La-or Chompuk, M.D.

Department of Pathology and Forensic Medicine

Faculty of Medicine, Naresuan University

AnemiaAnemia

Abnormal red blood cellAbnormal red blood cell

Variation in size: Variation in size: AnisocytosisAnisocytosisVariation in shape: Variation in shape: PoikilocytosisPoikilocytosisAbnormal in staining: Abnormal in staining: HypochromicHypochromic, , PolychromasiaPolychromasiaAbnormal in size: Abnormal in size:

-- MicrocyteMicrocyte : RBC < 6 : RBC < 6 µµm or MCV < 80 flm or MCV < 80 fl-- MacrocyteMacrocyte : RBC > 9 : RBC > 9 µµm or MCV > 100 flm or MCV > 100 fl

ภาวะโลหิตจางหรือภาวะซีด หมายถึง

การที่มี hemoglobin (Hb)

หรือ hematocrit (Hct)

หรือ red cell mass นอยลง

ตาม WHO classification ไดใหคําจํากัดความภาวะซีด ดังนี้

ผูชาย มีระดับ Hb < 13 g/dl หรือ Hct < 39%

ผูหญิงและเด็กโต < 12 < 36%

หญิงมคีรรภ < 11 < 33%

เด็ก 3 เดือนถึง 4 ขวบ < 11 < 33%

Signs and symptomsSigns and symptomsFatigueFatigueDizzinessDizzinessPallorPallorCold, clammy skinCold, clammy skinBrittle or broken nailsBrittle or broken nailsReduced exercise Reduced exercise tolerancetoleranceDyspneaDyspneaDepressionDepression

HeadachesHeadachesImpaired cognitionImpaired cognitionMenstrual Menstrual irregularitiesirregularitiesLoss of appetiteLoss of appetiteTachycardiaTachycardiaRalesRales, peripheral , peripheral edema, edema, tachypneatachypnea

Consequences of chronic anemiaConsequences of chronic anemia

Reduced function and quality of lifeReduced function and quality of lifeDecreased survival (< 65 yearDecreased survival (< 65 year--old)old)Increased risk of heart failureIncreased risk of heart failureChanges in neurological functionChanges in neurological functionIncreased risk of complications from Increased risk of complications from surgery and anesthesiasurgery and anesthesiaIncreased risk of coronary deathIncreased risk of coronary deathDecreased tolerance of chemotherapyDecreased tolerance of chemotherapy

Etiology

1. Blood loss2. Hemolytic anemia3. Impaired red cell formation

Classification of AnemiaClassification of Anemia

1.Etiologic classification

2. Morphologic classification

Etiologic classification

1. Blood loss:

acute; GI hemorrhage, accidentchronic; hook worm, hypermenorrhea

2. Hemolytic anemia:

2.1 intracorpuscular

1) membrane defects e.g. spherocytosis, elliptocytosis

2) enzymatic defects e.g. pyruvate kinasedeficiency, G6PD deficiency

3) hemoglobin defects e.g. thalassemia

2.2 extracorpuscular

1) immune- isoimmune- autoimmune e.g. autoimmune hemolytic anemia (AIHA)

2) nonimmune (idiopathic, secondary)

3. Impaired red cell formation

3.1 nutritional deficiency e.g.- iron- folic acid- vitamin B12- vitamin C- protein- vitamin B6

3.2 bone marrow failure

1) failure of all cell lines- congenital e.g. Fanconi’s anemia,

dyskeratosis congenital- acquired e.g. aplastic anemia

2) failure of a single cell line e.g. - congenital pure red cell aplasia- acquired red cell aplasia

3.3 dyshematopoietic anemia (decreased erythropoiesis, decreased iron utilization)

1) infection2) renal failure and hepatic disease

3.4 infiltration of bone marrow e.g. leukemia, lymphoma, disseminated carcinoma

Morphologic classification

1. MCV (Mean corpuscular volume)

2. MCHC (Mean corpuscular hemoglobin concentration)

Microcytic (MCV < 80 fl)Normochromic

Iron deficiency;earlyThalassemia traitSome hemoglobinopathies; Hb EAnemia of chronic disease*

HypochromicIron deficiency ; lateThalassemia trait

SideroblasticanemiaAnemia of chronic disease*

* most commonly normochromic/normocytic.

MacrocyticMacrocytic (MCV > 100 fl)(MCV > 100 fl)

B12 and B12 and folatefolate deficiencydeficiencyLiver diseaseLiver diseaseAlcoholism Alcoholism MyelodysplasticMyelodysplastic syndromesyndromeBlood loss # Blood loss # HemolysisHemolysis ##Hypothyroidism Hypothyroidism Some drugSome drugs s

# อาจเปน normocytic หรือ macrocytic ขึ้นกับความรุนแรง

Normochromic/NormocyticNormochromic/Normocytic (MCV 80(MCV 80--100 fl)100 fl)

Anemia of chronic diseaseAnemia of chronic diseaseAnemia of renal failure Anemia of renal failure Marrow infiltrationMarrow infiltrationAplasticAplastic anemia anemia Blood loss #Blood loss #HemolysisHemolysis ##

# อาจเปน normocytic หรือ macrocytic ขึ้นกับความรุนแรง

Evaluation of AnemiaEvaluation of AnemiaA. A. HematologicHematologic

1. Complete blood cell count (CBC)1. Complete blood cell count (CBC)2. RBC indices : MCV, MCH, MCHC2. RBC indices : MCV, MCH, MCHC3. 3. ReticulocyteReticulocyte countcount4. ESR (Erythrocyte sedimentation rate)4. ESR (Erythrocyte sedimentation rate)5. Stained blood smear : RBC morphology5. Stained blood smear : RBC morphology

