2. DISEASES
OF
HAEMOPOIETIC
SYSTEM

3. Blood is a unique organ: it is fluid and comes
into contact with almost all other tissues.
The blood cells are non-cohesive and supported
in the fluid medium of blood- the plasma.
The blood cells comprise the non- nucleated
erythrocytes and platelets, and the nucleated cells
or leucocytes.
In addition to primary disease of the blood –
forming organ – the bone marrow – many disease
states produce secondary changes in the blood.
 For this reason, the counting and
morphological examination of blood cells is
routine in the clinical assessment of disease ,
frequently providing valuable diagnostic
information

4. BLOOD CELL
FORMATION
(HAEMOPOIESIS)

5. SITE OF HAEMOPOIESIS
Fetus 0 – 2 months (yolk sac)
2 – 7 months (liver. Spleen)
5 – 9 months (bone marrow)
Infants Bone marrow (practically all bones)
Adults Vertebrae, ribs, sternum, skull,
sacrum and pelvis, proximal ends
of femur

6. HAEMOPOITIC STEM CELL AND PROGENITOR
CELLS
Haemopoiesis starts with a common, ‘Pluripotent
Haemopoietic Stem Cell’ which can give rise to
erythrocytes, leucocytes (including lymphocytes) and
platelets. The pluripotent stem cells possess the ability to
renew and differentiation.
By a series of cell divisions, cell committed to each cell
line are produced and further divisions result in mature
cells – erythrocytes, granular leucocytes, megakaryocyte
and T- and B- lymphocytes .

7. DIAGRAMATIC REPRESENTATION OF BONE MARROW PLURIPOTENT
STEM CELL AND CELL LINES THAT ARISE FROM IT

8. DISEASES OF HAEMOPOIETIC
SYSTEM
1. Anaemias
2. Haematological Malignancies
3. Bleeding Disorders
4. Blood Transfusion

9. ANAEMIAS

10. ANAEMIA
Definition: “Reduction in the concentration of
haemoglobin in the blood below the lower limit of
normal for a particular age and sex of an individual in a
particular environment”
Value of Haemoglobin less than 13.5 g/dl in
males, less than 11.5 g/dl in females and less than 15.0 g/dl
in new borns would indicate anaemia

11. ADULT REFERENCES OF RED BLOOD CELLS
_________________________________________________
Male Female
_________________________________________________
Haemoglobin (g/dl) 13.5 – 17.5 11.5 – 15.5
Haematocrit ; PCV (%) 40 -52 36 – 48
RBC count(X1012
/l) 4.5 – 6.5 3.9 – 5.6
Mean Cell Volume 80 -95 80 - 95
MCV (fl)
Mean Cell HAmeoglobin 27 -34 27 - 34
MCH (pg)
Mean Cell Haemoglobin 30 -35 30 -35
Concentration(MCHC)
Reticulocytes (%) 1 – 2.5% 1 – 2.5%

12. SYMPTOMS AND SIGNS OF ANAEMIA
Symptoms of Anaemia:
Level of haemoglobin at which patient develops symptoms depends
on the rate of development of anaemia. If haemoglobin has been
falling slowly, symptoms occur late,and if haemoglobin falls rapidly,
symptoms occur early.
•Patient may present with generalized weakness and easy
fatigability.
•Palpitation and breathlessness occur if anaemia is severe or patient
has underlying heart disease.
•Anorexia and indigestion are common
Signs of Anaemia:
•Pallor is the main sign. Usual sites to look for pallor are the nail
bed, hands , skin, lower conjunctiva.
•Koilonychia(spoon shaped nails) is seen in iron deficiency anameia
•Bone deformities occur in thalassaemia major
•Leg ulcers are a feature of sickle cell anaemia
•Systolic Murmur may be audible in pulmonary area
•Mild jaundice may occur in haemolytic anaemia.
•Different other signs and symptoms can be ascribed to a specific
cause of anameia

13. CLASSIFICATION OF ANAEMIA
1. Kinetic Classification of Anaemias
2. Morphologic Classification of Anameias

14. KINETIC CLASSIFICATION OF
ANAEMIAS
I. ANAEMIAS DUE TO EXCESSIVE BLOOD LOSS
(i) Acute blood loss anaemia
(ii) Chronic blood loss anaemia
II. ANAEMIAS DUE TO PRODUCTION FAILURE
(i) Haematenic deficiency: Iron, Folic Acid and B12
deficiency
(ii) Anaemia of chronic disorders: Infection,
inflammation, neoplasia; renal failure
(iii)Marrow Hypoplasia: Aplastic Anaemia; Pure red cells
Aplasia
(iv)Marrow Infiltration: Leukaemias; Lymphomas;
Myeloproliferative disorders; Myelodysplastic Syndrome

15. III ANAEMIAS DUE TO EXCESSVIE RED CELLS DESTRUCTION
(HAEMOLYTIC ANAEMIA)
1. HAEMOLYSIS DUE TO RED BLOOD CELLS ABNORMALITY
(Intracarpuscular Defect)
Congenital
a. Red blood cells membrane defects: Hereditary Spherocytosis
b. Enzyme defects: G.6PD Deficiency
c. Haemoglobinopathies: Thalassaemia; Sickle Cell Anaemia
Acquired
d. Paroxysmal Nocturnal Haemoglobuniria
2. HAEMOLYSIS DUE TO ABNORMALITY OUTSIDE THE RED
BLOOD CELL (Extracarpuscular)
a. Immune Haemolytic Anaemias:
(i) Autiimmune HAemolytic Anaemia
(ii)Alloimmune Haemolytic Anaemia
b. Non Immune:
(i)Malaria
(ii)MIcroangiopathic Haemolytic Anaemia

16. MORPHOLOGIC CLASSIFICATION OF ANAEMIAS
Reticulocyte Count
More than 2.5 % Less than 2.5%
Haemolysis Red Cells Morphology
Or
Haemorrhage
Normocytic Microcytic Macrocytic
- Chronic diseases - Iron deficiency - B12 deficiency
-Marrow problems - Thalassaemia - Folic Acid deficiency -
-Sideroblastic
anaemia
- Anaemia of Chronic
disorders

17. MORPHOLOGIC CLASSIFICATION OF ANAEMIAS
Causes of Microcytic and Hypochromic Anameias (MCV – Less than 80 fl)
1.Iron Deficiency Anaemia
2.Thalassaemias
3.Anaemia of Chronic Disoder
4.Sideroblastic Anaemia
 Causes of Normocytic and Normochromic Anaemias (MCV – 80 to 95 fl)
1. Many Haemolytic Anameias
2. Anaemia of Chronic Diseases
3. Acute blood loss
4. Mixed Deficiency Anaemia
5. Aplastic Anaemia
6. Bone marrow infiltration as in Lymphomas, Leukameias,etc
Causes of Macrocytic Anaemias (MCV More than 95 fl)
Megaloblastic Macrocytic Anameias
Megaloblastic Anameia
Nonmegaloblastic Anameia
1.Haemolytic Anaemias ( Reticulocytes will appear as Macrocytic cells)
2.Liver Disease
3.3. Alcohol
4.Aplastic Anaemia

18. IRON DEFICIENCY ANAEMIA
Iron deficiency anaemia is the most common cause
of anaemia in every country of world.
It is the most important cause of a microcytic
hypochromic anaemia, in which all the three red
blood cell indices (the MCV, MCH and MCHC) are
reduced, and the blood film shows small(microcytic)
and pale (hypochromic) red cells
The important causes of microcytic hypochromic
anaemia are:
(i) Iron deficiency anaemia
(ii) Thalassaemias
(iii) Sideroblastic anaemia
(iv) Anaemia of chronic disorder

19. The causes of a hypochromic microcytic anaemia. These include lack of iron
(iron deficiency), or of iron release from macrophages to serum (anaemia of
chronic inflammation or malignancy). Failure of protoporphyrin synthesis
(sideroblastic anaemia) or of globin synthesis (Alpha or Beta Thalassaemia).

20. IRON ABSORPTION AND METABOLISM
Iron Absorption: Iron absorbed from food and iron recovered from senescent red blood cells is
transported to the marrow and tissues. The iron laden transferrin binds to transferrin receptors
on the surface of erythroid precursors. It is then internalized, at which time the iron is released
for use in haemoglobin production. The transferin- transferin receptor complex is then returned
to surface of the cell and the transferin is released to complete the cycle

21. IRON ABSORPTION AND METABOLISM
Iron Absorption: Iron absorbed from food and iron recovered from senescent red blood cells is
transported to the marrow and tissues. The iron laden transferrin binds to transferrin receptors
on the surface of erythroid precursors. It is then internalized, at which time the iron is released
for use in haemoglobin production. The transferin- transferin receptor complex is then returned
to surface of the cell and the transferin is released to complete the cycle

22. Iron Absorption
ucosal uptake of heme and nonheme iron is depicted. When the storage sites of the body
e replete with iron and erytropoietic activity is normal, most of the absorbed iron is lost
nto the gut by shedding of the epithelial cells. Conversely, when body iron requirements
ncrease or when erytropoieis is stimulated, a greater fraction of the absorbed iron is transferred
nto plasma transferrin, with a concomitant decrease in iron loss through mucosal ferritin.
MT1,divalet metal transporter 1

23. Iron in
the body

24. Iron the diet is of two types – Haem Iron and Non Haem Iron.
Much of the dietary iron is non haem iron derived from cereals,
with a lesser component of haem iron derived from
haemoglobin or myoglobin in red or organ meat. Haem Iron is
more readily absorbed than non haem iron.
The transport and storage of iron is largely mediated by
transferrin. Transferrin contain two atoms of iron. It delivers
iron to tissues which have transferrin receptors, especially
erythroblasts in the bone marrow which incorporate iron in
haemoglobin . The transferin is then reutilized . At the end of
their life span red cells area broken down into macrophages of
the reticuloendothelial system and the iron is released from
haemoglibin, enters the plasma and provides most of the iron
on transferin. Some of the iron is stored in reticuloendothelial
cells as ferritin and haemosidrin.

25. CAUSES OF IRON DEFICIENCY ANAEMIA
I. CHRONIC BLOOD LOSS:
(i) Uterine Bleeding:
-Menorrhagia (excessive menstrual bleeding).
- Postmenopausal bleeding.
(ii) Gastrointestinal Bleeding:
- Peptic Ulcer
- Bleeding Haemorrhoids
- Hookworm infestation
- Aspirin or other nonsteroidal anti- inflammatory
drugs ingestion
II. INCREASED DEMAND:
Increased iron demand during infancy, adolescence,
Pregnancy, lactation and in menstruating women
III. MALABSORPTION:
Gluten Induced Enteropathy; Gastrectomy
IV. DIETRY:
Especially vegetarian diet

26. CLINICAL FEATURES OF IRON DEFICIENCY
ANAEMIA
 The patient develop the general symptoms and signs of anaemia and also
show a painless glossitis, brittle, ridged or spoon shape nails
(koilonychia), dysphagia (as a result of pharyngeal webs).
 Patients also show unusual dietary craving( Pica; perverted appetite
e.g., clay eating)
 In children the iron deficiency is particularly significant, as it can cause
irritability, poor cognitive function, decline in psychomotor development
and learning . Child with iron deficiency anameia can also show
behavioral problems
Koilonychia: typical ‘spoon’
shaped nails

27. IRON DEFICIENCY: LABORATORY DIAGNOSIS
Peripheral Blood Findings
(i)Haemoglobin is decreased
(ii) Red cells indices (MVC;MCH;MCHC) are
decreased.
(iii) Red Blood Cells Morphology: Microcytic and
Hypo chromic red cell morphology with pencil
shaped poikilocyttes. Red cells morphological
changes are proportional to degree of anaemia.
(iv) Platelet count is often moderately raised,
particularly in cases of localized bleeding site (reactive
thrombocytosis)
(v) In cases of worm infestation there can be Eosinophilia.
Biochemical Findings:
(i)Serum iron is decreased
(ii) Serum Total Iron Binding Capacity (TIBC) id increased
(iii) Serum Ferrritin is decreased
Bone Marrow Findings:
(i) Erythroid Hyperplasia; Erythroblasts are small (micronormoblasts) and
have ragged cytoplamic outlines
(ii) Iron Stain: Iron will be absent in stores as well as in erythroid series
cells

28. Red Blood Cells Morphology: Microcytic and Hypo chromic red cell morphology
with pencil shaped poikilocyttes.
Red cells morphological changes are proportional to degree of anaemia.
Pencil Shape Red cell

29. TREATMENT OF IRON DEFICIENCY ANAMEIA
It is usual to give 100 to 200 mg of elemental iron daily
to adults and 3 mg/kg body weight as a liquid
preparation to children.
Treatment response: Rise of haemoglobin at a rate of
2.0g/dl every three weeks .
Length of Iron Therapy: In order to replenish iron
stores continue iron therapy for 12 months after
haemoglobin level becomes normal.

