RED BLOOD CELL DISORDERS

I. ANEMIA
 refers to the decrease amount of hemoglobin in the blood and therefore, a
diminished amount of oxygen reaching the tissues and organs of the body.
 the condition maybe thought as reduction in the red cell mass, producing decrease
O2 –carrying capacity to meet the tissue demand.
 Reduction in the red cell mass may occur :
1. if the production of RBC is defective
2. if the RBC destruction/loss exceeds the capabilities of the bone marrow to
replace them.
 tests to detect anemia:
1. hemoglobin
2. hematocrit
3. RBc indices
4. RDW (red cell distribution width)
5. Retic count and reticulocyte production index
6. Peripheral Blood Smear
7. Total Iron Binding Capacity (TIBC)
8. Fecal urobilinogen
9. Serum bilirubin
10. Myeloid-Erythroid ratio (RR = 2:1 – 4:1)

 anemia basically results from either decrease (hypoproliferative) red cell production
or increased (hemolytic) red cell destruction.

CLASSIFICATION OF ANEMIA

1. Etiologic/Pathologic Classification – based on the principal underlying

pathophysiological mechanism.
 Relative anemia – e.g. pregnancy (increase plasma volume)
 Anemia associated with Hb synthesis – e.g. IDA, Sideroblastic, chronic disease
 Anemia associated with Defective Vit. B12 & Folate
 Anemia associated with BM function – e.g. Aplastic, myelophthisic,
myelodysplastic, renal failure, fanconi, PNH, APRCA, endocrine

2. Morphologic Classification – can be established using PBS and red cell indices.

a. Microcytic Hypochromic – TISC-L

b. Macrocytic Normochromic
b.1 Megaloblastic (seen in PBS and BM) – e.g. Vit. B12 and Folic acid def.
b.2 Megaloblastoid (seen in PBS but not in BM) – e.g. Reticulocytosis & liver dse.
c. Normocytic Normochromic – most anemias, except A and B
d. Normocytic Hypochromic – RA and Chronic inflammation
 3. Physiologic Classification – based on the ability of the bone marrow to respond to
anemia with increased erythropoiesis which involves the assessment of retic count and
RPI.
a. Inefficient Erythropoiesis
a.1 hypoproliferative anemia
a.2 maturation disorders – e.g. IDA, macrocytic anemia
b. Effective Erythropoiesis
a.1 blood loss anemia
a.2 hemolytic anemia

MICROCYTIC HYPOCHROMIC ANEMIAS :

1. Iron Deficiency Anemia – results when the iron stores of the body become depleted and
there is no more sufficient amount of iron available for hemoglobin production.

Causes:
a. blood loss – the most common cause; affects all ages especially in menstruating
women and frequent donation.
b. nutritional deficiency – common in infants; not common in adults
c. increased iron demand – pregnancy, lactation and adolescents

Iron Metabolism:

 approx. 4,000 mg in normal adult

 60 % present in circulating blood in the form of hemoglobin
 1 mg of RBc contains 1 mg of iron
 Storage iron – present in macrophages & RES in the form of:
a. Ferritin – water soluble complex of ferric salt and apoprotein
Apoprotein – MW = 450,000 Da consist of 24 subunits of
variable ration of H & L types (found in chromosome 11 &
19 respectively)
b. Hemosiderin – (no apoprotein) water insoluble consist mostly of the
aggregates of FeCOOH core aggregates; degradation occurs in the
lysosome.
 Transferrin – transport form of iron with a molecular weight of 80,000 Da found in
chromosome #3.
 Iron lost – excreted via the GIT and urine
Female: 2 mg/day because of menstrual blood loss
Male: 1 mg/day
 Approx. 1 mg of iron is lost through the urine after RBC breakdown.
 A normal adult absorbs (duodenum) 5-10 % of iron in his diet (normally 10-15 mg of
iron per day is present in the diet). This provides 1-2 mg which compensates for the
normal daily losses due to red cell turn over.

