ANEMIA AND THROMBOCYTOPENIA Kissová Jarmila, MD, Ph.D. Department of Hematology University Hospital Brno INTRODUCTION  Anemia is defined as a decrease in hemoglobin under lower level (for men 130 g/l, for women 120 g/l) (Nutritional anaemias. Report of a WHO scientific group. World Health Organ Tech Rep Ser 1968)  Classification of anemia is based on: - red cell parameters MCV (mean cell volume) MCH (mean cell hemoglobin) RDW (red cell distribution width) - reticulocyte count (hyperproliferative and hypoproliferative anemia) LABORATORY PARAMETERS ARE THE MOST USEFUL IN FORMULATING A PRACTICAL DIAGNOSTIC APPROACH 150-400109/l 7,8-11,0 fl 4,0-10,0 109/l platelets (PLT) MPV (mean platelet volume) leukocytes (WBC) 84-96 fl 28-34 pg 320-370 g/l 10,0-15,2% MCV (mean cell volume) MCH (mean cell hemoglobin) MCHC (mean cell hemoglobin concentration) RDW (red cell distribution width) women 120-160g/l women 3,8-5,4 10¹²/l women 0,35-0,46 hemoglobin men 135-176g/l erytrocytes (RBC) men 4,0-5,910¹²/l hematocrit (HCT) men 0,39-0,51 CASE HISTORY Positive anamnestic data Possible intepretation dyspnoe, weakness, palpitation, dizziness nonspecific symptoms without clear significance bleeding symptoms sideropenia, bleeding tendency, locus minoris resistentiae (tumor, inflammation) infection, tumors, chronic inflammation, fever, renal disease, thyropathy suspicion on anemia of chronic disease, eventually bone marrow involvement of tumor toxic effects alcohol, drugs, lead… jaundice, dark urine suspicion on hemolytic anemia nail fragility, hair breaking, swallowing disorder sideropenia nutrition, anorexia, weight loss sideropenia, vitamine B12 deficiency in vegetarians/vegans, suspicion on tumor, anemia of chronic disease crawling, neurologic symptoms vitamin B12 or folate deficiency drugs (antitrombotic, antireumatic therapy, therapy and other) sideropenia, myelosuppression family history of anemia hereditary hemolytic anemia, congenital hematopoietic disorders PHYSICAL EXAMINATION positive clinical examination possible interpretation skin/mucosal symptoms: • jaundice • hemorrghage (haematoma, suffusion, petechia) • pallor/“straw skin coloring“ • mucosal changes in the tongue • hemolytic anemia • I • ron deficiency anemia • without siginificancy/pernicious anemia • vitamin B 12/iron deficiency abnormality of secondary hemopoetic organs (lymph nodes, liver, spleen) suspicion on malignancy, in case of isolated splenomegaly on hemolysis melaena, enterrorhagia, haemorhoids iron deficiency, anemia of chronic disease neurological symptomatology vitamin B 12 or folate deficiency, rarely iron deficiency cor/vascular circulation murmurs, tachycardia, heart failure; usually without significancy for diferential diagnosis of anemia palpable tumor anemia of chronic disease, iron deficiency, bone marrow involvement Hypoproliferative anemia (reticulocytes  50× 109/l) z↑ fe ↓ MCV n.MCV ferr sideroblas tic anemia FI ≥1,55 ACD vyš zinc intoxicat ion iron deficiency a. β- thalasemia α-thalasemia ACD anemia with Epo deficiency ↑↑ ↓TSH, paraprotein, mixed vit.and Fe deficiency BM involvement, fibrosis, AA or PRCA acute bleeding folate deficiency diet, malabsorption pernicious anemia dysplasia MDS ↑ MCV ↓ ery n.,↑ ery n.CRP ↑ CRP n.ferritin ferr.<50 ferr.50-150 ferr.>150 ferr.<20 n.ferr. BM ring sideroblasts FI<1,55 etiology? no response to iron HP infection, Hb analysis (thalasemia) IRIDA syndrome Hb analysis n.↑HbA2 n. ↑HbF family study GF<30 GF≥30 ↓ EPO n.EPO ↑CRP n.CRP nHFR ↑HFR B12/ folate ↓B12,n.fol. n.B12,↓fol. n.B12 a fol. GFS, IF a PC pl atrof.gastr.