30. Form of
Iron
Preparation Size Iron content Usual oral
dose
FERROUS
SULPHATE
Tablet 300 mg 60 mg 3 tablets
daily
Syrup 40 mg/ml 8 mg/ml 25 ml
(5 TSP)
Drops 125 mg/ml 25 mg/ml
FERROUS
GLUCON-
- ATE
Tablet 300 mg 37 mg 5 tablets
FERROUS
FUMERATE
Tablet 300 mg 100 mg 2 tablets

31. PARENTRAL IRON
 It is given only in conditions where patient can not
tolerate oral iron or rapid replenishment of stores is
indicated.
Usually the total amount of iron required is 1.0 g to 2.0
gm

32. PARENTRAL IRON: IRON SUCROSE (VENOFER)
The commonly used preparation is Iron Sucrose.
Parental iron preparation contains Ferric Iron. Ferrous
iron being freely ionizable is extremely reactive.
- Composition: Iron Sucrose
- Formulation: 5 ml
- Iron Content: 20 mg/ml
- Iron content per ampule: 100 mg
- Dose in mg to raise Hb by 1 g/dl in adults: 200
- Administration: Intravenous infusion
Total calculated dose of venofer is administered
as fractional infusions on a daily basis or at convenient
intervals. One to two ampules ( 5 – 10 ml) of venofer
solution are diluted in 100 ml saline and infused slowly
over 1 – 2 hours.

33. MEGALOBLASTIC ANAEMIAS
This is a group of anaemias in which, due to
impaired DNA synthesis, the erythroblasts in the
bone marrow show a characteristic abnormality –
maturation of nucleus being delayed relative to
that of cytoplasm ( megaloblast)
In megaloblast the nuclear chromatin maintains
an open, stippled, lacy appearance despite normal
haemoglobin formation in the cytoplasm of the
erythroblasts, as they mature
Two main deficiencies lead to megaloblasstic
anaemia
(i) Folic Acid or Folate deficiency
(ii) Vitamin B 12 deficiency

34. VITAMIN B 12 AND FOLATE - COMPARISON
VITAMIN B 12 FOLATE
CONTENTS IN
FOOD
Vegetables – Poor
Meat – Rich
Vegetables – Rich
Meat – Moderate
EFFECT OF
COOKING
10 -30 % loss 60 – 90 % loss
SITE OF
ABSORPTION
Ileum Duodenum &
Jejunum
NEUROLIGCAL
MANIFESTATIONS
An Important feature Absent
MALNUTRITION Unusual Most common cause
of Folate deficiency
ONSET Rapid Onset (Takes
weeks)
Slow (Takes years)

35. ABSORPTION OF VITAMIN B 12
Absorption of B12 requires Intrinsic Factor (IF),
which is secreted by the parietal cells of the fundic
mucosa along with hydrochloric acid. Initially the
vitamin is released from its protein - bound form
by the action of pepsin in the acidic environment
of the stomach. The liberated vitamin is then bound
to salivary vitamin B12 – binding protein called
R- binder. In the duodenum, R- vitamin B12
complexes are broken down by the action of
pancreatic enzymes, and the released vitamin B12
then attaches to IF. In this form, IF – B12 complex
is then transported to ileum, where it adheres to
IF- specific receptors on the ileal cells. Vitamin B12
then transverses the plasma membrane to enter the
mucosal cell. It is picked up from the cell by a plasma
protein , Transcobalamin II, which is capable of
delivering it to liver and other cells of the body,
Particularly cells of the bone marrow where it is
incorporated in the nuclei for DNA synthesis.

36. ABSORPTION OF FOLIC ACID
Folic acid in the diet is in two form
Monoglutamates and Polyglutamates.
 More than 90% is polyglutamates .
Intestinal conjugases split
polyglutamates into monglutamates
that are readily absorbed in the
proximal jejunum. During intrstinal
absorption they are modified so that
only 5- methyltetrahydrofolate enters
the circulation as the normal transport
form of folate.

37. PATHOGENESIS OF HOW B12 AND FOLATE
DEFICIENCY PRODUCE MEGALOBLASTIC ANAEMIA
Lack of Vitamin B12 or Folate causes slowing of DNA synthesis in developing
erythroblasts with anaccumulation of cells in premitotic phase of cell cycle.
The neutropeina and thrombocytopenia also appears to result from ineffective
and abnormal precursor cells in the marrow due to impaired DNA synthesis

38. CAUSES OF VITAMIN B12 DEFICIENCY
1.Decreased intake of Vitamin B12:
Nutritional deficiency (Vegetarians)
2. Impaired absorption of Vitamin B12:
(i) Pernicious Anaemia ( Lack of Intrinsic Factor;
Antibodies against Intrinsic Factor)
(ii) Gastrectomy( No release of Intrinsic Factor)
3. Intestinal Causes:
(i) Lesions of small intestine
(ii) CoeliacDisease
(iii) Tropical Sprue
(iv) Fish Tapeworm( DIphylobothium Latum) infestation

39. CAUSES OF FOALTE DEFICIENCY
1. Decreased intake of Folic Acid:
Nutritional Deficiency
2. Impaired Absorption of Folic Acid:
(i)Coeliac Disease
(ii)Tropical Sprue
3. Increased demand:
(i) Pregnancy
(ii) Haemolytic Anaemias
(iii) Myeloproliferative disorders
(iv) Carcinoma
(v) Inflammatory disorders
(vi) Skin diseases
4. Drugs:
Dihydrofolate reductase inhibitors

40. CLINICAL FEATURES OF MEGALOBLASTIC ANAEMIA
Glossitis: tongue is beefy
red and painful
Angular stomatitis
 The onset is usually insidious with
gradually progressive symptoms and
signs of anaemia. The patient may be
mildly jaundiced (lemon yellow tint)
due to the excess breakdown of
haemoglobin resulting from
ineffective erythropoiesis in the bone
marrow
 Glossitis , sore tongue and
stomatiitis
 Mild symptoms of malabsorption
with loss of weight may be present
due to epithelial changes
 Lethargy, breathlessness and other
generalized signs and symptoms of
anaemia may be present

41. CLINCAL MANIFESTATIONS DUE TO VITMAIN B 12 DEFICIENCY
Vitamin B12 is required for two important reactions in the body:
Vitamin B 12
(i) Homocysteine Methionine
Vitamin B 12
(ii) Methylmelonyl CoA Succinyl CoA
Absence of B12 then leads to two
important consequences:
(i) Impaired methylation leads to
defects in myelinatioin of
neural tissues
(ii) Accumulation of Homcysteine
has toxic effects on
cardiovascular tissue and
neural tube

42. Demyelination of the
dorsal and dorsolateral
columns
A baby with neural tube
defect (spina bifida)
VITMAIN B 12 NEUROPATHY (SUBACUTE
COMBINED DEGENERATION OF SPINAL CORD:
B12 deficiency may cause a progressive neurtopathy
affecting the peripheral sensory, and posterior columns
The neuropathy is symmetrical and affects the lower
limbs more than the upper limbs. The patient notices
tingling in the feet, difficulty in walking and may fall
over in the dark. Rarely optic atrophy or psychiatric
symptoms (Megaloblastic Madness) are present
NUERAL TUBE DEFECT:
The accumulated Homocysteine can act as a toxic
substance and can lead to a damage to neural tissue.
Supplementation of maternal diet with folic acid during
Pregnancy reduces the incidence of neural tube defect
By 75%
CARDIOVASCULAR DAMAGE:
Raised Homocysteine damages cardiac and peripheral
and cerebral vascular tissue. So can lead to myocardial
Infarction, peripheral and cerebral vascular disease
and venous thrombosis

43. Lab Diagnosis of Megloblastic Anemia
1.Peripheral blood finidngs
2.Bone Marrow Findings
3.Special Tests
1. Peripheral Blood Findings
a. Anaemia
b. Pancytopenia (Anaemia + Leucopenia+ Thrombocytopnia)
c. RBC Morphilogy:Macrocytosis (Oval Macrocytes)
d. Hypersegmented Neutrophils: Neutrophils hyper- segmentation
is present when more than 5% of the neutrophils have 5 lobes or the
film show at least one sixed lobed neutrophils
Hyerpsegmentation is early sign of Vitamin B12 or folate deficiency
deficiency, and is useful in the diagnosis of megaloblastosis with
minimal or no anaemia
e. Howel Jolly Bodies
f. Basophilic Stippling
g. Cabbot’s Rings

44. 2.. Bone Marrow Findings in Megaloblastic Anaemia
a. ERYTHROPOIESIS :
- Megaloblasts All the nucleated series of erythroid cells show
megaloblastic change
- Their abnormal appearance is due to disturbance of cell growth and
maturation, resulting from interference with DNA synthesis.
- Cells are larger than erythroblasts
- Dissociation of Cytoplasmic and Nulcear maturation: Maturation of
nucleus lags behind that of cytoplasm . Haemoglobinization of
cytoplasm takes place while nucelus is immature
- Dyserythropoiesis : Increase in the proportion of more primitive cells
b. LEUCOPOIESIS
- Shift to left is observed
- Giant Metamyelocytes are seen
c. MEGAKARYOPOIESIS
- Megakaryocytes are norma lor decreased
d. IRON STAINING:
- Iron increased in fragments with increased siderocytes and
sideroblasts
- In cases of mixed deficiency (Iron +B12+ Foalate deficeincy) iron will
be absent

45. 3. Special Tests:
1.Serum Vitamin B12- Decreased
2.Serum Folic Acid-Decreased

46. Macrocytic Anemia (Meg.):

47. Megaloblastic Anemia :
Hypersegmented Neutrophils
Oval macrocyte

48. Marrow smear from a patient
with megaloblastic anaemia:
Megaloblast in various stages
of differentiation.
3. BONE MARROW FINDINGS IN
MEGALOBLASTIC ANAEMIA:
•Meglablasts:All the nucleated series of erythroid
series will show Megaloblastic changes. Cells are
larger in size and nuclear chromatin shows open
sieve like pattern.
•Orthochromatic Normoblasts: Cytoplasm is
haemoglobinized but nucleus is not pyknotic
(nuclear cytoplasimc dissociation)
•Giant Metamyelocytes: Myelocytes are
larger in size

49. TREATMENT OF MEGALOBLASTIC ANAEMIA
VITAMIN B12
DEFICIENCY
FOLATE
DEFICIENCY
Compound Hydroxycobalamin Folic Acid
Route Intramuscular Oral
Daily Dose 100 ug 5 mg
Initial Dose 6 X 1000ug
over 2-3 weeks
Daily for 4 months
Maintenance 1000 ug every 3
months
Depends on underlying
disease ; life long therapy
may be needed in chronic
haemolytic anaemias ,
myelofibrosis and renal
dialysis
Prophylactic -Total Gastrectomy
- Ileal Resection
Pregnancy; Severe
haemolytic anameias;
dialysis; prematurity

50. APLASTIC ANAEMIA
Aplastic Anaemia is defined as the presence of pancytopenia
in the peripheral blood and a hypocellular marrow in which
normal haemopoietic marrow is replaced by fat cells
Pancytopenia resulting from aplasia of the bone marrow
The diagnosis of aplastic anaemia is made on the basis of
(i) Pancytopenia
(ii) A hypocellular or aplastic marrow with increased
fat spaces
(iii) The virtual absence of reticulocytes

51. CAUSES OF APLASTIC ANAEMIA
I. CONGENITAL
Fanconi’s Aplastic Anaemia
II. ACQUIRED
1. Idiopathic
2. Chemical and Physical Agents
a. Agents which regularly produce aplasia if dose
is sufficient:
- Ionizing radiation
- Benzene
- Chemotherapeutic agents
b. Agents which occasionally produce aplasia:
- Antibiotics: Chloramphenicol, Cotrimaxazole
-Anti-inflammatory drugs: Phenylbutazone,
Indomethacin, Ibuprofen,
- Antirheumatic: Gold salts, Penicillamine
3. Viral Infections:
Hepatitis (Non A, Non B , Non C)
EB virus
HIV

52. PATHOGENESIS OF APLSTIC ANAEMIA
1. DIRECT DAMAGE: Can be caused by direct damage to the
haemopoietic marrow by radiation or cytotoxic drugs.
2. CHROMOSOMAL BREAKS: Seen in congenital aplastic
anaemia
3. FUNDAMENTAL STEM CELL ABNORMALITY: Some
forms of marrow insult presumably cause genetic damage that
results in the generation of stem cells with poor proliferative and
differentiative capacity
4. IMMUNE MECHANISMS: Different agents activate
cytotoxic T cells. These activated cytotoxic T cells then produce
different types of cytokines. These cytokines have specific receptors
for them on stem cells . The important cytokines in this aspect are :
(i) Interferon (IFN) – Gamma
(ii) Tumour Necrosis Factor (YNF)
(iii) Interleukin – 2 (IL – 2)

53. These cytokines then attach to their
receptor on stem cell and induce
damage to haemopoietic stem cell in
following manner:
(i) Decrease transcription of cellular
genes and entery in cell cycle.
(ii) Induces the formation of nitric
oxide synthase which then produces
toxic gas nitric oxide. The nitric oxide
then produces further toxicity to
other cells
(iii) Increased apoptosis (cell death)
This scenario is supported by
the observation that immuno-
suppressive therapy with
antithymocyte globulins combined
with cyclosporine has a salutary
effect in 60% to 70% of patients

54. CLINICAL FEATURES OF APLASTIC ANAEMIA
The onset is at any age with a peak incidence around 30
years and a slight male predominance
Onset in insidious or acute with symptoms and signs
resulting from anaemia (lethargy, breathlessness, pallor),
neutropenia(infections, fever) and thrombocytopenia
(bleeding tendencies).
Bleeding is often the presenting initial presentation.
Bruising, bleeding gums, epistaxis, petechiae and
mennorhagia are the most frequent haemorrhagic
manifestations
Infections, particularly of mouth and the throat are
common and generalized infections are frequently life-
threatening .

