1 14 WS_ Anemia and anti anemia drugs.pdf

1/19/24, 10:56 AM  Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024                       Fusion sessions are online learning activities followed by a live session where you will translate the conten...

1/19/24, 10:56 AM  Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024                       Fusion sessions are online learning activities followed by a live session where you will translate the content into practice. These require completing learning content in Canvas before attending live sessions. To encourage preparation, attendance, and participation, recordings of fusion sessions will not be posted; prepare accordingly so that you can fully participate. Remember: Learning from written materials is a critical professional and personal skill that RUSM is helping you develop through these sessions. https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 1/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 1. Work through the content on this page. 2. Contact faculty via email or office hours if you have questions about content to ensure you are prepared for the session. 3. Take the quiz. (You have three attempts.) 4. Attend and participate in the live session. 5. Take the quiz again. 6. Study missed content. 7. Take the quiz for the final attempt.  Anemia of diminished erythropoiesis is characterized by a reduced production of red blood cells in the bone marrow with the following decline of red blood cell count in the peripheral blood. This type of anemia can be caused by a variety of factors, including nutritional deficiencies, chronic inflammatory diseases, genetic disorders, and certain medications. Anemias of diminished erythropoiesis can manifest in different forms, such as iron-deficiency anemia, and anemia of inflammation, megaloblastic anemia, etc., that will be covered in this and the following presentations. Diagnosing anemia of diminished erythropoiesis involves a comprehensive medical evaluation, including CBC, PBS, and bone marrow aspirate/trephine. Identifying the underlying cause of the diminished erythropoiesis is crucial for determining the appropriate treatment strategy, which may involve addressing nutritional deficiencies, managing chronic diseases, or considering medications to stimulate red blood cell production. Hemolytic anemias represent a diverse group of blood disorders characterized by the accelerated destruction of red blood cells (hemolysis) within the bloodstream or in the spleen, liver, and lymph nodes. The breakdown of RBCs leads to a reduction in their lifespan, resulting in a decreased number of circulating red blood cells. hemoglobin, and hematocrit. Hemolytic anemias can be broadly categorized into two main types: anemias with extravascular hemolysis and anemias with intravascular hemolysis. Hemolytic anemias with extravascular hemolysis are primarily genetic mutations affecting their structure or function. Prototypic examples of this group of anemias are sickle cell anemia and thalassemias covered in the previous presentation titled “Hemoglobinopathy-Associated Anemias”. Hemolytic anemias with intravascular RBC destruction are triggered by immune reactions or trauma to RBCs. Understanding the underlying causes and https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 2/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 mechanisms of hemolytic anemias is crucial for accurate diagnosis and the development of targeted treatment strategies. Hemolytic anemias can vary in severity, ranging from mild to lifethreatening, depending on the underlying cause and the rate of red blood cell destruction. Common symptoms of hemolytic anemias include fatigue, pallor, jaundice, and splenomegaly. Megaloblastic anemias are a group of blood disorders characterized by abnormally large red blood cells (macrocytes) in the bloodstream and abnormally large erythroid precursors (megaloblasts) in the bone marrow. The main underlying cause of megaloblastic anemias is a deficiency vitamin B12 (cobalamin) or folate (folic acid) that leads to a disruption in DNA synthesis, inefficient cell division, and delayed maturation of erythroid cells in the bone marrow. Blood tests in megaloblastic anemias will reveal the presence of macrocytes in the peripheral blood, megaloblasts in the bone marrow, and specific deficiencies in vitamin B12 or folate. Treatment of megaloblastic anemias typically involves addressing the nutritional deficiency through dietary changes and vitamin supplementation. Acute blood loss may occur due to various reasons such as trauma, surgery, gastrointestinal bleeding, pathologic delivery, etc. With an acute blood loss occurs, the body attempts to compensate by increasing the production of new red blood cells to restore the normal levels of oxygen-carrying capacity in the blood. However, if