+/- pl GIT exam. BM incr.erythropo iesis, left shift consider vit. B12 Hyperproliferative anemia (high reticulocytes) hemolysis (↑ indirect bilirubin,↑ LD, ↓ haptoglobin) acute bleeding signs of extravascular hemolysis AIHA with cold antibodies AIHA with warm antibodies red cell abnormality TTP-HUS or other MAHA sy (HIV, ca) mikroangiopathy (prosthetic valve, chlopně, extensive thromboses) hereditary spherocytosis flowcytome try-PNH hereditary elliptocytosis thalasemia sickle cell anemia lead poisoning Heinz bodies (hemoglobino pathies, enzymopathi es) ultrasound of abdomen- hypersplenism copper overload positive Coombs test negative Coombs test signs of intravascular hemolysis fragmented ery thrombocytopenia no yes yes no yes no yes no LABORATORY EVALUATION IN THE DIAGNOSIS OF ANEMIA  blood count, cell differential of white blood cell count, reticulocyte count  red cell morphology  serum iron, transferrin saturation, serum ferritin, transferrin (or total iron binding capacity)  folate, cobalamin, serum bilirubin, lactate dehydrogenase, erythropoietin level, iron resorption testing, occult blood test …..  bone marrow examination with iron staining Red cell morphology From Bunn HF, Aster JC: Pathophysiology of blood disorders, 2011 ANEMIA CLASSIFICATION ACCORDING TO RED CELL PARAMETERS MCV (mean cell volume): <84 fl - microcytic a. 84-95 fl - normocytic a. >96 fl - macrocytic a. RDW (red cell distribution width) > 15,2 % – a. with anisocytosis < 15,2 % – a. with homogennous red cell population MCH (mean corpuscular hemoglobin): 28 - 34 pg normochromic a. < 28 pg hypochromic a. MICROCYTIC HYPOCHROMIC ANEMIA  iron deficiency anemia  thalassemia _____________________________  anemia of chronic disease  thalassemia  sideroblastic anemia RDW>15,2 RDW<15,2 NORMOCYTIC NORMOCHROMIC ANEMIA  iron deficiency anemia (initial stage)  myelofibrosis _________________________  primary bone marrow disorder (aplastic anemia, myelodysplastic syndrome…)  anemia of chronic disease  acute posthemoragic anemia  sideroblastic anemia  hemolytic anemias (hereditary spherocytosis, hemoglobinopathy) RDW>15,2 RDW<15,2 MACROCYTIC ANEMIA  pernicious anemia  megaloblastic anemia in pregnancy  sideroblastic a.  autoimunne hemolytic anemia _____________________________  aplastic anemia  myelodysplastic syndrome  liver disease, hypothyroidism RDW>15,2 RDW<15,2 RETICULOCYTES Low count 1. Iron deficiency anemia 2. Megaloblastic a. 3. Sideroblastic a. 4. Congenital dyserytropoetic a. 5. MDS High count 1. Hemolytic anemias 2. Chronic blood loss PATHOPHYSIOLOGICAL CLASSIFICATION OF ANEMIA 1. Anemia due to decreased red cell production 2. Anemia due to increased red cell destruction 3. Acute posthemoragic anemia ANEMIA DUE TO DECREASED RED CELL PRODUCTION 1. Decreased erythroid progenitors, ineffective erythropoiesis Pure red cell aplasia AA CDA MDS 2. Disorders of heme synthesis Iron deficiency Sideroblastic anemia 3. Disorders of DNA synthesis: megaloblastic 4. Disorders of globin synthesis Thalassemias Structural variants of hemoglobin ANEMIA DUE TO INCREASED RED CELL DESTRUCTION Intracorpuscular hemolytic anemias Membrane defects PNH Hemoglobin opathies Enzymopathies Extracorpuscular hemolytic anemias Immune Nonimmune ANEMIA THE PREVALENCE OF DIFFERENT TYPES Type of anemia Prevalence Iron deficiency 25 % Anemia of chronic disorders 25 % Acute bleeding (posthemorrhagic) 25 % Megaloblastic anemia 10 % Hemolytic anemia < 10 % Bone marrow failure < 10 % MICROCYTIC ANEMIA IRON DEFICIENCY ANEMIA • the most prevalent anemia in the world • iron deficiency in one third of the world´s population (WHO) IRON DISTRIBUTION IN THE BODY TOTAL AMOUNT 4 G iron in HGB 65 % stored iron 25 % enzymes 10 % transport form of iron 0.1 % DISTRIBUTION OF IRON IN THE BODY (MAN, 70 KG) protein localization iron content (mg) hemoglobin erythrocytes 3000 myoglobin muscles 400 cytochroms all tissues 50 transferin plasma and a extravascular fluid 5 feritin and hemosiderin liver, spleen and bone marrow 100-1000 IRON DEFICIENCY 3 levels of iron deficiency: prelatent sideropenia- reduction of storage iron, but the supply of iron to erythroblasts is not affected latent sideropenia- storage iron is exhausted, decreased iron supply for erythropoesis, but no anemia manifest sideropenia= iron deficiency anemia IRON DEFICIENCY STAGES prelatent latent manifest serum iron цmol / l normal < 12 < 10 transferin normal > 70 > 74 transferin saturation % normal < 15 < 10 ferritin < 20 < 15 < 10 normal 20-200 цg / l storage iron in BM slightly moderately significantly MCV