55. CLINICAL FEATURES OF APLASTIC ANAEMIA…contd
Lymph nodes, liver. Spleen are not enlarged
 Rarely jaundice can be feature in patients with post
hepatitis aplasia. The patients of aplastic anaemia having
a history of hepatitis, usually presents at a time when
clinically jaundice had already subsided.
At presentation it is necessary to take a detailed drug,
occupational and symptomatic history to try to establish
any etiological agent. Unfortunately it is not always easy.

56. LAB DIAGNOSIS OF APALSTIC ANAEMIA:
e peripheral blood film shows
ncytopenia(Anaemia; Leucopenia;Thrombocytopenia)
ere are no gross morphological changes in circulating
ls, except some macrocytosis of red cells
ere is absolute Reticulocytopenia.
anulocytes may show increased staining of granules, the
called toxic granulation of neutrophils.
telets are reduced and are of small and uniform size.
nocytes are usually reduced in proportion to
nulocytes.

57. 7. The bone marrow aspirate is usually easily obtained,
typically with many fragments, which appear hypocelluar
(more than 75% fat). There is relative increase in
lymphocytes, plasma cells. The remaining haemopoietic
cells are normal. In the early stages
Haemophoagocytosis may be prominent
8. Bone marrow trephine is essential to make a
diagnosis. It shows fat replacement of marrow, and normal
haempoietic tissue is absent or scanty

58. Vs
Normal bone marrow: From a
section of bone marrow trephine
biopsy. Marrow cells are
interspersed between fat spaces.
The arrow points to a
megakaryocyte
Aplastic Anaemia: Bone
marrow
trephine biopsy showing
markedly hypoplastic marrow
composed largely of fat cells

59. CAUSES OF PANCYTOPENIA
1. Aplastic Anaemia
2. Megloblastic Anaemia
3. Bone marrow infiltration by leukaemias,
lymphomas, multiple myeloma etc.
4. Myelofibrosis
5. Hypersplenism( peripheral blood pancytopenia with
normocellular or hypercellular marrow and
splenomegaly)

60. HAEMOLYTICHAEMOLYTIC
ANAEMIASANAEMIAS

61. HAEMOLYTIC ANAEMIAS
The distinguishing feature of all haemolytic anaemias is the
increased rate of red cells destruction
NORMAL RED CELL DESTRUCTION
Red cells destruction usually occurs after a mean lifespan of 120
days when the cells are removed extravasularly by the macrophages of
the reticuloendothelial system,(Extrvascular Haemolysis) especially
in the marrow but also in liver and spleen. As the red cell have no
nucleus, red cells metabolism gradually deteriorates as enzymes are
degraded and not replaced and the cells become non- viable. The
breakdown of haem from red cells liberates iron for recirculation via
plasma transferrin to marrow erythroblasts, and protoporphyrin which is
broken down to biilrubin. This circulates to the liver where it is
conjugated to glucuronides which are excreted into the gut via bile and
converted to stercobilinogen and stercoblin (excreted in faeces).
Strecoblinogen and stercolbilin are partly reabsorbed and excreted in
urine as urobilinogen and urobilin. Globin chains are broken down to
amino acids which are reutilized for general protein synthesis in the
body. Intravascular Haemolysis (breakdown of red cells in the
blood vessels) play little or no part in normal red cells destruction.

62. (a) Normal red cell breakdown- Extravascular: This takes place extravascullarly
in the macrophages of the reticuloendothelial system
(b) Intravascualar Haemolysis: Occurs in some pathological disorders

63. INTRAVASCUALR AND EXTRAVASCULAR
HAAMOLYSIS
There are two main mechanisms by which a red cells are destroyed in
haemolytic anaemias- Extravascular or Intravascular. In majority of the
anaemias the destruction is extravascular.
Causes of Extravascular Haemolysis
1.Haemoglobinopathies
Thalassaemias
Sickle Cell Anaemia
2.Hereditary Spherocytosis
3. Autoimmune Haemolytic Anaemias
4. Malaria
5. G6PD deficiency
Causes of Intravascular Haemolysis
1. ABO mismatched blood transfusion
2. Malaria
3. PNH
4. G6PD deficiency

64. INTRODUCTION TO HAEMOLYTIC ANAEMIAS
Haemolytic anaemias are defined as those anaemias
which result from an increase in the rate of red cell
destruction. Because of erythropoietic hyperplasia and
anatomical extension of bone marrow, red cells
destruction may be increased several- fold before the
patient becomes anaemic- compensated haemolytic
disease. The normal adult marrow, after full expansion, is
able to produce red cells at six to eight times provided
this is ‘effective’. Therefore haemolytic anaemia is not
seen unless the red cells life span is less than 30 days.

65. CLASSIFICATION OF HAEMOLYTIC ANAEMIAS
Hereditary Haemolytic Anaemias are the result of
‘intrinsic’ red cell defects
whereas
Acquired haemolytic anameias are usually the result of
an’extracarpuscular’ defect or environmental change.
Paroxysmal Nocturnal Haemoglobinuria (PNH) is an
exception because it is an acquired disorder but the PNH
cells have an intrinsic defect

66. LABORATORY FINDINGS IN HAEMOLYTIC
ANAEMIAS
The laboratory findings in haemolytic anaemia are
conveniently divided in three groups
1. Features of Increased Haemoglobin Breakdown
i. Jaundice and Hyperbilirubenemia
ii. Reduced plasma Haptoglobin and Haemopixin
iii. Increased serum LDH
iv. Haemoglobinemia
v. Haemoglobinuria
vi. Methhemoglobinemia
vii. Haemosidrinuria
Evidence
of
Intravascular
Haemolysis

67. 2. Features of Increased Red cells Production
Compensatory Erythroid Hyperplasia)
i. Reticulocytosis
ii. Macrocytosis and Plychromasia
iii. Erythroid hyperplasia of marrow
iv. Radiological changes in bones (seen only in
congenital anaemia)
3. Feature of Damage to Red Cell:
i. Spherocytes
ii. Increased red cells fragility
iii. Red blood cells fragmentation.

68. GENETIC BASIS OF DISEASES
There are three major categories of genetic disorders:
1. MENDELIAN DISORDERS: Disorders related to
mutant genes of large effect. Most of these disorders
follow mandalian pattern of inheritance.
2. CHROMOSOMAL DIORDERS: Associated with
numerical or structural changes in chromosomes
3. DISEASES WITH MULTIFACTORIAL(POLYGENIC)
INHERITENCE: Includes some of the common diseases
of humans, such as hypertension and diabetes. These
disorders are influenced by both genetic and
environmental factors

69. MENDALIAN DISORDERS
All Mendalian disorders are result of expressed
mutations in single or small gene clusters, the
chromosome number being normal.
Mutations involving single – gene disorders typically
follow one of three patterns of inheritance:
(i) Autosomal Dominant
(ii) Autosomal recessive
(iii) X- linked.

70. HOMOZYGOUS VS HETEROZYGOUS
DOMINANT VS RECESSIVE
Each individual possesses two factors for a
charactersitic.
If these factors are the same then the indivudual is
said to be Homozygous, but if these factors are different
then the individual is said to be Heterozygous.
 If a character manifests in heterozygous state it is
called Dominant
If a character manifests in homozygous state it is called
Recessive
The term coined for these hereditary characters or
factors is Gene.

71. AUTOSOMAL DOMINANT DISORDERS
Autosomal dominant disorders are manifested in the
heterozygous state. That is, a person with an autosomal
dominant trait possesses the abnormal (mutant) gene
which causes the disorder as well as normal allele.
At least one parent of an index case is usually affected;
both males and females can be affected, and both can
transmit the disease.
When an affected person marries an unaffected one,
every child has one in two chance (50%) of having the
disease. So, by chance an affected person may well have
all normal children. On the other hand, again by chance ,
he may be unlucky and all his children may be affected.

72. Autosomal dominant disorders tend to be extremely
variable in expression. Some individuals may be so
mildly affected that the condition hardly affects their
everyday life, but others may be so severely affected that
they may become complete invalids. Most affected
individuals lie somewhere between these two extremes
Common Autodsomal Dominant
Haematological Disorders
- Hereditary Spherocytosis – Haemolytic Anaemia
- von Willebrand Disease – Bleeding Disorder.

73. Autosomal recessive inheritance is the single largest
category of mendelian disorders.
These disorders are characterized by following features:
1. Autosomal recessive diseases are only manifest when
the gene is present in double dose, i.e, the person is
Homozygous for that particular gene and receiving
abnormal gene from both parents.
2. Usually Heterozygous are perfectly healthy and all the
offspring of an affected person are normal, unless the
affected person marries a heterozygote.
AUTOSOMAL RECESSIVE DISORDERS

74. 3. If both the parents are heterozygous (carriers) then in
each pregnancy there are 25% chances that the child can
have homozygous state (fully expressed Disease or Major
state), 25% chances of being normal and 50% chances of
having heterozygous state( Carrier or Trait or Minor)
4. Common Autosomal Recessive Haematological
Disorders:
- Thalasaemias
- Sickle Cell Anaemia
AUTOSOMAL RECESSIVE DISORDERS….. Contd

75. All sex – linked disorders are X- linked, almost all X-
linked recessive. The only gene assigned with certainty to
the Y- chromosome is the determination of testes; males
with mutations affecting the Y- linked genes involved in
spermatogenesis are usually infertile. And hence there is
no Y-linked inheritance.
An X- linked recessive trait is one determined by a gene
carried on the X- chromosome and manifest in the female
only when the allele is in the double dose, that is in the
homozygous state. In the male, a mutant allele carried on
the single X chromosome is always manifest because
there is no normal allele to counteract the effect of the
mutant allele as there is in heterozygous female.
X- LINKED DISORDERS

76. Since a male transmits an X- chromosome to each of his daughters
and a Y- chromosome to each of his sons, then all the daughters of an
affected male will be carriers but none of his sons will be affected.
An X- linked disorder is never transmitted from a father to his son.
When carrier female marries a normal male then her sons have a 1
in 2 (50%) chance of being affected and her daughters have a 1 in 2
(50%) chance of being carriers like their mother
So In X- linked disorders patients are invariably Males, unless a
patient of haemophilia marries a female carrier where disease can
manifest in a female.
The carriers of X- linked disorders are females.
COMMON X- LINKED HAEMATOLOGICAL DISORDERS
- Haemophilia A and Haemophilia B
- Glucose 6 Phosphate Dehydrogenase (G-6PD) deficiency.