Complete blood cell countComplete blood cell count

White blood cell count; 5,000 White blood cell count; 5,000 --10,000/cu.mm10,000/cu.mmRed blood cell count; 4.0Red blood cell count; 4.0--6.0 x106.0 x101212 /l/lHematocritHematocrit ((HctHct) or pack cell volume (PVC);) or pack cell volume (PVC);3535--45%45%Hemoglobin (Hemoglobin (HbHb); 12 ); 12 –– 17.5 g/dl17.5 g/dlWBC differential; PMN, lymphocyte, WBC differential; PMN, lymphocyte, monocytemonocyte, , RBC morphologyRBC morphology

–– MCV; MCV; Mean corpuscular (cell) volume; 80Mean corpuscular (cell) volume; 80--100 fl100 fl

MCV = {MCV = {HctHct (%) x10}/ RBC (x10(%) x10}/ RBC (x101212/l)/l)

–– MCH; MCH; Mean corpuscular hemoglobin; 26Mean corpuscular hemoglobin; 26--36 pg36 pg

MCH = {MCH = {HbHb (g/dl) x 10}/ RBC (x10(g/dl) x 10}/ RBC (x101212/l)/l)

–– MCHC; MCHC; Mean corpuscular hemoglobin Mean corpuscular hemoglobin concentration; 32concentration; 32--36 fl36 flMCHC = {MCHC = {HbHb (g/dl) x 100}/ (g/dl) x 100}/ HctHct (%)(%)

ReticulocyteReticulocyte countcount

- เปนคาที่บอกถึงความสามารถในการสรางเม็ดเลือดแดงของไขกระดูก - Reticulocyte /1,000 RBC >>> %

- Automation >> absolute reticulocyte count - Normal value of reticulocyte count

1.65±0.82 % in male2.45±0.82 % in female

- Absolute reticulocyte count = 30-85 x 103 /ul

Reticulocyte production index (RPI)

- สามารถบอกวา erythropoietic activity ในไขกระดูกสูงเปน กี่เทา

ของภาวะปกติ

RPI = (% reticulocytes x patient Hct/45)correction factor

โดยทั่วไป correction factor จะมีคาเทากบั 2 คือ เทากับจํานวนวันที่ reticulocyte จะอยูในกระแสเลือด ยกเวนเมื่อ Hct นอยกวา 15% จะใช คาเทากับ 3 แทน

RPI > 2 RPI > 2 -- effective effective erythropoiesiserythropoiesis

B. Urine analysisB. Urine analysis1. Appearance : Color, pH, Clarity, specific gravity1. Appearance : Color, pH, Clarity, specific gravity2. Test for protein, 2. Test for protein, BenceBence Jones proteinJones protein3. 3. BilirubinBilirubin, , UribilinogenUribilinogen4. Occult blood4. Occult blood5. Microscopic examination 5. Microscopic examination

C. Stool C. Stool 1. Appearance : Color, consistency1. Appearance : Color, consistency2. Occult blood2. Occult blood3. Examination for ova, parasites3. Examination for ova, parasites

DD.. SerumSerum oror PlasmaPlasma1.1. BUNBUN2.2. CreatinineCreatinine3.3. BilirubinBilirubin :: DirectDirect,, indirectindirect4.4. ProteinProtein5.5. SISI ((SerumSerum ironiron),), TIBCTIBC ((TotalTotal ironiron bindingbinding

capacitycapacity))EE.. SpecialSpecial teststests inin hematologyhematology

HbHb typingtyping // HamHam acidacid testtest // CoombsCoombs’’ testtest,, GG--66PDPD,,FerritinFerritin,, SucroseSucrose testtest,, AutohemolysisAutohemolysis testtest,,HaptoglobinHaptoglobin,, Flow Flow cytometrycytometry, , etcetc..

Iron deficiency anemiaIron deficiency anemiaVitamin B12 deficiency anemiaVitamin B12 deficiency anemiaFolateFolate deficiency anemiadeficiency anemiaAnemia of chronic diseaseAnemia of chronic diseaseAplasticAplastic anemiaanemia

Hemolytic anemiaHemolytic anemia

Iron Deficiency AnemiaIron Deficiency Anemia

The multiple forms of iron in the body The multiple forms of iron in the body

Iron in food:Iron in food:–– HemeHeme sources: meatsources: meat–– Non Non hemeheme sources: beans, clams, vegetablessources: beans, clams, vegetables

Iron in storage:Iron in storage:–– FerritinFerritin: liver, spleen, skeletal muscle, BM: liver, spleen, skeletal muscle, BM–– HemosiderinHemosiderin: macrophages: macrophages

Iron in circulation:Iron in circulation:–– Iron and Iron and globinglobin are recycled as a result of red are recycled as a result of red

cell senescencecell senescence

Enhancers of iron absorptionEnhancers of iron absorptionOrange juiceOrange juiceVitamin CVitamin CPicklesPicklesSoy sauceSoy sauceVinegarVinegarAlcoholAlcohol

Inhibitors of iron absorptionInhibitors of iron absorption

TeaTeaCoffeeCoffeeOreganoOreganoMilkMilk

Iron MetabolismIron Metabolism

Iron is Absorbed Primarily in Iron is Absorbed Primarily in DuodenumDuodenum-- 25% of Heme25% of Heme--Bound Iron (Red Meat)Bound Iron (Red Meat)-- 11--2% of Non2% of Non--Heme IronHeme Iron

Body Body LossesLosses of Iron are of Iron are LimitedLimited-- 11--2 mg/Day By Epithelial Cell Shedding2 mg/Day By Epithelial Cell Shedding

Mucosal BlockMucosal Block -- Maintains BalanceMaintains Balance

Causes of Iron DeficiencyCauses of Iron Deficiency

External Blood Loss External Blood Loss -- Most CommonMost CommonFemale Genital TractFemale Genital TractGastrointestinal TractGastrointestinal Tract

↑↑ Demand Demand -- Infancy, PregnancyInfancy, PregnancyDietary Deficiency Dietary Deficiency -- Rare Rare

(Vegetarian Diets)(Vegetarian Diets)Intestinal Malabsorption SyndromeIntestinal Malabsorption Syndrome

