Bone marrow

1. Bone marrow Red Yellow Bone Fat Reticulin Haematopoiesis – red, white, platelets lymphoid

2. Normal red cells Central pale area

3. Red cells Men Women • Hemoglobin (g/l) 140-180 120-160 • Hematocrit (%) 40-52 36-48 • Red cell count (1012/l) 4.5-6.53.9-5.6 • Reticulocyte count (%) 0.5-1.5 • Mean cell volume (fl) 80-95 • Mean corpuscular hemoglobin (pg) 27-33 • Mean corpuscular hemoglobin concentration (gm/dL)33-37

4. Red cells pathological conditions: • decrease in the circulating red cell mass (poss. with structural abnormalities) very common - anaemia II. increase in the circulating red cell mass less common polycythemia =erythrocytosis=polyglobuly

5. Polycythemia=increased concentration of red cells • RELATIVE - decreased plasma volume dehydration, stress • ABSOLUTE primary – neoplastic= polycythemia vera = myeloproliferative neoplasm secondary - increased erythropoietin stimulation • Appropriate • reactive – low levels of oxygen in the PB (heart disease, high altitude) • Inappropropriate

6. Red cells • Normal: uniform in size and shape • Pathologic: variation in size, shape, inclusions • Variation • size - anisocytosis • Shape – poikilocytosis

7. Red cells - functions • Deliver oxygen to the tissues • Anemia - reduction • of the total number of red cells • amount of hemoglobin • circulating red cell mass

8. Consequences of anemia - symptoms • ???????????

9. Dg. of anemia - history • Age of onset • Duration of illness • Prior therapy of anemia • Suddennes or severity of anemia • Chronic blood loss • Hemolytic episodes • Toxic exposures • Dietary history • Family history, racial background • Underlying diseases

10. Anemia – consequences, symptoms • Fatigue, syncope, dyspnea • Impairment of organ function due to hypoxia • Pallor, postural hypotension )decreased blood volume) • Heart murmurs, heart failure . Increased cardiac output

11. Anemia • Not a diagnosis per se • Look for an underlying problem • History, physical examination

12. Anaemia decrease in the total circulating red cell mass (hematocrit, hemoglobin concentration) Classification: A. underlying mechanism blood loss increased destruction decreased production B. morphology of erythrocytes size (micro-, macro-, normocytic) shape (spherocytosis, stomato-,...) color (degree of hemoglobinization: normo- hypo-, hyperchromic) MAYCOMBINE

13. Blood loss • acute or chronic • internal or external Acute • Hypovolemia – shock • Anemia – normocytic normochromic • Shift of water – hemodilution –↓ hematocrite • Compensatory increase of red cell production • Reticulocytes • Chronic → loss of iron→ iron deficiency • hypochromic sideropenic anemia

14. Iron deficiency anemiamechanism: blood loss, decreased production body iron = functional + storage F - 2g, M - 6g inadequate intake for metabolic demands Lack in diet or low absorption most common nutritional disorder in the world 2. Increased requirement (children, pregn., lact) !!!3. Chronic blood loss!!! - GIT, GYN most important cause of iron deficiency in the Western world

15. Hypochromic microcytic sideropenic anemia Small hemoglobinization (narrow Hb rim -periphery) Small red cells Iron deficiency Scattered fully hemoglobinized cells - blood transfusion

16. PB: ery pale + smallBM: erythroid hyperplasia, loss of ironalopecia, koilonychia, atrophy of tongue, gastric mucosaPlummer-Vinson (Kelly-Patterson) syndrome: siderop.an., atrophic glossitis, esophageal webs

17. Iron deficiency anaemia Pallor conjunctiva skin pale palmar creases

18. Iron deficiency anaemia koilonychia nails concave (or flat), ridged, brittle

19. Iron deficiency anaemia angular cheilosis fissuring and ulceration; pallor

20. Iron deficiency anaemia flattening and loss of papillae bald, fissured tongue

21. Causes of hypochromic anemia • Disorders of iron metabolism • Disorders of heme synthesis • Disorders of globin synthesis (thalassemia) Ad 1. Iron deficiency • Blood loss • Poor intake - growth, pregnancy, lactation • Malabsorption • Chronic infections or inflammatory states • neoplasia

22. Anaemia decrease in the total circulating red cell mass (hematocrit, hemoglobin concentration) Classification: A. underlying mechanism • blood loss → increased destruction decreased production

23. Increased destruction =lysis of red cells=hemolysis • intravascular – rare - mechanical injury – artificial valves or microthrombi, exogenous toxic agents, complement fixation (transfusion of mismatched blood) • extravascular - more common, when red cells considered foreign or less deformable Hemolytic anemia Abnormality: • intracorpuscular or extracorpuscular • hereditary (intra) or acquired (extra)

24. Hemolytic anemia • premature destructionof red cells • accumulation of the products of the hemoglobin catabolism • BM – increased erythropoiesis, extreme: extramedullary hematopoiesis • PB: reticulocytosis • high bilirubin –gallstones; jaundice, blr in urine • chronic duration: hemosiderosis Main clinical symptoms anemia, splenomegaly, jaundice; gallstones

