1. A Anemia

2. Blood formation SITES STEPS 1-Intrautrine life: Blood cells are formed in the liver and spleen up to the fifth months. After 5th month : bone marrow share in the formation of these cells. 2-After birth: Formation of these cells will be restricted to the bone morrow.

3. Blood formation 3-Adulthood The active bone morrow will be: Restricted to axial skeleton : flat bones, vertebrae, ribs, sternum, ilia. Some extension to the proximal ends of long bone mainly femur. Extramedullary haemopoiesis: When demand for blood formation is increased: The active red BM extends into the shafts of the long bones. The spleen and liver will regain their ability to produce blood elements when bone morrow is affected by some diseases. SITES

4. Blood formation STEPS Pleuri-potent cells Thrambocytopoiesis Granulocyto- poiesis Erthrocyto- poiesis CFU-Mega CFU-Mega Megakaryoblast Megakaryoblast Megadaryocyte Megadaryocyte Platelet Platelet CFU-Mega CFU-Mega Megakaryoblast Megakaryoblast Megadaryocyte Megadaryocyte Platelet Platelet CFU-G CFU-G Myleloblast Myleloblast Promyelocyte Promyelocyte Myelocyte Myelocyte Metamgelocyte Metamgelocyte Juvenil Juvenil Granulocyte (PML) Granulocyte (PML) CFU-G CFU-G Myleloblast Myleloblast Promyelocyte Promyelocyte Myelocyte Myelocyte Metamgelocyte Metamgelocyte Juvenil Juvenil Granulocyte (PML) Granulocyte (PML) BFU-E BFU-E CFU-E CFU-E Proerythroblast Proerythroblast Basophilic erythroblast Basophilic erythroblast Polychromatic erythroblast Polychromatic erythroblast Othrochromatic erythroblast Othrochromatic erythroblast Reticulocytes Reticulocytes BFU-E BFU-E CFU-E CFU-E Proerythroblast Proerythroblast Basophilic erythroblast Basophilic erythroblast Polychromatic erythroblast Polychromatic erythroblast Othrochromatic erythroblast Othrochromatic erythroblast Reticulocytes Reticulocytes SITES

5. Blood formation STEPS

6. Organelles (formed elements): RBCsWBCsThrombocytes Fluid components: plasma in which the above elements are suspended and contain fibrinogen. Blood Constituents

7. Blood formation Normal erythrocytopoiesis depends on: Healthy BM: normal stem cells and architecture. Elements essential for erythropoies: (Maturation factors ) Regulatory hormones: GPO, Androgen thyroxin, cortisol and ACT. Nutritional elements: Protein (high biological value), Mineral (Iron, cupper, znic, selenium ) Vitamins (B, Folic acid, vit c) Erythrocytopoiesis

8. Anemia Definition Types C/P Anaemia = reduction of O 2 carrying capacity of the blood with inadequate O 2 supply to tissue. Anaemia is diagnosed when there is a reduction of (RBCs number) below the reference range for age and sex of the individual. More is defined as reduction in the red cell mass More accurately is defined as reduction in the red cell mass

9. Anemia Definition Types C/P A-Dyshaemopoietic anaemia: (Decreased maturation due to deficiency of maturation factors essential for erythropoiesis). Mineral deficiency: iron, zinc, selenium, cupper Vitamin deficiency: B12, folic acid ; Vit C& pyridoxine Hormonal deficiency: anaemia of renal diseases, pituitary, thyroid or suprarenal deficiency. Protein deficiency : high class AETIOLOGICAL CLASSIFICATION I- Decrease red cell production.

10. Anemia Types B- Hypoproliferative anaemias (BM failure ): Aplastic anaemia. Myelophthisic anaemia (BM replacement anaemia). Anaemia of chronic diseases. AETIOLOGICAL CLASSIFICATION I- Decrease red cell production.

11. Anemia Types II- Haemolytic anaemia: Short life-span of RBCs III- Acute post haemorrhagic anaemia: Loss of RBCs IV- Mixed anaemia. eg. Megalobastosis associated with haemolysis V: Dilutconal anaemia: (raised plasma volume) Pregnancy Oliguric RF Volume-overload AETIOLOGICAL CLASSIFICATION

12. Anemia Types MORPHOLOGICAL CLASSIFICATION A. Microcytic-hypochromic anaemias: Thalassaemia. Iron deficiency anaemia. Anaemia of chronic disease. Sideroblastic anaemia: Hereditary Chronic lead poisoning.

13. Anemia Types MORPHOLOGICAL CLASSIFICATION B-Normocytic-normochromic anaemias: Acute post –haemorrhagic anaemia. Hemolytic anaemia. Aplastic anaemia. Myelophthisic anaemia. Anaemia of chronic diseases.

14. Anemia Types MORPHOLOGICAL CLASSIFICATION C- Macrocytic- normochromic anaemias: Megaloblastic anaemia. Marked reticulocytosis. Myelodysplastic syndromes. Myxoedema. Acquired sideroblastic anaemia.

15. Anemia Definition Types C/P 1-Tissue Hypoxia Impaired functions of the tissues, the degree of impairment depends an the need of the tissue to O2 so CVS, CNS and skeletal muscles are much affected. I- PATHOPHYSIOLOGY The clinical feature of the anaemia could be explained by the following factors.

16. Anemia 2- Compensatory mechanisms Increased COP. Increased O2 delivery from HB to the tissue. Increased erythropoietin production with stimulation of erythropoiesis Increased plasma volume. Redistribution of the blood from less to more vital organs. I- PATHOPHYSIOLOGY The clinical feature of the anaemia could be explained by the following factors. C/P

17. Anemia 3-Rate of blood loss: The rapid the rate of blood loss, the more the severe symptoms will occur especially in elderly. While the slowly falling HB allows for haemodynamic compensation with less symptom. 4- Cause: I- PATHOPHYSIOLOGY The clinical feature of the anaemia could be explained by the following factors. C/P

18. Anemia II- GENERAL SYMPTOMS OF ANAEMIA: 1-Neurological Dizziness, fainting, lack of concentration Blurred or diminished vision Headache, tinnitus Paraesthesia in the fingers and toes Insomnia, irritability. 2-CVS: Angina, dyspnea, palpitation and intermittent claudication by exertion HF in severe cases or presence of other organic cardiac disease, it is high COP failure. 3-Musculo skeletal: Easy fatigability. Tiredness and lassitude. C/P