Stages of Developing IDA:

 a. Iron Depletion – occurs when blood loss exceeds absorption, thus, a
negative iron balance exist.
- decrease stored iron
- decrease ferritin
- increase absorption
- increase TIBC
b. Iron Deficient Erythropoiesis – iron stores become exhausted but anemia
may not yet present.
- decrease plasma iron
- decrease transferring saturation (TS %)
- decrease sideroblast in bone marrow
c. IDA – anemia is detectable which results to microcytic hypochromic
blood picture.
- decrease total serum iron
- increase TIBC

2. Chronic Disease Anemia – usually seen in chronic disorders like chronic infections,
inflammatory process and malignant neoplasm’s.

 the basic defect is in the iron utilization for erythropoiesis; there appears to be a
blocked in the delivery of iron from the reticuloendothelial iron stores to the delivery
of red cells.
- decrease serum iron concentration
- normal to increase ferritin
- decrease TIBC (note: in IDA – TIBC is increased)

3. Sideroblastic Anemia – a group of disorder characterized by iron loading and accumulation

in the mitochondria of normoblast due to the defect in heme synthesis (decrease enzyme
activity of d-ALA)

 diagnostic feature is the presence of ringed sideroblast using the Prussian blue stain.

Types of Sideroblastic Anemia

a. Hereditary type – inherited form; sex-linked recessive (male) due to decrease

in aminolevulinic acid synthase activity.
b. Idiopathic type – not common; both sexes; also referred to as:
RARS – refractory anemia with ringed sideroblast
IASA – idiopathic acquired sideroblastic anemia
c. Secondary Sideroblastic Anemia – follows exposure to drugs and toxins such as
chloramphenicol, ethanol and those used in TB and neoplastic diseases.

PORPHYRIN AND HEME SYNTHESIS PATHWAY

 Suucinyl-CoA + glycine (mitochondria)

pyridoxal PO4
ALA synthase

d-ALA (delta-aminolevulinic acid) (cytoplasm)

PBG synthase

PBG (porphobilinogen)

PBG deasminase

Hydroxymethylbilane

Uroporhyrinogen III cosynthase

Uroporphyrinogen III (Uroporphyrin III)

Uroporphyrinogen decarboxylase

Coproporhyrinogen III (Coproporphyrin III)

Coproporphyrinogen oxidase

Protoporhyrin IX

Protoporphyrin oxidase

Protoporhyrin IX + Iron

Heme synthase/ferrocheletase

HEME

4. Lead Poisoing – occurs in both children and adults

  children may receive excessive exposure to lead (tingga) secondary to ingestion of
lead-containing paint.
 Diagnostic feature: Basophilic stippling
 Action of lead: inhibits the activity of 3 enzymes in heme synthesis pathway
- PBG synthase
- Heme synthase
- Coproporphyrinogen oxidase

5. Thalassemia – comprises a complex group of genetic abnormalities in globin chain synthesis.

 the thalassemia gene involves may either alpha or beta chain.

 it is caused by impaired production of one of the polypeptide chains of hemoglobin
molecule.
 the most common form is Beta chain synthesis impairment which is called BETA
THALASSEMIA.

CLASSIFICATION OF BETA THALASSEMIA

1. Thalassemia Major/ Cooley’s Anemia – this is a homozygous beta thalassemia;

maybe expressed as:
- ß°ß° - where ß chain synthesis is absent
- ß-ß- - where ß chain synthesis is reduced

 despite the abnormalities, α chain production is normal.

 most affected patients exhibit retarded growth and facial structure shows mongoloid
appearance.
 it starts during infancy and patient lives rarely beyond 20’s.

