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Definisi
Sindroma Klinik yang disebabkan :
- Penurunan masa eritrosit total dalam tubuh
- Penurunan Hb, Ht, Eritrosit
Definisi lain :
- Menurunnya jumlah hemoglobin dalam sel
darah merah sehingga oksigenasi ke jaringan
dan organ terganggu.
Biasanya diikuti dengan penurunan Ht
Kadar Hb dipengaruhi umur, jenis kelamin,
geofrafis dan metode pemeriksaan.
Anemia : Not a diagnosis in itself.
An Objective Sign
2. Peningkatan penghancuran
(HEMOLYSIS)
10
1.Penurunan pembentukan sel drh merah
– deficiency
– bone marrow failure
– dyshematopoietic anemia
Penurunan ....
Defect / kerusakan pembuatan heme
– Iron deficiency, anemia of chronic disease, lead
poisoning
Defect / kerusakan pembentukan globin
– Alpha and beta thalassemia
Defect pembuatan DNA
– Nutrient deficiencies (B12, folate)
Kegagalan produksi epo
– Renal disease
Penurunan . . . .
Hemolytic Anemia
– corpuscular – extracorpuscular
membrane defects immune
– isoimmune
enzyme defects
– autoimmune
hemoglobin defects
idiopathic
Peningkatan . . . .
Extracellular
– Antibody mediated
– Microangiopathic; HUS, DIC
– Drugs, toxins
– Hypersplenism
Peningkatan . . . .
Intracellular
– RBC membrane defects
HS, HE
– Enzyme defects
PK, G6PD
– Hemglobinopathies
Sickle cell, thalassemia
Anemia Classification
Size of RBC’s
– Microcytic (Small)
– Macrocytic (Large)
– Normocytic (Normal Size)
Concentration of Hgb
– Hypochromic (Less)
– Hyperchromic (More)
– Normochromic (Normal)
Microcytic / Hypochromic
– Chronic Blood Loss, Iron Deficiency, Thalassemia
Macrocytic (Megaloblastic) / Hyperchromic
– Vit B12 (Pernicious) or Folic Acid Deficiency
Normocytic / Normochromic
– Hemolytic, Aplastic, Myelophthisic, Acute Blood Loss, Chronic Renal
Failure
Anemia Hemolitik
Anemia karena peningkatan destruksi
eritrosit
Terjadi hiperplasi eritropoetik &
perluasan anatomis tulang
SS tl : 6 – 8 xN
Retikulosit meninggi
Pembagian Anemia Hemolitik
1. Anemia hemolitik herediter/intrinsik:
a. Defek membran: sperositosis,eliptosit
b. Defek enzim/metabolik : G6PD, PK
c. Defek Hb : sickle sel, HbC, HbD, HbE,HbSC,HbM, H
Koln&Zurich, Thalasemia
diet
family history
environmental exposures
symptoms (headache, exertion dyspnea,
fatigue, dizziness, weakness, mood or
sleep disturbances, tinnitis)
30
Pemeriksaan laboratorium /
darah tepi
RBC
Hgb
HCT
MCV - a calculated value
MCH
RDW /lebar distribusi eritrosit
Reticulocyte Count
Determination of RBC Indices
RBC count (RBC) - # RBC’s / 100 mL of Blood
(NORMAL = 36-45%)
ANEMIA
Erythrocyte Indices
Blood Smear
Hypochromic Microcytic
– Hemoglobin E trait
– Inborn errors of iron
– Iron deficiency anemia
metabolism
– Thalassemia
– Copper deficiency
– Sideroblastic anemia
– Severe Malnutrition
– Chronic infection
– Lead poisoning
Using MCV to Characterize
Anemia
Macrocytic
50
Blood cells are made in the
bone marrow
Anemia defisiensi besi
Etiologi :
1. masukan kurang : KEP, def.diet relatif
2. absorpsi kurang : KEP, diare kronis, sin-
droma malabsorpsi
3. sintesis kurang transferin kurang
4. kebutuhan bertambah : infeksi, pertum-buhan
yg cepat
5. pengeluaran yg bertambah : cacing ankilos,
amubiasis kronis, polip, hemolisis intravask.
52
How to make a red blood
cell
Genes
Erythropoietin
(kidney)
Nutrients
Bone
marrow
Iron, Folate, B12
Iron Deficiency Anemia
causes
– Dietary deficiency – Blood loss
gut problems
gall bladder
– Increased demand
lung
(growth)
nose
heart
– Impaired absorption kidney
menstrual problems
trauma
Anemia defisiensi Fe
Anemia o.k cadangan besi berkurang
Mikrositik hipokromik
MCV,MCH,MCHC menurun
Saturasi transferin menurun
Kadar feritin serum menurun
Hemosiderin ssm tulang menurun
Gejala anemia def.besi
Anak lemas, sering berdebar,lekas lelah, pucat, sakit
kepala, iritabel, dsb.
Tidak tampak sakit o.k.perjalanan kronis.
Pucat : mukosa bibir, faring, tapak tangan, dasar kuku,
konjungtiva okular kebiruan atau putih mutiara, papil
lidah atropi
Jantung membesar, bising sistolik. Pada ankilost : perut
buncit,edema.
