1. APPROACH TO HEMOLYTIC ANEMIA
Dr NAGLAA MAKRAM
CONSULTANT CLINICAL PATHOLOGY

2. OBJECTIVES
 Lab indication of hemolysis
 Intravascular v/s extravascular hemolysis
 D/D of hemolytic anemia
 Diagnose hemo. anemia with peripheral smear &
ancillary lab tests

3. 1ST STEP IN APPROACH TO HAEMOLYTIC
ANEMIA
1. Check the reticulocyte count to determine if the
anemia is from decreased production
(“hypoproliferative”, “reticulocytopenic”) or
increased destruction (“hemolytic”)/acute blood loss
(“reticulocytosis”)
3. If the the reticulocyte count is increased-
 Check a direct Coomb’s test
4. Look at the peripheral blood smear to
confirm/support the diagnosis

4. ANEMIA ALGORITHM, CONTINUED
 Patient with anemia and increased reticulocyte count-
What is the result of a Coomb’s test ??
Extrinsic red cell
defect
Vessel Valve
Toxin
Negative Positive
(autoimmune hemolytic anemia)
Intrinsic red cell
defect
Membrane
Hemoglobin
Cytoplasm
“Warm” “Cold”

5. Random hemolysis :—
In addition to the death of aging (senescent) red blood cells (RBCs), there is
age-independent RBC destruction (random hemolysis) in normal subjects in
range of less than 0.05 to 0.5 percent per day.
When hemolysis occurs, the degree of anemia is minimized by a
compensatory increase in the secretion of erythropoietin (EPO), which
enhances RBC production.
This response is manifested initially by an increase in the reticulocyte
percentage and absolute reticulocyte count, followed by an increase in
hemoglobin (Hgb) concentration.

6. HOW IS HEMOLYTIC ANEMIA DIAGNOSED?
Two main principles
 One is to confirm that it is hemolysis
 Two is to determine the etiology

7. FINDINGS IN HEMOLYTIC ANEMIA
HEMOGLOBIN FROM NORMAL TO SEVERELY REDUCED
MCV USUALLY INCREASED
Reticulocyte count and RPI Increased
Serum Unconjugated Bilirubin Increased
Serum LDH 1: LDH 2 Increased
Serum Haptoglobin Decreased
Urine Hemoglobin Present
Urine Hemosiderin Present
Urine Urobilinogen Increased
Cr 51 labeled RBC life span Decreased
Acid hemolysis test (PNH)

8. LAB FINDINGS AND INVESTIGATIONS
Assess Iron Overload via :
• Serum iron level is elevated, with saturation as high as
80%.
• ferritin and transferrin – elevated
• Aim: Serum ferritin <1000ng/ml.
 Red cell phenotyping (ideal)–transfusion

9. Extravascular Intravascular
HEMATOLOGIC
Routine blood film
Reticulocyte count
Bone marrow examination
Polychromatophilia
Erythroid hyperplasia
Polychromatophilia
Erythroid hyperplasia
PLASMA OR SERUM
Bilirubin
Haptoglobin
Plasma hemoglobin
Lactate dehydrogenase
Unconjugated
, Absent
N/
(Variable)
Unconjugated
Absent
(Variable)
URINE
Bilirubin
Hemosiderin
Hemoglobin
+
0
0
+
+
+ severe cases

10. POLYCHROMATOPHILIC CELLS

11. CORRECTING RETIC COUNT
Retic Index = Retic % x Patient Hct
Normal Hct
Absolute Retic = Retic % x RBC/mm3
Retic Production Index = Retic Index
Days in circulation
drpa
nkaj
yada
v05
@g
mail.
com

12. THE KEY TO THE ETIOLOGY OF
HEMOLYTIC ANEMIA
The history
The peripheral blood film

13. CASE 1
 3 yr old male child presenting with pallor, jaundice,
 Severe pain of long bones, fever
 CBC-anemia ,reticulocytosis , increased WBC
 LAB - LDH -600 (normal upto 200)
S. bilirubin- 5 mg%

14. PERIPHERAL SMEAR

15. DIAGNOSIS – OTHER TESTS
SICKLING TEST :
 It should not be performed on infants until they are at least
6 month old because of the presence of hemoglobin F as
the predominant hemoglobin at birth , therefore, this test
may give a false-negative result if performed too early (if
hemoglobin S is <10%).
 Recent blood transfusions, typically within the last three
months of the date of testing, may cause a false-negative
test result .
 False positive results may be due to polycythaemic , high
proteins and a variety of abnormal haemoglobins including
Hb’s I, Bart’s, C-Georgetown, Alexandra and C-Harlem.

