Textbook of Pediatric Hematology and Hemato-Oncology

Textbook of
Pediatric Hematology and

Hemato-Oncology
Textbook of
Pediatric Hematology and

Hemato-Oncology
Editor-in-Chief
MR Lokeshwar
Consultant Pediatrician and Pediatric Hematologist Oncologist

Shushrusha Citizens Co-operative Hospital and
Lilavati Hospital and Research Centre, Mumbai, India
Editors
Nitin K Shah
President, Indian Academy of Pediatrics, 2006

Consultant Pediatrician, PD Hinduja Hospital, Mumbai, India
Hon. Pediatric Hematologist Oncologist
BJ Wadia Hospital and Lions Hospital, Mumbai, India
Bharat R Agarwal
Head
Department of Pediatric Hematology and Oncology
BJ Wadia Hospital for Children Institute of Child Health
and Research Centre, Mumbai, India
Co-editors
Mamta Vijay Manglani
Professor and Head

Department of Pediatrics
Chief, Division of Hematology-Oncology
Program Director, Pediatric Center of Excellence for HIV Care
Lokmanya Tilak Municipal Medical College and
General Hospital, Mumbai, India
Anupam Sachdeva
Director, Pediatric Hematology-Oncology and

Bone Marrow Transplantation, Institute for Child Health
Sir Ganga Ram Hospital, New Delhi, India
Recipient, Dr BC Roy Award
Recipient, Silver Jubilee Research Award
Publication Editor
Asha Pillai
Medical Officer
Kashyap Nursing Home
Mumbai, India
Forewords
SS Kamath
Vijay N Yewale
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Textbook of Pediatric Hematology and Hemato-Oncology
First Edition: 2016
ISBN: 978-93-5152-143-3
Printed at
Dedicated to
Zinet Currimbhoy
Teacher of Teachers
in Pediatric Hematology and Oncology
for whom
Children with blood disorders and cancer were the greatest teachers!
Contributors
Aditya Kumar Gupta

MD FNB (Pediatric Hematology Oncology, SGRH)
Assistant Professor
Division of Pediatric HematologyOncology
Institute of Medical Sciences
Banaras Hindu University
Varanasi, India
[email protected]
Ajay Kumar
Senior Specialist
Department of Neonatology
Lady Hardinge Medical College
and Kalawati Saran Childrens Hospital
New Delhi, India
[email protected]
Aman Chauhan
Internal Medicine and Pediatrics
Combined Resident
Louisiana State University Health Science
Center
New Orleans, USA
[email protected]
Ambreen Pandrowala
Clinical Associate
Lilavati Hospital
Mumbai, India
[email protected]
Amol Dongre
Assistant Professor
Department of Medical Oncology
Jawaharlal Nehru Medical College
Wardha, India
[email protected]
Anand Deshpande
Consultant
Hematopathologist and In-Charge
Transfusion Medicine
PD Hinduja National Hospital
Mumbai, India
[email protected]
Anupa A Joshipura
Fellow Pediatric Hemato-Oncology
BJ Wadia Hospital for Children
Institute of Child Health and Research Centre
Mumbai, India
[email protected]
Anupama S Borker
Consultant Pediatric Oncologist
Somaiya Ayurvihar
Asian Institute of Oncology
KJ Somaiya Hospital Campus
Mumbai, India
[email protected]
Anupam Sachdeva
Director
Pediatric Hematology-Oncology and
Bone Marrow Transplantation
Institute for Child Health
Sir Ganga Ram Hospital, New Delhi, India
Recipient, Dr BC Roy Award
Recipient, Silver Jubilee Research Award
[email protected]
Aparna Vijayaraghavan
Registrar
Chennai, India
[email protected]
viii Textbook of Pediatric Hematology and Hemato-Oncology

AP Dubey
Director
Professor and Head
Maulana Azad Medical College and
Associated Lok Nayak Hospital
New Delhi, India
[email protected]
Arvind Saili
Director
Professor and Head
Lady Hardinge Medical College and
Kalawati Saran Childrens Hospital
New Delhi, India
[email protected]
ATK Rau
Pediatric Hematologist-Oncologist
Professor, Department of Pediatrics
MS Ramaiah Medical College
Bengaluru, India
[email protected]
Bharat R Agarwal
Head
Department of Pediatric Hematology and
Oncology
Institute of Child Health and Research
Centre, Mumbai, India
[email protected]
Bhavna Dhingra
Assistant Professor
All India Institute of Medical Sciences
Bhopal, India
[email protected]
Bipin P Kulkarni
Scientist B
National Institute of
Immunohaematology (Indian Council of
Medical Research, ICMR)
KEM Hospital Campus
Mumbai, India
[email protected]
www.niih.org.in
Brijesh Arora
Professor
Division of Pediatric Oncology
Tata Memorial Hospital
Mumbai, India
[email protected]
Deepak K Changlani
Pediatric Interventional Cardiologist
Lilavati Hospital and Research Centre
Mumbai, India
[email protected]
Dilraj Kaur Kahlon

Consultant Pediatric Hemato-Oncologist
Amandeep Hospital
Amritsar, India
[email protected]
Dinesh Yadav MD
Consultant Pediatrician
Vivekanand Hospital, Bhadra, India
Formerly Assistant Professor
Sri Aurobindo Institute of Medical
Sciences, Indore, India
[email protected]
Farah Jijina
Consultant Hematologist
PD Hinduja Hospital, Mahim, India
Professor
Department of Hematology
Seth GS Medical College and
KEM Hospital, Mumbai, India
[email protected]
Gaurav Narula
Associate Professor (Pediatric-Oncology)
Mumbai, India
[email protected]
Girish Chinnaswamy
Associate Professor (Pediatric-Oncology)
Mumbai, India
[email protected]
Contributors ix
Jagdish Chandra
Director-Professor of Pediatrics
In-Charge, Pediatric Hematology and
Thalassemia Day Care Centre
Programme Director, Pediatric Centre of
Excellence (HIV)
Lady Hardinge Medical College and
Kalawati Saran Childrens Hospital
New Delhi, India
[email protected]
Jayashree Mondkar
Professor and Head
Director
Human Milk Bank
Lokmanya Tilak Municipal Medical
College and General Hospital
Mumbai, India
[email protected]
Kana Ram Jat
Assistant Professor
New Delhi, India
[email protected]
K Ghosh
Director
Immunohaematology (ICMR)
KEM Hospital Campus
Mumbai, India
[email protected]
KN Aggarwal MD FIAP FAMS FNA
Former Professor and Director
Varanasi, India
Former Director
SGPGIMS, Lucknow, India
Professor
UCMS, Bhairwah, Nepal
Madhulika Kabra
Professor, Division of Genetics
New Delhi, India
[email protected]
[email protected]
Malobika Bhattacharya
Consultant Pediatrics
Kailash Hospital
Greater Noida, India
[email protected]
Mamta Vijay Manglani

Professor and Head
Chief, Division of Hematology-Oncology
Program Director, Pediatric Center of
Excellence for HIV Care, Lokmanya Tilak
Municipal Medical College and General
Hospital, Mumbai, India
[email protected]
Manas Kalra
Fellowship
Pediatric Oncology and BMT-Sydney
Consultant, Pediatric Hematologist
Oncologist and BMT Unit
Sir Ganga Ram Hospital
New Delhi, India
[email protected]
Maya Prasad
Assistant Professor
(Pediatrics)
Tata Memorial Hospital, Mumbai, India
[email protected]
MMA Faridi
Professor and Head
In-Charge
Division of Neonatology
University College of Medical Sciences
Guru Teg Bahadur Hospital
New Delhi, India
[email protected]
MR Lokeshwar
Consultant Pediatrician and Pediatric
Hematologist Oncologist
Shushrusha Citizens
Co-operative Hospital and Lilavati
Hospital and Research Centre
Mumbai, India
[email protected]
x Textbook of Pediatric Hematology and Hemato-Oncology

Mukesh M Desai MD
Hon. Hematologist Oncologist and
Immunologist
Professor
Department of Pediatric HematologyOncology (DNB)
Department of PHO
Chief Division of Immunology
Honorary Consultant Hematologist
B Nanavati Hospital
Sir HN Hospital
Saifee Hospital
Asian Heart Institute, India
[email protected]
Narendra Chaudhary
Assistant Professor
Pediatric Hematology-Oncology
Department of Child Health
Christian Medical College
Tamil Nadu, India
[email protected]
Neerja Gupta
Assistant Professor
Division of Genetics
New Delhi, India
[email protected]
Neha Vilas Dighe
Fellow
Mumbai, India
[email protected]
Nirav Buch MD FNB
[email protected]
[email protected]
Nirav Thacker
Senior Registrar Pediatric Oncology
Department of Pediatric Oncology
Mumbai, India
[email protected]
Nirmalya D Pradhan
Senior Pediatric Oncologist
Department of Pediatric Oncology
Mumbai, India
[email protected]
Nita Radhakrishnan
Consultant Pediatric Hematology
Oncology
Institute of Child Health
Sir Ganga Ram Hospital
New Delhi, India
[email protected]
Nitin K Shah
President
Indian Academy of Pediatrics, 2006
PD Hinduja Hospital, Mumbai, India
Hon. Pediatric Hematologist Oncologist
BJ Wadia Hospital and Lions Hospital
Mumbai, India
[email protected]
Pankaj Dwivedi
Fellow in Pediatric, Hematology and
Oncology
Hospital for Sick Children
Toronto, Canada
[email protected]
Pooja Balasubramanian
Clinical Associate
Lilavati Hospital and Research Centre
Mumbai, India
[email protected]
Pooja Dewan
Assistant Professor
Delhi, India
[email protected]
Priti Desai
Associate Professor
Department of Transfusion Medicine
Mumbai, India
[email protected]
Contributors xi
PS Patil MD FIAP
Neo Clinic
Samarth Nagar
Aurangabad, India
[email protected]
Rashmi Dalvi
Consultant Pediatric Oncologist
Bombay Hospital and Medical Research
Centre
Mumbai, India
Rajesh B Sawant MD Path

ConsultantTransfusion Medicine
PD Hinduja National Hospital and MRC
Mumbai, India
[email protected]
[email protected]
Ratna Sharma
Professor (Pediatrics)
In-Charge
Dr DY Patil Hospital
Navi Mumbai, India
[email protected]
Rajiv Kumar Bansal

In-Charge Thalassemia Unit
Santokba Durlabhji Hospital
Jaipur, India
[email protected]
Renu Saxena
Professor and Head
New Delhi, India
[email protected]
Raj Warrier MD FAAP FIAP

Section Head
Ochsner, Peds Hem/Onc
Ochsner for Children
Professor Emeritus and Clinical Professor
Louisiana State University Health
Sciences Center (LSUHSC)
New Orleans, USA
Professor
Tulane University School of Medicine
New Orleans, USA
Professor
University of Queensland, Australia
Manipal University, India
[email protected]
[email protected]
Revathi Raj
Consultant Pediatric Hematologist
Apollo Hospitals
Chennai, India
[email protected]
(Late) Ram Kumar Marwaha

Professor
In-Charge, Division of Pediatric
Hematology-Oncology
Advanced Pediatric Centre
Postgraduate Institute of Medical
Education and Research (PGIMER)
Chandigarh, India
[email protected]
Rhishikesh Thakre
Consultant Neonatologist
Neo Clinic
Aurangabad, India
[email protected]
Sadhna Arora
Genetics Unit
Old OT Block
New Delhi, India
[email protected]
Saroj P Panda
DM Trainee (Pediatric Oncology)
Mumbai, India
[email protected]
xii Textbook of Pediatric Hematology and Hemato-Oncology

Satya P Yadav
Senior Consultant and Head
Pediatric Hemato-Oncology and BMT
Unit
Fortis Memorial Research Institute
Gurgaon, India
[email protected]
[email protected]
SB Rajadhyaksha
Professor and Head
Department of Transfusion Medicine
Mumbai, India
[email protected]
Seema Gulia
Assistant Professor
Mumbai, India
[email protected]
Shanaz Khodaiji
Consultant Hematology and Transfusion
Medicine
PD Hinduja National Hospital and MRC
Mumbai, India
Consultant Hematologist
PD Hinduja National Hospital and
Medical Research Centre
Mumbai, India
[email protected]
Shripad Banavali
Professor and Head
Mumbai, India
[email protected]
Sonali Sadawarte
Consultant Hematologist and BMT
Physician Royal Hobart Hospital
Hobart, Tasmania, Australia
[email protected]
Sonika Agarwal
Pediatric Neurology Fellow
Baylor College of Medicine
Houston
TX, USA
[email protected]
Soundarya M
Associate Professor
Kasturba Medical College
Mangalore, India
[email protected]
Shilpa Sanjay Borse MD

Pediatrics
Dattatraya Nagar
Nagpur, India
[email protected]
Sriram Krishnamurthy
Associate Professor
Jawaharlal Institute of Postgraduate
Medical Education and Research
(JIPMER)
Puducherry, India
[email protected]
Shrimati Shetty
Scientist E
Immunohaematology (ICMR)
KEM Hospital
Mumbai, India
[email protected]
Sunil Gomber
Director Professor
In-Charge Hematology-Oncology
New Delhi, India
[email protected]
Contributors xiii
Sunil Udgire FNB
Fellow
Department of Hemato-Oncology
Mumbai, India
[email protected]
Swati Kanakia MD DCH PhD
Kanakia Health Care, Lilavati Hospital
and Research Centre
Raheja Fortis Hospital
Lion Tarachand Bapa
Hospital, Mumbai, India
[email protected]
Vineeta Gupta
Associate Professor and In-Charge
Varanasi, India
[email protected]
VP Choudhary
MD FIAP FIMSA FIACM FISHTM
Former Professor and Head

New Delhi, India
Director
Sunflag Hospital
Faridabad, India
[email protected]
Foreword
It is both a pleasure and a privilege to write a foreword for this first edition of Textbook of Pediatric Hematology and
Hemato-Oncology. Immense advancement has been made over the past decade in the field of hematology and hematooncology providing not only enhanced accuracy in the diagnosis of inherited and acquired malignant and nonmalignant
blood disorders but also new therapeutic strategies that have resulted in improved patient outcomes. The book with
its illustrations, tables, figures and clinical photographs provides a concise yet thorough comprehension of pediatric
hematology and will definitely become a reference book for the students and the practitioners.
I congratulate the Editor-in-Chief, MR Lokeshwar; Editors, Nitin K Shah and Bharat R Agarwal; Co-editors, Mamta
Vijay Manglani and Anupam Sachdeva; Publication Editor, Asha Pillai and the 72 reputed and dedicated pediatric
hematologists and hemato-oncologists from across the world who after 3 years of exhausting brainstorming sessions,
brought out the remarkable book with 50 chapters spread over 7 sections.
I am sure that the information contained herein will be a benchmark in the understanding of the best approaches to
the patients that we evaluate and manage.
SS Kamath
President, 2015
Indian Academy of Pediatrics (IAP)
[email protected]
Foreword
I am delighted to write the foreword for the first comprehensive book Textbook of Pediatric Hematology and HematoOncology. Postgraduate students look up to their teachers for a book by the editorial team of Doynes in the field of
Pediatric Hematology and Hemato-oncology with their vast experience in the field and past experience in writing will
fill in this void and meet the expectations of the postgraduate students. The Editor-in-Chief, MR Lokeshwar has been
well supported by the other editors, Nitin K Shah, Bharat R Agarwal, Mamta Vijay Manglani and Anupam Sachdeva.
The descriptive text along with clinical pictures make it an interesting reading material. It covers a vast spectrum of
conditions making it very useful to the reader. I congratulate the entire team which includes the contributors, section
editors, editorial board and M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who have worked
relentlessly to achieve this milestone for the book. Above all, my hearty congratulations to the ever-enterprising respected
Dr MR Lokeshwar who thought of this brilliant idea of Textbook on Pediatric Hematology and Hemato-Oncology. I wish
the best for the success and popularity of the publication among both postgraduate students and practitioners. It will be
a landmark publication on Pediatric Hematology Oncology in the history of medical literature.
Vijay N Yewale
President, 2014
Indian Academy of Pediatrics (IAP)
Preface
Pediatric Hematology and Hemato-Oncology as a pediatric specialty has developed rapidly in the Western countries since
last few decades and is now catching-up in developing countries. Gone are the days when the adult hematologists and
hemato-oncologists used to treat pediatric patients in need of specialized services. To begin with several pediatricians
got self-trained in pediatric hematology and hemato-oncology and pioneered training in field of pediatric hematology
and hemato-oncology in the form of several informal and formal courses throughout the country. This created interest
in budding pediatricians to join this field by undergoing fellowships or even formal training in pediatric hematology
and hemato-oncology abroad and now in India. The last step towards the growth of this specialty has been starting of
2 years of Post-Doctorate Fellowship in Pediatric Hematology and Hemato-Oncology by the National Board in India
with several pioneering centers now offering this course since last 7 years, as well as 1 year Post-Doctorate Fellowship
by the Maharashtra University of Health Sciences (MUHS) and even by the Indian Academy of Pediatrics (IAP). Several
formally trained Pediatric Hematologists and Pediatric Hemato-oncologists are now providing the specialized services
in private and public hospitals.
With the interest created in the field of pediatric hematology and hemato-oncology, there was also a felt need by the
students as well as practitioners alike to have a dedicated textbook on pediatric hematology and hemato-oncology. While
there are several reputed textbooks on pediatric hematology and hemato-oncology, many of them are also elaborate
and at times bogged down with details of molecular science which may not necessarily fulfill the needs of students and
practitioners who are looking at complete yet concise book.
With the single aim in mind of having a complete and yet easy-to-read textbook on pediatric hematology and hematooncology, we have attempted to bring out the first edition after 3 years of brain-storming and grueling process. The 50
chapters spread over 7 sections and authored by 72 reputed pediatric hematologists and hemato-oncologists from India
and abroad make the book elaborate enough to give enough to all the readers, yet curtailing it to more than 500 pages
making it concise enough! Further powered by illustrations, tables, figures and clinical photographs will make reading
a unique and memorable event for the readers. Each chapter is further enriched by references at the end and is peerreviewed making it scientifically as complete as possible. This being the first edition is bound to have some errors which
might have escaped our attention in spite of our best efforts. We would request all our readers to send their feedback to
us which will help us improve upon in the subsequent editions.
We are sure that the book will become a reference book for the students and a desk companion to the practitioners!
Editors
Acknowledgments
We would like to express our gratitude to many people who saw us sail through the publication of Textbook of Pediatric
Hematology and Hemato-Oncology by providing support, talking things over, read, write, offering comments and helping
us in bringing out the book.
We wish to especially thank the following people for their contributions:
Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Mr Tarun Duneja (Director-Publishing)
without whom the book would have not found its way, Ms Samina Khan (Executive Assistant to Director-Publishing)
for guiding us throughout, Mr KK Raman (Production Manager), Mr Sunil Dogra (Production Executive) and other
staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for assisting us in the editing, proofreading
and designing skills.
All the authors/contributors mentioned in the list of contributors.
Special thanks to Mr Harish Raut for assisting us in the editing, proofreading and designing skills.
All the patients and families for allowing us to continue to learn the subject.
We would also like to thank our family members for their support.
Last but not least, we begforgiveness of all those who have been with us over the course of years and whose names,
we have failed to mention.
Editorial Board
Contents
Section 1PHYSIOLOGY
1. Ontogeny of Erythropoiesis
Nirav Buch
2. Physiology of Blood Coagulation

Shrimati Shetty
10
3. Structure, Function and Physiology of Platelets

K Ghosh, Bipin P Kulkarni
15
Section 2 NEONATAL HEMATOLOGY

4. Variation in the RBC Parameters in the Newborn
MR Lokeshwar, Ambreen Pandrowala, Jayashree Mondkar
5. Physiological Anemia of Newborn, Anemia of Prematurity and Role
of Erythropoietin in the Management
Rhishikesh Thakre, PS Patil
23
29
6. Effect of Maternal Iron Status on Placenta, Fetus and Newborn

KN Aggarwal, Vineeta Gupta, Sonika Agarwal
36
7. Developmental Aspects of Hemostasis in the Fetus and Newborn

Bhavna Dhingra, Renu Saxena
41
8. Anemia in the Newborn

Jayashree Mondkar, Shilpa Sanjay Borse, MR Lokeshwar
45
9. Polycythemia and Hyperviscosity Syndrome

MMA Faridi, Sriram Krishnamurthy
57
10. Vitamin K Deficiency: Bleeding in Newborns

Arvind Saili, Ajay Kumar
64
11. Bleeding Neonate: Approach and Management

Mamta Vijay Manglani, Neha Vilas Dighe, Ratna Sharma, MR Lokeshwar
68
12. Approach to Neonatal Thrombocytopenia

Nitin K Shah
77
Section 3 RBC AND WBC DISORDERS

13. Introduction and Classification of Anemias in Children
Manas Kalra, Satya P Yadav, Anupam Sachdeva
14. Nutritional Anemia in Infancy, Childhood and Adolescents
MR Lokeshwar, Nitin K Shah
87
100
xxiv Textbook of Pediatric Hematology and Hemato-Oncology

15. Megaloblastic Anemia
Anupa A Joshipura, Nitin K Shah
126
16. Anemia of Chronic Disease

Dilraj Kaur Kahlon, Satya P Yadav, Anupam Sachdeva
149
17. Thalassemia Syndromes

Mamta Vijay Manglani, Ambreen Pandrowala, Ratna Sharma, MR Lokeshwar
163
18. Sickle Cell Anemia in Children

Swati Kanakia, Pooja Balasubramanian, MR Lokeshwar
190
19. Antenatal Diagnosis of Hemoglobinopathies

Neerja Gupta, Sadhna Arora, Madhulika Kabra
204
20. Red Cell Membrane Disorders (Spherocytosis, Elliptocytosis, Stomatocytosis)

Sunil Gomber, Pooja Dewan
213
21. Red Cell Enzymopathy

Bhavna Dhingra, Dinesh Yadav, Jagdish Chandra
219
22. Autoimmune Hemolytic Anemia

Rajiv Kumar Bansal
227
23. Paroxysmal Nocturnal Hemoglobinuria

Farah Jijina, Sonali Sadawarte
238
24. Diagnosis and Management of Acquired Aplastic Anemia in Children

Nitin K Shah
247
25. Inherited Bone Marrow Failure Syndromes

Revathi Raj
255
26. Benign Disorders of Neutrophils

Bharat R Agarwal
258
Section 4 BLEEDING DISORDERS

27. Approach to a Bleeding Child
Raj Warrier, MR Lokeshwar, Aman Chauhan
275
28. Diagnosis and Management of Hemophilia Patients

Farah Jijina
285
29. von Willebrand Disease and Other Rare Coagulation Disorders

Kana Ram Jat, Ram Kumar Marwaha
296
30. Acquired Inhibitors of Coagulation

ATK Rau, Soundarya M
311
31. Immune Thrombocytopenic PurpuraDiagnosis and Management

MR Lokeshwar, Deepak K Changlani, Aparna Vijayaraghavan
318
32. Platelet Function Disorders

Shanaz Khodaiji
332
33. Pediatric Thrombosis

Rashmi Dalvi
348
34. Disseminated Intravascular Coagulation in Neonates

VP Choudhary
356
Contents xxv
Section 5 TRANSFUSION MEDICINE

35. Blood Components in Pediatric Practice
Nitin K Shah, Sunil Udgire
363
36. Nucleic Acid Amplification Testing

Anand Deshpande, Rajesh B Sawant
372
37. Transfusion Transmitted Infections

AP Dubey, Malobika Bhattacharya
376
38. Noninfectious Hazards of Blood Transfusion

SB Rajadhyaksha, Priti Desai
384
Section 6 HEMATO-ONCOLOGY
39. Pediatric Acute Lymphoblastic Leukemia
Pankaj Dwivedi, Shripad Banavali
395
40. Pediatric Acute Myeloid Leukemia

Maya Prasad, Shripad Banavali
408
41. Chronic Myeloid Leukemia

Nirav Thacker, Brijesh Arora
419
42. Juvenile Myelomonocytic Leukemia

Gaurav Narula, Nirmalya D Pradhan
430
43. Pediatric Hodgkin Lymphoma

Amol Dongre, Brijesh Arora
439
44. Non-Hodgkin Lymphoma in Children and Adolescents

Seema Gulia, Brijesh Arora
451
45. Langerhans Cell Histiocytosis

462
46. Hemophagocytic Lymphohistiocytosis: Revisited

Mukesh M Desai, Sunil Udgire
470
47. Bone Marrow Transplantation

Nita Radhakrishnan, Satya P Yadav, Anupam Sachdeva
479
Section 7 GENERAL
48. Gene Therapy
Aditya Kumar Gupta, Nita Radhakrishnan, Anupam Sachdeva
491
49. Monoclonal Antibodies in Pediatric Hematology and Oncology

Saroj P Panda, Girish Chinnaswamy
496
50. Biological Response Modifiers

Anupama S Borker, Narendra Chaudhary
501
Index
511
1
Physiology
CHAPTERS OUTLINE
1.

Ontogeny of Erythropoiesis
Nirav Buch
2.

Physiology of Blood Coagulation

Shrimati Shetty
3.

Structure, Function and Physiology of Platelets

1
Ontogeny of
Erythropoiesis
Nirav Buch
DEVELOPMENT OF HEMATOPOIESIS
Hematopoiesis occurs in three different waves in humans:
yolk sac liver and the bone marrow named so based upon
the main sites of hematopoiesis. Their characteristics
reflect the oxygen needs and the characteristics of the
developing embryo (Fig. 1).1
Yolk Sac Phase

After 19 days of fertilization islands of hematopoietic
tissue appear in the yolk sac and develop within the
vasculature.1 Initially, clusters of mesodermal cells called

hemangioblasts develops in the extra-embryonic region.
They are initially solid but later inner cells disappear
and peripheral cells acquire morphology of vascular
endothelium, opening up vessel lumens. Cells adhering to
these endothelium form hematopoietic cells and are called
blood islands (Figs 2A to C). These cells (endothelium
and hematopoietic precursors) show CD 34 expression
(Figs 3A and B).2
They are macrocytic and contain embryonal hemo
globins: Gower I (22), Gower II (22) and Portland
Fig. 1 Chronology of appearance of hematopoietic stem cells in the developing human embryo2
4Section-1Physiology
Figs 2A to C Sequence of emergence of hematopoietic stem cell cluster within the human embryo. (A) Beginning from 27 days of
development, scattered groups of a few hematopoietic stem cells appear, adhering to the aortic endothelium in the preumbilical region.
Groups of 2 to 3 cells are also often detected in a more rostral region, where the aorta is still bifurcated; (B) From day 30, the hematopoietic
cell clusters increase in size and groups of cells are also encountered at the bifurcation of the vitelline artery, always associated with the
ventral aspect of the vascular endothelium; (C) The size of hematopoietic progenitor clusters attains several hundreds of cells at 36 days
of development. At subsequent stages, stem cell clusters undergo gradual decrease till 40th day
Abbreviations: A: Aorta; V: Vitelline duct; U: Umbilical Arteries; H: Heart.
I (22)and later in the development hemoglobin

F (22). Cells are large and are nucleated. These consist
mainly of erythroid precursors but during 6th and 7th
week few megakaryocytes also develop.1
This first wave of erythrocyte production in the yolk
sac is known as primitive, and erythrocyte production that
takes place in is known as definitive erythropoiesis.2
A
Onset of Blood Circulation

Primitive erythrocytes are detected in embryo at day 21
(3 somite stage) suggesting vascular connections between
the yolk sac and the embryo.2
Figs 3A and B Possible origin hematopoietic stem cell emergence

within the human embryo.2 (A) Redifferentiation hypothesis at 27
days of development, pre-existing endothelial cells in the ventral
aspect of human intraembryonic arteries differentiate locally
into blood cell progenitors; (B) Migration hypothesis scattered
mesodermal CD34-CD45cell precursors colonize the ventral
vascular wall and give rise to (blood-forming?) endothelial cells
and hematopoietic cell clusters
Transition from Yolk Sac to Hepatic

Erythropoiesis
Primitive nucleated erythroblasts are seen in early hepatic
rudiment from 4.5 to 5 weeks onwards. They rapidly decrease
in number and are replaced by definitive macrocytes. At day
23, rare CD 34 negative cells of erythromyeloid lineage are
detected followed by CD 34 +ve cells at day 30 suggesting
two distinct waves of hepatic colonization.2
Hepatic Phase
Hepatic colonization of hematopoietic progenitors start
by 6 weeks and the liver becomes a major hematopoietic
organ in the 2nd trimester with about half of nucleated
Chapter-1 Ontogeny of Erythropoiesis 5

cells of liver being erythroid precursors. These are
smaller than their yolk sac predecessors and result in
forming anucleate red cells that are megaloblastic. Chief
hemoglobin is HbF. The maturation of cells is extravascular
in association with macrophages of the erythroid islands.
The hematopoiesis now is multilineage and has erythroid
myeloid megakaryocytic and lymphoid precursors.1
Bone Marrow Phase (Table 1)

With hepatocyte proliferation hematopoiesis becomes
restricted in the liver and bone marrow hematopoiesis
begins in the fetal bone marrow by 16th to 18th weeks.
Fetal marrow becomes major site for hematopoiesis by
6th month of gestation. Hematopoiesis is multilineage with
normoblastic maturation. Chief hemoglobin contents are
HbF and HbA. Fetal marrow has dominant erythropoiesis
with M : E ratio at about 1:4.1
CYTOKINE REGULATION OF ONTOGENY

AND HEMATOPOIESIS
Several cytokines play an important role in hema
topoiesis. They are granulocyte colony-stimulating
factor, interleukin (IL)-6, IL-1, IL-4, IL-9, insulin growth
factor-1 and EPO. EPO plays an important role in
erythropoiesis. Loss of EPO/EPO receptor leads to failure
of fetal erythropoiesis causing fetal death. In adults,
EPO provides antiapoptotic and proliferative signals to
erythroid precursors (Fig. 4).1
Fig. 4 The phases of embryonal and fetal hematopoiesis. There is

a considerable overlap and gradual transition from stage to stage1
Transcriptional Regulation of Early

Hematopoietic Development (Fig. 5)
Hematopoietic Cytokines, Transcription

Factors and Lineage Commitment
Close Relation with Endothelium
The endothelium and hematopoietic progenitor cells
share several antigens supporting theory of hemogenic
endothelium or hemangioblasts. They are SCL, GATA-2,
C-kit, AA-4.1, CD34, Flit-3 ligand, Sca-1, VEGFR-1 and -2,
only with the exception of CD45 (Fig. 5).4
Fig. 5 Important transcription factors for primitive and definitive

hematopoiesis are SCL (stem cell leukemia hematopoietic
transcription factor), GATA-2 and Lmo-2. AML-1 is required for
definitive hematopoiesis4
Table 1 Comparison of embryonic, fetal and adult

erythropoiesis3
Transcription factors HoxB4 and Ikaros, activated nuclear

form of Notch1, cell, cycle inhibitor P21, and TGF/BMP4 family members, TNF-a receptor P55 signaling may
be important in the maintenance or promotion of the
hematopoietic stem cell renewal. Adjacent cells stromal
cells, endothelial cells and local cytokines are thought
to play an important role in regulation of HSC cell into
renewal or differentiation. TGF-b1, p21, p27, IL-3, GM-CSF,
BMP-4 and TNF-a are some of the important cytokines
involved.4
Lineages
Stem cell
Erythroid site
Nucleated RBC
a-globulin
b-globulin
Yolk sac
Erythroid
Cycling
Yolk sac
Yes
za1, a2
e
Liver
All
G0
Liver
No
a1, a2
gA, gD
Bone marrow
All
G0
Bone marrow
No
a1, a2
bd
Regulation of Self-renewal and

Differentiation of HSCs
Commitment to Lymphoid and

Myeloid Lineage (Fig. 6)
After 10 to 15 divisions, the descendent cells daughter
cells become fixed towards a single lineage. First cells
are believed to be either common lymphoid precursor
or common myeloid precursor. These have been
differentiated using specific expression patterns.4 It is
believed to be brought about by differential expression of
transcription factors. Several candidate transcriptional
factors differentially expressed in committed cells have been
identified using cDNA library and RT-PCR technologies.4
Fig. 7 Chromosome map of human globin chains9
ONTOGENY OF HEMOGLOBIN
Hemoglobin production switches from embryonic to
fetal hemoglobin at 6 to 7 weeks of gestation and finally
to adult hemoglobin at birth (Fig. 8). This is brought
about of sequential activation of z and e-genes on
chromosomes 16 and 11 respectively. This is unrelated to
site of erythropoiesis (Fig. 7).5 The pattern of expression
of genes occurs in 5 to 3 region as development
Fig. 8 Production of globin chains during the fetal and neonatal

period9
proceeds from embryonic, fetal and then adult life. In

fetus, z and e genes are expressed forming Gower 1,
Gower 2, and Portland hemoglobins and are seen in
yolk sac, para-aortic region and then the liver. Later
2a genes and the 2g genes are expressed forming
hemoglobin F. Later they are downregulated and adult
hemoglobins predominate (Table 2 and Fig. 10).6
Reduction of MCV, erythroblast count and CD 71
count is believed to be due to switch of erythropoiesis from
liver to bone marrow and maturation of hematopoietic
tissues.5
Fig. 6 Transcriptional regulation of common myeloid precursor
(CMP) commitment. CMPs differentiate into either common
precursors for granulocytic and monocytic lineages (GMPs) or
common precursors for both erythroid and megakaryocytic
lineages (EMPs). A separate pathway leading to eosinophils is
shown may be possible
Hemoglobin and Hematocrit Rise

in Fetal Period (Fig. 9)7
It has been determined that hemoglobin concentration
increases by 0.21 g/dL and hematocrit by 0.64
percent each week from 22 weeks to 40 weeks. Thus

reference values of hemoglobin and hematocrit can
be predicted using the formula : hematocrit = 28.59 +
(GA 0.6359) and hemoglobin concentration = 9.92 +
(GA 0.2087) where GA is the gestation age in weeks.

Hematologic values of normal fetuses are described in
Table 3.
Table 2 Hemoglobins in embryo fetus and adult life8

Developmental
phase
Hemoglobin name
Chain composition
Embryo
Portland
z2Gg2
z2Ag2
Gower I
z2e2
Gower II
a2e2
a2Gg2
a2b2
a2b2
A2
a2d2
a2Gg2
a2Ag2
Fetus
a2Ag2
Adult
Fig. 9 Hemoglobin production during the fetal and neonatal

period9
Fig. 10 Relative electrophoretic mobilities on starch gel electrophoresis at pH 86 of human hemoglobin variants10 positions of HbA2
and HbA are marked as red and yellow respectively
2.68
2.74
2.77
2.92
3.12
3.07
16
17
18
19
20
21
2.8
3.09
3.46
3.82
1821
2225
2629
> 30
Reference
2.43
4.46
3.87
3.43
3.22
3.49
3.48
3.19
3.1
2.97
2.89
2.17
3.18
3.05
2.75
2.38
2.65
2.76
2.65
2.44
2.51
2.47
2.69
13.64
12.91
12.20
11.69
12.30
13.0
12.3
12.4
12.4
12.5
10.9
15.85
14.29
13.8
12.96
13.1
14.1
13.5
13.6
13.3
13.2
11.6
+ 2 SD
11.43
11.54
10.6
10.42
11.5
11.9
11.1
11.2
11.5
11.7
10.2
2 S D
Mean
2 SD
Mean
+ 2 SD
Hemoglobin (g/dL)
RBC Count ( 1012/L)
15
Reference
Weeks of
gestation
43.55
40.88
38.59
37.3
37.3
39.3
37.5
37.3
37.4
38.1
34.6
Mean
50.75
45.28
42.53
41.62
40.8
43.4
40.6
41.5
40.2
40.2
38.2
+ 2 SD
Hematocrit (%)
123
126
129
135
137
143
143
131
132
135
146
145
155
151
+ 2 SD
126.46
132.94
142.07
36.35 114.38 123.72
36.48 118.5
34.65 125.1
32.98 131.1
Forestier et al
33.8
35.2
34.4
33.1
34.6
36
31
Millar et al
2 SD Mean
MCV (fL)
Table 3 Hematologic values of normal fetuses
2.7
2.6
2.5
2.4
2.0
2.4
1.6
105.04 6.40
110.54 4.08
117.26 3.73
9.39
4.92
5.9
2.99
3.4
3.8
3.3
3.3
2.8
4.1
2.3
Mean + 2 SD
120.13 2.57
115
120
123
126
129
131
135
2 SD
3.41
3.24
1.56
2.15
1.4
1.7
1.5
1.2
0.7
0.9
2 SD
WBC count corrected (

109/L)
232
242
247
234
223
170
211
192
202
208
190
319
311
306
291
284
230
259
237
227
265
221
145
173
188
177
162
110
163
147
177
151
159
Mean + 2 SD 2 SD
Platelet count ( 109/L)
REFERENCES

1. Proytcheva MA. Issues in neonatal cellular analysis. Am J

Clin Pathol. 2009;131:560-73.
2. Tavian M, Pault B. Embryonic development of the human
hematopoietic System. Int J Dev Biol. 2005;49:243-50.
3. Zon LI. Developmental biology of hematopoiesis. Blood.
1995;86(8):2876-91.
4. Zhu J, Emerson SG. Hematopoietic cytokines, transcription
factors and lineage commitment. Oncogene. 2002;21:3295313.
5. Al-Mufti R, Hambley H, Farzaneh F, et al. Fetal and
embryonic hemoglobins in erythroblasts of chromoso
mally normal and abnormal fetuses at 1040 weeks of
gestation. Hematologica. 2000;85:690-3.
6. Schechter AN. Hemoglobin research and the origins of

molecular medicine. Blood. 2008;112:3927-38.
7. Jopling J,Henry E,Wiedmeier SE,Christensen RD. Reference
ranges for hematocrit and blood hemoglobin concentration
during the neonatal period: Data from a multihospital health
care system. Pediatrics. 2009;123(2):e333-7. Accessed on
pediatrics.aappublications.org, on October 7, 2012.
8. Wood WG, Weatherall DJ. Developmental genetics of the
human haemoglobins. Biochem J. 1983;215:1-10.
9. Ohls RK. Core Concepts: The Biology of Hemoglobin.
Neo Reviews 2011;12:e29-e38. Accessed from http://
neoreviews.aappublications.org/cgi/content/full/
neoreviews;12/1/e29 on 06/04/2011.
10. Huehns ER, Shooter EM. Human haemoglobins. Med
Genet. 1965;2:48.
2
Physiology of Blood Coagulation
Shrimati Shetty
The three major components of blood coagulation are platelet, plasma and the endothelium. The platelets adhere to damaged
endothelium with the help of von Willebrand factor (VWF) and when activated, they aggregate and make a platform for coagulation
factors which then initiate a series of reactions on the damaged blood vessels. The reaction begins with the activation of contact factors
which then results in the sequential activation of these clotting factors, resulting in thrombin generation, which converts fibrinogen to
fibrin clot. A series of inhibitors to these coagulation factors keep them under check to maintain the thrombohaemorrhagic balance.
The most important of these inhibitors are protein C, protein S, antithrombin, tissue factor pathway inhibitor (TFPI) and heparin
cofactor II . The fibrinolytic system has an important role in the removal of clot formed, thus maintaining the hemostatic balance.
Thrombin has both pro- and anticoagulant role in the coagulation cascade and it is thrombomodulin which converts thrombin into an
anticoagulant enzyme by a negative-feedback regulation of its prothrombotic activity through its association with activated protein
C (APC). It also has an important role of linking coagulation with fibrinolysis through thrombin activable fibrinolytic inhibitor (TAFI).
The deficiency of factors in the Kallekrein-kinin system does not result in a bleeding phenotype; have a role in various noncoagulant
functions including apoptosis, proinflammatory and prothrombotic manifestations.
PLATELET ACTIVATION
Upon breach of vasculature, platelets get exposed to
collagen and VWF which facilitate their adhesion to the
subendothelium through GP-1b-V-IX receptors. The
adhesion of the platelets to the subendothelium results
in platelet activation which results in an inside out
signal, causing the exposure of phosphatidyl serine to
the outer surface, which forms catalytic surface for its
procoagulant activities. The activation also results in
secretion of platelet contents along with the exposure
of fibrinogen receptors resulting in platelet aggregation
at the site of injury. Platelets when activated also
trigger the coagulation reaction by providing a catalytic
surface which results in the formation of thrombin.
More than 250 active substances are released into
circulation from the granules present within platelets,
when platelet gets activated. Thrombin further
stimulates platelet activation through G-proteincoupled protease activated receptors (PAR-1 and PAR-
4), resulting in the release of adenosine diphosphate

(ADP) and thromboxane A2 (TXA2).1,2 Thus both
platelet activation and coagulation are interdependent.
Platelets have a wide array of receptors on their surface
which help both in adhesion and aggregation and it
is these receptors which have become the target for
anti-platelet therapies. Platelet aggregation requires
the platelet membrane glycoprotein receptor i.e. GP
IIb-IIIa, which helps in platelet aggregation by binding
to fibrinogen and fibronectin.3 Once the platelets are
activated, they release different types of granules into
the circulation which include ADP, platelet-activating
factor (PAF), VWF, serotonin, TXA2 and platelet factor
4.4 These stimulate and activate more and more platelets
resulting in the primary hemostatic platelet plug at the
site of wound. It is the same nature of the platelets of
showing a quick response to the vascular breach, which
is responsible for myocardial infarction or stroke under
pathological conditions.
Chapter-2 Physiology of Blood Coagulation 11
THEORIES OF BLOOD COAGULATION