the rate of blood loss exceeds the body's ability to produce new red blood cells, acute posthemorrhagic anemia will develop. Treatment of this anemia may involve immediate measures to stop the bleeding and blood transfusions to replace lost blood. Chronic blood loss anemia is characterized by a gradual and ongoing loss of blood, typically over an extended period of time, and is primary associated with chronic gastrointestinal bleeding or chronic menstrual bleeding in women. Chronic blood loss exhausts iron stores, therefore it falls in the category of with is studied with iron-deficiency anemia. Diagnosis of chronic posthemorrhagic anemia requires iron studies, and its management involves identification and treatment the source of the blood loss and supplementing with iron, either orally or intravenously, to replenish iron stores and promote red blood cell production. By the end of this session, you will be able to meet the following learning objectives: 1. Compare and contrast the aplastic anemia and pure red cell aplasia in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation. https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 3/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 2. Explain the etiology, pathogenesis and laboratory diagnosis, and correlate them with associated clinical features of myelophthisic anemia. 3. Explain the etiology, pathogenesis and laboratory diagnosis, and correlate them with associated clinical features of anemia of chronic kidney disease. 1. Explain the etiology, pathogenesis and laboratory diagnosis, and correlate them with associated clinical features of iron-deficiency anemia. 2. Explain the etiology, pathogenesis and laboratory diagnosis, and correlate them with associated clinical features of anemia due to inflammation. 3. Explain the etiology, pathogenesis and laboratory diagnosis, and correlate them with associated clinical features of sideroblastic anemia. 4. Interpret the indices used in the “iron panel” and provide differential diagnosis of microcytic hypochromic anemias based on iron panel data. 1. Explain the etiology, pathogenesis and laboratory diagnosis, and correlate them with associated clinical features of the following hemolytic anemias: Hereditary spherocytosis (HS) G6PD-deficiency anemia Immune hemolytic anemias (IHA): warm antibody and cold agglutinin types Anemia in malaria Paroxysmal nocturnal hemoglobinuria (PNH) Hemolytic anemia resulting from trauma to RBCs By the end of this session, you will be able to meet the following learning objectives: 1. Compare and contrast the B12- and folate-deficiency megaloblastic anemias in terms of etiology, mechanisms, and clinical, laboratory, and morphologic presentation. https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 4/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 1. Explain the etiology, pathogenesis and laboratory diagnosis, and correlate them with associated clinical features of anemia due to acute blood loss. 1. List the antianemia drug classes: Iron preparations, iron antidotes, vitamin B12 preparations, folic acid preparations, erythropoiesis-stimulating agents 2. Provide examples of drugs in each of the antianemia drug classes. 3. For the drugs listed above: Explain their molecular mechanism of action Explain their pharmacological effects Describe their important pharmacokinetic properties Describe their significant adverse effects and contraindications Describe their therapeutic uses  Examine the image below to learn more about the working classification of anemias of diminished erythropoiesis. https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 5/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Source: Dr. Michael Yakubovskyy, RUSM Anemia: decreased Hb leads to Normocytic anemia: MCG = 80-100µm³, Monocytic anemia: MCV <80µm³, or Macrocytic anemia MCV >100µm³ Normocytic anemia could be Anemias due to increased RBC destruction (hemolytic anemias) or Anemias due to decreased RBC production Anemias due to increased RBC destruction (hemolytic anemias) could be Anemias with extravascular hemolysis such as sickle cell anemia, Hb C anemia, Hereditary spherocytosis, G6PD deficiency, Immune hemolytic anemia, Anemia in malaria. Anemias due to increased RBC destruction (hemolytic anemias) could also be Anemias with intravascular hemolysis such as Paroxysmal nocturnal hemoglobinuria, G6PD deficiency, or Anemia resulting from trauma to RBCs Anemias due to decreased RBC production include aplastic anemias, pure red cell aplasia, myelophtisic anemia, anemia of chronic kidney disease, and anemia of inflammation Microcytic anemia: MCV <80µm³ can be Thalassemia, Iron-deficiency anemia, Anemia of inflammation, or Sideroblastic anemia. Macrocytic anemia MCV >100µm³ can be Folate-deficiency megaloblastic anemia, Vitamin B12-deficiency megaloblastic