Red Blood Cell & Bleeding Disorders *** High Yield

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Red Blood Cell Bleeding Disorders
High Yield
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Normal
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Normal Bone Marrow

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Bone marrow aspirates Biopsy specimens
Biopsy
aspirate
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Points need to know about Bone Marrow

• What is it?
• Location
• Composition
• How to obtain it?
• Why it is done?

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Peripheral Blood
Serum or plasma
Buffy coat
Hematocrit ( PCV) or Red cell volume
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Points need to know aboutperipheral Blood

• Difference between serum and plasma?
• What is Buffy coat made up of?
• ? Hematocrit or PCV ( packed Cell Volume)
• How to know the functional status of marrow by
  looking at peripheral blood?

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Adult Reference Ranges-Red Blood Cells
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Hematopoiesis

• Origin hematopoietic stem cells - unsettled
• Migration of stem cells
• Early months Yolk Sac
• Third month - Liver
• Fourth month - Bone marrow
• By birth Marrow is the Sole source of blood
  cells
• Up to puberty, entire skeleton - marrow is red
  active
• By age 18 years
• Marrow limited to vertebrae, ribs, sternum,
  skull pelvis, and proximal epiphyseal regions of
  the humerus and femur
• Remaining marrow yellow, fatty, and inactive
• Adults - 50 marrow space is active
• Clinical significance
• Premature infant - Hematopoiesis in liver
  (rarely spleen, thymus lymph nodes )
• Extramedullary Hematopoiesis - Abnormal in the
  full-term infant

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Hematopoiesis

• Clinical significance
• Premature infant - Hematopoiesis in liver
  (rarely spleen, thymus lymph nodes )
• Extramedullary Hematopoiesis - Abnormal in the
  full-term infant
• Stem cell dysfunction
• Marrow failure (Aplastic anemia)
• Hematopoietic neoplasms (Leukemias)
• Diseases distort the architecture ?Like
  Metastatic cancer, Granulomatous diseases ??
  result in abnormal release of immature precursors
  into peripheral blood
• Leukoerythroblastosis
• Resulting anemia is called as Myelophthesic
  anemia

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Bone Marrow - Morphology

• Bone marrow aspirates Biopsy specimens
• Marrow activity - ratio of hematopoietic elements
  to fat cells
• Normal - ratio is about 11 in adults
• Myeloid Erythroid ratio
• Normal - ratio is 31
• Myeloid - myelocytes, Metamyelocyte,
  granulocytes
• Erythroid - polychromatohpilic orthochromic
  normoblasts
• Clinical significance
• Cellularity
• Decreased - hypoplasia (lt25 cellularity)-
  Aplastic anemia
• Increased - Hyperplasia(gt75 cellularity)-
  hematopoiesis - hemolytic anemias, Leukemias
• ME
• Increased in Myeloid Leukemia
• Decreased (or Erythroid hyperplasia) in
  Anemias, Polycythemia

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Pathology
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?
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Anemia Blood loss

• A) Acute Blood Loss
• Earliest change in the peripheral blood
  -leukocytosis
• after 7 days ?reticulocytosis, reaching 10 to
  15 (what is normal reticulocyte count?)
• Early recovery ? Thrombocytosis
• B) Chronic Blood Loss
• Regardless of underlying cause -Iron deficiency
  anemia (IDA)

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Anemia Hemolytic

• Based on cause
• Hereditary disorders are due to intrinsic defects
  
• Acquired disorders to extrinsic factors (like
  auto antibodies)
• Based on site of lysis
• Intravascular hemolysis is manifested by
• (1) Hemoglobinuria,
• (2) Hemoglobinuria,
• (3) Jaundice
• (4) Hemosiderinuria.
• Decreased serum haptoglobin is characteristic of
  intravascular hemolysis.
• Extra vascular hemolysis
• Anemia, jaundice, Splenomegaly.

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Anemia Hemolytic

• Morphology
• Marrow-
• Erythroid Hyperplasia? increased numbers of
  erythroid precursors (normoblasts)
• Extramedullary Hematopoiesis
• Peripheral blood-
• Reticulocytosis, schistocytes (Fragmented RBC)
• In chronic cases-
• Hemosiderosis- why?
• Pigment gallstones (cholelithiasis) why?

