Pediatric Hematology

EDWIN V. RODRIGUEZ, MD
Pediatrician Pediatric Hematologist

Red Blood Cells

Hemoglobin carriers
Hemoglobin - main protein for oxygen delivery

RED CELL MORPHOLOGY

Anemias
Reduction of the RBC volume of hemoglobin concentration
below the range of values occurring in healthy individuals

Critical cut off: < 7 g/ dL of hemoglobin

Below this level, pallor in the skin and mucous membranes
become evident

Anemia: Signs and Symptoms

GENERAL

pallor
anorexia; tiredness
circulatory adaptation
susceptibility to
infection

SPECIFIC

hepatomegaly
splenomegaly
jaundice/hematuria
hemorrhage

Pathogenesis of Anemia
Iron, folic acid, proteins . . .
I (Deficiency Anemia)
Bone Marrow

II (Marrow Failure)
Circulation

III (Blood Loss)

Acute

Chronic

IV (Hemolysis)
Intravascular

Extravascular

Anemias
Classification of anemia based on RBC mean corpuscular
volume (MCV): microcytic, macrocytic, normocytic
Classification of anemia according to pathophysiology:
impaired production (nutritional deficiencies, bone marrow
failure), increased destruction (hemolysis) and massive
blood loss (injuries, parasitism)
Classification according to duration: acute, chronic,
recurrent (compensated)

Microcytic Anemia

POSSIBLE ETIOLOGIES
Iron deficiency anemia (IDA)
Thalassemia
Sideroblastic anemia
Anemia of chronic disorder (ACD)
Lead poisoning

HYPOCHROMIA, MICROCYTOSIS

Macrocytic Anemia
POSSIBLE ETIOLOGIES
Megaloblastic process (ovalocyte)
Reticulocytosis (bleeding, hemolysis)
Liver disease
Post-splenectomy
Chemotherapy
Hypothyroidism

ANISOCYTOSIS

POIKILOCYTOSIS

(ACANTHOCYTOSIS, ECHINOCYTES)

Physiologic Anemia of Infancy

Physiologic Anemia of Infancy
Normal newborns have HIGHER hemoglobin and hematocrit
levels and LARGER red blood cells.
Occurs during the first 6-8 weeks of life
Hemoglobin drops to 9-11 g/ dL
physiologic adaptation to extrauterine life
Premature infants have more extreme dips in hemoglobin levels
(7-9 g/dL) occurring within the first 3-6 weeks of life
Requires NO therapy
Diet must have adequate folic acid and iron
PRBC transfusion if hemoglobin < 6.5 g/ dL. Give 10-15 mL/kg

Anemia During the Neonatal Period

Hemorrhage:
Post-natal blood loss
External: bleeding from umbilicus, GUT
Internal: cephalhematoma, ruptured spleen
Intranatal blood loss
Umbilical cord abnormalities
Placental abnormalities
Prenatal blood loss
Transplacental fetomaternal
Intraplacental and retroplacental
Twin-to-twin transfusion

Anemia During the Neonatal Period

Hemolysis
Congenital erythrocyte defects
Acquired erythrocyte defects
Rh isoimmunization
ABO isoimmunization
Late onset anemia in immune hemolytic anemia
Non-immune hemolytic anemia
Vitamin E deficiency

Anemia During the Neonatal Period

Failure of Red Cell Production
congenital
Acquired: viral diseases

Anemia During the Neonatal Period

Anemia of Prematurity

Nadir of hemoglobin level: 7 g/ dl at 4-8 weeks

Reduced bone marrow erythropoietic activity
Low erythropoietin (Epo) levels
Low hemoglobin due to:

Decreased RBC production

Shorter RBC life span
Increased blood volume with growth

TREATMENT: recombinant human Epo, supplemental iron, PRBC

transfusion if needed

Anemia During the Neonatal Period

Acute Blood Loss

Acute distress: pallor, shallow breathing, tachycardia, shock

Low venous pressure
Hemoglobin may be normal initially then drops quickly within 24
hours
RBC: normochromic, macrocytic
Normal serum iron
Prompt treatment of anemia necessary to prevent death
Treatment: NSS, PRBC, iron

Anemia During the Neonatal Period

Chronic Blood Loss
Marked pallor disproportionate to the evidence of distress, CHF,
hepatomegaly
Normal or elevated venous pressure
Hemoglobin low at birth
RBC: hypochromic, microcytic, anisopoikilocytosis
Low serum iron at birth
Course generally uneventful
Treatment: iron therapy

Anemia During the Neonatal Period

Isoimmune Hemolytic Anemia due to Rh Incompatibility

Frequency:
unusual
Occurrence in firstborn:
5%
Predictably severe in subsequent pregancies: usually
Stilbirth or hydrops:
occasional
Pallor:
marked
Jaundice:
marked
Hepatosplenomegaly:
marked
Incidence of late anemia:
common

Anemia During the Neonatal Period

Rh Incompatibility

Mothers blood type:

Infants blood type:
Antibody type:
Coombs test:
Hemoglobin:
Serum bilirubin:
RBC:

Rh (-)
Rh (+)
Incomplete (IgG)
(+)
very low
markedly elevated
nucleated RBCs

Anemia During the Neonatal Period

Rh Incompatibility
Need for antenatal management: Yes
Exchange transfusion: Yes

Anemia During the Neonatal Period

IsoimmuneHemolysis due to ABO Incompatibility

Frequency:
common
Occurrence in firstborn: 40-50%
Predictably severe in subsequent pregnancies: no
Stillbirth/ hydrops:
rare
Pallor:
minimal
Jaundice:
minimal (< 24 hours)
Hepatosplenomegaly:
minimal
Incidence of late anemia: uncommon

