• 21 year man
• Presented with pancytopenia
• Hb 5.0 WBC 2.6,neutrophils 1.1, platelets
45, MCV 104.
• B12/folate/ferritin were normal.
• Main symptom tiredness
• Examination was unremarkable.

Maj Gen Dr Muhammad Ayyub
MBBS, PhD (London), MRCPath
(London), FRCPath (UK)
Prof & HOD AM College

• Introduction
• Aetiology
• Pathogenesis
• Clinical features & diagnosis
• Treatment
• Paroysmal Nocturnal Haemoglobinuria
(PNH)
• Case Study

• Peripheral blood pancytopenia and a hypocellular marrow in which normal marrow is replaced by fat cells.
• Abnormal cells are not found.

• Paul Ehrlich (1854-1915) described the first case of aplastic anaemia in a pregnant woman who died of marrow failure in1888.
• The term “aplastic anaemia” first used by
Anatole Chauffard in 1904.

• Suspect from signs and symptoms
• Made by check of full blood count, FBC
Hb
PCV
Male
13.5-
17.5g/dl
38-50%
MCV 80-100fl
MCH 27-34pg
WBC 4-11x10 9 /l
Neut 2.0-7.5
Lymph 1.5-4
Platelet 135-450
Female
11.5-16g/dl
36-45%
80-100fl
27-34pg
4-11x10 9 /l
2.0-7.5
1.5-4
135-450

• Red cell life span 120 days.
• Platelet life span 6 days.
• Granulocyte life span < 24 hours.
• Constant marrow activity needed to replace dead cells.

• INHERITED(20%) o Fanconi Anaemia o Dyskeratosis congenita o Shwachman-Diamond syndrome o Diamond-Blackfan anaemia.
• ACQUIRED(80%) o Idiopathic o Drug induced o Viral (hepatitis, EBV) o Ionising radiation o Toxins (pesticides, benzene, arsenic) o Pregnancy o leukaemic

• Important diagnosis to make.
• Implications for treatment.
• Detailed history and examination.
• Nail dystrophy, skin pigmentation and leukoplakia may suggest dyskeratosis.
• Short stature, metaphyseal dysarthrosis, pancreatic exocrine deficiency or family history of cytopenia in Shwachman-Diamond syndrome.
• Check for gene mutations can help.

• Rare condition; 2-5/million per year
• <1 in Ipswich catchment per year.
• Incidence is higher in East, environmental as migrants have incidence of local population.
• male to female incidence = equal
• Disease of young adults, 2 nd peak in 4 th -
5 th decade of life.

• Primary defect or damage to haematopoietic stem cell.
• possible Immunological attack on stem cells.
• HLA-D2 is overrepresented in patients, suggests a role for antigen recognition.
• Defective microenvironment (i.e. marrow stromal defect)

• Evidence shows marrow stromal cells have normal function.
• Normal growth factor production.
• Adequate marrow stromal function also evidenced by success of stem cell transplantation.

• Anaemia; tiredness & fatigue, palpitations,
SOB.
• Low white count; recurrent infections, flulike illness.
• Low platelets; easy bruising and bleeding.

• FBC
• Reticulocyte count
• Blood film.
• B12/folate.
• Liver function tests
• Virology
• Bone marrow aspirate & trephine
• PNH screen.

• Hypocellular
• Abnormal cytogenetics in 12% patients
• Trisomy 6, 8, or 15 most common, similar outcome to no clone.
• Monosomy 7 may have poor outcome, suggests possible hypoplastic MDS.

• Paroxysmal nocturnal haemoglobinuria.
• Historically test was Ham’s test; showed red cell lysis by complement activation in acidified serum.
• Currently test for absent proteins on cell surface. CD55(DAF) and CD59(MIRL)

• Stable AA
• Pancytopenia remains stable over months to years.
• Greater the degree of pancytopenia the worse the prognosis. (see severe aplastic anaemia)

• Progressive or fluctuating aplasia.
• Initially small degrees of pancytopenia or single lineage cytopenia.
• Progressive sometimes following viral infections.
• Occasionally single cytopenia e.g. thrombocytopenia becomes true aplastic anaemia.

• Unstable Aplasia.
• Improvement in counts may be associated with abnormal clones.
• PNH clone in up to 20% of long term aplastic anaemia.
• Often only detected by lab tests and not clinically significant.