Lab. dx:
- microcytic-hypochromic anemia with marked poikilocytosis and anisocytosis
- basophilic stippling - increase RETIC
- numerous target cells - 100 to 200 nRBC
- howell-jolly bodies & siderocytes - decrease OFT

2. Thalassemia Minor/ Cooley’s Trait – this is a heterozygous form characterized by

mild anemia.
 only 2-3% HbF compared to 40-60% of homozygous form.
 PBS: microcytic-hypochromic anemia with target cells, basophilic stippling and
occasional RBC seen on the blood film.

3. Thalassemia Intermedia – the mildest form of homozygous ß thalassemia (ß+ß+).

4. Thalassemia minima – causes no detectable clinical or laboratory abnormalities.

ALPHA THALASSEMIA – this results from reduced or abnormal α chain synthesis.
  as the capacity to produce α chain decreases, this results in accumulation of excess
gamma chain in the fetal life to form Hb Barts (γ4) and excess ß chains to form HbH
(ß4) later on.

DIFFERENTIAL DIAGNOSIS OF MICROCYTIC HYPOCHROMIC ANEMIAS

ANEMIA Serum TIBC Ferritin FEP HBA2 HbF RDW

Fe
Iron Deficiency Anemia L H L H N N-L H
Alpha Thalassemia H N H N N L -
Beta Thalassemia H N H N H H-V H
Chronic Disease Anemia L L H H N N N
Sideroblastic Anemia H N H L N N H

Legend : H – High L – Low N – Normal V – Varies

MACROCYTIC NORMOCHROMIC ANEMIAS:

- Megaloblastic anemia – seen in Bone Marrow and PBS such as Vitamin. B12
deficiency and Folate deficiency.

- Megaloblastoid anemia – seen in PBS but not in Bone Marrow such as

Reticulocytosis and Liver Disease anemia.

A. Megaloblastic Anemia – these types result from deficiencies of Vit. B12 and Folic acid and
from drugs that interfere with DNA metabolism.

Causes:

1. Vit. B12 (Cyanocobalamin) Deficiency

 MW – 1,355 Da, necessary for adequate DNA synthesis through its role in folic acid
metabolism.
 It comes from food and animal origin
 The only vitamin exclusively synthesized by microorganism (Escherichia coli)
 Absorbed in ileum with the aid of intrinsic factor or Castle’s factor (chromosome
#11) produced by parietal cells of the fundus of the stomach.

Deficiency is due to:

- Pernicious anemia – deficiency in IF of the stomach

 - Immersalund-Grasbeck Syndrome – malabsorption syndrome
- Diphylobothrium latum infection – competes cobalamin ingestion
- Euglena gracilis – need cobalamin for growth
- Blind Loop Syndrome – disease of small intestine
- Crohn’s Disease – inflammatory bowel disease
- Zollinger Ellison Syndrome – impaired Vit. B12 absorption but no
megaloblastic anemia char. by hyposecretion of gastric juice resulting to low
pH which in turn interferes with binding of Vit. B12 to IF.
- defective production
- inadequate intake

2. Folate (Pteromonoglutamic acid) Deficiency

 Very similar to Vit. B12 deficiency however the neurologic symptoms are absent.
 Seen in alcoholics and poor dietary habits
 Most common cause occurs however during pregnancy.

Note: Liver – chief site of folic acid storage

Proximal Jejunum – site of folic acid absorption
Folic acid – consist of 3 parts (pteridine, L-glutamic acid, p-aminobenzoate)

Test for Megaloblastic Anemia

1. Schilling Test – used to diagnose pernicious anemia

2. Methylmalonic acid and Homocysteine Assays – cobalamin is necessary for
isomerization of methylmalonate to succinate
3. Deoxyuridine Suppression Test – test to measure the ability of the marrow cells in
vitro to utilize deoxyuridine in DNA synthesis.
4. Peripheral Blood Smear
5. Serum Cobalamin and Folate Assay

B. Megaloblastoid Anemia

1. Liver Disease Anemia – associated with liver disease

Target cells are seen in obstructive jaundice
Spur cells seen in cirrhosis

2. Reticulocytosis – elevation in the number of reticulocytes (young RBC) in blood. The

number of reticulocytes is normally less than 1% of the total number of the red blood
cells. A higher proportion (above 1%) constitutes reticulocytosis.

