Anemic Syndrome and White Blood Cells Disorders

27. 11. 2020

Anemic syndrome and white blood cells disorders

Kristína Repová, M.D., PhD.

[email protected] Institute of Pathophysiology, Faculty of Medicine, Bratislava

Prepared exclusively for the purposes of distance education at the Faculty of Medicine, Comenius University in Bratislava in 2020/21

Hematopoeisis

• Hematopoietic organs: • Bone marrow: • forming of erythrocytes, granulocytes, monocytes, thrombocytes, partially lymphocytes • Thymus: • forming of T-lymphocytes • Lymphatic nodes, tonsils, spleen: • forming of B-lymphocytes

lymphoid multipotent stem cell pluripotent progenitor cell precursor cell stem cell myleoid multipotent stem cell

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Hematopoeisis

Pluripotent hematopoietic stem cell (self-renewal)

Myeloid multipotent Lymphoid multipotent stem cell stem cell

Megacaryocyte and Granulocyte and T-cell and NK B-cell erythroid progenitor Macrophage progenitor cell progenitor progenitor

Megacaryocyte Erythrocyte Granulocyte Monocyte progenitor progenitor progenitor progenitor (CFU-Meg) (CFU-E) (CFU-G) (CFU-M)

Myeloblast NK-cell Proerythroblast Monoblast Lymphoblast Lymphoblast Promyelocyte Megacaryoblast Erythroblast Myelocyte Promonocyte Prolymphocyte Prolymphocyte Megacaryocyte Reticulocyte Metamyelocyte Monocyte T-cell B-cell Thrombocyte Erythrocyte Band cell

Basophil Eosinophil Macrophage Dendritic cell Neutrophil

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I. Disorders of red blood cells II. Disorders of white blood cells III. Myeloproliferative and lymphoproliferative disorders

I. Disorders of red blood cells

1. Anemia 2. Polycythemia

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• Hemoglobin (Hb): • F: 120 - 160 g/l M: 140 - 180 g/l • ”: polycythemia, dehydration • ‘: anemia, hyperhydration • Red blood cells (RBC): • F: 4,2 - 5,4 x 10 12 /l M: 4,6 - 6,2 x 10 12 /l • ”: polycythemia, dehydration • ‘: anemia, hyperhydration • Hematocrit: • volume percentage of red blood cells in blood • F: 39±4 % (0,39±0,04) M: 44±5 % • ”: polycythemia, dehydration • ‘: anemia, hyperhydration • Reticulocytes: • 0,5 – 1,5 % • ”: bleeding, haemolysis (bone marrow compensation) • ‘ - 0: poor RBC production, aplastic anemia

• Erythropoietin:

• ”: secondary polycythaemia, ‘ paO2, sideropenic and some haemolytic anemias

• ‘: renal diseases, deficit of proteins, ” paO 2, polycythaemia vera

• MCV – mean cell volume: • 87,5 fl (80-96 fl) • to differentiate normo-, micro- and macrocytic anemias

• MCH – mean cell hemoglobin: • 29 pg (28-33 pg), 18 fmol • ”: hyperchromic anemias • ‘: hypochromic anemias

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1. Anemias

= ‘ plasma hemoglobin concentration: ♀ < 120 g/l, ♂ < 140 g/l = ‘ hematocrit = ‘ RBCs

• mild > 100 g/l • moderate 80 – 100 g/l • severe ˂ 80 g/l

• a sign (symptom) of other diseases

• normal paO2, in arteries, Hb fully saturated by O2

• Dilutive (relative) anemia: anemia caused by ” plasma volume

Anemic syndrome

• symptoms often present during ‘ Hb concentration in blood

1. ‘ O2 transport: • shortness of breath during exertion • weakness, fatigue • dizziness • angina • organ disorders • pallor: pale skin, lining mucosa, conjunctiva and nail beds 2. ‘ plasmatic volume: • pale or yellowish skin • postural hypotension 3. ” cardiac output: • palpitations • flow murmurs • tachycardia

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Adaptation to anemia

‘ blood viscosity tissue hypoxia ” Epo production ” 2,3-DPG in RBCs

vasodilation

‘ peripheral resistance

‘ O affinity ” cardiac output 2 ” erythropoiesis (shift to the right of the (hyperkinetic circulation) dissociation curve)

• fast adaptation, during exercise • develops within 24 h

Morphologic classification of anemias

according to MCV and MCH • • Normocytic: • after acute bleeding • Normochromic: after acute • aplastic anemia bleeding • hemolytic anemia: sickle cell anemia, • Hypochromich: ‘ Fe, thalassemia enzymatic defects, antibodies

• Hyperchromic: ‘ VT B 12 • Microcytic: • ‘ Fe • β-thalassemia major • hereditary spherocytosis • chronic infections • Macrocytic:

• megaloblastic: ‘ folate, VT B 12 • hypothyreosis, chronic liver failure

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Morphologic classification of anemias

• Acute bleeding • Hemolysis • ↓ B12 • Bone marrow aplasia • ↓ folate ‘ Fe • Bone marrow infiltration