normal 78-83 <78 MCH normal 25-28 <25 MCHC normal normal <320 CAUSES OF IRON DEFICIENCY A. Chronic blood loss Gastrointestinal- hemerhoids, diverticulosis, peptic ulcers, oesophageal varices, carcinomas, gastritis, colitis, drugs (aspirin, non-steroidal antiinflammatory drugs, anticoagulants), parasites, angiodysplasia Gynecologic- menorrhagia, metrorrhagia Urinary tract- hematuria, hemoglobinuria Hemodialysis Iatrogennic causes- blood donors, frequent blood sampling Self-inflicted blood loss B. Inadequate iron intake Poor diet Malabsorption- gluten-induced enteropathy, gastrectomy,… C. Increased demands Pregnancy, breast feeding Growth Erythropoetin therapy CLINICAL FEATURES OF IRON DEFICIENCY Nonspecific symptoms of anemia Fatiquability, weakness, dyspnoe on exertion, palpitation, pallor, reduced load tolerance Neuromusculatory system Increased lactate production durin the exertion, muscle weakness, neurastenia, neuralgia,reduces sensitivity, parestesia, cognitive behavioral disorders Epitel Nail fragility, nail thinning…koilonychia (rare and limited to severe chronic deficiency), hair loss, atrophy of lingual papillae, glositis, angular cheilitis, dysphagia Immune system Defects of specific cellular immunity, defective phagocytic functions Pica Pagophagia (ice), geophagia (clay), amylophagia (starch) Skeletal system Growth disorders in children Other Reduced sensitivity to cold Mild splenomegaly CLINICAL FEATURES OF IRON DEFICIENCY ANEMIA LABORATORY CHANGES OF IRON DEFICIENCY ANEMIA • microcytic hypochromic anemia • anizocytosis, poikilocytosis, anulocytes • normal or reduced reticulocyte count • reduced number of siderophages and sideroblasts in bone marrow • increased level of soluble transferin receptors (not affected by the acute phase reaction) • mild thrombocytosis is found • in small number of patients is leukopenia found PERIPHERAL BLOOD – NORMAL FINDING X IRON DEFICIENCY ANEMIA SERUM FERRITIN • Serum ferritin is the most important parameter for diagnosis of iron deficiency • Ferritin is acute phase protein! may be elevated in concomitant inflammatory diseases ferritin > 100 ug/l makes iron deficiency inlikely • Diagnosis of iron deficiency in inflammation or tumor decreased transferin saturation bone marrow examination therapeutic test: iron therapy for 3 weeks EVALUATION OF STAINABLE IRON IN BONE MARROW siderocytes erythrocytes with blue-green granules in cytoplasma sideroblasts erythroblasts with 1-3 granules (normal 20-60%) ring sideroblasts numerous granules form a ring around the nucleus siderophages macrophages extracelular iron present, rarely or absent SIDEROCYTES STORAGE IRON (ACD) RING SIDEROBLASTS SOLUBLE TRANSFERIN RECEPTORS • level of soluble transferin receptors is directly proporcional to transferin receptor expression on erythropoetic precursors • in case of iron deficiency induction of these receptors occurs • no affected by inflammation • increased level in iron deficiency anemia and anemia of chronic disease • ferritin index (FI)=sTfR/log ferritin (increased in iron deficiency anemia, decreased in ACD) DIAGNOSIS OF IDA LABORATORY FEATURES ■ Microcytosis: MCV < 84 fL ■ may be absent in more rapid loss of iron ■ Low mean cell HGB: MCH < 28 fL ■ Hypochromia: MCHC < 320 g/L ■ Low serum iron: < 10 mmol/L ■ similar to ACD (not useful for differential dg) ■ High TIBC (serum transferrin) ■ Low iron saturation of TIBC < 20 % ■ Low serum ferritin: approx. < 20 mg/L ■ Low marrow sideroblasts < 20 % ■ not necessary for diagnosis 38 THERAPY OF IRON DEFICIENCY ANEMIA • the basic rule is eliminating the causes of iron deficiency • oral iron therapy - daily total of 150-200 mg elemental iron - in case of intolerance- dose reduction to 100 mg/day (adverse effects comparable to placebo) - therapy is long-term (3-6 months after hemoglobin normalisation) - the patient should be instructed: do not give with meals - inhibition of resorption by tea, coffee, milk NORMOCYTIC ANEMIA Anemia with normal mean cell volume of erytrocytes (MCV) resulting from: - reduced production of erythrocytes (anemia