Hematologie in de tropen Excerpta uit een presentatie door dr.

Steven Van Den Broucke

• WORMEN!

– Schistosomiasis

– Fasciola hepatica

– Paragonimus

– Strongyloides stercoralis

– Toxocara

– Filariasis: W. bancrofti, Loa-loa, Onchocercosis

– Trichinella

– Anisakiasis

• Sommige protozoa

– Cysto-isospora belli

– Sarcocystis2

Eosinofilie

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Wormen: enkele voorbeelden

Toxocara: visceral larva migrans

Echino Ascaris

Schisto Fasciola

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Sarcocystis

THROMBOCYTOPENIA: frequent causes

among tropical diseases

- Malaria

-Arboviral infections: Dengue, Yellow-fever,

Crimean-Congo HF, Rift-Valley Fever

-Visceral Leishmania

- Rickettsiosis

- Sepsis with DIC

- Hypersplenism (HMS)

- ITP/TTP/HUS

- Acute HIV

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Perifeer bloeduistrijkje

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Bloeduitstruikje

P. Falciparum trophozoites Babesiosis, Maltese cross

BorreliaTrypanosomiasis

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Candida glabrata mimicking

‘improvement in platelet count

Streptococcus pneumoniae

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Malaria- (chronic, HMS) related Burkitt Lymphoma

- Anna, 14y from Pakistan

- Since 2 months vague abdominal pain

- Initially coughing, but the cough dissappeard

- Conjunctivae pale

Lab :

• RBC : 3 800 000/mm3

• Hb : 8,1 g/dl

• Hct : 25.1 %

• reticulocytes 2,4 %

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Pre-casus

GB: 9.200/mm3o Polynuclearso Neutrophiles: 82 %o Lymphocytes: 14 %o Monocytes: 4 %• Platelets: 726 000 /mm3

1 Describe the biological anomalies

2 What’s the most likely mechanismeof this anemia?

3 What tests will you ask?

4 What’s your diagnosis?

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Anna is a 14y old child from Pakistan. Since 2 months she complains of vague abdominal pain. When the symptoms began, she was coughing, but the coughdissappeard. You notice that the conjunctivae are pale and decide to do a blood examination.

Lab :

• RBC : 3 800 000/mm3

• Hb : 8,1 g/dl

• Hct 25.1 %

• MCV 66 fL

• MCH 21.3 pg

• MCHC 32 g/dl

• Reticulocytes 2,4 %20

Pre-Case

WBC: 9.200/mm3o Neutrophiles: 82 %o Lymphocytes: 14 %o Monocytes: 4 %• Platelets: 726 000 /mm3

• Panel A: normal, central pallor is< 1/3 diameter, RBC has same size as a lymphocyte nucleus (arrow)

• Panel B: beta-thallasemia (+ HbEdisease), with target cells (thickarrow), RBC < lymphocyte nucleus, some nucleated RBC (arrowheads)

• Panel C: severe iron deficiencywith hypochromia (thin arrows, microcytosis (thick arrows) and a pencil cell (arrowhead)

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Blood smear

Definition of anemia?

– <13g/dl (male)

– <12 g/dl (female)

• Red Blood Cell Count

• Hemoglobine (Hb)

• Hematocrit (Hct)

The are not always in parallel!

Measurements of anemia

NormalRBC count

normal but

anemic cause

microcytosis

RBC count low, but no

anemia cause

macrocytosis

Hb and Ht

Microcytosis

without anemia

cause RBC count

elevated

N Engl J Med 2014;371:1324-31.

DOI: 10.1056/NEJMra1215361 24

Microcytosis

1. Microcytic anemia, hypochrome, slightlyregenerative

2. Ferriprive anemia

3. Stool examination, peripheral bloodsmear, Hb-electrophoresis

4. Ankylostoma dd/thalassemia

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Acquired anemia in Africa

British Journal of Haematology, 2011, 154, 690–695

• ♂ 29 y, hospitalized with jaundice and anemia

• Fatigue, malaise, headache, intermittent testicular discomfort, yellowed eyes, dark urine, nausea, diffuse body aches developed and chronic leg pain worsened

• 4 m ago: visiting family's home in N-Africa for 3 months: then a prolonged cough productive of green sputum developed, associated with fatigue, subjective fevers, chills, drenching night sweats, and intermittent dyspnea at rest, and had a weight loss of 9.1 kg

Clinical case I : Anemia and Jaundice

Alberto Puig, M.D., Ph.D., and Anand S. Dighe, M.D., Ph.D.