77. HAEMOGLOBIN DISORDERS
OR
HAEMOGLOBINOPATHIES
Haemoglobin disorders result from:
1. Reduced synthesis of normal Alpha or Beta globin chains
-Alpha Thalassaemias
- Beta Thalassaemias
2. Synthesis of an Abnormal Haemoglobin
- Crystaline Haemoglobin (HbS, C, D, E, O etc)
(These are produced due to amino acid substitution)
- Unstable Haemoglobin

78. THALASSAEMIA
“The Thalassaemias are a heterogeneous group of genetic disorders of
haemoglobin synthesis all of which result from reduced rate of
production or absence of production of one of the globin chains of
haemoglobin”
According to globin chain, which is
produced in reduced amount, thalassaemias
are divided into two important groups:
(i) Beta ( β) Thalassaemias: Due to reduced synthesis
or absence of synthesis of Beta globin chains.
(ii) Alpha ( α ) Thalassaemias: Due to reduced synthesis or
absence of synthesis of alpha globin chains.
- In Beta thalassaemia the beta chain synthesis is decreased or absent but
there will be unimpaired synthesis of Alpha chains
-In some thalassaemias no globin chain is synthesized at all and hence
are called ……0
or ….. 0
thalassaemias, whereas in others some amount
of globin chain is produced but at a reduced rate; these are designated as
+ +

79. MOLECULAR ASPECTS
All the globin genes have three
axons (coding regions) and two
introns (non coding regions whose
DNA is not represented in the
finished protein). The initial RNA is
transcribed from both introns and
exons, and from this transcript the
RNA derived from introns is
removed by a process known as
splicing. The introns always begin
with a G-T dinucleotide and end
with an A-G dinucleotide. The
splicing machinery recognizes
these sequences as well as neighbouring conserved sequences.. The
RNA in the nucleus is also ‘capped’ by addition of a structure at the
5/
end which contains a seven methyl- guanosine group. mRNA is
polyadenylated at 3/
end.Thalassaemia may arise from
mutations or deletions of any of these sequences

80. CLINICAL AND GENETIC CLASSIFICATION
OF THALASSAEMIAS
I. BETA (β) THALASSAEMIAS: (Defects in transcription, processing or
translation of beta- globin mRNA
1. Beta Thalassaemia Major:)
-Homozygous state
-Severe anaemia; requires regular blood transfusions
2. Beta Tahlassaemia Minor( Trait)
- Heterozygous state
- Asymptomatic with mild or no anaemia; red cell
abnormalities seen.
- Defects in transcription, processing or translation of
beta- globin m RNA
3. Beta Thalassaemia Intermedia:
-One parent beta thalassaemia minor other parent
contributes a gene which lessens the deleterious effects.
- Severe, but does not require regular blood transfusions.

81. II.ALPHA THALASSAEMIAS: Defect is mainly deletion of
genes
(i) Alpha Thalassaemia Silent Carrier( - α/αα)
Asymptomatic; no red cells abnormality
(ii) Alpha Thalassaemia trait ( -α/-α) or (--/αα)
Asymptomatic like beta thalasseamia trait
(iii) HbH Disease --/-α
Severe resembles beta thalassaemia intermedia
(iv)Hydrops Fetalis (- - / - -)
Lethal in utero

82. BETA (β ) THALASSAEMIA SYNDROMES
Molecular Pathology of Beta Thalassaemia
Defects in Transcription, Processing or Translation of mRNA: The bulk of
eta thalassaemia mutations are single base changes or deletions or insertion
f one or two bases at various points in the genes. These mutations occur in
oth introns and exons ,and also outside the coding region
Deletions: Are rare. A part of mRNA is lost

83. Molecular Pathogenesis of Beta Thalassaemia
- Lesions in Beta Thalassameia – Usually point mutations
- Lesions in Alpha Thalassaemia – Mostly Gene Deletions
Important mutations in Beta Thalassameia are
2.Promoter Region Mutations: Several point mutations within the promoter
sequences reduce binding of RNA ploymerase and therby reduce the
transcription rate 75% to 80%.
›Since sone β globin is synthesized, the patients develop β +
thalassaemia
2. Chain Terminator Mutations : Two types of mutaitons can cause
premature termination of mRNA translation :
(a) A point mutation in one of the exons can lead to the formation
of a stop codon
(b) Single nucleotide substitutions or small deletions alter mRNA
reading frames and nitroduce stop codons downstream that
terminate protien synthesis ( frameshift mutaitons )
› Premature chain terminaiton by either of these mechanisms
geenrates nonfunctional fragments of the β globin gene. leading to β 0
thalassaemia

84. Molecular Pathogenesis of Beta Thalassaemia …contd
3. Splicing Mutations : Mutations that lead to aberrant splicing are the most
common cause of β –thalassaemia .Most of these effect intorn , but som e have
been located within exons.
If the mutation alters the normal splice junctions, splicing does not occur, and
all the mRNA formed is abonrmal. Unspliced mRNA is degraded within nucleus,
and β o
thalassaemia develops
Some mutations affect the intorns at locations away from the normal intron-
exon ssplice junction. These mutations create new sites sensitive to the action of
splicing enzymes at abnormal locations – within an intron , for example. Because
normal splice sites remain unaffected, both normal and abnormal splicing occurs,
giving rise to normal as well as abnormal β - globin mRNA. These patients
develop β +
thalassaemia

85. COMMON BETA THALASSAEMIA MUTAITONS IN
PAKISTAN

86. AUTOSOMAL RECESSIVE DISORDER
BETA THALASSAEMIA
•Mediterranean population, Middle East, India, Pakistan, Southeast
Asia, Southern Russia, China
• Rare in Africa except Liberia and parts of North Africa
• Occurs sporadically in all races
ALPHA THALASSAEMIA
•Widespread in Africa, Mediterranean population. Middle East,
Southeast Asia
THALASSAEMIA – POPULATION GENETICS

87. In Beta Thalassaemia Major there is a total lack or a
reduction in the synthesis of structurally normal beta-
globin chains with unimpaired synthesis of Alpha
chains.

88. Beta Thalassaemia – Clinical Features

89. CLINICAL FEATURES OF BETA
TAHLASSAEMIA MAJOR
1. Severe anaemia with failure to thrive on 3-7 months of
age after birth
2. Enlargement of spleen occurs due to excessive red cells
destruction, extramedullary haemopoiesis and later
because of iron overload. The large spleen increases
blood transfusion requirements due to increased pooling
of blood.
3. Liver also increased in size.
4. Expansion of bones caused by intense marrow
hyperplasia that leads to Thalassaemic Facies and to
thinning of the cortex of many bones with a tendency to
fractures and bossing of the skull .
5. Infections induced by blood transfusion:
- Hepatitis B
- Hepatitis C
- Human Immunodeficiency Virus (HIV)

91. •The facial appearance of a child with beta thalassae-
• mia major: Skull is bossed with prominent frontal
•and parietal bones; the maxilla is enlarged
•The skull X- ray in Beta Thalassaemia
Major: There is a ‘hair –on-end
appearance’ as a result of expansion of
the bone marrow into cortical bone

92. he patient requires regular blood
nsfusions to sustain an acceptable
emoglobin level. But iron overload
used by repeated transfusions is inevit-
e unless chelation therapy (removal of
n) is given. Each 500 ml of transfused
od contains about 250 mg of iron.Iron
m the excessive red blood cells break
wn and increased gastrointestinal iron
sorption also leads to increased iron in
body.
is iron overload then effects different
ans:
Liver: Cirrhosis Fibrosis) will take place.
Endocrine Organs: Accumulation of iron in different organs will lead to
lure of growth, delayed or absent puberty, diabetes mellitus,
pothyroidism and hypoparathyroidism.
Damage to Myocardium can lead to arrhythmias and cardiac failure.
d cardiac damage is the main cause of death

93. LABORATROY DIAGNOSIS OF BETA
THALASSAEMIA MAJOR
1.Peripheral blood film will show severe microcytic and
hypochromic blood picture with marked pokilocytosis
(fragmented red cells; target cells)
2. Reticulocytes count is increased.
3. Peripheral blood shows normoblasts

94. Beta Thalassaemia Major
 Microcytic and
hypochromic blood
picture
 Marked anisocytosis &
Poikilocytosis
 Nucleated RBC
 Fragmented red ells

95. 4. Haemoglobin electrophoresis shows accentuated band
of HbF(Fetal Haemoglobin)
5. Fetal Haemoglibin estimation by alkali denaturation
method (Betke’s method) will show elevated HbF
6. DNA Analysis by Polymerase Chain Reaction (PCR) to
look for molecular lesion (mutation or deletion)
7. Prenatal Diagnosis: During pregnancy fetus can be
diagnosed by taking Chorionic Villus Sample(CVS) of
fetus and then to do PCR to find out that whether
fetus is normal or he is having mutations which can
lead to beta thalassaemia major or minor.
LABORATROY DIAGNOSIS OF BETA THALASSAEMIA MAJOR…..
contd

96. Haemoblobin Electrophoresis on Cellulose Acetate
for Haemoglobin Defects

97. Normal Haemoglobin Electrophoretic Pattern

98. Beta Thalassaemia Minor (Trait)

99. Beta Thalassaemia Major

100. Haemoglobin E trait

101. Haemoglobin D trait

102. Haemoglobin C Trait

103. TREATMENT OF BETA THALASSAEMIA MAJOR
1.Regular blood transfusions are required to maintain the
haemoglobin level over 10 g/dl at all times. This usually requires 2-3
units every 4-6 weeks.
2. Regular Folic Acid 5 mg daily.
3. Iron Chelation Therapy is required to treat iron overload.
It is accompashied by:
(i) Subcutaneous infusion of Desferrioxamine(Desferol)
given through infusion pump at a rate of 20 – 40 mg/kg over 8 to 12
hours 5-7 days weekly.
(ii) Oral Iron Chelator Deferiprone (L 1) & Asunra
4. Vitamin C 200 mg daily, increases excretion of iron produced by
desferrioxamine.
5. Splenectomy, if transfusion requirements are increased. It can
not be employed before the age of 5 years
6. Allogeneic Bone Marrow or Stem Cell Transplant: It is
curative in selected patients

104. •Thalassaemics receiving blood transfusion
at a thalassaemia center

105. BETA THALASSAEMIA MINOR (TRAIT)
It is a heterozygous state. The person is carrying abnormal genes
from one parent and normal from other.
It is a common, usually symptom less abnormality characterized by
a hypchromic,microcytic blood picture (MCV and MCH very low)
with many target cells and minimal anisocytosis. The red cell count
(RBC count) is high (More than 5 X1012
/l, and mild anaemia
(Haemoglobin 10 – 15 g/dl)
The HbA2 level is increased (More than 3.5%; Range 4-6 %)
During periods of stress, such as pregnancy or infection the patient
can become anaemic.
It is important to identify cases of Beta Thalassaemia
Minor in a community where Thalassamia is prevalent
and where there is increased tendency of cousin
marriages, so as to give proper genetic counseling before
marriage

106. D/D OF MICROCYTIC AND HYPOCHROMIC BLOOD PICTURE
Blood film in Beta Thalasaemia
Major: Microcytic and Hypochromic
with fragmented red cells, target
cells and nucleated red cells(normoblasts)
Blood Film in Iron Deficiency
Anaemia: Microcytic and hypochromic blood
Picture with pencil- shape cells
Blood film in Beta Thalasseamia
Minor (Trait): Microcytic and
hypochromic blood picture with many
target cells and absence of
anisocytosis

107. •Iron Deficiency Vs Beta Thalassaemia Trait

108. •Iron Deficiency Vs Beta Thalassaemia Trait

109. Iron Deficiency Vs Beta Thalassaemia Trait
Microcytic hypochromic
morphology of red cells in
proportion to the degree of
anaemia, presence of pencil
shape red blood cells on
peripheral blood, red blood
cells count less than
5.0 millions/cmm and
decreased MCV usually
favours the diagnosis
of iron deficiency anaemia.
Uniformly microcytic
hypochromic blood picture
more pronounced as
compared to the level of
haemoglobin,minimal
anisocytosis , presence
of target shape cells, red
blood cells count more
than 5.0 millions/cmm
and decreased MCV favours
the diagnosis of beta
thalassaemia trait

110. “ More than the calf wishes to
suck does the cow wish to suckle”
Teaching Craze !!!