16.  Hemoglobin electrophoresis
 Hemoglobin fractionation by HPLC, the most
frequently used method to screen for hemoglobin
variants, including Hb S .
 Isoelectric focusing, a highly sensitive method that is
often used at large reference laboratories .

17. CLINICAL FEATURES OF SICKLE
HEMOGLOBINOPATHIES
Condition Clinical
abnorm
Hb level g% MCV,fl Hb
electropho
Sickle cell trait None,rare
painlss
hematuria
normal normal HbS/A:
40/60
Sickle cell
anemia
Vasocclusive
crises,AVN,gal
lstones,
priapism
7-10 80-100 HbS/A:100/0
S/beta0
thalasssemia
Vasoocclusive
Crises,AVN
7-10 60-80 HbS/A-100/0
HbF; 1-10%
S/beta+
thalassemia
Rare crises,
AVN
10-14 70-80 HbS/A:
60/40
HbSC --do--,
retinopathy
10-14 80-100 HbS/A;50/0
HbC;50%

18. DNA analysis :
This test is used to investigate alterations and mutations in
the genes that produce hemoglobin components.
It may be performed to determine whether someone has
one or two copies of the Hb S mutation or has two different
mutations in hemoglobin genes (e.g., Hb S and Hb C).
Genetic counseling :used for prenatal testing: amniotic fluid
may be tested at 14 to 16 weeks to provide a definitive
answer.
It can also be performed earlier with chorionic villus
sampling.

19. DIAGNOSIS?
SICKLE THALASSEMIA`

20. CASE 2
 6 yr old child presenting with severe pallor ,
jaundice growth delay
 Abnormal facies , hepatosplenomegaly+
 h/o recurrent blood transfusions
 CBC-Hb -3gm%, MCV-58FL,
-MCH- 19pg (nl-28-33)
P.S- MICROCYTIC,HYPOCHROMIA with
target cells +

21. DIAGNOSIS?

22. TARGET CELLS

23. Distinguishing thalassaemia minor from IDA
from CBC by applying formulae:
Formula Thal. IDA
MCV  RCC (Mentzer index) <13 >13
MCH  RCC < 3.8 > 3.8
(MCV2  MCH)  100 < 1530 > 1530
MCV – RCC – (Hb  5) – 3.4 < 0 > 0
(MCV2  RDW)  (100xHb) < 65 > 65
RDW-CV% <14.6 >14.6

24. Comparison of β Thalassemias
Parameter Minor Intermedia Major
Hb 10-13 6-10 2-8
MCV (fl) 60-78 50-70 50-60
MCH (pg) 28-32 22-28 16-22
RDW Normal S. increased Increased
Micro/hypo Film Mild Moderate Severe
Polychromasia V. Little Moderate Marked
Anisocytosis None Moderate Marked
Poikilocytosis None Moderate Marked
Targetting Present Present Present

25. 25
COMPARISON OF BETA THALASSEMIAS
GENOTYPE HGB A HGB A2 HGB F
NORMAL Normal Normal Normal
MINOR 80-95%, 3.5-7.5% 1-5%
INTERMEDIA 0-30% 3.5%-5.5% 20-70%
MAJOR 0 % 3.5 %-
5.5%
90-96 %
DNA analysis for mutations
Globin Chain Testing - determines ratio of globin chains being produced.

26. ALPHA THALASSEMIAS
disease Hb A
%
HbH % Hb , % MCV,fl
Normal α,α/α,α 97 0 15 90
Thalassemia traits
(genotype α,-/α,α)
90-95 rare 12-13 70-80
HbH (b4) (genotype α,-/-,-) 70-95 5-30 6-10 60-70
Hb Bart (genotype -,-/-,-)
(hydrops fetalis)
0 5-10 Fatal
inutero or
at birth
α+ thalassaemia homozygous (genotype α,-/α,-)
αo thalassaemia heterozygous (genotype α,α/,--)

27. HB-BART’S
 Is only detected at birth. But then disappears
(WHY???). So diagnosis of alpha thalassemia could
be established at birth directly in comparison of beta
thalassemia.