Anemia During the Neonatal Period

ABO Incompatibility

Blood type, mother:

Blood type, infant:
Antibody type:
Coombs test:
Hemoglobin level:
Serum bilirubin:
RBC morphology:

O(+)
A or B or AB
immune (IgM)
usually positive
moderately low
Variable elevated
spherocytes

Anemia During the Neonatal Period

ABO Incompatibility
Need for antenatal management: no
Exchange transfusion:
no

Iron Deficiency Anemia

Iron deficiency anemia (IDA)
Etiology: lack of sufficient iron for synthesis of hemoglobin
Most common hematologic disease of infancy
Clinical manifestations:
PALLOR: most important clue
Blue sclera
Irritability
Pagophagia: desire to ingest unusual substances (ice, dirt)
Anorexia
Tachychardia
Cardiac dilation
Systolic (high output) hemic murmurs

Iron Deficiency Anemia

Iron deficiency anemia
Laboratory findings
Mild IDA: Hemoglobin 9-10 g/ dL
Moderate IDA: Hemoglobin 6-8 g/ dL
Severe IDA: Hemoglobin < 5 g / dL
Stages of Iron Deficiency Anemia

Iron depletion
Iron deficiency without anemia
Iron deficiency anemia

Iron Deficiency Anemia

(hypochromic, microcytic red
cells)

IRON DEFICIENCY ANEMIA

Iron Deficiency Anemia

Iron Deficiency Anemia
Treatment
Oral ferrous salts (sulfate, gluconate, fumarate): 6 mg/ kg/ day in 3 divided

doses for 2-3 months

Iron rich diet (red meat, green leafy vegetables, eggs)
Limited milk intake: 500 mL/ day or less
Blood transfusion RARELY needed. Only when anemia is VERY SEVERE
(hemoglobin < 4 g/ dL) or when superimposed infection interferes with
expected response
RETICULOCYTOSIS increases within 72-96 hours after iron
administration (so a high or normal RETICULOCYTE COUNT on day 3 of
treatment is predictive of adequate response)

Response of Anemia to Iron

Supplementation
= most reliable indicator of iron-deficiency anemia.

= therapeutic dose should be calculated in terms of

elemental iron.
= 3 - 6 mg /kg /day in three divided doses
= duration is 6 - 8 weeks after hemoglobin level is
restored back to normal.

Response to Iron Therapy in Iron Deficiency Anemia

12-24 hours
replacement of intracellular iron enzymes; subjective
improvement; decreased irritability; increased appetite
36-48 hours
initial bone marrow response; erythroid hyperplasia
48-72 hours
reticulocytosis; peaking at 5-7 days
4 30 days
increase in hemoglobin level
1-3 mos
repletion of stores

Hemolytic Anemias
Definitions and Classification:
HEMOLYSIS: premature destruction of RBCs, shortened RBC
survival, increased BMA activity and increased reticulocyte
percentage and number
If the rate of RBC destruction > rate of RBC production = anemia
SUSPECT HEMOLYTIC ANEMIA if the reticulocyte count is HIGH
in the absence of bleeding or administration of hematinics

Hemolytic Anemias
Definition and Classfication:
Classification
CELLULAR: intrinsic abnormalities of the membranes, enzymes or
hemoglobin
EXTRACELLULAR: antibodies, mechanical factors, plasma factors

Most of the cellular causes of hemolytic anemia are INHERITED

while most of the extracellular causes are ACQUIRED.

Hereditary Spherocytosis
Hereditary Spherocytosis
Common in the newborn and may present as ANEMIA and
HYPERBILIRUBINEMIA requiring phototherapy or exchange
transfusions
May remain ASYMPTOMATIC into adulthood
Clinical manifestations: severe anemia with pallor, jaundice, easy
fatigability, exercise intolerance
SPLENOMEGALY happens usually after infancy
PIGMENTARY (BILIRUBIN) GALLSTONES appear as early as 4-5
years old
HIGH susceptibility to APLASTIC and HYPOPLASTIC crises
(parvovirus and other infections)

Hereditary Spherocytosis
Autosomal dominant inheritance
Primary defect is membrane instability due to dysfunction or
deficiency of a red cell skeletal protein
Ankyrin mutations (50-67%), alpha and beta spectrins, protein
4.2, and band 3
Vertical defect in RBCS progressive loss of membrane lipid
and surface - loss of surface area - spherocytes

Hereditary Spherocytosis
Diagnosis
History and PE
CBC platelet count
Red cell indices: Low MCV, high MCHC, high RDW
Reticulocyte count (3-15%)
PBS: microspherocytes (high surface/ volume ratio)
Osmotic Fragility Test (incubated): spherocytes lyse in higher
concentrations of NSS than normal RBCs)
Elevated total and indirect bilirubin
Obstructive jaundice due to elevated direct bilirubin (gallstones)

Hereditary Spherocytosis
Hereditary Spherocytosis
Laboratory Findings:
EVIDENCE OF HEMOLYSIS: reticulocytosis and hyperbilirubinemia
Hemoglobin: 6-10 g/ dL
Reticulocyte count: 6-20% (mean 10%)
MCV: normal
MCHC: increased
Morphology: polychromatophilic reticulocytes and spherocytes

Hereditary Spherocytosis
Treatment:

Folic acid supplement (1 mg/ dau)

Leukocyte depleted PRBC for severe erythroblastoopenic crisis
Splenectomy

Complications

Hemolytic crisis
Erythroblastopenic crisis
Folate deficiency
Gallstones
Hemochromatosis

