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Immune Haemolytic Anaemia

Mechanisms of Immune Red Cell Destruction Classification of Haemolytic Anaemias

Cell Mediated Immune Red Cell destruction Hereditary Acquired
Human macrophage & monocyte – receptor for Fc portion of IgG & C3 Membrane Defects Immune
Roles Metabolic Defects • Autoimmune
Spleen Liver Haemoglobin Defects • Alloimmune
Plasma Skimming Effect No Plasma Skimming Effect • Drugs Induced
Red cell bound IgG ↑ Dependent on cells coated with Red cell fragmentation syndromes
C3 March Haemoglobinuria
Extravascular Haemolysis Infections
Chemical, Physical Agents
PMH

Immune Haemolytic Anaemias

Autoimmune Alloimmune Drugs Induce d
Warm AIHA HTR Ab against a drug
Cold AIHA HDN (Red Cell Membrane
Cold agglutinin syndrome Allografts Complex)
Paroxysmal cold (BM Transplant) Deposition of
Combine/ Mixed AIHA compleme nt via drug-
protein (antigen)
Complement Mediated Intravascular Haemolysis True Autoimmune
Complement Activation – Classical, Alternative Pathways Haemolytic Anaemia
Usually stops at C3 stage (3b) – Extravascular Haemolysis
Complement beyond C3 stage – MAC formation, Intravascular Haemolysis
Autoimmune Haemolytic Anaemia (AIHA)

Definition
Group of disease – Haemolysis occurs be cause Antibody production by body
against its own Red cells
Characteristic
+ve DAT/ Coombs Test

Classification
Warm (70%) Cold (30%)
1° - Idiopathic 1° - Idiopathic
2° 2°
Malignancy – Lymphoma, CLL Infections – Mycoplasma pneu monia,
Alloallergic disease – SLE infectious mononu cleosis
Infections – Monon ucleosis syndrome Lymphoma
Drugs – Methyldopa, Fludarabine Paroxysmal Cold HbUria

Coombs Test

Direct Coombs Test/ Direct Antiglobulin Test (DAT)

Detect Abnormal Antibodies attached to surface of patient’s RBCs
Patient’s RBC + Anti-Human IgG Antiserum
Agglutination of RBCs
Patient’s RBC are coated with IgG
RBCs covered with complement(C3 ) & Anti-Human C3 Antiserum
Specific (C3 alone ) or Broad spectrum DAT (C3, IgG, IgA, IgM) Anti-Sera can be
used

Clinical Manifestation of Autoimmune Haemolytic Anaemia (AIHA) Indirect Coombs Test / Indirect Antiglobuli n Test
Warm AIHA Paroxysmal Cold Cold Agglutinin Detects Antibodies against RBCs foun d in Patient’s Serum
Haemoglobunuria Syndrome Normal RBCs + Patient’s Serum → DAT
Onset 30-60 y/o Young adult 60-90 y/o
Sex F↑ M=F M↑
Severity Variable Acute, Intermittent, Mild, Moderate
Anaemia Massive
HbUria Rare Common Severe cases only
Spleneomegaly Common Intermittent Common
Symptoms Cold Urticaria, Cold Intolerance,
Paresthesis, Rigor, Raynaud’s
Anaphylactic phenomenon
Treatment Corticosteroids Treat 1° Disease Avoid Cold
Splenectomy (Syphilis, Viral Immunosuppressive
Immunosuppresive infection)
Avoid Cold
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Warm AutoImmune Haemolytic Anaemia Cold AutoImmune Haemolytic Anaemia