• Peripheral Blood 2 of 3 o Granulocytes <0.5 x 10 9 /l o Platelets <20 x 10 9 /l o Reticulocytes <1%
• Marrow trephine
• Markedly hypocellular <25% normal

• Supportive with blood products.
• Prophylactic antibiotics.
• Growth factor support.
• Androgens.
• Immunosuppressive therapy with antilymphocyte globulin & cyclosporin.
• Allogeneic stem cell transplantation.

• Indicated for patients > 40 years
• Patients with no HLA matched sibling donors.
• Anti-Thymocyte Globulin(ATG) or antilymphocyte globulin (ALG), cyclosporin, methylprednisolone.
• Best results are for combination therapy.
• Response is slow, 4-12 weeks to see early improvement.

• Response rates 60-70%
• Relapses are common and continued supportive care needed.
• Up to 50% of relapsed patients will respond to 2 nd course of immunosuppressive therapy.

Treatment for adults with acquired severe aplastic anaemia.
Marsh, J. Hematology 2006;2006:78-85
Copyright ©2006 American Society of Hematology. Copyright restrictions may apply.

Treatment for adults with acquired non severe aplastic anaemia.
Marsh, J. Hematology 2006;2006:78-85
Copyright ©2006 American Society of Hematology. Copyright restrictions may apply.

• Age <40 years.
• Conditioning with Cyclophosphamide & antithymocyte globulin, with cyclosporin and methotrexate.
• Long term overall survival = 80-90%
• Chronic graft versus host disease (GVHD) remains a problem for 25-40% of patients.

Figure 1. Cumulative survival probability of patients with aplastic anemia
Montane, E. et al. Haematologica 2008;93:518-523
Copyright ©2008 Ferrata Storti Foundation

Figure 2. A. Effect of the year of diagnosis of aplastic anemia on cumulative survival probability
Montane, E. et al. Haematologica 2008;93:518-523
Copyright ©2008 Ferrata Storti Foundation

Table 2. Factors associated with death at 2 years after diagnosis
Copyright ©2008 Ferrata Storti Foundation
Montane, E. et al. Haematologica 2008;93:518-523

• Fludarabine based regimens.
• Umbilical cord blood transplants.

• An acquired haematopoietic stem cell defect with predominant haemolytic anaemia.
• A descriptive term for the clinical manifestation of haemolysis and haemoglobinuria manifest by dark coloured urine in the morning.

• Acquired haemolytic anaemia
• Thrombosis in large vessels e.g. hepatic abdominal, cerebral.
• Pancytopenia or aplastic anaemia.
• This triad makes PNH a unique syndrome

• Acquired stem cell mutation defect
• Inability to synthesize the glycosylphosphatidylinositol (GPI) anchor that binds certain proteins to cell membranes.
• Gene (PIG A) located on X-chromosome.
• Complement regulating proteins DAF, MIRL are lacking on all haemopoietic cells
• Consequent intravascular red cell destruction.
• Pathophysiology of thrombosis is not fully understood.

• Treat symptoms
• Folic acid for increased erythropoeisis
• May need iron if deficient
• Transfusions
• Anticoagulation
• Eculizumab (antibody against complement C5)
• Complement inhibition = risk of infection esp meningococcal. Vaccination required.

• Marrow aspirate cellular
• Trephine biopsy hypocellular
• PNH clone of 8-10% detected.
• Referred to London for 2 nd opinion and treatment plan.
• Sibling not an HLA match.
• Given not requiring blood or platelet transfusion then no specific treatment was indicated.

• Stable for 18 months
• Presented with headache & neck stiffness.
• Clinical impression of meningitis made.
• Initial CT scan no abnormality
• CSF, no organisms
• MRI scan confirmed thrombosis.
• Started on anticoagulation.
• PNH clone had increased to 82%.

• 4 weeks later admitted with further febrile episode.
• On antibiotics and anticoagulation.
• Developed left sided weakness and sensory loss.
• CT brain scan showed massive intracranial bleed.
• Transferred to neurosurgical centre at
Addenbrooke’s hospital.

• Eculizumab anti complement therapy.
• Used in haemolytic disease with > 50%
PNH clone.
• High cost £250k per year
• National commissioning Group (NCG) funded 2 centres nationally, Leeds and
London.
• Equal access to treatment irrespective of address.

• Rare condition.
• Needs accurate diagnosis to ensure proper treatment.
• Still devastating outcomes for young adults.
• New treatments may further improve survival.

• Postgraduate Haematology, by Hoffbrand
& Lewis Fifth Edition
• Making Therapeutic decisions in adults with Aplastic Anaemia; Judith Marsh. ASH education program Book 2006.