anemia, alcohol abuse macrocytic anemia, macrocytic anemia in liver disease https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 6/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 This section focuses on Normocytic anemia could be Anemias due to increased RBC destruction (hemolytic anemias - Anemias with extravascular hemolysis such as sickle cell anemia, Hb C anemia, Hereditary spherocytosis, G6PD deficiency, Immune hemolytic anemia, Anemia in malaria.) and Microcytic anemia: MCV <80µm³ including Iron-deficiency anemia, Anemia of inflammation, or Sideroblastic anemia. Click each section below to learn more about the types of normocytic anemias. Aplastic anemia: a life-threatening bone marrow (BM) failure manifested by BM hypoplasia due to suppression of multipotent myeloid cells Pancytopenia (anemia, neutropenia, and thrombocytopenia) in the peripheral blood (PB) Anemia: pallor and/or signs of congestive heart failure, such as shortness of breath, or pedal edema Neutropenia: fever, cellulitis, pneumonia, hepatitis (with jaundice), or sepsis Thrombocytopenia: bruising (e.g., ecchymoses, petechiae), gum bleeding, or nosebleeds Congenital/inherited: ≈20% Examples: Fanconi anemia, telomerase diseases (e.g., dyskeratosis congenita) Acquired: ≈ 80%; in majority of cases, the etiology is unknown Known causes of acquired AA Chemicals/drugs (alphabetic order): antibiotics, anti-convulsant, benzene, chemotherapeutic drugs, chloramphenicol, gold, NSAIDs, penicillamine, sulfonamides, etc. Whole body (ionizing) radiation https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 7/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Viruses: EBV, HIV, unknown hepatitis virus, etc. Autoimmune diseases: SLE, RA, PNH Postulated mechanisms Extrinsic: immune-mediated suppression of hematopoiesis 1. Alteration in antigen presentation on the surface of stem cells 2. Activation of cellular immune response 3. Activation of TH1 4. Release of IFNγ and TNF 5. Suppression and death of stem cells Intrinsic: absent or defective stem cells (stem cell failure), e.g., telomerase defects CBC Reticulocyte count Blood film VitB12/folate Liver function tests Virology BM aspiration and trephine/core biopsy PNH screening Anemia with morphologically normal RBCs (normocytic normochromic anemia) The reticulocyte count (RC) < 1% WBC changes Neutropenia/agranulocytosis: a decrease in all PMNs Thrombocytopenia Low monocyte count https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 8/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Relative lymphocytosis The severity of aplastic anemia is assessed via the degree of cytopenia Keith Chambers (https://commons.wikimedia.org/wiki/File:Normal_Adult_Blood_Smear.JPG) , CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) , via Wikimedia Commons Echinaceapallida (https://commons.wikimedia.org/wiki/File:Blood-rbcs.jpg) , CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0) , via Wikimedia Commons https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 9/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Gabriel Caponetti (https://commons.wikimedia.org/wiki/File:Bone_marrow_core_biopsy_microscopy_(trephine)_H%26E_panorama_by_gabriel_caponetti.jpg) , CC BY 3.0 (https://creativecommons.org/licenses/by/3.0) , via Wikimedia Commons Comez G, Sevinc A, Sever ON, Babacan T, Sarı I, Camci C - Case reports in medicine (2010) https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 10/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Suppression of red cell precursors in the BM → decreased RBCs production Granulocytic and platelet precursors are normal Major causes Thymoma → ?production of autoantibodies to erythropoietin (EPO) Parvovirus B19 infection Previously healthy individuals → transient reduction in RBC precursors → recovery Patients with existing hemolytic anemia → cessation of erythropoiesis (aplastic crisis) https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 11/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Image used with permission, CC BY 3.0 (https://creativecommons.org/licenses/by/3.0/) BM failure due to space-occupying lesions that destroy BM components Any disease associated with BM infiltration = "myelophthisic" processes Major causes Metastatic cancer, mostly breast, lung, and prostate Granulomatous inflammation, e.g., TB or sarcoidosis Myelofibrosis (a form of myeloproliferative disorders studied with WBC Disorders) PBS: leukoerythroblastosis: nucleated RBCs and immature myeloid cells (metamyelocytes, myelocytes) PBS Pancytopenia Tear-drop RBCs Leukoerythroblastosis https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 12/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 BM trephine Evidence of a primary process: cancer, granulomatous inflammation, fibrosis, etc. Hypocellularity Ed Uthman from Houston, TX, USA