Morawitz in 1905 put forward the first theory of blood
coagulation which is also referred as four clotting factor
theory.5 According to this theory, blood clotting is possible
due to the presence of four clotting factors, namely,
thromboplastin, prothrombin, thrombin and calcium.
The thromboplastin gets released on tissue injury which
converts prothrombin to thrombin in the presence of
calcium. Subsequent to the identification of the remaining
coagulation factors, two groups independently put
forward a revised blood coagulation model referred to as
the waterfall cascade model.6,7 According to this model,
all the blood coagulation factors remain in an inactive
state and they get activated by the upstream clotting factor.
The coagulation cascade shows two distinct pathways i.e.
extrinsic pathway initiated by the interaction of tissue
factor (TF) with the circulating serine protease factor
VIIa. This increases the catalytic activity of FVIIa several
fold which then activates factor X to Xa. Similarly in the
intrinsic pathway, there is a sequential activation of factors
XII, XI, IX the activated form of which then activates factor
X to Xa . Thus the two pathways converge into the common
pathway by the activation of FX to FXa which then binds
to FVa to form prothrombinase, which rapidly converts
prothrombin to thrombin. Calcium and phospholipids
are required for these sequential activation of coagulation
factors. Both extrinsic and intrinsic pathways cannot
work independent of each other as deficiencies of any
of these factors in either of the two pathways (excluding
contact factors and factor XII) can lead to lifelong bleeding
tendency (Flow chart 1).
Cell Based Model of Blood Coagulation

Though the waterfall hypothesis of blood coagulation
has expanded our understanding of blood coagulation,
more recent observations demonstrate that the cascade/
waterfall hypothesis does not fully simulate the in vivo
hemostasis. The cascade model of blood coagulation
highlights the importance of coagulation factors in the
generation of thrombin and overall hemostasis and the
role of cells is only to provide phospholipids surface for
the coagulation factors to generate thrombin. The cell
based model of coagulation shows the significance of cells
in coagulation. While the extrinsic pathway is initiated on
the TF bearing cells the intrinsic pathway takes place on
the platelets. The contact factors and factor XII are not
included in the cell based model of coagulation as the
deficiency of these factors does not result in bleeding.8-11
According to this model coagulation takes place in 3
phases i.e. initiation phase, amplification phase and
propagation phase.
Flow chart 1 The coagulation cascade
Initiation Phase
This phase begins with TF bearing cells and is referred
to as the extrinsic pathway. TF binds to activated FVII
(FVIIa) which in turn activates factor IX to Fix factor X
to Xa. Subsequently FXa activates FV to FVa forming
the prothrombinase complex on TF bearing cells.
The dissociation of FXa from these TF bearing cells is
prevented by inhibitors like antithrombin and tissue
factor inhibitor (TFPI). The FV can either come from
activated platelets at the sites of injury or from plasma,
both of which can be activated by factor Xa.12 When
present on the TF bearing cells FXa is resistant to its
inhibitor i.e. antithrombin. It has also been reported that
some amount of FVIIa remains bound to TF even in the
absence of injury thus facilitating mild activation of FX
and FV all the time.13
Amplification Phase
The amplification phase involves the activation of platelets
by the initial thrombin generated on the TF bearing cells.
Besides thrombin also activates coagulation factors V, VIII
and XI on the platelet surface resulting in small amounts
of thrombin on the platelet surface.14
Propagation Phase
This phase takes place on the surface of activated platelets.
FIXa produced during the first step binds to FVIIIa to
activate FX to FXa (Tenase complex). FXa then activates
FV to FVa which then activates prothrombin to result in
thrombin burst (prothrombinase complex). As more
and more platelets are recruited to the site of injury, the
thrombin generation gets amplified several fold resulting
in a thrombin burst which then acts upon fibrinogen to
form fibrin. The fibrin clot also consists of erythrocytes,
leukocytes and platelets which are held together by fibrin
chains. The thrombin activated FXIII then cross links these
fibrin chains to form a firm fibrin clot.
The Kallekrein-Kinin System

The Kallekrein-kinin system consists of 3 factors:
prekallekrein (PK), high molecular weight kininogen
(HMWK) and factor XII (FXII). Their role in the initiation
of the intrinsic pathway of coagulation is still not clear
as FXII can get autoactivated even in the absence of
prekallekrein.15 The deficiency of any of these factors does
not result in bleeding phenotype. Though the absence
of these factors prolongs the in vitro investigations like
activated partial thromboplastin time (APTT), their
physiological significance in hemostasis is unclear.
Recently there are several reports to support their role
in thrombosis.16 A polymorphism in FXII i.e. 46C/T has
shown strong association with arterial thrombosis.17 The
homozygous carriers of this polymorphism were found
to have reduced FXII levels which in turn will result in
reduced fibrinolytic activity, thus being implicated in
thrombosis.
FXIIa also activates FXI to FXIa which then activates
FIX to Fix. FXIa along with PK also releases bradykinin, the
proinflammatory factor from HMWK.18
COAGULATION PROTEASES AND

COFACTORS
Biochemically, coagulation factors can be classified into
two groups i.e. serine proteasesFVII, FIX, FX, FXI and
cofactors-FVIII and FV. The two main cofactors required
in most of the steps in blood coagulation including the
formation of tenase and prothrombinase complexes
are phospholipids and calcium. Calcium also has an
important role of binding the coagulation factors to the
platelet membrane.19
Vitamin K is an important cofactor for coagulation
factors which require post translational modification i.e.
gamma carboxylation of their glutamic residues which is
important for their efficient functioning (factors II, VII,
IX, X and their inhibitors i.e. protein C, protein S and
protein Z). Two enzymes take part in these processes

vitamin K epoxide reductase (VKORC1) and gamma
carboxylase (GGCX). The gamma carboxylase enzyme
adds the gamma carboxyl group to the glutamate residues
during which Vitamin K epoxide gets reduced. The
VKORC1 enzyme converts it into its active form. The
gamma carboxylation is required for an effective binding
of these serine proteases to the phospholipid surfaces.
Blood Coagulation Inhibitors

Blood coagulation inhibitors as well as fibrinolytic
inhibitors neutralize the coagulant or fibrinolytic proteins
to prevent excessive thrombosis or hemorrhage . The major
anticoagulant pathway is the protein C anticoagulant
pathway in which both FVIIIa and FVa required for tenase
and prothrombinase complex formation get neutralized.
Protein C shows a very high homology to all the remaining
vitamin K dependant clotting factors. Protein C shows
a very high homology to all the remaining vitamin K
dependant clotting factors. Protein S is an important
cofactor for activated protein C (APC) in its anticoagulant
action on FVa and FVIIIa. A mutation at Arg 506 in factor
V gene factor V Leiden) makes it resistant to APC cleavage.
Homozygotes for this mutation show 20-30 fold increased
risk of thrombosis.20 As the concentration of thrombin
increases it binds to another protein i.e. thrombomodulin
which then activates the inactive protein C to its activated
form. The APC inactivation by thrombin-thrombomodulin
complex takes place on the surface of endothelial cells
, where the APC is bound by a receptor i.e. endothelial
protein C receptor (EPCR).
Though protein S has initially been reported as a
cofactor for APC in neutralizing FVIIIa and FVa, studies
have shown that PS can independently neutralize these
factors.21 This is possible because PS generally remains
combined to C4BP protein. Besides, PS also has inhibitory
action against FXa by facilitating the interaction of FXa
with TFPI.22 It has also been reported that FV acts as a
cofactor in the inactivation of FVa by APC and PS.23
Antithrombin is another strong inhibitor which
inactivates both FXa and thrombin, besides its inhibitory
action against IXa, XIa and XIIa along with some of the
factors in the fibrinolytic pathway. The activity of AT is
increased several fold in the presence of heparin. Though
rare, AT deficiency leads to one of the most severe form
of thrombophilia. Heparin cofactor II is another inhibitor
of thrombin. Protein Z is another inhibitor which is an
inhibitor of FXa.
The major inhibitor of tissue factor is tissue factor
pathway inhibitor (TFPI) which is expressed on the
endothelial cells. The extrinsic pathway involving the
activation of X to Xa gets inhibited and there is a shift in the
Chapter-2 Physiology of Blood Coagulation 13

balance towards the intrinsic pathway of coagulation. TFPI
inhibits both TF-VIIa complex and FXa. Thus the initial
phase of extrinsic pathway is inhibited. However once
Xa takes part in the prothrombinase complex, it becomes
resistant to the action of TFPI. Various strategies have
been used to use inhibitors of TFPI as a novel therapeutic
protocol for haemophilia.24
FIBRINOLYTIC PATHWAY
Fibrinolytic pathway plays an important role in main
taining the thrombohaemorrhagic balance. A bleeding
tendency is seen in patients with hyperfibrinolysis, and
hypofibrinolysis is often accompanied with thrombosis.
The major fibrinolytic proteases are plasmin which
dissolves fibrin and the two plasminogen activators
i.e. tissue plasminogen activator (tPA) and urokinase
(uK). One of the important regulators of fibrinolysis
is thrombomodulin as it converts thrombin not only
to an anticoagulant enzyme but also to a inhibitor of
fibrinolysis by activating TAFI.. Fibrinolytic activity is also
controlled by inhibitors of fibrinolysis like plasminogen
activator inhibitor 1, alpha 2 antiplasmin, thrombin
activatable fibrinolysis inhibitor, plasminogen activator
inhibitor 2, alpha 2 macroglobulin. Thrombin-activable
fibrinolysis inhibitor (TAFI) is a fibrinolytic inhibitor
with carboxypeptidase activity and it neutralizes the lysis
of fibrin clots by removal of the carboxyl-terminal lysine
residues from fibrin.25
Platelet Interaction with Coagulant and

Anticoagulant Factors
It is now well known that platelets provide the phospha
tidyl serine surface for the tenase and prothrombinase
reactions to take place due the high affinity of PS
membranes to these coagulant proteins. The only vitamin
K protein which binds through receptors is thrombin
i.e. through PAR1 and PAR4 receptors on the surface of
the platelets. But besides this, platelets also have other
important functions in coagulation. Platelets have the most
important receptor for fibrinogen i.e a2bb3, the congenital
absence of which results in a platelet aggregation defect
termed as Glanzmann thrombasthenia. Though TF has
been found only in small concentrations on the platelets,
its inhibitor, TFPI has been found in high concentrations.26
Similarly, about 20% of FV in the plasma comes from
platelets which when activated comes out of the platelets
to take part in the prothrombinase complex.27 Whether
there exists any difference between the plasma FV and
platelet FV is not clear. Similarly FVIIa is known to bind
platelets via GP 1b-V-IX receptor. Besides FVIIIa and FIXa
also bind the phosphatidyl serine membrane facilitating
the formation of tenase complex. The binding of FXIa and

FXIIa to the platelet surface however is not clear. Among
the anticoagulant proteins both PC, PS and TFPI can bind
to the platelet surface to neutralize the corresponding
proteins. Thus platelets have a important role in blood
coagulation.
REFERENCES
1.
Mackman N. Triggers, targets and treatments for
thrombosis. Nature. 2008;451:9148.
2. Kahn ML, Zheng YW, Huang W, et al. A dual thrombin
receptor system for platelet activation. Nature.
1998;394:6904.
3. Wu YP, Vink T, Schiphorst M, et al. Platelet thrombus
formation on collagen at high shear rates is mediated by
von Willebrand factor-glycoprotein Ib interaction and
inhibited by von Willebrand factor-glycoprotein IIb/IIIa
interaction. Arterioscler Thromb Vasc Biol. 2000;20:16617.
4. FitzGerald GA. Mechanisms of platelet activation:
thromboxane A2 as an amplifying signal for other agonists.
Am J Correct. 1991;68:11B5B.
5. Riddel JP Jr, Aouizerat BE, Miaskowski C, et al. Theories of
blood coagulation. J Pediatr Oncol Nurs. 2007;24:12331.
6. Davie EW, Ratnoff OD. Waterfall sequence for intrinsic
blood clotting. Science. 1964;145:13102.
7. Macfarlane RG. An enzyme cascade in the blood clotting
mechanism, and its function as a biochemical amplifier.
Nature. 1964;202:4989.
8. Monroe DM, Roberts HR, Hoffman M. Platelet
procoagulant complex assembly in a tissue factor-initiated
system. Br J Haematol. 1994;88:36471.
9. Monroe DM, Hoffman M, Roberts HR. Transmission of
a procoagulant signal from tissue factor-bearing cell to
platelets. Blood Coagul Fibrinolysis. 1996;7:45964.
10. Kjalke M, Oliver JA, Monroe DM, et al. The effect of
active site-inhibited factor VIIa on tissue factor-initiated
coagulation using platelets before and after aspirin
administration. Thromb Haemost. 1997;78:12028.
11. Hoffman M1, Monroe DM 3rd. A cell-based model of
hemostasis. Thromb Haemost. 2001;85(6):958-65.
12. Briede JJ, Heemskerk JW, vant Veer C, et al. Contribution
of platelet-derived factor Va to thrombin generation on
immobilized collagen- and fibrinogen-adherent platelets.
Thromb Haemost. 2001;85:50913.
13. Bauer KA, Kass BL, ten Cate H, et al. Detection of factor X
activation in humans. Blood. 1989;74:200715.
14. Alberio L, Dale GL. Review article: platelet-collagen
interactions: membrane receptors and intracellular
signalling pathways. Eur J Clin Invest. 1999;29:106676.
15. Gailani D, Renne T. The intrinsic pathway of coagulation:
a target for treating thromboembolic disease. J Thromb
Haemost. 2007;5:110612.
16. Shariat-Madar Z, Mahdi F, Warnock M, et al. Bradykinin
B2 receptor knockout mice are protected from thrombosis
by increased nitric oxide and prostacyclin. Blood.
2006;108:1929.
17. Soria JM, Almasy L, Souto JC, et al. A quantitative-trait
locus in the human factor XII gene influences both plasma
factor XII levels and susceptibility to thrombotic disease.
Am J Hum Genet. 2002;70:56774.
18. Mller F, Renne T. Novel roles for factor XII-driven
plasma contact activation system. Curr Opin Hematol.
2008;15:51621.
19. Jackson CM, Nemerson Y. Blood coagulation. Annu Rev
Biochem. 1980;49:765-811.
20. Dahlbck B. New molecular insights into the genetics of
thrombophilia. Resistance to activated protein C caused
by Arg506 to Gln mutation in factor V as a pathogenic
risk factor for venous thrombosis. Thromb Haemost.
1995;74(1):139-48.
21. Maurissen LF, Thomassen MC, Nicolaes GA, et al. Reevaluation of the role of the protein S-C4b binding protein
complex in activated protein C-catalyzed factor Vainactivation. Blood. 2008;111:303441.
22. Heeb MJ, Mesters RM, Tans G,et al. Binding of protein S
to factor Va associated with inhibition of prothrombinase
that is independent of activated protein C. J Biol Chem.

1993;268:28727.
23. Nicolaes GA, Dahlback B. Factor V and thrombotic disease:
description of a janus-faced protein. Arterioscler Thromb
Vasc Biol. 2002;22:5308.
24. Shetty S, Ghosh K. Novel therapeutic approaches for
haemophilia. Haemophilia. 2014 Dec 18. doi: 10.1111/
hae.12615.
25. Boffa MB1, Nesheim ME, Koschinsky ML. Thrombin
activable fibrinolysis inhibitor (TAFI): molecular genetics
of an emerging potential risk factor for thrombotic
disorders. Curr Drug Targets Cardiovasc Haematol Disord.
2001;1:59-74.
26. Maroney SA, Cooley BC, Ferrel JP, et al. Murine
hematopoietic cell tissue factor pathway inhibitor
limits thrombus growth. Arterioscler Thromb Vasc Biol.
2011;31:8216.
27. Gould WR, Silveira JR, Tracy PB. Unique in vivo
modifications of coagulation factor V produce a physically
and functionally distinctplatelet-derived cofactor. J Biol
Chem. 2004;279:238393.
3
Structure, Function and
Physiology of Platelets
Platelets are one of the formed elements of blood. These are anucleate, disc-shaped cells 2 to 4 m in diameter and are present in blood
at a conc. 1,50,000 to 4,50,000/mL. The function of platelets is to bring about primary hemostasis and localize the active coagulant
enzymes which develop by a cascade of reactions from inert procoagulant precursors at the site of tissue injury. Platelets admirably
performs this job and when somebody gets severe thrombocytopenia (<10,000/mL) or, inherited or acquired platelet defects, their
silent but admirable function becomes apparent in the form of microcapillary or more serious cerebral bleeding and on the other
extreme, when their function is overdone various types of thrombosis may be the end result.
Platelets are produced from megakaryocytes in bone marrow. Megakaryocytes are naturally occurring giant cells where ploidy
value can reach up to 128N, but modal ploidy value for megakaryocytes are 16N to 32N. Megakaryocytes are produced from their
precursor progenitor cells by extensive proliferation and endoreduplication of the nuclei. A specific growth factor, thrombopoietin,
acts on committed megakaryocyte precursors by acting on c-MPL (CD110) receptor and can produce large number of megakaryocytes
and platelets.1 Presently nonpeptide analogs of thrombopoietin are available (eltrombopag) and are being used for various causes of
thrombocytopenia.
Human hemopoiesis being extravascular, the megakar

yocytes once matured, produce very long pseudopod
like structures through depolymerization of cellular
microtubules and microfilaments. These structures are
called proplatelets. Eventually, these proplatelets throw
off platelets through the endothelial gaps in the marrow
sinusoids.
ball with small surface projections. These projections

become irregular and longer when platelets are activated
(Fig. 2A).2
STRUCTURE AND ULTRASTRUCTURE

OF PLATELETS
In a well-stained blood film made from EDTA anticoagu
lated blood and stained with Romanowskys stain,
platelets appear as single 2 to 4 m anucleate cells which
are purple in color. These cells have granules in the
center (Chromomere) and denser peripheral nongranular
hyalomere (Fig. 1). If the blood smear is made directly from
fingerprick then the platelets are found in small and large
aggregates. Occasionally, the platelets can form satellites
around neutrophils (Satellitism) due to EDTA dependent
cold antibody present in some of the blood samples. Under
scanning electron microscope, platelets appear as a small
Fig. 1 Peripheral blood showing platelet clumping
B
Figs 2A and B SEM images of platelets adhered onto topographically structured polymethylmethacrylate (PMMA) surfaces
Transmission electron microscope shows detailed

cyto- architecture of platelets (Fig. 2B). It has a trilaminar
cell membrane, of which outermost layer is carbohydrate
rich and it invaginates the whole cell as surface canalicular
system, thus enormously increasing the surface area of the
cell membrane on which various glycoprotein receptors
are located. Platelets can also secrete a large number
of peptides and active chemicals and ions into this
canalicular system. Under the cell membrane of platelets
the myosin heavy chain, actin and other tubular proteins
are arranged in parallel array.
In the cytoplasm of platelet, (1) Dense Granule (called
delta granule), (2) Alpha granule, and (3) Lysosomes and
mitochondria are seen. Alpha and Delta granule contains
large number of peptides and other chemicals (Table 1).
These chemicals are responsible for various platelet func
tions. Some of the chemicals such as 5-hydroxytryptamine
(5HT) and peptides are absorbed by the platelets from
plasma. While some of the proteins and chemicals are
synthesized internally.3
Table 1 Platelet granules and their contents4
a granules
Dense granules
Lysosomes
PDGF
ATP
Acid hydrolases
TGF-b
ADP
CTAPIII
GTP
PF4
GDP
TSP
Serotonin
Fibronectin
Calcium
Fibrinogen
Magnesium
Vitronectin
vWF
Albumin
FV, FVIII
Protein S
PAI-1
HMWK
C1 inhibitor
Function of Platelets
Platelets main function is its involvement in primary
hemostasis, and in addition through release of growth
factors such as platelet derived growth factor, platelets also
help in wound healing. Hemostatic function of platelet
takes place in the following stages. Each of the stage is possible
through enactment of a series of biochemical reactions
involving ligand-receptor interaction, signal transduction,
release of cations like Ca2+ and active chemicals and
peptides, reverse signal transduction leading to changes
in receptor conformation and further reinforcement of
interaction and finally activation of coagulation cascade on
the surface of the platelet membrane, largely localizing the
clot at the site of tissue injury.5
Platelet function can be envisioned to take place
in vivo as:
Adhesion to injured capillary endothelium and subendothelium
Shape change, aggregation and secretion
Further aggregation and activation of coagulation.
Adhesion to Injured Capillary Endothelium

and Subendothelium
With this reaction, platelets are initially activated to adhere
to the collagen of capillary/vascular endothelium at the site
of the injury. Adhesion reaction is initiated by interaction
of Glycoprotein Ib/IX on the platelet membrane with
activated von Willebrand factor (Activated by shear stress
at the site of injury) and collagen in the injured vessel.
The interaction is strengthened by interactions of platelet
receptor Glycoprotein IIb/IIIa with fibrinogen.6,7
Shape Change, Aggregation and Secretion

At the site of tissue injury several platelet agonists are
released in small amounts, i.e. Thrombin, ADP, ATPase,
etc. Injury to the endothelium also exposes subendothelial
collagen which is an aggregation promoting ligand for
platelets. Small amounts of ADP from surrounding tissue
Chapter-3 Structure, Function and Physiology of Platelets 17

(red cells) cause platelets to change its shape through
contraction of microtubules and microfilaments. This
leads to appearance of pseudopodia like structures,
centralization of granules. As the process continues and
platelets are activated through activated von Willebrand
factor and fibrinogen via its GP Ib/IX and GP IIb/IIIa
receptors, a graded amount of secretion takes place
leading to release of ATP, ADP, 5HT from dense granules,
and various peptides involved in coagulation, fibrinolysis,
wound healing from alpha granules. This causes initial
weak aggregation reaction between platelets into a strong
irreversible aggregation of adhered platelets at the site
of tissue injury. Platelets also activates production of
Thromboxane A2 during its initial activation and this is
another pathway through which platelets are activated
and this pathway can be inhibited by drugs like aspirin,
which inhibits the enzyme cyclo-oxygenase irreversibly
preventing the entry of arachidonic acid into prostaglandin

synthesis pathway. Normally, healthy endothelium
produces many antiaggregatory and anticoagulant sub
stances. One such antiaggregatory substance is called
prostacyclin. When endothelial cells are damaged,
postacyclin production is reduced or stopped and this
leads proaggregatory thromboxane A2 to take the upper
hand. Healthy endo
thelium also produces anti-aggre
gatory nitric oxide and anti-coagulant heparin.3-7
With mild stimulus, dense granule products are
released and with stronger stimulus alpha granules and
finally acid hydrolases from lysosome are released.
Further Aggregation and Activation of Coagulation

As the reinforcement of adhesion and aggregation conti
nues at the site to tissue injury, the liquid phase of blood
Figs 3A to E Platelet aggregometry (A) Born principle, (B) ADP-induced platelet aggregation, (C) Collagen-induced platelet
aggregation, (D) Ristocetin-induced platelet aggregation, and (E) Arachidonic aggregation acid-induced platelet aggregation
coagulation is also activated. Initial liberation of tissue
thromboplastin produces a small amount of thrombin.
This thrombin and some ADP from tissue (mainly red
cells) initiate platelet activation. As part of activation
of platelets, the platelets change the nature of exposed
phospholipids on its surface membrane which in resting

state is electroneutral or slightly electropositive. Activation
causes the inner membrane phospholipids of platelet
to express outside. This phospholipid which is largely
phosphotidyl serine is electronegative and supports on it
A
Fig. 4A Platelet flow cytometry: Normal platelet rich plasma (PRP) sample
Chapter-3 Structure, Function and Physiology of Platelets 19
Fig. 4B Platelet rich plasma (PRP) of Glanzmanns thrombasthenia sample
the assembly of Tenase complex (Factor IXa, factor VIIIa,

calcium and phospholipids) and prothrombinase complex
(Factor Va, Xa and prothrombin). These complexes
ultimately produce explosive amount of thrombin locally
and strengthens locally adhered and aggregated platelets
by a blood clot.8
With passage of time, this aggregated platelet along
with clot, contracts through platelets actin-myosin
machinery and the clot is consolidated.
In the Born aggregometer, PRP is stirred in a cuvette
at 37C and the cuvette sits between a light course and a
photocell. When an agonist is added the platelets aggregate

and absorb less light and so the transmission increases and
this is detected by the photocell.
All the facets of platelet function can be investigated
in the laboratory by using platelet aggregometry (Figs
3A to E). Glycoprotein antigen expression and activation
on platelet surface can be quantitatied and visualized
by platelet flow cytometry (Figs 4A and B). Retraction of
platelets can be tested simply in the coagulation laboratory
by testing the changes in the volume of blood clot after it
has been incubated for 2 hours at 37C. Ultra-structural
Fig. 5 Schematic diagram of the platelet activation showing the major receptors and effectors.6-8 Biochemistry of platelet activation
(expert review of cardiovascular therapy)
study of platelets can show presence or absence of various

granules or granular contents. Secretory functions of
platelets can be tested by either seeing 3H labeled 5 HT
release or by quantitation of ADP and ATP release by
Chemiluminescence assays.
Platelets are biochemical dynamos. Activation of
platelets leading to its final aggregation and adhesive
state relates to complex chemical interaction of ligands
and agonists in vivo. A large part of such reactions are still
unknown and is being continuously elucidated.
But what we already know is substantial (Fig. 5) and
several reactions of this pathway are already exploited in
therapy and are useful in understanding hereditary and
acquired platelet dysfunction.
To summarize, platelets are of utmost importance
in the hemostatic system for the formation of primary
hemostatic plug. The granule secretions help recruit more
platelets to the primary plug, which eventually provides a
surface on which the secondary hemostatic system forms
a sturdy clot. The ruptured endothelium gradually repairs
itself and the vessel wall structure is restored. Dysfunction
of these processes and systems may lead to inherited or
acquired platelet function distorders.
REFERENCES
1. Saur Sebastian J, Sangkhae Veena, Geddis Amy E,
Kaushansky Kenneth, Hitchcock Ian S. Ubiquitination and
degradation of the thrombopoietin receptor c-Mpl. Blood.

2010;(115)6:1254-63.
2. Minelli C, Kikuta A, Tsud N, Ball MD, Yamamoto A. A
microfluidic study of whole blood behaviour on PMMA
topographical nanostructures. J Nanobiotechnology.
2008;6:3.
3. Orr MW, Boullin DJ. The relationship between changes
in 5-HT induced platelet aggregation and clinical state in
patients treated with Fluphenazine. Br J Clin Pharmacol.
1976;3(5):925-8.
4. Rendu F, Brohard-Bohn B. The platelet release reaction:
granules constituents, secretion and functions. Platelets.
2001;12(5):261-73.
5. Holmsen H. Physiological functions of platelets. Ann Med.
1989;21(1):23-30.
6. Jurk K, Kehrel BE. Platelets: physiology and biochemistry.
Semin Thromb Hemost. 2005;31(4):381-92.
7. Aslan JE, Itakura A, Gertz JM, McCarty OJ. Platelet shape
change and spreading. Methods Mol Biol. 2012;788:91100.
8. Heemskerk Johan WM, Bevers Edouard M, Lindhout
Theo. Platelet activation and Blood coagulation. Thromb
Haemost. 2002;88:186-93.
BIBLIOGRAPHY
1. Sharathkumar Anjali A, Shapiro Amy. Platelet function
disorders, 2nd edn. Indianapolis Hemophilia and
Thrombosis Center, Indianapolis, USA World Federation
of Hemophilia (WFH), 2008.
Neonatal Hematology
CHAPTERS OUTLINE
4.

Variation in the RBC Parameters in the Newborn

5.

Physiological Anemia of Newborn, Anemia of Prematurity and Role

of Erythropoietin in the Management
6.

Effect of Maternal Iron Status on Placenta, Fetus and Newborn

7.

Developmental Aspects of Hemostasis in the Fetus and Newborn

8.

Anemia in the Newborn

Jayashree Mondkar, Shilpa Borse, MR Lokeshwar
9.

Polycythemia and Hyperviscosity Syndrome

10. Vitamin K Deficiency: Bleeding in Newborns

11. Bleeding Neonate: Approach and Management

12. Approach to Neonatal Thrombocytopenia

Nitin K Shah
4
Variation in the RBC
Parameters in the Newborn
The fetal and neonatal period is a most dynamic phase,

as during this period there occur profound alterations
and adjustments, especially during transit of fetus
from dependent hypoxic, intrauterine lifeto totally
independent extrauterine existence. Erythrocytic system
undergoes serial adaptation to meet progressively
changing demands of oxygen in embryo, fetus and
neonate.
Hematology of newborn, remains a concern even
today, not only because of unique blood picture during this
period and normal variation in hematological parameters
but also in no other period of life is anemia known to occur
due to such varied causes.
Although the fetus is nourished and protected by the
mother during this period, fetus may suffer adverse effects
related to maternal malnutrition, illnesses, infections,
drug ingestions, etc.
Moreover, the proximity of two circulatory systems
(mother and the baby) also permit the free passage of
formed blood elements between mother and fetus as
seen in fetomaternal hemorrhage leading to anemia and
sensitization to RBC antigens. Also maternofetal hemorrhage
may occur, leading to hyperviscosity syndrome.
NORMAL HEMATOLOGICAL VALUES

IN THE NEWBORN
Hemoglobin
Various authors have reported values for the normal mean
hemoglobin concentration of the cord blood ranging from
15.7 to 17.9 gm% (Table 1). Approximately, 95 percent of
all values fall between 13.7 and 20.1 g/dL1,3,5-11
Table 1 Hemoglobin concentration of cord blood3

Mean g/dL
Hb g/dL range
16.6
Dochain et al. (1952)
17.9
14.4 21.6
Walker et al. (1953)7
16.5
Marks et al. (1955)8
16.9
12.3 22
Guest et al. (1957)
17.1
13.6 25
15.7
Dalal and Lokeshwar
16.2
13.2 22
Rama Rao11
15.13
14.16 3.26
Mollison (1951)
5
6
Sturgeon (1956)
10
3
Shortly after birth the Hb concentration increases by

as much as 2.5 to 6 gm%/dL depending on the amount of
placental transfusion. The redistribution of body fluids
with decrease in plasma volume after birth also accounts
for this rise. Failure of hemoglobin to rise during this
period is a marker of blood loss.
Hemoglobin levels return to cord blood values by the
end of the first week.
A significant Hb decrease during this time even if
absolute values of Hb are within the normal range is
also suggestive of hemorrhage or hemolysis.
During first several hours after birth, there is increase
in Hb concentration. Hb increases by 17 to 20 percent of
the initial level in the first 24 hours of life but then falls
slightly during the next 24 hours.3,19,25
At the end of the first week of life, the Hb concentration
is as high as it was in the cord blood.
24Section-2Neonatal Hematology
Anemia
Anemia during the first week of life is defined as a
hemoglobin value less than 14 g/dL.
Beyond the first week of life many factors influence
what is considered as normal hematological parameters
in newborn period. Naiman and Oskin,1 Mollison et al,5,31
Lokeshwar et al.3 and others10,12,13,15 have suggested that
13.5 g/dL be considered as lowest normal value for
cord blood Hb. Most authorities suggest that an Hb
concentration of 13.5 g/dL in cord blood be considered
as the lower limit of normal. Hb value for umbilical artery
blood tend to be about 0.5 g/dL higher than sample
obtained from umbilical vein.8
In a study (Lokeshwar et al.) of 100 newborn babies,
only 2 percent of neonates had Hb level less than 13 gm%
in cord blood.2,3
Hb concentration decreases in both term and preterm
infants to reach minimal levels of 9.4 to 14.5 g/dL in term
infants by 7 to 9 weeks of age. This physiological anemia
occurs because of a decline in erythrocyte mass due to the
following reasons:
In utero the fetal oxygen saturation is low at around
45 percent, erythropoietin levels are high and RBC
production is rapid. Reticulocyte counts are 3 to 7
percent reflecting erythropoiesis.
With improved oxygen saturation to 95 percent after
birth, the erythropoietin levels become undetectable
hence RBC production stops, reticulocyte counts are
low and the hemoglobin level falls.
This factor coupled with a reduced life span of fetal
RBCs results in anemia that is not a functional one as
oxygen delivery to the tissue is adequate as the levels of
Hb A and 2,3DPG increased.
At 8 to 12 weeks, hemoglobin levels reach their nadir
(Tables 2 and 3), oxygen delivery to the tissues is
impaired, erythropoietin production is stimulated and
hemoglobin starts increasing. The hemoglobin and
RBC count fall earlier and to a greater extent in preterm
infants leading to anemia of prematurity.
Table 2 Hematological parameters in the full term normal infant

studied at LTMG Hospital, Mumbai3
Hb (g%)
Hematocrit (%)
RBC (million/mm3)
16.2 3.6
46.66 5.1
4.9 1.2
1218 hours 18.79 2.8
49 4.8
5.3 0.8
72 hours
17.38 3.0
46.9 5.3
5.2 0.6
15 days
16.36 2.2
43.4 4.1
5.01 0.9
28 days
14.17 2.4
42.1 3.8
4.7 1.0
Cord blood
Table 3 MCV, MCH, MCHC and normoblast count in the full term
normal infant studied at LTMG Hospital, Mumbai3
MCV (fL)
MCH (Pg)
MCHC (%) Normoblasts

(cells/mm3)
Cord blood 113.04 5.3 34.33 1.4 33.9 0.8 600 186
1218 hours 108.96 5
35.1 1.9
34.4 0.6 283 122
72 hours
98.54 2.9
35.82 0.8 34.9 0.5 36 48
7 days
96.0 3.4
34.0 1.0
34.6 0.8
15 days
95.5 4.0
33.2 9.0
34.54 0.5
28 days
96.1 3.2
31.6 0.93 34.2 0.7
Table 4 Normal hematological values during the first-two

weeks of life in the term infants1
Value
Cord blood
Day 1
Day 3
Day 7
Day 14
Hb g/dL
16.8
18.4
17.8
17.0
16.8
Hematocrit (%)
53.0
58.0
55.0
54.0
52.0
Red cells (mm3)
5.25
5.8
5.6
5.2
5.1
MCV (fL)
107
108
99.0
98.0
96.0
MCH (Pg)
34
35
33
32.5
31.5
MCHC (g/dL)
31.7
32.5
33
33
33
Reticulocytes
37
37
13
01
01
Nucleated RBCs 500
200
05
Blood Volume
Immediately after birth, the blood volume of term
infants may range from 50 to 100 mL/kg, with mean of
85 mL/kg.4,5,7 If cord clamping is done early for instance
at 30 minutes of age, blood volume is 78 mL/kg as
compared to 98.6 mL/kg in case of delayed cord clamping.
By 72 hours, this difference in blood volume decreases.
The blood volume of premature infants ranges from
89 to 105 mL/kg during first few days of life (Table 4).6,7
This is mainly because of increase in plasma volume, with
the total RBC volume per kg of body weight being the same
to that of term infants.
By 1 month of age, this value remains at 73 to 77 mL/kg.
Newborns with tight cord around neck and with hyaline
membrane disease have low blood volume and those born
after late intrauterine asphyxia have higher blood volume.
Hematocrit
Normal values of hematocrit ranges from mean of 51.3 to
56 percent.1,3,13,20 Just as Hb value, hematocrit value also
Chapter-4 Variation in the RBC Parameters in the Newborn 25

shows increase during first few hours of life and reaches
original value of cord blood by one week and mean
capillary hemotocrit value is two percentage point higher
than the mean venous hematocrit value at one week age.
Gatti et al.16 reported capillary hematocrit on first
day of life to be 62.9 3.2 percent reaching 56.6 2.6 by
day 7 and 53.7 2.5 percent by day 10, whereas Guest
and Brown17 recorded mean cord blood hematocrit of
52.3 percent and 58.2 percent on first day, 54.31 percent
on 3rd day and 54.9 percent on 7th day. Mean capillary
hematocrit value is two percentage points higher than the
mean venous hematocrit values1 at 1 week of age.
RED CELL COUNT AND RED CELL INDICES7,8

Red Blood Cell Count
Red blood cell count also shows a great variability at
the time of birth and ranges from 4.6 to 5.2 million/
cumm.1,3,8,9,18
Our study of 100 newborn babies2,3 showed red blood
cell count in cord blood 4.9 1.2 million/cmm reaching
5.3 0.8 million/cmm after 12 to 18 hours and 5 1.12
million/cmm at 7th day and stabilizing at same level
thereafter throughout the neonatal period. Other studies
also have reported similar changes in red blood cell
count.1,8,9,18
Mean Corpuscular Volume7,21-24

Newborn red cells are generally much larger than adults
and average diameter of RBC is 8.5 to 9.3 cumm at birth
reaching the adult value of 7.5 Cu around 6 months of
age.19-21 Relative macrocytosis is observed in the newborn
period. Mean corpuscular volume (MCV) at birth ranges
from 104 to 118 fL. Compared to normal adult value of
82 to 92 fL. Mean corpuscular volume rapidly decreases
in first week of life and at the age of 2 months, cell size is
comparable to those in adult cells.7,21-24
MCV values less than 92 fL should strongly suggest
alpha thalassemia trait or iron deficiency. MCV is higher
in preterm infants 115 5 fL1,30 and decline to mean value
of 95 5 by 7th week of life.31
MCH is also increased in newborn period, values
ranging from 33.5 to 41.4 Pg as compared to adult values
of 27 to 31 Pg.1,3 However, MCHC in the newborn period is
quite similar to that in adult ranging from 30 to 35 percent
in newborn and 30 to 36 percent in adults.1,3
Reticulocyte Count and Nucleated RBC1,3,14,19,30

Average reticulocyte count at birth ranges from 1.6 to
6.2 percent, infants born prematurely have higher retic
Fig. 1 Normocytic normochromic RBC in newborn
counts, with values ranging between 6 and 16 percent in

infants born between 30th and 34th week (Fig. 2).
Term infants have an average 7.3 nucleated RBC/100
WBC with normal range of 0 to 24 at birth.
Infants born prematurely have higher retic count with
values ranging between 6 and 16 percent in infants born
between 30 and 36 weeks of gestation.
This increased retic count in first 2 to 3 days of life
reflects very active erythropoiesis during newborn period
and value drops to about 1 percent by 7th day of life.1,17,26,27,29
Persistent reticulocytosis in cord blood suggests
Hemolytic process1
Hypoxia
Blood loss.
The term infant has approximately 500 nucleated
RBCs/cm at birth (0.1% of red cell population) which
drops to 50 percent by 12 hours and 20 to 30 nucleated
RBC/cm by 48 hours (Fig. 1). It is unusual to see nucleated
RBCs in the peripheral smear of term infant after the age of
4 days.1,18 In other words the term infants have 7.3
nucleated red cells per 100 leukocytes at birth (ranging
from 0 to 24). In premature infants the average figures are
21 NRBC/100 WBC.28
In premature babies nucleated red cells may vary 1000
to 1500/mm3 at birth1 and decreases rapidly during first
week of life. However occasional nucleated RBCs may be
seen in the peripheral blood smear of 7-days-old infant.
Increased number of nucleated RBCs are seen in
following:1,28
After hemorrhage
Hypoxia
Hemolytic disease of newborn
Downs syndrome and congenital anomalies.
age. Diagnosis of anemia can be missed by evaluating
capillary blood Hb.
Moe et al.33 (1967) in their study of 54 infants with
erythroblastosis fetalis 25 out of 41 infants found to anemic
whereas only 14 could be considered as anemic according
to the value obtained from capillary sample.34
Capillary values should not be compared to previously
obtained cord venous blood values when one is looking
for changes in Hb concentration during first week of life
and venous blood should be obtained for this purpose.
The selection of the vein is unimportant as blood from
different sites of vein gives similar results.15,31
Fig. 2 Reticulocytes count
Factors affecting normal hematological values in

newborn1,3
Site of sampling
Time of sampling
Treatment of umbilical vessels at the time of delivery
Position of neonate after delivery
Gestational age of the infant
Fetomaternal transfusion
Maternofetal transfusion.
Various variables influence the interpretation of
normal values of Hb, HCT, RBC indices, reticulocyte count
at the time of birth and during early weeks of life.
Site of sampling
Capillary sampling collected by skin prick from heal or the
toe has a 5 to 10 percent higher hemoglobin concentration
than simultaneously collected venous sample.1
Oettinger and Mills29 reported this difference around
during 1st hour of life 3.6 to 8 gm%. However, in some
instances the capillary hemoglobinvenous Hb difference
may exceed 5 to 10 gm%.29-33
Stasis of the blood in the peripheral vesselsbecause of
sluggish circulation and resultant transudation of plasma
is believed to be the cause of higher capillary hemoglobin
as compared to venous hemoglobin.1
Capillary/venous hematocrit ratio is greater than 1 in
virtually all infants. A ratio higher than 1.2 is observed in
premature infants (before 30 weeks of gestation), infants
with acidosis (pH less than 7.2) and hypotension.32
Thus capillary Hb and hematocrit are falsely elevated
in sick infants with altered microcirculation. However,
an accurate determination of Hb concentration is most
important in the clinical management. Capillary venous
HCT ratio gradually decreases with increasing gestational
Time of sampling
During the first few hours after birth, an increase in
hemoglobin concentration takes place (as great as 2.56
g/dL)1,31,33 which is due to placental transfusion that occurs
during the time of delivery. Readjustment of the blood
volume after birth resulting in increased red cell count,
hematocrit and Hb concentration. Magnitude of increase
depends on the amount of placental transfusion.31
Treatment of umbilical vessels
The amount of blood received by the neonate depends
upon time of clamping umbilical cord at birth.36
At birth by allowing complete emptying of placental
vessel before cord is clamped, the blood volume of infant
may be increased by as much as 61 percent.43 Placental
vessels contain 75 to 125 cc of blood, i.e. 1/3rd to 1/4th
fetal blood volume.37
Within 15 seconds of birth about a quarter and at
the end of 1 minute, about half of placental transfusion
takes place. Placental transfusion occurs more rapidly in
women who receive ergometrin derivatives at the onset of
3rd stage of labor.1,3,35,37-40
During first hour of birth, plasma leaves the circulation.
Greater the placental transfusion the greater plasma loss.
On the third day of life, there are only small differences in
total blood volumes regardless of method of cord clamping.
In the group with late cord clamping, at 24 hours of age the
red cell mass was approximately 32 percent greater and
hematocrit was 15 percent higher.41,42
Hb percent difference can range from 2 to 4 gm%
between early clamping and delayed clamping with
hematocrit difference of 2 to 16 percent by various
authors37,40,43,44 during first week of life. By 6 weeks the
difference are no longer apparent.37,43,44
Position of the neonate after delivery
As umbilical arteries generally constrict shortly after birth,
no blood flows from the infant to mother. However, as the
umbilical vein remains dilated it permits the blood flow in
the direction of gravity.
Chapter-4 Variation in the RBC Parameters in the Newborn 27