Chronic disease ↓ MCV MCV and MCH ↑ MCV ↓ MCH normal ↑ MCH

• Macrocytic Microcytic Normocytic hyperchromic hypochromic normochromic anemia anemia anemia • Megaloblastic anemia

Pathophysiologic classification of anemias

A. Anemias due to B. Anemias due to ‘ RBCs production: ” RBCs loss: • ‘ Erythropoietin (Epo): • acute / chronic • severe renal dysfunction hemorrhage • severe protein deficiency • hemolytic anemias • chronic inflammatory diseases • ‘ factors essential for erythropoiesis: • ‘ Fe

• ‘ folate, VT B 12 • ‘ proteins • cellular dysfunction of hematopoietic Reticulocytes? tissues: • aplastic anemia • myelodysplastic sy. • leucemias • infiltration of hematopoietic tissue • fibrosis of bone marrow

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Pathophysiologic classification of anemias

↓ Hb

” RBCs loss ‘ RBCs production

‘ abnormal

” blood loss - hemorrhage Cytoplasmatic Nuclear Haemolytic defect defect anemias ↓ Fe ↓ B 12

Posthemorrhagic Aplastic anemia anemias Bone marrow infiltration

A. Anemias due to ” RBCs loss

A-a) Acute / chronic hemorrhage A-b) Hemolytic anemias

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A-a) Anemias due to blood loss

• Acute hemorrhage: 1. hypovolemia (not anemia) • blood loss > 500 ml g severe anemia and Fe loss 2. regulatory mechanisms g ” plasma volume g hemodilution g ‘ hematocrit g anemia 3. ‘ Hb g ” Epo g ‘ apoptosis of progenitor cells CFU-E in hematopoietic tissues g 1 CFU-E forms in 2-3 days 60-120 reticulocytes • 4-5 days after acute hamorrhage g ” reticulocytes in blood • Chronic hemorrhage: • loss of x10 ml blood/day g cumulative iron loss • if the loss of Fe exceeds increased resorption g restriction of erythropoiesis g iron deficiency anemia

A-b) Hemolytic anemias A. Extravascular hemolysis: • in spleen, liver, bone marrow • Fe and globin reutilize => no Fe deficiency, hemoglobinuria or hemosiderinuria • hem g bilirubin => ” indirect, nonconjugated bilirubin g jaundice, gallstones

B. Intravascular hemolysis: after transfusion, artificial heart valves, PNH, cold aglutinins • hemoglobin binds haptoglobin g macrofages g prevent hemoglobin loss • if the haptoglobin capacity is exceeded, in kidneys: • passing glomerular membrane g hemoglobinuria g Fe loss • fagocytosis by tubular cells: Hb g hemosiderin g after 3-4 days hemosiderinuria , may injure tubules, acute renal failure • fragments of RBCs g trombosis, embolism g cerebral, myocardial, renal ischemia • ‘ plasma haptoglobin, takes x days to produce by liver • ” plasma lactate-dehydrogenase from RBCs

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A-b) Hemolytic anemias

1.Intracorpuscular: • membrane defects • hereditary spherocytosis, elliptocytosis, paroxysmal nocturnal hemoglobinuria (PNH) • enzymopathies • defects of glucose-6-phosphate dehydrogenase (G6PD), pyruvate kinase • hemoglobinopathies • sickle cell anemia, thalassemia 2.Extracorpuscular: • physical and toxic injury • mechanic, heat, bacterial toxins, malaria • antibodies • agglutinins, auto-antibodies, anti-Rh antibodies

Hemolytic anemias intracorpuscular – membrane defects • Hereditary spherocytosis, elliptocytosis • AD, cytoskeletal and membrane defect with spectrin deficiency • vesicles form in membrane, when passing through spleen, RBCs are loosing part of membrane g spherical, ellipsoid shape of RBCs with ‘ deformability g hemolysis CP: anemia, splenomegaly, jaundice, gallstones Lab: ” reticulocytes, ” Epo Th: splenectomy • Paroxysmal nocturnal hemoglobinuria (PNH)  acquired chronic HA, mutation of PIG-A gene in RBCs g lack of protecting proteins against complement on the membrane of RBCs (CD55, CD59) • ‘ pH during sleep stimulates complement g hemolysis CP: nocturnal/morning hemoglobinuria, hemosiderinuria, anemia (normocytic, normochromic), aplastic anemia , pancytopenia, venous thrombosis (complement activates aggregation of Thro)

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Hereditary spherocytosis Hereditary elliptocytosis

Hemolytic anemias intracorpuscular – enzymopathies

• Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency: • inherited, X chromosome, G-6-PD defends cells against oxidative stress • the most common enzyme deficiency in humans  fava beans (= favism), infections, drugs (antimalarials, sulphonamides) g ” ox. stress g hemolysis CP: malaise, weakness, abdominal or lumbar pain, jaundice, dark urine (hemoglobinuria) • Pyruvate kinase deficiency: • AR, rare • ATP deficiency g ” K+ loss, Na + accumulation g rigid RBCs g hemolysis CP: neonatal jaundice, anemia

