Alya Putri Khairani | 130110110220

D1

HEMOLYTIC ANEMIA
Hemolytic anemias share the following features:
Premature destruction of red cells and a shortened red cell life span below the normal 120 days
Elevated erythropoietin levels and a compensatory increase in Erythropoiesis
Accumulation of hemoglobin degradation products released by red cell breakdown derived from
hemoglobin
The physiologic destruction of senescent red cells takes place within mononuclear phagocytes, which are abundant
in the spleen, liver, and bone marrow. This process appears to be triggered by age dependent changes in red cell
surface proteins, which lead to their recognition and phagocytosis. In the great majority of hemolytic anemias the
premature destruction of red cells also occurs within phagocytes, an event that is referred to as extravascular
hemolysis
Extravascular hemolysis is generally caused by alterations that render the red cell less deformable. Extreme
changes in shape are required for red cells to navigate the splenic sinusoids successfully. Reduced deformability
makes this passage difficult, leading to red cell sequestration and phagocytosis within the cords. Regardless of the
cause, the principal clinical features of extravascular hemolysis are (1) anemia, (2) splenomegaly, and (3) jaundice
Less commonly, intravascular hemolysis predominates. Intravascular hemolysis of red cells may be caused by
mechanical injury, complement fixation, intracellular parasites (e.g., falciparum malaria, or exogenous toxic
factors. Whatever the mechanism, intravascular hemolysis is manifested by (1) anemia, (2) hemoglobinemia, (3)
hemoglobinuria, (4) hemosiderinuria, and (5) jaundice. The large amounts of free hemoglobin released from lysed
red cells are promptly bound by haptoglobin, producing a complex that is rapidly cleared by mononuclear
phagocytes

MORPHOLOGY
Certain changes are seen in hemolytic anemias regardless of cause or type. Anemia and lowered tissue oxygen
tension trigger the production of erythropoietin, which stimulates erythroid differentiation and leads to the
appearance of increased numbers of erythroid precursors
(normoblasts) in the marrow. Compensatory increases in erythropoiesis result in a prominent reticulocytosis
in the peripheral blood. The phagocytosis of red cells leads to hemosiderosis, which is most pronounced in the
spleen, liver, and bone marrow. If the anemia is severe, extramedullary hematopoiesis can appear in the liver,
spleen, and lymph nodes. With chronic hemolysis, elevated biliary excretion of bilirubin promotes the formation of
pigment gallstones

CLASSIFICATION
Hemolytic Anemias may be classified as follow:
(1) Intracorpuscular defects
a) Hereditary defects

Defects in the red cell membrane

Enzyme defects

Hemoglobinopathies

Thalassemia syndrome
b) Acquired defects
Paroxysmal nocturnal hemoglobinuria
(2) Extracorpuscular defects
a) Immune Hemolytic Anemia
b) Infection
c) Exposure to chemicals and toxins
d) Exposure to physical agents
e) Microangiopathic and macroangiopathic hemolytic anemias
f) Splenic sequestration
g) General systemic disorders
APPROACH TO DIAGNOSIS
1. Tests Reflecting Increased Red Cell Destruction
Serum Unconjugated Bilirubin
>3-4mg/dL catabolism of heme from red cells phagocytosed by reticuloendothelial system
Serum Haptoglobin very sensitive rapid clearance by reticuloendothelial system of a complex formed
between liberated Hb and circulatory Haptoglobin
Others: Spectroscopic examination and Dipstick to detect hemoglobinemia, hemoglobinuria,
hemosiderinuria
2. Tests Reflecting Increased Red Cell Production
Reticulocyte Count (Romanowsky Stain) elevated (showing compensatory bone marrow response)
If there is anemia, reticulocytes may leave the bone marrow prematurely and mature in the circulation for
longer than the normal maturation time of 1 day

Alya Putri Khairani | 130110110220

-

LPDSNE
AoEmes
BsegP
F M
Iiac
NNtrH
ViTpny
EvVoe
Sesg
E T
Tia:
DGit T
Av s
GTe
ON
N
O
S
S

D1

RPI Index (Reticulocyte Production Index):