111. SICKLE CELL ANAEMIA
 Sickle Cell Anaemia or Sickle Cell Disease is an Autosomal
Recessive, Hereditary Haemoglobin disorder.
 The homozygous state is produced due to inheritance of an
abnormal beta globin gene (HbS gene) from both parents.
 The HbS gene is produced by a mutation in beta globin gene,
leading to substitution of Valine for Glutamic Acid at the sixth
position of Beta Globin Chain of Haemoglobin molecule.
Molecular pathology of Sickle Cell Anaemia: There is a single base change in
the DNA coding for the amino acid in the sixth position in the β- globin chain
( Adenine is replaced by Thymine) . This leads to an amino acid change
from Glutamic Acid to Valine

112. This substitution confers abnormal physicochemical
properties to red cells. Under unfavourable conditions,
most importantly hypoxia, the red cells destabilize and
undergo repeated cycles of distortion and
polymerization labelled as sickling.
This ultimately leads to :
(i) Increased destruction of red cells manifesting as
chronic haemolytic anaemia jaundice
(ii) Aggregation of distorted cells in blood
circulation leading to ischemic tissue damage

113. The change from glutamic acid to valine at
position 6 changes the 3-D structure of the
molecule
This makes hemoglobin sticky and changes
the shape of the RBC
It makes the molecule spiky and rigid rather
than round and flexible
The RBC can not move through capillaries

114. PATHOGENESIS OF
SICKLE
CELL DISEASE
On deoxygenation the
HbS molecules under-
go aggregation and
polymerization . This
change converts
haemoglobin from a
freely flowing liquid
to a viscous gel, leading
ultimately to formation of HbS fibers and resultant distortation of the
red cells, which acquire a sickle or holly- leaf shape.
Sickling of red cells is initially a reversible phenomenon; with
oxygenation, HbS returns to the depolymerazid state; However, with
repeated episodes of sickling and unsikling, membrane damage
starts and the cell become irreversibly sickled. . These deformed cells
retain their abnormal shape even they are fully oxygenated and
despite deagregation of HbS .The precipitation of HbS fibers has
deleterious effects on red cell membrane.

115.  The formation of HbS has two major consequences:
(i) A chronic Haemolytic Anameia
(ii) Occlusion of small blood vessels, resulting in
ischemic tissue damage.
Substitution of Valine for Glutmaiic Acid
at the 6th
position of Beta Chain
Revresible Sickling
Irreversible Sickling
Accumulation of sickle aggregates in Loss of red cells membrane
microvasculature
Viscosity of blood increased Excessive Red Cells Breakdown
Blockage of small blood vessels Chronic Haemolytic Anaemia
Tissue Infarction
Acute Crises Chronic Complications

116. VARIABILITY IN SICKLING
Sickle cell anaemia runs an extremely variable clinical
course. At one end of the spectrum it is characterized by a
crippling haemolytic anaemia, on the other end it can have
a milder course. The reasons are only partly understood:
1. Concentration of HbS: Susceptibility to sickling is
proportional to the concentration of HbS. Individuals with
sickle cell trait have less than 50% HbS in their cells and are
virtually without symptoms.
2. Cellular Dehydration: Cellular dehydration such as in
renal papillae will increase sickling
3. Other Haemoglobins: Fetal Haemolgobin inhibit
sickling, while HbC and D can enhance sickling
4. Deoxygenation: It is the most important factor in
determining sickling. Thus travel to high elevations or in
unpressurized aircrafts can precipitate sickling crises.

117. 5. Caliber of blood vessels: In high flow areas the shear
stresses can break down the gel structure of HbS, while in
the small or medium sized blood vessels the sickled red cells
aggregate.
6. Duration of Hypoxia: Areas of vascular stasis (such as
spleen) with lower O2 tension are prone to vascular occlusion
7. Cold Weather: Cold weather may precipitate sickling
because of vasoconstriction
8. Acidosis: Acidosis enhances sickling while alkalosis will
retard sickling
9. Other precipitating factors: Crises are often precipitated
by:
(i) Infections
(ii) Dehydration due to fever and gastrointestinal loss of
fluid
(iii) Acidosis due to poor oral intake

118. CLINCAL MANIFESTATIONS OF SICKLE CELL ANAEMIA
CLINICAL PRESENTATION
•High levels of fetal haemoglobin protect against sickling for the
first
8 to 10 weeks of life. After that the manifestations of
sickle cell disease may become apparent.
•Typically Sickle cell anaemia presents in infancy
with anaemia and jaundice . Most patients go
through the rest of their lives with a chronic
haemolytic anameia
• A common presenting symptom is ‘hand and foot
Syndrome’ which occurs early in infancy and is
characterized by a painful dactylitis and swelling of the
fingers or feet.
•Other particular problems in infancy are splenic
sequestration and fulminent Pneumonia.
Painful swollen fingers
(dactylitis) in a child
Hand Foot Syndrome: There
is marked shortening of the
right middle finger because
of dactylitis

119.  During early development of the disease there is often
splenomegaly . In most patients this gradually resolves
due to repeated infarctions of the spleen (Auto
splenectomy) . Indeed it is most unusual to feel the
spleen after the end of first decade. If a patient has a
palpable spleen after that probably he is suffering from
Sickle Cell – Beta Thalassaemia Disease , i.e., receive
sickle cell gene from one parent and beta thalassaemia
gene from the other parent
• Growth and development are usually normal although
there may be some skeletal deformities, including frontal
bossing of the skull due to expansion of bone marrow.

120. The complications of Sickle Cell Anaemia can be divided into two groups:
1. Acute and Episodic Crises
2. Chronic Complications
I. ACUTE AND EPISODIC CRISES
The word ‘crises’ is used to describe an acute and sometimes life-
threatening complication of sickle cell anaemia. Different crises are:
1.Painful Vaso- occlusive crisis: These are the most common
occurring with a frequency from almost daily to yearly. Tissue
hypoxia and infarction can occur any where in the body. It is
important to carefully evaluate the patient to differentiate painful
crises and pain caused by another process
COMPLICATIONS OF SICKLE CELL ANAMEIA

121. CLINICAL CONSEQUENCES
OF SICKLE CELL DISEASE

122. 2. Aplastic Crises: These occur as a result of infection with Parvo
Virus or Folate deficiency. These are characterized by sudden fall in
haemoglobin, usually require transfusion. They are characterized by
a fall in Reticulocytes and haemoglobin
3. Splenic and Hepatic Sequestration Crises: These are
caused by sickling within organs and pooling of blood, often with a
severe exacerbation of anaemeia. Hepatic and splenic sequestration
crises all may lead to severe illness requiring exchange transfusion .
Splenic sequestration is typically seen in infants and presents with
an enlarging spleen, falling haemoglobin and abdominal pain.
Treatment is with transfusion and patients must be monitored at
regular intervals as progression may be rapid. Attacks tend to be
recurrent and splenectomy is often advised in recurrent cases.
Splenic crises can lead to hypotension and death.
4. Acute Chest Syndrome: Characterized by acute onset of
dyspnoea, with chest pain. It is due to sequestration of sickle cells in
pulmonary arterial circulaition

123. 5. CNS Crises: Patient presents with a stroke, preceded by bizarre
neurological syndromes similar in nature to transient ischemic
attack. It is due to blockage of cerebral vessels by sickle cells.
6. Hyperhemolytic Crises: During painful crises there can be a
marked increase in the rate of haemolysis.
7. Megaloblastic Crises: The haemolytic crises can lead to
megaloblastic crises.
II. CHRONIC COMPLICATIONS
1. Severe Infections: It is the most common cause of death in
sickle cell anaemia and it can be associated with one or more of the
patterns of crises mentioned above. Babies and children with this
disease are particularly prone to develop Pneumococcal Septicemia
due to hyposplenism. Salomonella infections of bone leading to
Salmonella Osteomyelitis is also seen.

124. 2. Infarcts following repeated episodes of vascular occlusion:
Result largely from infarcts following repeated episodes of vascular
occlusions. Almost any organ can be involved Those at particular risk
are those which depend on small blood vessels for their blood supply.
(i) Bone Infarcts: Bones are particularly prone. Aseptic Necrosis of
Femoral or Humeral Head may lead to their destruction and pain.
(ii) Renal Infarcts: Damage to vasa rectae system can lead to a loss of
ability to concentrate urine and polyuria and nocturnal enuresis.
(iii) Pulmonary Infarcts : Occur quite frequently
3. Priapism: Recurrent attacks of painful priapism may lead to
permanent deformity of penis
4. Chronic, relapsing leg ulcers: A major problem
particularly in adults
5. Occular manifestations: Proliferative retinopathy

125. COURSE AND PROGNOSIS
The prognosis seems to depend upon the racial
background of the patient, socioeconomic and ill- defined
genetic factors and above all the availability of good
paediatric care in the early years.
In East Africa USA and Europe it has high mortality in
early years
In Saudi Arabia and India, a particularly mild form of the
condition occurs in which the mortality is extremely low in
childhood and a normal survival seems to be the rule. The
most common causes of death in the first year or two of life
are infections and splenic sequestration. Later in life
infection is still the most frequent cause of death.
If babies are maintained on prophylactic penicillin from
early in life, and if there is good paediatric care, it may be
possible to reduce the early mortality of sickle- cell
anaemia to a very low level

126. LABORATORY DIAGNOSIS OF
SICKLE CELL ANAEMIA
1. Haemoglobin level: The haemoglobin level is usually between
5 to 11 g/dl.
2. Sickle cells on peripheral blood: Considerable variation on red
cells size and shape is noted. Sickled cells and target cells are seen.
It is important to calculate the percentage of sickle cells, as the
number of sickle cells should remain less than 30% .
. Reticulocyte Count: Elevated reticulocyte count ;usually 10 to 20%
4. Screening Test for Sickle Cells: Different substances are used to
induce deoxygenation like:
- Sodium Metabisulphide
- Sodium Dithionite
. Haemoglobin Electrophoresis: In Homozygous state (HbSS) all the
haemoglobin is HbS, no HbA is detected. The amount of HbF is variable.
It is usually between 5 – 15%.

127. Sickle Cell Disease: Homozygous state.
Numerous Crescent Shaped sickle cells are seen.

128. Sickle Cell Test

129. Normal or Alpha
Thalassaemia Trait
Sickle Cell Trait
Sickle Cell Disease
Beta Thalassaemia Trait
Beta Thalassaemia Major
Sickle cell / Beta
Thalassaemia
Sickle cell/ HbC disease
Haemoglobin H Disease
Haemoglobin electrophoretic pattern in normal adult human blood and in
subjects with sickle cell (HbS) trait or disease, beta thalassaemia trait,
beta thalassaemia minor, HbS/beta thalassaemia or HbS/HbC disease

130. Normal Haemoglobin
Electrophoretic Pattern Sickle Cell Disease Sickle Cell Disease
with high HbF

131. 5. Bilirubin level: Is elevated
6. Serum LDH: Is elevated in crises
7. Blood Gases: should be estimated in crises especially to
estimate pCO2
8. Renal Function Tests: To assess for any degree of renal
impairment
9. Prenatal Diagnosis: Prenatal diagnosis is possible by
obtaining fetal chorionic Villous sample (CVS) and the
by performing Polymerase Chain Reaction (PCR)
analysis.

132. POLYMERASE CHAIN REACTION (PCR) FOR SICKLE CELL:
Sickle Cell Anaemia ; Antenatal Diagnosis: Direct DNA analysis. The
DNA has been digested by the restriction enzyme Mst II. The
replacement of an adenine base in the normal beta- globin gene by
thymine in the sickle cell gene removes a normal restriction site for
Mst II, producing a larger 1.3 – kb fragment that the normal 1.1 – kb
fragment to hybridize with the β - globin gene probe. In this case the
trophoblast DNA (T) shows both normal (A) and sickle (S) restriction
fragments and so is AS (sickle trait) , while the case of sickle cell
anaemia (SS) shows only band of HbS

133. SICKLE CELL TRAIT
• This is a benign condition with no anaemia and normal
appearance of red cells on a blood film.
• Screening Tests for Sickle cell are positive
• Haemoglobin electrophoresis will show 25 – 45% HbS,
rest is HbA.
• Haematuria is the most common symptom and is
thought to be caused by infarcts of renal papillae.
• Care must be taken with anaesthesia, pregnancy, at
high altitudes and during strenuous exercises.

134. TREATMENT OF SICKLE CELL ANAEMIA
1. Prophylactic: Avoid those factors known to precipitate crises,
especially:
- Dehydration
- Anoxia
- Infections
- Stasis of circulation
- Cooling of skin surface
2. Penicillin: Early deaths due to infections and crises can be
reduced by the administration of prophylactic oral penicillin.
Oral penicillin (62.5 mg t.d.s up to 1 year of age; 125 mg b.d at 1-3
years of age; 250 mg b.d thereafter) should be started as early as
possible and maintained throughout childhood and early
adolescence.
3. Vaccines: Pneumococcal , Meningococcal and Haemophilus
influenzae vaccines should also be given. As due to loss of
splenic functions body will not be in a position to get rid of
capsulated organisms.