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Hemolytic anemias intracorpuscular – hemoglobinopathies

• normal Hb: HbA = α2β2 • 2-3% HbA 2 = α2δ2 • fetal Hb = α2γ2 • Sickle cell anemia: • AD, usually Africans, resistance to malaria  mutation in the β-globin gene that changes the 6th amino acid from glutamic acid to valine => HbS • HbS polymerizes reversibly when deoxygenated g ‘ deformability of RBCs g sickle shape g microvascular vasoocclusion • HbS denaturates in RBCs g membrane injury g macrophages g chronic hemolytic anemia • sickle cell crisis : intermittent episodes of vasoocclusion in connective and musculoskeletal structures g painful ischemia: acute pain and tenderness, fever, tachycardia, anxiety • repeated micro-infarction: lungs (pulmonary hypertension), kidneys (renal papillary necrosis), bone and joint (aseptic necrosis), skin (ulcerations), CNS (stroke), spleen (calcification) Lab, CP: ” reticulocytes, ” Epo, ” nonconjugated bilirubin, jaundice, gallstones

Sickle cell anemia

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Hemolytic an emi as intrac orpus cular – hemoglobinopathies • Thalassemia: inherited, disorders of α (4 allels) or β (2 allels) -globin biosynthesis • α-thalassemia: α –chain deficiency, 4 grades • 3 loci deleted (HbH disease): severe hemolytic anemia

• 4 loci deleted: hydrops fetalis, HbH (β4) – precipitates in RBCs • β-thalassemia: mutations ‘ quantity of β-chains (β+) or they lack (β0) • thalassemia major (β0/β0): α –chains precipitate in RBCs, kill developing erythroblasts in the marrow = ineffective erythropoiesis , severe HA (microcytic, hypochromic), HbF,

HbA 2 • massive bone marrow expansion g maxillary marrow hyperplasia and frontal bossing, thinning and pathologic fracture of long bones and vertebrae g growth retardation; hepatosplenomegaly Th: RBCs transfusion g Fe overload g damage liver (cirrhosis), pankreas (DM 1. type), myocardium (fibrosis, heart failure) • thalassenia intermedia (β+/β+): anemia • thalassemia minor (β0/β or β+/β0): none / mild anemia

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β-thalassemia

Facial bone abnormalities: -Bossing of the skull -Hypertrophy of maxilla -Exposure of upper teeth -Depression of nasal bridge -Periorbital puffiness

Distribution of sickle cell anemia and thalassemia

Sposi: Interaction between Erythropoiesis and Iron Metabolism in Human β-Thalassemia - Recent Advances and New Therapeutic Approaches. InheritedHemoglobin Disorders. 2015. https://doi.org/10.5772/61716 . 28

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Hemolytic anemias extracorpuscular

• Mechanical injury:  thrombotic thrombopenic purpura, hemolytic-uremic syndrome, disseminated intravascular koagulation, transplant rejection: firbrin , aggregated Thro in arteriols or capillaries g fragmentation RBCs, endothelial dysfunction g microangiopathic hemolytic anemia  marathon, barefoot ritual dancing (march hemoglobinuria )  prosthetic heart valves • Toxic agents: Clostridium perfringens toxin, spider, snake toxins, malaria • Heat: > 49°C, burns • Drugs: - penicilin, ampicilin, cephalosporins g haptens on RBCs surface g antibodies - phenacetin, chinidin, rifampicin g bind plasmatic proteins and then complement binds RBCs - methyldopa g chronic production of autoAb against RBCs

Hemolytic anemias extracorpuscular – autoimmune (AIHA)

• Warm antibody hemolytic anemia: SLE, lymphoma, chronic lymphocytic leukemia • 37°C, IgG with Fc fragment binds RBCs g macrophages in spleen phagocyte RBCs g extravascular hemolysis g activation of complement g intravascular hemolysis (rare) • Cold agglutinin disease: mycoplasmal pneumonias, infectious mononucleosis, lymphoproliferative disorders • 4-30°C, IgM • hemolysis in the extravascular mononuclear phagocyte system of the liver • RBCs agglutinate in circulation g obliteration of colder acral parts = akrocyanosis • Paroxysmal cold hemoglobinuria: • Ab binds to red cells only at a low temperature (4°C) g warming g lysis of RBCs in the presence of complement g intravascular hemolysis CP: pallor, jaundice, abdominal pain, fever

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Hemolytic anemias extracorpuscular – autoimmune (AIHA)

• Rh incompatibility : • mother Rh neg. and fetus Rh posit. • hemolysis usualy in 2nd pregnancy • hemolytic anemia, jaundice of the newborns, hydrops fetalis

• AB0 incompatibility: • acute hemolytic reaction

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B. Anemias due to ‘ RBCs production

• ‘ erythropoietin (Epo): • severe renal dysfunction • severe protein deficiency • chronic inflammatory diseases • ‘ factors essential for erythropoiesis: • ‘ Fe

