 Introduction to Haematopoietic System and

Disorders of Erythroid Series









 BONE MARROW AND HAEMATOPOIESIS

 erythrocytes leucocytes thrombocytes

 HAEMATOPOIETIC ORGANS
 yolk sac liver and spleen bone marrow extramedullary haematopoiesis

 HAEMATOPOIETIC STEM CELLS

 lymphoid non- lymphoid or myeloid i.e. poiesis






 BONE MARROW EXAMINATION

 aspiration trephine biopsy

 BONE MARROW ASPIRATION

 Table 10.1
  TREPHINE BIOPSY Jamshidi trephine needle

 ERYTHROPOIESIS

 ERYTHROPOIETIN

 Significance




 ERYTHROID SERIES

 PROERYTHROBLAST
 BASOPHILIC (EARLY) ERYTHROBLAST
 POLYCHROMATIC (INTERMEDIATE) ERYTHROBLAST
 ORTHOCHROMATIC (LATE) ERYTHROBLAST
 RETICULOCYTE

 vital staining

 THE RED CELL

 RED CELL MEMBRANE

 proteins
 lipids
 Carbohydrates

 spherocytosis ovalocytosis echinocytosis stomatocytosis

 NUTRITIONAL REQUIREMENTS FOR ERYTHROPOIESIS

 Metals
 Vitamins
 Amino acids

 HAEMOGLOBIN globinhaemHbAHbF
 HbA2 

 RED CELL FUNCTIONS

 Oxygen carrying sigmoid shape
  lower affinity for oxygen
 fall in thepH
 A rise in red cell concentration of 2,3-BPG
 CO2 transport
 RED CELL DESTRUCTION

 NORMAL VALUES AND RED CELL INDICES

 normal red cell
 packed cell volume haematocrit haemoglobin content

 absolute values
 Mean corpuscular volume (MCV)

 Mean corpuscular haemoglobin (MCH)

 Mean corpuscular haemoglobin concentration (MCHC)

 Red cell distribution width (RDW)

 ANAEMIA—GENERAL CONSIDERATIONS

 PATHOPHYSIOLOGY






 GENERAL CLINICAL FEATURES

 The speed of onset of anaemia:

 The severity of anaemia:
 The age of the patient:
 The haemoglobin dissociation curve:
 SYMPTOMS
 SIGNS
 Pallor

 Cardiovascular system
 Central nervous system
 Ocular manifestations
 Reproductive system
  Renal system
 Gastrointestinal system

 GENERAL SCHEME OF INVESTIGATIONS OF ANAEMIA

o HAEMOGLOBIN ESTIMATION
o PERIPHERAL BLOOD FILM EXAMINATION
o Variation in size (Anisocytosis)
 macrocytosismicrocytosisdimorphic
 Macrocytes
 Microcytes
 Variation in shape (Poikilocytosis)
 Inadequate haemoglobin formation (Hypochromasia) hypochromasiahyperchromasia
 Compensatory erythropoiesis
 Polychromasia
 Erythroblastaemia
 Punctate basophilia basophilic stippling
 Howell-Jolly bodies
 5. Miscellaneous changes
 Spherocytosis

 Schistocytosis
 Irregularly contracted red cells
 Leptocytosis Target cell
 Sickle cells or drepanocytes
 Crenated red cells
 Acanthocytosis
 Burr cells
 Stomatocytosis
 Ovalocytosis elliptocytosis

 C. RED CELL INDICES




 LEUCOCYTE AND PLATELET COUNT
 RETICULOCYTE COUNT
 ERYTHROCYTE SEDIMENTATION RATE
 BONE MARROW EXAMINATION
 CLASSIFICATION OF ANAEMIAS

 PATHOPHYSIOLOGIC CLASSIFICATION

o Anaemia due to blood loss



o Anaemia due to impaired red cell formation
 Cytoplasmic maturation defects
o
o
 Nuclear maturation defects

 Haematopoietic stem cell proliferation and differentiation abnormality

o
 o
 Bone marrow failure due to systemic diseases
o



 Bone marrow infiltration
o
o
o
o
 Congenital anaemia
o
o
 hypoproliferative anaemias
o Anaemia due to increased red cell destruction (haemo lytic anaemias)



 MORPHOLOGIC CLASSIFICATION
o Microcytic, hypochromic
o Normocytic, normochromic
o Macrocytic