of chronic disease, aplastic anemia) - increased destruction or loss of erythrocytes (hemolysis, posthemoragic anemia) - uncompensated increase in plasma volume (excess fluid) - combination of conditions leading to microcytic and macrocytic anemia NORMOCHROMIC NORMOCYTIC ANEMIA retikulocytes increased normal / decreased hemolytic posthaemoragic endocrinopathy renal disease liver disease bone marrow examination low normal / high anemia of chronic disease early iron deficiency serum iron CAUSES OF NORMOCYTIC ANEMIA  anemia of chronic disease  nutritional anemia (inicial stage of iron deficiency anemia)  anemia in chronic renal failure  anemie in chronic heart failure  hemolytic anemia  primary bone marrow disorder aplastic anemia, pure red cell anemia myelodysplastic syndrom paroxysmal nocturnal hemoglobinuria  secondary bone marrow disorder drugs, toxins, radiation, viral infections myelofibrosis bone marrow infiltration (hematologic and solid tumors) liver disease endocrinologic disease ANEMIA OF CHRONIC DISEASE ANEMIA OF CHRONIC DISEASE, ACD specific group of acquired anemias associated with number of chronic diseases (lasting for more than 1-2 months)  does not include posthemoragic anemia, hemolytic anemia, bone marrow infiltration  anemia associated with liver, renal or endocrinologic diseases are not usually classified as ACD (multifactorial etiology, ACD is only one of causes)  the most prevalent anemia in inpatients and old people  occurs in more than half oncologic patients, incidence decreases in inflammatory conditions  interdisciplinary problem  usually confused with iron deficiency anemia and treated uncorrectly ETIOLOGY OF ANEMIA OF CHRONIC DISEASE  chronic infections (osteomyelitis, chronic kidney and urinary tract infections, HIV, chronic skin disorders- decubits, leg ulcers …)  chronic non-infectious inflammatory conditions (connective tissue disease, inflammatory bowel disease, nephritis, rheumatoid arthritis…)  malignancy (solid tumors and hematologic malignancy)  traumatic and postoperative conditions (burns, post-transplant conditions) PATHOGENESIS OF ANEMIA OF CHRONIC DISEASE  Increased production of inflammatory cytokines (TNF α, IL-1, IL-4, IL-6, IL-10 a IFN γ)  Increased production of hepcidin in the liver (regulatory protein of iron metabolism)  relative iron deficiency  suppression of erythroid progenitors (BFU-E) and precursors (CFU-E)  decreased production of erythropoetin and impaired ability of erythroid precursors to respond to EPO HEPCIDIN - KEY ROLE IN ACD  plays role in regulation of iron homeostasis  hepcidin binds to and leads to ferroportin degradation (the primary cell surface iron exporter) in cells (macrophages, enterocytes, hepatocytes)  is produced in liver - in tumors and inflammation (IL-6) - in high intake of iron  negative regulator of iron absorption in enterocytes and iron release in monocyte-macrophage system  decrease of serum iron can be a natural immunity mechanisms – antimicrobial peptid CHARACTERISTICS OF ACD  no marked anizocytosis (normal or slightly increased RDW)  normal or low reticulocytes  normal cellularity of bone marrow, no increase of erythropoesis  marrow contains increased storage iron DIFFERENCIAL DIAGNOSIS OF ACD ACD IDA ACD and IDA MCV (fl) N-↓ (>72) ↓/↓↓↓ ↓ RDW ↑- N ↑ ↑ serrum iron ↓ ↓↓/↓↓↓ ↓ serum ferritin (ug/l) N- ↑ ↓ (<20) < 30→ sideropenia serum transferin ↓- N ↑ ↓ transferin saturation(%) N- ↓ ↓ ↓ sTfR (0,8- 3,1 mg/l) N ↑ (2,0-20,0) N- ↑ sTfR/log.ferritin (0,3- 2,5) < 1,0 > 2,0 > 2,0 serum hepcidin ↑ ↓ ↓ BM- sideroblasts ↓ (< 20%) ↓ ↓ BM- siderophages N- ↑ ↓- 0 ↓- 0 ANEMIA IN CHRONIC RENAL FAILURE normocytic normochromic anemia hypoproliferative (low reticulocytes) must be considered in decreased glomerular filtration under 30 ml/min (Babitt JL, Herbert YL. Mechanismus of anemia in CKD. J Am Soc Nephrol 2012) MACROCYTIC ANEMIA MACROCYTIC ANEMIAS (MCV > 96 FL) Megaloblastic (tzv. megaloblastic hematopoiesis) - impaired synthesis of DNA • cobalamin/folate deficiency - 30-50% of all macrocytic anemias • congenital DNA synthesis