Pada KEP : hepatomegali, diatese hemorrhgik
56
Iron Deficiency Anemia
Symptoms
– GI – Cardiac
anorexia increased cardiac
pica output
atrophic glossitis cardiac hypertrophy
guaiac positive stool
– Musculoskeletal
– CNS impaired exercise
performance
fatigue
radiographic changes
irritability
Iron Deficiency Anemia
59
Iron Deficiency Anemia
61
Etiologi anemia defisiensi Fe
Kehilangan besi:
uterus : haid banyak
Sal. Cerna:varises oesophagus, ulkus peptikum,
carsinoma lambung/colon, hemorrhoid,
Cacingan, Ulcerative colitis,Hiatus hernia
Kebutuhan meningkat:
kehamilan, menyusui, pertumbuhan
Intake kurang:
diit buruk, malabsorbsi: gasterektomi,
coeliac disease
Diagnosis of iron deficiency
anemia
RBC’s are hypochromic (pale) and
microcytic (small) although mild cases
will be normocytic
Low serum iron, normal or high iron
binding capacity (TIBC, Transferrin)
Low % saturation
Low serum ferritin
Absent iron stores in bone marrow
Response to iron therapy
Pem. Lab. Anemia def. Fe
DT: mikrositik hipokromik, anisositosis
poikilositosis, sel pensil, target sel.
MCV ,MCH ,MCHC
Ssm tlg: eritroid hiperplasi, cadangan besi
Serum feritin ( N : 10-500 ug/L)
Retikulosit menurun, normal/naik
Serum Fe menurun, TIBC meningkat
Saturasi transferin menurun
Free Eritrosit Protophorpirin
Nilai normal :
66
Pengobatan anemia def.besi
Makanan adekuat ( baik, cukup).
Sulfas ferosus 3 x 10 mg/kgBB/hari
Transfusi darah : jika HB < 5 g%
Antihelmintik (obat cacing )
67
Iron Deficiency Anemia
Treatment
– oral iron supplementation: 6mg/kg/day of
elemental iron
for at least 3 months
check retic count after 2 weeks
side effects (educate family)
– goal: to replace iron stores, not just
circulating Hgb
Dietary sources of iron
parenteral therapy
– indications
poor compliance
severe bowel disease
intolerance of oral iron
chronic hemorrhage
acute diarrhea disorder
Dosing of Parenteral Therapies
– Iron Dextran
provides 50mg/ml elemental iron
for weight >15kg: dose (ml) =
0.0442 (desired Hgb - Observed Hgb) x LBW + (0.26 x LBW)
LBW (males)=50kg+2.3kg/inch of height over 5 ft.
LBW (females )=45.5kg+2.3kg/inch of height over 5 ft.
Marrow Morphology
Megaloblastic Non-Megaloblastic
Erythropoietin
(kidney)
Nutrients
Bone
marrow
Iron, Folate, B12
Folate and B12 Deficiency
Erythropoietin
(kidney)
Nutrients
Bone
marrow
Iron, Folate, B12
Genetic Anemia
Hemoglobinopathies (sickle cell
anemia)
Thalassemias (alpha & beta)
Membrane defects (elliptocytosis)
Red cell enzymes (G6PD )
thalassemia
88
Merupakan penyakit anemia hemolitik herediter
yang diturunkan dari kedua orang tua kepada
anak-anaknya sera resesif, menurut hukum
Mendel.
Pembagian (secara klinis) :
a. Talasemia mayor (bentuk homozygot)
Memberikan gejala klinis yg jelas
b. Talasemia minor
Biasanya tidak memberikan gjl.klinis
89
90
91
92
93
Gejala klinis dan laboratorium
Anemia berat tipe mikrositik,retikulosit >
Limpa dan hepar membesar
Anak besar : gizi buruk
Muka : fasies Mongoloid
Apusan darah tepi : anisositosis, hipokrom
poikilositosis, sel target (fragmentosit dan
banyak sel normoblast)
SI meninggi, IBC rendah/nol
94
Gejala klinis dan laboratorium . .
Kadar HbF tinggi >30%, kadang Hb patol.
Umumnya pasien datang pd umur 4-6th,
padahal gejala sudah tampak sejak 3 bl.
95
96
Pemeriksaan radiologis
Tulang : medula lebar, kortek tipis,
trabekula kasar.
Tengkorak : diploe, brush appearance
Sinus paranasalis : pneumatisasi rongga
97
Komplikasi
Karena anemi berat dan lama gagal
jantung / dekompensasi kordis
Transfusi berulang dan hemolisis kadar
besi dalam darah sangat tinggi hepar,
limpa, kulit, jantung, dll ggn fungsi alat
tsb / hemokromatosis.
Limpa yg besar : mudah ruptur / pecah/
robek. Hipersplenisme:leukopeni,trombo<.
98
Pengobatan
Tak ada obat yg menyembuhkan
Transfusi : bila kadar Hb <6g%, atau
anak lemah tidak mau makan
Mengeluarkan besi dari jaringan tubuh :
iron chelating agent (desferal) im/iv.
Splenektomi : usia >2th, sbl tanda
hipersplenisme dan hemosiderosis.
Vitamin : yg tidak mengandung besi
99
leukemia
100
Definisi
Leukemia merupakan penyakit keganasan
sel darah yang berasal dari sumsum
tulang, ditandai oleh proliferasi sel-sel
darah putih, dengan manifestasi adanya
sel-sel abnormal dalam darah tepi.
Ada gangguan dlm pengaturan sel leukosit
Leukosit dlm darah berproliferasi secara
tidak teratur dan tidak terkendali dan
fungsinyapun menjadi tidak normal.