Infants held below the level of placenta, as it happens
during normal delivery, continue to gain blood from
placenta, whereas infants held above the placenta which
is often seen during cesarean delivery, infant may bleed
into mother, thus leading to anemia in the neonate.35,37-41
In infants delivered at term with cesarean section,
maximal placental transfusion is achieved in seconds after
birth.37 Delay of 3 minutes in cord clamping after cesarean
section has been associated with signs of respiratory and
metabolic acidosis indicating that earlier clamping may
be preferable.37 Infants with delayed cord clamping had an
average red cells mass of 49 mL/kg at 72 hours as compared
to 31 mL/kg in infants with immediate cord clamping.38-42
However, in infants in whom cord ligation was delayed,
decreased incidence of RDS has been reported and
hence delayed cord clamping is indicated for premature
infants. Premature infants with increased red cell mass, as
consequence of delayed cord clamping, have been found
to have higher serum bilirubin level.43,45 There have been
reports of circulatory overload and congnitive cardiac
failure in the setting of delayed clamping (symptomatic
neonatal plethora).
However, when there is obvious evidence of fetoplacental or maternal bleeding before or during the birth
and infant appears pale and in shock, cord clamping should
be delayed, if resuscitation can be given simultaneously.
Thus numerous physiological changes occur in
succession and rapidity in fetus and neonates to adapt
to the changing pattern of life. This leads to rapid change
in normal hematological parameters from fetal period to
immediately after birth and throughout neonatal period
even hours, days and weeks after birth.
Interpretation of laboratory findings and institution
of appropriate therapy requires understanding of the
maturational process and normal physiological variations
that takes place during this period.1-3
REFERENCES
1. Oski FA, Nathan JL. Normal blood values in newborn
period-hematological problems of the newborn. Vol IV
in the series. Major Problems in Clinical Pediatrics WB
Saunders Company. 1982.pp.1-31.
2. Dalal R. Hematological parameters in the newborn
period. Thesis submitted for MD (Ped) Exam., University
of Bombay, under the guidance of Dr MR Lokeshwar.
1986.p.12.
3. Lokeshwar MR, Dalal R, Manglani M, Shah N. Anemia in
newborn. Ind J Pediatr. 1998;65:651-61.
4. Usher R, Shepard M, Lind J. The blood volume of newborn
infant and placental transfusion. Acta Paediatric Scand.
1963;52:497-512.
5. Mollison PL, Veall N, Cutbush M. Red cell and plasma
volume in newborn infants. Arch Dis Child. 1950;25:242-53.
6. Dochain J, Lemage L, Lambrechts A. Cited in Oski and

Naiman. Normal blood values in newborn period.
Hematologic problems in the newborn. WB Saunders Co,
Philadelphia. 1982.pp.1-31.
7. Walker JL, Turnbull EPN. Hemoglobin and red cells in
human foetus and their relation to the oxygen content of
the blood in the vessels of umbilical cord. Lancet.1953;2:
312.
8. Marks J, Gairdner D, Rescoe JD. Blood formation in infancy
III cord blood. Arch Dis Child. 1955;30:117.
9. Guest GM, Brown EW. Erythropoiesis and hemoglobin of
blood in infancy and childhood. Am J Dis. 1957;93:486.
10. Sturgeon P. Iron metabolisma review with special
consideration of iron requirement during normal infancy.
Pediatrics. 1956;18:267.
11. Rama Rao BR, Krishnamurthy PN, et al. Study of neonatal
hematological values in relation to maternal and foetal
factors and incidence of transplacental passage of foetal
erythrocytes. Ind Pediatr. 1979;16:591-5.
12. Wegelius R. On changes in the peripheral blood picture
of newborn infant immediately after birth. Acta Pediatr.
1948;35:1.
13. Chaplin H Jr. Cited by Mollison PL. Blood transfusion
in clinical medicine, 3rd edn. Springfield III, Charles
(Thomas). 1961.p.581.
14. Wough JF, Merchant FT, Maugham GB. Blood studies in
newborndetermination of Hb, PCV, reticulocyte and
fragility of erythrocytes over 98 days period. Am J Med Sc.
1939;198:646.
15. Gairdner D. Cited by Oski FA and Naiman JL. Hematologic
problems in newborn. WB Saunders Co, Philadelphia,
1982.
16. Gatti RA. Hematocrit value of capillary blood in the
newborn infants. J Pediatr. 1967;70:117.
17. Guest GM, Brown EW, Wing M. Erythrocytes and Hb of
blood in infancy and in childhood, variability in number,
size and Hb content of erythrocytes during first five years
of life. Am J Dis Child. 1938;56:529.
18. Lippman HS. Morphologic and quantitative study of blood
corpuscles in newborn period. Am J Dis Child. 1924;27:
473.
19. Heissen A, Schallo GR. Cited Oski FA, Naiman JL. Normal
blood value in newborn periodhematological problems
in newborn Vol.1 in the series Major problems in clinical
pediatrics. WB Saunders Co. 1982.pp.1-31.
20. Saragea T. Cited Oski FA, Naiman JL. Normal blood value
in newborn period hematological problems in newborn
Vol.1 in the series Major problems in clinical pediatrics.
WB Saunders Co. 1982.pp.1-31.
21. Breathnach GS. Red cell diameters in human cord and
neonatal blood. Quaterly J Exp Physiol. 1962;47:148.
22. Kato (1933). Physiological variations in reticulocyte in
newborn study of 219 cases. Cited Oski FA, Naiman JL.
Normal blood value in newborn period hematological
problems in newborn Vol. 1 in the series Major problems
in clinical pediatrics. WB Saunders Co. 1982.pp.1-31.
23. Faxen 1937. Red blood picture in healthy infants. Acta
Pediatr. 1937;19:1.
24. Schmairen AH, Haner HM. All thalassemic screening
in neonate by mean corpuscular volume and mean
corpuscular mean hemoglobin concentration. J Pediatr.
1973;83:794.
25. Marks J, Gardner D, Rosecoe JD. Blood formation in
infancy III cord blood. Arch Dis Child. 1955;30:117.
26. Seyfarth C, Jurgen SR. Cited Oski FA, Naiman JL. Normal
blood value in newborn period hematological problems
in newborn Vol. 1 in the series Major problems in clinical
27. Seip M. The reticulocyte level and erythrocyte production
judged from reticulocyte studies in the newborn infants
during first week of life. Acta Pediatr. 1955;44:355.
28. Anderson GW. Studies on nucleated red cell count in
chorionic capillaries and cord blood of various types of
frequency. Am J Obstet Gynaecol. 1941;42:1.
29. Oettinger L Jr, Mills WB. Simultaneous capillary and
venous hemoglobin determinations in newborn infants. J
Pediatr. 1949;35:362.
30. Vehlqust B. Cited by Oski FA, Naiman JL. Normal blood
value in newborn periodhematological problems in
newborn Vol. 1 in the series Major problems in clinical
31. Oh W, Lind J. Venous and capillary hematocrit in newborn
infants and placental transfusion. Acta Pediatr Scand.
1966;38:55-60.
32. Linderkamp O, Versmold HT, Strohacker I, et al. Capillary
hematocrit difference in newborn infant. Eur J Pediatr.
1977;127:9.
33. Moe PJ. Umbilical cord blood and capillary blood in the
evaluation of anemia in erythroblastosis fetalis. Acta
Pediatr Scand. 1967;31:391.
34. Rivara LM, Rudulph N. Postnatal persistence of capillary

venous difference in hematocrit and Hb values in low birth
weight and term infants. Pediatrics. 1982.
35. Usher R, Shephard M, et al. The blood volume of the
newborn infant and placental transfusion. Acta Pediatr
Scand. 1963;52:497.
36. Yao AC, Moinian M, Lind J. Distribution of the blood
between infants and placenta after birth. Lancet.
1969;2:871.
37. Yao AC, Wist A, Lind J. The blood volume of the newborn
infant delivered by cesarian section. Acta Pediatr Scand.
1967;58:585.
38. Yao AC, Hirvansalo M, Lind J. Placental transfusion rate
and uterine contraction. Lancet. 1968;1:380.
39. Hasselhost G, Allmeling A. Cited by Oski FA, Naiman JL.
Normal blood value in newborn period hematological
problems in newborn Vol. 1 in the series Major problems
in clinical pediatrics. WB Saunders Co. 1982.pp.1-31.
40. Colozzi AE. Clamping the umbilical cord its effect on
placental transfusion. N Eng J Med. 1954;250:629.
41. Mc Cue C, Garner FB, Hurt WB, et al. Placental transfusion.
J Pediatr. 1968;72:15.
42. Yao AC, Lind J, Tiisala R, et al. Placental transfusion in the
premature infant with observation on clinical courses and
outcome. Acta Pediatr Scand. 1969;58:561.
43. Demarch QB. Alt HL and Windle WF. Factors influencing
the blood picture of the newborn. Am J Dis Child. 1948;
75:860.
44. Lanzkowosky P. Effect of early and late clamping of
umbilical cord on infants hemoglobin level. Br Med J.
1980;2:1777.
45. Wu PC, Ku TS. Early clamping of umbilical cord: a study of
its effects on the infants. Clin Med J. 1960;80:351.
5
Physiological Anemia of Newborn,
Anemia of Prematurity and Role of
Erythropoietin in the Management
Anemia is the most common hematological abnormality in the newborn. Anemia is defined as a hemoglobin or hematocrit value that
is more than two standard deviations below the average for a particular gestational as well as chronological age.1 As a rule of thumb
a hemoglobin value less than 13 g/dL in first 2 weeks of life is labelled as anemia and warrants evaluation.
Anemia is a sign and not a diagnosis. There are two

categories of anemia:
1. Pathologic
2. Physiologic
Pathologic anemia in newborns results from accele
rated blood loss, destruction of red blood cells, or a defect
at some stage of red blood cell production.
Physiologic anemia is common and a normal
physiologic process in term infants. It is typically
asymptomatic requiring no intervention.
Anemia of prematurity (AOP) is an exaggerated and
pathologic response of the preterm infant (<32 weeks
gestation) to the transition from fetal to postnatal life.
The etiology, symptomatology, diagnosis, treatment and
prevention of anemia of prematurity are addressed.
PHYSIOLOGIC ANEMIA OF INFANCY

Immediately after birth with successful transition from fetal
to neonatal circulation, there is increase in blood oxygen
content and tissue oxygen delivery. This downregulates
erythropoietin production so that erythropoiesis is
suppressed. As a result of this, the hemoglobin concen
tration in healthy full-term and premature infants
undergoes typical changes during the first weeks of life.
All infants experience a decrease in hemoglobin and
hematocrit concentrations after birth. This physiological
decrease in Hb level is principally due to a reduced response
capacity for erythropoietin (EPO) production in the face of
anemia, even in the presence of symptoms and in spite of
Maturity
Term
12001500 gm
< 1200 gm
Table 1 Postnatal changes in Hb

Hb at nadir (g%)
Time of nadir (weeks)
9.511
612
810
510
6.59
48
the fact that erythroid precursors present in both the bone

marrow and the blood are highly sensitive to EPO. It is not
known why the bone marrow does not respond adequately
to this hypoxic stimulus. The maximum decline in Hb
is reached by 4 to 12 weeks and is earlier and of greater
severity in preterms compared to terms2 (Table 1).
The Hb concentration continues to decrease until
tissue oxygen needs are greater than oxygen delivery.
Term infants remain asymptomatic and tolerate the
physiologic process well, but very preterm infants, <32
weeks gestation, may become symptomatic or the Hb
drops to a critical level warranting a blood transfusion.
Further in preterms several other factors contribute in
exacerbating the physiologic fall in Hb leading to AOP
which are discussed later in the article.
ANEMIA OF PREMATURITY
Background
First described by Shulman in 1959, anemia of prematurity
(AOP) is a common hematological problem of premature
infants. AOP is an exaggerated and pathologic response of
the preterm infant to the transition from fetal to postnatal
life. It is often, unlike the physiological anemia in term
babies, a true anemia since oxygen delivery is diminished.
AOP is a normocytic, normochromic, hyporegenerative
anemia that is characterized by the existence of a low
serum EPO level in an infant who has what may be a
remarkably reduced hemoglobin concentration.
Incidence3
AOP typically is not a significant issue for infants born
beyond 32 weeks gestation. Frequency of AOP is related
inversely to the gestational age and/or birth weight.
Approximately 80 percent of very LBW (VLBW) infants
(<1500 g) and 95 percent of extremely LBW (ELBW)
infants (<1000 g) receive at least one red blood cell (RBC)
transfusion during their stay in the neonatal intensive care
unit (NICU). AOP spontaneously resolves by the time most
patients are aged 3 to 6 months.
Pathophysiology
The three basic mechanisms which occur singly or in
combination for the development of AOP include:
Inadequate red blood cell (RBC) production for
a growing premature infant. Fetal and maternal
erythropoiesis occurs independently throughout
gestation. Erythropoietin does not cross the placenta.
Erythropoietin is the main growth factor responsible
for erythropoiesis. The liver is the principal site of EPO
production during fetal life. By 32 weeks gestation,
RBCs are produced approximately evenly from both the
liver and bone marrow. Production of erythropoietin
shifts to the peritubular cells of the kidney after term
gestation.4 Interrupting a pregnancy prematurely does
not alter these ontological processes. Erythropoietin
(EPO) production is thought to be controlled by an
oxygen-sensing mechanism in the liver and kidney
and both anemia and hypoxia stimulate mRNA
transcription and EPO protein production. The liver
is less sensitive than the kidney in response to these
stimuli.5 Because it remains the major source of EPO in
the preterm infant, RBC production may be blunted.
Premature infants also have relatively poor iron
stores. Erythroid progenitors of premature infants
are quite responsive to EPO when that growth factor
finally is produced or administered, but the response
may be blunted if iron stores are insufficient.6
Iron stores are accrued during the last trimester of
pregnancy; premature infants therefore miss out on
this opportunity.
Shortened RBC life span or hemolysis: The average
life span of neonatal RBCs is approximately a half to
two thirds that of the adult RBC.7 This shorter life span
is due to the lower levels of intracellular ATP, enzyme

activity, and carnitine levels as well as the increased
susceptibility to lipid peroxidation and susceptibility
of the cell membrane to fragmentation. This shorter
life span means that the bone marrow must provide
new red blood cells at a very high rate just to maintain
adequate hemoglobin and hematocrit levels.8
Increased blood loss: Preterm infants loose blood
in different situations, some more avoidable than
others. The most common form of blood depletion in
the preterm population is iatrogenic losses secondary
to blood sampling. Phlebotomy losses for blood
tests are directly related to the length of an infants
stay in the NICU and the severity of illness. Hidden
blood loss (e.g. blood adherent to sampling syringes,
gauze pads, bedding, tubing) is inevitable and under
recognized. Accurate assessment of the volume of
blood removed for laboratory testing is imprecise
leading to underestimation of laboratory losses. One
milliliter of blood represents 1 percent of total blood
volume, especially in preterm babies. As a result very
preterms can lose close to their entire blood volume
within a few days of life, necessitating frequent blood
transfusions.9
Nutritional deficiencies of iron, vitamin E, vitamin
B12 and folate may exaggerate the degree of anemia.
Several other factors predispose to anemia of
prematurity.6,8,10 Some of these factors are common to
both the term and the preterm infant, but may be more
profound in the premature infant.
Lists factors that can contribute to the exaggerated
physiologic anemia of prematurity (Table 2).
Clinical Manifestations11
Infants with anemia of prematurity may be completely
asymptomatic. The signs and symptoms listed in Table 3 are
commonly seen but nonspecific and are not diagnostic
Table 2 Factors contributing to exaggerated physiologic
anemia of prematurity
Decreased RBC mass at birth
Rapid body growth resulting in hemodilution
Poor iron stores along with limited ability to build iron
stores
Increased iatrogenic losses from laboratory sampling
Shorter RBC life span
Inadequate erythropoietin production
Initial reliance on the liver as the primary site of
erythropoietin production
Abrupt decline in reticulocyte counts after the first few days
of life
Chapter-5 Physiological Anemia of Newborn, Anemia of Prematurity and Role of Erythropoietin 31

Table 3 Signs and symptoms of anemia of prematurity

Tachycardia
Tachypnea
Lethargy
Pallor
Apnea and bradycardia

Poor feeding
Poor growth
Metabolic acidosis
by themselves of AOP.5,7,11,12,17 Historically these clinical

symptoms have been attributed to anemia by clinicians
despite the fact that there is no relationship established
between low levels of hemoglobin and onset of symptoms.
Asymptomatic premature infants may tolerate hemoglobin
levels as low as 6.5 g/dL without showing any compromise
of their physiologic functions. Although some studies
conclude that the use of red blood cell transfusions in
anemic premature newborns revert these symptoms,
others affirm that this association is not so clear. It is now
recognized that resolution of these symptoms may be a
maturational process, not a hematologic issue.
Diagnosis12
In preterm infants, the hemoglobin and hematocrit levels
may be followed periodically, although no specific criteria
exist as to how often to monitor these levels. A rule of
thumb is to monitor the hemoglobin and the hematocrit
if symptoms of anemia of prematurity are present. The
CBC count demonstrates normal white blood cell and
platelet series. The hemoglobin is less than 10 g/dL but
may descend to a nadir of 6 to 7 g/dL; the lowest levels
generally are observed in the very premature. RBC indices
are normal (e.g. normochromic, normocytic) for age. The
reticulocyte count is low for the severity of anemia. The
finding of an elevated reticulocyte count is not consistent
with the diagnosis of AOP. Peripheral blood smear shows
no abnormal cells. Essentially, AOP is a diagnosis of
exclusion.
MANAGEMENT OF ANEMIA OF
PREMATURITY
Options available to the clinician treating an infant with
anemia of prematurity (AOP) are prevention, blood
transfusion, and recombinant EPO treatment.
Prevention Strategies
Delay in clamping the premature infants umbilical
cord during birth contributes to reducing the number
of transfusions to which they will later be subjected.13
It may be beneficial to maintain the fetus 20 cm below
the level of the placenta during 30 seconds after birth.
Although a tailored approach is required in the case of
cord clamping, the balance of available data suggest that
delayed cord clamping should be the method of choice.
A direct relationship exists between the volume of
blood extracted and the number of transfusions
performed. It is therefore necessary to conscientiously
limit the number of laboratory tests performed.
To avoid excess iatrogenic blood loss, the amount of
blood collected should be recorded.
Administration of iron may begin at 1 month of age
(2mg/kg/d) and continued until 6 to 12 months of age.
However, iron supplementation should not be started
in growing premature infants until adequate vitamin
E is supplied in the diet or supplemented; otherwise,
iron may increase blood cell hemolysis.14,15
Vitamin E is an antioxidant that is vital to the integrity of
erythrocytes. In its absence, these cells are susceptible
to lipid peroxidation and membrane injury. The
logical conclusion is that vitamin E deficiency might
contribute to the anemia of prematurity.16
The use of noninvasive monitoring devices, such
as transcutaneous hemoglobin oxygen saturation,
partial pressure of oxygen and partial pressure of
carbon dioxide, may allow clinicians to decrease blood
drawing; however, no data currently support such an
impact of these devices.3
Role of Blood Transfusion

Despite disagreement regarding timing and efficacy,
packed red blood cell transfusions continue to be the
mainstay of therapy for AOP. The frequency of blood
transfusions varies with gestational age, degree of illness,
and hospital practices. The goal of transfusion in infants
with anemia of prematurity is to restore or maintain
oxygen delivery without increasing oxygen consumption.
Goal of Anemia of Prematurity Therapy
Rationale for not Transfusing

Based on Hb Value Alone
Maintaining the premature newborns erythrocyte

mass as intact as possible.
Provide the growing neonate with adequate oxygen
carrying capacity to prevent symptomatic manifesta
tions of anemia while minimizing morbidity from
treatment.
There is no trustworthy marker for tissue hypoxia, hence

it should be considered that the appearance of symptoms
attributable to reduced tissue oxygen delivery may not
be solely due to low Hb levels, but also to other nonhematological factors such as cardiac output and oxygen
partial pressure, the percentage of fetal Hb and the activity
of 2,3 diphosphoglycerate. Therefore considering the Hb
level alone when making a transfusion decision, would
appear to be inadequate. There is no consensus as to
whether transfusions alleviate the signs and symptoms of
anemia of prematurity.17
Indications for Blood Transfusion

Transfusion practices vary markedly across units and
there is a lack of evidence- based studies to guide
practice.18 None of the clinical signs has been consistently
useful either alone or as a group in determining when to
transfuse an infant with low hemoglobin of (physiologic)
anemia of prematurity and iatrogenic losses. The most
common problem associated with anemia of prematurity
is identifying the threshold for transfusion. The guidelines
use specific hematocrit levels, clinical status, and
sometimes infants age to determine when to transfuse19,20
(Table 4). In many cases, the hematocrit levels are lower
than those used previously. In the Premature Infants
in Need of Transfusion (PINT) study, Kirplani et al.19
demonstrated that transfusion threshold in ELBW infants
can be moved downwards by at least 1g/dL without
incurring a clinically important increase in the risk of
death or major neonatal morbidity.
Issues in Blood Transfusion11,12

Donor exposure: A concern for infants who might
need multiple transfusions is exposure to multiple
donors. The use of multiple donors increases the risk
of infection and transfusion reactions. Donor exposure
can be reduced for infants who need small volume
transfusions (<1520 mL/kg) by using stored packed
red blood cells (PRBCs) from a single unit. This unit
is divided into multiple aliquots that are reserved for
a specific infant. This procedure has reduced donor
exposure to one or two donors for most infants.
Preservatives: Use PRBCs stored in preservatives
(e.g. citrate-phosphate-dextrose adenine [CPDA-1])
and additive systems (e.g. Adsol). Preservatives and
additive systems allow blood to be stored safely for up
to 35 to 42 days. The additives having mannitol should
not be used for neonates.
Screening: The risk of cytomegalovirus (CMV)
transmission can be reduced dramatically (but not
entirely) through the use of CMV-safe blood. This
can be accomplished by using either CMV serologynegative cells or blood processed through leukocytereduction filters. This latter method also reduces other
WBC-associated infectious agents (e.g. Epstein-Barr
virus, retroviruses, Yersinia enterocolitica).
Table 4 Transfusion guidelines

Hemoglobin
(g/dL)
Mechanical ventilation or symptoms of anemia
PRBC volume
11 or less
Moderate or significant mechanical ventilation requirement (MAP >8 cm H2O and FiO2 15 mL/kg PRBCs
> 0.4)
over 24 hours
10 or less
Minimal mechanical ventilation requirement

(any mechanical ventilation or CPAP >6 cm H2O and FiO2 >0.4)
15 mL/kg PRBCs
over 24 hours
8 or less
No mechanical ventilation requirement and one or

more of the following present:
24 or more hours of tachycardia (HR >180) or tachypnea (RR >80)
An increased oxygen requirement from the previous 48 hours
An elevated lactate concentration (2.5 mEq/L or more)
Weight gain <10 g/kg over previous 4 days while receiving 100 kcal/kg per day or
more
An increase in episodes of apnea and bradycardia (10 or more episodes in a 24 hours
period or 2 or more episodes in 24 hours requiring bag-mask ventilation) while
receiving therapeutic doses of methylxanthines
Undergoing some surgery
20 mL/kg PRBCs
over 24 hours (divide
into two 10 mL/kg
volumes if fluid sensitive)
Less than 7
No symptoms and an absolute reticulocyte count

< 100,000 cells/mL (RBC x % reticulocyte count)
15 mL/kg PRBCs over 24

hours
Do not transfuse to replace blood removed for laboratory tests or low hematocrit alone unless above criteria are met
Abbreviations: CPAP: Constant positive airway pressure; HR: Heart rate; MAP: Mean airway pressure; PRBC: Packed red blood cell; RBC:
Red blood cell; RR: Respiratory rate.
Why Minimize Transfusions in Neonates?

(Table 5)
Although transfusion may be lifesaving, like all medical
interventions, it is not without risk. Following are hazards
which need to be taken into account prior to transfusing
blood:
The number of infectious agents that may potentially
be transmitted by this route continues to grow and is
the most feared complication.
Risk of fatal transfusions contaminated with bacterial
agents, hyperkalemia and graft versus host disease.
Alterations of the immune system.
Inferior quality of practices in developing countries
collection, storage, screening policy and irradiation.
The safest blood transfusion is the one not
administered.
There is lack of evidence that early EPO versus late EPO
confers any substantial benefits (Role of erythropoietin)
As a relative deficiency of EPO is present in the anemia of
prematurity it appears logical to supplement EPO in these
infants. Recombinant erythropoietin (rEPO) has been
studied extensively since it became available for human
use in 1980. Despite several large EPO trials, there remains
no clear consensus for the efficacy of EPO in neonates,
and currently its use remains inconsistent between
centers.3,11,12,20
Early versus late erythropoietin: A Cochrane analysis
showed the use of early EPO (<7days of life) did not
significantly reduce the primary outcome of use of
one or more red blood cell transfusions, or number
of transfusions per infant compared to late EPO (>7
postnatal days) administration.20,21
Side effects20: Neutropenia and sepsis, rash, hypertension,
convulsions, poor weight gain and SIDS have been reported
in some but not all studies. Apparently the problem of
aplastic anemia reported in adults, was related to a specific
type of EPO, and even to a single shipment of this drug sent
out by a single laboratory. Animal data and observational
studies in humans support a possible association between
treatment with EPO and the development of ROP.
Table 5 Approaches to reducing transfusion needs
Development of, and adherence to, strict guidelines for
transfusion
Reducing iatrogenic blood loss
Autologous cord transfusion
Targeted use of erythropoietin
Iron supplementation
Current status of erythropoietin:3,11,12,20 Clearly, rEPO has

efficacy in stimulating erythropoiesis in preterm infants,
but success in the elimination or marked reduction in
the need for RBC transfusions has not been definitively
demonstrated.
rEPO therapy must be carefully considered and used
only when there is strong evidence of its need and
effectiveness.
There is no agreement regarding timing, dosing,
route, or duration of therapy exists. Meta-analysis of
controlled clinical trials show some benefit to EPO,
but they cannot give firm guidelines on its use or
recommend its routine use to prevent AOP. In short,
the cost-benefit ratio for EPO has yet to be clearly
established, and this medication is not accepted
universally as a standard therapy for the individual
with AOP.
When the family has religious objections to
transfusions, the use of EPO is advisable.
CLINICAL GUIDELINES FOR TARGETED USE

OF ERYTHROPOIETIN22-24
Indications for Erythropoietin
The greatest hope of success in reducing need for RBC
transfusions seems likely in preterm infants who are:
< 28 weeks.
Infants 28 to 32 weeks who are <3rd centile for weight.
With phlebotomy loses expected to be >30 mL/kg.
Dose and Route of Administration

In 750 Units/kg/week given as 3 doses on alternate days
by subcutaneous or intravenous injection beginning
at the end of the first week of life and for 6 weeks. The
subcutaneous route is preferred.
Iron supplementation: 0.4 to 1 mg/kg/day of iron dextran
is given via the parenteral nutrition solution. Once enteral
nutrition is initiated, 3 mg/kg/day of elemental iron should
be provided by supplement. When full enteral nutrition is
reached, elemental iron supplementation is increased to
6 mg/kg/day.
Vitamin E (Table 6) supplementation of 25 units/day
should be given orally when EPO is administered.
Practice pointers in management of anemia of
prematurity (Table 7):
It seems clear that the major clinical goal for neonates with
anemia is to reduce RBC transfusions, so as to minimize
multiple donor exposures, infection, and immune risks.
EPO alone cannot achieve this goal reliably.
transfusion alternative? The answer may be yes for
those nurseries willing to apply restrictive transfusion
criteria and a single-donor system of blood banking.
For nurseries employing liberal transfusion practices,
rEPO therapy using multidose vials may be a safe,
effective alternative to transfusion.25
Table 6 Medications used in the treatment of anemia of

prematurity10,15,23
Generic name
Epoetin alfa
Dosage/Route
Common
adverse
reactions
Neutropenia,
rash,
hypertension
convulsions,
SIDS
4001400
U/kg/wk
subcutane
ously given
every day or
every other
day
Ferrous sulfate 6 mg/kg/day
GI upset
PO based on
elemental iron
Folic acid
50 g/day PO Caution
if used
concurrently
with
phenytoin
Vitamin E
25 IU/day PO
Comments
Supplement
with iron and
vitamin E
Key Points: Physiologic anemia of infancy

N
ewborns do not mount adequate erythropoietin response
to hypoxia and anemia.
The postnatal drop in Hb is universal in newborns. Term
newborns reach a nadir of Hb between 6 and 12 weeks and
tolerate the physiologic process well. Few, if any, clinical
signs and symptoms are seen.
The exaggerated and pathologic response of the preterm
infant to the transition from fetal to postnatal life is called
anemia of prematurity (AOP). It is seen by 4 to 10 weeks and
is more profound and occurs earlier than anemia of infancy.
The clinical importance of knowing the postnatal drop in
Hb is in curbing the tendency of subjecting these infants to
un-necessary blood transfusions.
Interferes
with vitamin E
absorption
May contain
benzyl alcohol
as preservative
May induce
vitamin K
deficiency
Vitamin B12
0.4 g PO IM
Abbreviations: GI: Gastrointestinal; IM: Intramuscular; PO: By

mouth.
Table 7 Anemia of prematurity

A
nemia of prematurity is a diagnosis of exclusion and of
concern in preterms <32 weeks gestation
The critical threshold of hematocrit in which transfusion is
necessary in preterm infants remains to be determined
Reduction of the need for blood transfusions is associated
with rigorous transfusion policies and restrictive blood
testing
Exogenous replacement of erythropoietin has minimally
altered transfusion practice in preterm infants
Rather, a combination of strategies is best, including

reduction of phlebotomy losses, strict adherence to
a conservative transfusion protocol, selected use of
EPO with sufficient dosing, and optimizing nutrition to
promote growth and hematopoiesis.
We need to be prepared to accept lower Hb/Hct levels
in asymptomatic neonates, recognizing that overall
growth and stability are more important than any
specific Hb number for an individual infant.
Should rEPO therapy, as it is currently prescribed,
be discarded as a relatively useless and expensive
REFERENCES

1. Luchtman-Jones L, Schwartz AL, Wilson DB. The blood

and hematopoietic system. In: Fanaroff AA, Martin RJ,
eds. Neonatal-perinatal Medicine: Disorders of Fetus
and Infant, 7th edn. St. Louis, MO: Mosby. 2002.pp.1
182-254.
2. Luchtman-Jones L, Schwartz A, Wilson D. The blood
and hematopoietic system. In Fanaroff A, Martin R, eds.
Part 1: Hematologic problems in the fetus and neonate.
Neonatal-Perinatal Medicine: Diseases of the Fetus and
Infant, 6th edn. St. Louis: Mosby-Year Book. 1996.pp.
1201-51.
3. CF Potter, WM Southgate. Anemia of Prematurit http://
www.emedicine.com/ped/topic2629.htm. Accessed on 20
August 2008.
4. Ohls R. Erythropoietin production by macrophages from
preterm infants: Implications regarding the cause of
anemia of prematurity. Pediatric Research. 1994;35(2):
160-70.
5. Dallman PR. Anemia of prematurity: the prospects for
avoiding blood transfusions with recombinant erythro
poietin. Adv Pediatr. 1993;40:385-403.
6. Juul S. Erythropoietin in the neonate. Current Problems in
Pediatrics. 1999;29(5):133-49.
7. Mentzer WC, Glader BE. Erythrocyte disorders in infancy.
In: Taeusch HW, Ballard RA, Gleason CA, eds. Averys
diseases of the newborn. Elsevier Saunders. 2005.pp.
1180-214.
8. Downey P. Recombinant human erythropoietin as a
treatment for anemia of prematurity. J of Perinat and
Neonat Nur. 1997;11(3):57-68.

9. Walllgren G, Hanson JS, Lind J. Quantitative studies of

the human neonatal circulation. III. Observations on the
newborn infants central circulatory response to moderate
hypovolemia. Acta Paediatr Scand. 1967;179(Suppl):
43-54.
10. Gomella T, et al. Neonatology: Management, Procedures,
On-call Problems, Diseases, and Drugs, 4th edn. Stamford,
Connecticut: Appleton and Lange. 1999.pp.316-22.
11. Salsbury DC. Anemia of Prematurity. Neonatal Network.
2001;20(5):13-20.
12. SM Aher, K Malwatkar, S Kadam. Neonatal Anemia. Seminars
in Fetal and Neonatal Medicine. 2008;13:239-47.
13. Levy T, Blickstein I. Timing of cord clamping revisited. J
Perinat Med. 2006;34:293-7.
14. American Academy of Pediatrics, Committee on Nutrition.
Iron deficiency. In: Kleinman RE, ed. Pediatric nutrition
handbook. Elk Grove Village, IL: American Academy of
Pediatrics. 1998.pp.299-312.
15. Zenk K, Sills J, Koeppel R. Neonatal Medications and
Nutrition: A Comprehensive Guide, 2nd edn. Santa Rosa,
California: NICU INK. 2000.pp.184-5.
16. Oski FA, Barness LA. Vitamin E deficiency: a previously
unrecognized cause of hemolytic anemia in the premature
infant. J Pediatr. 1967;70:211-20.
17. Atias D. Pathophysiology and treatment of anemia
of prematurity. Journal of Pediatric Hematology and
Oncology. 1995;17(1):13-8.
18. Bednarek FJ, Weisberger S, Richardson DK, et al. Variation

in blood transfusions among newborn intensive care units.
SNAP II Study Group. J Pediatr. 1998;133:601-7.
19. Kirplani H, Whyte RK, Anderson C, et al. The premature
infants in need of transfusion (PINT) study: a randomized,
controlled trial of a restrictive (low) versus liberal (high)
transfusion threshold for extremely low birth weight
infants. J Pediatr. 2006;149:301-7.
20. Ohls RK. The use of erythropoietin in neonates. Clin
Perinatol. 2000;27:681-96.
21. Aher SM, Ohlsson A. Early versus late erythropoietin for
preventing red blood cell transfusion in preterm and/or
low birth weight infants. Cochrane Database Syst Rev.
2006;3:CD004865.
22. Irene Roberts. Management of neonatal anaemia: The role
of erythropoietin. CME Bulletin Haematology. 1997;1(1):5-7.
23. Young T. Mangum O Neofax. A Manual of drugs used in
neonatal care, 20th edn. Montralle, New Jersey, Thompson
Healthcare, USA. 2007.p.86.
24. Ronald G. Strauss. Controversies in the management of the
anemia of prematurity using single-donor red blood cell
transfusions and/or recombinant human erythropoietin.
Transfusion 34 Medicine Reviews, 2006;20(1):34-44.
25. Ellen M Bifano. Traditional and nontraditional approaches
to the prevention and treatment of neonatal anemia. Neo
Reviews. 2000;1:69-73.
6
Effect of Maternal Iron
Status on Placenta,
Fetus and Newborn
Maternal anemia (hypoferremia) results in increased preterm and low birth weight deliveries and higher rate of stillbirths. There
are irreversible structural alterations in placenta. The transfer of iron to fetus is reduced in spite of gradient in relation to severity
of maternal hypoferremia. The fetal hepatic and brain iron contents were reduced. The brain iron reduction was irreversible on
rehabilitation and was associated with irreversible neurotransmitter and their receptor alterations.
The outcome of severe pregnancy anemia has been

associated with increased incidence of premature births,
fetal distress, increased perinatal mortality and a higher
frequency of maternal deaths.1 In the case of moderate to
severe anemiabreathlessness, edema, congestive heart
failure and even cerebral anoxia have been observed.
200 anemic pregnant women observed in the University
Hospital, Institute of Medical Sciences, Varanasi, showed:
reduced gestation; higher incidence of premature labor,
preterm, low birth weight and stillbirth deliveries. These
newborns had low Apgar score and there were increased
number of neonatal deaths. Maternal mortality was 13
out of 200 anemic as compared to 1 in 50 controls. Similar
findings were reported in other Indian studies. Anemic
mothers do not tolerate blood loss during childbirth; as
little as 150 mL can be fatal. Normally a healthy mother
during childbirth may tolerate a blood loss of up to
1000 mL.2
CURRENT KNOWLEDGE IN THE

DEVELOPMENT OF IRON DEFICIENCY
Iron deficiency is an end result of a long period of negative
iron balance mainly due to poor dietary availability, rapid
growth and blood loss. The pathological stages are;
Prelatent deficiency: Hepatic (Hepatocytes and macro
phages), spleen and bone marrow show reduced iron
stores (reduced bone marrow iron and serum ferritin).
Latent deficiency: As the bone marrow iron stores

become absent, plasma iron decreases and bone
marrow receives little iron for hemoglobin regeneration
(bone marrow iron absent, serum ferritin <12 ug/L,
transferrin saturation <16 percent and free erythrocyte
protoporphyrin is increased), however, hemoglobin
concentration remains normal.
Iron deficiency anemia: This is a very late stage of iron
deficiency with progressive fall in hemoglobin and
mean corpuscular volume.
PREVALENCE OF NUTRITIONAL ANEMIA IN

PREGNANT WOMEN (INDIA)
National studies by the Indian Council of Medical
Research (ICMR)3covering 11 states; reported in 1989,
prevalence of anemia by estimating hemoglobin using
cyanmethemoglobin method in pregnant rural women as
87.6 percent, hemoglobin being <10.9 g/dL. These anemic
women were given different doses of iron 60, 120 and 180 mg
with 500 ug folic acid daily for 90 days in 6 states; 62 percent
in spite of iron-folate therapy for 3 months, continued to
remain anemic.4 Thus indicating that short-term treatment
as recommended in the National Anemia Control Program
may not be sufficient to control anemia in pregnancy.
However, it was observed that birth weight improved and
low birth weight deliveries were significantly reduced.5 The
administration of higher dose 335 mg of ferrous sulfate and
Chapter-6 Effect of Maternal Iron Status on Placenta, Fetus and Newborn 37

500 ug of folic acid for 14 weeks as weekly or daily dose, both
doses were found to be effective in control of pregnancy
anemia. This suggested that, even once a week ironfolate
administration will be of help.6
National Family Health Survey 199899 (NFHS-2) using
hemocue method reported prevalence of anemia as 49.7
percent in pregnant women; 56.4 percent in breastfeeding
nonpregnant women and 50.4 percent among nonpregnant
nonbreastfeeding women. Hemocue method estimates
higher levels of hemoglobin thus difficult to compare with
the other national studies. In 2005, NFHS-3 demonstrated
increase in prevalence of anemia, suggesting marginal rise
in anemia nation wide.7
Nutrition Foundation of India in 20022003studied
prevalence of anemia in pregnancy and lactation in
7 states (Assam, Himachal Pradesh, Haryana, Kerala,
Madhya Pradesh, Orissa, Tamil Nadu). The prevalence of
pregnancy anemia was86.1 percent (Hb <7.0 g/dLin
9.5%) and in lactation up to 3 months was 81.7 percent (Hb
<7.0 g/dL in 7.3%). The interstate differences responsible
for differences in prevalence of anemia were particularly
related to fertility, women education, nutrition status and
occupation, availability of antenatal services and iron
folate tablets as possible factors.8,9
The ICMR, 19992000conducted District Nutrition
Survey in 11 states covering 19 districts pregnancy anemia
prevalence was 84.6 percent (Hb <7.0 g/dLin 9.9%). The
study also found 90 percent adolescent girls with anemia
in these districts.10
The prevalence as well as severity of anemia during
pregnancy and lactation is grave. This is the period when
brain cells grow and neurotransmitters develop, iron is
essential for it.
IRON STATUS IN PREGNANCY

Fetal growth depends, to a large extent, on the
availability of iron from the mother.
Normal nonpregnant woman needs iron 1.3 mg/day.
Total pregnancy need of iron is 1000 mg or more.
Absorption6 mg/day in the last 2 trimesters.
350 mg of iron is transferred to the fetus and placenta.
250 mg is lost in blood at delivery.
450 mg is needed to increase the RBC mass.
Lastly around 240 mg is lost as basal losses.
In cesarean delivery blood loss is almost twice (500
mL). In moderate and severe anemia mother will die, if
blood loss is >150 mL.
During lactation iron loss is 0.3 mg/day.
PLACENTA IN IRON DEFICIENCY