TARGET CELLS WITH SOME SPHEROCYTES

RETICULOCYTOSIS

NORMOBLASTEMIA

Hereditary Spherocytosis
Hereditary Spherocytosis
Treatment
Supportive
SPLENECTOMY for children > 5 years old
Risk of Overwhelming Post-Splenectomy Infection is HIGH in children < 5.
Indications for splenectomy
Very severe anemia with reticulocytosis
Hypoplastic or aplastic crises
Poor growth
Cardiomegaly

G6PD Deficiency
Glucose-6-phosphate dehydrogenase deficiency
First enzyme of the pentose phosphate pathway
Deficiency diminishes the reductive energy of the RBC causing
hemolysis
Severity depends on the type pf G6PD, and the nature of the
hemolytic agent (oxidant stressor)
Sex linked recessive mode of inheritance
Point mutations: sporadic (not specific to any geographic area) or
polymorphic (malarial selection)

G6PD Deficiency
Pathogenesis

Red cell G6PD activity falls rapidly and prematurely

Decreased glucose metabolism
Diminished NADPH/ NADP and GSH/ GSSG ratios
Impaired elimination of oxidants
Oxidation of hemoglobin and sulfhydryl groups
RBC integrity impaired upon exposure to oxidizing agents

G6PD Deficiency
Clinical Manifestations:

Acute self-limiting hemolytic anemia with hemoglobinuria

Heinz bodies in circulating cells
Blister cells, fragmented cells and spheorcytes
Reticulocytosis
Hemoglobin normal between episodes

Hemolytic crisis:
Drugs (analgesics, antipyretics, antimalarial agents, sulfonamides,
nitrofurans, sulfones, miscellaneous)
Fava beans
Infections

G6PD Deficiency
Treatment

Avoidance of oxidant stressors

Genetic counselling
Chronic non-spherocytic hemolytic anemia (NSHA)
Severe chronic anemia: PRBC if hemoglobin < 9\8-10 g/ dL
Indications
Hypersplenism, severe chronic anemia, splenomegaly causing physical
impediment

PRBC transfusion
Hemoglobin < 7 g/ dL
Persistent hemoglobinuria and hemoglobin < 9 g/ dL

Hemoglobin Disorders
Classification of hemoglobin disorders
STRUCTURAL ABNORMALITIES
Hemoglobinopathies/ Qualitative defects
Changes in amino acid sequences of the globin chains
Single amino acid substitutions

THALASSEMIA SYNDROMES
Quantitative defects
Synthesis of 1 or more globin chains is decreased or totally suppressed

HEREDITARY PERSISTENCE OF FETAL HEMOGLOBIN

(HPFH)
Elevated levels of Hemoglobin F continuing throughout adult life

CHROMOSOME 11

22
(HbF)
Amount in red
cells after 1 yr
of age

CHROMOSOME 16

<1%

----

22
(HbA2)
<3%

22
(HbA)
<96%

Hemoglobin Types and Normal Values

Normal values:

Normal hemoglobin findings differ between adults and childre

ADULTS
Hb A1
Hb A2
Hb F
Hb S
Hb C

95-98%
2-3%
0.8 to 2%
0%
0%

CHILDREN
Hb F
newborn
6 months
over 6 mos

50-80%
8%
1-2%

*Values expressed as a percentage of total hemoglobin.

Thalassemia Syndromes
Thalassemia Syndromes

Heterogenous groups of heritable hypochromic anemias

Homozygous Beta thalassemia (Cooley Anemia,
Thalassemia Major)
Severe, progressive hemolytic anemia during the second 6
months of life
Regular blood transfusions are necessary to prevent the
profound weakness and cardiac decompensation
Without blood transfusion, life expectancy is less than 20
years old.

Thalassemia Syndromes
Thalassemia Syndromes
Clinical manifestations
Severe pallor
Hypertrophy of erythropoietic tissues in both medullary and extramedullary

locations occur bones become thin and pathologic fractures occurs

Massive expansion of the bone marrow in the face and skull produces a
characteristic facies.
Pallor, hemosiderosis (iron deposition in tissues) and jaundice -
greenish brown complexion
Hepatosplenomegaly due to extramedullary hematopoiesis and
hemosiderosis
Growth retardation

Thalassemia Syndromes
Thalassemia Syndromes
Clinical Manifestations
Delayed or absent puberty due to secondary endocrine abnormalities
DM occurs due to pancreatic hemosiderosis
Cardiac complications: intractable arrythmias, chronic CHF due to

myocardial hemosiderosis - death

Failure to thrive early in childhood
Skull x-ray: hair on end appearance, fractures, osteoporosis
Leg ulcers
Skin bronzing

Thalassemia Syndromes
Diagnosis
History and physical examination
Laboratory tests
CBC platelet count
Reticulocyte count
Red cell indices
Peripheral blood smear
Hemoglobin electrophoresis

Blood film in Thalassemia

Blood film in Thalassemia

Thalassemia Syndromes
Complications

Due to chronic anemia with no or minimal transfusions

Due to chronic blood transfusion with hemochromatosis
Poor compliance with chelation
Endocrine disturbances
Liver cirrhosis and liver failure
Cardiac failure to myocardial iron overload
Extramedullary hematopoiesis
Marked osteoporosis

Thalassemia Syndromes
Management
Hypertransfusion protocol (hemoglobin 10.5-11.0 g/dL)
Splenectomy
Persistent increase in blood transfusion by > 50% for > 6 months, annual PRBC
transfusion > 250 ml/kg/year with uncontrolled iron overload, leukopenia or
thrombocytopenia