disorders • drug- induced - methotrexate, cytosin-arabinosid, cyklophosphamide • toxic DNA synthesis disorders (arsenic) Nonmegaloblastic - no impaired DNA synthesis NONMEGALOBLASTIC MACROCYTIC ANEMIAS • accelerated erythropoiesis - hemolytic anemia - posthemorrhagic anemia • enlarged surface of red blood cells - liver disease - splenectomy • dysplastic anemias • alcoholism (macrocytosis without anemia) • hypothyreosis • chronic obstructive pulmonary disease COMPARISON OF NORMOBLASTIC AND MEGALOBLASTIC HEMATOPOIESIS NONMEGALOBLASTIC MEGALOBLASTIC nuclear-cytoplasmic asynchrony MEGALOBLASTIC ANEMIACAUSES- PART I Cobalamin deficiency Decreased intake - vegetarians/vegans - poor nutrition in older people Malabsorption - pernicious anemia - congenital deficiency of intrinsic factor - partial or total gastrectomy - celiac sprue (primary malabsorption) - selective cobalamin malabsorption with proteinuria (Imerslundové - Gräsbeckův syndrom) - blind loop syndrome - Ileal resection or disease - parasites (Diphylobothrium latum, Giardia intestinalis, Strongyloides stercoralis) - drugs- metformin - pancreatic insufficiency - Zollinger-Ellisonův syndrome (gastrinom) MEGALOBLASTIC ANEMIA-CAUSES PART II Folate deficiency Decreased intake - poor nutrition - special diet Increased loss - congestive heart failure - hemodialysis Drugs - anticonvulsants - sulphalasine Malabsorption - gluten enteropathy - congenital malabsorption Increased requirements - pregnancy, breastfeeding - hemolytic anemia - premature infants - tumors (carcinomas, lymphomas, myeloma) - inflammatory disorders - skin disease (severe psoriasis or dermatitis exfoliativa) Mixed - alcoholism - liver disease DRUGS CAN CAUSE MEGALOBLASTIC ANEMIA Antimetabolits antifolates Methotrexate Pyrimethamine Trimetoprime Sulphasalazine purine analogues 6-merkaptopurine 6-thioguanine Azathioprine Acyklovir Pyrimidine analogues 5-fluorouracil 5-fluorodeoxyuridine Zidovudine Inhibitors of ribonukleosid reduktase Hydroxyurea Cytosin arabinosid Anticonvulsants Difenylhydantoin Fenobarbital Karbamazepin Primidon Other drugs influencing folates Oral contraceptives Cykloserine Inhibitors of proton pumps Omeprazol Other N₂0 Metformin Kolchicin Neomycin Arzenic (According Lichtman MA et al. The Megaloblastic Anemias. Williams Manual of Hematology, 2011) PERNICIOUS ANEMIA Autoimmune disease in which atrophy of the gastric mucosa of the stomach reduces the number of parietal cells that produce the intrinsic factor necessary for absorption of vitamin B12.  intrinsic factor antibodies  parietal cell antibodies  gastric body mucosal atrophy PERNICIOUS ANEMIA  severe anemia acompanied by slow development of anemic syndrome  often neurologic symptoms (not correlated with severity of anemia)  macrocytosis often precedes anemia - MCV 110-130 fl (up to 160 fl) - presence of macroovalocytes, hypersegmented neutrophils - normal reticulocyte number  neutropenia  thrombocytopenia  hyperplastic bone marrow - megaloblastic erythropoiesis DIAGNOSTIC CRITERIA – PERNICIOUS ANEMIA Hemoglobin concentration < 130 g/l for men and < 120 g/l for women Hematologic features of cobalamin deficiency (makroovalocytes, retikulocytopenia, hypersegmented granulocytes, megaloblastic bone marrow) Laboratory proof of cobalamin deficiency Gastric mucosal atrophy Autoantibodies to intrinsic factor and/or to gastric parietal cells Presence of clinical signs of myelopathy, neuropathy or cognitive dysfunction TREATMENT OF PERNICIOUS ANEMIA - lifelong parenteral vitamin B12 substitution - initial dose 1000 ug intramuscular injection daily or every other day for 1 week - once a week 1-2 months - maintenance dose usually once a months - the most useful sign of a hematological response to therapy is an increase in the reticulocyte count on 7th to 10th day after B12 substitution start HEMOLYTIC ANEMIA WHEN WE THINK ABOUT HEMOLYTIC ANEMIA? • rapid onset of pallor and anemia • icterus with increased indirect bilirubin concentration • history of bilirubin lithiasis • splenomegaly • presence of circulating spherocytes (for