Iron transport: Normally placental iron transfer to fetus
becomes 3 to 4 times during 20 to 37 weeks of gestation.
The placenta traps maternal transferrin, removes iron and

actively transports it across to the fetus where it becomes
bound to fetal transferring and is distributed to the liver,
spleen and other fetal hemopoietic tissues, maintaining
higher levels of fetal iron as compared to the mother.
Placenta plays an important role in maintaining iron
transport to fetus. This process of iron transport is purely
a placental function over which mother and fetus has no
control, as placenta continues to trap iron even when
fetus is removed in animals.11 The placental trophoblastic
membrane appears to act as an effective barrier against
the further transport of iron to the fetus. In spite of this
efficient protective mechanism the placental iron content
reduces significantly in maternal hypoferremia.2,12-14 This
was a very important finding as earlier studies on Swedish
and American women had shown that cord iron does not
change in iron deficient pregnant women.15,16 However,
recent studies have confirmed that the maternal anemia
affects the placentofetal unit.17-20
Morphometry and biochemical alterations: Beischer et
al.21 analyzed data (from Australia, India, New Guinea,
Singapore and Thailand) and demonstrated that in
all the studies placental weight in maternal anemia
was higher than the control. This increase in placental
weight was higher with increasing parity. The placental
hypertrophy did not correspond to fetal size and had
no correlation with maternal serum protein. Ratten and
Beischer22 confirmed that the placental weight exceeds
the 90th centile in 20 percent of patients with hemoglobin
<8.2 g/dL and in 13.2 percent of those with hemoglobin
8.2 to 9.1 g/dL. The placental hypertrophy is postulated to
be due to hypoxia, which is supported by evidence of similar
phenomenon at higher altitudes. In our studies maternal
anemia was associated with low maternal serum albumin.
Both deficiencies were associated with reduced weight and
volume of placenta. Placentae in maternal anemia showed
reduced number of cotyledons and increase incidence of
ill-defined cotyledons and eccentric attachment of cord.
There was increased shrinkage in formalin in pregnancy
anemia.23-26 This reduction in placental weight was due to
reduced DNA (cell number), however cell size was increased
(weight/DNA). In maternal hemoglobin RNA content per
cell remained constant.27 Placental succinic dehydrogenase
activity was decreased, total NADP-dependent ICDH was
more than NAD+dependant ICDH in severe maternal
hypoferremia; suggesting impaired citric acid cycle.2
Histology
There was decreased villous vascularity leading to fibrosis
with increased endarteritis obliterans reflecting response
to hypoxia. There was progressive decrease of surface
area and volume of villi per unit volume of blood vessel
in relation to degree of anemia; suggesting maturational
arrest.2,26,28,29 On treatment with iron there was increase
in hemoglobin, cord iron and placental (nonheme iron)
and placental shrinkage in formalin reduced. However,
the reduced villus vascularity, increased villus fibrosis
and endarteritis obliterans in placenta of anemic mother
did not reverse. It was postulated that moderate-severe
anemia present from the early days of pregnancy induces
irreversible structural alteration, as iron is needed in 2nd
week of pregnancy for placenta formation.2
FETUSNEWBORN
Cord serum iron and hemoglobin were reduced in preterm
as well as full term infants of hypoferremic mothers. There
is an increased gradient in presence of maternal iron
deficiency for transport of iron from mother to fetus but the
transport remains proportionate to the degree of maternal
hypoferremia. The weight of full term singleton babies
born of anemic mothers was reduced in direct relation
to hemoglobin level. Similarly these babies showed a
progressive decrease in Apgar scores also.2 Fetal liver iron
stores are reduced significantly in maternal hypoferremia.
Normally bigger the infant and more advanced the
gestational age higher was the amount of iron in fetal liver,
spleen and kidney. The tissue iron content increases steeply
in last 8 weeks of gestation. Infant born before 36 weeks of
gestation, had half the iron content in hepatic reserve.30
Breast milkiron content is increased in hypoferremic
mothers, a phenomenon of Physiological Trapping.31,32
To understand more a rat model was created with
latent iron deficiency (low hepatic iron with out change in
hematocrit) in pregnancy.33-38 Fetal brain iron content and
neurotransmitters in maternal (Rat) latent iron deficiency.
Iron as a micronutrient is required for regulation of brain
neurotransmitters by altering the pathway enzymatic
system. To study iron deficiency a rat model was developed
to create iron deficiency (low hepatic iron) without change
in hematocrit.33
In postweaning rats iron decreased irreversibly in
all brain parts except medulla oblongata and pons.
Susceptibility to iron deficiency showed variable reduction
in different parts of the brain: corpus striatum-32 percent,
midbrain 21 percent, hypothalamus 19 percent, cerebellum
18 percent, cerebral cortex 17 percent and Hippocampus
15 percent.
Alterations in brain iron content also inducedsigni
ficant alterations in Cu, Zn, Ca, Mn, Pb and Cd.34
Fetal Latent Iron Deficiency (Rat) and

Brain Neurotransmitters
In latent iron deficiency there was irreversible reduction in
neurotransmitters:
Brain Glutamate metabolism(GAD, GDH, GABA-T) 35,37

Marked reduction in levels of brain GABA, L-glutamic
acid and enzymes for biosynthesis of GABA and
L-glutamate like glutamate decarboxylase and gluta
mate transaminase.
Binding of H3 Muscimol at pH 7.5 and 1 mg protein/
assay (GABA receptor) increased by 143 percent,
but glutamate receptor binding decreased in the
vesicular membranes of latent iron deficient rats by 63
percent33,38
Brain TCA-cycle enzymes-mitochondrial NAD+
linked dehydrogenase significantly reduced.
Brain 5-HT metabolismtryptophan, 5-HT,
5-HIAA significantly reduced.
The whole brain and corpus striatum showed
reduction in catecholamine, dopamine nor-epine
phrine, tyrosine and monoamine oxidase, while
tyrosine aminotransferase increased in corpus
striatum, in spite of reduction in whole brain
suggesting that latent iron deficiency induced
irreversible neurotransmitter alterations.39
Brain catecholamine metabolismwhole braindopamine, neonephrine, tyrosine and TAT signi
ficantly reduced; in corpus striatumsame as in
whole brain, except TAT was increased.40
These changes were specific to iron deficiency
as neurotransmitter alterations in fetal brain due to
malnutrition get normalized partially or completely on
rehabilitation.41,42
The significant effects on neurotransmitter receptors
(glutamate mediators) during early stages of iron
deficiency clearly indicate the deficits in both excitatory
and inhibitory pathways of the central nervous system,
showing an important role of iron in brain.33
To test the above findings in humans, babies born of
moderate to severely anemic mothers were examined
for impact of iron deficiency on mental functions. The
intrauterine growth retarded offsprings of anemic as
well as undernourished mothers showed hypotonia in
72 percent and hypoexcitability in 56 percent.43-45
There was modification of responses in several
neonatal reflexes, e.g. limp posture, poor recoil of limbs,
incomplete Moros and crossed extensor responses.
Their EEG had shortening of sleep cycle (REM AND
NERM), the reduction was more marked for REM sleep.
There was some inter and intrahemispheric asymmetry
and abnormal paroxysmal discharges; suggesting
dysmaturity of brain.43,44
The above findings were not specific to affects of
anemia on mental functions. Therefore effects of anemia
(nutrition controlled) on mental functions were then
studied in rural children during a period of three years.
Mental functions in nutrition controlled 388 rural
Chapter-6 Effect of Maternal Iron Status on Placenta, Fetus and Newborn 39

primary school (68 years of age), matched for social and
educational statuses were studied by WISC and arithmetic
test to assess intelligence, attention and concentration.
Anemia does not affect intelligence, except subtest-digit
span. In arithmetic test, attention and concentration was
poor in anemic children.46
Effects of iron deficiency and/or anemiaon brain: iron
deficiency anemia in infancy has been consistently shown
to negatively influence performance in psychomotor
development. Short-term iron therapy did not improve the
lower scores, despite complete hematological replenish
ment. Neurological maturation was studied in infants
6 months old, including auditory brainstem responses and
naptime 18 lead sleep studies. The central conduction time
of the auditory brainstem responses was slower at 6, 12 and
18 months and at 4 years, despite iron therapy beginning
at 6 months. During sleep-wakefulness cycle, heart rate
variabilitya developmental expression of the autonomic
nervous systemwas less mature in anemic infants. This is
possibly due to altered myelination of auditory nerves.47 It
has been observed that these changes are resistant to iron
therapy in children <2 years of age with iron deficiency with
anemia, but not in older children.48
These studies supported our earlier findings that
brain functions are significantly affected in latent iron
deficiency in the brain growth period and such changes
are irreversible. These have serious consequences, e.g.
poor cognition and learning disabilities.
SUMMARY
The above researches by our group are mainly on effects
of maternal hypoferremia on iron status of placenta,
cord blood (hemoglobin and ferritin), and fetus (brain
and hepatic iron content). The rat model of latent iron
deficiency showed irreversible brain iron reduction and
irreversible neurotransmitter alterations in brain growth
period. Once anemia sets in, the additional effects are
due to anoxia. Our nation is faced with the problem of
iron deficiency that leads to anemiaa clinical condition
due to deficiency of many nutrientsmainly iron, folic
acid and vitamin B12. Folic acid is essential from prenatal
period its deficiency causes neural tube defects.
ACKNOWLEDGMENTS
Thanks are due to Professor Dev K Agarwal for valuable
suggestions. The Indian National Science Academy sup
ported part finances.
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fetal organs. Acta Paediatr Scand. 1985;74:701-6.
31. Khurana V, Agarwal KN, Gupta S, et al. Estimation of total
protein and iron content in breast milk of Indian lactating
mothers. Indian Pediatr. 1970;7:659-65.
32. Franson GN, Agarwal KN, Mehdin GM, et al. Increased
breast milk iron in severe maternal anemia: Physiological
trapping or leakage. Acta Paediatr Scand. 1985;74:290-1.
33. Agarwal KN. Iron and the brain: neurotransmitter
receptors and magnetic resonance spectroscopy. Brit J
Nutr. 2001;85(Suppl 2):S147-S50.
34. Shukla A, Agarwal KN, Shukla GS. Effect of latent iron
deficiency on metal levels of rat brain regions. Biol Trace
Elem Res. 1989;22:141-52.
35. Taneja V, Mishra KP, Agarwal KN. Effect of maternal iron
deficiency on GABA shunt pathway of developing rat
brain. Indian J Exptl Biol. 1986;28:466-9.
36. Taneja V, Mishra KP, Agarwal KN. Effect of early iron

deficiency in rat on the gamma-amino butyric acid shunt
in brain. J Neurochem. 1986;46:1670-4.
37. Shukla A, Agarwal KN, Shukla GS. Latent iron deficiency
alters gamma-amino butyric acid and glutamate
metabolism in rat brain. Experentia. 1989;45:343-5.
38. Mittal RD, Pandey A, Mittal B, et al. Effect of latent iron
deficiency on GABA and glutamate receptors. Indian J Clin
Biochem. 2002;17:1-6.
39. Shukla A, Agarwal KN, Chansuria JPN, et al. Effect of latent
iron deficiency on 5-hydroxytryptamine metabolism in rat
brain. J Neurochem. 1989;52:730-5.
40. Shukla A, Agarwal KN, Shukla GS. Studies on brain
catecholamine metabolism following latent iron defici
ency and subsequent rehabilitation. in rat. Nutr Res.
1989;9:1177-86.
41. Prasad C, Devi R, Agarwal KN. Effect of dietary proteins on
fetal brain protein and glutamic acid metabolism in rats.
Neurochem. 1979;32:1309-14.
42. Prasad C, Agarwal KN. Intrauterine malnutrition and the
brain. Effect of enzymes and free amino acids related to
glutamate metabolism. J Neurochem. 1980;34:1270-3.
43. Bhatia VP, Katiyar GP, Agarwal KN. Effect of intrauterine
nutritional deprivation on neuromotor behaviour of the
newborn. Acta Paediatr Scand. 1979;68:561-6.
44. Bhatia VP, Katiyar GP, Agarwal KN, et al. Sleep cycle
studies in babies of undernourished mothers. Arch Dis
Child. 1980;55:134-8.
45. Agarwal S, Agarwal A, Bansal A, et al. Birth weight
patterns in rural undernourished pregnant women Indian
Pediatrics. 2002;39:244-53.
46. Agarwal DK, Upadhyay SK, Agarwal KN, et al. Anaemia
and mental functions in rural primary school children.
Ann Trop Paediatr. 1989;9:194-8.
47. Walter E. Effect of iron-deficiency anemia on cognitive
skills and neuromaturation in infancy and childhood. Full
and Nutr Bull. 2003;24(4 suppl):S104-10.
48. McCann JC, Ames BN. An overview of evidence for a causal
relation between iron deficiency during development and
deficit in cognitive or behavioral function. Am J Clin Nutr.
2007;85:931-45.
Developmental Aspects of
Hemostasis in the Fetus and Newborn
Development of the hemostatic system in the human fetus has long been an area of interest and research. Hemostatic system starts
developing in the embryonic period and undergoes evolution in the postnatal period as well till adult levels are reached. As the
process spans over a long period of time, multiple age appropriate (gestational and postnatal age) reference ranges are necessary. An
understanding of development of hemostasis helps in diagnosis and management of hemostatic problems during childhood.
INTRODUCTION
The hemostatic system is functionally intact in healthy
full-term newborns and clinical presentation of bleeding
or clotting is seen only in sick newborns especially the
preterm infants. All the screening tests of coagulation are
prolonged in the plasma of healthy infants compared with
adult values, in the absence of bleeding. Stable preterm
infants have more prolonged values than the healthy full
term infants.
Plasma concentrations of various coagulation proteins
mature at different rates in the fetus and newborn. The
normal adult range may be achieved as early as midgestation for some proteins and as late as several months
after birth for others. Thus, the fetus demonstrates a
unique balance in levels of specific coagulation proteins
in the maintenance of hemostasis.
The vitamin K status of a newborn is precarious at
birth and may cause significant bleeding in the absence
of other problems. Complications of birth process may
result in birth asphyxia, which is an important cause of a
consumptive coagulopathy with significant bleeding.
EARLIEST EVIDENCE OF THE FETAL

HEMOSTATIC SYSTEM
Fibrinogen has been found in the fetal liver as early as
5th week of gestation. von Willebrand factor (vWF) can
be demonstrated in the endothelial cells of the placenta
from 4th week onwards, with successive detection in the

fetal bone marrow and tissues over the next four weeks.
Synthesis of coagulation proteins is among the most active
in the fetus after production of plasma proteins such as
albumin.
COAGULATION SYSTEM
Coagulation Proteins
It has been demonstrated that the blood of fetuses does
not clot before 10 to 11 weeks of gestation. Thereafter, the
clotting time rapidly becomes equal to the adult values
or even less. Fibrinolytic activity can be detected by 10
to 11 weeks gestation and thereafter is similar to adult
values or even greater (indicating shorter lysis times). The
coagulation proteins do not cross the placenta or do so in
negligible quantities and need to be independently
synthesized by the fetus. Results obtained on healthy
full-term infants are significantly higher than are those
documented on healthy full-term fetuses in utero.
Similarly, prematurely born infants have higher levels
of coagulation proteins than their age matched counterparts in utero indicating fast maturation of the coagulation
system soon after birth.
Levels of factor V approximate the adult range by 12 to
15 weeks. Plasma concentration of fibrinogen reaches 100
mg/dL by 12 to 15 weeks of gestation. Plasma concentration
of most coagulation proteins are maintained at a constant
level throughout gestation until some time after 33 weeks,
when a maturational burst happens. From 19 weeks
onwards, all the coagulation proteins except factor V, VII,
VIII, XII, and antithrombins circulate at 50 to 100 percent
of the level achieved by full term. Factor V, VII, VIII, XII,
and antithrombins increase steadily throughout the
second and third trimesters.
The levels of vitamin K dependent factors and the
contact factors (XI, XII, prekallikrein and high molecular
weight kininogen) gradually increase to those approaching
adult levels by six months of life. The low levels of contact
factors are partly responsible for the prolonged APTT
during the first months of life. Plasma levels of fibrinogen,
factor V, VIII, XIII and von Willebrand factor are similar
to adult values at birth. Fibrinogen levels continue to
increase after birth. Plasma levels of factor VIII at birth
are towards the higher range of normal and levels of both
vWF and high molecular weight multimers are increased
at birth and remain so till three months of life.
Reduced production of coagulation factors and
increased clearance of plasma proteins leads to the
differences in the level of various plasma proteins.
Premature infants have accelerated clearance of fibrinogen
which can be attributed in some part to their increased
basal metabolic rate. Fetal fibrinogen has an increased
content of sialic acid which accounts for the differences in
its structure and function as compared to adult fibrinogen.
Regulation of Thrombin
Newborns have delayed and decreased regulation of
thrombin compared with adults. The amount of thrombin
generated is directly proportional to the concentration of
prothrombin and the rate of thrombin generation depends
on the concentration of other procoagulants.
Thrombin is directly inhibited by antithrombin (AT),
heparin cofactor II (HC II), and alpha 2 macroglobulin.
Alpha 2 macroglobulin is a more important inhibitor of
thrombin in plasmas from newborns as compared to
plasma from adults. The rate of inhibition of thrombin
is slower in newborn infants than it is in adults plasma
concentrations of protein C are very low at birth, and
remain decreased during the first six months of life.
Neonates have a two fold increase in the single chain form
of protein C, compared with the double chain form that is
predominant in adults and no difference has been found
in the functioning of the two forms. Newborns have lower
levels of total protein S at birth but functional activity is
similar to that in the adult because in newborns, protein
S is completely present in the free, active form due to the
absence of C4 binding protein. The interaction of protein S
with activated protein C in the newborn plasma is regulated
with by the increased levels of alpha 2 macroglobulin.
Plasma levels of thrombomodulin are increased in early

childhood, and decrease to adult values by the late teenage
years. Total tissue factor pathway inhibitor (TPFI) levels in
newborn infants are same as in older children or adults,
but free TPFI is significantly lower. Thrombi in newborn
infants do not propagate with the same propensity as in
adults, due to significantly low levels of fibrinopeptide A in
cord plasma.
PLATELETS
Mega-karyocytes appear in the liver at 8 weeks gestation
and platelets can be found in fetuses from 11 weeks
gestation. Initially the platelets are large and beyond 12
weeks the mean platelet volume is essentially normal.
Cord blood of preterm babies has increased number of all
megakaryocyte precursors as compared with term babies
and term infants have higher circulating megakaryocyte
progenitor numbers at birth compared with adults.
After 20 weeks of gestation, the platelet counts and the
mean platelet volume are similar to those in adults with
values between 1.5 and 5.5 lakh per cu.mm and 7 to 9 fL
respectively. The platelet function in term and preterm
babies has been found to be impaired in vitro.
The most consistent abnormalities are reduced
aggregation in response to adrenaline, ADP and thrombin.
Electron microscopic studies on cord platelets have shown
normal number of granules, however, the concentration
of serotonin and adenosine diphosphate (ADP), which are
stored in dense granules, is less than 50% of adult values.
GP Ib is present on fetal platelet membrane in adult
quantities, however GP IIb/IIIa is significantly reduced.
Despite these differences, the bleeding time is normal in
term and preterm infants.
Newborns have higher levels of thrombopoietin in the
cord blood as compared to adult values. The relatively
higher hematocrit of neonatal blood contributes to
increased blood clotting by increasing the number of
platelets directed to the vessel wall by virtue of laminar flow
and by offering a larger surface for the formation of fibrin
clots. vWF facilitates adhesion of platelets to collagen, and
it reaches normal adult values by 20 weeks gestation. At
full term, it has a higher total concentration and increased
number of larger (stickler) UlvWF.
Platelet receptors in the fetus mature around 12
to 16 weeks gestation except for decreased coupling
of epinephrine receptors. In response to activators,
the granular release is decreased in the fetus due to
diminished calcium channel transport and impaired
signal transduction. Platelets get activated during the
birth process by interplay of various factors which
include thermal changes, hypoxia, acidosis, adrenergic
stimulation and the thrombogenic effects of amniotic fluid.
Chapter-7 Developmental Aspects of Hemostasis in the Fetus and Newborn 43

Cord plasma levels of thromboxane B2, thromboglobulin
and platelet factor-4 are increased, the granular content
of cord platelets is decreased and epinephrine receptor
availability is reduced.
Bleeding Time
Infants during the first week of life have significantly
shorter bleeding times as compared to those in adults.
Enhanced platelet and vessel wall interaction, higher
plasma concentrations of vWF, enhanced function of vWF
due to a disproportional increase in the high molecular
weight multimeric forms, active multimers, large red cells
and high hematocrits all contribute to the shorter bleeding
time in infants.
VESSEL WALL
The endothelial cells and extracellular matrix components
of the vessel wall have procoagulant and anticoagulant
properties which are significantly influenced by age and
have a significant bearing on the hemostasis. One of these
anticoagulant properties is mediated by lipoxygenase and
cyclo-oxygenase metabolites of unsaturated fatty acids.
Prostaglandin I2 (PGI2) production from cord vessels
is higher than that of adult vessels. Levels of soluble
endothelial cell adhesion molecules and selectins are
also age dependent, due to differences in development
of endothelial cell expression and secretion of these
molecules. Nitric oxide (NO) modulates vascular tone in
fetal and postnatal lungs and is responsible for the normal
decline in pulmonary vascular resistance at birth. NO is a
potent inhibitor of platelet adhesion, aggregation
and stimulates disaggregation of platelet aggregates.
NO interacts with PGI2 and other metabolites of the
lipoxygenase pathway to modulate platelet function.
ANGIOGENESIS
Angiogenesis plays an important role in development
of the alveoli in the fetal and neonatal lung. Angiogenic
factors-angiogenin, basic fibroblast growth factor (bFGF)
and vascular endothelial growth factors (VEGF) in the
serum increase soon after birth.
FIBRINOLYTIC SYSTEM
Plasminogen levels in the neonates are approximately 50
percent and antiplasmin (AP) levels are approximately 80
percent of the normal adult values. Plasma concentrations
of plasminogen activator inhibitor-1 (PAI-1) and tissue
plasminogen activator (TPA) are significantly higher as
compared to adults due to enhanced release of these
two factors from the endothelium shortly after birth. The
enzymatic activity of fetal plasmin and its binding to

cellular receptors for fetal plasminogen is decreased but
still clot lysis is more rapid in fetal plasma due to decreased
inactivation of fetal plasmin by alpha-2 antiplasmin. The
proof of activation of the fibrinolytic system at birth lies
in the short whole blood clotting times, short euglobulin
lysis times (ELTs) and increased plasma concentrations of
fibrin related peptides.
CONCLUSION
Decreased concentration and activities of coagulation
proteins is responsible for the mild prolongations of all
the screening tests detected in healthy full-term infants.
Except for vWF, factors V, VIII and fibrinogen. All other
plasma coagulation proteins are generally low in the
newborn. These four coagulation proteins which are
all within or above the normal adult range at full-term
gestation, together with hematocrit, platelet number
and platelet adhesiveness make a major contribution to
hemostatic potential in the neonate and are to a certain
extent responsible for the hypercoagulability observed in
sick infants.
Full-term newborn infants have a balanced and
intact hemostatic system, despite apparent deficiencies
of procoagulant, regulatory and fibrinolytic activities.
The neonatal hemostatic system lacks adequate reserve
capacity to cope with massive stresses of low blood flow,
acidosis and sepsis, which becomes a clinical challenge in
the sick preterm infant.
Fetal hemostasis is a dynamic system that gradually
evolves by stages towards the adult state, but always
maintains equilibrium between activators and inhibitors
throughout intrauterine life until birth. The vascular
and hemostatic systems of the fetus and neonate are
continually evolving and this must be taken into account
when evaluating these systems for dysfunction.
SUGGESTED READING
1. Andrew M, Paes B, Milner R, Johnston M, Mitchell L,
Tollefsen DM, Castle V, Powers P. Development of the
human coagulation system in the healthy premature
infant. Blood. 1988;72:1651-7.
2. Andrew M, Paes B, Milner R, Johnston M, Mitchell L,
Tollefsen DM, Powers P. Development of the human
coagulation system in the full-term infant. Blood.
1987;70:165-72.
3. Elizabeth A Chalmers, Michael D Williams, Thomas A.
Acquired disorders of hemostasis. In: Robert J Arceci, Ian
M Hann, Owen P Smith, eds. Pediatric Hematology, 3rd
edn. USA:Blackwell Publishing Ltd. 2006.pp.624-42.
4. Ignjatovic V, Mertyn E, Monagle P. The coagulation
system in children: Developmental and pathophysiologic
considerations. Semin Thromb Hemost. 2011;37(7):723-9.
5. Lippi G, Franchini M, Montagnana M, Guidi GC.
Coagulation testing in pediatric patients: the young
are not just miniature adults. Semin Thromb Hemost.
2007;33(8):816-20.
6. Lippi G, Salvagno GL, Rugolotto S, Chiaffoni GP, Padovani
EM, Franchini M, Guidi GC. Routine coagulation tests
in newborn and young infants. J Thromb Thrombolysis.
2007;24(2):153-5.
7. Monagle P, Ignjatovic V, Savoia H. Hemostasis in
neonates and children: pitfalls and dilemmas. Blood Rev.
2010;24(2):63-8.
8. Parmar N, Albisetti M, Berry LR, Chan AK. The fibrinolytic

system in newborns and children. Clin Lab. 2006;52(34):115-24. Review.
9. Poralla C, Traut C, Hertfelder HJ, Oldenburg J, Bartmann
P, Heep A. The coagulation system of extremely preterm
infants: influence of perinatal risk factors on coagulation. J
Perinatol. 2012;32(11):869-73.
10. Sentilhes L, Leroux P, Radi S, Ricbourg-Schneider A,
Laudenbach V, Marpeau L, Bnichou J, Vasse M, Marret
S. Influence of gestational age on fibrinolysis from birth to
postnatal day 10. J Pediatr. 2011;158(3):377-82.
8
Anemia in the Newborn
Jayashree Mondkar, Shilpa Sanjay Borse, MR Lokeshwar
INTRODUCTION
Pediatricians caring for sick/full term/premature newborn
infants are often confronted with a variety of routine as
well as life-threatening hematological problems. Anemia
in neonatal period remains a cause for concern due to
likelihood of rapid decompensation in this vulnerable
group. Numerous physiological changes occur in
succession and rapidity in fetus and neonate, as the
erythrocyte system in utero undergoes serial adaptation
to meet progressively changing demand for oxygen from
embryo stage to term. Thus, there is rapid change in
normal hematological parameters from fetal period to
immediately after birth and throughout neonatal period
even hours, days and weeks after birth.1-5
An understanding about the basic physiology of
hematopoiesis and appreciation of normal hematologic
and laboratory values at birth is important because they
form the basis for the diagnosis, treatment and prevention,
of many diseases that afflict these neonates. Interpretation
of laboratory findings and institution of appropriate
therapy requires understanding of maturational process
and normal physiological variations that takes place
during this period.1-5
ANEMIA
Anemia in the term infants is defined as a hemoglobin
value of less than 13.5 g/dL during the first week of
life. Values for umbilical artery blood tend to be about
0.5 g/dL higher than sample obtained from umbilical
vein. Preterm infants have lower baseline values. Capillary
specimens obtained by heel stick have higher hemoglobin
and hematocrit values than samples obtained from the
umbilical vein or peripheral blood.4-9
Beyond the first weeks of life many factors influence

what is considered as normal hematological parameters
in newborn period. Hb concentrations decrease in both
normal term and preterm infants after birth to reach
minimal levels of 9.4 to 14.5 g/dL in term infants by 7 to 9
weeks of age.1,4,5
Physiological Anemia
This physiological anemia1,3-6 occurs because of a decline
in erythrocyte mass due to the following reasons:
During intrauterine period the fetal oxygen saturation
is low at around 45 percent, erythropoietin levels are
high and RBC production is rapid. Reticulocyte counts
are 3 to 7 percent reflecting ongoing erythropoiesis.
With improved oxygen saturation to 95 percent after
birth, the erythropoietin levels become undetectable
hence RBC production stops, reticulocyte counts are
low and the hemoglobin level falls.
This factor coupled with a reduced lifespan of fetal
RBCs, results in anemia that is not a functional one as
oxygen delivery to the tissue is adequate.
At 8 to 12 weeks, hemoglobin levels reach their nadir,
oxygen delivery to the tissues is impaired, erythropoietin
production is stimulated and hemoglobin starts increasing.
Hemoglobin values rise from 8 to 10 g/dL at 12 weeks of
gestation to 13.7 to 20.1 g/dL (mean of 16.8) at term.1,5
The hemoglobin and RBC count fall earlier and to a
greater extent in preterm infants leading to Anemia of
Prematurity.
Anemia of Prematurity
Anemia of prematurity (AOP)6,8-12 is an exaggeration of
the physiologic anemia of infancy. The hemoglobin and
RBC count fall earlier and to a greater extent as low as
7.8 to 9.6 g/dL in preterm infants leading to Anemia of
Prematurity. Shortened survival of RBCs to an average of
60 days (120 days life span in adult RBCs) and rapid body
growth with relative hemodilution are the contributory
factors. Besides, iatrogenic blood losses may be higher.
Premature infants may require additional folate and B12
to reduce severity of anemia of prematurity.9,10 Vitamin E
deficiencies is more common in small preterm infants.11
Pathological anemia in neonate may be caused by wide

spectrum of diseases and could be due to
Hemorrhage12-25
Hemolysis, increased RBC destruction26-36
Failure of red cell production.37-42
Nutritional anemia is not a cause of anemia during
neonatal period (unlike in older children) even when the
mother is severely iron deficient, as fetus is an effective
parasite of the mother. Anemia in the newborn often
accompanies and is complicated by conditions like asphy
xia, shock, jaundice which make the situation even worse.
Rupture of normal umbilical cord, rupture of anomalous

insertion of the cord and hematoma of the cord
containing large amount of blood, aneurysm of cord.
Malformation of placenta and cord velamentous
insertion, vasa previa.
The most common cause of anemia at or around the
time of birth is due to fetal blood loss associated with
conditions like placenta previa and accidental hemorrhage
due to abruptio placentae.14,15 When there is partial
separation of the placenta, blood loss is predominantly
maternal, however some fetal sinuses in the placenta
may rupture causing fetal blood loss and anemia. Also,
maternal blood loss and hypotension causes vasodilatation
in placental vessels causing placental pooling of blood,
thereby aggravating fetal hypovolemia. This abnormality
is more common in multiple pregnancies and incidence
of hemorrhage is seen between 1 and 2 percent.
Umbilical cord anomalies like venous tortuosity or
arterial aneurysm may lead to bleeding if injured.
Unattended precipitous delivery may lead to rupture
of normal umbilical cord. When cord ruptures, the tear
generally occur in fetal third and bleeding is immediate
and profuse.12,15
ETIOLOGY
Other Causes of Hemorrhage Includes
Hemorrhage12-25
Fetomaternal hemorrhage15-19,21,22
Fetoplacental hemorrhage14,15
Fetofetal hemorrhage23,24
Nonphysiologic Anemia in Neonate
Profound anemia appearing at birth or during first

24 hours of life is most often due to hemorrhage or
isoimmune hemolytic disorder. Bleeding in the newborn
though is often visible and evident, but if it occurs inside
the bodygastrointestinal tract and in the body cavity,
may not be recognized and may go unnoticed initially.
High index of suspicion in an anemic neonate without
jaundice and with negative direct Coombs test will help in
suspecting diagnosis of acute hemorrhage.
Degree of anemia depends upon whether acute or
chronic.
Incidence of Hemorrhage in Newborn12-25

Twenty-five percent of all infants admitted to neonatal
intensive care.
Five to ten percent of all severe neonatal anemias are
due to hemorrhage.
One percent of all newborn nursery admissions.
Anemia due to hemorrhage may occur in utero, during
labor and delivery or after birth.
Obstetric Causes of Blood Loss12,13,15,16

Abruptio placenta22/placenta previa
Incision of placenta at cesarean section
Fetomaternal Hemorrhage15-19,21,22
The passage of fetal erythrocytes in maternal circulation
occurs commonly during pregnancy.
In 50 percent of pregnancies some fetal cells are passed
in maternal circulation at some times during gestation
or during birth process.
In about 8 to 10 percent of pregnancies transplacental
blood loss ranges from 0.5 cc to 40 mL of blood.
In about 1 percent of cases the loss may be even greater
as much as 100 mL.
It may be acute or chronic in nature.
Fetal hemorrhage may also occur in substances of
placenta or may result in retroplacental hemorrhage.
More common type of fetomaternal hemorrhage
occurs when infant is held above placenta as during
cesarean delivery. Anemia has been reported when infant
is held above the placenta before clamping the cord. Blood
is continuously returned through the umbilical arteries to
the placenta, while hydrostatic pressure prevents continued
venous return to the infant.
When infant is held above the introitus the placental
transfusion is either markedly reduced or completely
prevented.
Chapter-8 Anemia in the Newborn 47

In infants born by cesarean section, it is advisable
to keep the baby at least 20 cm below the placenta for
approximately 30 seconds before clamping the cord.
Other causes of fetomaternal hemorrhage
Diagnostic amniocentesis10 to 32%.16,17
When infant is held above placenta during delivery
(particularly after cesarean section) before cord is
clamped
Traumatic injury to mother during pregnancy second
ary to
Vehicular accidents
Fall
Abdominal trauma
Application of fundal pressure during 2nd stage of
labor.
Maternal toxemia.
Erythroblastosis fetalis.
Placental chorioangioma and choriocarcinoma seen
in 1 percent of placenta.
Chronic causes of fetomaternal hemorrhage:18,19 Anemia
in fetus occurs slowly if hemorrhage occurs repeatedly
during course of pregnancy. Fetus tries to compensate
and adjust hemodynamically and infant when born may
present only with pallor, unexplained anemia and mild
hepatosplenomegaly. Chronic blood loss may lead to iron
deficiency anemia with hemoglobin values ranging from
4 to 6 gm/dL.18,19,22
High index of suspicion in an anemic neonate without
jaundice and with negative direct Coombs test will help
in suspecting diagnosis of acute hemorrhage. Degree of
anemia depends upon whether acute or chronic.
Diagnosis of fetomaternal hemorrhage:16-19 It is
confirmed by demonstrating the presence of fetal blood in
maternal circulation by
Kleihauer Betkes test (Fig. 1)
Differential hemagglutination
Mixed agglutination
Fluorescent antibody technique.
All tests are sensitive and are capable of detecting as
little as 0.1 cc of fetal blood in mothers circulation.
Kleihauer Betkes test may be false positive in
Maternal thalassemia minor
Sickle cell anemia
Hereditary persistence of fetal hemoglobinopathy.
If ABO blood group incompatibility is associated
diagnosis can be missed as infants A or B cells are rapidly
cleared from maternal circulation by maternal anti-A and
anti-B antibodies. The amount of blood lost in a fetomaternal hemorrhage, can be calculated by the following
formula:
Fig. 1 Kleihauer Betkes test: Dark pink color fetal cells in mothers
smear in a case of fetomaternal transfusion

Fetal RBC 240
Cc of fetal blood =
Maternal RBCs

Or 1 fetal RBC in 1000 maternal RBCs indicates 2 cc of fetomaternal hemorrhage.
Causes of fetoplacental hemorrhage:14-19,21 Multi-lobed
placenta may be associated with vasa previa(anomalous
vessels crossing the os) vessels may be well compressed
as well as lacerated during the 2nd stage of labor. The
prenatal mortality rate range varies 50 to 80 percent.
Fetofetal hemorrhage (Twin-to-twin transfusion):23,24
Simultaneous occurrence of anemia in one of the twins
and polycythemia in other should always arouse a
suspicion of twin-to-twin transfusion. Fetal transfusion is
seen in monozygotic twins with monochorial placentae.
Seventy percent of monozygotic twins have monochorial
placentae. Fifteen to thirty-three percent of such
pregnancies have feto-fetal transfusion.
Accidental Incision of Placenta or Umbilical

Cord During Cesarean Section
Lower segment cesarean section with anterior placenta
can result in direct placental injury. The placenta and
membrane should always be examined for the damage
from the fetal side following cesarean section. Hemoglobin
of the infant should be estimated at birth and again
12 to 24 hours later. Hemoglobin should also be estimated
in all neonates born to mothers with unusual vaginal
bleeding, placenta previa or abruptio placenta. Anemia
following obstetric accidents may not be realized if proper
attempt is not made to examine the placenta and cord in
time before disposing off the placenta and evidence of
cause of anemia may be lost.
Anemia in the newborn may follow hematoma of
the cord containing large amount of blood.25 Rupture of
umbilical cord, or of aneurysm of cord or aberrant vessels
and due to velamentous insertion. This abnormality is
more common in multiple pregnancies and incidence of
hemorrhage is seen between 1 and 2 percent. Umbilical
cord anomalies like venous tortuosity or arterial aneurysm
may lead to bleeding if injured. The condition is 10 times
more common in twin than in single term pregnancy.
Perinatal death rates in such situations are about 50 to 80
percent. Many are stillborn.
Hemorrhage in the postnatal period25
Unattended precipitous delivery may lead to rupture
of normal umbilical cord. When cord ruptures
tear generally occurs in fetal third and bleeding is
immediate and profuse. Severe bleeding may result in
stillbirth; may manifest with severe respiratory distress
and asphyxia.
Hemorrhage may be due to birth trauma resulting in
intracranial bleeding cephalhematoma, subgaleal
hemorrhage, retroperitoneal hemorrhage.
Therefore anemia in neonates from intensive care

unit may be caused by frequent blood sampling. It should
be remembered that removal of 8 to 10 cc of blood from
1500 gm neonate constitute 8 percent of the blood volume
which is equivalent to about 400 cc blood from the adult.
Vitamin K deficiency bleeding: Vitamin K is necessary
for synthesis of coagulation factors II (prothrombin), VII,
IX and X in the liver. Newborns are relatively vitamin K
deficient. Poor placental transfer of vitamin K, low vitamin
K stores at birth, low levels of vitamin K in breast milk, and
sterility of the gut are contributory factors. Bleeding can
occur from different sites, though GI bleeding is the most
common manifestation as hematochezia, hematemesis.
Hematuria, oozing around the umbilical cord, bleeding
from circumcision, and venipunctures may occasionally
occur. Hematomas at sites of trauma, such as large cephalhematomas and bruising, are also common findings.
Intracranial bleeding may occasionally occur. Significant
bleeding due to vitamin K deficiency bleeding and other
inherited bleeding disorders may result in severe anemia
in the newborn.
Other common causes

Slipped ligature.
Bleeding disorder in the neonate.
Hemorrhagic disease of newborn, now called vitamin K
deficiency bleeding.
Sepsis with DIC.
Intrauterine TORCH infections.
Iatrogenic anemia due to excessive blood sampling.
Various studies have shown that blood withdrawal for
investigations during first few weeks can range from 5 to
45 percent of total blood volume or 50.5 mL/kg per 28 days
period hospitalization.
1 mL of blood represents 1 percent of total blood
volume particularly in premature neonates
Blood lost during the sampling may be estimated by
recording the amount of blood collected in mL and by
weighing the cotton swab on an electronic weighing
machine, as two drop of blood in the cotton used
to stop bleeding represents 100 m of blood loss. Ten
percent of blood loss during sampling for laboratory
monitoring is hidden and represents blood on cotton
swabs, in the dead space of syringe or tubing of the
butterfly needle.
Blanchette and Alvin Zupersky7 in their study of 52
premature infants studied during first 6 weeks of life
reported mean blood loss through sampling 22.9 10
mL of packed cells. Forty-six percent of infants studied
had cumulative losses that exceeded their circulating
red cell masses at birth.
Diagnostic tools for complete blood count (CBC) for

diagnosing anemia
Manual counting techniques. Not reliable, not
reproducible
Electronic impedance principles/light scanner
principles.
Advantages of electronic methods
Accurate
Reproducible
Number of indices available in a short time.
Peripheral smear examination: In acute hemorrhage,
peripheral smear (PS) may show normochromic,
normocytic RBCs, whereas in chronic blood loss hypo
chromic, microcytic anemia.
Increased retic count and number of nucleated RBCs
are seen in both acute and chronic hemorrhage.
In chronic hemorrhage, the serum iron values are
decreased and in acute may be normal.
Hyperbilirubinemia is differentiating feature in anemia
of hemolysis versus hemorrhage. However, when there is
bleeding in tissues or body cavities, hyperbilirubinemia
may also occur in the latter situation.
Bone marrow aspiration if done may show no stainable
iron. However, bone marrow aspiration is not indicated
for diagnosis.
CLINICAL FEATURES
Acute Blood Loss
Clinical features depend on the rapidity of blood loss
and amount of loss of blood. Degree of anemia depends
upon whether blood loss is acute or chronic. Complete
obstetrical history gives clue to diagnosis.
In history of vaginal spotting during last trimester or
prior to delivery, suspect placenta previa.
Following acute hemorrhage Hb may not drop in
first 6 to 24 hours. Several hours may elapse before
profound anemia is documented. Even if Hb is
initially normal, neonate should be repeatedly
followed up closely during next 12 to 24 hours and
falling Hb may be noticed after some time due to
hemodilution that accompanies. If the neonate is in
shock, Hb determination should be performed on
venous blood as capillary Hb may be misleadingly
high. The infant looks pale, sluggish, gasping and
with features of circulatory shock. If 20 percent or
more blood is lost acutely, the signs and symptoms
of shock are present.
Jaundice is absent and bilirubin levels do not increase.
Mother may present with shaking chills as consequence
of transfusion reactions when there is blood group
incompatibility. This may result in stillbirth.
Examination of placenta and cord should be performed
before it is thrown to ascertain the site of blood loss.
Traumatic deliveries result in:

Subdural hemorrhage
Subarachnoid hemorrhage
Cephalhematoma
Blood loss in subaponeurotic area of the scalp.
Subaponeurotic
hemorrhage
usually
extends
throughout the soft tissue of the scalp and covers entire
calvaria and this blood loss can lead to exsanguination
and death. Boggy swelling of the head extending from
frontal region to nape of the neck may be present and
may be associated with the swelling of the eyelids. Hb
may drop as low as 2.2 g/dL at 48 hours of age and
infant may be in shock. It can be estimated that for
each centimeter of increase in head circumference
above that expected, 38 mL loss of blood and may also
develop hyperbilirubinemia.12,13
Other Hemorrhages12,13,25
Adrenal hemorrhage: Clinical picture including sudden
collapse, cyanosis, limpness, irregular respiration, presence
of flank mass accompanied by bluish discolora
tion of
overlying skin should suspect of adrenal hemorrh
age.
Presence of the free fluid can be demonstrated by clinical

examination as well as an ultrasound evaluation. Jaundice
may appear due to breakdown of RBCs from these
entrapped hemorrhages.
Splenic hemorrhage: Splenic hemorrhage should be
kept in mind in large babies with pallor, abdominal
distension, scrotal swelling and radiographic evidence of
peritoneal effusion following difficult delivery or in babies
with erythroblastosis fetalis. Umbilical venous pressure is
decreased rather than increased.
Hemorrhage may be subcapsular or free blood may be
present in the peritoneal cavity.
An infant with ruptured liver is generally normal for first
24 to 48 hours and suddenly goes into shock, as hematoma
ruptures the capsule, causing hemoperitoneum. Mass in
the right hypochondrium may be palpable.
Severe fetal bleeding may result in stillbirth; or may
manifest with severe respiratory distress and asphyxia
in the newborn. It is important to differentiate pallor
resulting from severe anemia from perinatal asphyxia.
ETIOLOGY
Anemia Due to Increased RBC Destruction
(Hemolytic Anemia)
Anemia as a consequence of hemolytic process is common
in the newborn period. A hemolytic process is defined as a
pathologic shortening of the life span of the red blood cell.
The normal life span of adult RBC is 120 days. However,
red cell life survival in term infants may be 60 to 80 days
and in 32 to 36 weeks gestation preterm babies cells may
survive only 35 to 70 days. Since destruction of 1 g/dL of
hemoglobin results in production of 35 mg of bilirubin,
hemolytic anemia in the newborn is always associated
with significant hyperbilirubinemia.
Causes of Hemolytic Anemia of Newborn27-37

Immune Hemolysis26-31
Allo/isoimmunization: Rh, ABO, minor group
Autoimmune: Autoimmune anemia due to passive
transplacental transfer of maternal antibodies.
Nonimmune Hemolysis32-36
RBC membrane defects32,33 (Hereditary spherocytosis,
elliptocytosis, stomatocytosis, etc.)
Enzyme defects (G6PD deficiency, pyruvate kinase
deficiency, glucose phosphate isomerase deficiency)34,35
Hemoglobinopathies36 (alpha thalassemia/structural
defects); beta thalassemia.
Hemolytic Disease of Newborn

Hemolytic anemia of newborn should be suspected
when there is
A rapid fall of hemoglobin concentration in the absence
of evidence of hemorrhage in early neonatal period
Evidence of increased red cell production: Reticulocytosis
and increased normoblasts in prognostic signs
Jaundice during first 24 to 48 hours of life
Abnormal erythrocyte morphology
Hemoglobinuria
Positive direct Coombs test.
Causes of Hemolytic Disease of Newborn

Isoimmunization, ABO/Rh (minor) blood group
incompatibility26-31
Congenital or acquired defects of RBCs32-36
Isoimmunization:26-31 Hemolytic disease of newborn as
a consequence of isoimmunization is caused by passage
of fetal red cells into the maternal circulation where they
stimulate the production of antibodies. Placental transfer
of these maternal antibodies directed against fetal red cell
antigens is the most common cause of neonatal hemolysis.
These antibodies of IgG class return to fetal circulation,
attach to the antigenic site on the fetal red cells leading to
hemolysis of these cells.
In this group of disorders, fetal and/or neonatal red
blood cell hemolysis results from the presence of maternal
antibodies to the red cell antigens in fetal circulation.
Rh isoimmunization: When an Rh negative mother
conceives an Rh positive baby, fetal red cells may cross
the placenta and sensitize the maternal immune system.
On subsequent exposure to Rh positive cells across
the placenta, the antibodies produced by the maternal
immune system may cross the placenta and cause
hemolysis of fetal red cells. As few as 0.2 mL of fetal cells
are sufficient to cause maternal anti-D sensitization.26,27,29
The initial IgM response is slow and weak. As IgM does
not cross placenta, no fetal effects are seen. On second
exposure to RhD, IgG antibodies formed readily cross
the placenta, into fetal circulation and binds to the RhD
antigen on fetal RBC membrane. Antibody coated fetal
red cells adhere to macrophages and lead to eventual
destruction of the cell. This hemolytic process can take
place starting in utero, resulting in marked compensatory
over production of nucleated red cells. During pregnancy
fetomaternal transfusion may occur spontaneously in
about 7 percent of cases in the first trimester,16 percent
in the second trimester and 29 percent in the third
trimester and in as much as 50 percent in the peripartum
period, leading to the formation of anti-D IgG antibodies
in the mother. Hence, the second and the subsequent

pregnancies have a higher chance of being affected.
In severely sensitized pregnancies, fetal marrow cannot
keep up with red cell destruction and extra-medullary
erythropoiesis resulting in hepatosplenomegaly occurs,
nucleated cells are poured into the circulation, giving this
disorder the name Erythroblastosis Fetalis.
Though Rh isoimmunization was the most common
cause of hemolytic anemia in the newborn in the past,
this condition is fast disappearing due to adequate
immunization of Rh negative mothers with anti-D.
ABO incompatibility:26-31 ABO incompatibility is
common and occurs in approximately in 20 percent of all
pregnancies. In only 1:1000 births, severe disease occurs.
ABO incompatibility has a similar pathophysiology but
is a relatively milder disease. Group O mothers have
a predilection for producing IgG antibodies against
antigens A and B as against the normally produced IgM
type. Antibody titers are usually >1:64. This is predilection
may run in families. Mothers may be produced as an
immune response to A and B antigens contained in food,
bacteria and vaccines. The presence of naturally occurring
antibodies in the maternal serum explains the frequent
occurrence of ABO hemolytic disease in first born infants
in contrast to Rh D disease in subsequent gestations.
A direct Coombs test usually positive in Rh
incompatibility and may be weakly positive in ABO
incompatibility.
Peripheral blood smear shows polychromasia,
increased number of erythroblasts.
In ABO incompatibility increased number of microspherocytosis may be seen on peripheral blood smear
examination.
Laboratory investigations will reveal blood group
incompatibility.
Levels of IgG, anti-A, or anti-B antibodies in the
mothers of babies with ABO hemolytic disease are
significantly higher than in the mother whose infants
do not have the disease increased.
Alloimmunization due to Minor Group Incompatibi
lity.29,31 Alloimmunization can occur due to a variety of
other fetal red blood cell antigens.
Rh blood group system, cc, ee, ec, ce, of the among
the antigens Rh group alloimmunization with E and C
occurs most frequently after anti-D sensitization
The principal antibodies found are anti-E, anti-C, antiKell, Duffy, Kidd, Fu, MNSs, etc.
Alloimmunization to the accounts for up to 10 percent
of severely affected fetuses. As the Kell antigen is expressed
on the surface of erythroid progenitors, whereas D antigen
is not, Kell sensitization in addition to causing hemolysis,
results in suppression of erythropoiesis.

While in utero, excess of bilirubin produced by
hemolysis is removed by the placenta hence at the time of
birth, child may not be jaundiced. Jaundice usually appears
in the first 24 to 48 hours of life as neonatal immature
liver is not in a position to conjugate excessive bilirubin
load. Significant hyperbilirubinemia is evident. It may be
accompanied by anemia and hepatosplenomegaly.
Hemolytic disease due to minor blood group incompatibility
should be suspected when Coombs test is positive and there
is no evidence of major blood group incompatibility in mother
and child. The principal antibodies found are anti-E, anti-C,
anti-Kell, Duffy, Kidd, Fu MNS systems.
Management:28,29 Management of severely affected iso

immunized fetus consists of early delivery with or without
fetal transfusions depending upon gestation of fetus.
Management of neonate depends on degree of hemolysis
and level of indirect hyperbilirubinemia.
All Rh negative mothers with Rh positive fetus,
should be given Rh immunoglobulin at 28 to 30 weeks
of gestations and within 72 hours after delivery and after
spontaneous or therapeutic abortion. Hyperbilirubinemia
must be aggressively treated to prevent kernicterus with
phototherapy, exchange transfusion. Whenever required
top-up transfusion with packed red blood cells may be
given for symptomatic anemia.
Autoimmune hemolytic anemia
Anemia may be due to warm or cold antibodies
which signify the temperature at which antibodies
become active. The rare combination of autoimmune
hemolytic anemia (AIHA) and pregnancy carries great
risks to both the woman herself and the fetus.
The degree of hemolysis in the fetus depends mainly
on the amount and avidity of the transferred antibody
for the fetal red cells. Fifty percent of women with this
condition are reported to improve during pregnancy,
especially in the third trimester. The diagnosis rests on
the demonstration of auto-antibodies directed against
red cell surface antigens. In practice, this is detected by a
positive direct antiglobulin Coombs test. Most of these
antibodies detected at 37C are of the IgG subclass.
Administration of prednisone, 2 mg/kg/day, to
the mother with prenatally active AIHA may both
reduce maternal hemolysis and reduce neonatal
morbidity. Management is to monitor carefully for
hemolysis, hyperbilirubinemia, jaundice, to prevent
kernicterus.28,29
Acquired hemolytic anemias in the newborn can
be caused by infection, drugs or toxins. Congenital
infections like syphilis, cytomegalovirus, rubella, 20
toxoplasmosis, mycoplasma pneumoniae, bacterial

and viral infections may cause hemolytic anemia.
IgM antibodies can cause disease and usually are
active between 0 and 30 degrees celsius, hence are
referred to as cold agglutinins. These antibodies with
complement coat RBCs and cause hemolysis.
Rapid onset of anemia, hyperbilirubinemia with
splenomegaly and hepatomegaly occur. Occasionally a
severe anemia requires treatment with corticosteroids,
IV IgG or and immunosuppressive agent.31
Management of affected fetus
Antibodies from the mother cross the placenta
and result in fetal red cell hemolysis. Presence of
autoimmune hemolytic anemia in mother may result
in hemolytic anemia in the newborn infant. Anemia
may be associated with bacterial and viral infections
in the newborn period and is often associated with
jaundice (both conjugated and unconjugated fraction)
and hepatosplenomegaly.
Intrauterine, viral infections like congenital CMV,
toxoplasmosis, congenital syphilis, herpes, all may
be associated with hemolytic anemia in the neonatal
period.
Nonimmune hemolytic anemia in the
newborn may occur due to
Conditions associated with defects of
Red cell membrane32,33
Red cell metabolism34,35
Hemoglobin synthesis37
Red cell under production38-43
Other causes include
Disseminated intravascular coagulation
Congenital infections.
Abnormalities of red cell membrane
Hereditary spherocytosis (Fig. 2)32,33
In approximately 50 percent of patients with hereditary
spherocytosis, history of neonatal jaundice can be obtained and
may be of a sufficient magnitude so as to need phototherapy
and exchange transfusion and may lead to kernicterus if left
untreated. A family history of chronic anemia, splenectomy,
cholecystectomy, pain in abdomen, unhealed ulcers may be
present. Physical examination of parents may reveal mild to
moderate splenomegaly.
Examination of peripheral blood smear (Fig. 3) reveals
characteristic microspherocytes and the osmotic fragility of
erythrocytes may be increased.
Spherocytes however may be seen in the newborn period in
other conditions like ABO incompatibility, septicemia, red cell
enzyme deficiency, etc.
Defects of red cell metabolism include
G6PD (Glucose 6 phosphate dehydrogenase) defi
ciency:34,35
With G6PD enzyme deficiency, oxidation of membrane
protein leads to precipitation of denatured hemoglobin
(Heinz bodies) thus shortening the RBC life span.
X-linked recessive disorder. History of anemia,
jaundice may be elicited in maternal cousins, maternal
uncles, maternal grandfather and grand uncles.
Hyperbilirubinemia in G6PD deficient males can be
very severe.
In India, G6PD deficiency is most commonly seen
in Parsis, Bhanushalis, Sindhis, Punjabi, Khoja
communities.
Because of the diminished capacity of neonatal RBCs
to deal with oxidative stress, as a result of lower glutathione
peroxidase, catalases as well as relative deficiency of
Fig. 2 Hereditary spherocytosis showing jaundice in

mother and child
Fig. 3 Spherocytes on peripheral smear
Vit E, newborn infants with G6PD deficiency are at a

greater risk of developing hemolytic anemia than are
adults. This particularly is the case in more severe types
affecting Asians and Mediterranean group. In this group
of patients, jaundice in the newborn period may be severe
leading to kernicterus. Jaundice that occurs, appears to be
due to accentuation of physiologic jaundice of newborn,
although jaundice may appear in some during first 24
hours.
Abnormal RBC morphology with evidence of Heinz
bodies in the RBC (Fig. 4).
Intravascular hemolysis may be associated.
Normal G6PD levels during acute hemolysis may not
rule out G6PD deficiency as younger RBCs contain
high level of enzymes. Hence, the test may have to be
repeated after 6 weeks.
Pyruvate kinase deficiency:35 The other common red
cell enzyme deficiency leading to hemolytic anemia in
newborn during first week of life is pyruvate kinase
deficiency.35 This disorder is generally characterized by
evidence of hemolysis with increased retic count, few or
no spherocytes on the peripheral smear, no blood group
incompatibility and a negative Coombs test. In some
instances abnormal RBC morphology with evidence of
Heinz bodies, intravascular hemolysis may be associated.
Furthermore, there is a tendency for jaundice to occur
more frequently in particular families and communities,
indicating that the genetic and environmental factors
may influence the presentation. In this group of patients,
jaundice may be severe leading to kernicterus.
Characterized by
Evidence of hemolysis
Increased retic count
Few or no spherocytes on the peripheral smear
Fig. 4 Heinz bodies in RBCs in G6PD deficiency

No blood group incompatibility

Negative Coombs test
Enzyme analysis is not easily available
It may need treatment like phototherapy/exchange
transfusion.
Hemoglobinopathies: Alpha thalassemia syndrome.36

Of the 4 varieties of alpha thalassemia the homozygous
alpha thalassemia which results from the absence of
all four genetic loci for alpha chain synthesis, presents
in the neonatal period. In the absence of alpha chains,
cord blood contains Barts hemoglobin (Gamma 4) and
Hemoglobin H (Beta 4). Most affected infants are stillborn,
although some may live for a few hours after birth. These
infants are hydropic at birth and thus are similar in
appearance to neonates with severe erythroblastosis due
to Rh incompatibility.
Gamma thalassemia syndrome: The production of
gamma polypeptides is regulated by four genes. The
complete absence of gamma chains is incompatible with
fetal life. Intermediate reduction of gamma-polypeptide
synthesis may produce a mild to moderate neonatal
anemia characterized by a reduced percentage of fetal
hemoglobin. This type of anemia resolves when significant
beta chain synthesis begins. It is important to note that
beta thalassemia does not present in the neonatal period.
Other unusual causes of neonatal anemia include
congenital dyserythropoietic anemia, leukemia, microan
giopathic, hemolytic anemia, DIC, etc.
Anemia due to red cell under production:37-42 Impaired
red cell production is an unusual cause of anemia in
the newborn period. Congenital pure red cell anemia
(Diamond Blackfan syndrome) is an uncommon disorder
in which red cell precursors in the bone marrow are
markedly reduced or virtually absent while white blood
cell and platelet production remains normal.
It occurs either due to a lack of erythroid stem cells or
immune suppression of stem cell differentiation.
Inheritance seems to follow an autosomal recessive
inheritance. The disorder should be suspected in any
newborn with anemia and reticulocytopenia, normal
platelets and leukocytes.
Musculoskeletal abnormalitiestriphalangeal thumbs
may occur in a third of patients. The diagnosis
is confirmed by examination of bone marrow
aspirate which reveals a virtual absence of erythroid
precursors. Mothers of affected children may have
increased incidence of miscarriages/abortion and
premature birth. Associated physical abnormalities
are triphalangeal or duplicated thumb, cleft palate,
epicanthal folds, hypertelorism, ptosis, short or

webbed neck, congenital heart diseases and short
stature.
Infections that cause anemia due to reduced red cell
production include parvovirus B1, CMV, toxoplasmosis,
congenital syphilis, rubella, herpes simplex. Maternal
infection with parvovirus B19 causes fetal anemia which is
severe enough to lead to intrauterine death due to hydrops
In addition to anemia, parvovirus infections cause marked
reticulocytopenia. Thrombocytopenia may also occur.41
Laboratory abnormalities include49

Macrocytic anemia
Absent/reduced reticulocytes
Elevated HbF
Absence of erythroid precursors in the bone marrow
Erythroidmyeloid ratio ranges from 1:6 to 1: 240
Pancytopenia, accompanied by reticulocytopenia,
leukopenia and thrombocytopenia may be seen in
severe septicemia and TORCH group of infections.
Transplacental transmission of parvovirus B19 cause
hypoplastic anemia, which when severe may lead to
intrauterine death. Those that survive intrauterine
infection may be born with hydrops fetalis.
Osteopetrosis/marble bone disease may present with
anemia in the newborn period, which could be due to
hemolysis or non-production. The disease is associated
with hydrocephalus, hepatosplenomegaly and marked
increase in the density of the bones particularly of long
bones, ribs and base of the skull.
Other rare causes of anemia include transcobalamin
II Fanconis anemia usually does not manifest in the
newborn period and often presents with anemia
around the age of 5 to 8 years.
MANAGEMENT OF NEONATAL ANEMIA49

The treatment of a neonate with anemia due to blood loss
depends on the degree of hypovolemia or anemia. Whether
the blood loss has been acute or chronic. Baby born pale at
birth should be differentiated from an asphyxiated baby.
Besides transfusion for hemorrhagic shock, adoption of
transfusion protocols take a variety of factors into account,
including hemoglobin levels, degree of cardiorespiratory
disease and traditional signs and symptoms of pathologic
anemia (Flow chart 1).
Anemia with Shock

Pale babies usually will have tachycardia with minimal or
no cyanosis, decreased central venous pressure (CVP) and
a rapid fall in hemoglobin with circulatory collapse.
Flow chart 1 Diagnostic approach to neonatal anemia49
Abbreviations: DIC: Disseminated intravascular coagulation; G6PD: Glucose 6-phosphate dehydrogenase deficiency;
Hb: Hemoglobin; MCV: Mean corpuscular volume.
Guidelines for management

Clear the airway
Administer oxygen and intubate if necessary
Insert the catheter in the umbilical vein and measure
CVP
Obtain blood specimen for investigation
Rapid expansion of the vascular space with 20 mL/kg
of isotonic saline or ringers lactate, followed by either
type specific cross matched whole blood or packed red
cells resuspended with saline.
In infants with severe anemia or hypoxia, O, Rh negative
RBCs are an acceptable alternative.
In infants with anemia with congestive heart failure.
Furosemide 1 mg/kg followed by a packed cell
transfusion of 10 to 15 cc/kg may be given (3 mL/kg
of packed cells or 6 mL/kg of whole blood rises the
hemoglobin by 1 g/dL).
In severely anemic babies with CHF, a partial exchange

transfusion with packed red cells may be carried out to
reduce circulatory overload.
Anemia due to Chronic

Hemorrhage/Hemolysis
Iron therapy is initiated for the neonates with anemia
who are stable without any signs and symptoms of
failure or hyperbilirubinemia even though Hb is low
and do not require blood transfusion.
Phototherapy and double volume exchange
transfusion for hyperbilirubinemia followed by a top
up packed cell transfusion if required is the main stay
of treatment for neonates with isoimmune hemolytic
anemia depending upon levels of bilirubin and Hb
levels and day of life (age).

In severely anemic babies with CHF, a partial exchange
transfusion with packed red cells may be carried out to
reduce circulatory overload.
Even though neonate has received the blood
transfusion, iron therapy is also needed because the
transfusions are not sufficient to totally replace the
iron lost due to hemorrhage.
Elemental iron in the dose of 2 mg/kg body weight
daily for three months is required to replenish iron
stores and return the hemoglobin to normal.
Recombinant erythropoietin treatment:43-48 Premature
infants respond to exogenously administered
recombinant human EPO with reticulocytosis, modest
decreases in the frequency of PRBC transfusions have
been documented primarily in premature infants.
The cost-benefit ratio for EPO has yet to be clearly
established.
Babies on erythropoietin therapy should receive oral
iron therapy.
Provision of adequate amounts of vitamin E, vitamin
B12, folate, and iron are important in the management
of anemia in premature infant.10,11
Diamond Blackfan syndrome can be managed by
corticosteroids and repeated blood transfusions and
supportive line of treatment.38-42
Anemia of transcobalamin II deficiency requires
weekly intramuscular injections of 100 micro grams of
vitamin B12.
PREVENTION OF ANEMIA
Newborn, particularly in premature infants reducing
the amount of blood taken for investigation purposes
diminishes the need to replace blood. The use of
noninvasive monitoring devices, such as transcutaneous
oxygen saturation, partial pressure of oxygen, and partial
pressure of carbon dioxide, may allow decreased blood
drawing.
Iron prophylaxis to adolescent girls, antenatal iron
administration during pregnancy, oral iron therapy 2 to 6
mg/kg/day in preterm babies, starting by 4 to 6 weeks and
continued till weaning has been adequately achieved is an
important preventive measure to prevent anemia in new
born period and early infancy.
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passage of fetal red blood cells and the pathogenesis of Rh
immunization during pregnancy. Lancet. 1963;2:489.
27. Cohen F, Zuelzer WW, Gustafson DC, et al. Mechanisms
of isoimmunization. I. The transplancental passage of fetal
erythrocytes in homospecific pregnancies. Blood. 1964;
23:621.
28. Desjardins L, Blajchman MA, Chintu C, et al. The spectrum
of ABO hemolytic disease of the newborn infant. J Pediatr.
1979;95:447.
29. Bowman J. The management of hemolytic disease in the
fetus and newborn. Semin Perinatol. 1997;21:39-44.
30. Brouwers HAA, Overbeeke MAM, van Ertbrugeen I, et al.
What is the best predictor of the severity of ABO-hemolytic
disease of the newborn? Lancet. 1988;2:641.
31. Kaplan E, Herz F, Scheye E. ABO hemolytic disease of the
newborn, without hyperbilirubinemia. Am J Hematol.
1976;1:279.
32. Mentzer WC, Glader BE. Hereditary spherocytes and other
anaemias due to abnormalities of the red cell membrane.
In Greer JP, Foerster J, Lukens JN, et al. Wintrobes Clinical
Hematology. 2004.p.1089.
33. UX SE. Disorder of red cell membrane. In Oski PA
Nathan DG, eds. Hematology of infancy and childhood
philiadelphia. WB. Saunders company. 1982.p.489.
34. Piomelli S, Corash LM, Davenport OD, et al. In vivo lability
of glucose-6-phosphate dehydrogenase in GdA- and Gd Mediterranean deficiency. J Clin Invest. 1968;47:940.
35. Matthay KK, Mentzer WC. Erythrocyte enzymopathies in
the newborn. Clin Haematol. 1981;10(1):31-55.
36. Pearson HA, Shanklin DR, Brodine CR. Alpha thalassemia

as a cause of non-immunologic hydrops. Am J Dis Child.
1965;109:168-72.
37. Hakami N, Neiman PE, Canellos GP, et al. Neonatal
megaloblastic anemia due to inherited transcobalamin II
deficiency in two siblings. New Engl J Med. 1971;285:1163.
38. Diamond LK, Allen DM and Magill FB. Congenital
(erythroid) hypoplastic anemia. Am J Dis Child. 1961;102:
149.
39. Diamond LK, Wang WC, Alter BP. Congenital hypoplastic
anemia. Adv Pediatr. 1976;22:349-78.
40. Alter BP. Nathan DG. Red cell aplasia in children. Arch Dis
Child. 1979;54:263-7.
41. Alter BP. The inherited bone marrow failure syndromes. In
Nathan DG, Orkin SH, eds. Nathan and Oskis Hematology
of Infancy and Childhood, 6th edn. Philadephia, WB
Saunders. 2003.p.280.
42. Aase JM, Smith DW. Congenital anemia and triphalangeal
thumbs. A new syndrome. J Pediatr. 1969;74:471.
43. Pearson HA. Anemia in the newborn: A diagnostic
approach and challenge. Semin Perinatol. 1991;15:2-8.
44. Meyer MP, Meyer JH, Commerford A, et al. Recombinant
human erythropoietin in the treatment of the anaemia of
prematurity: Results of a double-blind, placebo controlled
study. Pediatrics. 1994;93:918.
45. Strauss RG. Erythropoietin and neonatal anaemia. N Engl J
Med. 1994;330:1227.
46. Chen JY, Wu TS, Chanlai SP. Recombinant human
erythropoietin in the treatment of anemia of prematurity.
Am J Perinatol. 1995;12:314.
47. Doyle JJ. The role of erythropoietin in the anemia of
prematurity. Sem Perinatol. 1997;21:20-7.
48. Ohis RK, Ehrenkranz RA, Wright LL, et al. Effects of early
erythropoietin therapy on the transfusion of requirements
of preterm infants below 1250 grams birth weight.
Pediatrics. 2001;108:934-42.
49. Dallman PR. Anaemia of prematurity: The prospects
for avoiding blood transfusions with recombinant
erythropoietin. Adv Pediatr. 1993;40:385.
9
Polycythemia and
Hyperviscosity Syndrome
Polycythemia is defined as an abnormal increase in the red blood cell mass. In neonates the hematocrit rises soon after birth,
peaks at around 2 hours of age and falls to about 57 percent in next 12 to 18 hours of age. The most widely accepted definition of
neonatal polycythemia is a venous hematocrit greater than 65 percent (capillary hematocrit >70 percent) or a venous hemoglobin
concentration in excess of 22.0 g/dL.1, 2 This cut off value has been chosen based on the observation that blood viscosity exponentially
increases above a hematocrit of 65 percent.3 Other definitions of polycythemia include a venous hematocrit of 64 percent or more at
2 hours of age,4 or an umbilical venous or arterial hematocrit of 63 percent or more.5
Hyperviscosity is defined as thickness of the blood greater than 14.6 centipoise at a shear rate of 11.5 sec1. The normal blood
viscosity (mean SD) in the neonate is 1.18 0.17 centipoise at a shear rate of 11.5 sec1.2-6 Hyperviscosity and polycythemia have a
linear relationship up till a hematocrit of 60 percent. Hyperviscosity starts rising exponentially after a hematocrit of 65 percent and
markedly increases at a hematocrit of 70 percent or more.7 Hyperviscosity is influenced not only by the red cell mass, but also by other
factors such as plasma fibrinogen and local blood flow.
The terms polycythemia and hyperviscosity are often

used interchangeably although they are not equivalent as
is evident from the description. Polycythemia is significant
only because it increases the risk of hyperviscosity
syndrome. Hyperviscosity syndrome comprises symp
toms and signs caused by tardy flow and sludging of blood
within the blood vessels especially in the smaller arterioles
and capillaries. Sludging of blood occurs because
increased red blood cell mass causes a relative decrease in
the plasma volume and a relative increase in the proteins
and platelets. The sludging of blood within blood vessels
can also lead to thrombosis and infarcts in the territory
supplied by them.
Viscosity is difficult to measure. It is usually measured
by Wells-Brookfield cone-plate microviscometer. Since
instruments to measure viscosity are not readily available
in most neonatal intensive care units, hyperviscosity is
usually suspected on the basis of clinical symptoms and
signs in the presence of abnormally high hematocrit
(polycythemia).
INCIDENCE OF NEONATAL POLYCYTHEMIA

AND HYPERVISCOSITY
The true incidence of polycythemia and hyperviscosity
is not known since majority of infants are likely to be
asymptomatic normal newborns. Hematocrit is not
routinely recommended or drawn in this population, most
likely due to the controversy surrounding the treatment
of asymptomatic infant.8 The reported incidence of
polycythemia ranges between 0.4 and 12 percent; in
USA 1 to 5 percent newborns reportedly suffer from
polycythemia.2,5,7,9 This wide variation may be due to
different screening techniques, sampling sites (capillary
versus peripheral, central venous or arterial), varied
patient population, mode of delivery, method of measuring
(Coulter counter or centrifuged capillary blood), and
sampling time. Sampling time is the most important source
of this variation. The hematocrit normally rises after birth,
reaching a peak at two hours postpartum and then slowly
decreases over the next 12 hours. At two hours of life the
upper limit (2 SD) of a normal capillary hematocrit is
71 percent while it is 64 percent for a venous hematocrit.5
Hyperviscosity occurs in 6.7 percent of neonates.
Only 47 percent of infants with polycythemia
exhibit hyperviscosity and 24 percent infant with
hyperviscosity have polycythemia.4,10,11
It is more common in infants.
Small-for-gestational age (SGA).
Large-for-gestational age (LGA).
Infants born to diabetic mothers have predilection
for developing polycythemia. Thirty percent and forty
percent infants suffer from polycythemia if mothers
have diabetes or suffer from gestational diabetes
respectively.
PATHOPHYSIOLOGY
The mean venous hematocrit in term infants is 52 percent
at 12 to 18 hours of age5 though values up to 71 percent
have also been described as normal at 2 hours of age by
many authors.12,13
The initial rise in the hematocrit is related to
transudation of fluid out of the intravascular space. As the
venous hematocrit increases, the viscosity rises. When
the hematocrit increases to more than 65 percent, there is
exponential elevation in the blood viscosity that, coupled
with decreased deformability of the fetal erythrocytes,
in comparison to adult red blood cells, leads to sluggish
peripheral circulation, formation of microthrombi, fall in
the oxygen transport and tissue hypoxia (Flow chart 1).
Tissue hypoxia leads to increased glucose metabolism,
to generate adequate amounts of ATP by anaerobic respi
ration, hypoglycemia and metabolic acidosis. Hypoxia
and acidosis further aggravate hyperviscosity. Increased
viscosity of blood, in general, mimics symptoms and
signs of hypoperfusion. Polycythemia, therefore, creates
a pathophysiological situation analogous to shock.
Flow chart 1 Pathophysiology of polycythemia-hyperviscosity
Microthrombi formation may occur in the blood vessels

supplying cerebral cortex, kidneys, intestines and adrenal
glands, with potential long lasting sequelae.
INCREASED FETAL ERYTHROPOIESIS

(PRIMARY POLYCYTHEMIA)
Neonatal polycythemia can occur by two mechanisms.
1. Active form: Fetus/newborn produces excess number
of red blood cells due to physiological triggers like
perinatal hypoxia, uncontrolled maternal diabetes and
chromosomal defects in the fetus. It is also referred as
primary polycythemia.
2. Passive form: Fetus/newborn can acquire large
blood volume as a result of delayed cord clamping or
maternofetal transfusion. Increase in the red blood
cells by hypertransfusion is also called secondary
polycythemia.
The causes of neonatal polycythemia can be divided
according to temporal happenings like:
Before birth (antenatal)
During birth (intranatal)
After birth (neonatal).
These are summarized in Table 1.
It can be secondary to pre-eclampsia, primary
renovascular disease, chronic or recurrent abruptio
placentae, maternal cyanotic congenital heart disease
including Eisenmenger syndrome14 postdated pregnancy
and maternal smoking. Awonusonu et al. (2002) have
reported that the risk of symptomatic polycythemia
requiring partial exchange blood transfusion is 2.5 times
more in mothers who smoke (1.59%) during pregnancy
than those who do not (0.64%).15 Most of these maternal
conditions may also be associated with intrauterine
growth restriction (IUGR).
The incidence of polycythemia increases with
increasing severity of fetal growth retardation. In severely
growth retarded fetuses, a hematological syndrome
of polycythemia, thrombocytopenia, leukopenia and
increased numbers of nucleated red blood cells has been
described.16,17
Endocrine abnormalities: Conditions associated with
increased fetal oxygen consumption may result in fetal
hypoxia and subsequent polycythemia like congenital
thyrotoxicosis and Beckwith-Wiedemann syndrome or
infants of diabetic mother (IDM) with poor glycemic
control. Polycythemia in IDMs correlates with
macrosomia and neonatal hypoglycemia.
Chromosomal disorders: Trisomy 13, trisomy 18 and
trisomy 21 may be associated with polycythemia. The
exact mechanism is not well understood. However,
it has been observed that in trisomy 13, 18 and
21, placentae show trophoblastic hypoplasia and
Chapter-9 Polycythemia and Hyperviscosity Syndrome 59

Table 1 Etiology of polycythemia
Antenatal
Hypoxia
Intranatal
Hypoxia
IUGR, SGA infants
Intrapartum
asphyxia due to
etiologies such as
Obstructed labor
Prolonged labor
Abruptio
placentae
Infants of diabetic
mothers
Placental
insufficiency
Pre-eclampsia
Maternal smoking
High altitude
Postmaturity
Infants born
to mothers
with chronic
cardiopulmonary
conditions
Hypertransfusions
Primary
renovascular
disease
In utero asphyxia
Twin-to-twin
transfusion
Maternofetal
transfusions
Genetic syndromes
Trisomy
BeckwithWiedemann
syndrome
Miscellaneous
congenital
hypothyroidism,
Congenital adrenal
hyperplasia
Maternal use of
propranolol
Delayed clamping
of umbilical cord
Perinatal asphyxia
Hypertransfusions
Oxytocin use during
labor
Holding the baby
below the introitus
at the time of
delivery
Milking of the
umbilical cord
Neonatal
Genetic causes
Trisomy13, 18, 21
BeckwithWiedemann
syndrome
Endocrine causes
Infants of diabetic
mothers
Neonatal
thyrotoxicosis
Congenital
hypothyroidism
Congenital
adrenal
hyperplasia
hypovascularity, which has been attributed to low

levels of vascular endothelial growth factor (VEGF)
and placental growth factor (PLGF).18,19 VEGF and
PLGF are considered to play important roles in angio
genesis and vascular permeability during placental
development. Therefore, low levels of these factors
could cause chronic fetal hypoxia, resulting in inc
reased erythropoietin levels and polycythemia.20
High altitude: Babies born at high altitude are found to
have polycythemia due to relative paucity of oxygen.
HYPERTRANSFUSION (SECONDARY
POLYCYTHEMIA)
Delayed cord clamping: It allows increased blood
volume to be delivered to the infant. When cord
clamping is delayed to more than 3 minutes after
birth, neonatal blood volume increases by 30 percent.
Gravity may facilitate transfer of large blood volume to
the newborn because of the position of the delivered
infant in relation to the maternal introitus before cord
clamping. Oxytocin may enhance blood flow to the
infant via umbilical vessels in the event of delayed cord
clamping.
Twin-to-twin transfusion syndrome: It occurs in
approximately 10 percent of monozygotic twin pregnan
cies due to a vascular communications between twin
babies. The recipient twin suffers from polycythemia
and hypervolemia.
Maternofetal transfusion: It has been recognized as
a cause of blood transfer from the uterine vessels via
placenta to the fetal circulation due to placental vascular
malformations leading to hypervolemia, polycythemia
and hyperviscosity syndrome in the newborn infant.21
Intrapartum asphyxia: Perinatal asphyxia during
delivery, due to any cause, may shift blood volume from
the placenta to the fetus to maintain cerebral perfusion.
This may lead to increased blood volume in the perinate
followed by polycythemia and hyperviscosity.
CLINICAL FEATURES
Majority of appropriately grown term polycythemic
newborn infants have no symptoms, particularly if the
polycythemia is found on routine neonatal screening.
Symptoms, when present, are usually attributable to
hyperviscosity and poor tissue perfusion or to associated
metabolic derangements such as hypoglycemia. About
50 percent of polycythemic infants develop one or more
symptoms. Clinically the baby may manifest skin color
from red (polycythemia), blue (cyanosis resulting from
peripheral stasis), yellow (jaundice due to breakdown of
large amount of RBCs; 34.5 mg bilirubin is produced from
1g of hemoglobin) to pale when shock sets in.
Common early symptoms include plethora, lethargy,
hypotonia, poor suck and feeding, and tremulous
ness. Serious complications include cardiorespira
tory distress (with or without congestive heart failure),
seizures, peripheral gangrene, necrotizing enterocolit
is, renal failure (occasionally resulting from renal vein
thrombosis), hyperbilirubinemia and priapism. Most
of these symptoms are non-specific and may be relat
ed to the underlying causes rather than polycythemia
per se.
Central nervous system: It is the most common system
to be affected. Early effects include lethargy, poor
feeding, easy startle, hypotonia, difficult arousal,
tremors, irritability, jitteriness and seizures. Long term
sequelae include developmental delay and poor fine
motor control.
Metabolic derangement: Hypoglycemia is the most
common metabolic abnormality in the infant, reagent
glucose strips frequently give falsely low values
Therefore, blood sugar should always be reconfirmed by
a laboratory test. Hypocalcemia and hypomagnesemia
are also known to occur in polycythemia. The elevated
red blood cell mass increases catabolism of the
hemoglobin so hyperbilirubinemia is common and
even gall stones occasionally occur.
Cardiopulmonary system: Tachycardia, tachypnea,
congestive cardiac failure and cyanosis may be found.
Rarely persistent fetal circulation may develop with
poor prognosis. Polycythemia should be considered
as a differential diagnosis for transient tachypnea
of the newborn. Chest radiography may reveal
cardiomegaly, pulmonary plethora, hyperaeration and
pleural effusion. Echocardiographic findings include
increased pulmonary resistance, bidirectional shunt
and decreased cardiac output.
Gastrointestinal system: Features of gastrointestinal
affliction are poor suckling, vomiting, feed intolerance,
prefeed aspirates, abdominal distension, paralytic
ileus and necrotizing enterocolitis (NEC).
Renal system: Hyperviscosity affects renal perfusion.
Oliguria, acute renal failure, renal vein thrombosis and
decreased urinary sodium may occur in polycythemic
infants.
Miscellaneous: Thrombocytopenia, coagulation defects,
stroke, peripheral gangrene, thrombosis, priapism and
testicular infarction are well known complications of
polycythemia.
Laboratory Diagnosis
Certain high-risk groups such as small for gestational
age (SGA) infants, infants of diabetic mothers (IDMs),
monochorionic twins, large for gestational age (LGA)
infants or presence of risk factors (enlisted in Table 1)

should be screened for polycythemia.2
Screening is usually done in high-risk neonates at 2
hours of age. A normal value at 2 hours of age (venous
hematocrit <65%) does not warrant further screening
unless the neonate is symptomatic.
Hematocrit values >65 percent at 2 hours of age merit
repeat screening at 12 and 24 hours.
Polycythemia is diagnosed when venous hematocrit is
>65 percent.2
In the presence of clinical features suggestive of
poor circulation with plethora and/or cyanosis and
tachypnea, a venous hematocrit measurement is used
as a surrogate for diagnosing hyperviscosity because
former can be readily done and the latter exponentially
increases after a hematocrit of >65 percent.
Capillary or venous hematocritwhich one to
measure? Capillary hematocrit measurements depend
upon the blood flow and are significantly higher than
venous hematocrits and are therefore, unreliable.
However, capillary samples may be used for screening
but all high values should be confirmed by a venous
hematocrit for the diagnosis of polycythemia.
Hematocrit Measurement
Two methods are available:
1. Automated hematology analyzer: This calculates hem
atocrit from a direct measurement of mean cell volume
and the hemoglobin. Hematocrit (%) is approximately
three times the hemoglobin concentration in g/dL.
2. Microcentrifuge: Blood is collected in heparinized
microcapillaries (110 mm length and 12 mm internal
diameter) and centrifuged at 10,000 to 15,000 revolu
tions per minute (rpm) for 3 to 5 minutes. Plasma
separates and the packed cell volume is measured
to give the hematocrit. An automated analyzer gives
lower values as compared to hematocrits measured
by the centrifugation methods. Most of the reported
literature on polycythemia is based on centrifuged
hematocrits.8
Other laboratory tests to be done in a case of
polycythemia:
Kidney function tests: Renal functions should always
be evaluated in a case of symptomatic polycythemia.
Blood urea (BUN) and serum creatinine may increase.
There may be dilutional hyponatremia and serum
potassium may rise. Judicious fluid and electrolytic
intake is warranted for good prognosis.
Serum glucose and calcium levels should be deter
mined in all symptomatic polycythemia and infants
and vigorously treated if the patient has abnormal
levels.

