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Aplastic Anemia

Terminology:
• -aplastic anemia or hypoplastic anemia : pancytopenia in peripheral blood,
due to bone marrow hypoplasia . It is a complex nonregenerative anemia,
involving all the blood cell lines, but without infiltration of the bone marrow
with abnormal blood cells or nonhematopoietic cells;
• -synonymous : bone marrow insufficiency; bone marrow aplasia;
• -pure red blood cell anemia : aplastic anemia involving the erythroid
precursors only; the other hematopoietic lineages are normal;
• -hypoproliferative anemias : a heterogenous group of anemias, characterized
by a deficient or a lack of response to erythropoietin and related cytokines and
humoral stimuli;
• -myelophthisic anemia : anemia associated with quantitative and sometimes,
qualitative abnormalities of the WBC and platelets, generated by infiltration
of the bone marrow with abnormal hematopoietic or nonhematopoietic cells;

Definition. As mentioned before, aplastic anemia is a peripheral pancytopenia of

central origin, generated by the hypoplasia or aplasia of all the hematopoietic
lineages precursors, without infiltration of the bone marrow, neither with
hematopoietic or nonhematopoietic cells. Because all the hematopoietic lineages , are
involved, not only the erythropoietic one, the name “aplastic anemia” is inadequate,
but others (bone marrow aplasia or bone marrow insufficiency) are not currently
in use.

Etiology.

Aplastic anemia may be congenital or acquired:

• congenital :
Fanconi’s anemia;
Familial aplastic anemia;
Dyskeratosis congenita;
• acquired :
• idiopathic;
• secondary to :
• infections (HIV, tuberculosis; hepatitis; parvovirus):
• chemicals:
• drugs:
• dose-related;
• idiosyncratic;
• industrial chemicals;
• food additives, insecticides, air-conditioners etc.;
• radiation exposure;
• associated with physiological or pathological conditions:
• pregnancy;
• thymoma (the common association of thymoma is to pure RBC aplasia, but in
extremely rare cases, thymoma may be associated with aplastic anemia;
• myelodysplastic syndromes;
• paroxysmal nocturnal hemoglobinuria(PNH).
A peculiar attention should be paid to some currently used drugs : phenylbutazone,
sulphonamides and anticonvulsivants, which are frequently associated with aplastic
anemia. By far the most frequent associated with aplastic anemia is
Chloramphenicol.

Pathophysiology
The bone marrow might be compared with the soil : the harvest is poor if the soil is
inadequate, the grains are impaired , there are pests or no fertilizers, namely :
• a defective hematopoietic microenvironment (“the soil”)
• quantitative or qualitative intrinsic defect of the stem cells (“the grains”);
• immunologic suppression of hematopoiesis (“pests”):
• humoral (antibody-mediated);
• cell-mediated;
• lymphokine-mediated;
• abnormalities of cytokine production (“no fertilizers”).
In aplastic anemia the great majority of patients presents not an unique, but a
complex of pathophysiological factors which act , possibly, in a peculiar genetic
condition to generate the disease.

Clinical aspect.
Due to pancytopenia, clinical features at presentation are difficult, if not impossibly,
to differentiate from acute leukemia. The classical aspect of both nosological entities
associates the well-known three syndromes:
• anemic;
• infectious;
• hemorrhagic,
but, in aplastic anemia, there are also three negative clinical features :
• no lymph nodes enlargement,
• nor splenic enlargement,
 • neither liver enlargement.
If splenomegaly or lymph nodes enlargement appear during evolution of aplastic
anemia, it’s necessary to investigate the association of another disease (infectious or
neoplastic).
Laboratory aspect .
A.-Peripheral blood:
• red blood cells (RBC) : anemia, usually severe, is normochromic, normocytic (at
least at the onset; in evolution, a slight macrocytosis can appear) and aregenerative
(reticulocytes < 5% ; in absolute number ,<50,000/µ L); RBC are normal as
morphological aspect; the presence of nucleated RBC ,associated or not with
myelocytes , metamyelocytes and band neutrophils suggests extramedullary
hematopoiesis, as in osteomyelofibrosis or in slow-progressive neoplasia;
• white blood cells (WBC): granulocytes are decreased (in absolute count
<1,500/µ L), associated with monocytopenia; in isolated cases, abnormalities of
the granulocyte granules and increased values for the alkaline phosphatase (ALP)
may be observed; lymphocytes may be normal in absolute count, but in some
cases, functionally impaired on disparate subsets , acting very probably as a
pathogenic factor for aplastic anemia;
• platelets : thrombocytopenia is always present, but at a variable degree; in aplastic
anemia, platelets are functionally normal, so that the bleeding appear if the
medullary insuficiency has a sudden onset - in some hours or days and at very low
platelets count (below 50,000/µ L ); a severe hemorrhagic syndrome suggests
usually another disease; on the blood smear, platelets appear morphologically
normal ; the presence of bizarre-shaped platelets suggests another disease,
eventually with extramedullary hematopoiesis;

