Part 3 of Pathology of Anemias. acquired Hemolytic anemias. Immune hemolytic anemia, Microangiopathic hemolytic anemia. DIC.

1. Never say No, never say, ‘I cannot’, for
you are infinite. Even time and space
are as nothing compared with your
nature. You can do anything and
everything.
-- Swami Vivekananda

2. ….. foundation of clinical medicine
Shashidhar Venkatesh Murthy
A/Prof & Head of Pathology
College of Medicine & Dentistry
Clinical Pathology:
RBC 1.3: Hemolytic Anemia - Acquired

3. Pathogenetic Classification of Anemia:
 Decreased Production:
 Nutrient Deficiency.
 Iron def (IDA) / Megaloblastic (MBA)
 Hemopoietic cell defect:
 Anemia of chronic disorders (ACD)
 Aplastic anemia (AA).
 Dysplastic anemia. Myelodysplastic Syndromes
 Increased loss / destruction:
 Blood loss anemia – Acute / Chronic - bleeding.
 Hemolytic anemia – Congenital / Acquired.
 Acquired / External injury.
 Immune AIHA (Warm/Cold) Mechanical, Drugs & Parasites
 Congenital / Internal RBC defect
 Defective Membrane (Spherocytic an)
 Defective Hemoglobin (Sickle cell an.)
 Deficient Enzyme (G6PD)
3
2
Top 6 Anemias:
1. Iron Def. A
2. Megaloblastic
3. Anem. Of Chronic Dis.
4. Aplastic An.
5. Immune Hemolytic – Warm
6. Immune Hemolytic - Cold

4. Haemolytic Anemia: Introduction
 Anemia due to Increased RBC destruction
  life span (<120d) - Abnormal forms
 Bilirubin  Jaundice (Unconjugated)
  RBC production – BM Hyperplasia &
 Reticulocytes.
 Acute: Pallor, Jaundice (normal urine)
 Chronic: Splenomegaly, pigment gall stones.
 Intravascular & Extravascular Hemolysis*.
Jaundice
2. Jaundice
4. Splenomegaly
3. Pigment Gall stones
1. Pallor
Immune
Mech.
Infection
Porphyrin  Bil. Unconj
Globins
Iron
Bil. Conj
Conjugation
Normal

5. Intravascular Hemolysis.
 Etiology:
 Immune, Mechanical, Enzyme def.
transfusion mismatch, drugs,
infections.
 Lab diagnosis:
 Absent Haptoglobins.
 Haemoglobinemia
 Haemoglobinuria
 Haemosiderinuria
 Clinical features:
 Shock,
 Renal failure,
In Extravascular Hemolysis:
Unconjugated hyperbilirubinemia only* 5
Breakdown of RBC within Blood Vessel
Renal
failure

6. FBC Result: Hemolytic Anemia.
6

7. Hemolytic anemia: Morphology
7
 Abnormal RBC shapes
spherocytes in WIHA, target forms
in thalasssemia etc.
 Polychromatophils.
(Immature RBC - large, bluish, no
central palor - Reticulocytes)
 Nucleated RBC
small nucleus inside reticulocyte.
Thalassemia
Warm Ab Hemolytic Anemia
Giems stain (routine blood film)  Bluish, Large RBC ( MCV)

8. Hemolytic Anemia:  Reticulocytes
Reticulocyte
RBC
Reticulocytosis  Increased RBC production
Methylene blue stain
for cytoplasmic RNA
Giemsa stain (routine blood film)  Bluish, Large RBC ( MCV)

9. Only educated person is
one who has learned how
to learn and change.
-- Carl Rogers

10. Cell Mem
Hb
Enzymes
Haemolytic Anemia: classification
 Acquired / External Injury:
 Immune: IgG / Warm & IgM / Cold
 Physical: valve dis, March Hb.nuria, trauma, burns.
 Drugs: α-Methyldopa, cephalosporins, ibuprofen etc.
 Parasites / infections (malaria, septicemia (DIC)
 Congenital / Internal defects:
 Defective Membrane: Spherocytic anemia.
 Defective Haemoglobin: Sickle cell anemia, Thalassemia
 Deficient Enzyme: G6PD deficiency anemia.
10

11. Immune Hemolytic anemia IgG/IgM:
 Causes:
 RBC Antibody (Commonest.)
 Pathogenesis:
 Warm / IgG coated RBC lysis in spleen. Drugs,
Idiopathic. (predominantly extravascular)
 Cold / IgM - (Infections, Lymphoma) RBC
Clumping & complement fixation lysis in BV &
Liver. (predominantly intravascular)
 Morphology:
 Spherocytes (warm) / RBC clumps (cold).
 Clinical Features:
 Anemia, Jaundice. Splenomegaly in chronic.
 Diagnosis: Comb’s test *.
IgG
WARM
IgM
COLD
WARM / IgG
COLD / IgM
IgG Antibody

12. AIHA: Lab diagnosis – Coombs test.
12
Direct Coombs Test:
(for antigen on patient RBC)
Indirect Coombs Test:
(for antibodies in the serum.)
Pos
Neg
Online Video Tutorial
Patient RBC Patient Serum

13. MAHA - Microangiopathic Hemolytic An.
Mechanical damage:
Etiology:
 DIC, TTP, HUS
 Valve disease / Artificial valves.
 March Hemoglobinuria.
Morphology:
 Fragmented RBC: Schistocytes.
 Polychromasia – reticulocytes.
13

14. 14
The only person who never makes
a mistake is a person who
never does anything…!
- Theodore Roosevelt

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16. The pessimist waits for better times,
and expects to keep on waiting; the
optimist goes to work with the best
that is at hand now, and proceeds to
create better times.
-- Christian D. Larson