Serum bilirubin rises rapidly in babies who have
polycythemia due to increased RBC destruction
much beyond the neonatal hepatic conjugation
capacity. Serum bilirubin must be checked serially. If
nomograms are available then transcutaneous biliru
binometry can be a very useful modality to screen for
hyperbilirubinemia as it is a noninvasive technique.
However, when transcutaneous bilirubin index
suggests a higher serum bilirubin level, it should always
be confirmed by laboratory method before instituting
therapy for hyperbilirubinemia.
Arterial blood gases (ABG): Consider measuring ABG
values to assess oxygenation in the symptomatic infant
with respiratory distress and cyanosis.
Platelet count: Platelet count must be checked at base
line. Thrombocytopenia is present if thrombosis or
disseminated intravascular coagulation (DIC) has set
in. Thrombocytopenia may also be found in babies
born to pre-eclamptic mothers, who are prone to
develop symptomatic polycythemia.
Urinalysis: Proteinuria and casts may be present.
MANAGEMENT
Possible ways of avoiding polycythemia include early
cord clamping and holding the baby at the level
of the introitus at the time of delivery to minimize
hypertransfusion.
A good glycemic control and management of
growth retardation in the antenatal period may
prevent development of polycythemia and in turn
hyperviscosity after birth.
It is essential to exclude dehydration before a diagnosis
of polycythemia is made. A clue to dehydration could
be excessive weight loss. If this is present, increasing
the fluid intake would be the appropriate therapeutic
measure. The hematocrit should be measured again
after correction of dehydration.
Associated metabolic problems like hypoglycemia,
hypocalcemia and acidosis should be treated
simultaneously.
The principles of management of neonatal polycythemia
are:
To decrease red cell mass below threshold level.
To remove excess blood volume.
To maintain metabolic and blood gas homeostasis till
the condition reverts back to normal.
The following modes of therapy have been employed
for the treatment of polycythemia.
Conservative management with additional fluid
intake: This mode of therapy may be tried in cases of
asymptomatic polycythemia when the hematocrit
reaches 70 to 75 percent. An extra fluid aliquot of
20 mL/kg may be added to the daily requirements.2

Extra fluid intake may be ensured either by enteral route
(supervised feeding) or by parenteral route (IV fluids).
The rationale for this therapy is hemodilution and
resultant decrease in viscosity. However, liberal and
extra fluid therapy may be associated with problems
especially in preterm babies. Hence conservative
management by using extra fluids should be reserved
for hemodynamically stable babies with asymptomatic
polycythemia.
Partial exchange transfusion: Partial exchange trans
fusion (PET) is traditionally used as the method of
choice for the treatment of symptomatic polycythemia
to lower hematocrit as well as hyperviscosity. This
method is also employed to treat asymptomatic
polycythemia if hematocrit is >75 percent. PET aims to
decrease the hematocrit to a target packed cell volume
of 55 percent. PET is performed with either crystalloid
(normal saline or Ringers lactate) or colloid (5%
albumin or fresh frozen plasma) solutions. Crystalloids
are preferred because they are economical, easily
available, produce similar reduction in the hematocrit
as colloids22,23 and do not have the risk of transfusion
associated infections (e.g. HIV, hepatitis B, hepatitis C,
CMV). Additionally, adult plasma may potentially
increase the blood viscosity when mixed with fetal
erythrocytes.
The blood volume to be partially exchanged is calculated
by the following formula:
Volume to be exchanged (V mL) = infants blood
volume (observed hematocritdesired hematocrit)/
observed hematocrit.
The desired hematocrit is kept as 55 percent. Blood
volume is estimated to be 80 to 90 mL/kg in term and
90 to 100 mL/kg in preterm babies. As a rough guide, the
volume of blood to be exchanged is usually 20 mL/kg.
PET normalizes cerebral hemodynamics and imp
roves clinical status of the infants with polycythemia.1
PET has also been shown to reduce pulmonary vascular
resistance24 and increase cerebral blood flow velocity.25, 26
PET is a relatively simple procedure, but has numerous
potential complications. Unfortunately, there are no
data regarding the incidence of complications of PET;
one can only extrapolate from the data on full exchange
transfusions performed for neonatal hyperbilirubinemia.8
Reported complications in whole blood exchange include
apnea, cardiac arrhythmia, decreased PR interval,27
embolism, vessel perforation, accidental hemorrhage,
hypothermia, reduction in blood pressure, cerebral
blood flow fluctuations, sepsis, necrotizing enterocolitis
and portal vein thrombosis. Hypernatremia and raised
osmolality following whole blood exchange transfusion
have also been reported by Jain, Puri and Faridi (1997).28
However, whole blood exchange transfusion is expected
to have a higher incidence of complications than PET,
since the amount of blood to be exchanged is almost nine
times higher and the product utilized for the exchange is
donors blood.
The statement of the committee of the fetus and
newborn, American Academy of Pediatrics8 regarding the
treatment of neonatal polycythemia with PET reflects both
the concern and uncertaintyThe accepted treatment
of polycythemia is partial exchange transfusion. However
there is no evidence that exchange transfusion affects the
long term outcome. Universal screening for polycythemia
fails to meet the methodology and treatment criteria and
also, possibly the natural history criterion. Despite this
ambivalent statement, the standard practice in most
nurseries is to perform PET in symptomatic babies with
a hematocrit greater than 65 percent or in asymptomatic
babies with a hematocrit greater than 70 percent .29,30
PHLEBOTOMY
Michael and Mauer21 have described phlebotomy as a
successful treatment modality in cases suffering from
maternofetal transfusion. It seems logical to reduce
hypervolemia in cases of hypertransfusion state. Therefore,
phlebotomy can be employed in cases where polycythemia
is a result of passive or secondary polycythemia.
Routes for Partial Exchange Transfusion

PET may be done through a
Peripheral or central route: A peripheral route avoids
umbilical vessel cannulation and is done by using a
peripheral arterial and venous line. Blood is withdrawn
from the arterial line and replaced simultaneously
through the venous line.
A central route requires umbilical vein cannulation.
The umbilical venous catheter may be used for
withdrawing blood while the same amount of saline is
replaced through a peripheral vein. Alternatively the
umbilical venous catheter may be used both for the
withdrawal of blood and replacement with saline.
Dempsey et al.,31 in a recent systematic review
have shown that PET through umbilical route may
be associated with increased risk of necrotizing
enterocolitis (Relative risk 8.68, 95 percent CI 1.06,
71.1).
Short-term and long term outcome with polycythe
mia: PET reverses the short term pathophysio
logical
abnormalities associated with polycythemia hyper
viscosity syndrome. It improves capillary perfusion,
cerebral blood flow and cardiac function.1,24-26 However,
there is very little data to suggest that PET improves
long-term (neurodevelopmental) outcome in patients

with polycythemia. Studies by Black et al.16 and Goldberg
et al.17 did not demonstrate improvement in the long-term
outcome with the use of PET in symptomatic polycythemia.
Similarly PET has not shown any beneficial effect on
long-term outcome in neonates with asymptomatic
polycythemia.1

The recent systematic review by Dempsey et al.31 also
supports these findings. In this review, randomized or
quasi-randomized trials in term infants with polycythemia
and/or documented hyperviscosity were considered.
Clinically relevant outcomes included were short-term
(resolution of symptoms, neurobehavioral scores, major
complications) and long-term neurodevelopmental
outcome. There was no evidence of an improvement in the
long-term neurological outcome (Mental Developmental
Index, incidence of mental delay and incidence of
neurological diagnoses) following PET in symptomatic
or asymptomatic infants. Also, there was no evidence of
improvement in early neurobehavioral assessment scores
(Brazelton Neonatal Behavioral Assessment Scale). It
was concluded that PET may be associated with an early
improvement in symptoms, but there are insufficient data
to calculate the size of the effect.
It is probable that the underlying etiology of
polycythemia is a more important determinant of the
ultimate outcome. However, definitive data on long-term
outcome with treatment is still unavailable in infants
with symptomatic polycythemia and in asymptomatic
infants with hematocrit >70 percent. Therefore, it may be
advisable to perform a PET or consider plasma expansion
with additional fluids based on the presence or absence of
symptoms in these polycythemic neonates.
REFERENCES

1. Bada HS, Korones SB, Pourcyrous M, Wong SP, Wilson

WM 3rd, Kolni HW, et al. Asymptomatic syndrome of
polycythemic hyperviscosity: effect of partial exchange
transfusion. J Pediatr. 1992;120:579-85.
2. Jeevasankar M, Agarwal R, Chawla D, Paul VK, Deorari
AK. Polycythemia in the newborn. Indian J Pediatr. 2008;
75:68-72.
3. Nelson NM. Respiration and circulation before birth. In:
Smith CA, Nelson NM, eds. Physiology of the Newborn
Infant, 4th edn. Springfield: Charles C Thomas. 1976.
pp.17-25.
4. Drew JH, Guaran RL, Cichello M, Hobbs JB. Neonatal
whole blood hyperviscosity: The import factor influencing
later neurologic function is viscosity and not polycythemia.
Clinical Hemorheology and Microcirculation. 1997;17:
67-72.
5. Wexner EJ. Neonatal polycythemia and hyperviscosity.
Clin Perinatol. 1995;22:693-4.

6. Riopel L, Fouron JC, Bard H. Blood viscosity during the

neonatal period: the role of plasma and red blood cell type.
J Pediatr. 1982;100:449-53.
7. Ramamurthy RS, Berlanga M. Postnatal alteration in
hematocrit and viscosity in normal and polycythemic
infants. J Pediatr. 1987;110:929-34.
8. American Academy of Pediatrics Committee on Fetus
and Newborn Routine evaluation of blood pressure,
hematocrit, and glucose in newborns. Pediatrics. 1993;92:
474-6.
9. Gordon EA. Polycythemia and Hyperviscosity of the
Newborn. J Perinat Neonat Nursing. 2003;17:209-21.
10. Wiswell TE, Cornish JD, Northam RS. Neonatal polycy
themia: frequency of clinical manifestations and other
associated findings. Pediatrics. 1986;78:26-30.
11. Wirth FH, Goldberg KE, Lubchenco LO. Neonatal
hyperviscosity: I. Incidence. Pediatrics. 1979;63:833-6.
12. Shohat M, Merlob P, Reisner SH. Neonatal Polycythemia. I.
Early diagnosis and incidence relating to time of sampling.
Pediatrics. 1984;73:7-10.
13. Shohat M, Reisner SH, Mimouni F, Merlob P. Neonatal
polycythemia II. Definition related to time of sampling.
Pediatrics. 1984;73:11-3.
14. Mukhtar AI, Halliday HL. Eisenmenger syndrome in preg
nancy is a possible cause of neonatal polycythemia and
persistent fetal circulation. Obst Gynecol. 1982;60:651-2.
15. Awonusonu FO, Pauly TH, Hutchison AA. Maternal
smoking and partial exchange transfusion for neonatal
polycythemia. Am J Perinatol. 2002;19:349-54.
16. Black VD, Lubchenco LO, Luckey DW, Koops BL,
McGuinness GA, Powell DP, Tomlinson AL. Developmental
and neurologic sequelae of neonatal hyperviscosity
syndrome. Pediatrics. 1982;69:426-31.
17. Goldberg K, Wirth FH, Hathaway WE, Guggenheim MA,
Murphy JR, Braithwaite WR, Lubchenco LO. Neonatal
hyperviscosity II. Effect of partial exchange transfusion.
Pediatrics. 1982;69:419-25.
18. Debieve F, Moiset A, Thomas K, Pampfer S, Hubinont C.
Vascular endothelial growth factor and placenta growth
factor concentrations in Downs syndrome and control
pregnancies. Mol Hum Reprod. 2001;7:765-70.
19. Bdolah Y, Palomaki GE, Yaron Y, Bdolah-Abram T,
Goldman M, Levine RJ, et al. Circulating angiogenic
proteins in trisomy 13. Am J Obstet Gynecol. 2006;194:
239-45.
20. Widness JA, Pueschel SM, Pezzullo JC, Clemons GK.

Elevated erythropoietin levels in cord blood of newborns
with Downs syndrome. Biol Neonate. 1994;66:50-5.
21. Michael AFJ, Mauer AM. Maternal-fetal transfusion as
a cause of plethora in the neonatal period. Pediatrics.
1961;28:458-61.
22. Deorari AK, Paul VK, Shreshta L, Singh M. Symptomatic
neonatal polycythemia: Comparison of partial exchange
transfusion with saline versus plasma. Indian Pediatr.
1995;32:1167-71.
23. de Waal KA, Baerts W, Offringa M. Systematic review of
the optimal fluid for dilutional exchange transfusion in
neonatal polycythemia. Arch Dis Child Fetal Neonatal Ed.
2006;91:F7-F10.
24. Murphy DJ Jr, Reller MD, Meyer RA, Kaplan S. Effects of
neonatal polycythemia and partial exchange transfusion
on cardiac function: an echocardiographic study.
Pediatrics. 1985;76:909-13.
25. Rosenkrantz TS, OhW. Cerebral blood flow velocity in
infants with polycythemia and hyperviscosity: effects of
partial exchange transfusion with Plasmanate. J Pediatr.
1982;101:94-8.
26. Maertzdorf WJ, Tangelder GJ, Slaaf DW, Blanco CE. Effects
of partial plasma exchange transfusion on cerebral blood
flow velocity in polycythemic preterm, term and small for
date newborn infants. Eur J Pediatr. 1989;148:774-8.
27. Patil R. Hemodynamic and capillary blood gas changes
during exchange blood transfusion in early neonatal period.
Thesis submitted to National Board of Examinations for the
award of Diplomate of National Board in Pediatrics, 2007.
28. Jain A, Puri D, Faridi MMA. Biochemical changes during
exchange transfusion in hyperbilirubinemia in term
newborn babies. Indian J Clin Biochem. 1997;12:119-24.
29. Roithmaier A, Arlettaz R, Bucher HU, Krieger M, Duc G,
Versmold HT. Randomized controlled trail of Ringer
solution versus serumfor partial exchange transfusion in
neonatal polycythemia. Eur J Pediatr. 1995;154:53-6.
30. Acunas B, Celtik C, Vatansever U, Karasalihoglu S.
Thrombocytopenia: an important indicator for the
application of partial exchange transfusion in polycythemic
newborn infants? Pediatr International. 2000;42:343-7.
31. Dempsey EM, Barrington K. Short and long term outcomes
following partial exchange transfusion in the polycythemic
newborn: a systematic review. Arch Dis Child Fetal
Neonatal Ed. 2006;91:F2-F6.
10
Vitamin K Deficiency:
Bleeding in Newborns
Vitamin K deficiency bleeding (VKDB) refers to bleeding that occurs as a consequence of vitamin K deficiency during first six months
of life. Previously known as the hemorrhagic disease of the newborns, it has been renamed to emphasize that bleeding problems
during the neonatal period are not confined to those arising from vitamin K deficiency alone and that bleeding secondary to vitamin K
deficiency may occur beyond the first month of life.
DEVELOPMENT OF HEMOSTATIC SYSTEM

Hemostasis develops in an orderly way during intrauterine
life. The most basic reactioncontraction of blood vessels
in response to injuryis present from eight weeks, though
its strength does not become normal until much later.
Platelets appear in the circulation by 11 weeks and can
form aggregates by 12 to 15 weeks; they approximate
to adult numbers by 30 weeks. Clotting and fibrinolytic
plasma proteins are found from 10 to 11 weeks; the
concentrations of some clotting factors reach adult values
in utero, but of others, mainly those dependent on vitamin
K (II, VII, IX and X) are still low at term.
Normal neonatal hemostasis reflects a highly complex
process dependent on interactions between endothelial
cells, platelets and hemostatic proteins. It is now recog
nized that the traditional extrinsic pathway involving
tissue factors and factor VIIa, is the major pathway where
by coagulation is initiated and the thrombin plays a crucial
role in coagulation as well as platelet activation.
At birth concentrations of vitamin K dependent
factors (II, VII, IX and X) and contact factors (XI and XII)
are reduced to about 50 percent of normal adult values.
Similarly, concentration of the naturally occurring anti
coagulants, antithrombin, protein C and protein S are low
at birth and as a consequence, both thrombin generation
and thrombin inhibition are reduced in the newborn
period.
Biology of vitamin K: Vitamin K is a generic name for several

molecules sharing a 2 methyl1,4
naphthoquinone ring
but differing regarding the side chain at the 3position.
Phylloquinone or vitamin K1 is from plant origin and has a
phytyl side chain. The group of menaquinones or vitamin
K2 differs in the number of isoprenyl units in the side chain
and are synthesized by the bacteria in humans and animal
intestine. Menadione or vitamin K3 is a synthetic and water
soluble vitamin K without a side chain. This preparation is not
preferred as it has been shown to cause hemolytic anemia,
indirect hyperbilirubinemia and kernicterus. In our country,
only vitamin K3 preparations are available. Vitamin K acts as
a cofactor for gamma glutamyl carboxylase (GGCX) serving
as an electron donor for the post-translational conversion of
protein bound glutamate into Gamma-carboxyglutamate.
During this process, it is oxidized to vitamin K2, 3epoxide.
Gla residues are calcium binding groups which are essential
for the biological activities of proteins in which they are
found. Gla containing proteins are the coagulation factors
II, VII, IX and X but also protein C, protein S, protein Z,
osteocalcin, etc.
Vitamin K deficiency leads to the synthesis of under
carboxylated proteins unable to bind calcium and hence
inactive. In vitamin K deficient individuals, under
carboxylated forms of vitamin K dependent coagulation
proteins (proteins induced by vitamin K absence
PIVKA) are released from the liver into the blood. PIVKA
are inactive in the coagulation cascade. PIVKA II or
Chapter-10 Vitamin K Deficiency: Bleeding in Newborns 65

undercarboxylated prothrombin is a marker of subclinical
vitamin K deficiency.
CHEMICAL STRUCTURE OF VITAMIN K

Vitamin K Cycle
are at particular risk. Often, VKDB is the first sign of this

underlying condition. Vitamin K epoxide is recycled to
vitamin K by vitamin K epoxide reductase (VKOR). This
recycling process is inhibited by coumarin and warfarin.
CLINICAL FEATURES
Diagnosis
The diagnosis of vitamin deficiency may be suspected from
the results of coagulation screening where initially, there is
isolated prolongation of the prothrombin time followed by
prolongation of the APTT, in association with the normal
concentrations of fibrinogen and normal platelet count.
Confirmation of the diagnosis requires measurements of
PIVKA II.
Treatment
Vitamin K deficiency bleeding (VKDB): As a consequence

of limited stores at birth, neonates are prone to
vitamin K deficiency if no sufficient intake is provided.
Vitamin K deficiency has been traditionally classified as early,
classical and late depending on timing of the presentation.
Early VKDB: Presents within 24 hours of birth and is
almost exclusively seen in infants of mothers taking
drugs which inhibit vitamin K. These drugs include
anticonvulsants (carbamazepine, phenytoin and bar
biturates but not valproic acid), antitubercular drugs
(isoniazid, rifampicin), some antibiotics (cephalosporins)
and vitamin K antagonists (coumarin, warfarin).
Clinical presentation is often severe with cephalic
hematoma, intracranial and intraabdominal hemorrhage.
The incidence in an atrisk group without vitamin K
supplementation is 6 to 12 percent.
Classical VKDB: Occurs between 24 hours and 7 days
of life and is associated with delayed or insufficient
feeding. Clinical presentation is often mild, with bruises,
gastrointestinal blood loss or bleeding from the umbilicus
and puncture sites. Blood loss, however, can be significant,
and intracranial hemorrhage, although rare, has been
described. Without vitamin K supplementation, incidence
estimated is 0.01 to 0.44 percent.
Late VKDB: It is associated with exclusive breastfeeding.
It occurs between the ages of 2 and 12 weeks. Clinical
presentation is severe, with a mortality rate of 20 percent
and intracranial hemorrhage occurring in 50 percent.
Persistent neurological damage is frequent in survivors.
In fully breastfed infants who did not receive vitamin K
at birth, the incidence is between 1/15,000 and 1/20,000.
Infants with cholestasis or malabsorption syndromes
Once the diagnosis is confirmed, intravenous vitamin K

should be administered to correct the existing deficiency.
In suspected cases, vitamin K can be given while factor
concentrations are pending. In the presence of major
bleeding, factor replacement therapy may also be required
with fresh frozen plasma, prothrombin complex concen
trate (FII, FIX, FX), or a four factor concentrate containing
all the vitamin K dependent factors.
No formal studies were ever performed to establish
what dose might be appropriate before it became standard
practice to give every infant a 1mg dose at birth and to give
it intramuscularly simply because that was the only product
available. In 1990, an epidemiological study described an
association between intramuscular (IM) vitamin K at birth
and childhood cancer and leukemia. In response to these
findings, several European countries, Australia and New
Zealand changed their policy to oral prophylaxis. In the
following years, new studies failed to confirm the association
between IM vitamin K at birth and childhood cancer. A risk
of solid tumors can now almost definitely be ruled out, but
a small risk of leukemia cannot be excluded. When cases of
late VKDB started to reappear, Denmark, Canada, Australia
and New Zealand responded by reintroducing universal IM
prophylaxis, offering oral prophylaxis with repeated doses
to those parents refusing the IM injection at birth. Oral
prophylaxis with repeated doses has remained the policy in
the Netherlands and in Germany, using different products
and dosing schemes. The American Academy of Pediatrics
has always endorsed the IM route.
ORAL VITAMIN K
Oral vitamin K administration would appear to offer
several advantages for routine VKDB prophylaxis. In
addition to the concerns raised about a link with childhood
cancer, other disadvantages with IM administration
include the trauma and complications associated with this
route of administration (hematoma, vessel or nerve injury,
abscess, or osteomyelitis) and the higher cost of therapy.
While no oral liquid preparation is available, the injectable
product has been found to be safe and effective when given
by the oral route. Unfortunately, the rise in the use of oral
vitamin K prophylaxis has led to an increase in reports of
late VKDB. Several countries currently use an alternative
mixed micellar preparation of vitamin K (Konakion MM;
Roche) for multidose oral prophylaxis. This formulation
is expected to provide greater absorption than traditional
preparations and may make oral administration more
effective. Unfortunately this preparation is not available in
most of the countries including India.
The Cochrane Review

All trials using random or quasirandom patient alloca
tion, in which methods of vitamin K prophylaxis in infants
were compared to each other, placebo or no treatment,
were included. Two eligible randomized trials comparing
a single dose of intramuscular vitamin K with placebo or
nothing, assessed effect on clinical bleeding. One dose
of vitamin K reduced clinical bleeding at 1 to 7 days,
including bleeding after circumcision, and improved
biochemical indices of coagulation status. Eleven addi
tional eligible randomized trials compared either a single
oral dose of vitamin K with placebo or nothing, a single
oral with a single intramuscular dose of vitamin K, or
three oral doses with a single intramuscular dose. None
of these trials assessed clinical bleeding. Oral vitamin
K improved biochemial indices of coagulation status at
1 to 7 days. There was no evidence of a difference between
the oral and intramuscular route in effects on biochemical
indices of coagulation status. A single oral compared with
a single intramuscular dose resulted in lower plasma
vitamin K levels at two weeks and one month, whereas a
3dose oral schedule resulted in higher plasma vitamin K
levels at two weeks and at two months than did a single
intramuscular dose. It was concluded that a single dose
(1.0 mg) of intramuscular vitamin K after birth is effective
in the prevention of classic HDN. Either intramuscular or
oral (1.0 mg) vitamin K prophylaxis improves biochemical
indices of coagulation status at 1 to 7 days. Neither
intramuscular nor oral vitamin K has been tested in
randomized trials with respect to effect on late HDN. Oral
vitamin K, either single or multiple doses, has not been
tested in randomized trials for its effect on either classic
or late HDN.
The American Academy Recommendation

The vitamin K Ad Hoc Task Force of the American Academy
of Pediatrics (AAP) recommends: (1) Vitamin K, should be
given to all newborn as a single, intramuscular dose of 0.5

to 1 mg. (2) Additional research should be conducted on
the efficacy, safety, and bioavailability of oral formulations
and optimal dosing regimens of vitamin K to prevent
late VKDB. (3) Health care professionals should promote
awareness among families of the risk of late VKDB
associated with inadequate vitamin K prophylaxis from
current oral dosage regimens, particularly for newborns
who are breastfed exclusively.
Vitamin K and Preterm Newborn

Ever since the discovery of vitamin K, it has been clear that
premature infants are at particular risk of VKDB. Although
there is consensus on the fact that all premature infants
should receive vitamin K, neonatology units use a variety
of doses, dosing schedules, routes and formulations.
Reports have shown very high plasma vitamin K levels in
preterm infants receiving 0.5 to 1 mg at birth. Although
no toxic effects of these excessively high serum levels
have been recognized, caution is warranted because the
functions of some Gla proteins are not fully understood. A
recent randomized trial shows adequate serum vitamin K
levels in preterm infants receiving 0.2 mg at birth. In this
trial, preterm infants receiving 0.5 mg have elevated levels
of vitamin K epoxide, suggesting inefficient recycling of
vitamin K by VKOR in the immature liver. These findings
support current empirical dosage recommendations for
preterm infants advising a reduced dose of 0.3 mg for birth
weights <1,000 g and 0.5 mg for those >1,000 g and <1,500 g.
Vitamin K and Cholestatic Disorders

Due to fat malabsorption and inadequate intake, infants
with cholestatic liver disease are especially at risk for vitamin
K deficiency. Some of the current standard regimens
of oral vitamin K prophylaxis are mostly insufficient in
cholestatic patients making them extremely vulnerable
for VKDB. More than 80 percent of breastfed infants with
biliary atresia who received oral vitamin K prophylaxis
(1 mg oral vitamin K at birth followed by 25 microgram
daily) developed a VKDB at the time of diagnosis. Forty
three percent presented with an intracranial hemorrhage.
The empirical dosing guideline for oral vitamin K1 in
infants and children with chronic cholestasis is 2.5 to 5 mg
given two to seven times per week. Nevertheless, with this
regimen, subclinical vitamin K deficiency seems prevalent
despite normal prothrombin time (PT). In a group of
43 cholestatic children supplemented following this
schedule, 23 (54%) had elevated plasma PIVKA II levels
(>3 ng/mL) with normal PT. Vitamin K doses sufficient
to maintain normal coagulation may not be sufficient to
maximize carboxylation of coagulation factors. Based on
the abovementioned data, it is thus of utmost importance
Chapter-10 Vitamin K Deficiency: Bleeding in Newborns 67

that, as soon as the diagnosis of cholestasis is made in an
infant, extra vitamin K supplementation should be given
to prevent VKDB with its serious consequences. However,
the best strategy for vitamin K supplementation in chronic
childhood cholestasis still remains a critical issue. Current
regimens may be underestimating the optimal dosage of
vitamin K.
Current International Scenario

The various schemes for vitamin K administration being
followed world over with risk of late HDN has been
summarized in Table 1.
Table 1 Various schemes for vitamin K administration
Administration
scheme
Incidence per
1,00000
The Netherlands
1mg oral at birth

followed by 25 g
daily for 2 weeks
3.2
Germany
2 mg oral at birth
followed by 2 mg
at 1 and 4 weeks
0.44
Denmark
2 mg oral at birth
0
followed by 1 mg
weekly till 12 weeks
Great Britain
1 mg IM
0.1
1 mg oral,
continuing after 1
week
0.43
1 mg oral, not
beyond 1 week
2.9
Nil
6.2
CONCLUSION
There is no doubt that all newborns need vitamin K. Classic
VKDB is prevented by the administration of 0.3 to 1 mg
vitamin K at birth; IM administration is the preferred route
in atrisk groups. IM administration of vitamin K at birth
is effective in preventing both classic and late VKDB. In
exclusively breastfed infants, oral vitamin K administration
should be continued. Weekly oral administration of 1 mg
vitamin K is more effective in preventing late VKDB than
daily administration of 25 g. Infantile cholestasis needs
extra vitamin K supplementation. Current regimens may
be underestimating the optimal dosage of vitamin K.
BIBLIOGRAPHY
1. Chalmers EA. Neonatal coagulation problems. Arch Dis
Child Fetal Neonatal Ed. 2004;89:F475-8.
2. Controversies Concerning Vitamin K and the Newborn
Committee on Fetus and Newborn Pediatrics. 2003;
112;1912.
3. Fear NT, Roman E, Ansell P, Simpson J, Day N, Eden OB.
United Kingdom Childhood Cancer Study Vitamin K and
childhood cancer: a report from the United Kingdom
Childhood Cancer Study. Br J Cancer. 2003;89:1228-31.
4. Golding J, Paterson M, Kinlen LJ. Factors associated with
childhood cancer in a national cohort study. Br J Cancer.
1990;62:304-8.
5. Hey E. Vitamin K what, why and when? Arch Dis Child
Fetal Neonatal Ed. 2003;88:F80-3.
6. Puckett RM, Offringa M. Prophylactic vitamin K for vitamin
K deficiency bleeding in neonates. Cochrane Database
Syst Rev. 2000: issue 4.
7. Winckel MV, De Bruyne R, De Velde SV, Biervliet SV.
Vitamin K an update for the Pediatrician. Eur J Pediatr.
2009;168:127-34.
11
Bleeding Neonate:
Approach and Management
Normal hemostasis, the process that arrests bleeding after blood vessel injury, is achieved through normal functioning of platelets
and coagulation proteins along with vascular integrity. These functions are delicately balanced so that blood may freely circulate
within the intact vessels and if bleeding occurs, the site of bleeding can be effectively sealed. Disruption of one or more of these
factors results in bleeding. Blood is in a dynamic equilibrium between fluidity and coagulation. This is maintained by balance between
coagulation mechanism on one hand and fibrinolysis as well as anticoagulation on the other hand. Failure of this balance makes the
neonate susceptible for both hemorrhagic as well as thrombotic tendencies. Hemorrhage and thrombosis may result from variety of
pathological processes.1-10
Hemostatic functions in infants and newborns differ from

those in children and adults. However, abnormalities
in some of these functions predispose the neonate to
bleeding, especially the preterm and sick neonates in
the neonatal intensive care units. Bleeding in a neonate
can be one of the important causes of morbidity and
mortality and can be a life threatening situation due to the
small blood volume of the neonate. Hence, any bleeding
neonate requires prompt attention and a rapid diagnosis
and immediate institution of therapy.
Hemostatic proteins (coagulation factors) resulting in

a stable clot. Disruptions of one or more of these factors
results in bleeding. This is in balance with the natural
inhibitors of coagulation factors present in blood like
anti-thrombin III, protein C and protien S.
MECHANISM OF HEMOSTASIS3-8
Hemostasis can be considered in two phasesprimary
and secondary.
Primary Hemostasis
It is estimated that 1 percent of all nursery admissions Vessel Wall Contractions and Platelet
and 25 to 30 percent of neonatal intensive care unit Plug Formation
INCIDENCE
admissions are complicated by disorder of bleeding. This

problem is accentuated in preterms and low birth weight
babies and with their increasing survival the incidence of
encountering bleeding disorder has risen particularly in
neonatal intensive care units.1-13
NORMAL NEONATAL HEMOSTASIS

Normal neonatal hemostasis is a highly complex process
dependent on interactions between:
Endothelial cells of the blood vessels
Platelets
It is characterized by vessel wall contractions and

platelet plug formation in smaller vessels. Following
vascular endothelial disruption, a complex series of
biochemical reaction set into motion.
The exposed subendothelial structures attract platelets
and they adhere to the exposed collagen with the help
of von Willebrand factor and Fibronectin.
Following the platelet adhesion substances like ADP,
Thrombaxane A2 and platelet factor III are released.
This leads to primary platelet aggregation which
attracts more platelets to aggregate and to release
Chapter-11 Bleeding Neonate: Approach and Management 69

ADP and Thrombaxane A2 from its dense granules,
ultimately expanding the hemostatic plug.
Secondary Phase of Hemostasis3,12,14
It involves sequential activation of circulating coagulation

factors by intrinsic and extrinsic pathways ultimately
to form a secondary stable fibrin clot. This controls
hemostasis in large vessels.
Fibrinolytic Activity
Under normal hemostatic mechanisms, where fibrin is
deposited upon the vessel wall or in the tissues, fibrinolytic
processes are simultaneously stimulated so that fibrin is
slowly broken down into fibrin split products by plasmin
which is activated from its precursor plasminogen.
Normally fibrinolytic mechanism is also balanced by its
inhibitors present in the blood.8-10
Hemostasis in Newborn: Salient Features

Due to physiological immaturity there are both quantitative
as well as qualitative differences in hemostatic functions
in newborn as compared to older children.
Primary Phase of Hemostasis

Though capillary fragility is normal in term infants it
is increased in preterm. Vasoconstriction following
injury is therefore incomplete in preterms2,3,6,8,12 and
hence intracranial hemorrhage is more common in
premature babies.
Platelet count in both term and preterm babies are
similar to that in older children. However platelet
function such as adhesion, aggregation and release of
factors like ADP and Thrombaxane A2 are abnormal.
Secondary Phase of Hemostasis5,6,8,10,13,15

Extrinsic pathway involving tissue factor V and factor
VIIa, is the major pathway where by coagulation is
initiated and the thrombin plays a crucial role in
coagulation as well as platelet activation.
The concentrations of some clotting factors reach
adult values in utero, but concentrations of vitamin
K dependent factors (II, VII, IX and X) and contact
factors (XI, XII, prekalliekrien, high molecular weight
kininogen) are reduced to about 50 percent of normal
adult values. Levels of factors II, VII, IX, X are decreased
more so in preterm babies due to hepatic immaturity
and poor availability of vitamin K. Hence hemorrhagic
disease of newborn is more common in premature
babies.5,17 More immature the infant, lower is the factor
XII activity. Reduced concentrations of factor XII, XI
are partly responsible for prolongation of activated

partial thromboplastin time (APTT) that is observed in
low birth weight infants.
Factor VII levels reaches adult range by 5 days, while
other factors increase gradually over the 1st 6 months
of life.
von Willebrand factor (vWF) levels are increased at
birth and although they decline slightly, they remain
high. Neonatal VWF is made up of multimers which
have increased platelet aggregation in response to
Ristocetin.
Factor XIII level in cord blood is 50 percent of that
in adults, but as only small amount of factor XIII is
required for its activation or clot stabilization, this low
values in newborns have no clinical significance.5,16,17
The plasma level, molecular weight, amino acid compo
sition and immunological properties of fibrinogen in the
newborn is comparable to that of adult. But it is found to
coagulase more slowly and has different chromatogram
on DEAE cellulose. The term fetal fibrinogen is applied
to this factor and hence often newborn babies have
prolonged thrombin time.5,18
Inherited Permanent Abnormality of

Coagulation Factors

Hemophilia A (Factor VIII def.)

Hemophilia B (Factor IX def.)
von Willebrand disease, etc.
Other rare deficiency of coagulation factors
Coagulation factors are synthesized in the fetus from
around the tenth week of gestation,16 and are not
transferred transplacentally from mother to the baby.
Hence, the values of coagulation factors estimated in
newborn reflect the synthesis of the various factors in
them.16
At term, levels of factor V, VIII are equivalent to older
children and adults and hence if deficiency of these
factors is present during newborn period then it
suggests inherited factor deficiency in them.5
In healthy neonates this transient deficiency of clotting
factors does not play an important role as levels of 20 to
30 percent of coagulant activities are adequate for clot
formation. However, stresses like prematurity, sepsis,
asphyxia, apneic spells, hypoxia, acidosis, RDS, etc. can
tilt the balance leading to bleeding episodes.
Fibrinolytic Activity
In newborn fibrinolytic activity is transiently increased
as compared to adults or older children. It declines to
adult level by 6 hours in term neonate. Plasminogen
levels are only half that of an adult and FDP is normally
absent in healthy preterm and term infants. This low level
of plasminogen along with physio
logical deficiency of
circulating anticoagulants like antithrombin III, protein-C
promotes thrombotic tendencies in neonates. Deficiency
or low level of plasminogen (around 50% of adult valuereaches normal adult value by 6 months) along with
physiological deficiency of circulating anticoagulants like
antithrombin III and protein C and S, promotes thrombotic
tendencies in neonates.
In addition plasminogen is present in fetal form
with both reduced functional activity and decreased
binding to cellular receptors.
C4b binding protein is absent in neonates and protein
S therefore circulates in active free form.
Tissue factor pathway inhibitors (TFPI) or external
pathway inhibitors are around 65 percent of adult
values.
Antithrombin III, Protein C and Protein S

Similarly concentration of the naturally occurring
anticoagulants, antithrombin III, protein C and protein
S are low at birth and as a consequence, both thrombin
generation and thrombin inhibition are reduced in the
newborn period. Antithrombin III (ATIII) heparin cofactor II (HCII), beta-2 macroglobulin, are increased at
birth, continue to rise till the age of 6 months and reach
the twice normal adult values at this time.
Neonates are thus susceptible to hemorrhage and
thrombotic tendencies. This paradox is due to a combined
deficiency of coagulation factors along with defective
platelet function on one hand and decreased levels of
natural inhibitors of coagulation and fibrinolysis on the
other.
Local Pathological Lesion

Trauma
Slipped ligature
Cephalhematoma, etc.
Combined Factors Deficiencies

Disseminated intravascular coagulation (DIC).
Hepatic dysfunction.
Etiology of bleeding in neonate:11-13,15
Bleeding in a neonate may be due to:
Vascular abnormalities, e.g. in prematurityintracranial
hemorrhage.
Platelets abnormalities
Quantitative:
Congenital infections (CMV, Rubella, HIV)
Thrombocytopenia with absent radius (TAR syndrome)
Certain syndromes
Fanconis anemia
Amegakaryocytic thrombocytopenic purpura`

Sepsis
Increased platelet consumption
Immune thrombocytopenic purpura
Auto immuneChild born to mother with SLE or ITP
Neonatal alloimmune thrombocytopeniaPIA antigen
+ve child born to PIA -ve mother
Asphyxia, shock
Sepsis, polycythemia, hyperviscocity
Thrombosis due to catheter, hemangioma
IUGR with toxemia of pregnancy
Heparin induced thrombocytopenia.
Qualitative:
Drugs like aspirin given to mother and inherited
disorders of platelet function like
Glanzmanns thrombasthenia, Bernard Soulier synd
rome.
Exaggeration of transient deficiency of coagulation
factors: Hemorrhagic disease of newborn.
Transitory disturbances of coagulation mechanism
as a result of associated systemic disease process, e.g.
sepsis, liver disease, DIC, etc.
Inherited permanent abnormality of coagulation
factors: Hemophilia A and B, von Willebrand disease,
etc.
Trauma alone or often associated with other factor
deficiencies Slipped ligature, cephalhematoma, etc.5-8
Approach to Bleeding Disorders in Neonate

Detail historyantenatal, perinatal, postnatal, family
history
Complete physical examination
Selected laboratory investigations
Confirmatory tests.
History
Maternal History
Presence of an underlying maternal systemic diseases
like pre-eclampsia, cardiovascular diseases, viral infec
tion
Recent drugs taken like aspirin, anticonvulsants like
phenobarbitone and phenytoin Na and anticoagulants
History of collagen vascular disorder, past history of
ITP in mother.
Detailed Birth History

Type of delivery, birth asphyxia, trauma.
Gestational age should be noted.
History of vitamin K given to neonate, use of antibiotics
and whether neonate is receiving only breastfeeds.
Fig. 1 Wiskott-Aldrich syndrome
Family History
History should include:
Family history suggestive of bleeding disorder, e.g.
history of excessive bleeding after injury or history of
menorrhagia in female members.
Proper pedigree charting of any affected memebers,
both living and expired will help to know the type of
inheritance of the disorder.
X-linked inheritance: Factor VIII, IX deficiency
enquire similar history of bleeding episodes in male
siblings, maternal cousins, maternal uncles, etc.
Autosomal dominant: von Willebrands disease, dysfi
brinogenemia, hemorrhagic telangiectasia
Autosomal recessive: Other factor deficiencies
enquire history of consanguinity.
Physical Examination
A rapid and thorough physical assessment of the bleeding
neonate should include:
General examination.
Well BabyA Healthy Baby with

Bleeding Indicates

Hemorrhagic disease of newborn

Inherited coagulation factor deficiency
Isoimmune thrombocytopenia
Platelet function disorders
Vascular causes, slipped ligature, etc.
Sick Baby with Bleeding Indicates

Sepsis, asphyxia, RDS, hypothermia, apnic spells, acidosis, hypoglycemia, seizures, prematurity, hypovolemia,
shock, etc. In such babies bleeding is likely to be secondary phenomenon such as DIC, consumption platelet
coagulopathy, liver dysfunction, etc.3-5,12
Site of Bleeding
Bleeding from umbilicus in a healthy child without any
evidence of umbilical sepsis or slipped ligature, suspect
factor XIII deficiency or hypodysfibrinogenemia.
Bleeding from circumcision or hematoma at injection
site in a healthy child-suspect factor deficiency or
hemorrhagic disease of newborn.
Bleeding from GIT is probably due to swallowed
maternal blood or vitamin K deficiency.
In a sick child-suspect DIC.
Big cephalhematoma following normal delivery
(without prolonged or difficult labor) should lead to
suspicion of inherited bleeding disorders.
Petechiae or ecchymosis on presenting part, secondary
to congestion and birth trauma may be seen soon
after birth and they gradually disappear and are not
associated with bleeding anywhere else.
Skin bleeds like purpura or petechiae in a healthy childsuspect immune thrombocytopenia and differentiate
it from mosquito bites (Fig. 2).
Associated Findings
If associated hepatosplenomegaly jaundice or chorioretinitis present, it may suggest:
Congenital/acquired infections
Leukemia
Erythroblastosis fetalis
If associated with eczemaWiskott-Aldrich syndrome
(Fig. 1):
laboratory investigations are required to identify the
precise nature of the underlying cause of bleeding disorder.
It is necessary to confirm whether it is bleeding disorder
or not, particularly in a newborn baby with GI bleeding
as maternal blood swallow syndrome is seen during early
newborn period due to swallowing of maternal blood by
baby during the delivery or from the cracked nipple of
mother while feeding. Simple bedside test like Apt test will
differentiate these two as fetal hemoglobin is resistant to
denaturation by alkali where as adult hemoglobin present
in mothers RBCs denaturates.
Apt Test
Fig. 2 Mosquito bite
Associated Congenital Anomalies

TAR syndromeabsent radius with thrombocyto
penia
Large hemangioma with DIC suggest Kasabach
Merritt syndrome
Syndactyly with bleeding: Factor V deficiency
Ehler-Danlos syndrome: Ecchymosis, bruises, purpura
with hyperelastic skin.
Laboratory Approach (Table 1)

Though thorough history and clinical evaluation help
in suspecting the nature and type of bleeding disorders,
1 part of vomitus is mixed with 5 parts of saline and centri

fuged at 2000 rpm for 10 minutes. Add 4 cc of 10 percent
NaOH to 1 cc of supernatant centrifuged fluid. Brown
color indicates maternal blood and pink color fetal blood.5
In a suspected case of bleeding disorder further labora
tory tests need to be carried out. They can be divided into:
Screening tests
Special tests.
Screening Tests (Table 2)

They are applied to know the presence and nature of
bleeding disorder so that relevant special tests can be
done to confirm the diagnosis thus avoiding unnecessary
battery of tests in each case. They include:
CBC
Peripheral smear examination
PT, APTT, BT and clot retraction.
Table 1 Laboratory tests

Platelets
PT
PTT
BT
CR
Likely diagnosis
Sick infants
Decreased
Decreased
Normal
Normal
Increased
Normal
Increased
Normal/L
Increased
Normal
Increased
Normal/L
Increased
Increased
Normal
Normal
Decreased
Decreased
Normal
Normal
DIC
Early sepsis
Liver disease
Compromised vascular intergrity associated hypoxia, increased
prematurity, acidosis hyperosmolality
Healthy infants
Decreased Normal
Normal
Increased
Normal
Increased
Increased
Normal
Decreased
Normal
Occult infection or immune thrombocytopenia; thrombosis

Hemorrhagic disease of newborn (vitamin K deficiency) or
common pathway defect
Normal
Normal
Increased
Normal
Normal
Hereditary intrinsic clotting factor deficiencies
Normal
Increased
Normal
Normal
Normal
Factor VII deficiency
Normal
Normal
Normal
Normal
Normal
Bleeding due to local factors (trauma, anatomic abnormalities)
Factor XIII deficiency
Normal
Normal
Normal
Increased
Decreased Platelet abnormalities (rare)
Abbreviations: PT: Prothrombin time; PTT: Partial thromboplastin time; BT: Bleeding time; CR: Clot retraction time.