101
102
Klasifikasi / pembagian
1. Leukemia sistem eritropoetik
2. L. sistem granulopoetik : granulositik,
mielositik
3. L. sistem trombopoetik : L. megakario-
sitik
4. L . sistem limfopoetik : L. Limfositik
5. L. RES
103
Leukemia Limfositik Akut
Paling sering yg terjadi pada anak.
Etiologi : belum jelas, mungkin virus.
Faktor lain : eksogen ( sinar X, radioaktif,
hormon, bhn kimia, infeksi virus/bakteri.
Edogen : ras (Yahudi), kelainan kromosom
(Down sindrom), herediter
104
105
Acute Lymphoblastic Leukemia
Gejala klinis
Pucat, panas, perdarahan, splenomegali,
hepatomegali, limfadenopati.
Perdarahan : ekimosis, petekie, epistaksis,
perdarahan gusi.
Gejala tidak khas : sakit sendi, tulang (spt
reumatik ).
Infiltrasi sel leukemi ke alat tubuh :
purpura pd kulit, efusi pleura, kejang pd
leukemia serebral.
107
108
Pemeriksaan laboratorium
Darah tepi : pansitopeni, limfositosis, sel
blas (patognomonik utk leukemia)
Sumsum tulang : monoton, hanya sel
limfopoetik patologis, lainya terdesak/
aplasia.
Pemeriksaan lain : biopsi limpa, kimia
darah, CSS, sitogenetik
109
Diagnosis
Gejala klinis
Pemeriksaan darah tepi
Pemeriksaan sumsum tulang, limpa
110
Pengobatan
Transfusi darah ( bila Hb< 6 g%)
Kortikosteroid
Sitostatika
Pengobatan infeksi sekunder
Imunoterapi
111
112
The most important first
step in the diagnosis of
Anemias…….
113
The Peripheral Smear
RBC Fragments Microangiopathic Hemolytic
(Schistocytes) Anemia, Valve Hemolysis, Burns
Spherocytes AIHA, Hereditary Spherocytosis
Target cells Alcoholics, Hemoglobinopathies
Sideroblasts Myelodysplasia, Alcoholics
Teardrop cells Myelofibrosis/Myeloid metaplasia,
Thalassemia
Burr cells Uremia
Howell Jolly Splenectomy, Functional asplenia
bodies
Hypersegmented Megaloblastic Anemia
PMN 114
?
Young women with
surgery as child and
was told that she
could be at risk for
developing infections.
CBC normal
115
?
74 male presents with
neuropathy, loss of
balance, WBC 1.9,
HGB 7, PLT 120,000
116
?
A 20 YO woman
presents with
increasing weakness
over six weeks,fever
and Hb = 5.9 g/dl.,
white cells 18.0
x10ˆ9/l., platelets 35
x10ˆ9/l.
117
?
Young man with
recent travel presents
with fever of
unknown origin. WBC
18K, HGB 8 g, PLT
461,000
118
?
Elderly gentleman
presents with fatigue,
pallor and SOB. WBC
3K, HGB 6g, PLT
566,000
119
?
70 YO male admitted
to ICU with severe
pancytopenia,
bleeding,
hypotensive. Patient
is intubated
PT 15, PTT 40, PLT
36,000, WBC 2.2,
HGB 8 g.
120
?
46 YO presents with
history of alcohol
abuse, hypotension.
WBC 3.2, HGB 10g,
PLT 72,000
T. Bili 2.0, creatinine
4, BUN 68
121
122
123
Anemia
Microcytic Normocytic Macrocytic
MCV <80 MCV 80-100 MCV >100
Iron Deficiency ACD B12 Deficiency
125
Case 1
LABS:
WBC 1.7
HGB 8.9 G/DL
PLATELETS 109,000
MCV 109
SEGS 52%
LYMPHS 40%
MONO 5%
EOS 2%
METAMYELOCYTES 1%
126
Case 1
Additional tests……
127
SMEAR
128
Macrocytic Anemia
Abnormal maturation of nucleus in RBC
precursors
CAUSES:
- Alcoholism
– Pernicious Anemia (Vit B12 deficiency)
– Folic Acid deficiency
Tropical Sprue
Scandinavia - Fish tapeworm
129
Macrocytic Anemia
Megaloblastic
Vitamin B12 (Cobalamin) Deficiency
Folate Deficiency
MDS
Chemotherapy (Methotrexate,
Hydroxyurea, Azathioprine
SPURIOUS
Alcohol, Hypothyroidism, MM, Liver
disease, MDS, Aplastic Anemia 130
MEGALOBLASTIC DISEASE
Diagnosis: MCV> 100
Macrocytosis may be blunted in presence of
Fe deficiency or thalasemia
Low Reticulocyte count
Neutropenia and Thrombocytopenia
WBC :Hypersegmentation. Almost always
pathognomonic
131
FOLIC ACID
FOLIC ACID (pteroylmonoglutamic acid)
– Natural Source : fruits / vegetables
– May be destroyed by cooking
– Minimum daily requirement 50 micrograms/day
– Deficiency can develop within months
– FDA ordered Folic acid supplementation
(January, 1998) to all enriched grains
133
134
FOLATE DEFICIENCY
Inadequate Intake
Malabsortion due to Sprue,
Celiac disease
135
FOLATE DEFICIENCY
Increased Demand
– Cells with high rate of turnover
–Chronic hemolytic anemias
Pregnancy
– Deficiency in first few weeks - - > neural tube
defects in fetus
Malignancy
Chronic Exfoliative Skin Disorders
Hemodialysis pts
136
FOLATE DEFICIENCY
Medications
– 6 thioguanine, azathiprine, 6 mercaptopurine
– 5 FU, cytosine, arabinoside
Hydroxyurea, procarbazine, AZT
– Folate Antagonists - Methotrexate, pentamidine,
trimethoprim, triamterene, pyrimethamine, Dilantin
137
COBALAMIN (VIT B12)
Cobalt cannot be synthesized - required in diet !