19. Anemia II- GENERAL SYMPTOMS OF ANAEMIA: 4-GIT: Dyspepsia and anorexia 5-Gental Loss of libido & impotence Menstrual abnormalities as amenorrhea. 6-May be polyuria. C/P

20. Anemia III- PHYSICAL SIGNS: Pallor of the skin and mucous membranes The colour of the skin is unreliable because it depends upon the degree of skin pigmentation and the amount of fluid in the subcutaneous tissues. Best examined : palmer creases, nail bed, and mucous membrane. Peripheral oedema : Slight oedema of the legs probably due to increase in the capillary permeability secondary to hypoxia. High COP failure. Fever : Mild fever may occur in sever anaemia but other causes should be excluded C/P

21. Anemia III- PHYSICAL SIGNS: Fundal changes: Retinal hemorrhages of the flame shape type, exudates and rarely papilloedema. The cardiovascular system: The cardiovascular system: Increased velocity with decreased viscosity of the blood in addition to capillary dilation: Pulse; tachycardia, bounding pulse Cardiac examination :  Loud HS  S3 over mitral or tricuspid area  Haemic murmur: ejection systolic, hearted allover the precordium Raised jugular venous pressure. C/P

22. Anemia III- PHYSICAL SIGNS: Proteinuria and impairment of the concentrating power of kidneys due to anoxia of renal tubules. IV: SPECIAL MANIFESTATIONS RELATED TO THE CAUSE C/P

23. Microcytic Anemia Basic nutritional features and metabolism of iron Dietary sources : Red meat and liver, bread, eggs and green vegetables, mainly in ferric form, Daily minimum requirement 10-12mg of which about 1mg is absorbed.

24. Microcytic Anemia Basic nutritional features and metabolism of iron In the stomach the iron is released from its complex form and is reduced to ferrous form (action of gastrin and Hcl). Iron absorption takes place in the duodenum and proximal jejunum. Factor controlling iron absorption Iron absorption is under regulatory system (Apoferritin-Transferrin system ) present in the intestinal mucosa and regulate absorption of the iron according to body requirement. Absorption

25. Microcytic Anemia Basic nutritional features and metabolism of iron Absorption Factors enhancing iron absorption Pregnancy Iron deficiency anaemia Increased erythropoiesis Vit. C. Factors decrease iron absorption : Excess phosphate, tannates, phytate in diet Iron overload haemochromatosis Decreased erythropoies eg a plastic anaemia Malabsorption syndrome Decreased HCI atrophic gastritis.

26. Microcytic Anemia Basic nutritional features and metabolism of iron Transport There is a diurnal rhythm with higher level in the morning, iron is transported in the plasma bound to transferrin. Utilization : incorporation into Hb, myoglobin and tissue enzymes.

27. Microcytic Anemia Basic nutritional features and metabolism of iron Storage : About two-thirds of the total body iron is in the circulation as haemoglobin. Iron is stored in reticulo-endothelial cells, hepatocytes, spleen, bone marrow and skeletal muscle about two thirds as ferritin and one- third as haemosiderin. Iron loss: (0.5 mg/day). Via Hair and nail growth Epithelium of the skin and mucus membrane. body excreta : stool and urine

28. Microcytic Anemia Aetiology True deficiency (defective intake) Rare: Prolonged starvation and famines. Infancy (milk is poor in iron) Conditioned deficiency (normal demand and intake but there are defective absorption and utilization) Not common: Ferric form cause. Decreased HCL Iron binder: phosphate, phytate, tannates Malobsorption syndrome. Relative deficiency : (increased requirement ) common cause. Menstruating females. Pregnancy, labor. Growing children. Convalescence from disease. TTT DD Lab C/P

29. Microcytic Anemia Aetiology Chronic blood loss : the commonest cause Frank blood loss  Menorrhagia  Repeated GI bleeding, haemeptysis, epistaxis, haematuria  Bleeding tendencies  Repeated blood donation Occult blood loss via GIT:  Anckylstoma & schistomiasis  Oozing OV, PU.  Neoplasm.  Inflammatory bowel disease ulcerative colitis  TB enteritis.

30. Microcytic Anemia General manifestations of anaemia Especial manifestations of iron deficiency anaemia. Epithelial changes: GIT manifestations Angular stomatitis. Atrophic glossitis (red, glazed, smooth tongue). Atrophy of the gastric mucosa Small splenomegaly Dermatological changes Brittle nails thinning and ridging and loss of luster. Koilonychia; spoon-shaped nails in severe cases: Brittle hair TTT Aetiology C/P Lab DD

31. Microcytic Anemia Features of special types: 1- Plummer-Vinson –syndrome: Common in middle aged female Postcricoid esophageal web cause dysphagia 2- Ankylostoma infestation: Perverted appetite: (pica) eating mud, stones and chalk. Epigastric pain (DD= D. ulcer ), altering bowel habits Endemic parasites (trapezoid face) The symptoms are mild and to variable. Investigations:  Stool: Ova.  CBC: eosinphilia. C/P

32. Microcytic Anemia A.T o diagnose iron deficiency anaemia CBC: The red cells are microcytic, (MCV<80f1) and hypochromic (MCH < 27pg) anisocytosis and poikilocytosis (variation in size and shape). Eosinophilia is present in cases of ankylostoma infestation. Bone Marrow: Absent iron store, Normoplastic hyperplasia,  Hb in maturely erythroblasts. DD Lab C/P Aetiology TTT

33. Microcytic Anemia A.To diagnose iron deficiency anaemia Serum iron study Decreased serum iron (n=70-170 mg%). Increased total iron binding capacity (TIBC).(n=250-450mg%). Decreased serum ferritin levels.  Reflect iron stores.  The normal values are 30-300 mg/L in males and 15-200 mg/L in females and investigation of gastrointestinal tract are often required.  Falsely raised value in cases of acute phase reactant e.g malignancy. Decreased transferrin saturation (n=25- 50%) Lab

34. Microcytic Anemia B-Investigation for the causes B- Investigation for the causes Stool analysis: Occult blood, ankylstoma & Bilharizasis. Occult blood, ankylstoma & Bilharizasis. GI cause: GI cause:  Imaging : barium swallow, meal or enema.  Endoscopic studies: upper and lower.  Achlorhydria Haemostatic profile. Lab