example AIHA, hereditary spherocytosis) • other red cell abnormalities • increased lactate dehydrogenase level • decreased or absent haptoglobin level • direct antiglobulin test positivity • increased reticulocyte count Anemia due to a shortened survival of circulating red blood cells (the bone marrow can replace the increased turnover up to 10 times) CLASSIFICATION OF HEMOLYTIC ANAEMIAS hereditary acquired Membrane deffects hereditární spherocytosis, hereditary elliptocytosis Immune • autoimmune AIHA warm antibody type AIHA cold antibody type Metabolism red cell deffects G6PD deficiency, pyruvate kinase deficiency • alloimmune Hemolytic transfusion reactions Hemolytic disease of the newborn Hemoglobinopathy (Hb S, HbC, unstable Hb) • Drug associated hemolytic anemias Red cell fragmentation hemolytic anemias Infections malaria, clostridia Chemical and physical agents especially drugs, industrial/domestic substances, burns Secondary Liver and renal disease Paroxysmal nocturnal hemoglobinuria HEMOLYTIC ANEMIAS 69 corpuscular auto-immune extracorpuscular non-immune History, red cell count in smear direct antiglobulin test DAT ery osmotic resistance decreased positive negative LABORATORY FINDINGS OF HEMOLYSIS extravascular hemolysis intravascular hemolysis reticulocyte count increased increased indirect bilirubin increased increased haptoglobin can be low low or absent lactate dehydrogenase increased increased free hemoglobin normal significantly increased urine bilirubin absent absent urine hemosiderin absent positive urine hemoglobin absent positive in severe conditions COMMON CHARACTERISTICS OF HEMOLYTIC ANEMIA symptoms Anemia-related symptoms (pallor, fatigue, exertional dyspnoe, palpitations) and signs of hemolysis (jaundice, dark urine) laboratory findings Various degrees of macrocytic anemia with reticulocytosis, increased LD, indirect bilirubin, decreased haptoglobin level. intravascular hemolysis Sudden (acute) onset Often severe and symptomatic anemia Low back pain Fever, chills Hypotension, shock Dark or reddish urine with hemoglobinuria, delayed hemosiderinuria (≥7 days), thrombocytosis, leukocytosis Possible acute renal failure Delayed jaundice extravascular hemolysis Progressive (subacute or chronic) and insidious onset Mild to moderate anemia Splenomegaly History of gallstones Leg ulcers Dark urine Variable MCV, presence of spherocytes Hypocholesterolemia AUTOIMMUNE HEMOLYTIC ANEMIA (AIHA) Warm antibody AIHA Cold antibody AIHA IgG not monoclonal do not bind complement predominantly extravascular hemolysis intravascular hemolysis at high titer IgM often monoclonal bind complement predominantly intravascular hemolysis AUTOIMMUNE HEMOLYTIC ANEMIA (AIHA)LABORATORY FEATURES • Blood count: usually macrocytic anemia with reticulocytosis • Biochemistry: ↑ indirect bilirubin, ↑ LD • Special examination direct and indirect antiglobuline test (Coombs) Direct antiglobulin test Undirect antiglobulin test CLASSIFICATION OF AIHA WITH WARM ANTIBODIES ■ idiopatic form of AIHA ■ secondary forms • lymphoproliferative diseases • autoimmune disease • drugs: penicillin, chinidin, methyldopa 75 HAEMOLYTIC CRISIS IN AIHA WITH WARM ANTIBODIES ■ rapid drop in HGB concentration ►severe anemia ■ jaundice ■ abdominal pain, back pain ■ fever ■ splenomegaly Haematological emergency 76 MIKROANGIOPATHIC HEMOLYTIC ANEMIA, MAHA Group of disorders resulting from the fragmentation of erythrocytes by the microvascular thrombi DAT negative hemolytic anemia • Thrombotic thrombocytopenic purpura TTP, m. Moschkowitz • Hemolytic-uremic syndrome, HUS • HELLP syndrome in pregnant women PATOPHYSIOLOGY OF TTP / HUS • formation of platelet thrombi in microcirculation - vWF + thrombocytes + small amount of fibrin - terminal arteriols and capillaries - subendotelial hyaline deposit - normal level of clotting factors - consuming thrombocytopenia • mechanic hemolysis, DAT negative - schistocytes in peripheral blood TTP / HUS LABORATORY PICTURE ■ thrombocytopenia ■ anemia ■ schistocytes >4/1000 erythrocytes ■ high lactatedehydrogenase ( LD ) ■ elevated bilirubin ■ increased free serum haemoglobin ■ decreased haptoglobin ■ normal blood coagulation tests 79 TTP / HUS • young age: mean 42 years (18-72) • previously healthy individuals • acute onset • fulminant course • the disease can be fatal most death occur within 48 hours • incidence is rising TTP / HUS SYMPTOMATIC PENTAD • MAHA • thrombocytopenia • fever • acute renal failure • neurologic symptomatology APLASTIC ANEMIA • hematopoetic cell failure in the ability of selfrenewal and maintain constant stem cell pool • bone marrow hypocelularity • cytopenia • immune mechanisms- inhibition by Tlymphocytes, antibodies or lymphokines APLASTIC ANEMIA  by origin - inherited (Fanconi, Blackfan- Diamond) - acquired: idiopathic secondary  by severity - chronic cytopenia - severe aplastic anemia - very severe aplastic anemia SEVERE APLASTIC ANEMIA PERIPHERAL BLOOD FINDINGS • granulocytes < 0,5 x 109/l • reticulocytes < 1 % < 40 x 109/l • thrombocytes < 20 x 109/l THROMBOCYTOPENIA THROMBOCYTOPENIA - decrease of platelet count under 150 G/l - in practice border 100G/l - it is necessary exclude pseudotrombocytopenia (2% of patients) - in case of true thrombocytopenia examine peripheral blood by microscope Klasifikace trombocytopenieDecreased production Increased destruction Sequestration Aplastic anemia MDS Leukemia Lymphoma Drugs (DITP) Immune (ITP) DIC TTP HIT Drugs (DITP) ITP Portal hypertension with splenomegaly Liver cirhosis with congestive splenomegaly Gaucher disease Myelofibrosis Viral infections with splenomegaly SEVERITY OF THROMBOCYTOPENIA (ACCORDING TO NATIONAL CANCER INSTITUTE) PLT 75-150 G/l….. grade 1, mild thrombocytopenia PLT 50-75 G/l……..grade 2, moderate thrombocytopenia PLT 25-50 G/l…….. grade 3, severe thrombocytopenia PLT bellow 25 G/l .. grade 4, life threatening thrombocytopenia THROMBOCYTOPENIA PATOPHYSIOLOGIC CLASSIFICATION • Arteficial (pseudothrombocytopenia, in vivo) - clustering after the anticoagulant (EDTA) • Accelerated platelet destruction (the most frequent) - immune - nonimmune (TTP) • Platelet formation disorders • Abnormal platelet distribution in the body (pooling) - disorders of spleen - massive transfusion delivery THROMBOCYTOPENIA- DIF. DG. blood count Isolated thrombocytopenia pancytopenia acquired inherited acquired inherited ITP drug- related HIT HIV, HCV Aplastic anemia LeukemiaWiskottAldrich sy TAR Bernard- Soulier Vvelokardio facial sy Gray platelet sy Solid tumors Vit. B12 and folate deficiency Infections Fanconi anemia Dyskeratosis congenita Congenital amegakaryocytic thrombocytopenia MayHegglin an. DIAGNOSIS OF IMMUNE THROMBOCYTOPENIA IS PER EXCLUSIONEM • peripheral thrombocytopenia • normal megakaryocyte count in bone marrow • absent splenomegaly - mild splenomegaly is possible IMMUNE THROMBOCYTOPENIA Idiopatic, ITP Secondary • drug-induced - heparin - chinidin, chinin, rifampicin, acetaminofen trimethoprim-sulfametoxazol, hydrochlorothiazid • lymphoproliferation • lupus erythematodes • infections Aloimmune • newborn • transfusion reaction HEMORRHAGIC MANIFESTATION IN ITP • skin bleeding symptoms • mucosal bleeding - gingival - epistaxes - hematuria - menorrhagia - gastrointestinal bleeding • cerebral hemorrhage - in 1% with severe thrombocytopenia(<20x109/l) • posttraumatic bleeding - dental extraction, tonsilectomy, cutting wounds LABORATORY FINDINGS IN ITP • often platelets of varying size and appearance • abnormally large platelets 3-4 mm - increased MPV - inverse MPV correlation with the number of platelets - contrast with low MPV in hypersplenism • abnormally small platelets and fragments of platelets • platelet anizocytosis - increased PDW - picture of accelerated production of platelets • antiplatelet antibodies are not specified for ITP - often are increased in nonimmune thrombocytopenia and normal people - normal platelets have immunoglobulins in a-granules o release during platelet activation MEAN PLATELET VOLUME, MPV NORMAL RANGE 8-11 FL High level Immune thrombocytopenia Low level Hypersplenism MPN Thrombocytopenia associated with chemotherapy