BY 2.0 (https://commons.wikimedia.org/wiki/File:Myelofibrosis,_Reticulin_Stain_(6032644716).jpg) , CC (https://creativecommons.org/licenses/by/2.0) , via Wikimedia Commons https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 13/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Major mechanism: reduced EPO production In normal individuals, EPO is produced by renal cortex fibroblasts under the influence of low pO2 (hypoxia) Labs: mild-to-moderate-to-severe anemia CBC and PBS parameters Normocytic normochromic RBCs Reticulocyte count <2% Burr cells (echinocytes) Guy Waterval (https://commons.wikimedia.org/wiki/File:Echinocytes-11.JPG) , Apache License 2.0 (http://www.apache.org/licenses/LICENSE-2.0) , via Wikimedia Commons Click each section below to learn more about the types of microcytic anemias. https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 14/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Increased demand for iron and/or hematopoiesis: infancy, adolescence, pregnancy and lactation Iron loss Physiology: menstruation Pathology: surgery, complicated delivery, GI tract bleeding Decreased iron intake or absorption Vegetarian diet or malnutrition Malabsorption syndromes Condition after gastric and intestinal surgery Intestinal parasites Autoimmune atrophic gastritis Symptoms Fatigue (often out of proportion to anemia), exercise intolerance, palpitations, pica Decreased intellectual performance, depression, restless legs syndrome Signs Tachycardia Conjunctival pallor Skin changes: pallor, koilonychia, angular cheilitis/cheilosis, alopecia areata Atrophic glossitis Plummer-Vinson syndrome (triad): iron-deficiency anemia, dysphagia, and esophageal web https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 15/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 James Heilman, MD (https://commons.wikimedia.org/wiki/File:Angular_Cheilitis.JPG) , CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) , via Wikimedia Commons https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 16/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 A triad: iron-deficiency anemia, dysphagia, and esophageal web Esophageal web: a thin (<2 mm) eccentric membrane that protrudes into the esophageal lumen; esophageal webs are covered with squamous epithelium and most commonly occur anteriorly in the cervical esophagus Increased risk of esophageal or pharyngeal squamous cell carcinoma Additional findings Atrophic glossitis Angular cheilitis Atrophic glossitis https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 17/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Tahara T, Shibata T, Okubo M, Yoshioka D, Ishizuka T, Sumi K, Kawamura T, Nagasaka M, Nakagawa Y, Nakamura M, Arisawa T, Ohmiya N, Hirata I. A case of plummer-vinson syndrome showing rapid improvement of Dysphagia and esophageal web after two weeks of iron therapy. Case Rep Gastroenterol. 2014 Jun 7;8(2):211-5. doi: 10.1159/000364820. PMID: 25028578; PMCID: PMC4086037. Esophageal Web Samir (https://commons.wikimedia.org/wiki/File:Esophageal_web.jpg) , CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) , via Wikimedia Commons RBCs Microcytic (low MCV) Hypochromic (low MCH and MCHC) Anisocytosis (increased difference in cell size = RDW) Moderate pleiocytosis (increased difference in cell shape) WBC: WNL Platelets: WNL https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 18/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Hb: low (RR: men: 14-17.5 g/dL; women: 12.3-15.3 g/dL) HVT: low MCV: low MCH: low MCHC: low Red cell distribution width (RDW): high ESR: high Reticulocyte count: normal/low WBC: WNL Platelets: WNL Mild-to-moderately increased erythropoiesis Absence of iron in the BM (section and smears stained with Prussian blue) No iron in iron-storing macrophages No iron in proerythroblast mitochondria Normal proerythroblast may possess an iron-containing mitochondrion; in such case it is designated as a sideroblast https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 19/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 2 sideroblasts (proerythroblasts with iron-containing mitochondrion in each cell) Negative Prussian Blue stain in iron-deficiency anemia https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 20/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Two BM macrophages filled with hemosiderin particles (control) Source: Lichtman MA, Shafer MS, Felgar RE, Wang N: Lichtman's Atlas of Hematology: http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Parameter Normal Iron-deficiency anemia Serum iron 50 - 150 mcg/dL Low Serum ferritin (presence of iron in the stores) F: 24 - 307 ng/mL Low (no iron → no ferritin) M: 24 - 336 ng/mL Transferrin (Total Iron Binding Capacity,TIBC) [synthesized by 200 - 400 mg/dL High (low ferritin → high