35. Microcytic Anemia Microcytic anaemia Anaemia of chronic disease DD TTT C/P Lab Aetiology

36. Microcytic Anemia The aim of the treatment is to correct the anaemia and build up iron stores Correction of underlying cause if possible Correction of underlying cause if possible Iron replacement Iron replacement Oral iron: 200 mg anhydrous ferrous sulphate three times daily. 200 mg anhydrous ferrous sulphate three times daily. The response is a rise in Hb concentration of 1 gm/dl per week, The response is a rise in Hb concentration of 1 gm/dl per week, Side effects nausea, abdominal pain, diarrhea or constipation. Side effects nausea, abdominal pain, diarrhea or constipation. TTT DD Lab C/P Aetiology

37. Microcytic Anemia Parenteral iron: Indication : General intolerance of oral preparation even at low dose. Severe malabsorption and those who have gastrointestional diseases. Rapid iron loss. Preparation Iron sucrose ( ferrosac – venofer) Good safety and efficacy profile. Given IV or slowly IV infusion. Amp: 5ml = 100 mg. TTT

38. Microcytic Anemia Iron dextran (cosmofer - imferon) Good efficacy but more side effects. Giving IM, or IV infusion. Amp 2 ml = 100mg. Side effects: Local pain, staining inflammation, abscess formation General: hypersensitivity reaction, fever, rigor, hypotension N.B: Test dose is required prior to the use of iron therapy. TTT

39. Microcytic Anemia Transfusion therapy : It should be packed RBCs. Indications:  Sever (Hb < 7 gm/dl) andsymptomatizing anemia/dl)  Complicated anaemia:-HF TTT

40. Microcytic Anemia TTT Lab Mechanism Aetiology Type of anaemia may be microcytic hypochromic or more common normocytic normochromic. Endocrinal disorders : hypothyroidism, hypocorticalisin, hypogonadism in male. Inflammatory diseases : collagenosis, chron’s disease. Chronic infection: as TB, sarcoidosis, oestomylitis. Neoplastic diseases. Malabsorption. Organ failure, liver and kidney

41. Microcytic Anemia Decreased serum iron and TIBC. Normal or raised serum ferritin Normal BM iron. TTT Lab Mechanism Aetiology

42. Microcytic Anemia Definition Aetiology It is a refractory microcytic hypochromic anaemia (peripheral blood) characterized by the presence of sidroblasts in the bone marrow. Sidroblasts are:  Erythroblasts inside which iron accumulate into the mitochondria of erythroblasts owing to disordered haeme synthesis.  A ring of iron granules is formed around the nucleus.

43. Microcytic Anemia Inherited: X-linked disease transmitted by females. Acquired :  Primary: one of the myelodysplastic syndromes  Secondary:  Other types of myelodysplasia  Myeloproliferative disorders  Myeloid leukemia  Drugs as isoniazid, alcohol, lead Definition Aetiology

44. Microcytic Anemia Differential diagnosis of Microcytic anaemia:Sideroblasticanaemia Thalassaem ia Anaemia of Chronic disease Iron deficienc y Low in inherited but in acquired type Very low Low normal or normal ReducedMCV RaisedNormalReducedReduced Serum iron NormalNormalReducedRaised Serum TIBC RaisedNormal Normal or raised Reduced Serum ferritin PresentPresentPresentAbsent Iron in BM Ring forms Present Absent or reduced Absent Iron in erythroblasts

45. MacrocyticAnemia MACROCYTIC ANAEMIAS This can be divided into: 1-Megaloblastic type. 2-Non megaloblastic types depending on bone marrow findings.

46. MacrocyticAnemia MEGALOBLASTIC ANAEMIA Megaloblastic anaemia This anaemia in which DNA syntheses is impaired with delayed nuclear maturation. This will lead to formation of megaloblast i.e. large cells with large immature nucleic ( cellular gigantism). The cells affected are those rapidly developing: haematopoietic cells, GI mucosa, and skin. Megaloblastic changes occur in 1- Vitamin B12 deficiency or abnormal vit. B12 metabolism 2- Folic acid deficiency or abnormal folate metabolism 3- Congenital enzyme deficiencies in DNA synthesis or drugs interfering with DNA synthesis (hydroxyurea, azathioprine). 4-Myelodysplasia due to dyserythropoiesis.

47. MacrocyticAnemia Hematological values 1-MCV>96 Fl unless there is a coexisting cause of microcytosis. 2-The peripheral blood film shows macrocytes with hypersegmented polymorphs with six or more lobes in the nucleus. If severe there may be leucopenia and thrombocytopenia.

48. MacrocyticAnemia (COBLAMIN)12 VITAMIN B *Vit B12 is synthesized by certain micro- organism. *Sources: meat, fish, eggs, and milk but not plants *It is not destroyed by cooking. *Daily requirement is 1-2 mg / day. *Storage : the average adult stores 2-3 mg in the liver, it may take two years or more before B12 deficiency, develops as the daily losses are small (1-2mg).

49. MacrocyticAnemia Absorption: Vit. B12 is liberated in the stomach, bound by intrinsic factor (IF) and absorbed through the terminal ileum, transported by transcobalamin I and to lesser extend by transcobalamin II and III. It is essential for: 1-haematopoiesis 2-GIT mucosa integration 3-Formation of myelin of nervous system.

50. MacrocyticAnemia CAUSES OF VIT. B12 DEFICIENCY I- True deficiency: (Decreased intake) -Poor socioeconomic status. -Vegetarians, alcoholic II-condition deficiency A-Decreased absorption. 1-Decreased intrinsic factors commonest cause. *Pernicious anaemia. *Total or partial gastrectomy *Atrophic gastritis. *Gastric cancer. *Non- Addisonian pernicious anaemia a- In association with hypogammaglobulinemia, gastric atrophy, achlorhydria and absent intrinsic factor but no antibodies b-In infancy: Selective failure of IF, normal mucosa. C- Juvenil PA failure of IF secretion with gastric atrophy rarely with antibodies

51. MacrocyticAnemia 2-Malabsorption syndrome. 3-Ileal diseases: * Terminal ileum resection * TB enteritis. * Chron’s disease. * Blind loop syndrome with bacterial over-growth. * Infestation by fish tape worm Diphyllobothrium latum.