B.-Bone marrow:
1.- by aspiration : hypoplastic or aplastic; in some cases, slightly infiltrated with
lymphocytes, morphologically normal; the presence of a greater count of
lymphocytes (over 20%) in bone marrow or infiltration with altered
hematopoietic cells or non-hematopoietic cells reveals another disease;
2.- by biopsy : the bone marrow may appear infiltrated with fat cells; between
the hexagons of the fat cells, some scanty hematopoietic cells may appear ,
associated or not with lymphocytes and plasma cells. The medullary fibrosis may
appear, in rapport to the etiology (e.g., ionizing radiation), but without
neoosteogenesis, which permits the differential diagnosis with myeloid metaplasia
with myelofibrosis. If islands or active hematopiesis are identified, it is necessary
to continue investigations for differential diagnosis with myelodisplastic or
myeloproliferative syndromes.

Iron stores are usually increased.

C. Hemostasis tests : are normal, except a mild increase of the bleeding time ;
D. Biochemical investigations:
• serum iron is normal or slightly increased;
 •TIBC is low (= transferrin is saturated);
•the erythropoietin level is increased;
•Iron uptake is decreased by the bone marrow but increased by the liver;
•in children , a slight increase of the HbF can be observed , due to the effort of
“compensation” with development of an erythroid clone with this peculiar
hemoglobin;
E.-Imagistic investigations: by magnetic nuclear resonance , area of exacerbated
hematopoieis may be revealed. In this case, is absolutely necessary to continue
hematological investigations to exclude the diagnosis of a leukemia.

Diagnosis:
a.-the presence of the aplastic anemia may be ascertained by:

PANCYTOPENIA + DESERTIC BONE MARROW,

not infiltrated with atypical or nonhematopoietic cells;
• NO lymph nodes, splenic or liver enlargement.

b.-the differential diagnosis should be made with all other causes of pancytopenia :
• the desertic bone marrow excludes a hypersplenismus (in that case, the bone
marrow would be hyperplastic);
• the absence of atypical cells in the bone marrow excludes a proliferative
syndrome, either hematologic or non-hematologic;
• the anamnesis , evolution and specific biochemical data (bilirubin; Hb
electroforesis ; red blood cells enzymes etc.) exclude the aplastic crisis in
hemolytic anemia;

Natural course :
• the major risk of exitus exists during the first two years, because of complications
due to severe pancytopenia : infections, bleeding (especially cerebral), ischemic
alterations in the vital organs due to persistent and severe anemia; 25% of patients
only, survives after 1 year from the onset (the maximum mortality -50%- appears
during the first 10 months from the onset); if the patient survives , after this period
the lethal risk decreases, due to adaptive measures the organism develops; in 10 %
of cases, the complete recover may appear;
• another category of risk is evolution into acute leukemias (even after many years
of evolution), myelodysplastic syndromes, solid tumors;
• less frequent, the aplastic anemia may be complicated in evolution with
paraproteinemias, connective tissue diseases (which might be also a pre- or
paraneoplastic syndrome), hemolytic anemias ( which may precede an acute
leukemia);
• another category of risk is correlated with therapy : it is considered that
immunosupressive treatment is more frequently associated with malignancy, as
compared with bone marrow transplantation, but that one, in turn, is associated
 with graft-versus-host disease, risk of precocious death because of the
conditionning therapy for transplantation and a remote risk of malignancy ;

Prognosis :
• depends on etiology :
- aplastic anemia secondary to ionizing radiation exposure has frequently a
short-term evolution to an acute leukemia;
- aplastic anemia associated with hepatitis has a high incidence of mortality;
- aplastic anemia due to drugs has a somehow more favorable prognostic
features;
• there is no an absolute correlation with age and sex.

The International Aplastic Anemia Study Group (IAAG) appreciates the following
criteria to ascertain a severe aplastic anemia (any two blood criteria + either
marrow criterion denote a severe prognostic for aplastic anemia) :

Blood :
• neutrophils < 500/µ L;
• platelets <20,000/µ L;
• reticulocytes < 1% (as corrected value)* ;

Bone marrow:
• severe hypocellularity;
• moderate hypocellularity with < 30% of residual cells being hematopoietic;

*Reticulocytes as corrected value, namely :

reticulocytes % x actual hematocrite/normal hematocrite

Treatment

Immediately after the diagnosis, the patient with severe aplastic anemia (according
to the above criteria), should be evaluated for bone marrow transplantation and if it
is possible, blood transfusions should be avoided or extremely limited , because it
rises the risk of rejection.