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Anemia Hemolytic

• Hereditary Spherocytosis
• Prevalence - Northern Europe
• Genetics - Autosomal dominant (AD) in three
  fourths of cases
• The MCC of Autosomal dominant HS - Ankyrin
  mutation
• The MC protein deficient in HS - Spectrin
• Morphology
• Spherocytes Abnormally small, dark-staining
  (hyperchromic) red cells lacking the normal
  central zone of pallor not pathognomonic (seen
  in other conditions ?)
• Cholelithiasis (pigment stones) occurs in 40 to
  50 of adults.
• Splenomegaly -Moderate (500 to 1000 gm) what is
  the normal weight of spleen?
• Clinical Course
• characteristic features Anemia, Splenomegaly
  and jaundice
• Aplastic crisisHow you know - sudden worsening
  of the anemia
• accompanied by reticulocytopenia Cause -
  parvovirus infection,
• infects and kills red cell progenitors lifespan
  of red cells in HS is shortened
• to 10 to 20 days
• Hemolytic crises What you see - increased
  splenic destruction of red
• cells (e.g., infectious mononucleosis)
  

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Anemia Hemolytic

• Hereditary Spherocytosis contd
• Diagnosis
• Family history,
• Hematological findings,
• Laboratory evidence
• Osmotic lysis,
• ? mean cell hemoglobin concentration (MCHC)
• Rx - Splenectomy is often beneficial
• 2. Paroxysmal Nocturnal Hemoglobinuria
  
• Only hemolytic anemia caused by an acquired
  intrinsic defect in the cell membrane
• Results from acquired (somatic) mutations in
  phosphatidylinositol glycan A (PIGA) - essential
  for the synthesis of the GPI anchor
• GPI-linked proteins inactivate complement
  (mutations of these proteins ? uncontrolled
  complement activation)
• Complement mediated lysis of red cells, white
  cells and platelets

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Hereditary Spherocytosis (HS)
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Hereditary Spherocytosis (HS)
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Anemia Hemolytic

• Paroxysmal Nocturnal Hemoglobinuria contd
  
• Three GPI-linked proteins mutated / deficient in
  PNH
• decay-accelerating factor (DAF) or CD55
• membrane inhibitor of reactive lysis, or CD59
  (is the most important in PNH)
• C8 binding protein
• Clinical manifestations
• Venous thrombosis, (hepatic, portal, or cerebral
  veins-fatal in 50 of cases)
• prothrombotic state is due to Dysfunction of
  platelets
• ?risk of acute myeloid leukemia (AML)
• Rx immunosuppression

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Anemia Hemolytic

• 3. Glucose-6-Phosphate Dehydrogenase Deficiency
• Basic defect Inability of red cells to protect
  themselves against oxidative stress ?Leading
  to hemolytic disease
• Abnormalities in the hexose monophosphate (HMP)
  shunt or glutathione metabolism
• Variants
• G6PD B Normal variant
• G6PD A- 10 of African Americans
• G6PD Mediterranean-clinically significant
  hemolytic anemias
• Protective effect against Plasmodium falciparum
  malaria
• X- Linked recessive Males at highest risk
• Clinical patterns-
• Foods- fava beans (favism),
• Medications - antimalarials (e.g., primaquine
  and Chloroquine), sulfonamides, nitrofurantoin,
• Infections- viral hepatitis, pneumonia, and
  typhoid fever
• Hemolysis? causes both intravascular and Extra
  vascular lysis

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3. Glucose-6-Phosphate Dehydrogenase Deficiency

• Lab-
• Peripheral blood
• Heinz bodies. -denatured Hb (RBC stained with
  crystal violet)
• "bite cells"
• Spherocytes
• Features of chronic hemolytic anemia
  (splenomegaly, cholelithiasis) are absent