 HYPOCHROMIC ANAEMIAS




 IRON DEFICIENCY ANAEMIA

 IRON METABOLISM

 ABSORPTION mucosal

 block mechanismIron from diet containing haem is better absorbed than non-haem iron:
 nonhaem iron ferric reductaseferroportin hephaestin
 haem iron

 TRANSPORT transferrintransferrin receptors

 EXCRETION
 DISTRIBUTION
 Haemoglobin

 Myoglobin

 Haemand nonhaemenzymes
 Transferrinbound iron
 functional form
 Ferritin and haemosiderinstorage forms

 PATHOGENESIS





 see below

 ETIOLOGY

 FEMALES IN REPRODUCTIVE PERIOD OF LIFE

 Blood loss
 Inadequate intake
 Increased requirements

 Table 10.4

 POSTMENOPAUSAL FEMALES
 Post-menopausal uterine bleeding
 Bleeding from the alimentary tract
 ADULT MALES
 Gastrointestinal tract
 Urinary tract
 Nose
 Lungs
 INFANTS AND CHILDREN

 CLINICAL FEATURES

 ANAEMIA
 EPITHELIAL TISSUE CHANGES

 LABORATORY FINDINGS

o storage iron depletion

 iron deficient erythropoiesis

 frank iron deficiency anaemia

 BLOOD PICTURE AND RED CELL INDICES

 Haemoglobin
 Red cells dimorphic
 Reticulocyte count
 Absolute values
 Leucocytes

 vi) Platelets

 BONE MARROW FINDINGS

  Marrow cellularity

 Erythropoiesis cytoplasmic maturation lags behind

 Other cells
 Marrow iron
 BIOCHEMICAL FINDINGS
 serum iron
 Total iron binding capacity (TIBC)
 Serum ferritin

 Red cell protoporphyrin

 Serum transferrin receptor protein

 PRINCIPLES OF TREATMENT

 CORRECTION OF THE DISORDER

 CORRECTION OF IRON DEFICIENCY
o Oral therapy

o Parenteral therapy



o

 SIDEROBLASTIC ANAEMIA

 SIDEROCYTES AND SIDEROBLASTS

 SIDEROCYTES Pappenheimer bodies

 SIDEROBLASTS
 Normal sideroblasts
 Abnormal sideroblasts
 One type
 ringed sideroblast

 TYPES OF SIDEROBLASTIC ANAEMIAS

 HEREDITARY SIDEROBLASTIC ANAEMIA aminolevulinic acid (ALA) synthetase

 ACQUIRED SIDEROBLASTIC ANAEMIA

 Primary acquired sideroblastic anaemia

 Secondary acquired sideroblastic anaemia

o Drugs, chemicals and toxins:
o Haematological disorders:
o Miscellaneous:
  LABORATORY FINDINGS

 anaemia
 blood picture
 Absolute values

 Bone marrow examination

 Serum ferritin
 Serum iron
 iron deposition

 PRINCIPLES OF TREATMENT

 ANAEMIA OF CHRONIC DISORDERS

 PATHOGENESIS
 defective red cell production and reduced red cell lifespan
 Defective red cell production

 
 Reduced red cell lifespan

 LABORATORY FINDINGS

o Haemoglobin
o Blood picture
o Absolute values
o Reticulocyte count
o Red cell survival
o Bone marrow
o Serum iron and TIBC Table 10.5
o Serum ferritin

 ix) Other plasma proteins phase reactants

 MEGALOBLASTIC ANAEMIAS—VITAMIN B12 AND FOLATE DEFICIENCY






 MEGALOBLASTIC ANAEMIA
 maturation of the nucleus is delayed relative to that of the cytoplasmmegaloblastsmacrocytosis

 VITAMIN B12 METABOLISM

 BIOCHEMISTRY

 Table 10.
 SOURCES
 ABSORPTION
 TISSUE STORES
 FUNCTIONS
 Firstly, as methyl cobalamin (methyl B12)
 

 Secondly, as adenosyl cobalamin (adenosyl B12)

 

 FOLATE METABOLISM
 BIOCHEMISTRY pteroyl glutamic acid (PGA)
 SOURCES
 ABSORPTION AND TRANSPORT

 TISSUE STORES

 FUNCTIONS
 Thymidylate synthetase reaction
 Methylation of homocysteine to methionine