138
139
COBALAMIN DEFICIENCY
Inadequate intake “vegetarian”
Malabsorption
– Defective Release of Cobalamin from Food
– Inadequate Production of Intrinsic Factor
140
COBALAMIN DEFICIENCY
– Disorders of the terminal ileum
Tropical and Non Tropical Sprue
Regional Enteritis, Crohn’s Disease
Intestinal Resection
141
COBALAMIN DEFICIENCY
Blood
– Macrocytic Anemia
– Pancytopenia, elevated LDH/ Indirect Bilirubin
– Clin Sx: weakness, dizziness, vertigo, tinnitus, angina,
palpitations and CHF
– Physical Exam: pale, icteric, rapid pulse, enlarged
heart, systolic flow murmur
GI
– Based on rapidly proliferating GI epithelium
SORE TONGUE
ANOREXIA / WEIGHT LOSS
DIARRHEA 142
COBALAMIN DEFICIENCY
NEURO (may be permanent)
– Demyelination -> axonal degeneration -> neuronal
death
– Peripheral nerves, spinal cord (posterior and lateral
columns) , cerebrum
– SX: EARLY: Numbness and parethesias in extremities
LATER: weakness, ataxia, sphincter disturbances,
Decreased vibratory sensation
mild irritability --> dementia or psychosis
NEURO SX MAY BE PRESENT IN A PATIENT WHO IS
NOT ANEMIC
143
COBALAMIN DEFICIENCY
PERNICIOUS ANEMIA
Autoimmune destruction or gastric mucosal atrophy
Etio: Lack of Intrinsic Factor (IF) secreted by parietal cells
EPIDEMIOLGY
Males = females, often age >60
See in pts from Northern Europe or African
Americans
OTHER DISEASE ASSOCIATIONS
Graves Disease Myxedema
Thyroiditis Vitiligo
Hypoparathyroidism Agammaglobulinemia
Adrenocortical Insufficiency
144
PERNICIOUS ANEMIA
ABNORMAL LABS
Anti parietal cell antibody (anti Na,K ATPase (90%)
Anti IF antibody (60%)
– RX; Glucocorticoids may reverse disease
– H Pylori does NOT cause parietal cell destruction
ANATOMY: Gastric atrophy --> antrum is spared
Tx: All reversible except neurological changes
Complications : Gastric polyps 2x incidence of
cancer
145
Schilling Test
(Cobalamin Deficiency verification)
STAGE 1
STAGE 2
– Give Radioactive Cobalamin bound to IF by mouth
– IM injection of nonradioactive B12
– Measure 24 hour urine
– Will still be diminished if
Bacterial Overgrowth Syndrome, Blind Loop,
Pancreatic insufficiency, Celiac Sprue
146
147
FOLATE v COBALAMIN
DEFICIENCY STATES
Serum FOLATE COBALAMIN
Levels DEFICIENCY DEFICIENCY
148
TREATMENT
COBALAMIN DEFICIENCY
IM Cbl: 1000 µg (1 mg) every day x week,
followed by 1 mg every week x four weeks.
If the underlying disorder persists (PA) 1 mg
every month for life
Hypokalemia
Hypersegmented neutrophils disappear at 10 to 14
days.
Neurologic abnormalities often improve but may not
reverse fully
150
TREATMENT
Folate Deficiency
151
Case 2
70 YO male presents with fatigue, weight
loss, palpitations
Unremarkable PMHx, PSHx
WBC 1.9, HGB 8, PLT 79,000, MCV 100,
ANC 1.0
Normal B12/folate and iron levels
152
Case 2
What is the next diagnostic test…..
153
Case 2
Smear
Bone Marrow Biopsy
Ultrasound to evaluate Liver and Spleen
Hepatitis / Viral panel
154
Case 2
155
Case 2
Lineage Blood Marrow
157
Myelodysplasia
WHO system includes:
Refractory anemia (RA)
Refractory anemia with ringed sideroblasts
(RARS)
Refractory cytopenia with multilineage dysplasia
(RCMD)
Refractory cytopenia with multilineage dysplasia
and ringed sideroblasts (RCMD-RS)
Refractory anemia with excess blasts I and II
5q- syndrome
Myelodysplasia unclassifiable (seen in those cases
of megakaryocyte dysplasia with fibrosis and
others
158
IPSS SCORE
Unfavorable cytogenetics 1
Age > 60 years 2
Hgb <10 (g dl-1) 1
Plt <50 2
Plt >50 -250 1
1BM blasts >4% 1
diploid and 5q only were favorable cytogenetic,
all others were considered as unfavorable
cytogenetics.