Iron DeficiencyIron DeficiencyClinical ManifestationsClinical Manifestations

Anemia Anemia -- NonNon--Specific FindingsSpecific FindingsKoilonychiaKoilonychiaPlummerPlummer--Vinson SyndromeVinson Syndrome

--Hypochromic Microcytic AnemiaHypochromic Microcytic Anemia--Atrophic GlossitisAtrophic Glossitis--Esophageal Webs (Dysphagia)Esophageal Webs (Dysphagia)

Koilonychia Koilonychia -- Iron DeficiencyIron Deficiency Glossitis

Iron Deficiency Anemia Laboratory FindingsIron Deficiency Anemia Laboratory Findings

Hypochromic Microcytic AnemiaHypochromic Microcytic Anemia

((↓↓ RBC Count, RBC Count, ↓↓ MCV)MCV)↓↓ Serum Ferritin LevelsSerum Ferritin Levels↓↓ Transferrin SaturationTransferrin Saturation((↓↓ Serum Fe, Serum Fe, ↑ ↑ Transferrin)Transferrin)

Normal

Treatment:Treatment:

-- Correct causesCorrect causes

-- Iron supplementIron supplement

-- Breast feedingBreast feeding

MegaloblasticMegaloblastic AnemiaAnemia

Megaloblastic Anemia:Megaloblastic Anemia:

Impaired DNA Synthesis (Nucleus)Impaired DNA Synthesis (Nucleus)

Affects All Rapidly Dividing Cells Affects All Rapidly Dividing Cells --Mouth Mouth -- Atrophic GlossitisAtrophic Glossitis--GI tract GI tract -- Intestinal MalabsorptionIntestinal Malabsorption

Causes ofCauses of megaloblasticmegaloblastic anemiaanemia

VitaminVitamin BB1212 deficiencydeficiencyFolateFolate deficiencydeficiencyMiscellaneousMiscellaneous:: oroticorotic aciduriaaciduria,, liver liver disease, drugs e.g.disease, drugs e.g. purinepurine analoguesanalogues((66MPMP,, 66TQ TQ oror 55FUFU))

Vitamin B12 deficiencyVitamin B12 deficiency

CobalamineCobalamine

Prevalence: 15Prevalence: 15--25% of population25% of populationFunctions of Functions of cobalamincobalamin: : Coenzyme for 13Coenzyme for 13 enzymesenzymes

RDI = 2.4 RDI = 2.4 ug/dug/dSources:Sources: Meat, liver, Kidney, oyster, clams, fish, eggs, Meat, liver, Kidney, oyster, clams, fish, eggs, cheese and other dairy productscheese and other dairy products

Vitamin BVitamin B12 12 DeficiencyDeficiencyCauses:Causes:-- Dietary deficiencies in vegansDietary deficiencies in vegans

-- MalabsorptionMalabsorption States: Gastric Atrophy, States: Gastric Atrophy, Pernicious anemia (absence of IF), Pernicious anemia (absence of IF), GastrectomyGastrectomy, , ilealileal resectionresection

-- FoodFood--cobalamincobalamin maldigestionmaldigestion: : AchlorhydriaAchlorhydria, acid , acid suppressive drugssuppressive drugs

-- DiphyllobothriumDiphyllobothrium Latum Latum -- Fish TapewormFish Tapeworm

Vitamin BVitamin B1212 Deficiency Deficiency -- CauseCause

Western World Western World -- Pernicious AnemiaPernicious AnemiaAutoimmune DisorderAutoimmune Disorder--Autoantibodies to IF and Parietal CellsAutoantibodies to IF and Parietal Cells--Chronic Atrophic GastritisChronic Atrophic Gastritis--Achlorhydria Achlorhydria -- Absent HCLAbsent HCL

Signs & SymptomsSigns & Symptoms

Additional signs & symptomsAdditional signs & symptoms–– Sore, smooth, beefy red tongueSore, smooth, beefy red tongue–– Numbness and Numbness and parenthesiaparenthesia, weakness, ataxia, weakness, ataxia–– Cognitive disturbances (forgetfulness, Cognitive disturbances (forgetfulness,

dementia, psychosis)dementia, psychosis)–– Increased risk for venous and arterial Increased risk for venous and arterial

thrombosis and cardiovascular diseasethrombosis and cardiovascular disease

Glossitis with cobalamin deficiency. The smooth shiny tongue results from loss of papillae over the lingual surface. Thinning of the epithelium sometimes give the tongue a red “beefy”appearance.

Vitamin BVitamin B12 12 DeficiencyDeficiency

Clinical Clinical -- Similar to Folate Deficiency, but also Similar to Folate Deficiency, but also include include DemyelinatingDemyelinating Neurologic DisorderNeurologic Disorder

-- Affects Both Sensory and Motor TractsAffects Both Sensory and Motor Tracts( ( subacutesubacute combined degeneration)combined degeneration)

-- Lack of Correlation With AnemiaLack of Correlation With Anemia

Laboratory FindingsLaboratory Findings::

Low Serum Vitamin BLow Serum Vitamin B1212 LevelsLevelsNormal RBC Folate LevelsNormal RBC Folate LevelsAbnormal Schilling Test Abnormal Schilling Test -- Impaired Absorption Impaired Absorption of Radioactive Vitamin Bof Radioactive Vitamin B1212 Correctable by Correctable by Addition of IFAddition of IFAntiAnti--Intrinsic Factor Antibodies (AntiIntrinsic Factor Antibodies (Anti--Parietal Parietal Antibodies Less Sensitive)Antibodies Less Sensitive)

Treatment:Treatment:

CobalaminCobalamin

ParenteralParenteral BB1212 -- Improves Anemia, Improves Anemia, +/+/-- Resolution of Resolution of NeurologicNeurologic SymptomsSymptoms

Caution!Caution! Anemia of BAnemia of B12 12 Deficiency Also Deficiency Also Improves With Improves With FolateFolate SupplementationSupplementation