O
O

s
h
B

A
t

i e
s

I
I )

b
s

e
S

o
s

e
f

n
o

t
I

Hereditary Defects of the Red Cell Membrane

Structures of RBC membrane to deform and regain its original biconcave disc shape is determined by three factors:
1. Cell surface area-to-volume ratio
2. Viscoelastic properties of membrane, which depend on the structural and functional integrity of the
membrane skeleton
3. The cytoplasmic viscosity, which is determined primarily by Hb
The hereditary Hemolytic Anemia due to red cell membrane protein defects may be classified according to the
morphological abrnotmality of the red cells. Four main groups are delineated:
(1) Hereditary Spherocytosis (HS)
(2) Hereditary Elliptocytosis (HE) and morphologically related disorders
(3) Hereditary Stomatocytosis
(4) Hereditary Xerocytosis
To gain insight into the pathogenesis and to
enable a correlation of the genotype with the
observed morphological phenotype, it is useful to
divide the interaction between the red cell
membrane components into 2 categories:
a) Vertical interactions
Between membrane skeleton and the
bilayer and mainly involve SpectrinAnkyrin-Band 3 associations
b) Horizontal interactions
Between components of the membrane
skeleton and include Spectrin dimer selfassociation and Spectrin-Actin-Protein
4.1 complex formation

Hereditary Spherocytosis

Alya Putri Khairani | 130110110220

D1

HS is characterized by osmotically fragile, spherical red cells, and is the most common hereditary anemia in people
of northern European origin. The underlying molecular defects in HS are heterogenous and several genetic loci
have been implicated. In the vast majority of cases, the resulting protein abnormalities are quantitative with
decreased amount of the membrane proteins involved in vertical interaction between the bilayer and the skeleton
which there are defects (protein deficiencies) in Spectrin, Ankyrin, Band 3, Protein 4.2
PATHOPHYSIOLOGY
The fundamental expression of the membrane defect in HS is a loss of surface area of red cell, resulting in a
decreased surface-to-volume ratio. This is morphogically as Spherocytosis, although it should be noted that the
majority of HS cells are spherostomatocytic rather than truly spherocytic. Such cells tolerate less swelling than
normal red cells and are osmotically fragile. The decrease in surface-to-volume ratio also makes the cells less
deformable than normal

CLINICAL MANIFESTATION
The classic presenting features of patients with HS are the triad of jaundice, anemia, and enlarged spleen, but
many patients do not show all of these signs. The age at presentation can vary from within a day or two after birth
to old age, and sometimes the condition is diagnosed only during family studies or investigation for other reason
CLINICAL LABORATORY FINDINGS
For Extravascular Hemolysis: Hyperbilirubinemia found in half of the patients and Haptoglobins are
variably reduced
For Intravascular Hemolysis: Hemoglobinemia, Hemoglobinuria, or Hemosiderinuria do not occur
Mean Corpuscular Hemoglobin Concentration (MCHC) is elevated, probably reflects mild cellular
dehydration
Morphology hallmark: Spherocyte
PROGNOSIS
After Splenectomy, RBC survival improves dramatically, enabling most patients with HS to maintain a normal Hb
level

Alya Putri Khairani | 130110110220

D1

Hereditary Elliptocytosis
HE is a group of disorder found in all race groups and characterized by the presence of elliptical red cells in the
peripheral blood. HE syndrome is heterogenous in terms of inheritance, clinical manifestation, and underlying
molecular defects
Three major clinical and morphological phenotypes have been delineated: Common HE, including HPP;
Spherocytic HE; and Southeast Asian Ovalocytosis

CLINICAL LABORATORY FINDINGS

Phenotypes
Hemolysis
Common HE
Asymptomaticc

Morphology
Elliptocytes

HE with infantile
Poikilocytosis

Moderately severe up to
age 2 years

Elliptocytes
Poikilocytes

HPP

Severe

SAO

Asymptomatic

Microspherocytes
Poikilocytes
Few Elliptocytes
Large Ovalocytes

PATHOPHYSIOLOGY

Most Common Defects

Impaired Spectrin
Tetramer formation or
Protein 4.1 deficiency
Impaired Spectrin
Tetramer formation or
Protein 4.1 deficiency
Impaired Spectrin
Tetramer formation and
Spectrin deficiency
9-amino acid deletion in
Band 3