159
Myelodysplasia
IPSS Score
Low risk0
Intermediate risk 1 0.5 – 1
Intermediate risk 2 1.5 – 2
High risk >2.5
160
Myelodysplasia
Low Risk MDS
-Neutropenia or thrombocytopenia
-Erythropoietin resistance
161
Erythropoietic Growth Factors
Caution in patients with uncontrolled
hypertension
Risk of thrombosis
Lack of response
Survival benefit in patients with
malignancy
162
Myelodysplasia
High Risk MDS
-Refractory anemia/ thrmbocytopenia and
neutropenia
-Higher Blast percentage but less than
20%
-Multiple Karyotypic abnormalities
163
Myelodysplasia
High Risk MDS
- Supportive Care
-Bone Marrow Transplant
-Hypomethylating Agents
--5 Azacitadine
--Decitabine
164
Case 3
47 YO African American Female presents
with fatigue, heavy menstrual bleeding,
body aches.
FHx: anemia of unknown etiology
Social Hx, PMHx is unremarkable
WBC 5K, HGB 9.8 g, PLT 166,000, MCV 56
How do you approach this case?
165
Case 3
Serum Ferritin 15
Iron saturation 9%
TIBC 470
B12 and folate are normal
Retic 2.6%
Bone marrow biopsy
166
Iron DeficiencyAnemia
167
Iron Deficiency Anemia
Etiology
1. Dietary deficiency
2. Malabsorption (Subtotal gastrectomy,
celiac sprue)
3. Bleeding (Gastrointestinal, Genitourinary,
Hemoptysis, Epistaxis, Pregnancy)
4. Intravascular hemolysis (PNH, Trauma,
Hemosiderinuria)
5. Chronic renal failure
168
Iron DeficiencyAnemia
Poor correlation between hemoglobin level and
symptoms
TREATMENT
1. Oral
2. Parenteral:
Iron dextran < 70% utilized
Need Test dose
Total dose (mg) = deficit in Hb (gm/100ml) x weight
(lb) + 1000mg
Watch for anaphylaxis
3. Treat underlying
170
Case 3
Patient was treated with oral iron for 3
months and follow-up labs showed
– WBC 5.2, HGB 11, MCV 60, PLT 222,000
171
Case 3
Patient was treated with oral iron for 3
months and follow-up labs showed
– WBC 5.2, HGB 11, MCV 60, PLT 222,000
172
Target cells: Seen in ETOH, Liver Disease, Hemoglobinopathies
173
174
THALASSEMIA
A Defect in Hemoglobin Synthesis
Definition – defect in Hemoglobin subunit
synthesis (2α and 2β)
175
THALASSEMIA
TYPE a (alpha)
TYPES:
a-Thalassemia – alpha globin unit synthesis
decreased or absent
b subunits will ppt
Four subtypes
176
Thalassemia
Alpha Beta
Thalassemia Thalassemia
MCV 74+/- 4 63 +/- 4
177
THALASSEMIA
A Defect in Hemoglobin Synthesis
b-Thalassemia - beta globin unit synthesis decreased
or absent, a subunits will ppt
179
THALASSEMIA
Clinical Manifestations
Skeletal-
– Osteoporosis – vertebral compression Fx (next
slide)
– Skull has a “hot cross bun” configuration
– Pneumatization of the sinuses is delayed (next
slide)
Distortion of the maxillary bones, as well as
poor development of the sinus cavities
Hand: Metacarpals. Metatarsals, phalange
make it look rectangular and convex shaped.
180
THALASSEMIA
A Defect in Hemoglobin Synthesis
181
182
THALASSEMIA
CHF/ CARDIOMEGALY
Chest radiograph typical of severe β-
thalassemia. widening of the rib ends and
cardiac dilation.
183
THALASSEMIA
Clinical Manifestations
Shortened RBC survival
DECREASED MCV
Iron- normal !!
Heart – Cardiomegaly
Growth + Development – is retarded – both
skeletal and dental ages.
Secondary Iron Overload
184
THALASSEMIA –
Clinical Manifestations
Liver – Hepatomegaly due to extramedullary
hematopoiesis.
185
THALASSEMIA
Therapy
Trait – None indicated
Splenectomy –
Chelation:Deferoxamine / Fe Chelation
(Keep Iron Saturation <50%)
Iron Supplementation Contraindicated
186
THALASSEMIA
Therapy
Genetic Counseling
recommended.
Autosomal Recessive
pattern of inheritance
187
Hemolytic Anemia
Hemoglobinopathies
188
189
What is Sickle cell disease
An inherited disease of red blood
cells
Abnormal hemoglobin.
Sickle-shaped red cells interrupt
blood flow by blocking small blood
vessels
Tissue damage due to lack of blood
flow and severe pain due to tissue
hypoxia
190
Hemolytic Anemia
Sickle Cell Disease
– Microinfarction
Pulmonary (Acute Chest), Avascular Necrosis, CVA,
CHF, RF, Skin ulcerations
– Pain
Joint, Musculoskeletal, Abdominal
– Asplenism
– Sepsis, Recurrent Infection
– Fetal loss, high Maternal Morbidity
– Aplasic Crisis - Infection, Folate Deficiency
– Sequestration Crisis - HgB, Retics.,
Hepatosplenomegaly
191
Hemolytic Anemia
Sickle Cell Disease - TREATMENT
Treatment
PAIN CRISIS
– Supportive, Conservative & Expectant
– Treat Infections Early; Pneumococcal Vaccine
– Folate Supplementation Daily
– Opiod Analgesics PRN; Dependence Common
in advanced Stages
192
Hemolytic Anemia
Sickle Cell Disease - TREATMENT
Treatment
CHEST SYNDROME
– Supportive, Conservative & Expectant
– Folate Supplementation Daily
– Opiod Analgesics
– Oxygen / Hyperbaric
– Correct Dehydration
– Hypertransfusion in Crisis
– Hydrea- reduce ulcers, transfusion, crises
193
Case 5
36 YO female presents with history of URI
symptoms, ear ache, fever.