Definition Cold Agglutinin Syndrome

AIHA caused by production of Antibody (IgG) against own Red Cell Antigen Definition
(strongly at 37°C) Caused by IgM AutoAntibodies – exhibit maximal reactivity at 4°C
> 40 y/o Cold environment – Exacerbate condition
Female ↑ Chronic disease
Half of cases Idiopathic, remaining cases are 2° to predisposing condition > 50 y/o (peak 70 y/o)
2° Etiology (1° - Idiopathic)
Etiology Adults – Lymphoproliferative Disease (Lymphoma, CLL, In fection)
Reactions of Antigens on surface of RBC with circulating Antibody Children – Infection (Mycoplas ma pneumonia, Mononucleosis, HIV)
(Mostly does not involve Complement Reaction) Epstein Barr Virus, Cytomegalovirus
Non-Hodgkin’s lymphomas, Hodgkin’s disease, Autoimmune disorders (RA, Normally All have Circulating Antibodies directed against RBC but in ↓ conc. to
SLE), Drugs (Methyl Dopa) trigger disease. In Cold Agglutinin Disease, the concentration is ↑
Pathogenesis
Pathogenesis After Mycoplasma pneumoniea, Mononu cleosis cause ↑ col d Antibody prod.
Most common antibody = IgG In B-cell Lymph oma, CLL - ↑ cold antibody produ ction by malignant B-cell
At body temperature (28-31°C) (During winter months)
↓
Antibodies (generally IgM) bind to RBC (I, i, Pr antigens)
↓
Activate Classical pathway of Complement System
(Agglutination → Acrocyanosis)
↓
If comple ment response Sufficient,
RBC damaged by MAC causing Intravascular haemolysis
↓
If comple ment response Insu fficient,
RBC damaged by Opsonization & Extravascular haemolysis in RES
Clinical Laboratory
Chronic Anaemic Symptoms Similar to Warm AIHA
(Fatigue, SOB, Weakness) (Except – Spherocytosis ↓ marked)
Dark Urine Red cells agglutination (in the cold)
Acrocyanosis DAT reveals complement (C3d ) only
(Ears, Nose Tips, Fingers, Toes) on Red Cell Surface
(Gangrene of digits) (alluted IgM in central circulation)
Clinical Laboratory Findings (caused by Autoagglutination causing Urine Hb & Hemosiderin ↑
Short Period Anaemia FBP local blood stasis) Haptoglobin ↓ or Absent
Jaundice ↑ Spherocytes, Larger Polychromatic Pallor, Jaundice Treatment
Remit & Relapse & Nucleated RBC Hepatosplenomegaly Keep patient Warm
Splenomegaly Hb, HCT Lymphadenopathy Treat Underlying causes
Associated with ITP (Evan’s syndrome) Normal – Mild Haemolysis Alkylating agents (chlorambucil)
Underlying disease (SLE, Hodgkin’s) ↓ - Severe Haemolysis Splenectomy
Reticulocyte – Persistently ↑ (does not help unless massive)
Treatment WBC Steroids are not helpful
Remove all causes Normal – Idiopathic AIHA
Corticosteroids Varies greatly - 2° AIHA
Splenectomy Platelet count Agglutination of Red Cells
Immunosuppressive drugs Normal – Idiopathic warm AIHA
Blood Transfusion ↓ - Evan Syndrome Paroxysmal Cold Haemoglobinuria (Donath-Landsteiner Haemolytic Anaemia)
(least incompatible blood) LDH ↑ Definition
Serum Haptoglobin ↓ Rare syndrome
Urine Acute Intravascular Haemolysis after Exposure to Cold environment
↑ Urobilinogen Caused by D-L autoantibody (cause severe haemolysis even in ↓ titer)
-ve Hemosiderin, Hb Conditions
DAT +ve (95% AIHA) Cold – Specificity for P antigen on RBC
Bone Marrow (Erythroid Hyperplasia) Warm – Lysis with complement
2° Etiology (1° - Idiopathic)
Laboratory Late stage or Congenital Syphilis in Chronic cases
Viral Upper Respiratory Illness
Viral Infections – Measles, Mumps, Epstein-Barr Virus (EBV),
CytoMegaloVirus(CMV), Varicella zoster virus, Adenovirus, Coxsackie A9,
Parvovirus, Influenza A
Bacterial Infection – Mycoplasma pneumoniae, Haemop hilus influenza,
Klebsiella pneumoniae, Escherichia coli
Pathophysiol ogy

Spleen congested (Spherocytes)

Clinical Investigation Management

Mild Jaundice Donath Landsteiner test Keep patient Warm
Splenomegaly (Agglutinate in cold but Treat underlying cause
Spherocytes, Nucleated young RBC,
Acrocyanosis reversible after warm) Rutiximab & Campath
Spherocytes, Nucleated RBC Reticulocyte
Chronic Haemolytic Direct Antiglobulin test Splenectomy (does not
Anaemia aggravated by Monoclonal IgM help unless massive)
cold & associated with antibodies Steroid does not help
Intravascular
Haemolysis
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Alloimmune Haemolytic Disease