Table 2 Screening tests for bleeding disorders18-20
Test
Adult
Full term
Preterm
Prothrombin
time (sec)
12 1
14 1.3
14 1.3
Partial
thromboplastin
time
42 4
51 10
57 10.5
Thrombin
clotting time
(2U)
25 2
23 2.9
23 2.4
Factor II (%)
81 17
50 14.5
31 8.6
Factor V (%)
90 19
79 17
70 22
Factor VII-X (%)
93 20
54 12.2
37 11
Factor VIII (%)
87 27
126 56
116 73
Factor IX (%)
99 23
35 12.6
28 11
Factor X (%)
89 23
45 12
31 9.0
Antithrombin
III (%)
99 10
58 9.6
33 9.0
Fibrinogen
(mg/dL)
315 60
215 35
256 20
The following table shows the interpretation and

the likely causes of bleeding in a given case and further
confirmatory tests required to be done in such newborn.
Laboratory screening tests in differential diagnosis of
the bleeding infant.
Confirmatory Tests
Platelet Disorders
Thrombocytopenia with normal PT/APTT in a
healthy neonate suggest allo- or autoimmune thrombocytopenia
If autoimmune thrombocytopenia mothers platelet
count study for thrombocytopenia to rule out chronic
ITP/Test for collagen disorder should be done.
If alloimmune thrombocytopenia mothers platelet
count study is normal. Platelet study in the mother and
childmother will be PLA1 antigen negative and a
child PLA1 positive.
Low platelet count with normal PT/APTT in a sick
child suspect platelet consumption as in septicemia
and if associated with prolonged PT/APTT it suggest
DIC. Do peripheral smear examination for burr cells,
broken RBCs, helmet cells, serum fibrinogen which is
decreased and FDP is increased.
Coagulation Factors Defects

Normal platelet count with prolonged PT/APTT in a
healthy child suspect vitamin K deficiency or defect in
the common pathways and hence do thrombin time

and serum fibrinogen estimation. Therapeutic trial
with vitamin K will normalize PT/APTT in hemorrha
gic disease of newborn.
Low serum fibrinogen with prolonged thrombin
time suggest hypofibrinogenemia. If fibrinogen level
is normal and thrombin time is prolonged then it
suggests dysfibrinogenemia or presence of inhibitors,
heparin, etc.
In a sick child normal platelet count and prolonged PT
and APTT suggest liver disorderliver function test
are needed.
Normal platelet count with normal PT and increased
PTT in a healthy child suggest intrinsic pathway defect
like hemophilia A, B or factor XI deficiency. Correction
studies are required and estimation of factor levels.
Normal platelet count with normal APTT with
increased PT suggest extrinsic pathway defect due to
deficiency of factor VIIcorrection studies and factor
assay are needed for establishing diagnosis.
If all screening tests are normal including normal
platelet count, PT and APTT following conditions should
be kept in mind.
Local factors: Slipped ligature, umbilical sepsis,
compromised vascular integrity, etc.
Qualitative platelet disorders: Bleeding time will be
prolonged with poor clot retraction. Do aggregation
study.
Factor XIII deficiency: Do urea solubility test.
Ehler-Danlos syndrome: Clinical examination for skin
elasticity.
Hemorrhagic telangiectasia: See for telangiectasia in
mucous membrane of nose, bulbar conjuctiva, tongue
and tips of the fingers.
Vitamin K and Neonatal Hemostasis

(Fig. 3)12-17
Biology of Vitamin K
Vitamin K deficiency bleeding (VKDB) also known as the
hemorrhagic disease of the newborns refers to bleeding
that occurs as a consequence of vitamin K deficiency
during first year of life.
Vitamin K
Phylloquinone or vitamin K1 is from plant origin.
The group of menaquinones or vitamin K2 differ in
the number of isoprenyl units in the side chain and
are synthesized by the bacteria in humans and animal
intestine.
Menadione or vitamin K3 is a synthetic and water
soluble vitamin K without a side chain. This preparation
is not preferred as it has been shown to cause hemolytic
Fig. 3 Vitamin K deficiency
carboxylase is therefore limited in preterm because

precursor proteins themselves are deficient, often
below 30 percent of adult value.
Though colostrums contain adequate amount of
vitamin K, lesser colonization by bacterial flora of
the gut of exclusively breastfed infants contribute to
lower plasma level of vitamin K. Cows milk contains
6 ug/dL of vitamin K1 as compared to breast milk which
contains 1.5 ug/dL vitamin K deficiency is classified
based on timing of presentation as follows:
Early VKDB
Classical VKDB
Late VKDB.
Clinical Presentation
anemia, indirect hyperbilirubinemia and kernicterus.
Vitamin K acts as a cofactor for gamma glutamyl
carboxylase (GGCX) serving as an electron donor for the
post-translational conversion of protein bound glutamate
into gamma carboxyglutamate. During this process it
is oxidized to vitamin K2, 3epoxide. Gla residues are
calcium binding groups which are essential for the
biological activities of proteins in which they are found. Gla
containing proteins are the coagulation factors II, VII, IX
and X and procoagulants like proteins C, protein S, protein
Z, osteocalcin, etc.
Vitamin K deficiency leads to the synthesis of under
carboxylated proteins unable to bind calcium and
hence inactive. In vitamin K deficient individuals,
undercarboxylated forms of vitamin K dependant
coagulation proteins (proteins induced by vitamin
K absence PIVKA) are released from the liver into
the blood. PIVKA are inactive in the coagulation
cascade. PIVKA II or undercarboxylated prothrombin
is a marker of subclinical vitamin K deficiency. As a
consequence of limited stores at birth, neonates are
prone to vitamin K deficiency if no sufficient intake is
provided.
Early VKDB: Hemorrhagic disease of newborn.

Clinical presentation is often mild, with bruises,
gastrointestinal bleeding. Severe manifestations include
cephalohematoma, intracranial and intra-abdominal
hemorrhage (Fig. 4). The incidence in an atrisk group
without vitamin K supplementation 6 to 12 percent.
Occurs between 24 hours and 7 days of life.
Classical VKDB: Associated with delay or insufficient
feeding.
Clinical presentationwithout vitamin K supple
mentation incidence estimated is 0.01 to 0.44 percent.
Bruises, gastrointestinal blood loss or bleeding from
the umbilicus and puncture sites
Blood loss, however, can be significant, and intracranial
hemorrhage, although rare, has been described.
Late VKDB: Occurs in breastfed infants after 2nd month
of life.
Early Vitamin K Deficiency Bleeding

Presents within 24 hours of birth.
Seen in infants of mothers taking drugs which inhibit
vitamin K
Anticonvulsants (carbamazepine, phenytoin and
barbiturates)
Antitubercular drugs (isoniazid, rifampicin)
Antibiotics (cephalosporins)
Vitamin Kantagonists (coumadin, warfarin).
In preterms the liver is immature and incapable of
optimal synthesis of many of precursor proteins. The
action of vitamin K, as cofactor for gamma glutamyl
Fig. 4 Cephalohematoma
Predisposing Factors

Prolonged antibiotic use

Prolonged/recurrent diarrhea
Cholestasis
Malabsorption syndromes
Clinical presentation may be severe with mortality rate
as high as 20 percent. Intracranial hemorrhage is seen
in 50 percent of these infants with residual neurological
damage in survivors.
In fully breastfed infants who did not receive vitamin
K at birth, the incidence is between 1/15,000 and
1/20,000.
Diagnosis of HDN
The diagnosis of vitamin K deficiency may be suspected
from the results of coagulation screening. Initially there is
isolated prolongation of the prothrombin time followed by
prolongation of the APTT, in association with the normal
concentrations of fibrinogen, normal CBC and platelet
count.
Confirmation of the diagnosis requires measurements
of PIVKA II.
Treatment
Intravenous vitamin K should be administered to
correct the existing deficiency.
Factor replacement therapy may also be required
with fresh frozen plasma or prothrombin complex
concentrate (FII, FIX, FX).
for multidose oral prophylaxis. Unfortunately this

preparation is not available in most of the countries
including India.
Single dose (1.0 mg) of intramuscular vitamin K
after birth is effective in the prevention of classic HDN.
Vitamin K, should be given to all newborn as a single,
intramuscular dose of 0.5 to 1 mg. All premature infants
should receive vitamin K. Reports have shown very high
plasma vitamin K levels in preterm infants receiving 0.5
to 1 mg at birth and adequate levels in those receiving 0.2
mg at birth.
Current empirical dosage recommendations for
preterm infants:
Dose of 0.3 mg for birth weights <1,000 g
0.5 mg for those >1,000 g and <1,500 g.
CONCLUSION
As a child is not a miniature adult so also a neonate
is not a miniature child. It is important to realize and
to keep in mind the normal physiological variations
of hematolog
ical parameters in term and preterm
neonates. The causes of bleeding in neonates are much
different from that in adult or an older child and hence
the approach to bleeding neonate is different than that
in older children.
REFERENCES

Prevention
Routine prophylaxis with 1 mg vitamin K at birth.

(Daily requirement of 5 to 10 g in infants) and given
intramuscularly simply because that was the only
product available.
In 1990 an epidemiological study described an asso
ciation between intramuscular (IM) vitamin K at birth
and childhood cancer and leukemia. In response to
these findings, several European countries, Australia
and New Zealand changed their policy to oral pro
phylaxis. In the following years, new studies failed to
confirm the association between IM vitamin K at birth
and childhood cancer. A risk of solid tumors can now
almost definitely be ruled out.13,14
The American Academy of Pediatrics has always
endorsed the IM route.
No oral liquid preparation is available, the injectable
product has been found to be safe and effective when
given by the oral route.
Several countries currently use an alternative synthetic
preparation of vitamin K1 (Konakion MM; Roche)
1. Bleyer WA, Hakami N, Shephard TH. The development

of hemostasis in the human foetus and newborn infant. J
Pediatr. 1971;79:838.
2. Gross SJ, Stuart MJ. Hemostasis in the premature infant.
Clin Perinatol. 1977;4(2):259-304.
3. Oski FA, Naiman JJ. Hematological problems in the newborn.
2nd edn, WB Saunders and Co, Philadelphia. 1972.p.236.
4. Glader BE, Buchman GR. Bleeding neonate. Pediatr.
1976;58:548.
5. Rosenberg RD. Physiology of coagulationThe fluid
phase. In: Hematology of Infancy and Childhood, Nathan
DG, Oski FA (Eds). Philadelphia, WB Saunders and Co.
1981.p.1145.
6. Blanchette V, Zipursky A. Hematological problems.
Neonatology Gorden Avery, 3rd edn, JB Lippinocott
company, Philadelphia. 1981.pp.664-71.
7. Stuart MJ. Bleeding in newborn and pediatric patients. In:
Hemostasis and Thrombosis, Eds - Colamn RW, Hirsh J,
Marder VJ, Salzman EW. 2nd edn, JB Lippincott Company,
Philadelphia. 1987.pp.942-59.
8. Devina Prakash, Marwaha RK. Disorders of hemostasis in
the newborn. Proceedings of first national workshop on
neonatal hematology-oncology. 1988.pp.29-41.
9. Hathway WE. Coagulation problems in the newborn
infants. Pediatr Clin N Am. 1970;17:929.
10. Hathway WE. The bleeding newborn. Semin Hematol.
1975;12:175.
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11. Gordon EM, Fatnoff OD. Studies on some coagulation
factors in the normal newborn. Am J Pediatr Hematol
Oncol. 1980;2:213.
12. Winckel MV, De Bruyne R, De Velde SV, Biervliet SV.
Vitamin K an update for the Pediatrician. Eur J Pediatr.
2009;168:127-34.
13. Golding J, Paterson M, Kinlen LJ. Factors associated with
childhood cancer in a national cohort study. Br J Cancer.
1990;62:304-8.
14. Fear NT, Roman E, Ansell P, Simpson J, Day N, Eden
OB. United Kingdom Childhood Cancer Study Vitamin
K and childhood cancer: a report from the United
Kingdom Childhood Cancer Study. Br J Cancer. 2003;89:
1228-31.
15. Puckett RM, Offringa M. Prophylactic vitamin K for vitamin

K deficiency bleeding in neonates. Cochrane Database
Syst Rev,2000: issue 4.
16. Controversies Concerning Vitamin K and the Newborn
Committee on Fetus and Newborn Pediatrics. 2003;112:
1912.
17. Hey E. Vitamin K what, why and when. Arch Dis Child
Fetal Neonatal Ed. 2003;88:F80-F3.
18. Chalmers EA. Neonatal coagulation problems. Arch Dis
Child Fetal Neonatal Ed. 2004;89:F475-F8.
19. Hathway WE. Fibrin split products in serum of newborn.
Pediatr. 1970;45:1970.
20. Buchman CR. Coagulation disorders in neonates. Ped Clin
N Am. 1986;33:203-20.
12
Approach to Neonatal
Thrombocytopenia
Nitin K Shah
After birth the platelets are produced by megakaryocytes in the bone marrow and have a life of 9 to 10 days. In the fetus they are
produced predominantly in the liver. Platelets appear in the circulation in a fetus by 5 to 6 weeks of gestational age and platelet count
steadily rises to 159 34 109/L by 10 to 17 weeks of gestation and 240 60 109/L by 18 weeks of gestation, remaining constant at
that level thereafter until birth and beyond. Hence the lower limit of the platelet count in a newborn, irrespective of the gestational
age, remains at the adult level, i.e. > 150 109/L.
Thrombocytopenia in a newborn is defined as platelet

count lower than 150 109/L, though clinical bleeding
is usually seen with platelet count less than 50 109/L or
even lower. Spontaneous and severe bleeding is usually
seen when the platelet count drops to <20 109/L.
Presence of significant bleeding at higher platelet counts
should arouse suspicion of associated platelet dysfunction
as is seen in cases with inherited thrombocytopenia, e.g.
Bernard-Soulier syndrome.
A minimum platelet count of 7 109/L is required for
maintenance of the vascular integrity, and in that sense
a normal platelet count of > 150 109/L provides a lot of
reserve functional capacity. Similarly, 30 percent of the
circulating platelets are stored in the spleen which can
be brought in to the circulation during the need or stress.
Normal bone marrow contains 6 106 megakaryocytes/kg
body weight.
The normal daily platelet production is approximately 35,000
4,300 platelets per microliter of blood to maintain steady
levels of about 2,50,000 1,00,000 platelets/mL. Normal bone
marrow can respond by increasing the platelet production by 7
to 8 fold during periods of thrombocytopenia.
Platelets are required at each stage of hemostasis.

With the help of von Willebrand factor, they adhere to
the exposed endothelial cells at the site of injury and help
to form the primary platelet plug.
They secrete granules that contain the factors to help

aggregate further platelets and coagulation factors that
help form a clot locally. They secrete vasoactive amines
that lead to vasospasm to prevent further blood loss.
Platelet membrane provides the surface required for
the coagulation to proceed.
There are several growth factors that are required
for the formation of platelets from megakaryocytes
in the bone marrow. These include IL3, IL6, IL11, stem
cell factor, leukemia inhibitory factor, erythropoietin
and the most important, thrombopoietin (Tpo). Tpo,
discovered in 1994, is a polypeptide glycoprotein that
binds to its receptor c-mpl (named after its cell of
discovery, i.e. acute myeloproliferative leukemic cell)
expressed on the megakaryocytes, megakaryocytic
precursors, hematopoietic precursor cells and platelets.
Tpo acts to commit early precursor cells to lineage
specific differentiation and enhances production and
release of platelets in the circulation. It acts via further
signal conduction pathway and prevents apoptosis in
the target cells. It also appears to play a role as panhematopoietic growth factor which explains why defects
in its metabolism ultimately leads to total bone marrow
failure, as seen in rare cases of congenital amegakaryocytic
thrombocytopenia. Tpo levels are inversely proportional
to the total megakaryocytic mass. High levels of Tpo
indicate aregenerative type of thrombocytopenia.
The bone marrow in neonates is very sensitive to
insults like hypoxia which leads to suppression of the
megakaryocytes more than other precursor cells. This
explains why thrombocytopenia is more common than
other cytopenias in neonate, especially following hypoxic
stress.
Incidence
There very few prospective studies which have specifically
looked at the incidence of thrombocytopenia in newborns.
Recent prospective studies have shown that 0.5 to 4.1 percent
of the neonates have thrombocytopenia. 30 percent of the
babies admitted to the NICU have platelet counts < 150 109/L
and around 10 percent of the babies will have counts < 100
109/L.
Fortunately most of the episodes of thrombocytopenia

in NICU are mild to moderate but 20 percent of them
(6 percent of the neonatal admissions) will have severe
thrombocytopenia with counts < 50 109/L who are at a
risk of severe bleeding including intracranial bleeds. 80
percent of these babies with severe bleeds are sick, preterms who have sepsis or necrotizing enterocolitis (NEC).
Causes of Neonatal Thrombocytopenia

While traditionally one can classify the causes of neonatal
thrombocytopenia in to those caused by (Table 1).
Reduced Production
Increased destruction or consumption
Sequestration
Dilutional
A combination of these.
It does not help while approaching a case of neonatal
thrombocytopenia as most of the causes listed are rare.
It is easy to group the cases as per their onset, the nadir
of counts, the type of recovery, their mechanism of disease,
their associated findings, presence of physical anomalies,
presence of immunodeficiency and syndromes which
helps to narrow down the differential diagnosis.
Patterns of Neonatal Thrombocytopenia

While there are many etiological causes of neonatal
thrombocytopenia, this helps us narrow down the etiology.
Most of the patients fall into two types of patterns.
Early onset type 75 percent of the neonatal throm
bocytopenia. Most babies have low platelet at birth or soon
after birth, in the first 72 hours of life. The causes include
thrombocytopenia due to chronic or acute hypoxia like in
a preterm, IUGR baby risk factors like perinatal asphyxia,
Table 1 Causes of neonatal thrombocytopenia

Perinatal hypoxia:

Maternal diabetes
Maternal hypertension, pre-eclampsia
Intrauterine growth restriction (IUGR)
Immune causes:
Alloimmune
Autoimmune
Infections:
Perinatal infections: Bacterial, TORCH, HIV
Late onset sepsis/NEC
Disseminated intravascular coagulation (DIC):

Asphyxia, infections
Mis-matched transfusions
Congenital thrombotic thrombocytopenic purpura (TTP)
A
neuploidy: Trisomy 18, trisomy 13, trisomy 21, Turners
syndrome
Inherited
Giant platelets: Bernard-Soulier syndrome, May-Hegglin
anomaly, Sebastian syndrome, Fechtner syndrome, Epstein
syndrome, Alports syndrome, Montreal platelet syndrome,
Quebec syndrome, Gray platelet syndrome

Immunodeficiency: Wiskott-Aldrich syndrome

X-linked thrombocytopenia
Hemophagocytic lymphohistiocytosis
Bone marrow failure: Fanconis anemia
Thrombocytopenia with absent radius (TAR) syndrome
Congenital amegakaryocytic thrombocytopenia
Premalignant: Monosomy 7
Others
onsumption: Kasabach-Merritt syndrome, vascular
C
thrombosis, hepatic hemangioendothelioma
Metabolic: Propionic academia, methylmalonic academia
Miscellaneous
Congenital leukemia
Exchange transfusions
(i) Rh disease of newborn
(ii) Subcutaneous fat necrosis of the neonate
maternal diabetes, placental insufficiency, maternal

hypertension or pre-eclampsia. The platelet counts
in low normal in the first 2 to 3 days, falls to a nadir at
4 to 5 days and recovers by 7 to 8 days. The counts rarely
drop below 50 109/L. If the pattern of recovery does not
follow this path one has to think of other causes of early
onset thrombocytopenia like chromosomal anomalies,
congenital or perinatal infections, inherited causes or
immune causes.
Late onset type: This accounts for the remaining 25 percent
of the cases and usually associated with late onset sepsis
Chapter-12 Approach to Neonatal Thrombocytopenia 79

with or without NEC. The counts drop to a low level and
there may be significant bleeding in these babies.
Important Causes of Neonatal

Thrombocytopenia
Neonatal Alloimmune Thrombocytopenia
This is the platelet equivalent of the Rh disease where alloantibodies are produced by the mother against the paternal
platelets antigens inherited by the newborn from the
father which are missing in the mother. These antibodies
pass across the placenta and destroy the babys platelets
resulting in often moderate to severe thrombocytopenia.
Unlike in Rh disease, in more than 50 percent of cases the
first born babies are also affected. In 80 percent of cases
the missing platelet antigen in the mother is HPA-1a
(also known as PlA1), in 10 to 15 percent it is HPA-5b and
in the rest it is HPA-3a, HPA-1b or some other unknown
and rare antigen. In Asian communities, it is usually the
HPA-4 antigen. Development of the alloantibodies in
HLA-1A negative women is strongly associated with HLA
DRB3 0101 (odds ratio of 140).
1:350 pregnancies are associated with maternal antiplatelet antibodies, but only 1:1000 livebirths are associated
with neonatal alloimmune thrombocytopenia proving
that a good number of them are silent or unnoticed. The
affected neonates, who otherwise look well, present with
purpura, bruising, mucosal bleeds and thrombocytopenia
at birth or immediately after birth. The platelet count
is usually < 30 109/L. The 20 percent of the affected
neonates develop severe bleeding including intracranial
bleeds. 20 to 50 percent of the intracranial bleeds start in
the intrauterine life and 20 percent of the survivors develop
long-term neurodevelopmental sequelae. The diagnosis is
done by laboratory testing for the antiplatelet antibodies.
Treatment
Treatment of the mildly affected babies without
mucosal bleeds or with platelet count above 30 109/L
is conservative.
Those with significant mucosal bleeds, evidence of
intracranial bleeds or platelet count < 30 109/L need
specific treatment including platelet transfusions,
IVIg and steroids. HPA compatible platelets need to
be transfused. While one can use washed mothers
platelets (which obviously will be negative for the
missing platelets), HPA-1a negative platelets are
usually stored and easily available in major centers in
the west.
If severe thrombocytopenia persists in spite of the
platelet transfusions, one need to give IVIg in the dose
of 2 gm/kg body weight over 2 to 5 days and or IV
methylprednisolone in the dose of 1 mg/kg 8 hourly.

The treatment is required for 1 to 6 weeks till the
platelet counts is in the safe range.
The severity depends on the maternal antibody titers.
The second born neonate is usually severely affected, if
the first baby was symptomatic or had intracranial bleeds
especially with intrauterine onset. In such cases, fetal
monitoring of the platelet counts is advocated and the
mother is given IVIg in the dose of 1 to 2 gm/kg/week
with prednisolone in the dose of 0.5 to 1 mg/kg/day. The
fetus can also be given in utero HPA compatible platelet
transfusions if the maternal treatment alone dose not
help. Elective LSCS is also advocated to prevent trauma to
head.
Neonatal Autoimmune Thrombocytopenia

This occurs due to transplacental transfer of the antiplatelet autoantibodies. It is suspected because of the prior
history of thrombocytopenia in the mother due to ITP, SLE
or some such auto-immune disease. The platelet count
in the mother may be normal even when the antibodies
persist, especially following splenectomy. The antibodies
are formed against the common platelet antigens like
gp1b/IX or gpIIb/IIIa. The disease is generally milder than
the alloantibody mediated neonatal thrombocytopenia.
The newborn is usually normal at birth with even normal
platelet count which drops after few days. Less than 10 to 15
percent of the babies have platelet counts < 50 109/L and
the bleeding is usually milder. Intracranial bleeds occur
in < 1 to 2 percent of babies. In most the platelet counts
recover in the next 2 to 3 weeks though rarely they may
take a longer time. There is no role of antenatal treatment
or LSCS. After birth, treatment is required in presence of
significant bleeding or platelet counts < 30 109/L. The
treatment consists of IVIg and/or steroids as in the case
of alloimmune thrombocytopenia. Like in ITP, there is no
role of platelet transfusions as the autoantibodies will react
with all the platelets as the target antigens are common to
all the donors. The prognosis is usually excellent.
Thrombocytopenia following hypoxia: This is the most
common cause of early onset pattern of thrombocytopenia.
The newborn is usually a preterm or an IUGR baby
who has risk factors like maternal diabetes, maternal
hypertension or pre-eclampsia or perinatal asphyxia. The
counts are 100 109/L in first few days, fall to a nadir of
50 109/L at 4 to 5 days and recover by 7 to 8 days. The
counts often recover above the normal levels. They
may also have neutropenia and polycythemia besides
thrombocytopenia. Though platelet destruction is an
important cause, especially in acute hypoxia where DIC
with thrombocytopenia is seen in 50 percent of such
babies, in most with chronic hypoxia there is decreased
production too as the major contributing factor. Less
than 10 percent of such babies have evidence of DIC
and the Tpo levels are high suggestive of aregenerative
type of thrombocytopenia. There is evidence of
increased erythropoiesis with increased levels of EPO
and circulating normoblasts. This with increased Tpo
levels suggests preferential differentiation towards
erythropoiesis with depressed megakaryopoiesis. This is
because the megakaryocytes are sensitive to hypoxia and
are suppressed with hypoxia temporarily. The bleeding
is usually mild. Most do not need any specific treatment.
Those who are symptomatic need platelet transfusions.
Thrombocytopenia due to Neonatal Infections

Perinatal sepsis: Perinatal bacterial sepsis can occur in
1 to 2/1000 livebirths. The common organisms include
group B sepsis or E. coli in the west and gram-negative
organisms like Klebsiella or E. coli in our country. The 50
percent of the sepsis cases develop thrombocytopenia
and DIC is an important cause of low platelet counts.
The platelet counts are low early in life and recover
with the treatment of the primary cause.
Congenital infections: TORCH group of infection can
lead to thrombocytopenia. Most, but not all, will have
other signs like jaundice, anemia, congenital defects,
hepatosplenomegaly, etc. Acute cytomegalovirus
(CMV) is a common cause of such thrombocytopenia.
0.5 to 1 percent of all newborns develops congenital
CMV infection and though only 10 to 15 percent of
them are otherwise symptomatic, 75 percent of them
have low platelet counts. There may be associated
neutropenia and the thrombocytopenia may persist for
several months. Similarly, 40 percent of those infected
with toxoplasma can develop low platelet counts.
Other common cause in our country is perinatal HIV
infection and rubella infection as MMR is still not a
part of our national schedule.
Late onset sepsis: A common cause of late onset of
thrombocytopenia is late onset of sepsis with or
without NEC. Thrombocytopenia may be the first sign
of infection, though usually other signs of infection
are also present. The platelet counts falls after the first
72 hours and may take around 7 to 8 days to recover
after the treatment for sepsis is started and effective.
Less than 10 percent of these patients have DIC. The
Tpo levels are high suggesting aregenerative type of
thrombocytopenia. This is also evident by the fact
that thrombocytopenia persist even after the infection
is under control. This suggests that the cause of low
platelet is less production due to suppression of the
megakaryocytes. The counts are usually < 30 109/L
and 15 to 20 percent of the patients have significant

bleeding. Platelet transfusions are required for the
symptomatic patients.
Consumption of Platelets
Disseminated intravascular coagulation (DIC):
Con
sumption and destruction of platelets occur
in DIC which usually occurs following perinatal
asphyxia or neonatal infection. The newborn will
have the signs of the primary disease and will have
severe thrombocytopenia with significant bleeding.
The patient may have the signs of thrombosis like
gangrene. The prothrombin time and activated
partial thromboplastin time will be prolonged and
D-dimers or the fibrinogen split products (FDP) will
be raised. The peripheral smear will show evidence of
microangiopathic hemolytic anemia along with low
platelet counts. Treatment will include use of platelets
along with fresh-frozen plasma besides treatment of
the primary cause.
Kasabach-Merritt syndrome: Large hemangioma
can occur over extremities, trunk, neck or in internal
organs. Platelets can get trapped in the slow circulation
within the hemangioma and can lead to local
consumption or localized DIC with consumption of
other coagulation factors too. There may be multiple
afferent and feeders to the hemangioma. The mass
may not be restricted to the defined anatomical layers
and usually infiltrates deep in to the tissues making
it difficult to excise the hemangioma. The diagnosis
is obvious when the hemangioma is seen externally,
whereas it can be difficult if the hemangioma is in
some organ. Very low platelet counts, evidence of
microangiopathy, raised D-dimers or FDP levels and
high retic count will suggest the diagnosis. Imaging
and vascular studies will help define the extent of the
lesion which may be actually much widespread than
appearing visibly. Medical treatment includes use
of FFP followed by anti-fibrinolytic agents hoping to
induce thrombosis of the important feeding vessels.
Interferon therapy and vincristine can help shrink
the lesion permanently; however, they have their own
side effects. Surgery often is mutilating and may land
up into amputation.
Congenital and Inherited Thrombocytopenia

This includes causes like chromosomal anomalies and
rare inherited causes of low platelet count. The counts
are low at or soon after the birth. In most, but not all,
there are other features of the basic disease. The platelet
count can be very low in some of them needing platelet

transfusions and other treatment. The counts take a
long to recover and may be low for months. Those with
associated thrombasthenia bleed a lot at relative higher
platelet counts. Some of them will have typical platelet
morphology on smear examination.
Chromosomal anomalies: The incidence of throm
bocytopenia in various aneuploidy cases varies from
86 percent in trisomy 18 to 31 percent in trisomy 13,
6 percent in trisomy 21 and 31 percent in Turners
syndrome. Usually the thrombocytopenia is not severe
and many a times, it is associated with neutropenia
and polycythemia as seen in placental insufficiency.
The mechanism of thrombocytopenia may also be
similar to that seen in placental insufficiency.
Inherited thrombocytopenia: Inherited thrombo
cytopenias are a rare but interesting group of disorders
which provided dome insight in to the molecular
mechanisms for megakaryopoiesis. For some of these
disorders, the molecular defects have been identified,
like mutation of the CMPL in congenital amegakaryocytic
thrombocytopenia, defect in transduction pathway after
binding of Tpo to CMPL in TAR syndrome, mutations
in CBFA2 transcription factor gene RUNX1 (AML1)
in familial platelet syndrome with predisposition to
AML, mutation in GATA-1 transcription factor (xp
11) in X-linked thrombocytopenia with microcytosis,
mutation in myosin heavy chain A gene (MYH9) in giant
platelet syndromes including May-Hegglin anomaly
and mutations in the WASP gene in Wiskott-Aldrich
syndrome and X-linked thrombocytopenia. Most, but not
all, have associated congenital anomalies to point to the
possible diagnosis. Many of them have abnormal platelet
morphology like giant platelet on peripheral smear
examination. Some have associated platelet dysfunction
leading to more bleeding than expected for the platelet
count.
Thrombocytopenia with giant platelets: This group
includes the disorders like Bernard-Soulier syndrome;
May-Hegglin syndrome and its variants like Sebastian
syndrome, Fechtner syndrome, Epstein syndrome and
Alport syndrome; Montreal platelet syndrome; Quebec
syndrome and gray platelet syndrome.
Bernard-Soulier syndrome: It is an autosomal recessive
disorder. The platelet count is moderately low but
the bleeding is quite significant. The platelets can be
as large as 20 microns in diameter with cytoplasmic
vacuoles. The defect is in the demarcation membrane
system. This results in defect in gpIb-V-IX complex
leading to poor adhesion. Diagnosis is made by absent
response to Ristocetin in platelet function study. A close
differential with similar results is von Willebrand disease
which can be differentiated by normal von Willebrand
factor levels and pattern. Treatment includes platelet
transfusions for significant bleeding. Stem cell trans

plant will be curative in this condition.
May-Hegglin anomaly: This is an autosomal dominant
condition characterized by thrombocytopenia,
giant platelets, large inclusions in granulocytes and
monocytes known as Dohle bodies and presence of
physical defects like hearing loss, renal failure and
cataract. The platelet count is moderately low in the
range of 80 to 1,00,000/cumm but with significant
bleeding due to associated platelet dysfunction. The
defect is in the MYH9 gene that codes for Myosin
II-A which is the only protein expressed in platelets
and neutrophils, which explains the characteristic
defects seen in platelets and neutrophils. DDAVP,
anti-fibrinolytic agents help control bleeding. Platelet
transfusions are rarely required.
Gray platelet syndrome: It is an autosomal recessive
disorder with mild thrombocytopenia and significant
bleeding. The platelets are unable to store alpha granule
proteins. This leads to poor aggregation especially with
thrombin, ADP and collagen. The platelets appear
large, gray and bland with vacuolations. The treatment
is platelet transfusion for significant bleeding.
Inherited thrombocytopenia with immunodeficiency:
This includes Wiskott-Aldrich syndrome and hemoph
agocytic lymphohistiocytosis.
Wiskott-Aldrich syndrome: This is an X-linked disorder
characterized by thrombo
cytopenia, eczema and
immunodeficiency. It is caused by mutations in the
WASP gene located at Xp11-12 band. The WiskottAldrich syndrome protein is known to be involved in
the signal transduction and it regulates actin filament
assembly in platelets as well as lymphocytes affecting
their cytoskeleton. This explains the association of
thrombocytopenia and immunodeficiency. Patients
present with thrombocytopenia early in life with more
bleeding than expected based on the platelet counts.
The platelets are small in volume and the mean
platelet volume (MPV) is characteristically low (as is
also seen in patients with TORCH group of infection).
Patient usually has lower GI bleeding. Eczema and
immunodeficiency develop as the child grows.
Some patients have milder phenotype with minimal
immunodeficiency as the defect is restricted only to
the platelets even when they have the same WASP
gene mutations (though restricted only to the exon 2
of the gene), these patients are grouped as X-linked
thrombocytopenia. Often these patients are mistaken
as ITP later in the life.
The treatment of Wiskott-Aldrich syndrome includes
control of bleeding with platelet transfusions and treatment
of infections. In those with difficulty, splenectomy will also
help as also IVIg at times. Bone marrow transplantation
is the only curative treatment possible at present. The 10
percent of the patients can progress to develop lymphoma
later in their life.
Hemophagocytic Lymphohistiocytosis (HLH)

This is a rare but interesting disease caused by mutations
in the genes for perforin or granzymes involved in the
killing of phagocytosed material by the phagosomes of the
macrophage-monocyte series and NK cells. Absence of
effective killing by the phagosomes leads to unnecessary
stimulation of the macrophages and monocytes leading to
production of cytokines by these cells leading to what is
described as cytokine storm which leads to all the symptoms
like hemophagocytosis, cytopenias, liver dysfunction, CNS
changes, fever, DIC, increased triglycerides levels, etc. It is
an autosomal recessive disorder which can present even
at or soon after the birth with fever, thrombocytopenia,
convulsions, hyperbilirubinemia and cytopenias.
The diagnosis is made by high index of suspicion and
demonstrating hemophagocytes in the bone marrow
or organs like liver, spleen or lymph nodes. Sometimes,
hemophagocytes are also seen on the peripheral blood
smears. The treatment includes use of steroids and VP16 to induce remission. Bone marrow transplant will cure
those who do not respond to conservative management.
Inherited thrombocytopenia with bone marrow
failure: This includes three disorders that is:
1. Congenital amegakaryocytic thrombocytopenia,
2. Thrombocytopenia with absent radius syndrome (TAR
syndrome)
3. Fanconis anemia.
Congenital Amegakaryocytic Thrombocytopenia

This is a rare autosomal recessive disorder presenting as
neonatal thrombocytopenia which progresses over the
time to total bone marrow failure. It presents with bleeding
and thrombocytopenia in the first few days to weeks of
life where it may be confused with many other common
etiologies especially alloimmune thrombocytopenia.
20 percent of the patients can develop intracranial
hemorrhage. 10 to 30 percent of them can have associated
orthopedic or CNS anomalies. It is only when the patient
dose not recover that a bone marrow is ordered which
will pick up absent or grossly reduced megakaryocytes
with normal granulopoietic and erythropoietic elements.
It is caused by mutations in the CMPL genes which
results in marked maturation of the megakaryocytes and
its precursors. As the action of Tpo via CMPL is vital for
maturation of other hemopoietic cells, even the other series
will get affected with time including the stem cells due
to lack of preservation of apoptosis induced by Tpo. This
explains why there is total bone marrow failure with time.
While platelet transfusions help controlling the bleeding,

the only curative treatment is bone marrow transplant. The
50 percent of them will progress to aplastic anemia over
next 5 years. And 5 percent of them can develop leukemia.
IL3 and GM-CSF have limited role and Tpo has no role
what so ever in the treatment of these patients.
Fanconis Anemia and TAR

Both are autosomal recessive disorders characterized by
inherited bone marrow failure. Both have characteristic
physical anomalies. Both are caused by known mutations.
Mutations in HOXA10, HOXA11 and HOXD11 genes are
implicated for TAR whereas more than 3 different types
of Fanconis anemia gene mutations are identified for
Fanconis anemia.
The TAR presents with thrombocytopenia, bleeding
and characteristic forearm deformity due to absence of
radius. Isolated abence of radii is seen in only 10 percent
of the patients and 50 percent of the patients also have
associated defects in ulna, knees or humorous, besides
absent radii. The thumb on the affected side is always
present in TAR, which differentiates it from Fanconis
anemia (which rarely can present in neonatal period) where
such radial deformities are seen but the thumb is always
absent from the affected side. Besides this, other anomalies
seen in Fanconis anemia seen include short stature,
microcephaly, mental retardation, hyperpigmentation,
hypogonadism, renal anomalies, other skeletal anomalies
like rudimentary thumb, absent thumb, triphalangeal
thumb, etc. Fanconis anemia usually presents as anemia
in later life though it can presents in neonatal period in
10 percent of the cases. While TAR tends to improve after
the age of one year, Fanconis anemia usually progresses
with time in to complete bone failure and has high chances
of developing malignancies. The only curative treatment is
bone marrow transplant with proper conditioning regime
avoiding radiation. Another syndrome of congenital
thrombocytopenia with radioulnar synostosis (CTRUS)
is described where the patient has absent pronationsupination due to fusion of radius and ulna. It behaves
similar to TAR with improved platelet counts after the age
of 1 year. Defect in HOX 11a is implicated in this condition.
Miscellaneous Causes
There are some rare but important and distinct causes of
neonatal thrombocytopenia like osteopetrosis which leads
to thrombocytopenia and later bone marrow failure due to
calcification of marrow spaces; congenital leukemia and
metastatic neuroblastoma which cause thrombocytopenia
due to bone marrow infiltration by the malignant cells and
organic acidemias and other metabolic disorders which
all can lead to bone marrow suppression.
BIBLIOGRAPHY
1. Boppana SB, Fowler KB, Britt WJ, Stagno S, Pass RF.