FolateFolate deficiency anemiadeficiency anemia

Folic acidFolic acid

Purposes of folic acidPurposes of folic acid–– Metabolism of serine, Metabolism of serine, glycineglycine, , methioninemethionine, ,

and and histidinehistidine–– PurinePurine and and pyrimidinepyrimidine synthesissynthesis

Folic acidFolic acid

RDI 400 RDI 400 ug/dug/dGood sources: cereal, beef liver, cowpeas, Good sources: cereal, beef liver, cowpeas, spinach, asparagus, wheat germ, orange spinach, asparagus, wheat germ, orange juice, baked beans, green peas, broccoli, juice, baked beans, green peas, broccoli, egg noodles, white rice, avocado, egg noodles, white rice, avocado, peanuts, romaine lettuce, tomato juice, peanuts, romaine lettuce, tomato juice, white bread, cantaloupe, papaya, banana, white bread, cantaloupe, papaya, banana, whole wheat breadwhole wheat bread

Metabolism of folate

Causes of Causes of folatefolate deficiencydeficiency

Dietary: general malnutrition, alcoholismDietary: general malnutrition, alcoholismImpair absorption: Tropical Impair absorption: Tropical spruesprue, Celiac , Celiac diseasediseaseIncreased requirements: infancy, Increased requirements: infancy, pregnancy, lactation, anticonvulsant pregnancy, lactation, anticonvulsant drugs, drugs, folatefolate antagonist, chronic antagonist, chronic exfoliativeexfoliative dermatitis dermatitis

Signs and SymptomsSigns and Symptoms

AdditionalAdditional signs & symptomssigns & symptoms–– DiarrheaDiarrhea–– CheilosisCheilosis–– GlossitisGlossitis

Folate DeficiencyFolate DeficiencyLaboratory Findings:Laboratory Findings:

-- MacrocyticMacrocytic anemia (MCV >100 fl)anemia (MCV >100 fl)-- Decreased folic acid Decreased folic acid -- Increased Increased homocysteinehomocysteine levellevel

Red Blood Cell Folate Red Blood Cell Folate -- Reflects Tissue Content of Reflects Tissue Content of Folate Throughout BodyFolate Throughout Body

Serum Folate Serum Folate -- Levels Fluctuate Based on Recent Levels Fluctuate Based on Recent Intake, Do Not Reflect StoresIntake, Do Not Reflect Stores

Megaloblastic AnemiaMegaloblastic AnemiaPeripheral BloodPeripheral Blood

RBCsRBCs -- Large Oval: Large Oval: MacroovalocytesMacroovalocytes-- MCV > 100MCV > 100 flfl

HypersegmentedHypersegmented Neutrophils Neutrophils

Thrombocytopenia, Neutropenia (Severe)Thrombocytopenia, Neutropenia (Severe)

Megaloblastic Anemia Megaloblastic Anemia -- Bone MarrowBone Marrow

NuclearNuclear-- Cytoplasmic AsynchronyCytoplasmic Asynchrony::

Erythroid Series (Hallmark Changes)Erythroid Series (Hallmark Changes)--MegaloblastsMegaloblasts--Erythroid HyperplasiaErythroid Hyperplasia

Myeloid SeriesMyeloid SeriesMegakaryocytic Series Megakaryocytic Series -- (Infrequent)(Infrequent)

Normal Erythroids (Left); Megaloblasts (Right)Normal Erythroids (Left); Megaloblasts (Right)

TreatmentTreatment

Folic acid 1 mg dailyFolic acid 1 mg dailyTreatment for 1Treatment for 1--2 months2 monthsIndefinite treatment may be necessary for Indefinite treatment may be necessary for cases of cases of malabsorptionmalabsorption and chronic and chronic malnutritionmalnutrition

Anemia of chronic disease

Anemia of Chronic DiseaseAnemia of Chronic Disease

Normochromic Normocytic AnemiaNormochromic Normocytic Anemia(or Hypochromic Microcytic) (or Hypochromic Microcytic) Chronic Disorders (Inflammation or Tissue Chronic Disorders (Inflammation or Tissue Necrosis) Necrosis)

--Chronic Microbial IllnessesChronic Microbial Illnesses--Chronic Immune DisordersChronic Immune Disorders--NeoplasmsNeoplasms

Often Often ↓↓ TIBC, TIBC, ↑↑ FerritinFerritin

Diseases associated with anemia of chronic inflammationDiseases associated with anemia of chronic inflammation

Acute infectionsAcute infectionsChronic infections: TB, infective Chronic infections: TB, infective endocarditisendocarditis, chronic UTI, chronic fungal , chronic UTI, chronic fungal infection, HIVinfection, HIV

Chronic inflammatory disorders: Chronic inflammatory disorders: Rheumatoid arthritis, collagen vascular Rheumatoid arthritis, collagen vascular diseases, hepatitis, diseases, hepatitis, decubitusdecubitus ulcerulcer

Diseases associated with anemia of chronic Diseases associated with anemia of chronic inflammationinflammation

Chronic renal insufficiencyChronic renal insufficiencyHypothyroidismHypothyroidismProteinProtein--energy malnutritionenergy malnutritionMalignancy: Malignancy: metastaticmetastatic carcinoma, carcinoma, hematologichematologic malignancymalignancy

Laboratory findingsLaboratory findings

NormochromicNormochromic, , normocyticnormocyticNormal or increased Normal or increased ferritinferritin (indicates (indicates increased iron stores)increased iron stores)Decreased serum ironDecreased serum ironDecreased TIBCDecreased TIBC

Treatment of ACITreatment of ACI

Correct or improve underlying Correct or improve underlying abnormalityabnormalityIron is not effective unless a true iron Iron is not effective unless a true iron deficiency is also occurringdeficiency is also occurringTransfusions (for some indication)Transfusions (for some indication)Erythropoietin (for some indication)Erythropoietin (for some indication)

Aplastic Anemia

Acquired BM failure syndromesAcquired BM failure syndromes

AplasticAplastic anemiaanemiaPure red cell Pure red cell aplasiaaplasiaParoxysmal nocturnal Paroxysmal nocturnal hemoglobinuriahemoglobinuriaMyelodysplasiaMyelodysplasia