Definition Haemolysis Disease of Newborn (HDN)

Body gains Immunity from Another individual (same species) against own cells Definition
Alloimmunity can occur Destruction of RBC of Fetus & Neonate by Antibodies from Mother
After Transfusion of Fluids (blood, plasma ) ↓ Red Cell Life Span of Fetal/ Neonate
After Allografts (grafts) (maternal Allo-Antibodies against Red Cell Antigens acquired from father)
Fetus after Maternal Antibodies have passed through placenta in fetus Causes
(Hemolytic disease of newborn, Fetomaternal Alloimmune Thrombocytopenia) Destruction of RBCs of Fetus by Antibodies produced by mother
(Fetal Red Cell contain corresponding Antigen, binding of Antibody will occur)
Haemolytic Transfusion Reaction (HTR) Coated RBCs are removed by Mononuclear Phagocytic System
Definition Pathophysiol ogy
RBC Transfuse d to patient is Destroyed by patient’s own immune system
Classification
Type Antibody Primary Degree of Example
detected Antibody Complement
initially Type Binding
Acute Intravascular Yes IgM Full (C1-9) ABO
Acute Extravascular Yes IgG None/ Partial Rh
Delayed Intravascular No IgG Full (C1-9) Kidd
Delayed Extravascular No IgG None/ Partial Duff
Immune Mediated HTR caused by
IgM (ABO antibodies)(Anti-A,B,AB) results in Severe, Intravascular Haemolysis
IgG (Rh, Kell, Duffy) results in Mild, Extravascular Haemolysis
Types
Acute HTR Delayed HTR
Occur within minutes At least 24h after post-transfusion
Incompatible Red Cells transfused 2° Immune response
into patient who has corresponding Previously immunized by Transfusion,
antibodies Pregnancy Clinical
Clinical Clinical Less Severe Severe Intrauterine Death
Fever ↓ HCT Mild Anaemia Icterus Gravis Hydrops Fetalis
Chills +ve DAT (Coombs test) Neonatorum Edematous, Ascites, Bulky Swollen,
Heat in vein when blood transfused Haemoglobinuria (Kernicterus) Friable Placenta
Pain in Lumbar region Mild ↑ Serum Bilirubin Brain damage Pathophysiol ogy
Constricting Chest Pain (infant) cause d by Extravascular haemolysis,
Tachycardia ↓Hb to pretransfusion level after 1-2 ↑ unconjugated- Extramedullary Erythropoiesis
Hypotension weeks posttransfusion indirect bilirubin Hepatic, Cardiac Failure
Haemoglobinemia
Pathophysiol ogy Mechanism of Alloimmunization Before Birth After Birth
Anaemia (Destruction or Red Cells) Anaemia (Destruction of Red Cells)
ABO Incompatible HTR Donor APCs Heart Failure Heart Failure
↓ (macrophages, dendritic cells, B cells) Fetal Death Bilirubin ↑
Fixation of C5b9 complexs Present Donor Antigens to Recipient T cells
Kernicterus
MAC occurs ↓
↙ ↘ Recognition of MHC Class I Severe Growth Retardation
Release C3a, C5a Formation of alloantigens by CD4+ recipient T cells Rh Haemolytic Disease of Newborn (Rh HDN)
(anaphylatoxins) pores in red cell ↓ Antibodies against Anti-D (↓ common – Anti-c, Anti-E)
membrane Activation, Development of Mother is cause of Anti-D Rh –ve
↓ ↓ 1° Immune Response Firstborn infant is Unaffected
Bronchospasm Intravascular ↓
Sensitization of Mother occurs
Mast cell Haemolysis Formation of Memory Cells
degranulation ↓ (from T cells) (during Gestation, at Birth)
Hypotension Hemoglobinuria All subsequent offspring inhering D-antigen will be affected (Anti-D HDN)
Pulmonary Hemoglobinemia Pathogenesis
dysfunction Fetomaternal Hemorrhage
V/Q abnormality ↓
Investigation Anti-RBC Antibody titers of patients Maternal Antibodies formed
Recheck Sample, Patient ID with alloimmunization frequently ↓ against Paternally derived antigens
Measure below detactable levels ↓
During subsequent pregnancy,
• Urinary Hb placental passage of maternal IgG
• Serum LDH, Bilirubin, Allowing incompatible units to be antibodies
Haptoglobin transfused ↓
Intravascular Haemolysis Occur in patients previously Maternal antibody attaches to Fetal
↓ developed Antibodies from previous Red Blood Cells
Produce Free Hb in circulation Transfusion, Pregnancy ↓
↓ Fetal Red Blood Cell Hemolysis
Taken by Haptoglobin (saturation)
↓ At time of pretransfusion screening,
Haemoglobinuria antibody is too weak/↓ to be Factors affecting Immunization & Severity
Haemosiderinuria (if severe) detected by standard procedures Antigenic exposure
Hyperbilirubinemia Host factors
Management Management Antibody specificity
Maintain BP, Renal Perfussion Suspect Transfusion Reaction Influence of ABO group (ABO In compatible Rh +ve cells Haemolysed before Rh
IV Dextran, Plasma, Saline, Frusemide Stop Transfusion antigen can be recognized by Mother’s immune system)
Hydrocortisone, Antihistamine Assess Patient Clinically Prevention of Rh-HDN
(alleviate shock) Verify Patient, Blood Identifiers Prevention of Active Immunization (Anti-D)(↑ tittered Rh-Ig (Rhogam))
IV Adrenaline (severe shock) Blood Bank Investigation Calculation of dose (Kleihauer test for Fetal Hb)
Compatible Transfusion ABO Haemolytic Disease of New Born
Dialysis (Acute Renal Failure) Clinical Laboratory
Anaemia (mild) Microspherocytes
ABO-HDN (1st pregnancy) Bilirubin ↑ later (1-3d after birth)
Mechanism protecting Fetus Cord Blood collection
Relatively Weak A,B antigens RBC (reveal Anti-A, Anti-B)
Widespread distribution of antigen
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Drug-Induced Immune Haemolytic Anaemia