 BIOCHEMICAL BASIS OF MEGALOBLASTIC ANAEMIA

 Thymidylate synthetase reaction 

 Homocysteinemethionine reaction

 methyl-folate trap hypothesisformate-saturation hypothesis

 ETIOLOGY AND CLASSIFICATION OF MEGALOBLASTIC ANAEMIA

 VITAMIN B12 DEFICIENCY

 FOLATE DEFICIENCY

 OTHER CAUSES

 Table 10.8

 CLINICAL FEATURES

 Anaemia
 Glossitis
 Neurologic manifestations
 Others
  LABORATORY FINDINGS

o General laboratory investigations of anaemia

o Special tests to establish the cause of megaloblastic anaemia

o General Laboratory Findings

 BLOOD PICTURE AND RED CELL INDICES
 Haemoglobin
 Red cells macro- cytosis
 Reticulocyte count
 Absolute values
 Leucocytes
 Platelets

 BONEMARROWFINDINGS
 Marrow cellularity
 Erythropoiesis Megaloblasts nuclear
 maturation lags behind that of cytoplasm
 Other cells
 Marrow iron
 Chromosomes
 BIOCHEMICAL FINDINGS
 serum unconjugated bilirubin and
 serum iron and ferritin
o Special Tests for Cause of Specific Deficiency

 TESTS FOR VITAMIN B12 DEFICIENCY

 SERUM VITAMIN B12 ASSAY

 Microbiological assay Euglena gracilisLactobacillus leichmanniiEscherichia coli Ochromonas malhamensisE. gracilis
is
 Radioassay
 SCHILLING TEST (24-HOUR URINARY EXCRETION TEST)
 Stage I: Without IF


 Stage II: With IF


 Stage III: Test for malabsorption of vitamin B12
 SERUM ENZYME LEVELS
 TESTS FOR FOLATE DEFICIENCY formiminoglutamic acid (FIGLU) urinary excretion
 URINARY EXCRETION OF FIGLU
 SERUM FOLATE ASSAY
 Microbiological assay Lactobacillus caseiL. casei
 Radioassay 
 RED CELL FOLATE ASSAY
 PRINCIPLES OF TREATMENT

 PERNICIOUS ANAEMIA

 PATHOGENESIS

 other auto- immune diseases

 circulating autoantibodies
 Relatives
 Corticosteroids
  agammaglobulinaemia
 HLA types

 MORPHOLOGIC FEATURES

 CLINICAL FEATURES

 PRINCIPLES OF TREATMENT

 HAEMOLYTIC ANAEMIAS AND ANAEMIA DUE TO BLOOD LOSS


 DEFINITION AND CLASSIFICATION
 compensated haemolytic disease

 Firstly, (intravascular haemolysis)(haemoglobinuria)

 Secondly, (extravascular

 haemolysis)

 Acquired haemolytic anaemias (i.e. extracorpuscular)

 Hereditary haemolytic anaemias (i.e. intracorpuscular)

 GENERAL ASPECTS

 GENERAL CLINICAL FEATURES

o
o
o
o

 Table 10.10



 LABORATORY EVALUATION OF HAEMOLYSIS





o Tests of Increased Red Cell Breakdown

 Serum bilirubin
 Urine urobilinogen
 Faecal stercobilinogen
  Serum haptoglobin 
 Plasma lactic dehydrogenase
 Evidences of intravascular haemolysis

 Tests of Increased Red Cell Production

o Reticulocyte count
o Routine blood film
o Bone marrow
o X-ray of bones

 Tests of Damage to Red Cells

o Routine blood film
o Osmotic fragility
o Autohaemolysis test
o Coombs’ antiglobulin test
o Electrophoresis
o Estimation of HbA2
o Estimation of HbF
o Tests for sickling.
o Screening test for G6PD deficiency

o Tests for Shortened Red Cell Lifespan

 ACQUIRED HAEMOLYTIC ANAEMIAS

o IMMUNOHAEMOLYTIC ANAEMIAS

 Autoimmune haemolytic anaemia (AIHA)



 Drug-induced immunohaemolytic anaemia
 Isoimmune haemolytic anaemia

 Autoimmune Haemolytic Anaemia (AIHA)

 ‘WARM’ ANTIBODY AIHA
 PATHOGENESIS

 Table 10.12

 CLINICAL FEATURES



 

o
 LABORATORY FINDINGS









 ‘COLD’ ANTIBODY AIHA

 PATHOGENESIS
 Cold agglutinin disease I
 Mycoplasma ,
 Paroxysmal cold haemoglobinuria (PCH) P
 Mycoplasma,