Unremarkable past medical history
WBC 11 K, HGB 5 g, PLT 202,000
What is the next step……
194
Case 5
Iron studies are normal except for ferritin
988
B12/Folate are normal
Additional laboratory data requested
195
Case 5
Iron studies are normal except for ferritin
988
B12/Folate are normal
Peripheral Smear
Additional laboratory data requested
LDH 1000, Haptoglobin 5, T.Bili 3, Retic
12%
196
Hemolytic Anemia
197
Hemolytic Anemia
Acquired
198
Hemolytic Anemia
Immune
199
Hemolytic Anemia
Immune Mediated
200
Hemolytic Anemia
Alloantibody Immune
Transfusion Reactions
– Recipient Antibody to Donor Antigen
– Increased Risk with Transfusions
– Single Donor Donation Decreases
Erythroblastosis Fetalis – IgG-Anti-Rh
– Rh- Mother Carrying Rh+ Fetus
– RhoGam (IgM-Anti-Rh) at Delivery/Miscarry
201
Hemolytic Anemia
Autoimmune
Warm Antibody – IgG or < IgA
– Inefficient C3 & C4 Fixation
– Active at 37oC, Nonagglutinating
– Evan’s Syndrome- associated thrombocytopenia
– Symptoms: Inc RI, SM, Spherocytosis
– Destruction in Spleen
– Idiopathic 20%
CLL 20%, Lymphoma 10%, Misc. 10%
Collagen Vascular 15%, Thyroid Disease 10%
GI Diseases (UC) 10%
– Treatment
Steroids, Immunosuppression, Splenectomy 202
Case 5
36 YO female presents with history of URI
symptoms, ear ache, fever.
Unremarkable past medical history
WBC 11 K, HGB 5 g, PLT 202,000
203
Hemolytic Anemia
Autoimmune
Cold Antibody – IgM
– Efficient Complement Fixation (C3)
– Active at 4oC, Agglutinate; Dissociate at 32oC
– Destruction in Liver, Intravascular
Mycoplasma (5-10 days post recovery),viral illnesses
Lymphoproliferative, Often Chronic
MGUS
– Treatment
Acute - Usually Self Limited, Warm Environment
Chronic – Steroids, Splenectomy not Helpful; Immune
Suppression
204
Hemolytic Anemia
Acquired – DIC
Microangiopathic
Disseminated Intravascular Coagulation (DIC)
Obstetrical, Bacterial Sepsis, Carcinoma,
Trauma
Diffuse Microthrombi Followed by
Fibrinolysis Consuming Coagulant Proteins
Extensive Hemorrhage, Thrombocytopenia,
Fragmented RBC’s (Schistocytes),
PT/PTT, Fibrin Split Products (FSP), Mod.
Hemolysis
Severe disease usually with low Plasma
Fibrinogen Level
TREATMENT: Underlying Disorder
205
Hemolytic Anemia
Hereditary
206
Hemolytic Anemia
Microangiopathic – TTP
Thrombotic Thrombocytopenic Purpura
(TTP)
Etiology Unclear; Immunologic, Microaneurysm
Anemia with Fragmented RBC’s, Retics, Moderate
Thrombocytopenia, Jaundice, Petechiae < ITP
PT, PTT, Fibrinogen, FSP usually near NL
Fever, Abdominal Pain, Arthralgias
Bleeding Unusual; Course Days to Weeks
Death Due to Renal Failure, Cerebral Ischemia
Plasmaphoresis, Steroids
207
Transfusion Reactions
Type Onset Laboratory Treatments
Acute hemolytic Within hours + DAT IVF, Stop
transfusion
Delayed hemolytic 2-12 days + DAT (Also IVF
Indirect +)
Febrile nonhemolytic Within hours - DAT Supportive
209
Hemolytic Anemia
Microangiopathic – HUS
Hemolytic Uremic Syndrome (HUS)
ASSOCIATED WITH E.COLI: O-157-H7
infection
(5-10% of infections)
Intracorpuscular Defect Acquired in Stem Cells
Viral Prodrome, Young Children
Acute Hemolytic Anemia, Thrombocytopenic
Purpura, Oliguria, Venous Thrombosis
Blood Smear & Coagulation Studies Similar ITP
Neurologic Deficits Uncommon
Dialysis, Transfusion
Mortality 5% to 20%
210
211
REFERENCES
References for Hematology lecture dated 9/25/08
1. Myelodysplasia, Blood, 1 August 2008, Vol. 112, No. 3, pp. 479.
2. BMJ 1998 / B12 Deficiency
3. Appelbaum FR, Gundacker H, Head DR, et al. Age and acute myeloid leukemia. Blood.
2006;107:3481–3485
4. Silverman LR, McKenzie DR, Peterson BL, et al; Cancer and Leukemia Group B. Further analysis of
trials with azacitidine in patients with myelodysplastic syndrome: studies 8421, 8921, and 9221
by the Cancer and Leukemia Group B. J Clin Oncol. 2006;24:3895–3903.