Etiology of Etiology of aplasticaplastic anemiaanemia

Inherited:Inherited:–– FanconiFanconi anemiaanemia–– DyskeratosisDyskeratosis congenitacongenita

Etiology of acquired Etiology of acquired aplasticaplastic anemiaanemia

IdiopathicIdiopathic

Radiation: cancer irradiationRadiation: cancer irradiationChemicals: chemotherapy drugs, benzeneChemicals: chemotherapy drugs, benzene

Chemicals (idiosyncratic): Chemicals (idiosyncratic): chloramphenicolchloramphenicol, gold, , gold, peniclillaminepeniclillamine, , NSAIDsNSAIDs, sulfonamides, , sulfonamides, propylthiouracilpropylthiouracil

Etiology of acquired Etiology of acquired aplasticaplastic anemiaanemia

Viruses: Hepatitis; nonViruses: Hepatitis; non--A, nonA, non--B, nonB, non--C, C, nonnon--G, EBV, HIVG, EBV, HIV

Immune disorders: SLE, Immune disorders: SLE, thymomathymoma, , transfusiontransfusion--associated graftassociated graft--versusversus--host host disease, pregnancydisease, pregnancy

Bone Marrow Aplasia (Lack of Cells)Bone Marrow Aplasia (Lack of Cells)

Failure of Multipotent Stem CellFailure of Multipotent Stem Cell-- TT--cell Mediated Suppression orcell Mediated Suppression or-- Genetic DamageGenetic Damage

Bone Marrow Bone Marrow -- Markedly Markedly HypocellularHypocellular

Peripheral Blood Peripheral Blood -- PancytopeniaPancytopenia-- Normochromic Normocytic RBCsNormochromic Normocytic RBCs

Characteristic features of aplastic anemia

Peripheral blood Peripheral blood pancytopeniapancytopeniaReticulocytopeniaReticulocytopeniaBone marrow Bone marrow hypocellularityhypocellularityDepletion of Depletion of hematopoietichematopoietic stem cellsstem cells

AplasticAplastic AnemiaAnemiaNormal BM

Myelophthisic AnemiaMyelophthisic Anemia

BM Replacement >> BM failure:BM Replacement >> BM failure:

Metastatic Carcinoma Most CommonMetastatic Carcinoma Most CommonDestruction By NonDestruction By Non--Neoplastic Process Neoplastic Process is Less Common i.e. Fibrosis, Infectionis Less Common i.e. Fibrosis, InfectionPeripheral Blood Cytopenias, Immature Peripheral Blood Cytopenias, Immature Circulating CellsCirculating Cells

Breast Cancer Replacing BMBreast Cancer Replacing BM

Hemolytic AnemiaHemolytic Anemia

Definition of hemolytic anemia

- Short life span of RBC

- Defect in structure and metabolism >> destruction in RE system; spleen

- Hemolysis in RE system; extravascular hemolysis

Signs & SymptomsSigns & Symptoms

Pale, Pale, ictericictericSplenomegalySplenomegaly; prominent if chronic & EVH; prominent if chronic & EVHGall stone; Gall stone; espesp in the youngin the youngHxHx of drug intake of underlying diseaseof drug intake of underlying disease

? Hemolytic anemia? Hemolytic anemia

↑↑ rbcrbc destruction & production at the destruction & production at the same timesame timePersistent anemia despite increased Persistent anemia despite increased erythropoiesiserythropoiesis with out blood losswith out blood lossHbHb drop drop ≥≥ 1 g/dl per week1 g/dl per weekHemoglobinuriaHemoglobinuria or signs of IVHor signs of IVH

TreatmentTreatment

1.1. SplenectomySplenectomy2.2. Immunosuppressive agentImmunosuppressive agent3.3. Prevent hemolytic reactionPrevent hemolytic reaction4.4. Blood transfusionBlood transfusion

ThalassemiaThalassemia and and HemoglobinopathyHemoglobinopathy

โครงสรางโครงสราง และการควบคุมการสรางฮีโมโกลบินและการควบคุมการสรางฮีโมโกลบิน

hemoglobin= hemoglobin= hemeheme 4 4 molecules+globinmolecules+globin chain 2 chain 2 pairs (pairs (αα globinglobin 11 คูและคูและββ globinglobin 11 คูคู) )

αα chains; chromosome 16 chains; chromosome 16 ββ chains; chromosome 11chains; chromosome 11

การสรางสายการสรางสายโกลบินโกลบิน

ThalassemiaThalassemiaภาวะที่ทําใหมีการสรางสายภาวะที่ทําใหมีการสรางสายโกลบินโกลบิน ((globinglobin) ) ปกติลดลงหรือไมสรางเลยปกติลดลงหรือไมสรางเลย ทําใหสรางฮีโมโกลบินปกติลดลงหรือไมสามารถสรางฮีโมโกลบินปกติไดเทําใหสรางฮีโมโกลบินปกติลดลงหรือไมสามารถสรางฮีโมโกลบินปกติไดเลยลย ซึ่งสามารถถายทอดทางพันธุกรรมไดซึ่งสามารถถายทอดทางพันธุกรรมได,, autosomalautosomal recessiverecessive

แบงเปนกลุมใหญไดเปนแบงเปนกลุมใหญไดเปน อัลฟาธาลัสอัลฟาธาลัสซีเมียซีเมีย ((αα thalassemiathalassemia) ) และเบตาธาลัสและเบตาธาลัสซีเมียซีเมีย ((ββ thalassemiathalassemia))

HemoglobinopathyHemoglobinopathyภาวะผิดปกตทิี่เกดิจากการเปลี่ยนแปลงของภาวะผิดปกตทิี่เกดิจากการเปลี่ยนแปลงของกรดอะกรดอะมิโนมิโน บนสายบนสายโกลบินโกลบิน ซึ่งซึ่งถายทอดทางพันธุกรรมถายทอดทางพันธุกรรม ทําใหมีการเปลี่ยนแปลงของคุณสมบัติทางกายภาพหรือทําใหมีการเปลี่ยนแปลงของคุณสมบัติทางกายภาพหรือ