NORMOCYTIC NORMOCHROMIC ANEMIA:

1. Aplastic Anemia – primary defect is failure to produce RBC, WBC and platelets.
  Also referred to as pancytopenia
 The depletion is the production of precursor cells is the result of the damage to the
hematopoietic stem cells.

a. Acquired Aplastic Anemia – due to the exposure to certain physical and chemical
agents (chloramphenicol) such as ionizing radiation, benzene, heavy metals, etc.

b. Idiopathic Aplastic Anemia – unknown origin and accounts for 50 % of the cases of
aplastic anemia.

c. Fanconi’s Anemia – also Familial / Congenital Aplastic Anemia

- occurs in children; mental and physical abnormalities present.
- melanin deposits are common which shows up patches of brown pigmentation
of the skin.
- increase HbF, increase OFT, increase ESR

2. Pure Red Cell Aplasia – disease in which RBC production is suppressed with little or no
abnormalities found in the white blood cells and platelets.

a. Diamond-Blackfan Anemia – also Congenital Pure Red Cell Aplasia due to defective
CFU-E in the stem cell of the Bone Marrow.

3. Congenital Dyserythropoietic Anemia – disorder characterized by normoblast in bone

marrow which shows multinuclearity, karryorrhexis and bizzae malformations.

a. Type I – mild macrocytic anemia with marked anisocytosis and poikilocytosis.

- cabot rings and basophilic stippling often present
- diagnostic feature: thin fuelgen positive, internuclear chromatin bridges
joining 2 normoblasts.

b. Type II – HEMPAS (hereditary erythroblast multinuclearity with positive acidified

serum test).

c. Type III – shows normocytic to slightly macrocytic anemia.

4. Hemolytic Anemias – due to either 2 etiologic groups:

(intracorpuscular or extracorpuscular defects)

Intracorpuscular (Mechanism: Action of Complement)

Due to Enzyme Defects:

A. G6PD Deficiency – this defect is associated with PP shunt (HMS); the primary
importance of which is the involvement with the metabolism of
reduced glutathione which is important in protecting the RBC
damage by oxidizing agents.

Pathophysiology:
- when there is G6PD deficiency, the RBC is unable to generate
NADPH rapidly enough to combat the effects of oxidizing agents.
Hemoglobin is oxidized to methemoglobin which denatures and
precipitates Heinz bodies.

- hemolysis occurs as a result to increased rigidity of RBC caused

by Heinz bodies and membrane damaged from oxidants.

B. Pyruvate Kinase Deficiency – PK is the enzyme in EMP and the most common cuse
of non-spherolytic hemolytic anemia involving this pathway.

- PK deficient RBC have decreased lifespan due to lack of ATP

and their inability to utilize glucose.
- NO Heinz body formation

C. Pyrimidine-5-Nucleotidase Deficiency – there is a resultant accumulation of

pyrimidine nucleotides from RNA in reticulocyte.

D. Glucose Phosphate Isomerase Deficiency – deficiency in anaerobic glycolysis and is

the 3rd most common cause of enzyme deficiency.

Due to Membrane Defects:

A. Congenital Spherocytosis – also Congenital Hemolytic Anemia; caused by defect in

RBC membrane involving the spectrin (a skeletal protein on the internal surface of
RBC membrane)

B. Hereditary Elliptocytosis – caused by a defect in spectrin dimmers resulting in free

unconnected dimmers.

C. Abetalipoproteinemia – also Basse Kornsweig Syndrome; characterized by the absence

of betalipoprotein in the blood which are major components of RBC membrane.