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Anemia Hemolytic

• 4. Sickle Cell Disease
• Basic defect
• production of defective hemoglobins- hereditary
  hemoglobinopathy
• sickle hemoglobin (HbS) -point mutation at the
  sixth position of the ß-globin chain
• substitution of a valine residue for a glutamic
  acid residue
• Incidence
• 8 of black Americans are heterozygous for HbS-
  (40 of the hemoglobin is HbS)
• In Africa, 30 of the native population are
  heterozygous.
• Advantages
• Protection against falciparum malaria
• Mechanism of Sickling
• deoxygenated, HbS molecules undergo aggregation
  and polymerization
• Sickling -initially a reversible
• precipitation of HbS fibers also causes oxidant
  damage, not only in irreversibly sickled cells
  but also in normal-appearing cells
• sickle red cells - abnormally sticky

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Hemolytic Anemia Sickle cell
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Anemia Hemolytic

• 4. Sickle Cell Disease
• Factors affect the rate and degree of Sickling
• Promotes Sickling
• Amount of HbS
• HbC
• Decrease in pH
• intracellular dehydration
• length of time red cells are exposed to low
  oxygen tension (spleen and the bone marrow
  microvascular beds )
• Inhibit Sickling
• Co-exists a- Thalassemia
• HbA HbF
• Pathogenesis of micro vascular occlusions
• reversibly sickled cells express higher than
  normal levels of adhesion molecules and appear
  abnormally sticky in certain assays
• plasma hemoglobin (released from lysed RBC) binds
  to and inactivates NO
• Clinical
• Expansion of the marrow
• prominent cheekbones
• skull X-ray- crew-cut appearance

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Anemia Hemolytic

• 4. Sickle Cell Disease
• Clinical contd
• children during early phase -splenomegaly
• leg ulcers in adult patients (rare in children)
• adolescence / adulthood -autosplenectomy
• Infarction also seen in bones, brain, kidney,
  liver, retina, and pulmonary vessels (producing
  cor pulmonale - ?)
• pigment gallstones
• Clinical Course
• infection with encapsulated organisms,
  -pneumococci and Haemophilus influenzae
• Septicemia and meningitis -MCC of death in
  children
• Vaso-occlusive crises- also called pain crises
  (MCC of morbidity and mortality)
• episodes of hypoxic injury and infarction (MC
  sites - bones, lungs, liver, brain, spleen, and
  penis)
• In children, painful bone crises
• extremely common
• DD- acute osteomyelitis
• hand-foot syndrome
• acute chest syndrome
• slow pulmonary blood flow
• "spleenlike," lungs

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Anemia Hemolytic

• 4. Sickle Cell Disease
• Clinical Course contd
• Aplastic crises- parvovirus B19
• Sequestration crises - children with intact
  spleens
• Chronic tissue hypoxia
• Renal medulla
• hyposthenuria (inability to concentrate urine)
• ? propensity for dehydration and its attendant
  risks
• Diagnosis
• Suggested by -sickle cells in peripheral blood
  smears
• Confirmed by -Hemoglobin electrophoresis
• Prenatal diagnosis
• amniocentesis or chorionic biopsy
• Rx. Hydroxyurea
• increase in the concentration of HbF
• anti-inflammatory agent by inhibiting the
  production of white cells
• increases the mean red cell volume
• oxidized by heme groups to produce NO
• reduce pain crises in children and adults

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Anemia Hemolytic

• 5. Thalassemias
• Genetic disorders leading to decreased synthesis
  of either the a- or ß- globin chain of HbA
• hematologic consequences are due to
• low intracellular hemoglobin ? hypochromia
• relative excess of unimpaired chain? membrane
  damage
• ß-Thalassemias
• Most are point mutations (unlike a-thalassemia -
  deletions )
• MC mutations- Splicing mutations Anemia -
  mechanisms
• Free a chains precipitate
• Form insoluble inclusions inclusions cause cell
  membrane damage
• 1. normoblasts in the marrow undergo apoptosis
  (ineffective Erythropoiesis)
• 2. inclusion-bearing red cells escape marrow ?
  splenic sequestration
• both 1 2 lead to ?
• ?Erythropoietin secretion -expanding mass of
  erythropoietic marrow
• impairs bone growth ? skeletal abnormalities
• Extramedullary hematopoiesis (liver, spleen, and
  lymph nodes)
• excessive absorption of dietary iron? secondary
  hemochromatosis