52. MacrocyticAnemia B-Decreased utilization: *Rare congenital enzyme deficiency. *Lack of transcoblamin II. III-Relative deficiency : (increased demand) *Infancy, pregnancy, lactation *Haemolylsis and active haematopoiesis *Malignancy. *Thyrotoxicosis IV- Increased loss: Hemodialysis V- Decrease of stores. Far advanced chronic liver diseases

53. MacrocyticAnemia PERNICIOUS ANAEMIA (ADDISONIAN ANAEMIA) DEFINITION Pernicious anaemia (PA) is a condition in which there is atrophy of the gastric mucosa with consequent failure of intrinsic factor production and vitamin B12 malabsorption.

54. MacrocyticAnemia AETIOLOGY 1-Most probably autoimmune disease with genetic tendency. 2-There is an association with other autoimmune disease (Thyroid disease, vitiligo and Addison’s disease). 3-Atrophic gastritis (decrease HCL + IF) associated with production of parietal cell antibodies 4-Intrinsic factor antibodies which are specific for the diagnosis and are of two types, blocking antibodies which inhibit the binding of IF to B12 and precipitating antibodies which inhibit the binding of B12-IF complex to its receptor sites in the ileum. 5-It is common in the elderly over 60 years in fair haired and blue eyed people and in females than males. 6-The relatives may have clinical features of autoimmune disease

55. MacrocyticAnemia PATHOPHYSIOLOGY Both vit Bi2 and folic acid are essential for DNA synthesis and maturation. In cases of megaloblastic anaemia there is a deficient DNA synthesis, so the rate of cell division of many cells in the body is rate. The most affected cells are those with rapid rate of division and growth. i.e. haematoportic cells (RBC, WBC, platelet ) and, gastric mucosa + inability to form myelin sheath

56. MacrocyticAnemia RBCs (Megaloblastosis = cellular gigantism) 1-Megaloblasts (cell gigantism ): these are large cells (megalo) with relatively small nucleus (blasts). The cytoplasm is markedly in crease because RNA synthesis is normal while the nucleus is slowly growing because deficient DNA synthesis. 2-In BM, the normblast are replaced by these megaloblasts. Some of these abnormal cells are destroyed in BM. (intramedullary haemolysis)

57. MacrocyticAnemia 3-Some of these erythroid megaloblasts lose their nuclei and joined peripheral blood as macrocytes, irregular shape with remnant of the nucleus. these cells are hatched and destroyed by the spleen. During its circulation. 4-So anaemia is multifactorial - Defective erythropoiesis - Intramedullary haemolysis. - Destruction by the spleen. 5-Increased Serum bilirubin -Increased medullary haemolysis. -Increased splenic destruction of RBCs.

58. MacrocyticAnemia WBCs: (leucopenia) Myeloid megaloblasts are present in BM and give hypersegmented PNL to the peripheral blood. Leucopenia due to deficient DNA synthesisThrombocytopenia Due to deficient DNA synthesis. NB : Since the three blood elements are effected in megaloblastic anaemia, it is better to call it megaloblastic pancytopenia.GIT Is affected in the same manner, with secondary atrophy epithelial cells of the tongue, stomach and even intestine. Nervous system Only with B12 deficiency., failure of synthesis of myelin synthesis

59. MacrocyticAnemia CLINICAL FEATURES The onset is insidious. 1- Haemtological manifestations -General manifestation of anaemia. -Thrombocytepenia  Bleeding tendencies -Leucpenia  risk of infection -Hepatosplenomegaly. -Colour of the skin is lemon yellow owing to combination of pallor and jaundice.

60. MacrocyticAnemia 2- GIT manifestations - Atrophic glossitis, (red – glozed tongue) -Angular stomatitis. -Gastric atrophy dyspepsia, anorexia nausea, vomiting. -Intestinal atrophy diarrhoea and malabsorption Cancer stomach on top of atrophic gastritis

61. MacrocyticAnemia 3- Neuropsychatice manifestations (only with vit B12 deficiency). A-Neurological manifestations (3Ps): Peripheral neuropathy (LMNL) Pyramidal tract affection (UMNL)  spastic paraplegia. Posterior column affection  loss of deep sensation and sensory ataxia. NB: Combination of the two lessons is called sub acute combined degeneration of the spinal cord (SCD) b- Dementia c- Optic atrophy d- psychosis rare

62. MacrocyticAnemia 4- Association with other autoimmune features: (in pernicious anaemia) 1- Thyrotoxcoais 1- Thyrotoxcoais 2- Hashimoto’s disease. 2- Hashimoto’s disease. 3-Vitiligo 3-Vitiligo 4-Rheumatoid disease 4-Rheumatoid disease 5-Primary billiard cirrhosis 5-Primary billiard cirrhosis

63. MacrocyticAnemia INVESTIGATIONS: I- CBC a- RBCs: Marocytic normochromic anaemia. Poikilocytosis and anisocytosis Howell-Jolly bodies may be present b-WBCs: Moderate Leucopenia. Shift to the right Giant hyperpigmented neutrophil. C -Platelets Moderate thrombocytopenia. Giant platelets d-Reticulocyte are decreased but increased by treatment with vit B12 or folic acid

64. MacrocyticAnemia II- Bone marrow: Show megaloblastic erythropoiesis. The most characteristic is dissociation between nuclear & cytoplasmic development in erythroblasts with the nucleus maintaining a primitive appearance despite maturation and haemoglobinization of the cytoplasm. Erythroid hyperplasia, maturation defect in erythropoiesis, giant metamyelocytes, atypical megakaryocytes with hypersegmented nuclei.

65. MacrocyticAnemia III- Estimation of serum B12 level is low using radioisotope dilution or immunological assays. IV. Biochemistry Serum iron is high, more than 175 mcg/100 ml. Increased serum indirect bilirubin reflect mild haemolysis and ineffective erythropoiesis. Increased serum lactic dehydrogenase (LDH) reflecting ineffective megaloblastic erythropoiesis. V. Immunology Parietal cells antibodies and gastrin receptor antibodies, present in 70% of patients. (not specific) Intrinsic factor antibodies type I blocking (more specific) and type II precipitating antibodies.

