1. APLASTIC ANEMIA Dr. Bhavesh S. Jarwani

2. APLASTIC ANAEMIA Empty Marrow Syndrome Is a disorder characterized by marked reduction or absence of erythroid, granulocytic and megakaryocytic cells in the marrow with resultant pancytopenia and reduced number of CD34+ and colony forming cells.

3. Hematopoitic cell destruction by Immune Mechanisms in Acquired Aplastic Anemia. There is normal stromal cells but decreased number of colony forming cells and stem cells as it can be seen in Ps, radiographically, and also the stem cells number

4. Immune Mechanics in Aplastic Anemia T cells: mononuclear cells from the ps or marrow suppressed the csf by the progenitor cells have elevated numbers of the cytotoxic T Lymphocytes Cytokines: peripheral blood from this patients had raised levels of the soluble cytokines as y-INF and TNF and also y-INF mRNA, evidence of the gene expression

5. Incidence: 5-10 cases per million persons per year Age: Bimodal distribution –young adults (15-30 years) –elderly (above 60 years) Same incidence in Male and Female Geographic distribution –more common in Asia than in North America and Europe

6. Etiology Acquired: –Drugs: Antimetabolites, antimitotic agents, gold, chloramphenicol, phenylbutazone and sulfonamides –Radiation –Chemicals: benzenes, Solvents, insecticides –Viruses : Hepatitis A,B,C, E, G, and Parvo B19, CMV –PNH –Misc: pregnancy, connective tissue disorders, Graft-vs-Host disease Hereditary: –Fanconi’s Anemia –Dyskeratosis congenita –Shwachman Syndrome Idiopathic: –50-65 % of cases

7. Etiology Drugs may be having direct dose dependent toxicity to the marrow or having Idiosyncrasy to the drugs: –Antineoplastic and antimetabolites are having direct dose dependent toxicity –Chloramphenicol having first immediate dose dependent toxicity and long term Idiosyncrasy after one to two w eeks later Radiation: –Chronic exposure to low-dose and localized exposure leading to development of aplastic anemia Benzene and insecticides: –direct and also induction of the hapten leading to i mmune mediated bone marrow suppression Virus: –Hepatitis A,B,C,E and G. Parvovirus B19, CMV Pregnancy:

8. Etiology PNH: –defect in PIG-A gene, so partial or complete inability to construct Glycosylphosphatidylinositol(GPI) anchor for the attachment of CD55, CD59 –diagnosis: Ham’s test, Flow cytometry using antibodies against cell surface antigens CD55, CD59 which are lacking in disease Congenital disorders: –Fanconis Anemia –Shwachaman syndrome –Dyskeratosis congenita

9. Pathogenesis: Having stem cell defect: how? Having immune mechanism in this disease progress Evidence: immunosupresion better results in BMT, Better treatment with Antithymocyte globulin and alsoimmuno-suppression having comparable results to BMT Activated T cells: overproduction of the cytokines as interferon y and TNFb that in turn leading to hematopoietic progenitors

11. How the destruction occurs: induction of the killing through programmed cell death. Progenitor cells have Fas receptor, triggering that though the cytokines induces the apoptosis. Also induces the production of the nitric oxide by marrow cells that in turn leads to the cell destruction transcription regulator is required, I.e. IRF, interferon regulatory factor-1, and this is required for the negative action of the INF-y.

12. ANTIGENS ENCITING APLASTIC ANEMIA: Either endogenous or exogenous: –exogenous: hepatitis, drugs –endogenous: somatic mutation in the HSC leading to autoimmunity and at last the marrow failure immune response to peptides derived from the aberrantly processed proteins like GPI Determinants of the autoimmunity: –HLA class I and II are associated with many human autoimmune diseases, HLA-DR2 is over expressed in American and Europe. –specific class 2 haplotypes in Japanese that are respondent to the CSA Drugs: –genetically defined metabolic detoxification pathway in aplastic a nemia

13. Presentation of Anemia, Neutropenia and Thrombocytopenia Hemorrhagic lesion of the gums in a patient with aplastic anemia caused by infection with Capnocytophaga ochraceus; such lesions are easily confused with those of herpes simplex.

14. 26-year-old woman with acute aplastic anemia and 1 day of facial pain/swelling. Mouth open involuntarily due to perioral edema. Needle aspirate of small purplish area near right alar revealed P aeruginosa.