25. Haemolytic anaemia splenomegaly and jaundice

26. Haemolytic anaemia jaundice normal

27. Increased destruction of ery=hemolysis I. Intrinsic (intracorpuscular) causes A. hereditary • membrane – cytoskeleton, lipid synthesis • enzymes – deficiencies - G6PD, glutathione synthetase, pyruvate kinase • hemoglobin - deficient synthesis of globin, structurally abnormal Hb B. acquired • membrane defect: paroxysmal nocturnal hemoglobinuria • II. Extrinsic (extracorpuscular) causes • antibodies, trauma, infection, chemical injury sequestration

28. Examples of hemolytic anemia • Membrane defects – • Proteins underlying the red cell membrane • Shape, stability, flexibility

29. Hereditary spherocytosis (peripheral smear) anisocytosis and several dark-appearing spherocytes with no central pallor. Howell-Jolly bodies (small dark nuclear remnants)

30. Hereditary spherocytosis AD (AR, sporadic);most common her. hemol. A. Membrane defect – cytoskeleton – protein spectrin (and ankyrin) deficiency Round erythrocyte= spherocyte, less deformable Vulnerable to spleen sequestration and destruction Main clinical symptoms anemia, splenomegaly, jaundice; gallstones Chronic hemolytic anemia (mild to normal) Acute anemic episodes: aplastic crisis (parvovirus) hemolytic crisis

31. Splenic sinus A red cell squeezing from the red pulp cordsinto the sinus lumen. Note the degree of deformability required for red cells to pass through the wall of the sinus.

32. Red cell membrane cytoskeleton Alterations leading to spherocytosis and hemolysis Mutations weakening interactions involving α-spectrin, β-spectrin, ankyrin, band 4.2, or band 3 cause the normal biconcave red cell to lose membrane fragments and become spherical spherocytic cells: less deformable than normal, become trapped in the splenic cords, phagocytosed by macrophages.

33. Pathophysiology of hereditary spherocytosis

34. Haemolytic anaemia: reticulocytes precip. RNA

35. Hereditary elliptocytosis Usually mild, rarely severe

36. Hemolytic anemia • Intracorpuscular • Enzyme deficiencies

37. G6PD deficiency enzymes protecting the red cell against the oxidative stress G6PD deficiency → loss of protection → oxidant injury infections, drugs, beans (favism) → hemolysis; otherwise normal morphologic changes of chronic HA rarely present hundreds of genetic forms of G6PD common pathologic alleles: G6PDA-,G6PD Mediterranean X-linked→ males homozygous, women heterozygous Mediterranean, Middle East, Africa Protection against malaria

38. G6PD deficiency • Clinical and laboratory findings • Episode of acute hemolytic anemia in anotherwise healthy person; neonatal jaundice • following oxid. injury – drug (antimal. – primaquine,; sulfoamides, nitrofurantoin, nalidixic acid; TNT, , infections, food • Variable severity

39. Enzyme deficiency: G6PD deficiency effects of oxidant drug exposure (PB) Red cells with precipitates of denatured globin (Heinz bodies) splenic macrophages pluck out these inclusions → "bite cells"

40. Increased destruction of ery=hemolysis I. Intrinsic causes A. hereditary • membrane – cytoskeleton, lipid synthesis • enzymes – deficiencies - G6PD, glutathione synthetase, pyruvate kinase →hemoglobin– abnormal quantity (deficient synthesis of globin) quality (structurally abnormal Hb)

41. Sickle cell anemia (PB) • Shape: sickle • Hereditary hemoglobinopathy • Structurally abnormal hemoglobin HbS • abnormal physiochemical properties • B-globin – 6th position, • Molecular defect: point mutation • valine for glutamic acid

42. Sickle cell anemiaHemolysis, microvascular occlusion

43. Sickle cell anemia • Oxyg. HbS: liquid • Deoxyg.:viscous gel →fibers HbS - aggregation and polymerization • Sickle shape; Initially: reversible (with oxygenation) • Repeated: irreversible sickling • Membrane damage

44. Rate and degree of sickling 1. Amount of HbS Heterozygotes: HbS and HbA – only sickle cell trait (sickling when marked hypoxia) Homozygotes: severe anemia 2. Hemoglobin concentration the higher, the worse 3. Fall in pH→ deoxygenation

45. Sickle cell anemia - clinical manifestation • chronic hemolytic anemia (ery survival 20 days) chronic hyperbilirubinemia, Hbemia, jaundice, gallstones aplastic crisis 2. occlusion of small vessels → thrombosis, ischemia, necrosis painful crises 3. splenomegaly 4. increased susceptibility to infections 5. activation of the bone marrow, extramedullary haematopoiesis

46. Diagnosis • Clinical, laboratory – blood smear • HbS - electrophoresis • Clinical course variable • Therapy symptomatic

47. Thalassemia • Deficient synthesis of globin chains • Globin chain absent or amount reduced • β - major, minor (more common), intermedia • β +,0 • Homo/heterozygous • α +,0

48. Scleral jaundice Haemolytic autoimmune anaemia

49. Pathogenesis of β-thalassemia major aggregates of unpaired α-globin chains not visible Blood transfusions correct the anemia reduce the stimulus for marrow expansion, but add to systemic iron overload

50. Thalassemia major: gallbladder - bilirubin gallstones