• ‘ folate, VT B 12 • ‘ proteins • cellular dysfunction of hematopoietic tissues: • aplastic anemia • myelodysplastic sy. • leucemias • infiltration of hematopoietic tissue • fibrosis of bone marrow

 Lab: ‘ reticulocytes in blood

B-a) Anemia due to erythropoietin deficiency

 bilateral nephrectomy, bilateral chronic renal failure  chronic disease (rheumatoid arthritis), malignant diseases: • inflammatory cytokines (IL-1, TNF, IFN-γ) ‘ renal reactivity to hypoxia g ‘ Epo • Fe deficiency (accumulation in macrophages, Fe for immunity) • shorter life of RBCs

• ‘ EPO g apoptosis of CFU-E, ‘ CFU-E in bone marrow, ‘ reticulocytes in blood • Epo is partialy produced in liver • normocytic, normochromic anemia

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B-b) Iron deficiency anemia – iron metabolism

• 3,5–5 g iron (Fe) • iron stores: ferritin and hemosiderin • Ferritin: ”: iron overload, liver disease, malignancies ‘: iron deficiency anemia • transport iron: transferrin • ”: iron deficiency g negative feedback g ” transferrin synthesis in hepatocytes • ‘: impaired proteosynthesis, malnutrition, loss (proteinuria), acute / chronic inflammation (negative acute phase reactant) • transferrin saturation: ”: 80–90 % in hereditary hemochromatosis ‘: iron deficiency • functional iron: hemoglobin, myoglobin, cytochromes, katalases, peroxidases

B-b) Iron deficiency anemia

Iron deficiency: • blood loss : UGS (menorrhagia, renal hemorrhagia), GIT (ulcers, varices, hemorrhoids, ...) • impaired iron recycling : chronic infections (does not release from macrophages) • insufficient iron intake : malnutrition • impaired resorption : achlorhydria (atrofic gastritis), malabsorption (celiac disease, ulcerative colitis, phytates in grains, tannins in tea) • increased demand for iron: rapid growth in infancy or adolescence, pregnancy, lactation

1. prelatent iron deficiency (negative iron balance): demands for (or losses of) iron exceed the body's ability to absorb iron from the diet, enough iron for erythropoiesis 2. latent iron deficiency (iron deficient erythropoiesis): iron stores depleted, ‘ marrow iron stores, erythropoiesis present 3. manifest iron deficiency: iron deficiency anemia - microcytic hypochromic

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B-b) Iron deficiency anemia

• erythroblasts mature longer in BM, they can undergo more divisions g microcytes

CP: smooth red tongue, angular stomatitis, spoon nails, infections Lab: - ‘ reticulocytes - ‘ ferritin (iron stores depleted) - ‘ serum iron - ” transferrin - ‘ transferrin saturation - ” Epo

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B-b) Iron deficiency anemia

pale conjunctiva

smooth red tongue, angular stomatitis

Microcytic and hypochromic red cells smaller than the nucleus of a lymphocyte associated with marked variation in size (anisocytosis) and shape (poikilocytosis).

spoon nails (koilonychia)

B-c) Megaloblastic anemia – Folate and cobalamin deficiency anemia

 defects in DNA synthesis , the cell cycle is slowed down during formation of RBCs, granulocytes and megakaryocytes

• Hb synthesis in the cytoplasm continues unchanged=> megaloblasts in BM and megalocytes in blood • premature destruction of megaloblasts in bone marrow=> inefficient erythropoiesis • shortened life-span of the megalocytes=> premature hemolysis

Lab: - ‘ reticulocytes in blood - pancytopenia

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B-c) Folate deficiency anemia

Folate deficiency: • dietary • ” utilization: growth, pregnancy, malignancies • malabsorption: small intestine diseases, methotrexate

• cobalamin deficiency (VT B 12 )

• folate: thymidine synthesis for DNA • deficiency manifests after x weeks – months • in vegetables (long cooking destroys folate)

B-c) Vitamin B 12 (cobalamin) deficiency anemia

Vitamin B12 deficiency: • dietary : vegans • intrinsic factor (IF) deficiency: IF is secreted by parietal cells of stomach, in duodenum IF binds VT B 12 , in lower ileum IF-VT B 12 is absorbed and in enterocyte B12 binds transcobalamin II g plasma): atrophic gastritis => pernicious anemia megaloblastic, macrocytic

• ” bacterial consumption of VT B 12 in intestine : blind loop syndrome, diverticulosis, Crohns disease • loss (inherited / resection) or inflammation of terminal ileum

• deficiency manifests after x years • in meat, fish, and dairy products • B12 is needed to form tetrahydrofolate during conversion of homocystein to methionin CP: - homocysteine accumulation => thrombi - damage to NS (can be permanent): methionine deficiency g axonal demyelization, neuronal loss => paresthesia, impaired reflexes, balance, cognition

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B-c) Megaloblastic anemia

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B-d) Aplastic anemia • pancytopenia with bone marrow hypocellularity - bone marrow failure