N Engl J Med 2013; 368:2502-2509

• 1 y earlier: after tibial surgery for motorbike accident, the hematocrit decreased to 34.4%, with a MCVof 77 fl (nl 80 to 100); anemia resolved within 4 months

• Other medications: ginkgo biloba, a multivitamin, nicotine patches

• Smokes, marihuana

• Whilst in Algeria: brother died of unknown disease

• Drank unpasteurized cow milk, sheep exposure

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History

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Hb –

electroforesis

normal

Mantoux neg

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MCV,

thick/thin

smear,

liverset, FA,

B12: normal

Coombs neg,

bloodcultures

neg, no

schistocytes

CXR : normal

US: mild

hepatic

steatosis, no

splenomegaly

Peripheral Blood smear

Peripheral Blood smear

The morphologic features of the red cells are mostly normal, although

there are a few target cells, possible bite cells (arrow), and irregularly

contracted cells (arrowhead). No schistocytes or spherocytes are seen.

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Target Cells, Heinz bodies and Bite cells

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Peripheral smear in Heinz body hemolytic anemia showing Heinz bodies and bite cells

Puig A, Dighe AS. N Engl J Med 2013;368:2502-2509.

Peripheral Blood smear

G6PD level of 1.9 U

g/Hb (nl 8.8 to 13.4)

• X-linked recessive (♂ heterozygote,♀ homozygote)

• Mostly in men of Asian, African, Mediterranean, and Middle Eastern descent

• Unlike the other inherited hemolytic anemias, G6PD deficiency is most often a self-limited disease that presents shortly after an oxidative insult to red cells, such as infection, drug exposure, or ingestion of fava beans

G6PD-deficiency

Common Genetic Variants of Glucose-6-Phosphate Dehydrogenase (G6PD).

Puig A, Dighe AS. N Engl J Med 2013;368:2502-2509.

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Pathogenesis

Glutathione

Oxidized Glutathione

Glutathione

peroxidase

Glutathione

Reductase

• Why only in red blood cells?

don’t have mitochondria

• Partial malaria protection (cfr. Sickle cell)

• Neonatal icterus

• Serious infections: H2O2 production neutrophils/macrophages

G6PD-deficiency

Acetyl-CoA for fatty acid

syntheses produced in mitoch

and leave mitochondria with

citrate: in cytosol citrate to

oxaloacetaate and malate

malate+ NADP+ converted to

pyruvate + C02 + NADPH

• Caveat when testing for G6PD

• In some variants, the G6PD level may be normal during the acute hemolytic episode because of the destruction of older, more deficient red cells

• If the G6PD level is normal during an acute hemolytic episode, G6PD testing should be repeated 1 month after the hemolysis resolves

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• Fava beans “Vicia fava”

• Pollen eaten or inhaled

• Toxic divicine and isouramil: oxidants normally reduced and inactivated by reduced gluthatione

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Favism

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Sickle Cell anemia

Hemoglobine structure

• Normal adult

– Hb A (22) 97%

– Hb A2 (22) 2%

– Hb F (22) 1%

• Pathological:

– Hb S: 2 2 S

– Hb C: 2 2 C

– Hb E: 2 2 E

– HbH : 4 (Cfr. alfa-thalassemia)

– Hb Barts: 4

Pathophysiology of Sickle Cell Disease

• In hemoglobin S, substitution of T for A in the 6th codon of ß-globin gene leads to replacement of hydrophilic glutamicacid by hydrophobic valine

• On deoxygenation, Hb S polymers form, causing sickling and damage the RBC membrane.

• Some sickle cells adhere to endothelial cells, leading to vaso-occlusion

• Oxygenated Hb S is normally soluble.

• On deoxygenation the abnormal hydrophobic

valine (purple knobs) becomes exposed and

sticks to another deoxygenated sickle

hemoglobin molecule, resulting in polymers.

• The higher the concentration of deoxygenated

Hb S and the lower the pH, the faster the

reaction.

• Upon reoxygenation, polymer quickly falls apart

• RBC’s less flexible cannot pass capillaries (diameter often half diameter of RBC)

• Polymerization = slow process more in slow circulation (shock,…) before reoxygenation in lungs

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Sickle Cell Anemia

• If:

– O2

– pH

– Dehydration

– Slow circulation

– Low Hb F (Hb F reduces efficiency of polymersiation)

• Sickling damage membrane proteins adhesion to endothelium

• haemolysis

• infarction

• splenic infarction infections

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Sickling

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• Heterozygous carriers protected

• Parasites acidification sickling RBC destroyed in spleen

• Heterogygotes longer life expectancy then nl Hb Sickle disease much shorter!