Alya Putri Khairani | 130110110220

D1

CLINICAL MANIFESTATION
Most patients are asymptomatic and do not have any obvious physical signs. Patients with clinically significant
hemolysis have splenomegaly, pallor, scleral icterus, and (in rare cases) leg ulcers
Hereditary Stomatocytosis and Hereditary Xerocytosis
This is a heterogenous group of rare disorders characterized by alterations in the permeability of the red cell
membrane to cations.
Hereditary Stomatocytosis : Hydrocytosis, which the red cells are swollen
Hereditary Xerocytosis: The cells are markedly dehydrated
ETIOLOGY AND PATHOPHYSIOLOGY
Hereditary Stomatocytosis
The basic abnormality of Stomatocytic red cells is a marked increase in the passive permeability of Sodium into the
cell and of Potassium out of the cell. The defect in Sodium permeability is greater than that for Potassium. Although
the Sodium-Potassium pump is stimulated by the influx of Sodium, it cannot cope with the influx and the total
cation content of the cell increases, with resultant water influx and formation of Hydrocytes. Because of the influx
of the water, Stomatocytes have an increase volume with a decreased surface-to-volume ratio and the attendant
consequences of decreased rec dell deformability and susceptibility to splenic sequestration
Hereditary Xerocytosis
Red cells from patients with Hereditary Xerocytosis have an increased efflux of Potassium that approximates
Sodium influx. Although the Sodium-Potassium pump is stimulated by the influx of Sodium, it is insufficient to
correct the loss of Potassium. Irreversible Potassium and total cation loss occurs with resultant dehydration and
formation of Xerocytes

Alya Putri Khairani | 130110110220

D1

CLINICAL LABORTORY FINDINGS

Stomatocytes : Red cells with a cenral slit or stoma. On scanning electron microscopy, the cells have a
bowl-like appearance
Xerocytes : Target cells are present, reflecting the greater surface-to-volume ratio of these cells
MCV in both HS and HX is elevated
MCHC is increased in HX and decreased in HS

Hereditary Enzyme Deficiencies

Glucose-6-Phosphate Dehydrogenase Deficiency
G6PD deficiency is transmitted by a mutant gene located on the X chromosome. The gene encoding G6PD has
been mapped to the Xq28 region in humans
CLINICAL MANIFESTATIONS
The majority of G6PD-deficients are asymptomatic most of the time and go through life without ever being aware
of their genetic trait. Symptoms of the disorder are related to the severity of the hemolytic episode. 2 or 3 days
after the administration of the offending drug (ex:/ Napthalene & TNT), the erythrocyte count decreases, along with
the Hemoglobin content
LABORATORY TESTING
A fall in Hb and Ht
Hemoglobinuria
Heinz bodies in erythrocytes
Elevated serum Bilirubin levels
Markedly decreased or absent Haptoglobin levels

PATHOGENESIS

Alya Putri Khairani | 130110110220

D1

Pyruvate Kinase Deficiency

PK deficiency is inherited as an autosomal recessive trait, but true homozygotes are rare and are restricted to
children of consanguineous parents. The common mode of inheritance is that of double heterozygosity; that is,
when 2 mutant variants of the PK enzyme are simultaneously inherited from each parent
PATHOGENESIS

CLINICAL MANIFESTATION

Alya Putri Khairani | 130110110220

D1

The severity of the hemolytic disease associated with PK defiency varies from mild to severe, depending on the
properties of the mutant enzymes. True homozygotes are anemic and jaundiced at birth and may require repeated
transfusions during life. Less severely affected patients may come to clinical attention later in childhood or early
adulthood because of anemia, jaundice, or an enlarged spleen
LABORATORY TETSING
The peripheral blood smears of patients with PK deficiency typically show a normochromic, normocytic anemia with
varying degrees of Reticuocytosis. Accelerated erythropoiesis may result in Polychromasia, Poikilocytosis,
Anisocytosis, and nucleated red blood cells. Both the Hb and Ht levels are decreased from normal. The serum
usually has a moderate increase in unconjugated bilirubin, and the Haptoglobin level is decreased or absent

Methemoglobin Reductase Deficiency

Hemoglobinopathies
The majority of hemoglobinopathies result from -chain abnormalities. Some individuals with -chain abnormalities
present with abnormal physical properties resulting in clinical disease. Most hemoglobinopathies arise from a single
amino acid substitution that represent a molecular alteration. The abnormality was demostrated by electrophoresis
to be located in the protein portion of hemoglobin molecule.
At the molecular level, a single-base DNA substitution in the corresponding triplet codon produces one amino acid
change (common cuase of hemoglobinopathy). Other molecular changes that are more rare include: multiple-base
substitutions, production of long/short subunits, and the occurrence of fusion subunits
CLASSIFICATION