transferrin) https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 21/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Parameter Normal Iron-deficiency anemia Transferrin saturation (TSAT) (serum iron/transferrin) 20 - 50% Low (low iron and high transferrin) Iron in BM, Prussian blue stain (the gold standard) Adequate presence of iron: macrophages with iron, few sideroblasts (not ringed) No iron *Erythrocyte zinc protoporphyrin 30 - 70 ng/mL RBC High hepatocytes, synthesis is regulated by ferritin] Syn.: anemia of chronic inflammation, anemia of chronic disease Causes Chronic bacterial infections (e.g., osteomyelitis, or lung abscess) Chronic immune disorders (e.g., SLE, or IBD [inflammatory bowel disease]) Malignant tumors (e.g., carcinoma of the lung or breast) Neoplastic cells induce a chronic inflammatory response with following cytokine release Two mechanisms: inflammation → IIL-6 synthesis → Activation of hepsidin → Inhibition of ferroportin → sequestration of iron in enterocytes, BM macrophages, and hepatocytes → reduced iron supply to erythroid progenitors → Inhibition of erythropoiesis In addition, inhibition of ferroportin in enterocytes → decline in iron transfer to transferrin → iron deficiency Reduction in EPO synthesis → inhibition of erythropoiesis Mild-to-moderate anemia: normocytic normochromic → microcytic hypochromic https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 22/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Hepsidin-mediated iron-deficiency contributes to transformation of normocytic normochromic anemia to microcytic hypochromic CBC Normal-to-low MCV, MCH, and MCHC RDW: normal Reticulocyte count: <2% https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 23/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Parameter Anemia of Inflammation Serum iron Low (serum iron is low, similar to iron-deficiency) Serum ferritin High (iron is locked in stores) Transferrin Low ( high ferritin - low transferrin) Transferrin saturation Low (iron is more deficient than transferrin) Iron in BM Accumulation of iron in macrophages No sideroblasts Erythrocyte zinc protoporphyrin High https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 24/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Microcytic hypochromic anemia with following characteristic features Mitochondrial defect, iron supply/store is adequate Iron accumulates in mitochondria arranged in a ring/circle around the nuclei of proerythroblasts (“ringed sideroblasts”) Incorporation of iron into Hb is inhibited Causes Genetic causes → hereditary anemias, e.g., X-linked sideroblastic anemia due to deficiency in ALAS2 [δ-aminolevulinic acid (δ-ALA) synthase 2] Acquired causes Alcoholism → mitochondrial damage Pyridoxine (B6) deficiency → inhibition of δ-ALA synthase 2 (mostly associated with isoniazid therapy of TB) Lead (Pb) poisoning → denaturation of ferrochelatase Myelodysplastic syndrome (MDS) with ringed sideroblasts https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 25/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Pb binds to disulphide groups and damage enzymes involved in heme synthesis Denaturation of ferrochelatase → inability to incorporate iron in protoporphyrin ring Denaturation of ALA dehydrase → inability to convert ALA to porphobilinogen Denaturation of ribonuclease → prevention of breakdown of ribosomes → persistence of ribosomes → coarse basophilic stippling in mature RBCs Pb competes with Ca2++ ions and gets deposited in the epiphyses of growing bones All sideroblastic anemias CBC: Low MCV, MCH, and MCHC PBS Microcytic hypochromic RBCs with Coarse basophilic stippling BM Ringed sideroblasts (≥ 5 granules in a peri-nuclear position, encircling onethird or more of the circumference of the nucleus) Iron-laden macrophages (ferritin and hemosiderin) Additional tests for Pb-induced sideroblastic anemia Elevated Pb level in blood and urine Elevated δ-ALA level in the urine https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 26/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 27/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Parameter Sideroblastic anemia RBC inclusions Coarse basophilic stippling Serum iron High (deficient incorporation of iron in protoporphyrin; iron absorption and transportation are not affected) Serum ferritin High (iron transportation and storage are not affected) Transferrin Low (high ferritin → low transferrin) Transferrin saturation High (high iron and low transferrin) Iron in BM Accumulation of iron in macrophages and proerythroblasts (ringed sideroblasts ) Erythrocyte zinc protoporphyrin High Sideroblast https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 28/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Two BM macrophages stained for iron https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 29/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Parameter