66. MacrocyticAnemia VI- other investigations ***Gastric biopsy: proximal 2/3 of stomach atrophic. ***Augmented histamine test: achlorhydria. ***Schilling test. *Aim 1- Diagnosis of pernicious anaemia. 2- To detect its cause whether malabsorption or IF deficiency. *Methodology Large dose of unlabelled B12 (1000ug) is given IV to saturate body sores. Radiolabelled B12 (lug) is given orally, the amount of radio labellol B12 on the urine. Urine of the next 24 hours is measured Results If radiolabelled B12 excretion is low there may be 1- Malabsorption 2- Pernicious anaemia. Repeated the test after giving IF orally if it increase in the urine, this means that the cause is IF deficiency.

67. Macrocytic Anemia TREATMENT Treatment of the cause : if possible. Replacement therapy. Initial treatment is often as the 1000 mg B12 IM/day for 2 weeks then in a dosage of 1000 mg twice/week till correction of anaemia. Maintenance therapy 1000 mg IM every 3 months. Neurological damage can be precipitated by treating incorrectly with folic acid. Transfusion therapy by packed RBCs in the flowing conditions sever anaemia (Hb < 7 gm/dl ) Heart failure. Marked symptoms.

68. MacrocyticAnemia FOLATE DEFICIENCY Basic nutritional features and metabolism of folate*** Dietary folate source : ***Important sources are liver, kidney and fresh green vegetables, nuts, yeast, cooking probably destroys, at least half the folate in food, ***Minimum daily requirements 100-200 ug. Absorption is chiefly in the jejunum. Total body store is about 10 mg mainly in the liver Store is sufficient for 4 months. Function It is essential for nucleic acid synthesis maturation. It is deficiency lead to Nuclear maturation defect., of blood cells and megaloblastic erythropoiesis. GIT: mucosal cells.

69. MacrocyticAnemia CAUSES OF FOLATE DEFICIENCY: I- True deficiency (decreased intake) Poor intake particularly in infancy, old age, poor social conditions, starvation alcohol excess. Poor intake due to anorexia as in GIT disease e.g. Partial gastrectomy, coeliac disease, Crohn’s disease, cancer.

70. MacrocyticAnemia II- Relative deficiency (increased demand) Physiological: pregnancy, lactation, prematurity Pathological: Haematological disease with excess red cells production e.g haemolysis. Malignant disease with increased cell turnover Inflammatory disease e.g. rheumatoid arthritis, Crohn’s disease. Metabolic disease e.g. homocystinuria (rare congenital defect in the conversion of homocysteine to cystathion folate).

71. MacrocyticAnemia III - Conditioned deficiency normal intake and requirement but their may be : a) Decreased absorption * Malabsorption: in small bowel disease. * Drugs : pill or anticonvulsant. b) Decreased utilization * Antifolate drugs. anticonvulsants, methotrexate, pyrimethamine and trimethoprim IV- Increased loss * Haemodialysis or peritoneal dialysis closely bound to plasma protein, so easily removed.

72. MacrocyticAnemia CLINICAL FEATURES * May occur at any age, degrees of folate deficiency are very common and mild deficiency states are frequently unrecognised. * The clinical picture is multivarious because of the variety of possible underlying causes. * The onset may be insidious or rapid as when negative folate balance is precipitated by e.g infection * Anaemia and sometimes slight jaundice. * Glossitis. * No defined neurological changes.

73. MacrocyticAnemia INVESTIGATIONS * Essentially as in vit B12 deficiency. * Howell Jolly bodies and target cells in the blood film would suggest splenic atrophy (coeliac disease) * Bone marrow show megaloblastic changes. * Reduced folate levels: (N= 2.5-25mg/ml) serum levels are labile and red cell levels are better reflection of tissue folate by radioisotope dilution or immunological methods N.B Microbiological methods were used in the past but has the disadvantage that antibiotic therapy could lead to falsely low results.

74. MacrocyticAnemia Treatment 1)Folic acid therapy is contraindicated if there is any suspicion of B12 deficiency (Neurololgical changes may be precipitated or worsen). 2) Folic acid: 5mg daily is more than adequate. 3) Prophylactic folic acid is also given in chronic hematological disorders where there is rapid cell turnover 5mg each week. 4) Prophylactic folic acid (400ug daily) is recommended in pregnancy.

75. MacrocyticAnemia MACROCYTOSIS WITHOUT MEGALOBLASTIC CHANGES A raised MCV with macrocytosis on the peripheral blood film can occur with a normablastic BM. In all these conditions, the level of Vit B12 and folate are normal. The exact mechanisms are uncertain, but it seems there is increased lipid deposition in the red cell membrane.

76. MacrocyticAnemia CAUSES 1)Physiological : pregnancy and newborn. 2) Pathological * Alcohol excess * Liver disease * Reticulocytosis * Hypothyroidism * Some haematological disorders (e.g aplastic anaemia, sideroblastic anaemia * Drugs (e.g cytotoxics as azathioprine) * Agglutinated red cell measured on red counters. * Cold agglutinis due to autoagglutination of red cells, MCV decreases to normal with warming of the sample to 37OC. An increased number of reticulocytes lead to a raised MCV because they are large cells.

77. MacrocyticAnemia HAEMOLYTIC ANAEMIAS Definition : The haemolytic anaemias are a group of diseases in which red cell life span is shortened.

78. MacrocyticAnemia PATHOPYSIOLOGY: * Haemolysis of RBC can occur either. 1) Intravascular ie within the circulation. 2) Extra vascular ie : by phagocytes in RES in the liver, bone, spleen. * Bone marrow compensatory reactions: Erythriod hyperplasia in BM, can increase erythropoiesis several times, so that anaemia may not develop till RBCs life span is less than 20 days Reticuylocytosis is hallmark. Slight macroytosis in the peripheral blood

79. MacrocyticAnemia Consequences 1) Excess haemolysis increases bilurbin since the liver can increase its capacity several time, the jaundice is mild if hot at all. 2) The intravascular librated Hb is bound to &-2 globulin (haptoglobin) and Hb haptoglobin is rapidly cleared from the circulation by REs, and plasma level of haptoglobin is reduced, In cases of excessive IV haemolysis, haptoglobin is depleted, there is haemoglobinanemia and haemoglobinuria and dark urine 3) Extramedullary erythropoiesis will cause specific bone charges.