• Also HbE, other Hb-pathies: why in Africa sickle, in SE-Asia HbE?

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Sickle cell and malaria

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Sickle cell: epidemiology

• Heterozygosity = sickle cell trait

– 2/3 Hb A, 1/3 Hb S

• Homozygosity = diseases

– No Hb A, 3-6 m after birth Hb F dropped and mainly Hb S• (double heterozygotes: e.g Hb SC)

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Sickle cell: clinically

• Icterus

• Bilirubinate gall stones

• Fish vertebrae due to marrow expansion

• Necrosis of humerus head

• Priapism

• Dactylitis55

Sickle cell: clinically

• Hair-on-ends with frontal ‘bossing’

• Occlusion central retinal artery

– R/ urgent transfusion

• Autosplenectomy : splenic atrophy

– Infections ++

• Acute chest syndrome

– ARDS

– Rib/vertebral infarction

– Infection due to hypoventilation 2° pain 56

Sickle cell: clinically

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A. Retinalis occlusions

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Sickle Cell: risk of CVA

• Hb electroforesis

• Peripheral blood smear

• Emmel’s test

• DNA: mutations in 6°codon of -globin gene59

Sickle cell: diagnosis

• This smear shows multiple sickle cells (blue arrows). There are also findings consistent with functionalasplenia, including a nucleated red blood cell (upper left), a red blood cell containing a Howell-Jolly body (black arrow), and target cells (red arrow).

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Peripheral Blood smear

Howell-Jolly bodies

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Hemoglobin electrophoresis

Hb A Hb A2 Hb F Hb S

• Normal 97 2-3 0.3-0.8 -

• Sickle cell trait 64 2-3 1 33

• Sickle cell disease - 2-3 1 96

• Sickle cell disease R/ Hydrea - 2-3 10-15 85

• Sickle cell - thalassemia 35 3-8 2 63

• Beta Thalassemia minor 92 3-8 2

• Beta Thalassemia major variable

• Beware : if Hb A2 > 8% probably co-migration of Hb C, Hb E, ...

Control electrophoresis with different technique needed

• BM transplantation

• Hydroxyurea (Hydrea): preventive 3x500 mg/d

– Hb F , goal = > 15%

– NO production

– WBC’s and platelets less inflammation and vascular adhesion/injury

– VCAM-1 expression

– Teratogenic

• Folic acid• (penicillin prophylaxis: benzathine peni 1x/m children < 5y; today vaccine)

• Vaccination: pneumococcus, influenza, hepB

• Malaria prevention

• Transfusion: not routinely

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Sickle cell: treatment

• Antibiotics

• (Exchange-)transfusions

• Oxygen

• Pain control: paracetamol, NSAID’s, morphin

• (Hyperbaric oxygen “Caisson”)

• Fluids ++: 3-4 l/d

• Bicarbonate

• Avoid hypoventilation: 10 max inspirations/2h

• (desmopressin: causes hypoNa RBC’s swell deoxy-Hb S diluted)

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Sickle cell: Acute crisis

64NEJM, June 9, 2005

♀ 22y, D/ of sickle cell disease at 6y

1 m ago: pain in both arms R/ symptomatic

Now: low back pain thighs and back of the knees

Despite ibuprofen worse to hospital: pain 10/10

Nausea and 1x vomiting

No other symptoms

R/ IV meperidine hydrochloride, diphenhydramine, morphine sulfate, ketorolactromethamine, and fentanyl

Clinical Case II : Back and Leg Pain and Respiratory Failure

• Still severe pain

• SatO2 76%, RR 24/’, lungs clear

• O2 NR-mask

• Next hour: cough, RR 45/’, bilat crepitus, SatO2 73%

• CPAP started 7.5 cm H20

• 1 U PC’s transfusion

• 5 h later: SatO2 40% intubation

• R/ broad spectrum AB, steroids, 2° U PC

• Prone postion, vecuronium paralyzation, FiO2 100%, PEEP 22 cm H20, PIP 47 cm H20

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Dramatic evolution

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- Pulm art pressure

(mean) : 46 mmHg

- Echocardio: RV dilat

- Pulm art occlusion

pressure (wedge) : 18

mmHg

• Nitric oxide (NO) inhalation

• 5 U PC exchange transfusion

• Preparation cannulation for ECMO

• BP dropped: no response to maximal treatment with:

– norepinephrine, vasopressin, phenylephrine, dopamine, epinephrine and atropine

– No response to CPR

• † 56 h after first symptoms

• Autopsy

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Further evolution

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• 1° † cause in Sickle cell; 2° most cause of hospitalization (after veno-occlusive crisis)

• Pulmonary infiltrate with 1 of:

– Cough

– Dysnea

– Fever or

– WBC raise

• Occlusion of pulmonary vessels by sickled red cells

– O2 → polimerization HbS ++ → occlusion ++

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ARDS in Sickle Cell Anemia: Acute Chest Syndrome

1. Infection

2. Trombo-embolism

3. Atelectasis : eg hypoventilation 2° rib pain or opiates

4. ???