Chelation therapy (ferritin > 1000ng/ ml)

Desferriioxamine 40 mg/ kg IV or 40-60 mg/ kg/ day SC 4-6 nights/ week

Causes of Death

Congestive heart failure

Arrhhythmia
Sepsis secondary to OPSI
Multiple organ failure due to hemochromatosis

Thalassemia Syndromes
Beta thalassemia intermedia
Do not require transfusions
Hemoglobin 7-10 g/ dl
Marked medullary expansion, hepatosplenomegaly, growth retardation, facial
anomalies and hyperbilirubinemia if not adequately transfused
Mostly healthy if managed vigorously
Treatment:
Folic acid 1 mg/ day
Iron rich diet/ supplements should be avoided
Chelation therapy (if needed)
PRBC transfusions if hemoglobin < 7 g/ dl, aplastic crisis, acute infection
splenectomy

Thalassemia Syndromes
Beta thalassemia minor
Asymptomatic
Discovered on routine blood test: slightly reduced hemoglobin,
basophilic stippling, low MCV, normal RDW
Discovered in family investigation

Thalassemia Syndromes
Alpha thalassemia
Types
Silent carrier: deletion of 1 alpha gene
Alpha thalassemia trait: deletion of 2 alpha genes
Hemoglobin H disease: deletion of 3 alpha genes
Hydrops fetalis: deletion of all 4 alpha genes

Hydrops fetalis

Anemia of Bone Marrow Failure

Aplastic Anemia
Causes of Acquired Aplastic Anemia
Idiopathic: > 70% cases
Secondary

Pregnancy
Malnutrition
PNH
Myelodysplastic syndrome
Hypoplastic preleukemia
Immunologic disorders: GVHD
Infections: hepatitis A, B, C, AIDS, EBV, rubella
Irradiation
Toxins: benzene, toluene
Chemicals: insecticides
Drugs
Unpredictable, normal doses (defect or damage to pluripotent stem cells): antibiotics,
anticonvulsants, anti-rheumatics, antimalarials, anti-diabetics
Predictable, does-dependent, rapidly reversible: ^ MP, MTX, chlorampehnicol

Anemia of Bone Marrow Failure

Etiologic classfication
Direct toxicity: radiation, chemotherapy, benzne
Immune mediated causes: iatrogenic, hepatitis, pregnancy, idiopathic

White Blood Cells

Leukocytosis
Causes:
Physiologic (newborn: 38,000/ cumm)
Emotional disorders
Ovulation, labor, pregnancy
Acute infections: bacterial, viral, fungal, protozoal, spirochetal
Metabolic causes: diabetic coma, seizures
Drugs: steroids, epinephrine
Poisoning: lead, mercury
Acute hemorrhage
Malignant neoplasms
Connective tissue diseases
Hematologic diseases

White Blood Cells

Leukocytosis

Neutrophilia
Lymphocytosis
Monocytosis
Basophilia
Eosinophilia

White Blood Cells

Leukemoid Reaction

TWBC> 50,000/ cu mm
Shift to the left: presence of young WBCs
With evidence of infection
No anemia, thrombocytopenia, blasts
Normal BMA
LAP increased

EOSINOPHIL

NEUTROPHIL

LYMPHOCYTE

MONOCYTE

BASOPHIL

Lymphocytosis
Physiologic: 4 months-4 years old
Leukemia
ALL

Infections
Chronic
TB, syphilis
Acute
Moderate lymphocytosis: measles, rubella, mumps, varicella
Marked lymphocytosis: acute infectious lymphocytosis, infectious
mononucleosis, CMV, pertussis

Atypical Lymphocytosis
Less than 20%
Miscellaneous: hematologic (LCH, ALL, lymphoma) lead intoxication, stress
Radiation
Infections
Bacterial: TB
Viral: mumps, varicella, rubella, HSV, VZV
Protozoal: toxoplasmosis
Rickettsial: ricekttsialpox
Spirochetal: syphilis

More than 20%

Infectious mononucleosis
Infectious hepatitis
Post-transfusion syndrome
CMV
Drug hypersensitvity: PAS, phenyotin

Platelets
Important in the first phase of coagulation platelet plug formation
Platelet size: 1-4 um (younger platelets are larger)
Platelet count: 150,000-400,000/ cumm
Distribution: 1/3 in the spleen + 2/3 in the bloodstream
Life span: 7-10 days

PLATELETS

Platelets
Clinical manifestations of platelet disorders
BLEEDING: skin and mucous membranes
Petecchia, purpura, ecchymoses, epistaxis, hematuria,
menorrhagia, GI hemorrhage, intracranial hemorrhage

Platelets
Platelet diseases based on platelet size
MACROTHROMBOCYTES (HIGH MPV)
ITP or any condition with increased PLT turnover
Bernard Souillier syndrome
May Hegglin anomaly
Gray platelet syndrome
NORMAL SIZE (NORMAL MPV)
Hypocellular BMA or Metastasis to the BMA
MICROTHROMBOCYTES (LOW MPV)
WAS
TAR syndrome
Storage pool disorders
IDA

Platelets
Laboratory evaluation of platelets and platelet function:

Examination of peripheral blood smear

Bleeding time
Platelet count
Platelet aggregation studies (platelet aggregometry)

Platelets
Pathophysiological Classification of
thrombocytopenic states:

Increased PLT destruction

Disorders of PLT distribution or pooling
Decreased PLT production deficient thrombopoiesis
Pseudothrombocytopenia

ITP
Most frequent cause of thrombocytopenia
immune-mediated PLT destruction due to auto-antibodies,
drug-dependent antibodies or alloantibodies
Syndrome characterized by:

Thrombocytopenia (PLT < 100,000/ cumm)

Shortened platelet survival
Presence of antiplatelet antibody in the plasma
Increased megakaryocytes in the bone marrow

ITP
Types of ITP according to duration
ACUTE: < 6 months
RECURRENT: PLT decreases after having returned to
normal levels
CHRONIC: > 6 months

ITP
Age
Sex distribution
Seasonal predilectiion
Preceding infection
Associated autoimmmune
conditions
Onset
PLT count
Eosinophilia/ lymphocytosis
IgA
Duration
Prognosis

ACUTE ITP
children
equal
(+)
(+)

CHRONIC ITP
adults
> females
(-)
(-)

low
acute
< 20,000
(+)
normal
2-6 weeks
spontaneous
remission (80%)

high
insidious
40-80, 000
(-)
lower
months to years
fluctuating chronic course

ITP
Clinical manifestations
Age: 2 8 years old
Sex: equal
Predisposing factors: preceding viral infection occurring 3 weeks
(50-80%)
Non-specific URTI, rubella, measles, varicella, pertussis, mumps,
CMV, hepatitis A, B, C, EBV, parvovirus
Smallpox or live measles vaccination

Pathogenesis of ITP
Platelet antibodies
Platelet survival

ITP
Infantile ITP
- infants less than 2 years old
- higher male/ female ratio
- less frequent occurrence of infection before ITP
- less frequent occurrence of chronic ITP
- poor response to treatment
- more severe clinical course

ITP
Clinical manifestations
Bleeding on the skin: anterior surfaces of the lower extremities
and over bony prominences
Bleeding in the mucous membranes
Bleeding in internal organs: CNS, eyes, middle ear, deep muscles
and joints
PALLOR is usually ABSENT unless significant bleeding has taken
place.
HEPATOSPLENOMEGALY is usually ABSENT.
CERVICAL LYMPHADENOPATHY is usually ABSENT.

ITP
Laboratory findings

LOW PLT COUNT (always < 50,000/ cu mm)

PERIPHERAL BLOOD SMEAR: low PLT
BONE MARROW ASPIRATE: increased megakaryocytes
COAGULATION PROFILE: PROLONGED bleeding time, normal
PT and aPTT

Related laboratory tests: ANA and anti-dsDNA (connective tissue

disorders), Blood typing, Coombs test, Liver function tests, EBV
tests

ITP
Diagnosis

Clinical examination
PLT count and peripheral blood smears
Bone marrow aspiration
Exclusion of secondary causes of thrombocytopenia

THROMBOCYTOPENIA:
Immune Thrombocytopenic Purpura

ITP
Drugs capable of causing thrombocytopenia through druginduced antibody formation:

Anti-inflammatory drugs
Antibiotics
Anti-neoplastics
Anti-convulsants, sedatives and anti-depressants
Cardiac and antihypertensive drugs
H2 antagonists
Cinchona alkaloids
Others: food (beans)

ITP
Treatment
No treatment when the PLT count is > 20,000/ cu mm
Treatment recommended if PLT < 20,000/ cu mm + significant
mucous membrane bleeding or PLT < 10,000/ cu mm with minor
purpura
Steroids
High dose IV immunoglobulin
Anti-D therapy
Rituximab
Plasmapheresis
PLT transfusions
Splenectomy

ITP
Splenectomy
Indications
Severe acute ITP with acute life-threatening bleeding unresponsive to
medical treatment.
Chronic purpura with bleeding symptoms
PLT count persistently < 30,000/ cu mm

OPSI (Overwhelming Post-Splenectomy Infection)

Vaccinations against N. meningitidis, H. influenzae b, Strep pneumoniae

Lifelong daily prophylaxis with Penicillin V 250 mg BID
All febrile episodes should be aggressively managed

ITP
Treatment of life threatening bleeding:

PLT transfusion
IV steroids
IV immunoglobulin
Emergency splenectomy

ITP
Prognosis
EXCELLENT: 50% recovery within 1 month, 70-80% recovery
within 6 months
Spontaneous remission after 1 year is uncommon, although may
occur after several years
Age > 10, insidious onset, female gender: high risk for chronic ITP
In Chronic ITP: 50-60% eventually stabilize without treatment and
without recourse to splenectomy

NEONATAL THROMBOCYTOPENIA
Causes of neonatal thrombocytopenia
Normal or increased megakaryocytes in the bone marrow
(megakaryocytic thrombocytopenia)
Immune (autoimmune, alloimmune)
Infection
Drugs
DIC
Inherited thrombocytopenia
Decreased or absent megakaryocytes in the bone marrow
(amegakaryocytic thrombocytopenia): isolated megakaryocytic
hypoplasia, generalized bone marrow disorders, metabolic
causes

NEONATAL THROMBOCYTOPENIA
NITP (neonatal idiopathic or autoimmune purpura)
Passive transfer of PLT antibody from the mother
Mothers have LOW PLT counts
Self-limiting but may last for several weeks
Transplacental passage of maternal IgG autoantibodies into the fetal circulation
- destruction of fetal PLT
True maternal ITP vs. GESTATIONAL THROMBOCYTOPENIA: maternal
thrombocytopenia is NOT severe (PLT > 100,000/ cu mm) and infants are NOT
at risk of thrombocytopenia
Treatment:
IV immunoglobulin
Steroids
Exchange transfusion
PLT transfusions