80. MacrocyticAnemia CAUSES: A - CORPUSCULAR CAUSES: 1) Congenital Abnormalities: Membrane defects: * Hereditary spherocytosis * Hereditary elliptocytosis Hereditary stomatocytosis Haemoglobinopathies: * Sickle cell anaemia * Thalassaemia Enzymopathies 1) Abnormal aerobic glycolysis e.g. G6PD deficiency 2) Abnormal anerobic glycolysis e.g pyruvate kinase deficiency 3) Non glycolytic enzymopathies

81. HaemolyticAnemia 2) Acquired Abnormalities 1- Paroxysmal nocturnal haemoglobinuria 2- Vitamin E deficiency B- EXTRACORPUSCULAR CAUSES: 1- Immune mechanisms a ) Alloimmune antibodies (iso-immune): * Incompatible blood transfusion * Haemolytic disease of the newborn * After allogenic BM or organ transplantation b) Autoimmune haemolytic anaemias 1-Warm reactive antibodies (react at 37 oC and does not bring agglutination type of AB= IgG ). * Idiopathic * Secondary to CLL, Lymphoma, SLE and rheumatoid disease * Secondary to drugs e.g methyldopa.

82. HaemolyticAnemia 2- Cold reactive antibodies (react at 32oC and usually agglutinates and haemolyse red cells, type of AB = IgM). * Cold haemoagglutinin disease - Idiopathic -Secondary (mycopolasma pneunemia infection, infectious mononucleosis, lymphomas. * Paroxysmal cold haemoglobinuria - Idiopathic -Secondary (some viral infections congenital & tertiary syphilis). c) Immunochemical mechanisms: drug induced haemolytic anaemias

83. HaemolyticAnemia 2- Mechanical injury * Cardiac haemolytic anaemia (valve prosthesis). * Microangiopathic haemolytic anaemias. March haemoglobinuria. 3- Chemicals and Drugs * Snake venom * Lead * Naphthaline * Phenacetin * Sulpha drugs * Hypophosphataemia

84. HaemolyticAnemia 4- Infections * Clostridium welchii septicemia (Secondary to septic abortion) * Malarial infestation (Black water fever) 5- Metabolic causes * A betalipoproteinemia : A canthocytosis * Liver porphyria : * Spurr cell anaemia * Zieve’s syndrome * Wilson disease * Severe hypophosphataemia 6- Secondary to systemic disease : * Renal and liver failure * Burn 7-Hyperslenism

85. HaemolyticAnemia CLINICAL FEATURES OF HAEMOLYTIC ANAEMIA General features of anaemia General features of haemolytic anaemia 1)Haemalytic jaundice. * Mild degree. * Skin is lemon yellow * Sclera tinge of jaundice. * Dark stool. * Normal urine which darken on exposure to air 2)Heapatosplenomegaly: * Common in chronic haemolysis except in cases of sickle cell anaemia where there self-splenectomy 3) Biliary obstruction and /or gall bladder stones. * Pigment stones: extra hepatic obstruction. * Viscid bile: intrahepatic obstruction. NB. In this situation jaundice becomes, mixed ( haemolytic + obstructive) and abdominal pain my be present. 4- Leg ulcer: Chronic leg ulcer surrounded by pigmentation cause by extra vascular iron deposition. Ulcers develop on the malleoli

86. HaemolyticAnemia 5-Different types of crisis: a) Heamolytic crisis * Fever, rigors: pyrogen release from RBCs. * Generalized bone pain * Acute abdominal pain, backache, may be vomiting. * Aggravation of anaemia (pallor), deepening as jaundice, and dark colouration of urine * Investigations: - Dark urine: haemoglobinuria. - Increased serum biliurbin - Reticulocytosis - BM erythroid hyperplasia. * Cause may be infection B- A plastic crisis * Inability of BM to replaced the destructed RBCs - Severe anaemia without jaundice. - Reticulocytopenia. - BM erythroid hypoplasia. * Cause: viral infection especially parvovirus B19 and HBV.

87. HaemolyticAnemia C- Sequestration crisis Trapping and pooling of RBCs in the spleen (mainly and liver). D- Megaloblastic crisis * Anaemia severe without jaundice. * Decreased reticulocytic count * Macrocytic anaemia. * BM : megabloblastic Cause: folic acid deficiency. E- Vaso-occlusive crisis (Thrombotic phenomenon) * Painful. * Only in cases of sickle cell anaemia.

88. HaemolyticAnemia Features or the cause e.g thalassaemia, sickle cell anaemia. COMPLICATIONS * Haemolytic crisis:. * A plastic crisis: * Folate deficiency caused by increased BM requirement * Gall stones *In sickle cell anaemia: signs and symptoms of thrombotic phenomena.

89. HaemolyticAnemia INVESTIGATION FOR CASE OF HAEMOLYTIC ANAEMIA 1)Diagnosis of Haemolytic anaemia 1- CBC * Normocytic normochromic anaemia with reticulocytosis * Microcytic anaemia: thalassaemia, spherocytosis. * Macrocytic + reticulocytosis: megaloblastic crisis * Reticytopenia: a plastic crisis. * Morphological evidence of RBC damage: as red cell fragment, cell containing malarial parasites. * Morphology of RBCs: eg spherocytes & sickle cells * WBCs thrombocytes are normal but may increase due to bone marrow stimulation.

90. HaemolyticAnemia 2- Short life span of RBCs: Measured by radioactive corium labeled RBCs 3- Bone marrow * Hypercellular normabloastic marrow. * Hypocellular in a plastic crisis. * Megaloblastic in folate deficiency. 4-Increased serum LDH 5-Incresesd serum biliurbin, fecal stercobilinogen and urinary urobilinogen.

91. HaemolyticAnemia Tests for detection the site of haemolysis. In intravascular haemolysis vs. extravascular the following parameters are presents. * Haemoglobin anemia, Haemoglobinuria and haemosideringuria * Reduced plasma haptoglobin and haemopexin * Presence of met haemalbumin in plasma. Tests for the cause * RBC morphology. * Osmotic fragility. * Hb electrophoeresis. * Estimation of G6 PD. * Coomb’s test.

92. HaemolyticAnemia HEREDITARY SPHEROCYTOSIS Pathogenesis: A hereditary autosomal dominant disorder in which the corpuscular membrane is abnormally less deformable and more permeable to sodium. This is due to an abnormality of the protein as pectrin in the corpuscular membrane which causes water imbibition and rupture or red blood cells.