Pt cardiac arrest cause?

Progressive RV failure sec. to pulm hypertension sec. to

ARDS

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Causes Acute Chest Syndrome

1. Maintaining adequate oxygenation is a matter of life or death

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Treatment Acute Chest Syndrome

1. Maintaining adequate oxygenation is a matter of life or death

2. Early O2

3. If no improvement of saturation:

– Early exchange transfusion

– Early NO

– Early mechanical ventilation

– Early ECMO?

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Treatment Acute Chest Syndrome

1. Transfusion of PC’s

– Cavé volume overload

– Cavé viscosity

2. Red-cell exchange (pheresis)

CAVE:

- transfusion reactions: deleucocyctated and preferably

also minor blood-group match

- difficult to distinguish hemolytic transfusion reactions

from Sickling

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Transfusion therapy in Acute Chest Syndrome

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Photomicrographs of Lung and Bone Marrow (Hematoxylin and Eosin).

Panel A and B: Bone marrow emboli, consisting of

particles of bone marrow surrounded by fibrin, are

present in small pulmonary arteries

Panel C: a section of bone marrow shows the

absence of cellular detail, indicating infarction (left),

as compared with a section of normal bone marrow

from the same patient (right)

Sickle cell disease with the acute chest syndrome

resulting from a vaso-occlusive crisis that caused bone

marrow infarction and pulmonary bone marrow emboli

Final diagnosis

Thalassemia

Hemoglobine structure

• Normal adult

– Hb A (22) 97%

– Hb A2 (22) 2%

– Hb F (22) 1%

• Pathological:

– Hb S: 2 2 S

– Hb C: 2 2 C

– Hb E: 2 2 E

– HbH : 4 (Cfr. alfa-thalassemia)

– Hb Barts: 4

– Hb Portland: 2- 2

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Genetics and labo according to subtype

HbH : 4, Hb Barts: 4

Hb Portland: 2- 2

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-Thal

-Thal

• Because α chains dissociate into monomers more readily than do β or γ chains, they form hemichromes at a faster rate which explains why β-thalassemia is clinically much more severe than α-thalassemia.

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-thal

-thal

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• ♀ 62y

• Excertional dyspnea and fatigue since some months

• Born in Cambodia

• Hx arthritis in left knee and asthma

• Had a lung biopsy in the past for unclear reasons

• Clin: spleen palpated 12 cm below costal margin

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Clinical Case III : Anemia and paraspinal masses

Case 25-2011 — A 62-Year-Old Woman with Anemia and Paraspinal Masses

Edward J. Benz, Jr., M.D., Carol C. Wu, M.D., and Aliyah R. Sohani, M.D.

N Engl J Med 2011; 365:648-658, Aug 18, 2011

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• Extramedullary hematopoiesis = myeloid metaplasia

• Neoplasms

– Nerve sheat tumor = Schwannoma

– Lymhoma

• Leukemias: CLL, CML, AMML

• Infections : tuberculosis

• Myeloproliferative disorders : myelofibrosis

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Paraspinale masses: Differential diagnosis?

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Hypochromic Microcytic Anemia

Mentzer Index: MCV/RBC count

NEVER MCV < 70

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52/6.05 = 8.6

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Hypochromic Microcytic Anemia

Mentzer Index: MCV/RBC count

= 52/6.05 = 8,6

NEVER MCV < 70

• SE-Asia: genetic thalassemia mutations

• Major?

• → by definition transfusion dependent

• Minor (trait)?

• = Asymptomatic

• Intermedia?

• Such a severe form to produce extramedullaryhematopoiesis and D/ only at 62y old???

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What is a-typical about this case if it’s thalassemia?

• Anisopoikilocytosis

• Microcytosis

• Hypochromic

• Dacrocytes

• Target cells

• Elliptocytes

• Spherocytes

• Schistocytes

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Peripheral smear

• uniform microcytosis and hypochromia

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Beta thalassemia trait

• Which type?