• Idiopatic aplastic anemia: • 50-65% aplastic anemias, more severe than secondary viral infections, drugs (chloramphenicol) autoimmune defect of pluripotent stem cells or BM stroma • Secondary aplastic anemia: cytostatic drugs – transient anemia parvovirus B19 infection myelotoxic drugs: benzene, pesticides

CP: - anemia – pallor, fatigue, tachycardia, hyperkinetic circulation - thrombocytopenia – petechiae, hematomas, bleeding from gums, GIT, menorrhagia - granulocytopenia – bacterial, fungal infections

Lab: - BM: ‘ erythroblasts, megakaryocytes, granulocytes precursors - blood: pancytopenia – anemia, leukopenia, thrombocytopenia, ‘ reticulocytes

B-d) Aplastic anemia

• Fanconi’s anemia: • aplastic anemia with pancytopenia • AR, chromosomes are peculiarly susceptible to DNA cross-linking agents g malignancy • congenital developmental anomalies involving the thumb, radius, and genitourinary tract • growth and mental retardation • skin hyperpigmentation - café au lait spots • Myelophthisis: • fibrosis of the bone marrow invading tumor cells osteopetrosis infection of mycobacteria (both Mycobacterium tuberculosis and M. avium), fungi, or HIV, and in sarcoidosis

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B-d) Aplastic anemia

• Pure red cell aplasia: • isolated absence of RBCs precursors • antibodies against Epo • Diamond-Blackfan sy.: • AD, severe macrocytic anemia, in BM ‘ reticulocytes and erythroblasts • Pure red cell aplasia (PRCA): • acquired, idiopatic thymom, lymphatic malignities, lupus erythematodes, rheumatoid arthritis, infections (parvovirus B19, HIV, EBV)

B-e) Anemia of chronic disease • inflammation, infection, tissue injury, cancer g proinflammatory cytokines  chronic infections : TBC, pulmonary inflammation, subacte bacterial endocarditis, osteomyelitis, AIDS  chronic inflammation : ulcerative collitis, rheumatic, systemic diseases  autoimmune diseases  malignancies : carcinoma, lymphoma, leukemia, myeloma  chronic renal failure (‘ Epo)  trauma, postoperative state

• anemia: normocytic, normochromic gg hypochromic a microcytic

• Mechanisms: • shortened life-span of RBCs (macrophage activation) • ‘ proliferation and differentiation of erythroid precursors • ‘ Epo production / resistance of erythroid precursors to Epo • changed iron metabolism, specific deficit for erythropoiesis • inflammatory cytokines (IL-1β, IL-6, TNFα, IFNγ) • primary disease (hemorrhage, malnutrition, …)

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Zarychanski, CMAJ 2008,179(4):333-337

B-e) Anemia of chronic disease – iron • Functional iron deficiency : not enough of iron for erythropoiesis, BUT it is sequestrated in macrophages • Hepcidin: • sequestration of iron within macrophages (essential nutrient for the growth of microorganisms, promotes infection and facilitates the growth of malignant cells) • stimulated by inflammation (IL-6) • rapidly ‘ serum iron • ‘ iron resorption in duodenum Anemia of Iron deficiency chronic disease anemia Serum iron ‘‘ Transferrin ‘ - normal ” Transferrin saturation ‘‘ Ferritin normal - ” ‘ Soluble transferrin receptor normal ” Cytokine levels ” normal

Weiss, Goodnough, N Engl J Med 2005;352:1016

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B-f) Renal anemia

Chronic kidney disease

‘ filtration and removal ‘ Epo from kidneys uremic toxins of phosphates

hyperphosphatemia

‘ RBCs survival phosphates + calcium g calciumphosphate komplex ‘ erythropoiesis in BM • normocytic accumulation in normochromic anemia joints and bones • ‘ reticulocytes ‘ BM sensitivity to Epo hypocalcemia

stimulates parathyroid glands g parathormone

2. Polycythemia

• Cellular disorders of hematopoietic tissue: • polycythaemia vera rubra (g Myeloproliferative diseases) • Polycythemia due to ” Epo stimulation: tissue hypoxia: high altitude, pulmonary diseases, right-to-left shunts, carbon monoxide intoxication ectopic Epo production: tumors of kidneys, liver, uterus • Relative (stress) polycythemia (Gaisbock sy.): • ‘ plasma volume arterial hypertension, obesity, smoking dehydration severe burns

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Pathophysiologic classification of anemias

I. Disorders of red blood cells II. Disorders of white blood cells III. Myeloproliferative and lymphoproliferative disorders

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II. Disorders of white blood cells

1. Leukopenia 2. Leukocytosis 3. Disorders of granulocyte function

Normal values: Leukocytes: 4-10 x 10 9/l Neutrophils: 65% 3,9 x 10 9/l Eosinophils: 3% 1,8 x 10 8/l Basophils: 0,5% 3 x 10 7/l Monocytes: 4% 2,4 x 10 8/l Lymphocytes: 27,5%

Neutrophil pool

1. bone marrow (90%) 2. circulation (2–3% ): • circulating pool (1/2): not in contact with the endothelium • marginated leukocytes: are in close physical contact with the endothelium 3. tissues