 CLINICAL FEATURES





 LABORATORY FINDINGS
o
o young red cells are affected more
o
o
o IP

 Drug-induced Immunohaemolytic Anaemia

 METHYL DOPA TYPE ANTIBODIES 

 PENICILLININDUCED IMMUNOHAEMOLYSIS
 INNOCENT BYSTANDER IMMUNOHAEMOLYSIS

 Isoimmune Haemolytic Anaemia

o MICROANGIOPATHIC HAEMOLYTIC ANAEMIA

 EXTERNAL IMPACT

 CARDIAC HAEMOLYSIS
 FIBRIN DEPOSIT IN MICROVASCULATURE
 Abnormalities of the vessel wall
 Thrombotic thrombocytopenic purpura
 Haemolytic-uraemic syndrome
  Disseminated intravascular coagulation
 Vasculitis in collagen diseases

o HAEMOLYTIC ANAEMIA FROM DIRECT TOXIC EFFECTS

 Malaria
 Bartonellosis
 Septicaemia Clostridium welchii
 Other microorganisms Escherichia coli
 Copper
 Lead poisoning
 Snake and spider bites
 Extensive burns

o PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA (PNH)

 PATHOGENESIS

 decay accelerating factor (DAF, CD55) membrane inhibitor of reactive lysis (MIRL, CD59),

 CLINICAL AND LABORATORY FINDINGS






 in vitro Ham’s test

o HAEMOLYTIC ANAEMIA IN SPLENOMEGALY

 HEREDITARY HAEMOLYTIC ANAEMIAS




 HEREDITARY ABNORMALITIES OF RED CELL MEMBRANE

 Hereditary Spherocytosis

 PATHOGENESIS
 Spectrin deficiency

 -spectrin spectrin
 Ankyrin abnormality
 microspherocyteshyperspheroidal red cells
 CLINICAL FEATURES
 Anaemia
 Splenomegaly
 Jaundice
 Pigment gallstones

 LABORATORY FINDINGS
 Anaemia
 Reticulocytosis

 MCHC
 osmotic fragility is increased
 Autohaemolysis test
 Direct Coombs’ (antiglobulin) test

 Hereditary Elliptocytosis (Hereditary Ovalocytosis)

 spectrin

 Hereditary Stomatocytosis
 stomatin

 HEREDITARY DISORDERS OF RED CELL INTERIOR

 Red cell enzyme defects (Enzymopathies) Defects in the hexose monophosphate shunt:
 Defects in the Embden-Meyerhof (glycolytic) pathway:

 Disorders of haemoglobin (haemoglobinopathies)

 Structurally abnormal haemoglobin:

 Reduced globin chain synthesis:

 Red Cell Enzyme Defects (Enzymopathies)

 G6PD DEFICIENCY

 PATHOGENESIS
 CLINICAL FEATURES
 Acute haemolytic anaemia

 affects the older red cells only

 Chronic haemolytic anaemia
 Neonatal jaundice

 LABORATORY FINDINGS
o During the period of acute haemolysis, Heinz body haemolytic anaemia.
o Between the crises,

 PK DEFICIENCY
 LABORATORY FINDINGS






 Haemoglobinopathies

 Qualitative disorders
 Quantitative disorders
 homozygous heterozygous 

 STRUCTURALLY ABNORMAL HAEMOGLOBINS

 SICKLE SYNDROMES
 falciparum
 As heterozygous state
 As homozygous state
 As double heterozygous states 

 Heterozygous State: Sickle Cell Trait

 LABORATORY FINDINGS
 Demonstration of sickling
 Haemoglobin electrophoresis

 Homozygous State: Sickle Cell Anaemia

 PATHOGENESIS

 Basic molecular lesion single point mutation substitution of valine for glutamic acid 
 Mechanism of sickling sickling in vitro
 Reversibleirreversible sickling
 Factors determining rate of sickling:

 Presence of non-HbS haemoglobins:

 Intracellular concentration of HbS
 Total haemoglobin concentration
 Extent of deoxygenation
 Acidosis and dehydration
 Increased concentration of 2, 3-BPG in the red cells
 CLINICAL FEATURES
 Anaemia
 Vasoocclusive phenomena
 Microinfarcts
 Macroinfarcts
  Constitutional symptoms