RBC additional features Thalassemias ß- thal : basophilic stippling, nucleated RBCs ⍺- thal : aggregates of HbH similar to Heinz bodies, or aggregates of Hb Barts (supravital stain) Serum iron Normal-to-high (activated intestinal absorption, ineffective erythropoiesis) Serum ferritin Normal-to-high (higher iron → higher ferritin) Transferrin Normal-to-low (high ferritin → low transferrin) https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 30/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Parameter Thalassemias Transferrin saturation Normal-to-high (normal-high iron and normal-to-low transferrin) Iron in BM Accumulation of iron in macrophages Erythrocyte zinc protoporphyrin Normal Parameter RBC characteristic features Irondeficiency anemia Anemia of Sideroblastic Inflammation anemia Coarse basophilic stippling https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs Thalassemias Basophilic stippling Nucleated RBCs Aggregates ofHbH 31/80 1/19/24, 10:56 AM Parameter Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Irondeficiency anemia Anemia of Sideroblastic Inflammation anemia Thalassemias Aggregates of Hb Barts Serum iron ↓ ↓ ↑ N* to ↑ Serum ferritin ↓ ↑ ↑ N to ↑ Transferrin ↑ ↓ ↓ N to ↓ Transferrin saturation ↓ ↓ ↑ N to↑ Iron in BM store None ↑ ↑↑ ↑ Erythrocyte zinc protoporphyrin ↑ ↑ ↑ N  Click each section below to learn more about the types of hemolytic anemias. Common in Northern Europe Autosomal dominant disorder due to a defect in the RBC membrane skeleton Outcome: loss of membrane fragments → decrease in RBC surface membrane → spherocytes 3 normal RBCs in the center https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 32/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 RB concave w malaria ——- Moxon CA, Grau GE, Craig AG. Malaria: modification of the red blood cell and consequences in the human host. Br J Haematol. 2011 Sep;154(6):670-9. doi: 10.1111/j.1365-2141.2011.08755.x. Epub 2011 May 28. PMID: 21623767; PMCID: PMC3557659. Spherocyte RBC abd spherocytes —- Mustafa I, Al Marwani A, Mamdouh Nasr K, Abdulla Kano N, Hadwan T. Time Dependent Assessment of Morphological Changes: Leukodepleted Packed Red Blood Cells Stored in SAGM. Biomed Res Int. 2016;2016:4529434. doi: 10.1155/2016/4529434. Epub 2016 Jan 21. PMID: 26904677; PMCID: PMC4745630. https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 33/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 34/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Anemia Splenomegaly: 0.5 - 1.0 kg Intermittent jaundice usually due to a viral infection with following hemolytic crisis Parvovirus B19 infection → aplastic crisis Gallstones Leg ulcers NB: spectrum of clinical manifestations: mild-to-moderate-to severe Majority of HS patients present a mild clinical course Some patients may develop life-threatening anemia and require blood transfusions CBC RBC count: normal-to-reduced Normocytic RBCs (MCV 80-100 µm3) Hb: normal-to-reduced HCT: normal-to-reduced MCH: normal-to-reduced MCHC: increased Reticulocyte count: increased (>3%) PBS Small in diameter RBCs without central pallor = spherocytes (MCV, MCH, and HCHC are normal) Characteristic, but not pathognomonic: also seen in immune hemolytic anemias (AHA) Polychromasia Nucleated RBCs Howell-Jolly bodies Bone marrow: erythroid hyperplasia with a normoblastic reaction Serum bilirubins: unconjugated hyperbilirubinemia Diagnosis of HS in asymptomatic patients requires confirmation with osmotic fragility test https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 35/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 36/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Ed Uthman from Houston, TX, USA (https://commons.wikimedia.org/wiki/File:Spherocytes_(4670166434).jpg) , CC BY 2.0 (https://creativecommons.org/licenses/by/2.0) , via Wikimedia Commons Normal biconcave RBC lyse in 0.5-0.3% NaCl solution Spherocytes start to lyse (red line) in 0.85% NaCl solution https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 37/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Splenectomy → elimination of splenic sequestration → reduction in phagocytosis of spherocytes and their extravascular hemolysis → reduction of anemia and other manifestations Confirmation of splenectomy in PBS: increased amount of Howell-Jolly bodies (illustrated), appearance of target cells Side-effects of splenectomy Reduction in immunity to encapsulated microorganisms (pneumococci, meningococci, H. influenzae type B) → sepsis https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 38/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Hepatic and mesenteric thrombosis A recessive X-linked disorder Common in Africa, Mediterranean, and among African Americans Probably protects from Plasmodium falciparum malaria As a rule, not so severe as