Definition
Acquired form of Haemolytic Anaemia caused by Interaction of drugs with
Immune System
Result is Production of Antibodies against RBC & Premature RBC destruction
= Immune Haemolytic Anaemia 2° to Drugs
= Anaemia – Immune Haemolytic - 2° to Drugs
Rare in Children

Etiology
Drugs
Cephalosproins (antibiotic)
Levodopa
Methyldopa (IgG mediated type II Hypersensitivity)
Penicillin & its derivatives (↑ dose)
Quinidine (IgM mediated activation of Classical Complement pathway & MAC)
NSAIDs
G6PD Deficiency – Breakdown of RBC d ue to stress in cell
(not immune system)(rare)

Mechanisms
Antibody directed Deposition of True autoimmune
against a drug-red cell complement via drug- haemolytic anaemia
membrane comples protein (antigen) (role of drug unclear)
Antibody complex onto
red cell surface
Penicillin Quinidine Methyldopa (+ve
Ampicillin Rifampicin Coombs w/o he molysis)

Penicillin Quinidi ne Methyldopa

In each case, coated (ops onised) cells are destroyed in RES

In each case, Haemolytic Anaemia disappears when drugs are discontinued
(except – Methyldopa – autoantibody may persist for several months)

Clinical
Dark Urine
Fatigue
Pale Skin Colour
Tachycardia
Shortness of Breath
Yellow skin colour (Jaundice)
Splenomegaly

Investigations
DAT/ Coombs Test +ve (usually C3b)
Indirect Coombs +ve (if offen ding drug is added to test)
Indirect Bilirubin ↑
Serum Haptoglobin ↓
Hb present in Urine
Haemosiderin present in Urine
Urine Urobilinogen ↑
Absolute Reticulocyte count ↑
FBC shows Red Blood Cell Count & Hb ↓

Treatment
Cessation of Drug
Prednisone, Corticosteroids (↓ Immune respon se against RBC)
Folic acid supplementation (Treat Folic Acid Deficiency anaemia)
Blood Transfusions (Severe Symptomatic Anaemia)