135. 4. Malarial Prophylaxis: Malarial prophylaxis is mandatory for visits to areas
where malaria is endemic
5. Folic Acid: 5 mg daily
6. Blood Transfusions:
•Adaptation to anaemia is particularly successful because of the low oxygen
affinity of HbS.
•Patients with sickle cell anaemia manage well with relatively low haemoglobin
levels. Regular blood transfusion is not required.
•The blood transfusions are sometimes given repeatedly or prophylactically, to
patients:
-who have frequent crises;
-who have had major organ damage, for example of the
brain.
- who have aplastic crisis.
•The aim is to suppress HbS production over a period of several months or even
years.
• To take care of the complications of chronic blood administration:
- Iron Overload
- Viral Infections like Hepatits B , C and HIV
- Alloimmunization to minor blood group antigens

136. 7. Management of Painful Crises: Should be managed in
hospital. Methods employed to manage painful crises are:
- Rest
- Warmth
- Rehydration
(i) Oral fluids
(ii) Intravenous normal saline (3 liters in 24 hours)
- Antibiotics, if infection is present
- Analgesics: Suitable drugs are paracetamol, a non-
steroidal anti-inflammatory agent and opiates, e.g.
continuous infusion of Dimorphine.
- Blood transfusion if severe anaemia
- Exchange blood transfusion – if there is repeated
occurrence of painful crises.

137. 8. Lung Crises: Once suspected patient should be managed in
hospital in intensive care unit. Oxygen should be administered
and blood gase should be monitored.
9. Exchange Transfusion: Exchange transfusion is usually
required under following circumstances in sickle cell anaemia:
- For major surgical emergencies
- For repeated painful crises
- In patients with neurological symptoms
- Visceral damage
- If priapism failed to treat by conservative management.
The aim of exchange transfusion is to decrease the number of sickle
cells less than 30 -40%.
10. Total Hip Replacement: Chronic hip pain and difficulty
with walking due to aseptic necrosis of the femoral heads may
require total hip replacement.
11. Eye changes: Laser therapy

138. 12.Renal problems: Hameaturia and renal failure should be
managed accordingly.
13. Priapism: It occurs quite frequently. It has been found that
nearly two third of major episodes are preceded by ‘stuttering’
attacks and effective therapy at this stage is necessary. Measures
for treating priapism are:
- Stilbestrol – 5 mg daily may be effective in preventing a
major episode of priapism in patients who have minor
episodes.
- Exchange transfusion
- Corporal aspiration with irrigation of normal saline
-Cavernous spongiosum shunt
14. Leg Ulcers: Bed rest; elevation; zinc sulphate dressings.
A transfusion program or skin grafting can enhance healing.

139. 15. Splenectomy
Usually upto the end of first decade there is
autosplenectomy. But in patients who have recurrent attacks of
splenic sequestration syndrome, splenectomy is indicated.
16. Antisickling Agents:
Hydroxyurea: (15.0 to 20.0 mg/kg per day) can increase HbF
level and has been shown to improve the clinical course of
patients who are having three or more painful crises each year. It
should not be used during pregnancy.

140. 17. Stroke:
• As the life expectancy of patients with sickle cell disease increases, more
adults presenting with CNS symptoms can be anticipated.
• Adults are at greater risk for intracranial haemorrhage and children at risk
for ischemic stroke.
• In adults patients with sickle cell anaemia it is important to identify and
address other risk factors for stroke, such as hypertension, abnormal
lipids, diabetes and smoking.
• The clinical presentation of intracranial haemorrhage is usually more
dramatic than that of ischemia and may include severe headache,
vomiting , stupor, coma and haemipresis.
• Blood transfusions and exchange are the main stay of treatment.
• Hydroxyurea has been used for secondary prevention by different groups
and appears promising as an alternative to transfusion in older children
and young adults.
• For transient ischemic attacks Aspirin, Colopidegral, Dupyridamol, along
with Warfarin.
• For ischemic stroke: (i) Tissue Plasminogen (tPA) within 3 hours . Risk of brain
haemorrhage is 6.4%, and out of these half are fatal. (ii) Aspirin – 325 mg one –
time dose within first 48 hours.

141. 18. Bone Marrow OR Stem Cell Transplantation: It can cure
the disease and many patients have now been successfully
treated. The mortality rate is less than 10%. Transplantation is
only indicated in the severest of cases whose quality of life or life
expectancy are substantially impaired
19. Gene Therapy: Hameoglobinopathies like sickle cell anaemia
and beta thalassaemia major are also a target for gene therapy.
Gene therapy with lentivirus vectors has been successful in
sickle transgenic mice. An anti-sickling beta globin gene was
introduced into the sickle transgenic mice. Long term expression
(upto 10 months) was achieved. In addition haematological
parameters correction, inhibition of cellular dehydration and loss
of sickling tendency were also demonstrated.

142. HEREDITARY SPHEROCYTOSIS
Hereditary Spherocytosis is characterized by an
intrinsic defect in the red cell membrane that renders
erythrocytes spheroidal, less deformable, and vulnerable
to splenic sequestration and destruction.
POPLUATION GENETICS
Its prevalence is high in North Europe. In
approximately 75% of cases, the inheritance is Autosomal
Dominant . The remaining have an autosomal recessive
form of the disease that is much more severe than the
autosomal dominant form

143. MOLECULAR
PATHOLOGY
OF HEREDITARY
SPHEROCYTOSIS(HS)
e spheroidal shape of
d blood cells is
aintained by some
egral proteins in its
embrane. In HS
netically there are
utations in any of
ese proteins. The
portant membrane
otein abnormalities in association with Hereditary Spherocytosis are:
•Spectrin deficiency or mutations
• Ankyrin deficiency or mutations
•Pallidin (Protein 4.2) abnormalities
A deficiency of Spectrin seems to be most common abnormality in all
tients with Hereditary Spherocytosis. Spectrin deficiency is associated with
duced membrane stability and loss of membrane fragments as the cells are
posed to shear stresses in the circulation. The resulting reduction in cell
rface to volume ratio “forces” the cells to assume the smallest possible
ameter for a given volume namely ,a sphere

144. As these spherocytes are trapped in the sluggish circulation of
spleen then the deformed red cells are destroyed and engulfed by
phaogocytic cells (macrophages). The cardinal role of spleen in
the premature demise of the spherocytes is proved by the
invariably beneficial effect of splenectomy .
Red cells membrane proteins defects
Destabilization of red cell membrane
Loss of red cells membrane
Formation of Spherocytes
Entrapment of Spherocytes in sluggish splenic circulation
Phagocytosis of spherocytes by macrophages

145. CLINICAL FEATURES OF HEREDITARY
SPHEROCYTOSIS
•The characteristic clinical features of Hereditary
Spherocytosis are :
- Anaemia
- Splenomegaly
- Jaundice
• The severity of the disease varies from patient to patient.
The anaemia may present at any age from neonatal ( rarely
as a case of neonatal jaundice), to infancy to adult hood to
old age.
• Jaundice is typically fluctuating.
• In 20% to 30% the disease is largely asymptomatic.
• Splenomegaly occurs in most patients
• Pigment gall stones, derived from bilirubin released after
red cells breakdown, are frequent
• Aplastic crises, usually precipitated by parvovirus infection,
may cause a sudden increase in severity of anaemia

146. LAB DIAGNOSIS OF HEREDITARY
SPHEROCYTOSIS
1. Anaemia is usual but not invariable.
2. Reticulocyte Count: Increased
3. Blood Film: Shows Microspherocytes
which are densely staining red cells
with smaller diameter then normal
red cells.
HS: Note the anisocytosis and several
dark- appearing spherocytes with
no area of central pallor
Deeply staining spherocytes with
large polychromatic cells
(reticulocytes)

147. LAB DIAGNOSIS OF HEREDITARY
SPHEROCYTOSIS. contd
4. Serum Bilirubin Increased (indirect
Hyperbrubinemia)
5. Ultrasound abdomen: To rule out gall stones
6. Osmotic Fragility Test: To demonstrate the
increased fragility of spherocytes. The red cells
lyse in hypotonic saline solutions.

148. TREATMENT OF HEREDITARY SPHEROCYTOSIS
1 .Splenectomy: It is the principal form of treatment. It should
not be performed unless clinically indicated because of severe
anaemia or gall stones.
It is preferable to perform Splenectomy after the age Of 5 years.
It will produce a rise in haemoglobin level to normal.
Spherocytes will remain.
2. Folic Acid: In severe cases to prevent folate deficiency.

149. GLUCOSE – 6 – PHOSPHATE DEHYDROGENASE
DEFICIENCY
The erythrocyte and its membrane are vulnerable to injury by exogenous
and endogenous oxidants. Abnormalities in the Hexose monophosphate
shunt or in Glutathione metabolism resulting from deficient or impaired
enzyme function reduce the ability of red cells to protect themselves against
oxidative injuries and lead to Hemolytic Anaemia. The most important of
these enzyme derangements is Deficiency of Glucose – 6 – Phosphate
Dehydrogenase(G6PD) activity.G6PD reduces
NADP to NADPH while oxidizing glucose -6-
phosphate. NADPH then provides the
reducing power that converts oxidized
glutathione to reduced glutathione. The
reduced glutathione so generated protects
against oxidant injury by catalyzing the
breakdown of oxidant compounds
like H2 O2

150. ant G6PD gene
ient or Decreased production
of G6PD Enzyme
ility of glucose 6 phosphate
dize into 6- phospohgluconate
re of reduction of NADP to NADPH
re of NADPH to reduce oxidized
Glutathione
e to breakdown oxidants like HH22 OO22
ased Red cell Susceptibility to get
maged by different Oxidants
ions and other oxidants causes oxidation of sufhydryl groups of the globin chains
uration of hemoglobin and formation of precipitates (HEINZ BODIES)
Bodies get attached with red cells m membrane
d Cells break down (Haemoyltic Anaemia)

151. POPULATION GENETICS
• Sex Linked (x- Linked) : Males are affected
•The inheritance is sex-linked, affecting males, and females are carriers.
The female carriers show approximately half normal red cell G6PD
values.
• The main races affected are in West Africa, the Mediterranean, the
Middle East and South East Asia. The degree of deficiency varies,
often being mild (10 – 15% of normal activity) in Black Africans, more
severe in Orientals and most severe in Mediterranean's. Severe
deficiency occurs occasionally in white people
• G-6-PD DEFICIENT VARIANTS: More than 400 deficient variants
due to pint mutation or gene deletion are identified. G6PD type B is
the most common. The others are G-6PD A-
and G6PD Mediterranean

152. AGENTS WHICH MAY CAUSE HAEMOLYTIC ANAMEIA
IN GLUCOSE -6- PHOSPHATE DEHYDROGENASE
DEFICIENCY
I. Infections and other acute illnesses:
Diabetic ketoacidosis
II. Drugs :
-Antimalarials: Primaquine, Pamaquine, Chloroquine, Fansidar,
Maloprim
-Sulphonamides and Sulphones, e.g., Cotrimaxazole
- Other Antibacterials – Nitrofurantoin, Chloramphenicol,.
-Analgesics – Aspirin, Phenecitin
- Miscellaneous – Naphthol, Naphthalene (moth balls), Vitamin K
analogues.
III. Fava beans (possibly other vegetables)
(Usually the patient having a deficiency of G6PD is
asymptomatic, but when ever he is exposed to an oxidant stress
(drugs,fava beans or infections) haemolytic anaemia will take
place)

153. CLINCAL FEATURES OF G-6-PD DEFICIENCY
 The haemolysis in G-6-PD is both intravascular and
Extravascular.
 The clinical presentation can be of three types:
1. Acute Haemolytic Anameia: It is the most common
presentation. There is rapidly developing intravascular
haemolysis with haemoglobinuria, hemoglbinemia and sudden
fall in haemoglobin level, which is precipitated by infection and
other acute illnesses, drugs or the ingestion of fava beans. The
anaemia may be self limiting as new red cells are made with near
normal enzyme levels
2. Neonatal Jaundice:
3. Continuous congenital haemolytic anaemia: Very rare.