DQH eu ma nl io t gai t l aoi vtb i evi nse

Ho pe am t ho ig e l so b i n o p a t h i e s

More inclusive method of classification (5 major

categories):
1. Abnormal hemoglobins without clinical
significance
2. Aggregating hemoglobins
3. Unbalanced synthesis of hemoglobin
(thalassemia)
4. Unstable hemoglobins
5. Hemoglobins with abnormal heme function

Alya Putri Khairani | 130110110220

D1

Thalassemia
Thalassemia is a blood disorder passed down through families (inherited) in which the body makes an abnormal
form of hemoglobin, the protein in red blood cells that carries oxygen. The disorder results in excessive destruction
of red blood cells, which leads to anemia.
Causes, incidence, and risk factors
Hemoglobin is made of two proteins: Alpha globin and beta globin. Adult hemoglobin (HbA) is a tetramer composed
of two chains and two chains encoded by a pair of functional -globin genes on chromosome 16 and a single globin gene on chromosome 11. Thalassemia occurs when there is a defect in a gene that helps control production
of one of these proteins.
There are two main types of thalassemia:

Alpha thalassemia

Occurs when a gene or genes related to the alpha globin protein are missing or changed (mutated).

The most common cause of reduced -chain synthesis is deletion of -globin genes.

Occur most commonly in persons from southeast Asia, the Middle East, China, and in those of African

descent.
Beta thalassemia
-

Occurs when similar gene

defects affect production of the
beta globin protein.

Classified into two categories:

(1) 0-thalassemia, associated
with total absence of -globin
chains in the homozygous state
(2) +-thalassemia,
characterized by reduced (but
detectable) -globin synthesis in
the homozygous state.

Impaired -globin synthesis

results in anemia by two
mechanisms. The deficit in HbA
synthesis produces "underhemoglobinized," hypochromic,
microcytic red cells with
subnormal oxygen transport
capacity. A more important
factor is diminished survival of
red cells and their precursors,
resulting from the imbalance in
- and -chain synthesis.

Occur in persons of

Mediterranean origin, and to a lesser extent, Chinese, other Asians, and African Americans.
There are many forms of thalassemia. Each type has many different subtypes. Both alpha and beta thalassemia
include the following two forms:

Thalassemia major (must inherit the defective gene from both parents to develop this syndrome)

Thalassemia minor (occurs if receive the defective gene from only one parent. Persons with this form of
the disorder are carriers of the disease and usually do not have symptoms). Thalassemia minor is much
more common than thalassemia major.
Symptoms
The most severe form of alpha thalassemia major causes stillbirth (death of the unborn baby during birth or the
late stages of pregnancy).
Children born with thalessemia major (Cooley's anemia) are normal at birth, but develop severe anemia during the
first year of life.
Other symptoms can include: bone deformities in the face, fatigue,growth failure, shortness of breath, and yellow
skin (jaundice).

Alya Putri Khairani | 130110110220

D1

Persons with the minor form of alpha and beta thalassemia have small red blood cells (which are identified by
looking at their red blood cells under a microscope), but no symptoms.
Clinical and Genetic Classification of Thalassemias
Clinical
Nomenclature

Genotype

Disease

Molecular Genetics

-Thalassemias
Thalassemia
major

Homozygous 0thalassemia (0/0)

Severe; requires blood transfusions

Homozygous +thalassemia (+/+)

Thalassemiainter
media

0/

Severe, but does not require regular

blood transfusions

+/+
Thalassemia
minor

0/

Rare gene deletions in 0/0

Defects in transcription,
processing, or translation of globin mRNA

Asymptomatic with mild or absent

anemia; red cell abnormalities seen

+/
-Thalassemias
Hydropsfetails

-/- -/-

Lethal in utero without transfusions

HbH disease

-/- -/

Severe; resembles thalassemiaintermedia

-Thalassemia
trait

-/- / (Asian)

Asymptomatic, like -thalassemia

minor

Mainly gene deletions

-/ -/ (black
African)
Silent carrier

-//

Asymptomatic; no red cell abnormality

Signs and tests

A physical exam may reveal a swollen (enlarged) spleen.
A blood sample will be taken and sent to a laboratory for examination.

Red blood cells will appear small and abnormally shaped when looked at under a microscope.

A complete blood count (CBC) reveals anemia.

A test called hemoglobin electrophoresis shows the presence of an abnormal form of hemoglobin.
A test called mutational analysis can help detect alpha thalassemia that cannot be seen with hemoglobin
electrophoresis.