เคมีของสายเคมีของสายโกลบินโกลบิน ทําใหโครงสรางของสายทําใหโครงสรางของสายโกลบินโกลบินผิดปกติไปผิดปกติไป การสรางสายการสรางสายโกลบินโกลบินยังคงเทาเดิมยังคงเทาเดิม หรือมีการลดลงของสายหรือมีการลดลงของสายโกลบินโกลบินรวมดวยรวมดวย ฮีโมโกลบินผิดปกตทิี่พบบอยในประเทศไทยคือฮีโมโกลบินผิดปกตทิี่พบบอยในประเทศไทยคือ HbHb E E และและHbHbConstant Spring; Constant Spring; HbHb CSCS

Clinical manifestations:Clinical manifestations:ββ--ThalassemiaThalassemia

1.1. ThalassemiaThalassemia major; homozygous major; homozygous –– Severe, transfusionSevere, transfusion--dependent anemiadependent anemia–– HbHb 33--6 g/dl6 g/dl–– Without transfusions, death occurs at an early Without transfusions, death occurs at an early

age from profound anemiaage from profound anemia

2.2. ThalassemiaThalassemia minor; heterozygousminor; heterozygous–– Usually asymptomaticUsually asymptomatic–– More common than More common than ThalassemiaThalassemia majormajor

3.3. ThalassemiaThalassemia intermediaintermedia; ; heterogenousheterogenous

αα-- ThalassemiaThalassemia–– severity is related to the number of severity is related to the number of αα--globinglobin

genes deletedgenes deleted

1.1. Silent carrier state; asymptomaticSilent carrier state; asymptomatic2.2. αα--ThalassemiaThalassemia trait; clinical = trait; clinical = ββ--thalthal minorminor3.3. Hemoglobin H disease; deletion of three Hemoglobin H disease; deletion of three αα--

globinglobin genes; clinical = genes; clinical = ββ--thalthal intermediaintermedia4.4. HydropsHydrops fetalisfetalis; deletion of all four ; deletion of all four αα--globinglobin

genes; genes; HbHb BartsBarts, not compatible with life, not compatible with life

Bleeding DisordersBleeding Disorders

HemostasisHemostasis::

A normal physiologic process maintaining A normal physiologic process maintaining blood in a fluid, clotblood in a fluid, clot--free state in normal free state in normal blood vessels, while inducing a rapid, blood vessels, while inducing a rapid, localized localized hemostatichemostatic plug at sites of plug at sites of vascular injuryvascular injury

Normal Normal HemostasisHemostasisBlood vesselBlood vesselPlateletPlateletCoagulation SystemCoagulation SystemFibrinolysisFibrinolysis SystemSystemNatural AnticoagulantNatural Anticoagulant

Blood vesselBlood vesselEndotheliumEndothelium

Maintain fluidityMaintain fluiditySubstrate releaseSubstrate release

ThrombogenesisThrombogenesisAntithromboticAntithrombotic

Connective tissuesConnective tissuesCollagen type III, IV etc.Collagen type III, IV etc.Muscular layerMuscular layer

Normal Normal HemostasisHemostasis--PlateletPlateletPlatelet AdhesionPlatelet AdhesionSubstrate Release Substrate Release Shape ChangeShape ChangePlatelet AggregationPlatelet AggregationPlatelet plug formation and vasoconstriction Platelet plug formation and vasoconstriction

= Primary = Primary hemostatichemostatic plug formation plug formation which is enough to stop which is enough to stop bleeding from small and shallow wound.bleeding from small and shallow wound.

Coagulation SystemCoagulation SystemTo promote fibrin polymerizationTo promote fibrin polymerizationSecondary Secondary hemostatichemostatic plug formation= primary plug formation= primary hemostatichemostaticplug + fibrin polymerizationplug + fibrin polymerization

Classical PathwayClassical PathwayIntrinsicIntrinsicExtrinsicExtrinsicCommonCommon

FibrinolysisFibrinolysis

HMWKHMWKF.XIIF.XII tt--PAPA FibrinFibrinKininogenKininogen urokinaseurokinase

PlasminogenPlasminogen PlasminPlasmin

FDPFDPStreptokinase Streptokinase

Factor XIIFactor XIIHMWKHMWK

Factor XIFactor XI Factor XIaFactor XIa

Factor IXFactor IX Factor IXaFactor IXa Factor VIIFactor VIIFactor VIIIaFactor VIIIa Tissue factorTissue factor

Factor XFactor X Factor XaFactor Xa Factor XFactor XFactor VaFactor Va

Activated Protein CActivated Protein C Antithrombin IIIAntithrombin IIIProtein SProtein S ProthrombinProthrombin ThrombinThrombin

Protein CProtein C FibrinogenFibrinogen FibrinFibrin

AnticoagulantAnticoagulant

HeparinHeparinAction Action

Inhibit thrombin, Inhibit Factor Inhibit thrombin, Inhibit Factor XaXa, Inhibit Factor IX and XI, Inhibit Factor IX and XICaumadinCaumadin

Action inhibit vitamin K Action inhibit vitamin K epoxidaseepoxidase, Vitamin K dependent , Vitamin K dependent factor depletion (II, VII, IX and X) factor depletion (II, VII, IX and X) Dose adjustment by INR (adjusted PT ratio to ISI) Dose adjustment by INR (adjusted PT ratio to ISI)

Clinical ApproachClinical ApproachHistory TakingHistory TakingPhysical examinationPhysical examination

““80% of correct diagnosis can be made 80% of correct diagnosis can be made by history taking and physical examination.by history taking and physical examination.””

QuestionsQuestionsBleeding disorders VS Local bleeding?Bleeding disorders VS Local bleeding?HemostasisHemostasis defects?defects?Acquired VS Hereditary?Acquired VS Hereditary?