93. HaemolyticAnemia CLINICAL PICTURE: 1)Symptoms usually appear during the first decade of life, but may be delayed. 2) Common features of haemolytic anaemia. 3) Slight or moderate enlargement of the spleen. 4) Pigment biliary stones in long standing cases. 5) Chronic leg ulcers.

94. HaemolyticAnemia INVESTIGATIONS: 1- CBC * Spherocytosis, red cells are spherical instead of being ] biconcave. * Reticulocytosis. * Anaemia of moderate degree. 2- Osmotic fragility is characteristically increased, haemolysis usually begins at podium chloride concentration of 0.6 % or even higher 3- Direct coomb’s test is negative, excluding an autoimmune cause of spherocytosis and haemolysis.

95. HaemolyticAnemia TREATMENT : The principal form of treatment is splenectomy although this should not be performed unless clinically indicated because of anaemia. Splenectomy lengthens the life span of redcells, correct anaemia, prevents haemochromatosis, but does not affect the character of red cells.

96. HaemolyticAnemia ELLIPTOCYTOSIS This has similar clinical and laboratory features to hereditary spherocytosis except for the appearance of the blood film, but is usually a clinically milder. Occasional patients require splonectomy.

97. HaemolyticAnemia PAROXYSMAL NOCTARAL HAEMOGLOBINURIA AETIOLOGY * The only one of corpuscular causes of haemalysis which is acquired. * The exact a etiology is unknown. * It results from increased sensitivity of RBCs membrane to be damage by the complement system

98. HaemolyticAnemia CLINICAL FEATURE 1)Feature of haemolytic anaemia - Haemolysis occurs mainly after sleep by night leading haemoglobin anemia and haemoglobinuria. 2) Abnormal platelets  thrombi 3) Abnormal WBCs  inspection 4) Abdominal pain due visceral ischemia caused by micro thrombi.

99. HaemolyticAnemia COMPLICATIONS 1)Thrombosis 2) Plastic anaemia. 3) Acute myeloid leukaemia

100. HaemolyticAnemia INVESTIGATIONS 1)General investigation of haemalytic anaemia. 2) Activation of complement to cause haemolysis. - Ham’s test haemalysis by adding acid to the blood

101. HaemolyticAnemia TREATMENT : 1- Symptomatic 2- Prodinisone. 3- BMT.

102. HaemolyticAnemia HAEMOGLOBINPATHIES Normally haemoglobin consists of. * Globin :protein which is formed from 4 polypeptide chain * Haem : iron-protoporphyrin complex Haemoglobinopathies: These are clinical syndromes resulting from abnormalities in the structure of globin molecule, with the production of abnormal haemoglobin. There are three main categories : 1 )Structural variant of Hb: e.s HbS. 2) Failure to synthesize Ht: e.g thalassemia. 3)Failure to switch from fetal Hb (HbF) to adult Hb (HbA) : Heridetary persistence of Fetal Hb (HPFH).

103. HaemolyticAnemia Structure of globinNormal %HbType of Hb  2  2 (2 alpha + 2 Beta)  2  2 (2 alpha+ 2 Deta)  2  2 ( 2alpha + 2 gamma) 97-98 1-2 A A2 F Normal  4 (  -thalassaemia)  4(Homozyqous  - thalassaemia) ---- H Barts Abnormal production  2  2 (abnormal  -chain)  2  2. ---- SCSC Abnormal chain structure

104. HaemolyticAnemia SICKLE CELL ANAEMIA Symptoms vary from a mild asymptomatic disorder to severe haemolytic anaemia and recurrent severe painful crises. A herediatary autosomal recessive disorder. The homozgotic form is due to the presence of the abnormal haemoglobin, (Hbs), which on exposure to hypoxia, the deoxygenated Hbs forms in soluble aggregates that distort the erythrocytes and increase their rigidity causing sickling deformation and subsequent fragmentation. In addition, the unyielding elongate crescentic erythrocytes form aggregates that block terminal arterioles, capillaries and veins, resulting in tissue infractions and perivascular oedema in the involved organs (vascular occlusion)

105. HaemolyticAnemia Investigations: 1)CBC The level of Hb is in the range 6-8gm/dl with high reticulocytic count (10-20%). * Blood films show features of hyposplenism * Sickling of red cells on a blood film can be induced in the presence of sodium metabisulphite which cause hypoxia. 2) Hb electrophoresis: * There is no Hb A, 80-85% Hb S and 2-20% HbF. * The parents of the affected child will show features of sickle cell trait

106. HaemolyticAnemia Sickle cell trait (Heterozygous sickling disorder) These individuals have no symptoms unless extreme circumstances cause anoxia such as flying in non-pressurized aircraft or problems with anaesthesia. * Sickle cell trait protects against plasmodium falciparum malaria. * 60% Hb A and 40% Hb S * The blood count and film are normal * The diagnosis is made by a positive sickle test or by Hb electrophoresis.

107. HaemolyticAnemia THE THALASSAEMIAS The thalassaemia are anaemias originally found in people living on the shores of the Mediterranean, now known to affect people throughout the world. The defective synthesis of globin genes in thalassaemia leads to imbalanced globin chain production leading to precipitation of globin chains within the red cell precursors and resulting in ineffective erythropoiesis. Precipitation of globin chains in mature red cell leads to haemolysis.

108. HaemolyticAnemia TYPES: Two types named after the chain which is missed. A- Alpha thalassaemia Production of alpha chain is decreased. It is replaced by gamma or beta chain with for motion of Hb Bart (4g) or Hb H (4b) types. 1- a-Thalassaemia major - Homozygosis (2abnormal gene) - Hb Bart & Hb H are 80-90%. - In compatible with life and results in intrauterine fetal death from hydrops foetalis 2- a-Thalassaemia minor - Heterozygous (only one abnormal gene). - H B Barts & Hb H are 10-20%. - Presented by mild Microcytic hypochromic anaemia, jaundice, and splenomegaly 3- a- Thalassaemia silent carrier or trait, -Asymptomatic

109. HaemolyticAnemia B- Beta- thalassaemias There is defective production of beta-chain with excess production of Hb F and Hb A2 Types 1- b-thalassaemia major -Homozygous (2 abnormal gene) -Hb F > 80-90% 2- b- thalassaemia minor (trait) - Heterozygous (only one abnormal gene) - Both Hb F (10%) and Hb A2 (10%). - Presented in adults by mild Microcytic hypothermic anaemia and splenomegaly. -Commonly symptomatic and require treatment. 3- b Thalassaemia intermedia -Mild anaemia -Rarely requiles treatment.