5. Kantarjian H, Gandhi V, Cortes J, et al. Phase 2 clinical and pharmacologic study of clofarabine in
patients with refractory or relapsed acute leukemia. Blood. 2003;102:2379.
6. Faderl S, Gandhi V, O’Brien S, et al. Results of a phase 1–2 study of clofarabine in combination
with cytarabine (ara-C) in relapsed and refractory acute leukemias. Blood. 2005;105:940
7. Burnett AK, Mohite U. Treatment of older patients with acute myeloid leukemia—new agents.
Semin Hematol. 2006;43:96–106.
8. Greenberg et al. International Scoring System for Evaluating Prognosis in Myelodysplastic Syndromes.
Blood 1997;89:2079-2088.
9. Silverman LR, Demakos EP, Peterson BL, et al (2002). "Randomized controlled trial of azacitidine
in patients with the myelodysplastic syndrome: a study of the cancer and leukemia group B". J.
Clin. Oncol. 20 (10): 2429–40.
212
Malaria
Clinical Manifestation
– 1 to 6 weeks after Innoculation
– P. vivax & P. ovale Recurrent 6 – 12 Months
– Chills, Fever, Myalgia, Splenomegaly, Anemia;
Leukocytosis Rare
– P. falciparum – Encephalitis, ARDS
– Blackwater Fever – Massive Immune Hemolysis, Renal
Failure
Treatment
– P. falciparum - Chloroquine Resistant; Quinine &
Doxycycline
– Others - Chloroquine Responsive
– P. vivax & P. ovale; Add Primaquine
Prophylaxis – Chloroquine, Mefloquine 213
Hemolytic Anemia
Infectious - Babesiosis
Malaria-Like Intraerythrocyctic Parasite
Eastern and Western Seaboard,
Ixodidae Ticks; Rodents, Pets
Symptoms: Febrile Hemolytic Anemia
Incubation 1-3 weeks
Flu like Symptoms, Myalgias, Dark Urine
Asplenic individuals can have overwhelming
disease
Often co-infection with Borrelia burgdoferi
214
Hemolytic Anemia
Infectious - Babesiosis
Membrane Abnormalities
– Hereditary Spherocytosis
Hemoglobinopathies
– Sickle Cell Anemia
– Hemoglobin C & SC Disease
– Thalassemia
– Defective Metabolism
– Glucose-6-phosphate Dehydrogenase Deficiency
217
Hemolytic Anemia
Membrane Abnormality
Hereditary Spherocytosis
– Common Hemoglobinopathy in Whites
– Defective Fragile Red Cell Membrane; Spherocytes
– Hemolysis in Spleen; Splenomegaly, Common
Skin Ulcers Over Ankles
– Mildly Reduced HgB, Increased Retics.
– Occasional Jaundice, +Gallstones, Anemia is mild to
severe, Increased MCHC, Aplastic Crisis in Viral Infection
or Folate
– Splenectomy Curative (Don’t forget vaccinations!)
– Lifelong Folate
218
219
Hemolytic Anemia
Acquired Nonimmune
Paroxysmal Nocturnal Hemoglobinuria
221
222
223
224
Hemolytic Anemia
G6-PD Deficiency – What causes a
crisis?
Oxidative Drug-Induced Hemolysis
– Sulfonamides, Dapsone; Nitrofurantoin
– Antimalarials; Primaquine, Chloroquine
– Vitamin K (Water Soluble), Probenecid
– Occasional - Infection, Diabetic Ketoacidosis
Mediterranean Variant
– Quinine, Quinidine; Aspirin
– Favism – Exposure to Fava Bean or Pollen
225
Hemolytic Anemia
G6-PD Deficiency
Laboratory Studies
– Heinz Bodies (Precipitated GS-SG HgB)
– Bite cells
– NL 50% Enzyme Decline in 120d RBC Life
Black Variant (A-); RBC Survival, w/o Anemia
Mediterranean; Survival, Anemia w/o Exposure
G6PD enzyme normal with active hemolysis
– Acute Phase
RBC, 25% in A-, > Mediterranean
Plasma HgB, Uncong. Billi., Haptoglobin
± Hemoglobinuria
Heinz Bodies Cleared After Day 1 Bite Cells
226
Hemolytic Anemia
G6-PD Deficiency
227
Other Anemias
Bloom’s Syndrome: AR, Ashkenazi Jews,
Mild anemia, stunted growth,
Photosensitivity, Mental Retardation,
Facial erythema, Infertility (men)
228
Acute Intermittent Porphyria
AD, presents in adulthood
Polycythemia Vera
Low EPO, Inc RBC Mass, SM.Treat w/Phlebotomy, Hydrea, ASA
Symptoms: HA, Visual Changes, Fatigue, Pruritus, Epistaxis, DVT,
High B12 levels
If Hct >54- rule out secondary causes- Hypoxia, Carboxyhem,
Tobacco, EPO tumors). SHOULD GET BM BIOPSY
Myelofibrosis
Essential Thrombocythemia
CML
230
MYELODYSPLASTIC DISORDERS
MDS- Refractory anemia, RA with ringed
sideroblasts, RA with excess blasts, RA with
excess blasts in transformation, CMMOL
CLL
CML
AML
ALL
Non-Hodgkins Lymphoma
Hodgkins Lymphoma
232
CHRONIC LYMPHOCYTIC LEUKEMIA
235
CHRONIC MYELOGENOUS LEUKEMIA
236