Most important questionsMost important questions

Multiple bleeding sitesMultiple bleeding sitesOnsetOnsetFamilial historyFamilial historyProlonged bleeding, Prolonged bleeding, ↑↑ frequencyfrequencyInappropriate with injuriesInappropriate with injuriesPrevious medical illness and medicationsPrevious medical illness and medications

DeepDeepdeep deep ecchymosisecchymosis, ,

hematomahematomararerareretroperitoneal retroperitoneal

hematoma,hemarthrosishematoma,hemarthrosis

SuperficialSuperficialpetechiaepetechiae, superficial , superficial

ecchymosisecchymosiscommoncommonrarerare

SitesSitesSkinSkin

MucosalMucosalOthersOthers

DelayedDelayedImmediateImmediateOnsetOnset

Secondary Secondary HemostasisHemostasisPrimary Primary HemostasisHemostasis

CBCCBC --the most informative test for the most informative test for thrombocytopenic bleedingthrombocytopenic bleeding

BTBT --test primary test primary hemostasishemostasisvascular defect and platelet functionvascular defect and platelet function

VCTVCT --test intrinsic and common pathwaytest intrinsic and common pathwayaPTTaPTT --test intrinsic and common pathwaytest intrinsic and common pathwayPTPT --test extrinsic and common pathwaytest extrinsic and common pathwayMixing Mixing --deficiency VS inhibitordeficiency VS inhibitor

Laboratory Investigation

Bleeding time:Bleeding time:* Quantity of platelet* Quantity of platelet* Quality of platelet; adhesion, aggregation* Quality of platelet; adhesion, aggregation* Vascular function* Vascular function* * DukeDuke methodmethod (< 6 min), I(< 6 min), Ivyvy methodmethod (2(2--6 min)6 min)* Abnormal * Abnormal BleedingBleeding timetime::

thrombocytopeniathrombocytopenia ( platelet <( platelet <100,000100,000 //ulul))vonvon WillebrandWillebrand diseasediseaseDrugs;Drugs; aspirinaspirinGlanzmanGlanzman’’ss thrombastheniathrombasthenia

Activated partial thromboplastin time (APTT):

* intrinsic pathway* เปนการตรวจสอบที่เลียนแบบปฏิกิริยาการแข็งตัวของเลือดที่เกิดในรางกายโดย* normal value ~ 27 – 38 seconds

* prolonged APTT;- ขาด intrinsic pathway เชน hemophilia A (F VIII), hemophilia B (F IX)

- มีสารกันการแข็งตัวของเลือดไดแก circulating anticoagulant, F VIII antibody,

heparin และ FDP- DIC (disseminated intravascular coagulation)

Prothrombin time (PT):

* extrinsic และ common pathway* report of PT- second- % activity- prothrombin index- prothrombin ratio- international normalized ratio (INR); monitor

Rx with anticoagulant warfarin

International normalized ratio(INR) =

* normal value ; 0.75 – 1.3* therapeutic level; 2 - 4.5* Prolonged prothrombin time- ขาด extrinsic pathway- oral anticoagulant- severe liver disease- ขาด vitamin K

Bleeding disordersBleeding disorders

Hemorrhagic diathesis may be caused byHemorrhagic diathesis may be caused by–– Increased blood vessel fragilityIncreased blood vessel fragility–– Platelet disordersPlatelet disorders–– Coagulation defectsCoagulation defects

Laboratory testing:Laboratory testing:–– Bleeding time Bleeding time -- ProthrombinProthrombin timetime–– Platelet countsPlatelet counts -- Partial Partial thromboplastinthromboplastin timetime–– Special test (Special test (e.g.clottinge.g.clotting factor levels)factor levels)

Increased vascular fragilityIncreased vascular fragility–– PetechialPetechial and and purpuricpurpuric hemorrhagehemorrhage–– EtiologyEtiology

Infections; Infections; meningococcusmeningococcus and and rickettsiarickettsia >>> >>> vasculitisvasculitis , or DIC, or DICPoor vascular support; abnormal collagen, Poor vascular support; abnormal collagen, amyloidosisamyloidosisHenochHenoch--SchonleinSchonlein purpurapurpura; ; purpuricpurpuric rash, abdominal pain, rash, abdominal pain, polyarthralgiapolyarthralgia, acute , acute glomerulonephritisglomerulonephritis

ThrombocytopeniaThrombocytopenia–– Normal platelet count 140,000 Normal platelet count 140,000 –– 400,000 /400,000 /cu.mmcu.mm–– PetechialPetechial hemorrhagehemorrhage–– Causes;Causes;

Decreased production; ineffective Decreased production; ineffective megakaryopoiesismegakaryopoiesis, , aplasticaplasticanemia, disseminated canceranemia, disseminated cancerDecreased survival; immuneDecreased survival; immune--mediated platelet destruction, drug, mediated platelet destruction, drug, HIV, systemic HIV, systemic coagulopathiescoagulopathiesSequestration; retain is red pulp of enlarged spleenSequestration; retain is red pulp of enlarged spleenDilution; massive whole blood transfusionDilution; massive whole blood transfusion

ThrombocytopeniaThrombocytopenia

PltPlt > 100,000 : can surgery> 100,000 : can surgeryPltPlt < 100,000 :< 100,000 : prolonged BTprolonged BTPltPlt < 50,000 : bleeding after trauma/< 50,000 : bleeding after trauma/SxSxPltPlt < 10,000< 10,000--20,000 : spontaneous bleeding20,000 : spontaneous bleedingPltPlt < 5,000 : increase risk ICH< 5,000 : increase risk ICH

Immune Thrombocytopenia Immune Thrombocytopenia PurpuraPurpura (ITP)(ITP)–– Acute ITPAcute ITP

Transient Transient antiplateletantiplatelet autoantibodiesautoantibodiesOften in children after viral infection; rubella, CMV, viral Often in children after viral infection; rubella, CMV, viral hepatitis, infectious mononucleosishepatitis, infectious mononucleosis

–– Chronic ITPChronic ITPPlatelet Platelet autoantibodiesautoantibodiesDestruction occurs in the spleenDestruction occurs in the spleenSplenectomySplenectomy benefits 75% to 80% of patients.benefits 75% to 80% of patients.

