perfringens septicaemia may cause severe intravascular haemolysis Chemicals or drugs Dapsone and sulfasalazine cause haemolysis by oxidative denaturation of haemoglobin Arsenic gas, copper, chlorates, nitrites and nitrobenzene derivatives may all cause haemolysis
Plasmodium

 This

rare acquired non-malignant clonal expansion of haematopoietic stem cells There is deficient in GPI-anchor protein It results in intravascular haemolysis and anaemia because of increased sensitivity of red cells to lysis by complement Episodes of intravascular haemolysis result in haemoglobinuria, most noticeable in early morning urine which has a characteristic redbrown colour

 The

disease is associated with an increased risk of venous thrombosis in unusual sites such as the liver or abdomen. PNH is also associated with hypoplastic bone marrow failure, aplastic anaemia and myelodysplastic syndrome Management is supportive with transfusion and treatment of thrombosis. Recently the anti-complement C5 monoclonal antibody ecluzimab was shown to be effective in reducing haemolysis.