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Anemia Hemolytic

• 5. Thalassemias
• ß-Thalassemia major
• most common in Mediterranean countries (Africa
  and Southeast Asia)
• In USA, highest in immigrants
• Anemia manifests 6 to 9 months after birth, (Hb
  synthesis switches from HbF to HbA) Hemoglobin-3
  and 6 gm/dL
• Peripheral blood smear marked anisopoikilocytosis
  micro-cytic hypochromic red cells, Target
  cells basophilic stipplingfragmented RBC
  (Schistocytes) Reticulocytosis Normoblasts
  (nucleated RBC)
• HbF - markedly increased (major red cell
  hemoglobin)
• Morphology expansion of bone marrow, facial
  bones,"crew-cut" appearance - skull X-rays
  Splenomegaly ( up to 1500 gm)
• Clinical course
• Untreated children-growth retardation, die of
  anemia
• With Cardiac disease -important cause of death
  (due to iron load)
• Only curative therapy -Bone marrow
  transplantation
• Hemosiderosis and secondary Hemochromatosis
• Prenatal diagnosis possible

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Anemia Hemolytic

• 5. Thalassemias
• ß-Thalassemia minor
• much more common than thalassemia major -offer
  resistance against falciparum malaria
• peripheral blood
• hypochromia, microcytosis, basophilic stippling,
  and target cells
• bone marrow-Mild erythroid hyperplasia
• best confirmatory test -Hemoglobin
  electrophoresis
• HbF - normal or slightly increased
• HbA2 - 4 to 8 of the total hemoglobin (normal
  HbA2- 2.5 0.3)

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Anemia Hemolytic

• 5. Thalassemias
• a-Thalassemias
• normally four a-globin genes
• severity varies with the number of a-globin genes
  affected
• free ß and ? chains are more soluble than free a
  chains
• 1. Silent Carrier State
• single a-globin gene is deleted
• insufficient to result in anemia
• completely asymptomatic
• 2. a-Thalassemia Trait
• deletion of two a-globin genes
• clinical picture identical to ß-thalassemia minor
• small red cells (microcytosis), minimal or no
  anemia, and no abnormal physical signs
• 3. Hemoglobin H Disease
• mostly in Asian populations (rarely in African )
• only one normal a-globin gene
• moderately severe anemia
• 4. Hydrops Fetalis
• most severe form of a-thalassemia

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What is this?
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Anemia Hemolytic

• 6. Immune type (IHA)
• Causes - extra corpuscular mechanisms
• Diagnosis - Coombs antiglobulin test
• 1. Warm Antibody Immunohemolytic Anemia
• MC type(48 to 70) MCC is idiopathic (primary)
  antibodies are immunoglobulin G (IgG) class
  against Rh blood group antigens
• Other antigens- penicillin and cephalosporins
  Quinidine, a-methyldopa
• 2. Cold Agglutinin Immunohemolytic Anemia
• IgM antibodies Causes can be Acute ( mostly
  viral infectious - IM, CMV, influenza virus, HIV,
  Mycoplasma) Chronic with lymphoid neoplasms or
  idiopathic Clinical symptoms - pallor, cyanosis
  of the peripheral body parts (Raynaud phenomenon)
  exposed to below 30C temp. (fingers, toes, and
  ears )
• 3. Cold Hemolysin Hemolytic Anemia paroxysmal
  cold Hemoglobinuria
• complement dependent IgGs (also called Donath
  -Landsteiner antibody) - bind to P blood group
  antigen on the red cell surface at low
  temperatures Abs are conditions Mycoplasma
  pneumonia, measles, mumps, and ill-defined viral
  and "flu" syndromes first recognized with
  syphilis

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Anemia Hemolytic

• 7. Traumatic (mechanical)
• 1.cardiac valve prostheses (artificial mechanical
  valves )
• 2. narrowing or obstruction of the
  microvasculature
• Microangiopathic hemolytic anemia (MCC is DIC)
• Other causes -malignant HTN, SLE, TTP, HUS,
  disseminated cancer
• common feature mechanical RBC injury
• Schistocytes , "burr cells," "helmet cells," and
  "triangle cells"

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