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1. Leukopenia

• Neutropenia:  often, severe infections: fever, fatigue, anorexia, sore throat, otitis media, inflammation of UGS  ‘ production: • iatrogenic injury to BM: cytotoxic or immunosuppressive therapies • aplastic anemia, myelofibrosis

• folate, VT B 12 deficiency • infections: tuberculosis, brucellosis, tularemia, infectious mononucleosis, malaria, viral hepatitis, leishmaniasis, AIDS • cyclic neutropenia: ‘ neutrophils in 20 days cycles  Peripheral Pooling (Transient Neutropenia): • hypersplenism • overwhelming bacterial infection (acute endotoxemia) Peripheral Destruction: • antineutrophil antibodies • rheumatoid arthritis, lupus erythematosus

1. Leukopenia

• Eosinopenia:  acute bacterial infection  treatment with ACTH and glucocorticoids

• Basopenia:  treatment with ACTH and glucocorticoids

• Lymphopenia:  ” ACTH  radiation  cytostatic therapy

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2. Leukocytosis

• Neutrophilia:  ” production: • glucocorticoids , G-CSF (release from BM); infection (bacterial, fungal); inflammation (thermal injury, tissue necrosis, myocardial and pulmonary infarction); myeloproliferative diseases (myelocytic leukemia, myeloid metaplasia, polycythemia vera)  ” marrow release: • glucocorticoids , acute infection (endotoxin), inflammation (thermal injury)  ‘ or defective margination: • drugs (epinephrine , glucocorticoids, NSAIDs); stress , excitement, vigorous exercise; leukocyte adhesion deficiency syndrome  acute hemorrhage or hemolysis, ketoacidosis, acute poisoning

• Leukemoid reaction: physiological response to stress or infection, neutrophilia with mature neutrophils and marked “left shift”=> benign

2. Leukocytosis

• Eosinophilia:  parasite, helminthic infection  allergies: hay fever, asthma, eczema  allergic reaction to drugs : iodides, aspirin, penicillins, cephalosporins  rheumatoid arthritis  malignancies: Hodgkin's disease, chronic myeloid leukemia

• Basophilia:  ulcerative collitis , rheumatoid arthritis, tumors  CML, Hodgkin's disease  estrogens

• Lymphocytosis:  viral infections: infectious mononucleosis, CMV  ALL, CLL

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3. Disorders of granulocyte function • Leukocyte adhesion deficiency – LAD:  AR, impaired phagocyte adherence, aggregation, spreading, chemotaxis • ‘ or absence of marginal pool g neutrophilia • granulocytes are not able to concentrate in inflammatory sites g recurrent infections of skin and mucosa, gingivitis, periodontal disease • Abnormal chemotaxis: Chédiak-Higashiho sy.:  ‘ chemotaxis and phagolysosome fusion g recurrent pyogenic infections , especially with S. aureus • Disorders of Phagocyte Function: • Chronic Granulomatous Diseases:  no respiratory burst in neutrophils, monocytes, and eosinophils g severe infections of skin, ears, lungs, liver, and bone (catalase-positive microorganisms: S. aureus , Aspergillus spp.) g granulomas , can obstruct GI or GU tracts • Myeloperoxidase Deficiency: • MPO forms hypochlorous acid, defect compensated by NADPH oxidase activity g systemic candidiasis

I. Disorders of red blood cells II. Disorders of white blood cells III. Myeloproliferative and lymphoproliferative disorders

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III. Myeloproliferative and lymphoproliferative diseases

1.Myeloproliferative : 2.Lymphoproliferative : a) Myelodysplastic syndrome (MDS) a) Acute lymphoid leukemia (ALL) b) Acute myeloid leukemia (AML) b) Chronic lymphoid leukemia (CLL) c) Chronic myeloid leukemia (CML) c) Hodgkin's lymphomas d) Polycythaemia vera rubra (PVR) d) Non-Hodgkin's lymphomas e) Essential thrombocythemia e) Plasma cells disorders f) Idiopathic myelofibrosis g) Mastocytosis

Pluripotent hematopoietic stem cell (self-renewal)

Myeloid multipotent Lymphoid multipotent stem cell stem cell

Megacaryocyte and Granulocyte and T-cell and NK B-cell erythroid progenitor Macrophage progenitor cell progenitor progenitor

Megacaryocyte Erythrocyte Granulocyte Monocyte progenitor progenitor progenitor progenitor (CFU-Meg) (CFU-E) (CFU-G) (CFU-M)

Basophil Eosinophil Macrophage Dendritic cell Neutrophil

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1. Myeloproliferative diseases

• primary proliferation of hematopoietic myeloid stem cells in bone marrow and extramedullary (spleen, liver)

a) Myelodysplastic syndrome (MDS) b) Acute myeloid leukemia (AML) c) Chronic myeloid leukemia (CML) d) Polycythaemia vera rubra (PVR) e) Essential thrombocythemia f) Idiopathic myelofibrosis g) Mastocytosis