1. Mild + severe –thalassemia allele eg. β+/βº

2. HbH = 4 = -thalassemia intermedia

3. E/ –thalassemia : coinheritance of a β-thalassemia allele and the allele for βE-globin (SE-Asia)

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Thalassemia intermedia

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Genetics and labo according to subtype

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4 4

−α/−−

−−/−−

ααND/−−

Homozygosity for mild forms of β+ thalassemia

Compound heterozygosity for β+/βº thalassemia

Compound heterozygosity for β thalassemia and another beta chain variant (eg, β-

thal/Hgb E)

Coinheritance of homozygous β thalassemia with genes for increased gamma chain

synthesis (ie, HPFH)

Coinheritance of homozygous β+ thalassemia with alpha thalassemia (eg, β+/β+ with -

a/-a, --/aa, -a/aa, or --/-a)

Coinheritance of heterozygous β thalassemia and triplicated or quadruplicated alpha

genes (eg, aa/aaa or aa/aaaa)

Dominant forms of beta thalassemia

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Thalassemia variants which may present as BetaThalassemia intermedia

• D/ at 62y = strange

• Chest masses and splenomegaly not noticed before when lung biopsy was done?

• Long-standing or more recent?

• Mutations acquired vs. congenital?

• Hb H Disease or Hb E/Thalassemia?

• -thal heterozygozicity (ex. -thal/HbE) less likely cause mostly more severe

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Some questions…

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Hb-electrophoresis

HbH

• HbH disease : inactivation of three of four α-globingenes

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Electrophoresis for hemoglobin H

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HbH inclusions = Heinz bodies = 4 precipitates

• Deletion mutations in ¾ α-globin genes that are common in Southeast Asians:

– the −−SEA double-gene deletion and

– the −α3.7 single-gene

• No mutation was found in the remaining α-globin or β-globin genes

• Final diagnosis:

• α-thalassemia intermediaHbH disease due to 3 mutations in the α-globingenes

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PCR of patient

• Commonest monogenic diseases, > 200 different mutations of the and ß globin genes

• Thalassaemia: intrauterine death to extremely mild, symptomless anaemia

• R/ regular blood transfusion and adequate iron chelation therapy: prognosis ↑ severe forms

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General info on Thalassemia

• 4.83 % world carry globin variants

• 1.67 % heterozygous for α- and β-thalassemia

• 1.92 % carry sickle hemoglobin

• 0.95 % carry hemoglobin E

• 0.29 % carry hemoglobin C

• worldwide symptomatic globin disorders:

– 2,4/1000 birhts• 1,96/1000 sickle disease

• 0,44/1000 α-thalassemia and β-thalassemia

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Epidemiology

Peripheral blood film of child with ß

thalassaemia major

Small pale red cells and nucleated red blood

cells

Microcytes and target cells

This field shows target cells, hypochromic cells, microcytic cells, red cellfragments, red cells with bizarre shapes, and a single nucleated red cell(arrow).

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Peripheral blood smear in β-thalassemia intermedia

Iron stain of liver of

child with ß

thalassaemia,

showing extensive

iron loading

Pathophysiology of ß thalassaemia

47-year-old ♀, transfusion-dependent β-thalassemia intermedia with worsening

dyspnea for a few days. RR 28/’, p 113/’. Nl oxygenation with supplemental oxygen,

clear lungs, jugular venous distention. Hemoglobin 4 g%, Hct 15%.

CXR and CT-Tx: enlarged central pulmonary arteries (pulmonary hypertension), due

to chronic anemia, hemolysis, and increased tendency for microthrombi in pulmonary

vasculature. Bilat paravertebral soft-tissue masses and marked medullary expansion in

bones (esp. ribs) due to extramedullary hematopoiesis.

Beta thalassemia major

Expansion red bone marrow

in maxilla

Hair-on-ends skull

Skull bossing due to

expansion of the diploë

Beta thalassemia major :

expansion of diploe

Bilirubinate stones are frequent in chronic hemolysis

Other etiology: Oriental recurrent cholangitis (often secondary to Ascaris)

. Alpha thalassemia major

• Anemia, hydrops fetalis, stillbirth, or death soon after birth.

• Hemoglobin electrophoresis : 80% hemoglobin Bart's (tetramer of gamma chains = γ4) and 20% hemoglobin Portland (= δ2γ2, normally present only in embryonic life in the first trimester).

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Thalassemia treatment centre in Sindh

(Pakistan)

• http://itg.author-e.eu/Generated/pubx/173/illustrated_lecture_notes_on_tropical_medicine.htm

• http://www.kabisa.be/

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Voor verdere informatie

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Thank you!!