SCA, thalassemias, and HS 1. G6PD-deficiency 2. Limited production of NADPH 3. Limited production of reduced glutathione (GSH) 4. Limited ability to metabolize H2O2 5. Accumulation of pro-oxidant compounds (e.g., superoxide) 6. Cross-linking of reactive sulfhydryl groups in globin chains 7. Precipitation of denatured globins with formation of Heinz bodies https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 39/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Rasburicase administered to degrade uric acid produces an equimolar amount of H2O2 H2O2 is rapidly degraded by the combined action of glutathione peroxidase, catalase, and Prx2 (peroxiredoxin-2); all three mechanisms are NADPH dependent 1. Oxidative stress in G6PD-deficient individuals; stressors Infections. e.g., pneumonia or viral hepatitis → inflammatory response → generation of ROS Drugs, e.g., antimalarials, sulfonamides, nitrofurantoins https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 40/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Food, e.g., fava beans 2. Cross-linking of sulhydryl groups in globin chains 3. Formation of globin precipitates attached to the cytomembrane (Heinz bodies) 4. Episodic hemolysis Extravascular: fragments of RBC membrane with attached Heinz bodies are plucked out by splenic macrophages —> formation of bite cells and spherocytes Intravascular: Heinz bodies directly damage the RBC membrane Episodes of acute hemolysis 2-3 days after oxidant exposure: anemia, hemoglobinemia, and hemoglobinuria No features of chronic hemolysis: neither splenomegaly, nor cholelithiasis Lab findings Bite cells Spherocytes Heinz bodies identified with supravital stains Bite Cells https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 41/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 Heinz Bodies (cresyl violet) Also known as autoimmune hemolytic anemia (AIHA) Types Warm antibody type (80%) https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 42/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 IgGs bind RBCs at 37˚ C (Warm is Good) Cold agglutinin type (20%) IgMs bind RBCs at lower temperatures (best 0-4˚ C) Extravascular hemolysis in both types Both direct and indirect positive Coombs test in both types 1. Known predisposing conditions Autoimmune disease: SLE Drugs Antigenic drugs: penicillins and cephalosporins Tolerance-breaking drugs: ⍺-methylodopa Lymphoid neoplasms 2. Production of antibodies (IgGs) 3. Attachment of IgGs to RBC surface 4. Binding of IgGs to Fc-receptors on splenic macrophages 5. Plucking out of RBC fragments (extracellular hemolysis, as in HS) → spherocytosis https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 43/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 A. Blood film showing moderately severe autoimmune hemolytic anemia (AHA). Note the high frequency of microspherocytes (small hyperchromatic RBCs) and the high frequency of macrocytes (putative reticulocytes). B. Blood film showing severe AHA. Note the low density of red cells on the film (profound anemia), high frequency of microspherocytes (hyperchromatic), and the large red cells (putative reticulocytes). Note the two nucleated RBCs and the Howell-Jolly body (nuclear remnant) in the macrocyte. Nucleated RBCs and Howell-Jolly bodies may be seen in AHA with severe hemolysis or after splenectomy. C. Blood film showing severe AHA. Monocyte engulfing two red cells (erythrophagocytosis). Note the frequent microspherocytes and scant red cell density. D. Reticulocyte preparation showing AHA. Note the high frequency of reticulocytes, the large cells with precipitated ribosomes. The remaining cells are microspherocytes. (Reproduced with permission from Lichtman’s Atlas of Hematology, www.accessmedicine.com.) https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 44/80 1/19/24, 10:56 AM Week 1: Fusion Session | Workshop: Anemia and Antianemia Drugs: Hemtlgy Onclgy Infectn Imm - January 2024 1. Predisposing factors Infections: Mycoplasma pneumoniae, EBV, CMV, HIV, etc. Lymphoid neoplasms 2. Transient production of antibodies (IgMs) 3. Attachment of IgGs to RBC surface in the body parts with temperature below 30°C (fingers, toes, and ears) 4. Agglutination of RBCs (→ Raynaud phenomenon) 5. Activation of complement (particularly C3b) 6. Recognition of C3b by macrophages in the spleen, liver, and BM 7. Plucking out of RBC fragments (extracellular hemolysis, as in HS) → spherocytosis Two PBSs (images) from the same patient Image A: RBC agglutination at 30°C (cold agglutinin IHA for RBC agglutination) Image B: no RBC agglutination at 37°C CBC RBC count: normal-to-reduced Normocytic RBCs (MCV 80-100 µm3) Hb: normal-to-reduced HCT: normal-to-reduced MCH: normal-to-reduced https://rossmed.instructure.com/courses/3318/pages/week-1-fusion-session-%7C-workshop-anemia-and-antianemia-drugs 45/80