110. HaemolyticAnemia b- THALASSEMIA Thalassemia minor (Trait): This common carrier state is asymptomatic, anaemia is mild or absent, the red cells are hypochromic and microcytic with a low MCV and MCH. DD: * Iron deficiency anaemia. * Thalassaemia trait the serum ferritin and the iron stores are normal, * Hb electrophoresis usually show a raised Hb A2 and often a raised HbF. *Iron should not be given to these patients unless they develop coincidental iron deficiency.

111. HaemolyticAnemia Thalassaemia intermedia * Patients are symptomatic with moderate anaemia and who do not require transfusions. * Patients may have splenomegaly and bone deformities recurrent leg ulcers, gall stones and infection.

112. HaemolyticAnemia b- THALASSAEMIA MAJOR (COOLEY’S ANAEMIA – MEDITERRANEAN ANEAMIA) CLINICAL PICTURE: 1) The onset is during the first year of life (3-6 mouth ) 2) The children fails to grow, (stunted growth) mongoloid faces, bone deformities. 3) Feature of haemalytic anaemia jaundice and huge splenomegaly 4) Extramedullary haematopoiesis: that soon cause hepatosplenomgaly, bone expansion giving rise to classical thalassaemic facies (mongoloid facies).

113. HaemolyticAnemia 5) Feature of haemochromatosis: liver cirrhosis, bronze skin, cardiomegaly. 6) The disease is more common among Mediterranians. 7) Positive family history. 8) Usually recurrent bacterial infection.

114. HaemolyticAnemia  - THALASSAEMIA In contrast to  -thalassaemia it is caused by gene deletions, the gene for  -chains is duplicated on both chromosomes 16. Deletion of one  chain gene (  +) or both  chain (  o). * If all four genes are absent there is no  -chain synthesis and Hb Barts (γ4) is present. Hb. Barts can not carry oxygen and is incompatible with life and infants are either stillborn or die very shortly after birth. (hydrops fetalis) * If three genes are deleted there is moderate anaemia and splenomegaly (Hb H disease). Hb A, Hb Barts and Hb H (B4) are present, Hb A2 is normal or reduced * If two genes are deleted (  -thalassaemia trait), there is microcytosis with or without mild anaemia.

115. HaemolyticAnemia ENZYMOPATHIES 1- GLUCOSE -6- PHOSPHATE DEHYDROGENASE DEFICIENCY. Glucose-6- phosphate dehydrogenase (G6 PD) Functions to reduce nicotinamide adenine dinucleotide phosphate (NADPH) while oxidizing glucose-6- phosphate. It is the only source of NADPH in red cells and as NADPH is needed for the production of reduced glutathione, a deficiency renders the red cell susceptible to oxidant stress, and cause oxidation of NADPH which permits oxidation of protein SH groups I the red cell membrane and eventually causes irreversible oxidative denaturation of Hb which becomes attached to red cell membrane to form Heinz bodies. Red cells containing such inclusion bodies become destroyed in the lifer and spleen

116. HaemolyticAnemia A gents which may cause haemolysis in (g6PD) deficiency * Infections and other acute illnesses e.g diabetic ketoacidosis * Drugs 1- Sulphonmides e.g co-trimoxazole 2- Ant. Bacterial e.g into furans, chloramphenicol 3- Analgesics e.g aspirin phen a cetin 4- Anti malarial e.g primquine and quinine

117. HaemolyticAnemia CLINICAL PICTURE Rapidly developing intravascular haemolysis with haemoglobinuria precipitated by infecting and other acute illness, drugs or the ingestion of fava beans.

118. HaemolyticAnemia DIAGNOSIS: * Between crises the blood count is normal * Direct enzyme assay. * During crisis, the blood film may show contracted and fragmented cells “bite” cells and blister” cells which have Red Heinz bodies removed by the spleen. * Haemoglobinaemia and haemoglobinuria in acute stag.

119. HaemolyticAnemia TREATMENT -Withdrawal of the drug or toxic substance -Blood transfusion is life saving in severe cases.

120. HaemolyticAnemia 2- PYRUVATE KINASE DEFICIENCY. This is inherited as an autosomal recessive, the affected patients being homozygous or les common heterozygous. the red cells become rigid as result of reduced adenosine triphosphate (ATP) formation. Direct enzyme asay is needed to make the diagnosis.

121. HaemolyticAnemia ACQUIRED NON IMMUNE HAEMOLYTIC ANAEMIA Paroxysmal nocturnal haemoglobinuria (PNH) This is rare acquired red cell defect in which a lone of red cells is particularly sensitive to destruction by activated complement. These cells are continually haemolysed intravascularly. The underlying defect is an inability of PNH cells to make glycosyl-phosphatidylinositol (GPI) which anchors surface proteins such as delay accelerating factor (DAF) membrane inhibitor of reactive lysis (MIRL) to cell membranes. DAF and MIRL and other proteins are involved in complement degradation and in their absence the hemolytic action of complement is not regulated.

122. HaemolyticAnemia CLINICAL PICTURE:- 1)Haemolysis which may be precipitated by infection or surgery. 2) Urine voided at night and in the morning on waking is dark in colour, the reason for this phenomenon is not clear. 3) Venous thrombotic episodes are very common

123. HaemolyticAnemia INVESTIGATIONS 1)Intra vascular haemolysis 2) Ham’s test. Cells from a patient with PNH lyse more readily in acidified serum than do normal cells.

124. HaemolyticAnemia TREATMENT 1)Blood trans fusion for patients with severe anaemia 2) Long tern anticoagulation may be necessary for patients with recurrent thrombotic episodes 3) BMT but only in patients under so years with an hla- identical sibling.

125. HaemolyticAnemia APLASTIC ANAEMIA DEFINITION A condition associated with acellular or hypoellular bone marrow. A number of patients have failure of production of one or two cell lines e.g red cell aplasia (Blackfan diamond syndrome) or aplastic crisis in haemolytic anaemia,

126. HaemolyticAnemia Thanks