28. ALPHA THALASSEMIA WITH BASOPHILIC
STIPPLING

29. HB-H PREPARATION
Same preparation as
Retic count stain, but
with extended time of
incubation, instead of
15 minutes, 2 hours
incubation is required.

30. Hydrops Fetalis
The blood film of neonate with hemoglobin Bart’s hydrops fetalis showing
anisocytosis, poikilocytosis and numerous nucleated red blood cells
(NRBC).

31. CASE 3
 45 yr old male came to OPD in a remote PHC with burning
micturition
 Urine R/M shows numerous pus cells++++
 UTI diagnosed & medical officer gave cotrimoxazole 2 bd X
5days
 1 wk later,pt developed severe pallor,palpitation,jaundice
 Lab- increased LDH, S.BILIRUBIN, RETIC COUNT
 P.S- shows irreg cells like

33. BLISTER CELLS

34. HEINZ BODIES

35. DIAGNOSIS?
 G-6PD DEFICIENCY
 INVESTIGATION-
• Peripheral smear: bite cells , heinz bodies - polychromasia
• G-6PD LEVEL
Quantitative , qualitative , PCR

36. Patients with acute hemolysis, testing for G6PD deficiency may
be falsely negative because older erythrocytes with a higher
enzyme deficiency have been hemolyzed.
Young erythrocytes and reticulocytes have normal or near-
normal enzyme activity.
Female heterozygotes may be hard to diagnose because of X-
chromosome mosaicism leading to a partial deficiency that will
not be detected reliably with screening tests.
 G6PD deficiency should be considered in neonates who
develop hyperbilirubinemia

37. Pyruvate Kinase Deficiency
 Deficient ATP production, Chronic
hemolytic anemia
 Inv;
P. Smear: PRICKLE CELLS ( Contracted rbc with
spicules)
Decreased enzyme activity

38. PRICKLE CELL

39. CASE 4
 14 YR old female present with anemia, jaundice
 Rt hypochondrial pain
 o/e- vitals stable.pallor+,icterus+,splenomegaly +
 Usg- cholilithiasis
 Lab; elevated LDH, S.Bilirubin , reticulocyte
count MCHC, , RDW decreased Hb, MCV.
 Peripheral smear shows-
hyperdense cells

41. DIFFERENTIAL DIAGNOSIS
 Hereditary spherocytosis
 Autoimmune hemolytic anemia
 Other diagnostic tests- osmotic fragility
- coombs test
 The acid glycerol lysis test
 Screen family members

43. The red cell lipid composition regulates the membrane
permeability to glycerol.
The added glycerol slows down the rate of water entry into
the red cells.
Measure the time taken for absorbance of red cell
suspension at 625 nm in glycerol to fall to half of its original
value before glycerol addition (AGLT50)
Also detects autoimmune haemolytic anaemia, hereditary
persistence of fetal haemoglobin, pyruvate kinase deficiency,
severe glucose- 6-phosphate dehydrogenase deficiency,
pregnant women (one-third), chronic renal failure on dialysis

44. Classification Trait Mild Moderate Severe
Haemoglobin (g/dl) Normal 11–15 8–12 6–8
Reticulocyte count %
Normal
(<3%) 3–6 >6 >10
Bilirubin (μmol/l) <17 17–34 >34 >51
Spectrin* per
erythrocyte (% of
normal) 100 80–100 50–80 40–60
Splenectomy
Not
required
Usually not
necessary
Necessary
before puberty
Necessary –
after 6 years if
possible

46. Symptoms of HS may appear in the perinatal period:
jaundice is common in the first 2 d of life.
 Some neonates with HS may be transfusion-
dependent(unusual) due to their inability to mount an
adequate erythropoietic response in the first year of life .
Recent evidence suggests that erythropoietin may be of
benefit in reducing or avoiding transfusion, and can usually be
stopped by the age of 9 months .
 Children who require one or two transfusions early in life
frequently become transfusion independent

47. An artifact showing ‘macrospherocytosis’ on a blood film
can be produced as a result of cold storage of blood
samples from patients with cryohydrocytosis, which is a
variant form of hereditary stomatocytosis (‘atypical HS’)
It is particularly important to rule out stomatocytosis where
splenectomy is contraindicated because of the thrombotic
risk.
Atypical cases may require measurement of erythrocyte
membrane proteins to clarify the nature of the membrane
disorder and in the absence of a family history.
 Occasionally molecular genetic analysis will help to
determine whether inheritance is recessive or non-dominant.