154. LABORATORY DIAGNOSIS OF
G- 6 PD DEFICIENCY ANAEMIA
Red cells showing loss of cytoplasm with
separation of remaining haemoglobin from
cell membrane Blister cells or Bite Cells)
“Bite cell” in the center and supravital stain
showing Heinz Bodies
1. Between crises blood count is
normal.
2. Screening Tests: Different screening
tests can demonstrate the ability of
G6PD to reduce NADP
3.G6PD Assay: Quantitative
assessment of G6PD levels in red cells.
4. “Blister Cells” or “Bite cells”: These
are the cells in which Heinz bodies
are removed by spleen.
5. Demonstration of Heinz Bodies:
Heinz bodies are formed by denatured
haemoglobin. Can be seen in
reticulocyte stain.
6.Features of Intravascular
Haemolysis: Haemoglobinuria.
7 Hyperbilirubinemia: Indirect Bilirubin
is increased

155. TREATMENT OF G-6-PD DEFICIENCT ANAEMIA
1. The offending drug is stopped.
2. Any underlying infection is treated.
3. A high urine output is maintained.
4. Blood transfusion undertaken where necessary for severe anaemia
5. G-6PD deficient babies are prone to neonatal jaundice and in
severe cases phototherapy and exchange transfusion may be
needed.

156. Malignancies
Of
Haemopoietic
System

157. Main Type Sub Type
I LEUKAEMIAS 1. Acute Leukaemia
(i) Acute Lymphoblastic Leukaemias(ALL)
L1 ; L2 ; L3
(ii) Acute Myeloid Leukaemias(AML)
M0; M1; M2; M3; M4; M5; M6; M7
2. Chronic Leukaemia
(i) Chronic Myeloid Leukaaemia(CML)
(ii) Chronic Lymphocytic Leukaemia(CLL)
II PLASMA CELL
DYSCRASIAS
Multiple Myeloma and other plasma cell dyscrasia
III MYELOPROLIFRATIV
E DISORDERS
1. Chronic Myeloid Leukaemia
2. Polycythemia Rubra Vera
3. Essential Thrombocythemia
4. Myelofibrosis
IV LYMPHOMAS 1. Non – Hodgkin's Lymphomas
(i) B – Cell (ii) T- Cell
2. Hodgkin’s Lymphoma
(i) Lymphocyte Predominant (ii) Lymphocyte Rich(iii)
Lymphocyte Depleted (iv) Mixed Cellularity (v)
Nodular Sclerosis

158. LEUKAEMIAS
The leukaemias are group of disorders
characterized by the accumulation of
malignant white cells in the bone marrow
and blood
Neoplastic proliferation of cells of
haemopoetic origin which arises after
somatic mutation in a single haemopoetic
stem cell, the progeny of which forms a
clone of leukaemic cells.

159. CLASSIFICATION OF LEUKAEMIAS
Leukaemias are mainly classified into four types – Acute
and Chronic leukaemias which are further subdivided into
Lymphoid and Myeloid.
Leukaemia
Acute Chronic
Lymphoid Myeloid Lymphoid Myeloid
ACUTE LEUKAEMIA:
Acute Myeloid Leukaemia : M 0 to M7
Acute Lymphoblastic Leukaemia: L1 to L3
CHRONIC LEUKAEMIAS:
Chronic Myeloid Leukaemia
Chronic Lymphocytic Leukaemia

160. Incidence of Different Types of Leukaemias
According to Age
• ALL is predominantly a childhood disease
• CLL occurs mainly in the elderly
• AML and CML have a wider age distribution.

161. Classification OF ACUTE LEUKAEMIAS
 Acute Leukaemia is defined as the presence of over 30%
blast cells in the bone marrow at the time of presentation
 It is further subdivided into Acute Myeloid Leukaemia
(AML) and Acute Lymphoblastic Leukaemia (ALL) on the
basis of whether the blasts are shown to be myeloblasts or
lymphoblasts.
Acute Leukaemias are usually aggressive disease in which
the malignant transformation causes accumulation of early
bone marrow haemopoietic progenitors , called blast cells.
The dominant clinical feature of these diseases is usually
bone marrow failure caused by accumulation of blast cells. If
untreated these diseases are usually fairly rapidly fatal.

162. Clinical features to some extent are helpful in the
differentiation of ALL and AML, but are not definitive.
The age profiles of acute luekaemias are distinctive. ALL
has a peak in childhood and AML in adult age. The
overlap is such, that age is not a useful criterion in
classifying leukaemias.
Significant lymph node enlargement (diameter
exceeding 2 cm) is more common in ALL than AML.
Solid masses of leukaemic cells (Chloromas or
Granulocytic Sarcomas) are indicative of AML.
Extensive involvement of gums is seen characteristically
in Acute Moncytic Leukaemia (M4 or M5)

163. MORPHOLOGIC APPROACH TO ACUTE LEUKAEMIAS
The experienced morphologist can classify about 70% of acute
leukaemias as either ALL or AML by the blast appearance on
routine haematology stains (Romanosky stain) , on the basis of
nuclear or cytoplasmic features. For the rest of the cases
different diagnostic modalities are employed to make a
diagnosis.
The modalities which can be used to diagnose haematological
malignancies are:
1. Routine haematological stains: On the basis of that the
lineage of abnormal cells can be determined in 70% of cases
2. Cytochrmistry or Special stains: There are different
special stains for every specific cell type
3. Monoclonal antibodies or CD (Cluster Differentiating)
markers: Specific antibodies for every lineage are used. They
are employed by two ways:
(i) Immunocytochrmistry
(ii) Flowcytometery

164. DIFFERENCES BETWEEN LYMPHOBLAST AND MYELOBLAST
LYMPHOBLAST MYELOBLAST
Size: Smaller as compared to
myeloblast
Larger than lymphoblast
Nuclear Chromatin: More clumped
and irregularly distributed
Chromatin is fine, delicately stippled
or lacy, and evenly distributed
Nucleoli: May be indistinct or
number varies from 1 to 2 . There is a
condensation of chromatin along
with the nuclear and nucleolar
membrane
Nucleoli are single or multiple and
are usually prominent. Nuclear and
molecular membranes are indistinct.
Nuclear outlines: May be folded or
convoluted.
-
Amount of Cytoplasm: Scant Abundant cytoplasm, as compared to
lymphoblast
N:C Ratio: Very high High

165. Granules in Cytoplasm: Absent May be present
Auer Rods Absent Present
Accompanying cells: - Maturing cells of myeloid series may
be seen
Cytochrmistry or Special Stains:
• Acid Phosphatase (ACP) stain:
Positive in T-ALL
• Periodic Acid Schiff (PAS) stain:
Positive in B - ALL
•
•Sudan Black B stain:
Positive in M1, M2, M3,M4
• Non Specific Esterase (ANAE):
Positive in M4 and M5
Flowcytometery and
Immunocytochemistry:
Will show T- Lymphoid or B-
Lymphoid markers
T – ALL: CD 3 ; CD7
B- ALL: CD 19; CD22; CD10
Will show Myeloid or Moncytic or
Megakaryocytic markers
CD Marker for Myeloid series:
CD 13; CD33

166. Lymphoblasts VS Myeloblasts
A: Lymphoblasts have fewer nucleoli than myeloblasts,and the nuclear
chromatin is more condensed. Cytoplasmic granules are absent
B: Myeloblasts have a delicate nuclear chromatin, prominent nucleoli,
and fine azurophilc granules in the cytoplasm

167. Leukaemia Diagnosis: First Routine Stain

168. Second: Cytochemistry
Acid Phosphatase Periodic Acid Schiff
Sudan Black
Alpha Nephythyl Acetate Esterase

169. Third: CD Markers
Flowcytometery
Immunocytochemisrtry

170. Fourth :Cytogenetics

171. Acute LeukemiaAcute Leukemia
CYTOCHEMICAL PROFILES IN ACUTE LEUKEMIACYTOCHEMICAL PROFILES IN ACUTE LEUKEMIA
MPO & Sudan Black B NSE PAS
AML + + ±
(Monocytic, diffuse)
ALL - ± +
(Focal)
(75%)
+, positive; -, negative; ±, not definitive.
NSE: Non Specific Esterase
PAS: Periodic Acid Schiff

172. Immunologic Markers for Classification of ALL and AML
AML
ALL
Marker Precursor T cell* T cell
B Lineage
CD 19 - + -
CD 22 - + -
CD 10 - +or - -
T Lineage
CD 7 - - +
CD 3 - - +
tdT* - + +
Myeloid
CD 13 + - -
CD 33 + - -
Glycophorin +(M6) - -
CD 41 +(M7) - -
Myeloperoxidase +(M0)
*B-ALL resembles precursor B-ALL immunologically,but has surface Ig and is tdT negative

174. FAB Classification of Acute Lymphoblastic leukaemia
ALL – L1: Small monomorphic blasts with high N:C ratio
ALL – L2: Large. hetrogenous,nucleolated , low N:C ratio
ALL - L3: Burkitt type , basophilic and vacuolated
cytoplasm.
The L1 blast show uniform, small uniform, small blast
cells with scanty cytoplasm.
The L2 type comprise mixed population of small and
large blasts with more prominent nucleoli and cytoplasm.
The L3 blasts are large with prominent nucleoli.
strongly basophilic cytoplasm and cytoplasmic vacuoles.
FRENCH AMERICAN AND BRITISH (FAB)
CLASSIFICATION OF ACUTE LYMPHOBLASTIC
LEUKAAEMIAS

175. Acute Lymphoblastic Leukaemia:
FAB Type ALL – L1
Lymphoblasts show monomorphic
appearance, very high N:C ratio;
Nucleoliare indistinct; Chromatin is
course and there is condensation
of chromatin along nuclear membrane

176. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE LYMPHOBLASTIC LEUKEMIAACUTE LYMPHOBLASTIC LEUKEMIA
L1 - small cells with scant cytoplasm, regular
nuclear contours with occasional clefting, and scant
cytoplasm.

177. Acute Lymphoblastic Leukaemia FAB Type ALL – L2
Large Heterogeneous population of blast cells; Nucleolated;
Low N: C ratio.

178. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE LYMPHOBLASTIC LEUKEMIAACUTE LYMPHOBLASTIC LEUKEMIA
L2 - Large cells with variable cytoplasm, irregular
nuclear contours with clefting, and prominent one or
more nucleoli.

179. Acute Lymphoblastic Leukaemia FAB Type ALL – L3:
Lymphoblasts with strongly basophilic cytoplasm and showing
vacuolation.

180. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE LYMPHOBLASTIC LEUKEMIAACUTE LYMPHOBLASTIC LEUKEMIA
L3 - Medium to large cells
with moderately
abundant intensely
basophilic cytoplasm
and prominent
cytoplasmic vacuolation,
regular nuclear contours,
prominent nucleoli.

181. Acid Phosphatase staining in ALL: Showing cytoplasmic positivity; Localized
staining in the Golgi zone. Reaction is typical of T- ALL

182. Periodic Acid Schiff (PAS) stain in Acute Lymphoblastic Leukaemia
Block Positivity of Cytoplasm. Typical of B- ALL

183. FRENCH AMERICAN BRITISH(FAB)
CLASSIFICATION OF ACUTE MYELOID
LEUKAEMIA(AML)
AML – M0 : Undifferentiated Myelobalastic leukaemia ;
require cell markers.
AML – M1: Myeloblastic without maturation; requires
peroxidase stain or Sudan Black B stain
AML – M2: Myeloblastic with maturation
AML – M3: Acute Promyelocytic Leukaemia;
Hypergranular promyelocytes
AML – M3 VARIENT: Micro or Hypogranular
promyelocytes
AML – M4: Acute Myelomoncytic leukaemia; with both
granulocytic and monocytic maturation
AML – M5: Acute Monoblastic Leukaemia
AML – M6: Erythroleukaemia
AML – M7: Acute megakaryoblastic Leukaemia

184. AML – M0. Undifferentiated blasts which are negative with cytochrmical
reactions for AML(Sudan Black B and ANAE) and positive with antibodies
against myeloid antigens :CD13 and CD33. Morphologically these blasts
resemble L2 type but this case is not ALL because all lymphoid markers
(B and T ) were negative .

185. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
AML-M0
• Large agranular blasts.
• Myeloperoxidase
negative or <3% +.
• CD13 and/or CD33 +.
• B and T-lineage
markers are negative.