Septic trombocytopenia BONE MARROW IN ITP • non-specific changes in megakaryocytes - same morphology as in other types of accelerated platelet destruction - bone marrow examination is not necessary in ITP(under 60 years of age) - is usefull for the exclusion of other diseases • megakaryocytes - large size, gigantic megakaryocytes - increased number - accelerated platelet production, increased young elements ACUTE IMMUNE THROMBOCYTOPENIA • sudden appearance • infection precedes 3 weeks before - viral infection in children, respiratory infections - varicella zoster, EBV - vaccination • severe thrombocytopenia in children, bleeding symptoms usually mild - spontaneous remision in 90% of children - usually duration 4-6 weeks in children CHRONIC IMMUNE THROMBOCYTOPENIA • prolonged mild bleeding symptoms • fluctuating course • bleeding episodes last day to weeks - can be cyclic course - spontaneous remision are incomplete - benign course IMMUNE THROMBOCYTOPENIA - diagnosis per exclusionem - nonspecific proof of antiplatelet antibodies - start therapy in platelet count under 30G/l - 1-st line therapy- corticosteroids (prednison 1 mg/kg, dexamethazon 40 mg) - immunoglobulins 0,4 mg/kg/day 5 days or 1g/kg 1-2 days - 2-nd line therapy- splenectomy, immunosupression, rituximab 375 mg/m2 one a week for 4 weeks - use of thrombopoetin receptor agonists (chronic ITP relapsed or refractery) POST- TRANSFUSION PURPURA, PTP • severe thrombocytopenia occuring after a blood transfusion, it is caused by alloimmunisation against platelet antigens (about a week after transfusion) - unclear pathophysiology • potencially fatal reaction • rare occurence, usually - multiparous women - previously transfused patients DIAGNOSIS OF PTP IS CLINICAL • it is necessary to consider this diagnosis after blood transfusion, if the thrombocytopenia occurs in 3-14 days - exeptionally after blood plasma • spontaneous regression in 1-3 weeks • therapy - IVIG - plazmaferesis - corticosteroids DIFFERENCIAL DIAGNOSIS OF ITP • acute leukamia • myelodysplastic syndrome • aplastic anemia • thrombotic microangiopathy, TTP/HUS • disseminated intravascular coagulopathy, DIC • arteficial thrombocytopenia HIT-4T SCORING SYSTEM(CLINICAL CRITERIA) Category 2 points 1 point 0 points 1. thrombocytopenia platelet count fall > 50% and platelet nadir ≥ 20G/l platelet count fall 30- 50% or platelet nadir 10-19G/l platelet count fall < 30% or platelet nadir < 10G/l 2. timing of platelet count fall clear onset between days 5-10 or platelet fall ≤ 1 den (prior heparin exposure within 30 days) consistent with days 5- 10 fall, but not clear (e.g. missing platelet counts) or onset after day 10 or fall ≤ 1 day (prior heparin exposure 30-100 days ago) platelet count fall < 4 days without recent heparin exposure 3. thrombosis or other sequelae new thrombosis (confirmed) or skin necrosis at heparin injection sites or acute systemic reaction after intravenous heparin bolus progressive or recurrent thrombosis or nonnecrotizing (erythematous) skin lesions or suspected thrombosis (not proven) none 4. other causes for thrombocytopenia none apparent possible definite 0-3 low probability, 4-5 intermediate probability, 6-8 high HIT- LABORATORY DIAGNOSTICS category immunologic tests functional tests principles detect circulating antibodies against PF4/heparin detect antibodies, which activate cell depending on heparin examples ELISA serotonin release assay HIPA (heparin- induced platelet activation assay) advantages high sensitivity, simple design, widely available high sensitivity and specifity disadvantages limited specificity technically difficult and limited availability THROMBOCYTOPENIA AND SURGERY (BCSH) • stomatologic procedures ≥ 10G/l • dental extraction ≥ 30 G/l • small surgical procedures ≥ 50 G/l • large surgical procedures ≥ 80 G/l • lumbal puncture, epidural anesthesia, gastroscopy, biopsy, catheter insertion, liver biopsy ≥ 50G/l • brain surgery, some eye surgery ≥ 100 G/l • Caesarean section (SC) > 50G/l • SC+ epidural anesthesia ≥ 80G/l • vaginal delivery 30-50 G/l