The actual possibilities of therapy are the following :

I.-Etiologic therapy;
II.-Pathogenic therapy:
 1.-bone marrow transplantation;
2.-immunomodulatory therapy;
3.-hematopoietic stimulatory therapy;

III.-Symptomatic therapy:
1.-antianemic;
2.-antiinfectious;
3.-hemostatic;

IV.-General measures to avoid infectious and hemorrhagic complications.

I.-The etiologic therapy.

Theoretically, it’s essential to detect and remove the etiological factor(s), but, unfortunately, almost
never possibly in practice: either the etiologic factor(s) cannot be known, or cannot be removed ( e.g.,
ionizing radiation of the environment, fertilizers and insecticides which entered already in natures
circuit etc.), or the damage on the bone marrow is irreversible. If the aplastic anemia is due to
arsenic, gold or lead salts, or even to some radioactive isotopes, it might be tried to remove them
from the body by chelating agents (BAL, Penicillamine, EDTA) , but the curative results are quite
unsatisfactory.
2.-The pathogenic therapy .
a.-Bone marrow transplantation : therapy of choice in aplastic anemia in the following situations ,
but attention ! the option for bone marrow transplantation should be done immediately after
diagnosis, because previously blood transfusions increase the risk for graft-versus-host disease or
graft rejection :
• severe disease ( according to the IAAG criteria),
• in which the patient’s own hematopoietic stromal microenvironment is functional ( otherwise the
bone marrow transplantation is useless, because there aren’t possibilities to provide a nutritive
support to the foreign stem cells), namely :
• routine indications (in the above-mentioned conditions):
• patients under 20 years old with an HLA-identical sibling;
• patients between 20-40 years old, if they have a compatible donor;
• patients with an identical twin, regardless the age of the patient;
• exceptional indications:
• patients > 50 years with an identical twin and a severe disease;
• in any patient, if the disease is severe and other therapeutic interventions failed;

The bone marrow grafts can be :

• syngeneic (from an identical twin)- a fortunate, but a rare situation; the bone marrow
transplantation can be performed regardless the age of the patient, without immunosuppressive
conditioning;
• allogeneic :
• from a compatible HLA-matched donor;
• from unrelated donors : in exceptional cases, as a “salvage” therapy . The radio-chemotherapic
conditioning approach is necessary, both before and after bone marrow transplantation (to
accept the graft and respectively, to avoid the graft-versus-host reaction);
• new approaches :
• use of HLA-identical nonsibling donors;
• use of mismatched donors with T-lymphocyte-depleted grafts;
• use of blood umbilical cord from unrelated donors;
Results of the classical method (HLA-matched sibling donors):
• in untransfused patients : 80% long-term survival:
• in previously transfused patients : 65% long-term survival;

Failure of the method may be due to :

• the graft rejection because of the p[atient’s bone marrow environment;
• the previously blood transfusions;
• the graft-versus-host disease;
• complications of the conditioning therapy : anemia, infections, bleeding.
b.-Immunomodulatory therapy. It’s the choice for cases in which aplastic anemia is due to
immunologic attack ( the presence of “pests”)and/or for those not eligible for the bone marrow
transplantation:
1.-antithymocyte globulin (ATG):
• modalities of action ( not entirely known ) :
• modulation of cytokines;
• supression of T-activated supressor lymphocytes;
• preparation : equine antithymocyte globulin for intravenous use;
• risk : anaphylactic shock , thrombocytopenia, myelodysplastic syndromes;
• dosage :15 mg/Kg diluted in 500 mg saline and infused IV over 4-6 hours, daily, for 10
consecutive days; association of corticoid therapy is necessary at least from the VIIth day , to
prevent allergic reactions;
• efficiency: in 50% of cases;
• relapse : in 1/3 of responders;
2.-Cyclosporine A: a T-lymphocytic immunomodulator:
5-10 mg/Kg/day, po, eventually associated with ATG;
3.-Corticoids :
• prednisone, 1mg/Kg/day,po, for three weeks at least, to test the efficiency; the general risks for
corticoid therapy (especially infections )are amplified, because of the impaired host defense
already present ; if the corticoids are efficient, then it can be used as pulse-therapy (every two
days, or three days, or weekly);
• to decrease (at least at psychical level) the digestive intolerance to corticoid therapy and to
modulate the fluid and electrolytic balance , parenteral corticoids can be used;
• “heroic” corticoid therapy may be sometimes efficient : methylprednisolone , 500 - 1000 mg daily
for 3 to 14 days has been successful , but the risk of severe secundary effects is great : aseptic
necrosis of the hips, electrolytical and fluid imbalance, diabetes, renal insufficiency , psychosis