–– Clinical features; adult, female, easy bruising or Clinical features; adult, female, easy bruising or nosebleeds, nosebleeds, petechialpetechial hemorrhage, internal hemorrhage hemorrhage, internal hemorrhage ((melenamelena, , hematuriahematuria))

–– DxDx; ; Clinical; Clinical; petechiaepetechiaeBM biopsy; increased BM biopsy; increased megakaryocytesmegakaryocytesBleeding time; prolongBleeding time; prolongPT and PTT; normalPT and PTT; normal

DrugDrug--induced thrombocytopeniainduced thrombocytopenia–– ImmuneImmune--mediated platelet destructionmediated platelet destruction–– Drug acting as Drug acting as haptenhapten–– Drug withdrawal leads to clinical improvementDrug withdrawal leads to clinical improvement

Hemorrhagic disorders related to defective platelet Hemorrhagic disorders related to defective platelet functionsfunctions–– Congenital disorders; Congenital disorders;

Defective platelet adhesionDefective platelet adhesionDefective platelet aggregationDefective platelet aggregationDisorders of platelet secretionDisorders of platelet secretion

–– Acquired disorders;Acquired disorders;Aspirin ingestion; suppress TXAAspirin ingestion; suppress TXA2 2 synthesis (necessary for synthesis (necessary for platelet aggregation)platelet aggregation)Uremia; defect in platelet functionUremia; defect in platelet function

Hemorrhagic diathesis related to abnormalities in Hemorrhagic diathesis related to abnormalities in clotting factorsclotting factors

Clinical features;Clinical features;–– Large Large ecchymosesecchymoses or or hematomahematoma after injury, or prolonged after injury, or prolonged

bleeding after a laceration or surgical procedurebleeding after a laceration or surgical procedure–– Bleeding of GI, urinary tracts , weightBleeding of GI, urinary tracts , weight--bearing joints.bearing joints.

Hereditary deficiencies; hemophilia, von Hereditary deficiencies; hemophilia, von WillebrandWillebranddiseasediseaseAcquired deficiencies; Acquired deficiencies; vitvit. K deficiency, liver disease, DIC. K deficiency, liver disease, DIC

von von WillebrandWillebrand diseasedisease

Level of Factor VIII are often reduced because Level of Factor VIII are often reduced because vWFvWFstabilizes factor VIII in circulation.stabilizes factor VIII in circulation.Defect in platelet function and coagulation pathway; Defect in platelet function and coagulation pathway; prolonged bleeding time and partial prolonged bleeding time and partial thromboplastinthromboplastin timetimeCilinicalCilinical; spontaneous bleeding from mucous membranes, ; spontaneous bleeding from mucous membranes, excessive bleeding from wounds, excessive bleeding from wounds, menorrhagiamenorrhagia

Hemophilia AHemophilia A

XX--linked recessive disorder; malelinked recessive disorder; maleFactor VIII deficiency Factor VIII deficiency Clinical features develop only in the presence of Clinical features develop only in the presence of severe deficiency ( factor VIII levels < 1% of normal)severe deficiency ( factor VIII levels < 1% of normal)Mild or moderate degrees of deficiency (levels 1%Mild or moderate degrees of deficiency (levels 1%--50% of normal); asymptomatic50% of normal); asymptomatic

Clinically associated withClinically associated with–– Massive hemorrhage after trauma or operative Massive hemorrhage after trauma or operative

proceduresprocedures–– Spontaneous hemorrhages in regions of the body Spontaneous hemorrhages in regions of the body

normally subject to trauma; joints (normally subject to trauma; joints (hemarthroseshemarthroses) >> ) >> progressive, crippling deformitiesprogressive, crippling deformities

–– Prolonged PTT and normal bleeding timeProlonged PTT and normal bleeding time–– DxDx; factor VIII assay; factor VIII assay

Hemarthrosis

TreatmentTreatment–– Replacement therapy; recombinant factor VIII or factor Replacement therapy; recombinant factor VIII or factor

VIII concentratesVIII concentratesFactor VIII antibodyFactor VIII antibody–– History of factor VIII replacementHistory of factor VIII replacement–– DxDx; Mixing test, factor VIII antibody; Mixing test, factor VIII antibody

Hemophilia BHemophilia B (Christmas disease)(Christmas disease)XX--linked recessive; malelinked recessive; maleFactor IX deficiencyFactor IX deficiencyClinically indistinguishable from hemophilia AClinically indistinguishable from hemophilia ADxDx; Factor IX assay; Factor IX assay

Hemophilia CHemophilia CADADFactor XI deficiencyFactor XI deficiency

Disseminated Intravascular Coagulation (DIC)Disseminated Intravascular Coagulation (DIC)

DIC is an acute, DIC is an acute, subacutesubacute, or chronic , or chronic thrombohemorrhagicthrombohemorrhagic disorder occurring as disorder occurring as a a secondary complication in a variety of diseases.secondary complication in a variety of diseases.Activation of the coagulation sequence >>> Activation of the coagulation sequence >>> formation of formation of microthrombimicrothrombi throughout the throughout the microcirculation.microcirculation.

Consumption of platelets, fibrin, coagulation factors Consumption of platelets, fibrin, coagulation factors >>> activation of >>> activation of fibrinolyticfibrinolytic mechanismsmechanismsClinical; Clinical; –– Signs and symptoms relating to infarction caused by Signs and symptoms relating to infarction caused by

microthrombimicrothrombi..–– A hemorrhagic diathesis resulting from activation of A hemorrhagic diathesis resulting from activation of

fibrinolyticfibrinolytic mechanisms and depletion of the elements mechanisms and depletion of the elements required for required for hemostasishemostasis..