CHRONIC MYELOGENOUS LEUKEMIA
Symptoms:
SM (60%), leukocytosis, thrombocytosis, Blast
crisis- fever, night sweats, bone pain,
ecchymoses
Diagnosis:
Philadelphia chromosome (9;22) translocation
Treatment:
Tyrosine kinase inhibitors (Imatinib, Desatinib)
Hydroxyurea
Interferon Alpha with or without cytarabine
Stem Cell Transplant 237
CHRONIC LYMPHOCYTIC LEUKEMIA
M4 Acute myelomonocytic 20 – 25
leukemia
240
Bennett et al, Br J Haematol, 1976
FAB Classification
FAB Morphology Frequency
Subtype (%)
Myelomonoblasts with abn
M4E0 5
eos
M5 Acute monocytic leukemia 10
monoblasts, promonocytes
or monocytes comprise 80%
of nonerythroids
M6 Erythroleukemia 5
>50% of nucleated cells
erythroid
M7 Acute megakaryocytic 1-3
leukemia
241
Bennett et al, Br J Haematol, 1979
Leukemic Auer Rod in
Myeloblast Leukemic Myeloblast
242
M4 M5
243
M6
244
AML- Acute Myelogenous Leukemia
Risk factors
Ionizing radiation
Chemical exposure: benzene
Previous chemotherapy:
Melphalan, Cyclophosphamide, Etoposide
Genetic factors:
Downs syndrome, Klinefelter’s, Fanconi’s anemia
MDS
245
AML- Acute Myelogenous Leukemia
Prognosis
Age
Performance status
Secondary AML
Previous chemotherapy
WBC >20,000/µL
246
1)Good prognosis features:
cytogenetic interpretation (t15:17, t8:21 or i16)
60% of patients are cured with multiple cycles of high
dose AraC
248
Major Clinical Features
Incidence/Prevalence
Estimated new cases in US in 2002: 10,600
80% >15 years old; median age 70 years
Estimated deaths in US in 2002: 7,400
Mortality in US = 7/100,000/year
Pancytopenia
Extramedullary disease
Skin, gingiva – M5
CNS – M5, ? Increased in M4EO
Orbit – M2 with t(8;21) and CD56 expression
249
Major Clinical Features
Hyperleukocytosis
– microgranular APL, monocytic differentiation
– 11q23 and inv(16)(p13;q22)
– >100,000 myeloblasts/L
– leukostasis (obstruction, vascular injury,
hypoxemia)
– leukaphoresis, hydroxyurea, RT, chemotherapy
Coagulation abnormalities
– abn plt function
– consumption: APL > M5, M4
Metabolic abnormalities
– tumor lysis syndrome
– renal tubular dysfunction
Typhlitis (mimics appendicitis)
250
Chloroma
Gingival
Hyperplasia in
M5
251
Diagnosis
Peripheral smear
Identification of myeloblasts
Bone Marrow Biopsy
252
Common Induction Regimen
253
Tumor Lysis Syndrome
Rapid cell turnover
Prevent with Fluids, Allopurinol, Sodium
Bicarbonate
Test Result
Uric Acid Increased
Potassium Increased
Phosphate Increased
Calcium Decreased
254
PLASMA CELL DISORDERS
Multiple Myeloma
Plasmacytoma
MGUS (Monoclonal Gammopathy of Undetermined
Significance)
POEMS (Polyneuropathy w/Organomegaly,
Endocrinopathy, M-Protein production, and Skin
changes)
Waldenstrom’s Macroglobulinemia
Amyloidosis (ASSOCIATED WITH FACTOR X
DEFICIENCY) types- AA, AL, Familial, Dx: Fibers
stain with Congo Red- Apple green Birefringence
Cryoglobulinemia
255
PLASMA CELL DISORDERS
If Suspected:
256
MULTIPLE MYELOMA
Second most common hematologic malignancy
More common in African Americans
Associated with
Monoclonal Spike
Lytic Lesions – increased risk of fracture, Cord Compression
Renal insufficiency
Bence Jones Proteinuria
Hypercalcemia
Hyperviscosity
Peripheral Smear: Rouleaux Formation
Increased Risk of Bacterial Infections
258
MM – Monoclonal Band
259
Multiple Myeloma
Major 1. Plasmacytoma
Criteria 2. BM with >30%
Plasma cells
3. M protein
Dx made
with 1M IgG >3.5 g/dL
+1m or IgA >2.0 g/dL
3m
minor 1.BM with >10-30%
criteria Plasma cells
2. M protein less than
above
3. Lytic bone lesion
4. Decreased 260
Multiple Myeloma
Lytic lesions
261
Severe aplastic anemia
Disease of bone marrow – etiology either
toxin, genetic, or autoimmune
Incidence: 3 per million per year
Genetic include Fanconi anemia –
accounts for 20%
Radiation, chemicals, or viruses for toxin
(Benzene, Radiation, Parvo B19, Hepatitis)
262
Treatment of SAA
Bone Marrow Transplant – if matched
related donor around 70-85% cure and
little chance of leukemia.
Immunosuppressive therapy – cyclosporin,
antithymocyte globulin, and prednisone
May add erythropoietin, and Neupogen
Supportive with transfusion and chelation
263
Thalassemia Screening
264