4.-Cytostatics :
• are difficult to use as immunodepressors, because of hematological secondary effects, except the
Vinca Rosea alkaloids, which are well tolerated; indication : cases with documented immune
pathogeny (bone marrow infiltration with mononuclear cells); dosage : 0.5 mg in saline
physiological solution in intravenous infusion for 20 min.; if well tolerated, without decrease of
platelets and WBC, the same dose can be repeated every 4 to 7 days, for 4 times at least (risk :
peripheral polyneuropathy);
• “heroic” chemotherapy : because during the preparative therapy for bone marrow transplantation,
some cases recover “spontaneously”, high-dose Cyclophosphamide has been used as unique
therapy : 45 mg /Kg /day for 4 days, with or without Cyclosporine A for an additional 100 days .
In this trial (presented by Williams), 7/10 patients recovered completely and remain in remission
11 years later.
c.-Hematopoietic stimulators :
1.—cytokines : are inconstantly efficient and for short periods only , but should be tried however
in patients which are not suitable for bone marrow transplantation because of peculiar reasons. It
 has been used recombinant erythropoietin, GM-CSF (250-350 µ g daily by subcutaneous
injection), IL-1 , a potent stimulator of marrow cell production and IL-3 . It has been suggested
that the poor and inconstant response is due to the deficiency of the bone marrow stem cells, so
that because of the impaired maturation, the cytokines are not able to act because the target
( the more “mature” cells) is poor ;
2.- androgens : stimulate erythropoietin production. A great variety of androgens are in use:
testosterone, methyl-testosterone, oxymetholone, fluoxymesterone, testosterone enanthate ,
nandrolone , according to different schedules :
• Nandrolone decanoate , 400 mg intramuscularly per week for at least 3 to 6 months; risk : local
hematoma; impairment of the liver functional tests : hepatocytolysis, hyperbilirubinemia ;
• or : oxymetholone 1-2 mg/Kg per day for 3-6 months;
3.-Lithium Carbonicum: acts similarly to the CSF-GM :
• dosage : 600 mg per day, orally, for at least 10 to 21 days;
• risk : precipitates a hepato-renal insufficiency ; therefore, the lithium-therapy is forbidden during
functional hepato-renal impairment, as well as in the ECG alteration (risk of paroxysmal rhythm
disturbances).
3.-The symptomatic therapy:
a.-Antianemic therapy : a long-term treatment with folic acid may be followed, eventually in
association with B-12 vitamin (but generally the plasmatic level of the B-12 is increased during
aplastic anemia). The administration of iron is forbidden, because of the risk of hypersideremia
with secondary hemochromatosis (hypersideremia is already present in aplastic anemia and
repeated blood transfusions increase it);
• blood transfusions : packed red blood cells, platelets concentrates and white blood cells
concentrates are indicated only during a severe impairment of the general condition (severe blood
loss, infection etc. ), because of :
• allergic risk with rapid progression of cytopenia;
• inhibition of the still active hematopoietic islands of the bone marrow;
• hemochromatosis;
• iso-immunization;
Patients to whom a bone marrow transplantation is intended, should not to be transfused, if
possible.
b.-antiinfectious therapy: broad-spectrum antibiotics, associated with granulocytic concentrates,
according to the same schedules as in acute leukemia;
c.- hemostatic therapy : systemic hemostatics, including Vitamin K, fibrin stabilizers( tranexamic
acid, epsilon-aminocaproic acid), platelet proaggregants (Etamsilat*, Dicynone*), platelet
concentrates, even fresh plasma transfusions may be used , according to the severity of bleeding.
Splenectomy: doesn’t increase the hematopoiesis, but improves sometimes the platelet and
granulocyte number, but the immediate high mortality during surgery because of bleeding or later,
because of severe infections, makes this an exceptional therapeutical procedure.
Post-therapeutical course and prognosis. Bone marrow transplantation and immunosupressive
therapy improved significantly the prognosis : marrow transplantation is successful in 50-75 % of
cases, but complications appear as graft-vs-host reaction or graft rejection. The highest mortality
still appears during the first two years after diagnosis , even in transplanted patients. After this
period, the organism adapted himself to the low values of neutrophils and platelets and can survive
for longer periods, even over 10 years.
REMEMBER!
• Etiology : especially radiation , chemicals and thymoma;
• Diagnosis : pancytopenia + desertic bone marrow;
• Therapy : bone marrow transplantation in patients <40 y old; immunomodulators;
• associated therapies : hematopietic stimulators, supportive care (symptomatic therapy);
• major risk of death : during the first two years.