NEONATAL THROMBOCYTOPENIA
NATP (neonatal alloimmune or isoimmune
thrombocytopenia)
Born to mothers with NORMAL PLT counts
Immunization due to fetomaternal passage of PLT in which there
is incompatibiltiy of fetal and maternal antigens
Associated with human PLT antigen (HPA-1a) or Pl A1
Also causes associated platelet qualitative defects due to
impairment of PLT aggregation

NEONATAL THROMBOCYTOPENIA
Diagnosis of NATP
Congenital thrombocytopenia
Normal maternal PLT count and negative history of maternal ITP
No evidence of systemic disease, inefction, malignancy or
hemangioma
Recovery of platelets within 2-3 weeks.
Increased megakaryocytes in bone marrow aspiration

NEONATAL THROMBOCYTOPENIA
Treatment

PLT transfusion (washed or irradiated)

IV immnoglobulin
steroids

HEMOSTASIS
Physiology of hemostasis
Vascular phase: vasoconstriction
Platelet phase: platelet plug formation or primary hemostatic
mechanism
Plasma phase: fibrin thrombus formation (initiation, amplification,
propagation)

CLOTTING CASCADE

Intrinsic Pathway

Extrinsic Pathway

Contact
XII
XIIa
XI

XIa

Tissue Factor

IX

IXa

VIIa

VIIIa+Pl

Xa
Va+Pl
II

Fibrinogen

IIa
Fibrin Clot

VII

FIBRINOLYSIS
MECHANISM for the removal of physiologically deposited

fibrin
Clot lysis is brought about by the action of PLASMIN on
fibrin
PLASMINOGEN (zymogen) is synthesized in the liver.
Alpha 1 antiplasmin is a PLASMIN inhibitor.
Tissue plasminogen activator (tPA) is the principal
intravascular activator of plasminogen is found in body
tissues and fluids.
Urokinas plasminogen activator (uPA) is found in urine.

FIBRINOLYSIS
Plasmin SPLITS fibrin and fibrinogen into FDPs (fibrin
degradation products) or FSPs (fibrin split products)

Fragment X
Fragment Y
Fragment D
Fragment E

NATURAL INHIBITORS OF
COAGULATION
Antithrombin III (heparin cofactor)
Antiplasmin (alpha 2-plasmin inhibitor)
Alpha-2 macroglobulin
Alpha-1 antitrypsin
C1 inhibitor
TAFI (thrombin activatable inhibitor of fibrinolysis)
TFPI (tissue factor pathway inhibitor)
Protein C
Protein S
Protein C inhibitor

HEMOSTASIS IN THE NEWBORN

Platelets

Increased PLT adhesion due to increased vWF and HMW vWF multimers
PLT aggregation abnormalities
PLT activation is increased due to increased TXA2, beta thromboglobulin and
PF 4

Blood vessels
Increased capillary fragility
Increased prostacyclin production

Plasma factors
Increased plasma levels of tPA and PAI-1
Decreased activity of anticoagulant factors AT III, PC, PS

TESTS FOR HEMOSTASIS

Laboratory evaluation to detect hemostatic disorders:

CBC platelet count

Bleeding time
Platelet function analyzer
Bleeding time
PT
aPTT
Fibrinogen
Thrombin time
Mixing studies
Clotting factor assays
vWF antigen : quantitative assay for vWF

TESTS FOR HEMOSTASIS

Von Willebrand factor (ristocetin cofactor acitivty):
functional/ qualitative assay for vWF
Platelet aggregation studies: qualitative assessment of PLT
function
Urea clot lysis assay screening for FXIII deficiency

CONGENITAL COAGULATION FACTOR

DISORDERS
Hemophilia

Most common severe coagulation disorders

Due to deficiency or defect in clotting factors VIII, IX, XI
Sex linked recessive mode of transmission
Almost exclusively affects males
Mothers are carriers
30% has a positive family history
30% has no family history and may be due to spontaneous
genetic mutation

HEMOPHILIA
Type of hemophilia
According to the missing clotting factor
Hemophilia A: missing clotting factor VIII
Hemophilia B: missing clotting factor IX
Hemophilia C: missing clotting factor XI
According to severity
MILD: clotting factor level > 5%
MODERATE: clotting factor level 1-5%
SEVERE: clotting factor level < 1%
According to frequency of bleeding
MILD: once a year or even rarely; with trauma
MODERATE: once every quarter: with or without trauma
SEVERE: once a month or even more often: spontaneous

HEMOPHILIA
Common sites of bleeding for hemophiliacs

Hemarthrosis (joints): HALLMARK of hemophilia

Intramuscular hematoma
Hematuria
Mucous membranes

hematoma/bruises
post-venipuncture

 hemarthrosis

hemarthrosis

2 yr old Hemophilia A
with inhibitor,
developed
scalp hematoma

Pseudotumor in a
hemophilia A patient

HEMOPHILIA
High Risk Bleeding sites

CNS (intracranial, intraspinal)

Retropharyngeal
Retroperitoneal
Hemorrhage causing compartment/ nerve compression syndrome
Femoral (iliopsoas muscle)
Sciatic (buttock)
Tibial (calf muscle)
Perineal (anterior compartment of the leg)
Median and ulnar nerves (flexor muscles of the forearm)

HEMOPHILIA
Laboratory tests
Prolonged aPTT
Decreased specific clotting factor assays
Corrected mixing studies

Treatment
DDAVP for mild hemophiliacs
Facilitates release of factor VIII and vW factor in the circulation
Clotting factor replacement therapy
Blood components: fresh frozen plasma, cryoprecipitate, cryosupernate
Plasma derived or recombinant clotting factor concentrates

HEMOPHILIA
Complications of the disease
Crippling joint deformity
Psychological incapacity