1-a) Myelodysplastic syndrome

 mutation of pluripotent myeloid stem cell g monoclonal pathologic hematopoiesis g refractory anemias • acquired genetic alterations / immune response g apoptosis of marrow cells g ineffective hematopoiesis • BM is normo-/hyper-cellular (not aplastic), but part of the cells are pathologic (dysplastic ) blood cell precursors

RF: Down sy., Fanconi`s anemia, alkylating agents, radiation, benzene CP: severe anemia , can progress to AML ( preleukemic state ), infections , hemorrhages Lab: blood: ‘ RBCs, reticulocytes, granulocytes, monocytes, thrombocytes = pancytopenia

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1-b) Acute myeloid leukemia (AML)

• males > 65 r.  pathologic monoclonal hematopoiesis from different genetic disorders (t(15;17), t(8;21), inv(16), ...) in one of myeloid cells • rapid and uncontrolled proliferation of malignant hematopoietic cell • later defect of maturation and differentiation (accumulation of blasts) • inhibited apoptosis

Lab: - blood: - hiatus leukemicus – presence of blasts and completely mature elements, without intermediate forms - ” leukocytes, absolute count are leukemic blasts - BM: > 20% blasts from all nuclear cells in BM, uniform, morphology depends on the type of AM

1-b) Acute myeloid leukemia (AML)

CP: - fatigue, weakness, anorexia, weight loss, fever - ‘ erythropoiesis: normochromic normocytic anemia, ‘ reticulocytes - ‘ normal granulocytes and monocytes: infections – bacterial and fungal inf. of skin, mucosa, lungs - trombocytopenia: hemorrhage, in CNS (neurologic signs) - ” blasts in blood: DIC - infiltration of organs by pathologic blasts: spleno-, hepatomegaly, lymphadenopaty, skin, gingivnal mucosa, testes

RF: - acquired AML: mutagens – alkylating agents, radiation, benzene - inherited predisposition to AML: Down sy., neurofibromatosis 1. type, Fanconi`s anemia

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Clinical presentation of AML

gingival infiltrations infiltrations of the tongue

1-b) Acute myeloid leukemia (AML)

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1-b) Acute myeloid leukemia (AML)

1-c) Chronic myeloid leukemia (CML)

• males > 50 y. • higher grade of maturation of myeloid granulocytes than in AML

 t(9,22) - translocation between chromosomes 9 (protooncogene c-abl ) and 22 (gene bcr ) = Philadelphia chromosome g fusion gene bcr/abl g protein p210 BCR-ABL constitutively active as a tyrosine kinase enzyme: • ” resistance to apoptosis • ” proliferation g supresses normal hematopoiesis • inhibits DNA repair g genomic instability g the cell more susceptible to developing further genetic abnormalities g malignant clones replace normal cells g malignant phase = blast crisis • ‘ adhesion to marrow stromal cells

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1-c) Chronic myeloid leukemia (CML)

Lab: - blood: ”” dysfunctioned granulocytes (Leu: > 100 x 10 9/l), g infections - ” Leu g ” blood viscosity g leukostasis - ” Tro g thrombi 1. chronic phase: < 10% blasts, 85% of patients 2. accelerated phase : 10 – 19% blasts 3. blast crisis: > 20% blasts

CP: - fatigue, anemia, dyspnoe, weight loss, fever, sweating - infections, thrombosis, bleeding - leukostasis g vasoocclusive disease, cerebrovascular accidents, myocardial infarction, venous thrombosis, priapism, visual disturbances, pulmonary insufficiency - splenomegaly

1-c) Chronic myeloid leukemia (CML)

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1-d) Polycythaemia vera rubra (PVR)

• clonal disorder of a multipotent hematopoietic progenitor cell g accumulation of phenotypically normal RBCs , granulocytes, and platelets  acquired clonal mutation in JAK2 g ” sensitivity of progenitor cells to growth factors (Epo, IGF, IL-3, GM-CSF), some BFU-E differentiate without Epo

CP: - hypervolemia g ” BP, kompensatory vasodilation (warm skin) - aquagenic pruritus - ” bleeding (in CNS!, GIT, UGT, epistaxis) - ” hematocrit g ” blood viscosity g thrombosis , ” cardiac performance - splenomegaly Lab: - ” RBCs (6-8 x 10 12 /l), Hb, hematocrit - ” Leu, Thro

- normal O2 saturation - ‘ Epo

1-e) Essential thrombocythemia

Lab: - BM: ” megakaryoblasts a megakaryocytes - blood: Thro: 3000 x 10 9/l, but defective

CP: - trombosis - bleeding : epistaxis, GIT

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1-f) Idiopathic myelofibrosis

 megakaryocytes produce growth factors (PDGF) g fibroblast proliferation g bone marrow fibrosis • gradual loss of marrow hematopoiesis, activation in spleen, liver => extramedullary hematopoiesis

CP: - anemia, trombocytopenia, granulocytopenia - splenomegaly, hepatomegaly

Lab: - Teardrop-shaped RBCs, nucleated red cells, myelocytes, and promyelocytes

1-g) Mastocytosis

• clonal expansion of mast cells in BM, skin, gastrointestinal mucosa, liver, and spleen