48. Iron, folate or vitamin B12 deficiencies can mask the
laboratory features.
Obstructive jaundice alters the lipid composition of the
red cell membrane, masking the film appearances and
reducing the haemolysis.
Co-inheritance of other haematological disorders, such
as beta thalassaemia trait or SC disease, can lead to
confusion in the diagnosis and variable clinical effects
.

49. AUTOIMMUNE HAEMOLYTIC ANAEMIA
 hemolysis, MCV decreased
 P Smear: microspherocytosis,
 Confirmation:
Warm
Direct Coomb’s Test / Antiglobulin test
Cold
DAT positive with polyspecific and anticompliment antisera

50. DAT
•Sensitivity/Specificity:
>99% patients with warm agglutinin AIHA will exhibit a positive result;
<1% normal population have + result.

51. In some cases the density of attached
autoantibody may be too low for detection by DAT.
This may be resolved by flow cytometric assessment
of red cell Ig density .
Polyspecific DAT reagents may also fail to detect
some autoantibodies, particularly IgA, as anti-IgA is
not usually incorporated into the reagent.
Application of specific anti G, A, M and
complement DAT reagents may resolve some cases

52. INSERT TITLE TEXT HERE
MACROCYTE
SPHEROCYTE
IMMUNOHEMOLYTIC ANEMIA

53. CASE 5
 32 yr old presented 4 days history of distention of
abdomen and rt hypochondrial pain and has h/o
passage of dark colored urine at night for weeks
 On USG- hepatomegaly,gross ascites,hepatic vein
thrombosis
Lab : Hb – 7gm%. WBC- 2200, PLC- 80,000
LDH- 600, S.BR- 4 mg%
urine bile pigment +,heme dip stick++
What is the diagnosis?

54. PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
 Acquired chronic H.A
 Persistent intra vascular hemolysis
 Pancytopenia
 Lab :HBuria,hemosiderinuria,increased LDH,bilirubin
 Risk of venous thrombosis
 C/F – hemoglobinuria during night
 P.S – polychromatophilia, normoblasts
 B.M – normoblastic hyperplasia
 Def.diagnosis-flow cytometry CD59-,CD55- RBC,WBC
Acid haemolysis test
Acid hemolysis test (PNH)A

55. Caused from a defect in the production of GPI
protein anchors on the surface of all blood cell
Protect red cells from the activity of the
complement system. but 2 are important in
protecting red cells from destruction: CD55 (DAF)
and CD59
Defect makes the red cells in particular
susceptible to destruction by the complement
system. Intravascular hemolytic anemia.

56. “FOOT STRIKE HEMOLYSIS”
 Caused by RBC destruction from repeated trauma
• Elevated temperature in muscle, turbulence and
acidosis may also be involved
  Bilirubin
  Haptoglobin
  Schistocytes
 Slight  MCV & Reticulocytes
 Preferential breakdown of older rbcs
 Hemoglobinuria
 Anemia resolves w/ d/c exercise

57. THANK YOU

58. BETA THALASSEMIA
 Mutn. Beta globin expression
 M.C- derange splicing of m-RNA
 HYPOCHROMIA ,MICROCYTIC anemia

59. AUTOIMMUNE HEMOLYTIC ANEMIA
 Result from RBC destruction due to RBC
autoantibodies: Ig G, M, E, A
 Most commonly-idiopathic
 Classification
 Warm AI hemolysis:Ab binds at 37 C
 Cold AI Hemolysis: Ab binds at 4 C

60. 1.Warm AI Hemolysis:
 Can occurs at all age groups
 F > M
 Causes:
50% Idiopathic
Rest - secondary causes:
1.Lymphoid neoplasm: CLL, Lymphoma,
Myeloma
2.Solid Tumors: Lung, Colon, Kidney, Ovary,
Thymoma
3.CTD: SLE,RA
4.Drugs: Alpha methyl DOPA, Penicillin ,
Quinine, Chloroquine
5. UC, HIV