 LABORATORY FINDINGS





 Double Heterozygous States

 
 OTHER STRUCTURAL HAEMOGLOBINOPATHIES

 HbC Haemoglobinopathy
 

 HbD Haemoglobinopathy
 HbD PunjabHb-Los Angeles
 HbE Haemoglobinopathy
 
 Haemoglobin OArab Disease

 UnstableHb Haemoglobinopathy
 congenital non-spherocytic haemolytic anaemia congenital Heinz body haemolytic anaemia

 REDUCED GLOBIN CHAIN SYNTHESIS: THALASSAEMIAS

 DEFINITION
 quantitative abnormalities of polypeptide globin chain synthesisthalassasee Fig. 10.27

 Table 10.14
 GENETICS AND CLASSIFICATION
 and
 thalassaemia minor trait
 thalassaemia major

 PATHOPHYSIOLOGY OF ANAEMIA IN THALASSAEMIA

 Thalassaemia 
 Thalassaemia Heinz bodies

 

 THALASSAEMIA
 MOLECULAR PATHOGENESIS 

 

 
 

 
 
 
 

 Hb Bart’s Hydrops Foetalis

 
 CLINICAL FEATURES in utero

 LABORATORY FINDINGS
o
o
o
o
o

 HbH Disease
 
 Hb Constant Spring
 CLINICAL FEATURES 

 LABORATORY FINDINGS






 -Thalassaemia Trait
 

 homozygous -thalassaemiaheterozygous -thalassaemia

 
 heterozygous -thalassaemia
 CLINICAL FEATURES 
 
 LABORATORY FINDINGS 



 

 -THALASSAEMIAS
 MOLECULAR PATHOGENESIS 
 hereditary persistence of foetal haemoglobin (HPFH)
 

 
 Transcription defect: thalassaemia
 Translation defect: thalassaemia
 mRNA splicing defect:

 + thalassaemia
 thalassaemia
 
 Homozygous form: Thalassaemia major thalassaemia major 

 thalassaemia major
 

 Thalassaemia intermedia 

 
 Heterozygous form: thalassaemia minor (trait) 
 

 thalassaemia minor 

 Hb Lepore syndrome 
 
 -Thalassaemia Major
 thalassaemia major
 CLINICAL FEATURES
  


 LABORATORY FINDINGS
o Anaemia

o Blood film
o Serum bilirubin
o Reticulocytosis
o MCV, MCH and MCHC
o WBC count is
o Platelet count
o decreased osmotic fragility
o Haemoglobin electrophoresis 
o Bone marrow aspirate examination

 PRINCIPLES OF TREATMENT 








 
 -Thalassaemia Minor
 
 CLINICAL FEATURES

 Haemolytic Anaemias and Anaemia Due to Blood Loss

 LABORATORY FINDINGS
 Mild anaemia
 Blood film
 Serum bilirubin
 Mild reticulocytosis
 MCV, MCH and MCHC
 decreased osmotic fragility
 Haemoglobin electrophoresis

 PRINCIPLES OF TREATMENT 
 
 PREVENTION OF THALASSAEMIA

 ANAEMIA OF BLOOD LOSS

 ACUTE BLOOD LOSS




  LABORATORY FINDINGS
o
o
o

 CHRONIC BLOOD LOSS

 APLASTIC ANAEMIA AND OTHER PRIMARY BONE MARROW

DISORDERS

 Bone marrow failure
 Aplastic anaemia
 Other primary bone marrow disorders
 APLASTIC ANAEMIA

 Table 10.15

 ETIOLOGY AND CLASSIFICATION

 PRIMARY APLASTIC ANAEMIA

 Fanconi’s anaemia
 Immune causes in vitro
 SECONDARY APLASTIC ANAEMIA
 Drugs
 Dose-related aplasia
 Idiosyncratic aplasia

 Toxic chemicals
 Infections
 Miscellaneous

 CLINICAL FEATURES






 LABORATORY FINDINGS

 Anaemia
 Leucopenia
 Thrombocytopenia
 Bone marrow examination

 Table 10.16
 PRINCIPLES OF TREATMENT

 General management


 Specific treatment
 Marrow stimulating agents
  Immunosuppressive therapy
 Bone marrow transplantation Other indications

 MYELOPHTHISIC ANAEMIA







 LABORATORY FINDINGS
 leucoerythroblastic reaction

 PURE RED CELL APLASIA

 Transient selflimited PRCA

 Acquired PRCA
 Chronic B19 parvovirus infections

 Congenital PRCA (BlackfanDiamond syndrome) RPS19