Complications of the treatment

Transfusion transmissible viral infections
Inhibitor development

VON WILLEBRAND DISEASE

Most common hereditary bleeding disorder

Autosomal dominant mode of transmission
Due to deficiency, dysfunction or complete absence of von
Willebrand factor
Functions of the vWF:
Mediates adherence of platelets at sites of endothelial damage
promoting formation of the platelet plug
Binds and transport s factor VIII protecting it from degradation by
plasma proteases

VON WILLEBRAND DISEASE

Site of synthesis: megkaryocytes and enodthelial cells
Site of storage: alpha granules (platelets) and Weibel Palade bodies

(endothelial cells)
Clinical manifestations: muco-cutaneous bleeding, prolonged oozing
from surgery or after trauma
Types of vWD

Type I
Type 2A
Type 2B
Type 2N
Type 2M
Type 3

VON WILLEBRAND DISEASE

Type 1 VWD

Most common form of the disorder

Mild to moderate decrease in plasma VWF
Plasma VWF has normal structure
Low ristocetin cofactor and VWF antigen
DDAVP is effective

VON WILLEBRAND DISEASE

Type 2A VWD
Decreased PLT dependent VWF function + lack of large HMW
multimers in plasma and platelets
Localized in the A2 domain of VWF
DDAVP is effective
Clotting factor concentrates (intermediate purity) may help

VON WILLEBRAND DISEASE

Type 2B VWD
Dominant gain in functional mutations in the A1 domain of VWF
MILD thrombocytopenia present due to spontaneous
agglutination of platelets
Reduced PLT aggregation with ristocetin
DDAVP is CONTRAINDICATED due to transient
thrombocytopenia resulting from release and clearance of
abnormal VWF
Clotting factor replacement (intermediate purity) is effective

VON WILLEBRAND DISEASE

Type 2N VWD
Abnormal VWF that DOES NOT bind factor VIII - unbound
factor VIII is rapidly cleared from the circulation - low factor VIII
MISDIAGNOSED as hemophilia
Clotting factor concentrate (intermediate purity) may be effective

VON WILLEBRAND DISEASE

Type 2M VWD
Abnormal binding site on VWF for PLT GP Ib -- reduced
ristocetin cofactor activity (functional defect)
Multimers of all sizes are present
DDAVP is effective for heterozygous variants
Clotting factor concentrates (intermediate purity) is effective for
homozygous variants

VON WILLEBRAND DISEASE

Type 3 VWD
Severe bleeding disorder with major deficits in both primary and
secondary hemostasis
Plasma FVIII and vWF are UNDETECTABLE.
Plasma derived clotting factor concentrates (intermediate purity)
may cause ANAPHYLACTIC reactions so only recombinant
preparations are used
Recombinant FVIIa may help

VON WILLEBRAND DISEASE

Platelet type-pseudo VWD
Mutation in the PLT GP Ib receptor
Similar to type 2B VWD
Excessive binding of VWF to PLT GP Ib receptor -
PLT activation and VWF removal from the circulation -
low plasma VWF - increased PLT aggregation
PLT transfusion is the treatment of choice

VON WILLEBRAND DISEASE

Acquired VWD
Low VWF in a person with no lifelong bleeding disorder
Associated Disorders
Malignancies
Autoimmune disorders
Myeloprliferative disorders
Lymphoproliferative disorders
Drugs
Angiodysplasia
Mechanisms:
Specific autoantibodies
Adsorption onto malignant cell clones
Depletion in conditions of high vascular shear force

ACQUIRED HEMOSTATIC DISORDERS

Vitamin K Deficiency Bleeding (VKDB)
Hemorrhagic Disease of the Newborn
At birth, factors 2, 7, 9, 10 are physiologically LOW.
Lowest point is on DAY 3 of life.
Due to low body stores of vitamin K plus subsequent
poor intake of vitamin K
Minimum requirement: 25 ug of vitamin K

VITAMIN K DEFICIENCY BLEEDING

Conditions associated with deficiency of Vitamin K dependent clotting
factors:

Normal newborn (normal by 3 months of age), prematurity

Diet
Altered bacterial colonization
Hepatocellular disease
Drugs

Clinical manifestations:
Bleeding on days 2-4
Sites of bleeding: GIT, umbilicus, internal organs

VITAMIN K DEFICIENCY BLEEDING

Laboratory findings:

RBC morphology
normal
aPTT
prolonged
PT
prolonged
Fibrin split products
normal
Platelets
normal
Clotting factors decreased 2, 7, 9, 10

VITAMIN K DEFICIENCY BLEEDING

Treatment
Vitamin K
Fresh frozen plasma transfusion

DIC
INTRAVASCULAR consumption of PLT and plasma clotting factors
Widespread coagulation results in the deposition of fibrin thrombi and
the production of a hemorrhagic state
Accummulation of fibrin in the micorcirculation leads to mechanical
injury to the RBC - RBC fragmentation and microangiopathic
hemolytic anemia
Phases:
Thrombin causes intravascular coagulation + consumption of PLT, fibrinogen,
FV, FVIII, FXIII
Plasminogen is converted to plasmin by tPA causing release of FDP or FSP
leading to clot lysis

DIC
Laboratory findings

Prolonged PT and aPTT

Decreased fibrinogen
Decreased PLT count
Increased FDP or FSP
Presence of fragmented RBC
Increased PF 4
Increased fibrinopeptide A
Decreased FV, FVIII, FXIII