CP: - histamin g pruritus , flushing, palpitations and vascular collapse, gastric distress, lower abdominal crampy pain, and recurrent headache - ” cell burden g urticaria pigmentosa (lesions of darker skin and very bad itching) at skin sites, bone pain and malabsorption - fibrotic changes in liver, spleen, and bone marrow

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2. Lymfoproliferative diseases

• malignant diseases of lymphoid cells: • disseminated form – lymphatic leukemia • localized form – lymphoma

• from B-cells • from T-cells

a) Acute lymphoid leukemia (ALL) b) Chronic lymphoid leukemia (CLL) c) Hodgkin's lymphomas d) Non-Hodgkin's lymphomas e) Plasma cells disorders

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2-a) Acute lymphoid leukemia (ALL)

• children, 4 y. • blocked differentiation and clonal expansion of lymphoid cells on different grade of differentiation, in 80 – 90% B-cells

 EBV, carcinogens, inherited syndromes (Fanconi`s anemia, Down sy., neurofibromatosis)  genetic aberrations: • chromosome count (hyperdiploidity) • chromosome structure (t(9;12), t(8;14) – protooncogene deregulation, c-myc – uncontrolled proliferation, Ph-chromosome)

2-a) Acute lymphoid leukemia (ALL)

CP: - fatigue, weakness, bleeding, anemia - adenomegaly , splenomegaly, hepatomegaly - periostal infiltration – pain in joints and bones - meningeal infiltration – neurologic symptoms, ” intracranial pressure - infiltration of n. opticus – visual disturbances

Lab: - blood: leukocytosis - BM: lymfoblast infiltration (> 30%) - anemia, trombocytopenia (suppressed formation)

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2-a) Acute lymphoid leukemia (ALL)

2-b) Chronic lymphoid leukemia (CLL)

• > 50 y., males, most frequent type of leukemia • especially from B-cells

 ” bcl-2 expression g disorders of apoptosis g accumulation of pathologic clones of lymfocytes, extravascular infiltration (lymph nodes, liver, spleen)  disorders of differentiation and maturation g infections, autoimmune diseases

CP: - malaise, weight loss, nocturnal sweating, fever - lymphadenopathy, splenomegaly, hepatomegaly Lab: - leukocytosis 15 – 200 x 10 9/l - massive marrow infiltration g suppressed remained hematopoiesis g anemia, granulocytopenia, trombocytopenia

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2-b) Chronic lymphoid leukemia (CLL)

2-c-d) Lymphomas

• malignancies of the lymphocyte system (BM, thymus, lymphatic nodes, spleen, lymphatic tissue of resp. system, GIT, ...) and its precursor cells • constitutive "B" symptoms: • weight loss > 10% in the last 6 months • temperatures ≥ 38 ° C • sweating

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2-c) Hodgkin's lymphomas

• males, 15 – 30 y., > 50 y.

 EBV

CP: - cervical, axillary, inguinal lymphadenopathy - cytokines irritate the nerves in the skin g itching of the skin - splenomegaly - enlarged lymph nodes in mediastinum g cough , superior vena cava syndrome Lab: Reed-Sternberg cells (esp. B-cells)

2-c) Hodgkin's lymphomas

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2-d) Non-Hodgkin's lymphomas (NHL)

• 20 – 40 y. • clonal expansion of malignant lymphocytes, with preserved function and migration

 EBV ( Burkitt's lymphoma ), HTLV-1 ( Adult T cell leukemia/lymphoma ), immunodeficiency  t(14;18) ” bcl-2 expression g inhibits apoptosis of pathological clone g accumulation

• Nodular forms: primary in lymph nodes CP: - lymphadenopathy (Waldeyer`s ring, cervical, axillary, inguinal) - fever, sweating • Extranodular forms: • also progression of nodular forms NHL; in GIT, skin, CNS, orofacial area, ... • maltomas : lungs, small intestine, pharynx; stomach (H. pylori), thyroid gland (Hashimoto's thyroiditis)

2-d) Non-Hodgkin's lymphomas (NHL)

• Indolent : • grow very slowly • follicular lymphoma • Aggressive : • may develop rapidly • Diffuse large B-cell lymphoma (DLBCL)

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2-d) Non-Hodgkin's lymphomas (NHL)

Lymphadenophy in B-NHL

2-e) Plasma cells disorders

• monoclonal gammopathy: ” production of pathologic Ig (paraprotein) • ‘ production of normal Ig g bacterial infections

• Multiple myeloma: • diffuse, accumulation of pathological cells in bone marrow , pathological fractures of vertebrae and ribs • ” bone reabsorption by osteoclasts g osteoporosis , hypercalcemia (lethargy, depression, renal injury) • myeloma kidney: selective proteinuria (light Ig chain lambda), pyelonephritis • anemia • Waldenström`s macroglobulinemia: • pathologic clone in BM, spleen, liver, lymph nodes, blood