D. Congenital Stomatocytosis – also Hydrocytosis; due to increased amount of sodium

and decreased amount of potassium brought about by passive permeability of red cell
membrane resulting to irreversible exchange which brings about stomatocyte
formation. May also due to lack of Rh group antigen on red cell surface (Rh null).
Extracorpuscular

A. Autoimmune Hemolytic Anemia – due to warm and cold agglutinins

Warm Autoantibodies – this is caused by warm reactive antibodies (IgG) bind

optimally @ 37°C and the red cell antibody complexes
are cleared by the spleen.

Cold Autoantibodies – this is caued by IgM cold reactive antibodies with anti-I and
anti-I specificity; also commonly found as complication of
Mycoplasma pneumoniae (I), and respiratory IM.

B. Paroxysmal Cold Hemoglobinuria – caused by complement dependent hemolytic

antibody called Donath-Landsteiner (IgG); hemolysis occurs as the antibody is bound
to the RBC in the presence of complement at low temperature, followed by return to
body temperature.

Warm Antibody Cold Antibody PCH

1. Optimal rxn. temp 37°C 0-4°C 0-4°C(Ab binds to cell)
37°C (hemolysis occur)
2. Thermal amplitude 20-37°C 0-32°C < 15°C
3. Immunoglobulin type Usually IgG Usually IgM IgG (Donath-
Landsteiner
[Link] activation May bind to Binds to complement Binds to complement
complement
5. Bld. Group specificity Rh, Kell, others Ii Pp
6. Mechanism of cell Extravascular Extravascular (hepatic) Intravascular
destruction (splenic)
7. Treatment Steroid, splenectomy, Avoid cold Avoid cold
immunosuppresants

C. Microangiopathic Hemolytic Anemia – this is generally of fibrin deposits within the

small vessels, as found in association with TTP (thrombocytopenic purpura) and
intravascular coagulation.
Present also in the following:
Malignant hypertension, Disseminated Carcinoma, Hemolytic Uremic Syndrome

D. PNH (Paroxysmal Nocturnal Hemoglobinuria)

 There appears to be an acquired intrinsic defect in the red blood cells that makes the
cell more sensitive to lysis by heat labile serum factors (complement)
 The defective membrane maybe due to the deficiency of DAF (decay-accelerating
factor) that normally inhibits complement mediated lysis.
  Characterized by intravascular hemolysis and hemoglobinuria during and following
sleep in the classic case.
 Has no specific treatment.

II. OTHER CELL DISORDERS

1. Hemochromatosis – accumulation of iron in the parenchymal cells and injures the tissue
(as contrast with hemosiderosis which is characterized by iron accumulation in the
macrophages causing little parenchymal cell injury.
Clinical picture: bronze colored skin from melanin deposits in the skin exposed to sunlight.

2. Porphyria – inherited or acquired metabolic disorders caused by specific enzyme defects

necessary for the synthesis of heme molecule.

a. Congenital Erythropoietic Porphyria – also Gunther’s Disease; a

deficiency in Uroporphyrinogen III cosynthase.
b. Porphyria Cutanea Tarda – caused by decreased production of
uroporphyrinogen decarboxylase.
c. Erythropoietic Porphyria – caused by decreased activity of heme
synthetase/ferrocheletase.
d. Acute Intermittent Hepatic Porphyria – due to deficiency in
Uroporphyrinogen I synthetase.
e. Variegate Porphyria – deficiency in protoporphyrinogen oxidase.

3. Hemoglobinopathies – syndromes brought about by abnormal hemoglobin structures

due to amino acid deletions, substitutions, deletions or elongations.

HbS – ß6 glu-val Normal Hb : HbA1 – 2 α, 2 ß

HbC - ß6 glu-lys HbA2 – 2 α, 2 d
HbD - ß6 glu-glys HbF – 2 α, 2 y
HbE – ß26 glu-lys Portland – 2 y, 2z
HbO – ß121 glu-lys Gower I – 2 e, 2 z
Gower II – 2 α, 2 e

Note: Hb Barts – 4 y
HbH – 4 ß

Chromosome # 11 – ß, y, d, e
Chromosome # 16 – d, z