DIC
Disease states associated with DIC
Tissue injury (trauma, crush injuries, head injury, burns,
venoms, malignancy, obstetrical accidents, major
surgery)
Endothelial cell injury and/ or abnormal vascular
surfaces (infection, immune complexes, malignancy)
Platelet, leukocyte or RBC injury (incompatible blood
transfusion, infection, allograft rejection, drug
hypersensitivty)

DIC
Treatment

Remove/ reverse underlying disorder

IV heparinization
IV direct thrombin inhibitors
Anti-PLT drugs
Anti-thrombin concentrates
Activated Protein C concentrate
Replacement therapy
PLT concentrates
Cryoprecipitate
Fresh frozen plasma

THROMBOSIS
Mechanisms of thrombosis
INHERITED THROMBOPHILIAS
Impaired neutralization of thrombin
Failure to control the generation of thrombin
Malfunction in the system of natural anticoagulants that
maintain the fluidity of blood

Decreased AT III - impairment of thrombin neutralization

Decreased PC or PS - diminished control of thrombin generation
Mutations in FV or FII - slows down proteolytic activation of factor
Va - augmented generation of thrombin

THROMBOSIS
Clinical manifestations of hypercoagulable states

Family history of thrombosis

Recurrent spontaneous thromboses
Thrombosis in unusual sites
Resistance to anticoagulant therapy
Coumarin necrosis syndrome
Recurrent spontaneous abortions
Thrombosis during pregnancy or oral contraceptives
Migratory superficial thrombophlebitis
Antiphospholipid syndrome (APAS)
Autoimmune disorders
Malignancy
Nephrotic syndrome
infections

THROMBOSIS
Laboratory findings
Primary hemostasis
Thrombocytosis
PLT aggregation
Increased PLT adhesiveness
Increased beta-thromboglobulin, VWF, PF4
Short PLT life span

THROMBOSIS
Laboratory findings
Secondary hemostasis
Shortened PT/ aPTT
Elevated coagulation factors (1,2,5,7,8,9,10,11)
Reduced ATIII, PC, PS
Factor V Leiden/ APC resistance
PT gene mutation
Increased alpha-2-antiplasmin, PAI, alpha-2-macroglobulin
Increased lipoporotein
Deficient thrombomodulin
Increased fibrinopeptide A
Increased FDP or FSP
Short fibrinogen life span
Dysfibrinogenemia
Homocysteinuria
Lupus anticoagulants
Anticardiolipin antibodies

VENOUS THROMBOSIS
DEVELOP under conditions of SLOW blood flow
Activation of the coagulation system with or without
vascular damage
Venous thrombi: large amounts of fibrin with numerous
RBC, PLT and WBC (red thrombus)
Produces significant obstruction to blood flow
Most serious consequence: DEEP VEIN THROMBOSIS
embolization causing PULMONARY EMBOLISM

VENOUS THROMBOSIS
Detection of DVT
Clinical assessment
Signs and symptoms of DVT
Presence or absence of an alternative diagnosis
Presence and number of predisposing factors for DVT
Impedance plethysmography
Venous ultrasound
D-dimer assay
Venogram

VENOUS THROMBOSIS
Risk factors for PE

Recent surgery
Immobilization (> 3 days bed rest)
Previous DVT or PE
Lower extremity plaster cast
Lower extremity paralysis
Strong family history of DVT or PE
Cancer
Post-partum

ARTERIAL THROMBOSIS
Develops under conditions of RAPID blood flow
Results from processes that DAMAGE the vessel
wall
Arterial thrombi: tightly coherent PLT that contain
small amounts of fibrin and few RBC (white
thrombus)
Most serious consequence of arterial thrombosis:
VASCULAR OCCLUSION

ARTERIAL THROMBOSIS
Risk Factors for Arterial Thrombosis

Cardiac catheterization
Cardiac procedures
Umbilical artery catheterization
Renal artery thrombosis
Hepatic artery thrombosis
Kawasaki disease
APAS

ARTERIAL THROMBOSIS
Specific Risk factors

Homocysteine
Lipoprotein A
Fibrinogen
FDP (D-dimers)
TPA
PAI-1
CRP

ARTERIAL THROMBOSIS
General Risk Factors

Cigarette smoking
Cholesterol
Hypertension
Pregnancy
Diabetes
Obesity
Physical inactivity

THROMBOSIS IN THE NEWBORN

Congenital: multiple-gene disorder
Acquired
Systemic Arterial Thromboembolic Disorders
Arterial ischemic stroke
Renal Vein thrombosis: most common non-catheter related
venous thrombotic event in the newborn
Central venous catheter related thrombosis: most common cause
of acquired thrombosis in the newborn
Umbilical venous catheters
Central venous catheters
Systemic venous thromboembolic disorders
Sinovenous thrombosis

TREATMENT OF THROMBOSIS
Anticoagulant therapy
Thrombolytic therapy
Intracaval filter
Pulmonary embolectomy

ANTI-THROMBOTIC AGENTS
Warfarin
Competitively inhibits vitamin K - decreased posttranslational carboxylation of factors 2,7,9,10

Heparin
Catalyzes the activity of the natural anticoagulant ATIII
Protamine sulfate is the ANTIDOTE for heparin
overdose

ANTI-PLATELET AGENTS
Aspirin
Acetylates cyclooxygenase - interferes with the production of
TXA2 - impaires PLT aggregation

Dipyridamole
Increases cyclic AMP inhibits PLT function
Indications
Cardiac disorders
Cardiovascular events
Kawasaki disease

THROMBOLYTIC AGENTS
Dissolve established thrombus by converting
endogenous plasminogen to plasmin which can
lyse existing thrombus
Tissue Plasminogen Activator (tPA)
Urokinase
Streptokinase