186. AML – M1: AML without maturation; 20% of cases ; Very immature
but > 3% are Sudan Black B or myeloperoxidase positive; Few granules
or Auer rods and little maturation beyond the myeloblast stage
AML – M1: Auer rod highlighted by the peroxidase cytochemical reaction
(peripheral blood)

187. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
AML-M1
• A/granular blasts, >90% of
non-erythroid cells.
• At least 3% are
myeloperoxidase or Sudan
black +.
• Remaining 10% or less cells
are maturing granulocytes.
Auer Rod

188. AML – M2: AML with Maturation; 30 -40% of cases; Full range of
myeloid maturation through granulocytes. Auer rods present in
most cases. Presence of t (8 ; 21) defines a prognostically favourable
subgroup.

189. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
AML-M2
• A/granular blasts, from
39-80% of non-
erythroid cells.
• Monocytic cells <20%.
• Granulocytes
(promyelocytes to
neutrophils >10%).

190. AML – M2 (Sudan Black B): Strong positivity in cytoplasm

191. AML – M3:Acute Promyelocytic leukaemia; 5 – 10 % of cases;
Majority of cells are hypergranular promyelocytes; often with many
Auer rods per cells; Aggregates of Auer rods (Faggots) can also
be seen; Patients are younger in age (median age 35 – 40 years) and
often develop Disseminated Intravascular Coagulation (DIC). The t (15
; 17 ) is characteristic.
Aggregates of Auer Rods

192. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
AML-M3
• Majority of cells are
abnormal
promyelocytes.
• Faggot cells (cell with
bundles of Auer rods).
• Microgranular variant
also occurs.

193. AML – M3 variant: Acute Promyelocytic Leukaemia – Variant;
Micro or Hypogranular bilobed promyelocytes

194. AML – M4: Acute Myelomoncytic Leukaemia with both granulocytic and
monocytic maturation.15 – 20% of cases; Myelocytic and monocytic
differentiation evident; Myeloid elements resemble M2 AML.
Monoblasts are positive for nonspecific esterases.

195. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
• AML-M4
• Myeloblasts and
monoblasts are >30%.
• Myeloblasts and
granulocytes are 20-80%.
• Monocytic cells >20%.
• PBM >5.0 x 109/L.
• AML-M4Eo

196. AML – M4: Both Sudan Black B ( left) and Non Specific Esterase -
- ANAE (right) are positive

197. M5a Acute Monoblastic Leukaemia without maturation in which
more than 80% of blasts are monoblasts

198. M5b Acute Monoblsatic Leukaemia with Maturation less than
80% of blasts are monoblasts.

199. AML – M5b: Strong Non Specific Esterase (ANAE) reaction

200. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
AML-M5
• 80% of non-erythroid
cells are of monocytic
lineage.
• M5a (80% monoblasts).
• M5b (<80% monoblasts).

201. AML –M5a subtype: A peripheral smear shows one monoblast and five
promonocytes with folder nuclear membranes

202. AML – M6 Acute Erythroleukaemia; 5% of cases ; Dysplastic ereythroid
precursors (some megaloblatoid, others with giant or multiple nuclei)
predominate , and within the nonerythroid cells, >30% are
myeloblasts; seen in advanced age.

203. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
AML-M6
• >50% of all nucleated
marrow cells are of
erythroid lineage.
• 30% of the non-erythroid
cells are blasts.

204. AML – M6

205. AML – M7 : Acute Megakaryocytic Leukaemia; constitute 1% 0f cases; Blasts
of megakaryocytic lineage predominate; Appearance of blasts is like
lymphoblasts with budding cytoplasm; Platelets appear to shed out from
the cytoplasm; Cytoplasmic blebs are PAS and ANAE positive; Blasts react
with platelet specific antibodies GP IIb/ IIIa;. Myelofiborsis or increased
marrow reticulin seen in most cases;

206. Acute Leukemia - MorphologyAcute Leukemia - Morphology
ACUTE MYELOGENOUS LEUKEMIAACUTE MYELOGENOUS LEUKEMIA
AML-M7
• At least 30% of nucleated
cells are blasts.
• The blasts demonstrate
platelet peroxidase by EM
or IHC.

207. INCIDENCE OF ACUTE LYMPHOBLASTIC
LEUKAEMIA
Acute Lymphoblastic Leukaemia is
the common form of leukaemia in
children
Its incidence is highest at 3 – 7 years,
falling off by 10 years.
There is a lower frequency of ALL
after 10 years of age with a secondary
rise after the age of 40.

208. CLINICAL FEATURES OF
ACUTE LYMPHOBLASTIC
LEUKAEMIA
Clinical features are secondary to the following:
1. Bone Marrow Failure leading to:
- Anaemia (pallor; lethargy; dyspnoea)
- Neutropenia (fever; malaise; features of mouth ,
throat, skin, respiratory, perianal or other infections)
- Thrombocytopenia (spontaneous bruises; purpura;
bleeding gums and menorrhagia)
2. Organ infiltration – tender bones, lymphadenopathy,
moderate splenomegaly, hepatomegaly
If CNS involvement then headache, nausea,
vomiting blurring of vision and diplopia

209. Purpura over the lower limbs in a
Patient with acute leukaemia

210. Marked cervical lymphadenopathy
in in a patient with Acute Lymphoblastic
Leukaemia

211.  Haematological investigations reveal normocytic and
normochromic anaemia
 Thrombocytopenia in most cases
 Total Leucocytes Count (TLC) may be decreased,
normal or increased to 200 X 10 9
/l or more
 The blood film typically shows a variable numbers of
blast cells
 The bone marrow is hypercellular with >30%
leukaemic blasts.
 Blast cells are characterized by morphology,
cytochemistry, immunological markers and cytogenetic
analysis
Lab Diagnosis of Acute Lymphoblastic Leukaemia

212. Lab Diagnosis of Acute Myeloid Leukaemia
 Haematological investigations reveal a normochromic
normocytic anaemia
 Thrombocytopenia in most cases
 Total Leucocytes count (TLC) is usually increased and
blood film examination typically shows a variable
numbers of blast cells
 The bone marrow is hypercellular and typically contains
many leukaemic blasts(> 30%)
 Blast cells are characterized by morphology,
cytochemistry, immunological markers and cytogenetic
analysis
 Tests for DIC are often positive in patients the
promyelocytic variant of AML

213. Prognostic Factors in Acute Lymphoblastic Leukaemia
Determinant Favourable Unfavourable
Age 3-7 yrs <1, >10 yrs
Sex Female Male
Race White Black
WBC Count <10 X 10 9
/l >50 X10 9
/l
Time of Remission <14 days >28 days
Organomegaly Absent Massive
Mediastinal mass Absent Present
CNS Leukaemia Absent Present
FAB Morphology L1 L2,L3
Immunophenotype Early Pre B cell T-cell,B-cell
Cytogenetics Hyperdiploidy Pseudodiploidy
t(9;22)
t(8;14)
t(4;11)
t(14q+
)

214. INCIDENCE OF ACUTE MYELOID
LEUKAEMIA
Acute Myeloid Leukaemia occurs in all age groups. It is
the common form of acute leukaemia in adults and is
increasingly common with age.
AML forms only a minor fraction (10 – 15%) of the
leukaemia in childhood.

215. CLINICAL FEATRUES OF ACUTE MYELOID
LEUKAEMIA
 Clinical features resemble those of Acute Lymphoblastic Leukaemia.
 Anaemia and Thrombocytopenia are often profound.
 A bleeding tendency and disseminated intravascular coagulation
(DIC) is characteristic of the M3 variant of AML.
 Tumour cells can infiltrate a variety of tissues . Gum hypertrophy and
infiltration , skin involvement and CNS
disease are characteristic of Myelomoncytic
 (M4) and monocytic (M5) types.
An isolated mass of leukaemic blasts is
usually referred to as a granulocytic sarcoma.

216. Leukemic infiltrates in gums in AML-M5

217. Mediastinal widening in a 4-year-old boy with ALL
Mediastinal Widening in ALL

218. TREATMENT OF ACUTE LEUKAEMIAS
General Supportive Treatment:
Blood products support to treat anaemia and
thrombocytopenia.
 Antibiotic coverage to treat infections.
Insertion of central venous catheter (Hickman) via a
skin tunnel from the chest into the superior vena cava to
give access for giving chemotherapy , blood products,
antibiotics, intravenous feeding, etc.
 Prevention of vomiting.

219. SPECIFIC TREATMENT OF ACUTE LYMPHOBLASTIC
LEUKAEMIA
I.CHEMOTHERAPY: Induction
Intensification / CNS directed phase
Interim Maintenance I
Delayed Intensification I
Interim Maintenance II
Delayed Intensification II
Maintenance Chemotherapy
II.BONE MARROW OR PERIPHERAL BLOOD STEM CELL
TRANSPLANT:
In most children it is usual to attempt to cure without transplant. It
is reserved for patients with poor prognostic factors

220. SPECIFIC TREATMENT OF ACUTE MYELOID
LEUKAEMIA
Induction
Consolidation
Consolidation
Possible stem cell Further consolidation
transplantation

221. CHRONIC LEUKAEMIAS
The chorinc leukameias are distinguished from acute
leukaemias by their slow progression.
Chronic leukaemias can be broadly subdivided
into :
(i) Chronic Myeloid Leukaemia
(ii) Chronic Lymphocytic leukaemia

222. ACUTE LEUKAEMIA CHRONIC
LEUKAEMIA
Leukemic cells do not
differentiate
Leukaemic cells retain
ability to differentiate
Bone marrow failure Proliferation without
bone marrow failure
Rapidly fatal if
untrateated
Survival for a few years
Potentially curable Not presently curable
without bone marrow
transplant
Acute leukaemia Vs Chronic Leukaemia

223. CHRONIC MYELOID
LEUKAEMIA(CML)
 The disease occurs in either sex (male : female) ratio of
1.4:1), most frequently between the ages of 40 and 60 years.
However it may occur in children and neonates, and in
very old.
 In most cases there are no predisposing factors but the
incidence was increased in survivors of the atom bomb
exposures in Japan.
CLINICAL FEATURES
The clinical features of Chronic Myeloid
Leukaemia include:
1.Symptoms related to hypermetabolism, eg.,
weight loss, lassitude, anorexia or night sweats.
2. Splenomegaly is nearly always present and is frequently
massive.

224. 3. Features of anaemia may include pallor, dyspnoea, and
tachycardia.
4. Bruising, epistaxis, menorrhagia or haemorrhage from
other sites because of abnormal platelet function.
5. Gout or renal impairment caused by hyperuricaemia
from excessive purine breakdown may be a problem.
6. In many patients diagnosis is made incidentally from
a routine blood count

225. Massive splenomegaly in chronic myeloid leukaemia. The
palpable margins of the spleen are indicated

226. LABORATORY FINDINGS IN CHRONIC MYELOID
LEUKAMEIA
White blood cell count : markedly increased. Usually more
than 50 X 10 9
/l.
On differential cell count a complete spectrum of myeloid cell
is seen in the peripheral blood. The levels of Neutrophils and
Myelocytes exceed those of blast cells and promyelocytes
Bimodal peak of neutrophils and myelocytes)
Peripheral blood film in CML showing
leucocytosis alongwith immature
forms of Myeloid series

228. Promyelocyte
Myeloblast
Neutrophil
Myelocyte
Metamyelocyte

229. 3. Increased circulating Basophils.
4. Normocytic and normochromic anaemia
5. Platelet count may be increased ( most frequently), normal
or decreased.
6. Neutrophil alkaline Phosphatase score (NAP ) is invariably
low.
7. Bone marrow is hypercullar with granulopoieitc
predominance.
8. Demonstration of Philadelphia Chromosome on
cytogenetic analysis of blood or bone marrow.
It is a reciprocal translocation between chromosome
between 9 and 22 – t(9;22)

230. Philadelphia Chromosome
Karyotype showing the t ( 9:22)
The Ph chromosome is arrowed

231. 2 3 4 51
7 8 9 10 11 126
13 14 15 16 17 18

232. The Philadelphia Chromosome:
a) There is a translocation of the long
arm of chromosome 22 to the long arm
of chromosome 9 and reciprocal
translocation of the long arm of
chromosome 9 to chromosome 22.
This reciprocal translocation brings most
of the ABL gene into the BCR region of
chromosome 22(and part of the BCR
gene into juxtaposition with the
remaining portion of ABL on chromosome
number 9.
b) The breakpoint in ABL is between exons
1 an 2. The breakpoint in BCR is at one of
the points in the major breakpoint cluster
regions m- BCR.
c)This results in a 210 – kDa fusion protein
product derived from the BCR- ABL fusion
gene.

233. Phases of CML
1. Chronic Phase of CML
2. Accelerated phase of CML
3. Blast Crisis in CML
- Myeloid Blast Crisis(80%)
- Lymphoid Blast Crisis(20%)