15. Diagnosis and differential Diagnosis Peripheral Smear normocytic, and normochronic with low reticulocyte count index <2%.i.e. hypoproliferative marrow Bone Marrow marrow spicules with empty fat cells and very few hematopoietic cells. Presence of dysplasia suggest MDs, so as karyotype anomaly suggest MDS. Other tests: LDH, haptoglobulin, hams test, flow cytometry to know about PNH and also for fancony’s anemia hairy cell Leukemia: cytochemical I.e. tartrate-resistent acid phosphatase, and phenotypic, I.e. CD25+ monoclonal B cells Classification: Severe: when nautrophic <500, platelets <20,000/microL, and reticulocyte <20,000/microL Supersevere: when neutrophic count<200/microL

16. CharacteristicAAHMDSMDS Abnormal neutrophils NoYes Abnormal mega.,NoYes Increased blastsNoSometimesOften FibrosisAbsentOccasional PNH15%25%4% Progenitor cellsVery lowLow normalVariable Progress to LeuVery low25%>25% T cell activationYes Increased TNF, INKy Yes yes

17. Course and prognosis of the disease: –with transfusion support alone: 80 % of cases succumb to death in 18 to 24 months, related to PMN count –with MBT and Immunosuppresion: curative in 60 to 90 % of cases, risk of CGVH threat Supportive care: –transfusion of the blood products, CMV seronegative should be given transfusion from the family members should be avoided to prevent sensitization. –pooled donor platelets but leads to sensitization –in refractory cases need HLA matched transfusion –packed cells filtrated to remove leukocyte and platelets –iron overload : give chelating therapy deferoxamine –CMV prophylaxis –Staph. Aeureus * hospitalization * menses

18. Treatment modalities: –ATG: purified monomeric IgG from hyperimuune horse with human thymocyte and thoracis duct lymphocytes –50 - 70 % good response –20-30 complete and durable recovery –70-80 have partial response Complication: –MDS 30-6- % –also secondary solid tumors –response after 8 to 12 weeks Other drugs to suppress immunity: –cyclosporine and cyclophosphamide and also high dose steroid Growth factors: –Erythropoeitin, CG-CSF, GM-CSF, ILs 1,3, 6

19. Response is slow Response is often incomplete Response may require successive course of immunosuppression Relapse is common and require maintenance therapy Evolution to clonal disease is common: Overall 15% of the cases develop clonal disease like MDS or PNH Much higher after immunossuppression that BMT

20. Kinetics of the response to immunusuppressive treatment:

21. Relapse: Definition: –Decrease in any of the peripheral cell counts to less than 50% of the median sustained counts during remission. –Return of the counts to levels meeting the definition of severe a plastic anemia. –Or by resumed need of blood transfusion support. Risk: 35% at 11 years –45% at 5 years –and reaches plateau at 64% between 7 to 10 years

22. Remission criteria: RemissionTransfusionsPeripheral blood counts CompleteNoAll cell lines normal for age and gender PartialNoCriteria for severe not met andOne cell line improvement Hb: +3 g/dL(is initial <6 gm/d PMN +0.5*10^9/L(pre <0.5) *2 (if pre >5*10^9) Platelets+20*10^9/L(pre <20.. *2 ( if pre >20….) No remissionYesEarlier criteria not met with

23. Relapse after initial treatment

24. Failure free survival in patients treated with ALG and ALG+CsA

25. DrugsMechanism of actionPractice or in research only ATGDepletion of T cells, Tolerance, Induction?? In clinical practice CSABlock of cyclophilin A dependent imuune activation, inhibition of IL-2 and interferon –y production In clinical practise CyclophosphamideT cell depletionSevere Aplastic Anaemia, NIH Anti-IL-2R antibodies Elimination of activated lymphocyte Moderate aplastic anemia, pure red cell aplasia, and NIH Mycophenolic acidNoncomeptitive reversible inhibition of inosine monophosphate dehydrogenase, inhibition of T cell proliferation With ATG and CSA in children NIH, also for relapse SirolimusInactivate of Protein kinase p70, block in IL2 dependent proliferation of T cells Only for solid organ transplantation

26. Current and Future treatment strategies Evaluation of the best timing of immunosuppression Multidrug immunosuppression vs sequencial immunosuppression Early retreatment with immunosuppression Improvement of current protocol –dose of G-CSF –newer growth factors like stem cell factor New immunosuppresive protocol –high dose cyclophosphamides –new immunosuppressive treatment