Symptomatic cytomegalovirus infection in infants born to
mothers with pre-existing immunity to cytomegalovirus.
Pediatrics. 1999;104:5-60.
2. Dame C. Thrombopoietin in thrombocytopenias of
childhood. Semin Thromb Hemost. 2001;27:215-8.
3. De Moerloose P, Boehlen F, Extermann P, Hohfeld P.
Neonatal thrombocytopenia: incidence and characte
rization of maternal antiplatelet antibodies by MAIPA
assay. Br J Hematol. 1998;100:735-40.
4. Forestier F, Daffos F, Catherine N, Renard M, Andreux
JP. Developmental hematopoiesis in normal human fetal
blood. Blood. 1991;77:2360-3.
5. Hall CW. Kasabach-Merritt syndrome: Pathogenesis and
management. Br J Hemat. 2001;112:851-2.
6. Henter J-I, Samuelsson-Horne A-C, Arico M. Treatment
of hemophagocytic lymphohistiocytosis with HLH-94
immunochemotherapy and bone marrow transplantation.
Blood. 2002;100:2367-73.
7. Hohlfeld P, Forestier F, Kaplan C, Tissot JD, Daffos F. Fetal
thrombocytopenia: a retrospective survey of fetal blood
samplings. Blood. 1994;84:1851-6.
8. Kaplan C. Alloimmune thrombocytopenia of the fetus and
the newborn. Blood Rev. 2002;16:69-72.
9. Kaplan RN, Bussel JB. Differential diagnosis and

management of thrombocytopenia in childhood. Pediatr
Clin N Am. 2004;51:1109-40.
10. Lipton JM, Westra S, Haverty CE, et al. Case records of the
Massachusetts General Hospital. Case. 28-2004: Newborn
twins with thrombocytopenia, coagulation defects, and
hepatosplenomegaly. N Engl J Med. 2004;391:1120-30.
11. Murray NA, Watts TL, Roberts IAG. Inhibition of
megakaryocytes in late, sepsis associated throm
bocytopenia in preterm babies. Blood. 1999;94:450a.
12. Oliver TP. Neonatal thrombocytopenia. Recent Adv
Pediatr. 2005;22:105-19.
13. Parikh TB, Udani RU, Nanavati RN, Rao BV. Fanconis
anemia in newborn. Indian Pediatr. 2005;42:285-7.
14. Sola MC, Calhoun DA, Huston Ads, Christensen RD. Plasma
thrombopoietin concentrations in thrombocytopenic and
non-thrombocytopenic patients in a neonatal intensive
care unit. Br J Hematol. 1999;104:90-2.
15. Vanden OS, de Hass M, Vanden BE. Screening for c-mpl
mutations in patients with congenital amegakaryocytic
thrombocytopenia identifies a polymorphism. Blood.
2001;17:3675-6.
16. Webert KE, Mittal R, Sigouin C, Heddle NM, Kelton JG.
A retrospective 11-year analysis of obstetric patients
with idiopathic thrombocytopenic purpura. Blood. 2003;
102:4306-11.
RBC and WBC Disorders

CHAPTERS OUTLINE
13. Introduction and Classification of Anemias in Children

14. Nutritional Anemia in Infancy, Childhood and Adolescents

15. Megaloblastic Anemia

16. Anemia of Chronic Disease

17. Thalassemia Syndromes

Mamta Vijay Manglani, Ambreen Pandrowala

Ratna Sharma, MR Lokeshwar
18. Sickle Cell Anemia in Children

19. Antenatal Diagnosis of Hemoglobinopathies

20. Red Cell Membrane Disorders (Spherocytosis, Elliptocytosis, Stomatocytosis)

21. Red Cell Enzymopathy

22. Autoimmune Hemolytic Anemia

Rajiv Kumar Bansal
23. Paroxysmal Nocturnal Hemoglobinuria

24. Diagnosis and Management of Acquired Aplastic Anemia in Children

Nitin K Shah
25. Inherited Bone Marrow Failure Syndromes

Revathi Raj
26. Benign Disorders of Neutrophils

Bharat R Agarwal
13
Introduction and Classification
of Anemias in Children
Anemia can be defined as a reduction in the hemoglobin concentration, hematocrit, or the number of red blood cells (RBC) per cubic
millimeter. Conventionally, the lower limit of the normal range is set at two standard deviations below the mean for the normal
population. Thus, 2.5 percent of the normal population will be mistakenly classified as anemic. The primary function of red blood
cells is to deliver adequate quantities of oxygen to meet the bodys metabolic demands. Thus, a measure of oxygen metabolism
and accompanying cardiovascular compensation should be considered in defining anemia. Children with cyanotic congenital heart
disease, respiratory insufficiency, or hemoglobinopathy that alters oxygen affinity can be functionally anemic with hemoglobin in the
normal range.1,2
Hemoglobin (Hb) concentration varies with age, with

higher values being present in the newborn and adolescent
male. The high Hb level at birth occurs in response to the
low fetal ambient oxygen tension (PO2 of 30 mm Hg).
Immediately after birth, the rise in arterial PO2 (around 90
mm Hg) decreases erythropoietin production, producing
the physiologic anemia seen in the first 2 months of
life (i.e. Hb concentration of around 10 g/dL at 2 months
of age). This period is followed by a steady rise in Hb,
reaching a maximum at about 14 years of age. The zenith
of hemoglobin concentration occurs earlier in preterm
infants and may be more in terms of lower Hb levels as
well as prolonged anemia. Table 1 gives the approximate
values of some vital hematologic parameters in pediatric
age group.
extrusion of the nucleus that causes loss of RBC synthetic

ability. Normal RBCs survive an average of 120 days,
while abnormal RBCs can survive as little as 15 days. The
hemoglobin molecule is a heme-protein complex of two
pairs of similar polypeptide chains. There are six types
of hemoglobin in developing humans: the embryonic,
Gower 1, Gower 2, Portland, fetal hemoglobin (HbF) and
normal adult hemoglobin (HbA and HbA2). HbF is the
primary hemoglobin found in the fetus. It has a higher
affinity for oxygen than adult hemoglobin, thus increasing
the efficiency of oxygen transfer to the fetus. The relative
quantities of HbF rapidly decrease to trace levels by the
age of 6 to 12 months and are ultimately replaced by the
adult forms, HbA and HbA2.
PHYSIOLOGY OF HEMOGLOBIN
PRODUCTION
CLASSIFICATION OF ANEMIAS
Erythropoietin is the primary hormone regulator of red

blood cell (RBC) production. In the fetus, erythropoietin
comes from the monocyte/macrophage system of the
liver. Postnatally, erythropoietin is produced in the
peritubular cells of the kidneys. Key steps in red blood cell
differentiation include condensation of red cell nuclear
material, production of hemoglobin until it amounts
to 90 percent of the total red blood cell mass and the
Anemias can be classified according to their appearance

in the microscope, which is the morphologic. The former
methodology classifies anemias into:
Morphologic classification:
Microcytic
Macrocytic
Normocytic types.
The latter classification categorizes anemias into three
main categories (Table 2)3:
88Section-3RBC and WBC Disorders

Table 1 Age-specific blood cell indexes
Age
Hemoglobin g/dL
(g/L)
Hematocrit (%)
MCV, mm3 (fL)
MCHC, g/dL (g/L)
Reticulocytes
2
630 weeks
gestation*
13.4 (134)
41.5 (0.42)
118.2 (118.2)
37.9 (379)
28 weeks gestation
14.5 (145)
45 (0.45)
120 (120)
31.0 (310)
(5 to 10)
32 weeks gestation
15.0 (150)
47 (0.47)
118 (118)
32.0 (320)
(3 to 10)
Term (cord)
16.5 (165)
51 (0.51)
108 (108)
33.0 (330)
(3 to 7)
13 days
18.5 (185)
56 (0.56)
108 (108)
33.0 (330)
(1.84.6)
2 weeks
16.6 (166)
53 (0.53)
105 (105)
31.4 (314)
1 month
13.9 (139)
44 (0.44)
101 (101)
31.8 (318)
2 months
11.2 (112)
35 (0.35)
95 (95)
31.8 (318)
6 months
12.6 (126)
36 (0.36)
76 (76)
35.0 (350)
6 months2 years
12.0 (120)
36 (0.36)
78 (78)
33.0 (330)
26 years
12.5 (125)
37 (0.37)
81 (81)
34.0 (340)
(0.51.0)
612 years
13.5 (135)
40 (0.40)
86 (86)
34.0 (340)
(0.51.0)
Male
14.5 (145)
43 (0.43)
88 (88)
34.0 (340)
(0.51.0)
Female
14.0 (140)
41 (0.41)
90 (90)
34.0 (340)
(0.51.0)
Male
15.5 (155)
47 (0.47)
90 (90)
34.0 (340)
(0.82.5)
Female
14.0 (140)
41 (0.41)
90 (90)
34.0 (340)
(0.84.1)
(0.11.7)
(0.72.3)
1218 years
Adult
Abbreviations:
MCV: Mean corpuscular volume; MCHC: Mean corpuscular hemoglobin concentration.
* Values are from fetal samplings.
Less than one month, capillary hemoglobin exceeds venous: 1 hour3.6 gm difference; 5 days2.2 gm difference; 3 weeks1.1
gm difference. Adapted with permission from Siberry GK, Lannone R, Eds. The Harriet Lane handbook: a manual for pediatric house
officers, 15th edn. St Louis: Mosby, 2000.
Table 2 Physiologic classification of anemia3

Classification of anemia according to underlying mechanism
Specific examples
Mechanism
Blood loss
Acute blood loss
Chronic blood loss
Increased red cell destruction (hemolysis)
Inherited genetic defects
Red cell membrane disorders
Enzyme deficiencies
Hexose monophosphate shunt enzyme deficiencies
Glycolytic enzyme deficiencies
Hemoglobin abnormalities
Deficient globin synthesis
Structurally abnormal globins (hemoglobinopathies)
Acquired genetic defects
Deficiency of phosphatidylinositol-linked glycoproteins
Trauma
Gastrointestinal tract lesions, gynecologic disturbances
Hereditary spherocytosis, hereditary elliptocytosis

G6PD deficiency, Glutathione synthetase deficiency
Pyruvate kinase deficiency, Hexokinase deficiency
Thalassemia syndromes
Sickle cell disease, unstable hemoglobins
Paroxysmal nocturnal hemoglobinuria
Contd...
Chapter-13 Introduction and Classification of Anemias in Children 89

Contd...
Mechanism
Antibody-mediated destruction
Mechanical trauma
Microangiopathic hemolytic anemias
Specific examples
Hemolytic disease of the newborn (Rh disease), transfusion
reactions, drug-induced, autoimmune disorders
Hemolytic uremic syndrome, disseminated intravascular
coagulation, thrombotic thrombocytopenia purpura
Defective cardiac valves
Bongo drumming, marathon running, karate chopping
Malaria, Babesiosis
Clostridial sepsis, snake venom, lead poisoning
Abetalipoproteinemia, severe hepatocellular liver disease
Hypersplenism
Cardiac traumatic hemolysis

Repetitive physical trauma
Infections of red cells
Toxic or chemical injury
Membrane lipid abnormalities
Sequestration
Decreased red cell production
Inherited genetic defects
Defects leading to stem cell depletion
Defects affecting erythroblast maturation
Nutritional deficiencies
Deficiencies affecting DNA synthesis
Deficiencies affecting hemoglobin synthesis
Erythropoietin deficiency
Immune-mediated injury of progenitors
Inflammation-mediated iron sequestration
Primary hematopoietic neoplasms
Space-occupying marrow lesions
Infections of red cell progenitors
Unknown mechanisms
Fanconi anemia, telomerase defects

Thalassemia syndromes
B12 and folate deficiencies
Iron deficiency anemia
Renal failure, anemia of chronic disease
Aplastic anemia, pure red cell aplasia
Anemia of chronic disease
Acute leukemia, myelodysplasia, myeloproliferative disorders
Metastatic neoplasms, granulomatous disease
Parvovirus B19 infection
Endocrine disorders, hepatocellular liver disease
Classification and on the basis of the underlying

physiologic process.
Anemias associated with decreased red cell production
Anemias due to increased red cell destruction
Anemias due to blood loss.
It is also important to realize that as in other issues the
diagnosis of anemia can be easily made from the history
and physical examination. Some of the salient features in
the history as well as physical examination are given in
Tables 3 and 4.
Role of complete blood counts (CBC) and peripheral smear
(PS) for diagnosis of anemia: CBC, red cell indices and
PS play an immensely vital role in helping a clinician for
the differential diagnosis of anemia. It is imperative that
care is taken in obtaining the sample. Venous samples
are preferred. When capillary samples are obtained, it
is important that the extremity is warm and that a free
flow of blood is obtained. To ensure accurate results, an
adequate volume of blood should be obtained to avoid
excessive dilution by the anticoagulant. Analysis of the
hemoglobin concentration is preferred as it is determined
by direct spectrophotometry. In contrast, the hematocrit is
determined indirectly by calculations using the red count
and mean corpuscular volume (MCV).
The next step is to evaluate the red cell indices. Of

these, the MCV is the most useful. MCV is the mean
volume of single red cell expressed in femtoliters. It is a
red cell index directly measured by the electronic counter
and enables the classification of anemia by red blood cell
size as microcytic, normocytic, or macrocytic (Flow charts
1 and 2) (Figs 1 and 2).4
While this classification is arbitrary and categories are
not mutually exclusive, it provides a useful starting point
for directing further evaluation. In children less than age
10 years and above 2 years, the lower limit for the MCV is
approximately 70 fL + age in years. After 6 months of age, the
approximate upper limit for the MCV is 84 + 0.6 fL per year
until the upper limit of 96 fL in adults is reached. The mean
corpuscular hemoglobin (mean Hb content of a single red
cell expressed in pictograms, MCH) and mean corpuscular
hemoglobin concentration (hemoglobin concentration
within individual red cells expressed in %, MCHC) are
calculated values and generally less diagnostic. The MCH
usually parallels the MCV. Both the MCV and MCH have
small measurement errors and biological variations. The
MCHC is a measure of cellular hydration status. It remains
relatively constant throughout development and in most
clinical settings. A high value (> 35 g/dL) is characteristic
of spherocytosis, while a low value is most commonly
Symptom
Maternal history
Family history
Age
Gender
Neonatal history
Pica
Diet history
Infections
Drugs
Hemoglobinuria
Bleeding manifestations
Diarrhea
Dactylitis or painful episodes
Blood loss
Table 3 History of a child with anemia

Implications
Anemia, blood loss during pregnancy, pica may predispose for iron deficiency
Anemia, splenomegaly, gallstones, splenectomy, leg ulcers, jaundice, transfusion dependency
indicates hemolytic anemia. Look at the ethnicity and race as sickle cell anemia and thalassemia are
more common in certain communities
Iron deficiency is unlikely in term infants before 6 months of age. Anemia which manifests in the
neonatal period is the result of recent blood loss, isoimmunization, or initial manifestation of
congenital hemolytic anemia or congenital infection
G6PD and PK deficiency seen in males as inheritance is X linked
Anemia and jaundice may point to a congenital hemolytic anemia such as HS, prematurity
predisposes to an early iron deficiency state
Indicates iron deficient state
Predominant cows milk leads to cows milk allergy and GI blood loss leading to iron deficiency
Hepatitis induced aplasia, infection assorted hemolysis, parvovirus induced red cell aplasia, worm
infestation leads to blood loss and Fe deficiency
Oxidant induced hemolytic anemias, phenytoin induced megaloblastic anemia, drug induced
aplastic anemia
Indicates an intravascular hemolysis like autoimmune or G6PD deficiency
May indicate a second cell line being involved or a bleeding or clotting defect which may be causing
the anemia
Malabsorption or inflammatory bowel disease
Sickle cell anemia, bony pains may indicate a infiltrative disorder of marrow
Acute or chronic
Table 4 Physical examination of a child with anemia

Physical findings
Tachycardia, respiratory distress
Hemolytic facies
Platonychia, koilonychia
Glossitis
Blue sclera
Vitiligo
Telangiectasias on body
Splenomegaly, jaundice
Lymphadenopathy
Hepatomegaly
Cardiomegaly
Bleeding manifestations
Knuckle pigmentation, loss of position or
vibration sense
Failure to thrive
Facial or digital anomalies
Rectal examination
Implications
Acute anemia or decompensated state
Chronic hemolytic anemia
Iron deficiency or cobalamin deficiency
Pernicious anemia
Similar lesions in the GIT
Hemolytic anemia
Infiltrative disorder
CCF, infiltrative disorder
Chronic anemia
Bleeding diathesis or secondary to marrow infiltration
B12 deficiency
Chronic anemia, systemic illnesses
Fanconis anemia, Diamond-Blackfan syndrome
Rectal varices or polyp
associated with iron deficiency. The red cell volume

distribution width (RDW) reflects the variability in cell
size and can be used as a measure of anisocytosis.2,4 Some
kind of anemias can easily be diagnosed on distinctive
abnormalities seen on the peripheral smear (Table 5 and
Figs 1 to 19).1,5
The next step is to assess the white blood cell (WBC)

and platelet counts. Is the anemia isolated or are other
cell lines affected? Pancytopenia results from disorders
that are distinct from those causing simple anemia and
generally mandate analysis of the bone marrow. Thus
on the basis of morphology we can divide the anemias

Flow chart 1 Classification of anemia based on morphology4
Flow chart 2 Approach to anemia6
into microcytic hypochromic and an approach to this is

given in Flow chart 3.6 The anemias can be macrocytic
and an algorithmic approach to macrocytic anemias is
given in Flow chart 4.6 The normocytic normochromic
anemias are associated with many systemic disorders
and an approach to them is delineated in Flow chart 5.6
A leukoerythroblastic blood picture (nucleated red cells,
reticulocytosis, a shift to the left in the neutrophil cell line,
tear drop red cells) is characteristic of diseases in which

the normal bone marrow is replaced by tumor or other
diseases. Elevated WBC and/or platelet counts in children
are most often due to reactive processes. While infection
is the most common cause, other etiologies including iron
deficiency anemia, autoimmune disorders, or hemolytic
anemia, vitamin E deficiency, and postoperative states
are possible. Microscopic examination of the PBS can
Fig. 1 Dimensions of a normal RBC
Fig. 2Microcytic hypochromic anemia: RBC have a increased

central pallor and the size of RBC is smaller than the nucleus of a
lymphocyte
Table 5 Some peculiar red cell abnormalities on the smear1,5

Morphologic characteristic Basis of the abnormality
Comment
Howell-Jolly bodies
RBC nuclear remnants
Increased with brisk hemolysis, increased following splenectomy, pernicious
anemia, CDA
Basophilic stippling
RNA remnants/
Impaired globin chain
production (thalassemia; lead
aggregated ribosomes
intoxication), unstable hemoglobinopathies and iron deficiency
Pappenheimer bodies
Iron ferritin granules in
Increased following splenectomy increased with transfusional iron overload
cytoplasm
Heinz bodies
Hemoglobin aggregates
Burr cells
Acanthocytes (spur cells)
Nucleated RBCs
Sickle cells
Membrane perturbance
Membrane perturbance
Normoblast nuclei
RBC distortion by
hemoglobin polymers
Low ratio of hemoglobin
to red cell membrane;
RBC dehydration
Defective membrane
protein
Target cells
Spherocytes
Needs brilliant cresyl blue, crystal violet stains. Unstable Hb, enzymopathies,
hemoglobin H and thalassemia syndromes
Chronic renal failure, common smear preparation artifact
Hepatic insufficiency
High with brisk hemolysis present with myelophthisis
Sickle cell disease
Prominent in thalassemia
Present with iron deficiency
Hereditary disorder
Immune hemolysis
aid in further focusing the differential. Assess the size,

color, and shape of the red cells. The normal red blood
cell is about the size of the nucleus of a small lymphocyte.
On a well-stained blood smear the area of central pallor
in a normal erythrocyte has a diameter about one-third
of that of the entire cell. Cells with excessive central
pallor are hypochromic. Absence of central pallor is
seen in spherocytosis. Polychromasia with large cells is
indicative of reticulocytosis. Distinctive abnormalities
in shape are suggestive of red cell membrane disorders
(e.g. spherocytosis, stomatocytosis, or elliptocytosis) or
hemoglobinopathies (e.g. sickle cell disease, thalassemia).
Presence of inclusions such as basophilic stippling (as

seen in thalassemia, lead poisoning) should be noted.
Nucleated red blood cells are never normal, except in the
newborn, and are indicative of a stressed marrow. The
number and morphology of WBCs and platelets should
also be assessed. Toxic granulation suggests an acute
inflammatory state while hypersegmented neutrophils are
characteristic of vitamin B12 and folate deficiency.
Reticulocytes are newly formed red cells with residual
strands of nuclear material called reticulin that remain
following extrusion of the nucleus from bone marrow
normoblasts. These new erythrocytes are 10 to 20 percent

Flow chart 3 Approach to microcytic hypochromic anemia6
Flow chart 4 Approach to macrocytic anemia6

Flow chart 5 Approach to normocytic normochromic anemia
Fig. 3 Macrocytic anemia with RBC larger than the size of

nucleus of lymphocyte
Fig. 4 Spherocytes lack central pallor and may appear smaller

than typical red
larger than red cells on average and have a faint bluish

tint with Wright-Giemsa stain. Staining with a supravital
dye such as brilliant cresol blue highlights the residual
nuclear material and definitively identifies reticulocytes.
These staining characteristics persist for only 1 or 2 days
following release from the bone marrow. Thereafter, the

erstwhile reticulocytes are identical to other red cells
already in the circulation. The pathophysiology of anemia
involves either the production of too few erythrocytes or
the production of large numbers of red cells in concert
Fig. 5 Stomatocytes
Fig. 8 Basophilic stippling: Numerous, small purple inclusions in

RBCs. Aggregates of ribosomal RNA. Most commonly seen in lead
poisoning
Fig. 6 Elliptocytes
Fig. 9Toxic granulation: Increased basophilic granules in

neutrophils. Seen in severe infections, burns, malignancies, and
pregnancy. Distinguish from basophils
Fig. 7 Sickle cells
Fig. 10Dohle bodies: Sky blue inclusions in cytoplasm of

neutrophils. Seen in infections, burns, myeloproliferative disorders,
and pregnancy. Composed of RER and glycogen granules
Fig. 11 Peripheral smear from a patient with infection shows

granulocytes with Dohle bodies
Fig. 14 The RBC deformity (arrow) shown in this image is referred

to as a bite cell: G6PD deficiency
Fig. 12 The open, sieve-like chromatin (salt and pepper) pattern

in nucleus of megaloblastic cells is apparent
Fig. 15 Note the fragmented schistocytes, burr cells, and helmet

cells
Fig. 13 Reticulocytes: Immature RBCs. Contain residual ribosomal

RNA. Reticulum stains blue using a supravital stain (new methylene
blue). Counted and expressed as % of total red cells
Fig. 16 Howell-Jolly bodies are red cell inclusions which are

residual nuclear fragments
with their rapid destruction or loss. The reticulocyte count

is the arbiter of the type of anemia, being low in the former
instance and high in the latter. This basic distinction
allows the clinician to home dramatically the search for
the cause of the anemia. A terminological peculiarity

sometimes confuses discussions of reticulocytes. The
reticulocyte count reported by most clinical laboratories
is given as a percentage of reticulocytes with respect to red
Fig. 17Pappenheimer bodies: Clusters of dark blue granules,

irregular in size and shape. Composed of iron and ribosomal RNA.
Seen in sideroblastic and hemolytic anemias
Fig. 18 Acanthocytes are red cells which retain a spherical shape

but have a spiculated appearance
have fewer red cells than normal. Consequently, the use

of a percentage of red cells to determine reticulocyte
production is invalid in the very circumstance where it is
most needed. A normal reticulocyte count of 1 percent in
the face of a hemoglobin value of 5 g/dL and 2.0 106 red
cells/L is patently abnormal. A number of formulae have
been promulgated that purport to correct for the anemia
and allow a clinician to assess whether the reticulocyte
percentage value is elevated or depressed. This semantic
and conceptual trap is best avoided by using the true
reticulocyte count, which is the number of reticulocytes per
microliter of blood. This value is also termed the reticulocyte
number to distinguish it from the percentage reticulocyte
count. When the hemoglobin level is normal, blood contains
between 50,000 and 1,00,000 reticulocytes/L. An anemia
with a reticulocyte number below this level is prima facie
evidence of a hypoproliferative anemia.2,5 The reticulocyte
percentage can be corrected to measure the magnitude of
marrow production in response to hemolysis as follows:
Reticulocyte index = reticulocyte % observed
hematocrit/normal hematocrit 1/ where is a
maturation factor of 1 to 3 related to the severity of the
anemia. The duration of maturation as blood reticulocytes
is taken as . The value for for various hematocrit is as
follows: Hct 45%- 1.0, Hct 35%- 1.5, Hct 25%- 2.0, Hct
15%- 2.5. The normal reticulocyte index is 1.0; therefore,
the index measures the fold increase in erythropoiesis.
The usual marrow response in acute hemolytic anemia is
reflected by a reticulocyte index of 2 to 3, whereas in long
standing chronic hemolysis, the increase in erythropoiesis
is approximately 6-fold.7
APPROACH TO HEMOLYTIC ANEMIA
Fig. 19 Target cells
cells in the sample. The normal value is 1 to 2 percent. This

reflects the practice of enumerating reticulocytes relative
to erythrocytes in the early days of hematology when this
work entailed manual counting of many microscopic
fields. Expression of reticulocyte count as a percentage
of red cells is a reasonable practice as long as the number
of red cells is in the normal range. Anemias by definition
Hemolysis is defined as an abnormally increased rate of

red blood cell destruction. It may be acute or chronic,
congenital or acquired, and intrinsic or extrinsic to the
RBC. With chronic hemolysis, anemia may or may not be
present depending on the rate of red cell destruction and
the degree of bone marrow compensation. Moreover, the
clinical signs and laboratory findings in hemolysis depend
on both the rate and site of red cell destruction. If red cells
are destroyed extravascularly in the reticuloendothelial
system, the normal site of red cell catabolism, Hb is
degraded to iron, bilirubin metabolites, and amino acids.
Because hepatic clearance of bilirubin can increase
substantially, a normal serum bilirubin does not exclude
hemolysis. Unconjugated (indirect) bilirubin will be
increased in more severe hemolysis resulting in jaundice.
When hemolysis occurs intravascularly, free hemoglobin is
released into the plasma where it is bound by haptoglobin
and subsequently cleared in the liver or lost in the urine.
An increase in plasma hemoglobin, a decrease in serum

haptoglobin, and the presence of hemoglobinuria suggest
intravascular hemolysis.
Congenital hemolytic anemias include disorders of
the red cell membrane (e.g. hereditary spherocytosis,
stomatocytosis, or elliptocytosis), hemoglobinopathies
(e.g. hemoglobin SS), and red cell enzyme deficiencies (e.g.
glucose-6-phosphate dehydrogenase (G6PD) deficiency,
pyruvate kinase deficiency). A family history positive for
anemia, splenomegaly, jaundice, and/or gallstones supports
a congenital hemolytic anemia. Ethnic background can
also be helpful. Hereditary spherocytosis can occur in any
ethnicity, but is most common in whites. An elevated MCHC
and spherocytes on the PBS supports this diagnosis. An
MCHC greater than 35.4 coupled with an RDW >14 is almost
always diagnostic of hereditary spherocytosis. The osmotic
fragility test or ektacytometry are confirmatory. Family
members should also be screened. G6PD deficiency is most
common in those of African or Mediterranean descent (with
the latter tending to have more severe disease). Individuals
with G6PD deficiency often present with acute hemolysis
after an infection or after encountering an oxidant stress.
Signs of acute intravascular hemolysis with tachycardia,
jaundice, and hemoglobinuria will be observed. The PBS
reveals schistocytes and spherocytes initially, then becomes
normal after the enzyme deficient cells are hemolyzed. The
sickle cell syndromes are usually detected by newborn
screening in the United States and the pediatrician becomes
aware of the diagnosis before anemia or other clinical
manifestations occur. More detailed information about
these syndromes can be found elsewhere in this volume. In
any patient with congenital hemolytic anemia, an aplastic
episode is the exception to the rule that hemolytic anemias
are associated with reticulocytosis. While many viruses
have been implicated, human parvovirus B19 is the most
frequent cause. Complete suppression of erythropoiesis
can last for 7 to 10 days after infection. Prompt intervention
with red blood cell transfusions as needed can be life saving.
Acquired hemolytic anemias can be immune-mediated
or secondary to factors that cause mechanical damage to
the red cells such as toxins, mechanical or abnormal heart
valves, and fibrin strands in disseminated intravascular
coagulation (DIC) or hemolytic uremic syndrome (HUS).8,9
Immune-mediated destruction is confirmed by a positive
direct and indirect Coombs test. Spherocytes may be seen
on the PBS. Antibody-mediated hemolytic anemia can
occur as part of a more generalized autoimmune process
(such as lupus) or after exposure to a drug. However, in
children it is most often a self-limited disease following
a viral illness. In neonates, immune-mediated hemolysis
is due to placentally-transferred maternal antibodies.
Historically, this was most commonly due to sensitization
to the Rh antigen in Rh negative mothers. The advent
of anti-D serum in women who are a potential set-up
for sensitization has caused a dramatic decrease in the

incidence of this disease. Currently, immune-mediated
hemolysis in the infant most often reflects a maternal
response to other blood group antigens. Mechanical
damage is usually intravascular and associated with red
cell fragments on the PBS. The history and/or physical
examination can often identify the source of damage.2
The following clinical situations warrant a specialist
referral:
Anemia requiring transfusion
Acute or active bleeding resulting in anemia
Moderate to severe anemia in a child or elderly or a
pregnant lady
Anemia showing no response or inadequate response
to transfusions
Anemia showing no response or poor response to
medical treatment
A chronic or recurrent anemia
Anemia of chronic renal failure
Recurrent or long standing bleeding disorders
Anemia of systemic disease, if disproportionate to
disease or of moderate severe degree
Anemia secondary to bleeding disorders, leukemia or
hematological malignancies
Where the underlying causative disease is likely to
result in progressive or persistent anemia
Anemia where the underlying causative disease is
undiagnosed or not clear
Where surgery or other intervention procedure is
contemplated
When there are co-existent abnormalities of platelet or
leukocyte
When you are uncertain of your diagnosis or treatment.
Key Points
There are numerous ways of classifying the causes of
anemia, and no one way is necessarily superior to another.
Regardless of the specific algorithm followed in evaluating
severe anemia, it is essential that easily remediable causes
such as nutritional deficiencies, hemolysis, and anemia
of renal insufficiency are identified early and treated
appropriately.
In general, the differential diagnosis of severe anemia
can be substantially narrowed by subcategorization into
microcytic, normocytic, and macrocytic subtypes on
the basis of mean corpuscular volume.
However, such classification is a starting point and not
infallible. Each category then can be deciphered using a
stepwise approach that utilizes readily accessible laboratory
tests.
Hematology referral is always appropriate for complicated
or less defined cases.
REFERENCES
1. Oski FA, Brugnara C, Nathan DG. A diagnostic approach

to the anemic patient. In: Nathan G, Orkin SH, eds. Nathan
and Oskis Hematology of Infancy and Childhood, 6th edn.
Philadelphia: WB Saunders. 2003.pp.409-18.
2. Hermiston ML, Mentzer WC. A practical approach to
the evaluation of the anemic child. Pediatr Clin N Am.
2002;49:877-91.
3. Cotran RS, Kumar V, Collins T. Red Cells and Bleeding
Disorders. In: Cotran RS, Kumar V, Collins T, eds. Robbins
Pathologic Basis of Disease, 6th edn. Philadelphia: WB
Saunders. 2001.pp.601-43.
4. Sandowitz PD, Amanullah S, Souid AK. Hematologic
emergencies in the pediatric emergency room.
Emergency Medicine Clinics of North America. 2002;20:
177-98.
5. Bridges KR, Pearson HA. Principles of anemia evaluation.

In: Bridges KR, Pearson HA, eds. Anemias and other red
cell disorders. The McGraw-Hill companies. 2008.pp.3-27.
6. Glader B. Anemia: General considerations. In: Greer
JP, Foerster J, Lukens JN, et al. eds. Wintrobes Clinical
Hematology, 11th edn. Philadelphia: Lippincott Williams
and Wilkins. 2004.pp.947-77.
7. Segel GB. Definitions and classification of hemolytic
anemias. In: Kliegman RM, Behrman RE, Jenson HB, eds.
Nelson textbook of Pediatrics, 18th edn. Philadelphia:
Saunders. 2007.pp.2018-20.
8. Blaine ER, Brady KM, Tobias JD. Hematologic emergencies.
In: Nichols DG, et al., eds. Rogers Textbook of Pediatric
Intensive Care, 4th edn. Philadelphia: Lippincott Williams
9. Fasano R, Luban NLC. Blood Component Therapy. Pediatr
Clin N Am. 2008;55:421-45.
14
Nutritional Anemia in Infancy,
Childhood and Adolescents
Anemia is diagnosed when Hb concentration and

HCT (number and size of RBCs) is lower than the level
considered normal for the persons age/sex group.
Nutritional anemia (NA) is the most common cause of anemia
in childhood. Nutritional anemia is a pathological condition in
which hemoglobin and hematocrit levels becomes abnormally
low, because of deficiency of, one or more essential nutrients
needed for Hb formation, and for hemopoiesis, regardless of the
cause of these deficiencies. When anemia is due to nutritional
deficiency, increasing the persons intake of deficient nutrient
will raise the Hb and HCT.
World Health Organization (WHO) criteria for the

diagnosis of anemia (Table 1) are hemoglobin levels less
than 11 gm% in children between 6 months and 6 years
and below 12 gm% in children between 6 and 14 years.
In developing countries like ours, besides deficiency
Table 1 Criteria for diagnosis of anemia

Hemoglobin levels to diagnose anemia (g/dL)1
Age group
No anemia
Mild Moderate Severe
Children 659 months
>11
1010.9
799
<7
of age
Children 511 years
>11.5
1111.4 810.9
<8
of age
Children 1214 years
> 12
1111.9 8-10.9
<8
of age
Non-pregnant women
> 12
1111.9 810.9
<8
(15 years of age)
Pregnant women
> 11
1010.9 79.9
<7
Men
> 13
1112.9 810.9
<8
Source: Hemoglobin concentration for the diagnosis of anemia
and assessment of severity. WHO
of food specific nutrients (like iron, folic acid, vitamin

B12, protein, vitamin C, vitamin E, trace elements, etc.),
poor health facilities, poor socioeconomic status, faulty
dietary patterns, the degree of urbanization, educational
background, prevalence of hook worm and other worms
infestations, repeated bacterial infections, tuberculosis,
urinary tract infections (UTI), etc. vitamin A deficiency
and other mineral deficiencies, etc. also influences the
incidence of anemia particularly in children.
However, many individuals with seemingly normal
Hb level respond to iron administration with a rise in Hb,
which implies that they were actually deficient in iron.
Hence assessing the frequency of iron deficiency anemia
in a population by means of Hb measurement tends to
underestimate true prevalence.2
IRON DEFICIENCY ANEMIA

IN CHILDREN
Iron lacks the glitter of gold, and the sparkle of silver, but it
outshines both in biologic importance. Nancy C Andrews.3
Historical
Pallor known since Mahabharata. Father of Pandavas was
known as Pandu as he was looking pale white. Therapeutic
use of iron was known in Greek mythologyDrinking
wine in which sword rusted, was line of treatment. Loha
Bhasma and Mandura Bhasma being used in Ayurveda
since 5000 years use of iron salt is the main therapy of
modern medicine.4
Iron Deficiency Anemia

Iron deficiency anemia (IDA) is most widespread micro
nutrient deficiency and affects infants, young children
Chapter-14 Nutritional Anemia in Infancy, Childhood and Adolescents 101

(624 months), preschool children, adolescents and parti
cularly women of childbearing age, and pregnant and
lactating mother.
Inspite of efforts of increasing the awareness, educa
tion, food fortification and multiple control programmes
nutritional anemia still remains widely prevalent with sig
nificant morbidity in developing countries and to a lesser
extent even in the developed countries.57
Iron is important for a number of iron-dependent
enzymes including the catalaze, peroxidase, cytochromes,
and ribonucleotide reductase. It plays a vital role in
hemoglobin which is important for oxygen carriage in
multicellular organisms like man.
An Estimated Global Prevalence1-30

One-third (2030%) of worlds population, i.e. 2150
million people are iron deficient, out of which 1200
million are anemic, of which 90 percent live in third world
countries. Recent World Health Organization (WHO)/
United Nations Childrens Fund estimates suggest that
the number of children with iron-deficiency anemia (IDA)
is greater than 750 million.1 Although the prevalence of
anemia is estimated at 9 percent in countries with high
development, in countries with low development, the
prevalence is 43 percent in absolute numbers; anemia
affects 1.62 billion people globally with about 293 million
children of preschool age, 56 million pregnant women
estimated to be anemic. With global anemia prevalence
estimates of 47 percent in children younger than 5 years,
42 percent in pregnant women, and 30 percent in nonpregnant women 1549 years. In the tropical countries,
the incidence is at times almost 100 percent. IDA is an
extremely serious public health problem in India, 1624
babies die everyday due to IDA (The World Health Report
Preventing Risks, Promoting Life, 2002).
Young children and pregnant women are most
affected, with an estimated global prevalence of 43 percent
and 51 percent respectively. IDA is most common in the
age group of six months to three years.21-30 Children aged
12 to 17 years (adolescence) and espe
cially among
pregnant women and lactating mothers.
The reported prevalence of nutritional anemia in
preschool children varies from 44 to 74 percent.22-30
In the adolescent period (1019 years), it has been
found that the incidence of nutritional anemia is about
11 to 90 percent and increases from 10 years onwards
and continues to remain high till 18 years of age.31-40 With
increasing age, the prevalence rate declines in males, and
not in the females.
At least half of all married women aged 15 to 49 years
and adolescent girls are believed to have some degree
of IDA. Anemia is estimated to contribute to more than
115,000 maternal death and 591,000 perinatal deaths

globally per year. Almost 58 percent pregnant women in
India are anemic and it is estimated that anemia is the
underlying cause for 2040 percent of maternal deaths
in India. Iron deficiency is by far the most common
nutritional cause of anemia. The prevalence of anemia
has actually increased from NFHS-2 to NFHS-3. The
percentage of children with any anemia increased from
74.3 percent in NFHS-2 to 78.9 percent in NFHS-3 in the
period between the two surveys, there was an increase
in the prevalence of mild anemia (from 23% to 26%) and
moderate anemia (from 46% to 49%) percent of pregnant
women and 24 percent of men. The prevalence of anemia
among ever married women increased from 52 percent in
NFHS-2 to 56 percent in NFHS-3.30,69 However, it may be
associated with folic acid deficiency and other nutritional
deficiencies like vitamin B12, pyridoxine, copper, etc. The
condition is more prevalent in developing countries (36%)
than in industrialized developed countries (8%).
India falls in the category of high prevalence for nutritional
anemia.2,41
IDA among Pregnant and Lactating Women42-51

The overall iron requirement increases from a preadolescent level of 0.7 to 0.9 mg Fe/day to as much as
2.2 mg Fe/d or perhaps more, in heavily menstruating
young women. Hence, adolescent girls are unlikely to
acquire substantial iron stores during this period; intake
may average as little as 10 to 11 mg Fe/day. The low
iron stores in these young women of reproductive age,
will make them susceptible to IDA during pregnancy.
Dietary intake alone is insufficient in most cases to
meet the requirement of pregnancy. Adequate iron
supplementation of adolescent girls is essential towards
lowering the incidence of anemia during pregnancy.
Recent study showed that prevalence of IDA among
pregnant and lactating women is over 75 percent and more
than half of pregnant women and a third lactating women
are moderately or severely anemic. In some states, an
anemia prevalence as high as 87 percent has been found
among pregnant women from disadvantaged groups.47
In pregnant women, the incidence of nutritional
anemia vary from developed countries:
Europe
18%
South Asia
75%
South-East Asia
63%
India
88, 3888%
Each year out of 500,000 maternal deaths 100,000 are

due to iron deficiency. Mortality attributable to anemia
was found to be 20 percent in Africa and 22.6 percent in

Asia. Iron requirements are higher during the second and
the third trimester and iron balance during this period
depends more on the adequate intake of bioavailable iron
rather than the store at conception.
Iron Requirements in Different Age Groups
Table 2 Incidence of anemia in developing countries

like India1-25,27,30-36,40
Amongst preschool children
70% (7690%)
13 years
6374%, (ICMR 1977,

NFHS1998-99)
School age children
37%, (6080%)
Pregnant females
30 mg/day
Females 1130 years
15 mg/day
Children between the age group of 74

635 months
Adult males
10 mg/day
36 years ICMR in 19778
44%
Up to 10 years
10 mg/day
50%
Full-term infants
1 mg/kg/day from 4 months of age
Low birth weight babies
Adolescent period 1019 years,

and increases from 10 years
onwards and continues to remain
high till 18 years of age2
Babies < 1000 g
Nonpregnant women
35%, (8184%)
10001500 g
Pregnant women
50% (3050%)
8088%
Women from South Asia
60%
South-East Asia
50%
Africa
4050%
Adult male
18% (4856%)
Surprisingly, IDA is not just a problem in developing

countries. According to CDC, although ID is more com
mon in developing countries, a significant prevalence was
observed in US during early 1990s in toddlers and women
of childbearing age. In one study, 7 percent toddlers (12
years), 916 percent of adolescent and adult females
(1249%) were found to have iron deficiency. Although
incidence of iron deficiency is uncommon, they are still
above the healthy people 2010 objectives of 5 percent,
1 percent and 7 percent for toddlers, preschoolers and
females 12 to 49 years respectively. Anemia is a major
contributory factor for increased maternal morbidity
and mortality and accounts for 19.1 percent maternal
death.44,45,48,50
REPORTED INCIDENCE OF IDA IN CHILDREN

(TABLE 2)
Nearly half of the world women with anemia live in
SouthAsia
In a recent study, in an urban slum of Delhi, nearly half
of the anemic young children had other nutritional
deficiencies notably vitamin B12 and folic acid as the
direct or associated cause52
Gopalan37 in 1997 reported that only 38 percent from
urban Delhi, 19 percent of rural Rajasthan only had
normal Hb level
Dr Currimbhoy17 reported anemia 70 to 80 percent in
children in 60s
Dr Mamta Manglani et al. 60 to 70 percent in 90s
Dr MR Lokeshwar reported in office practice 50 to 60
percent (unpublished data)
Thirty to ninety percent of adolescent children in India
are anemic depending upon socioeconomic condition
and whether from rural or urban area31-40
Report of the NFHS-230,79 shows that the prevalence of

anemia has not much changed in 1998 to 1999 and is
still 74 percent among children of 6 to 35 months of
age. It has now been realized that iron deficient state
without anemia is even much more common. Over the
last 50 years, the prevalence of iron deficiency anemia
has ranged between 68 and 97 percent in children.
Infants, toddlers, preschool and adolescents are at a
great risk of developing IDA.21-25,27,30-36,40
Shahbuddin et al. from Bangladesh35 reported anemia
in 94 percent adolescent boys and 98 percent adolescent
girls. Who conceive during or shortly after adolescence are
likely to enter pregnancy with low or absent iron stores or
IDA.
Classification of countries with respect to degree of
public health significance is:16
High-risk
40 or > % of population anemic
Medium risk
1540% population anemic
Low-risk
Less than 15% population anemic
SOURCES OF IRON
Major sources of food iron and type of dietary iron
available:
Ultimate absorption of iron into mucosal cells mainly
depends upon bioavailability of iron in the various
foodstuffs.

Dietary iron is available as.
Heme iron.
Nonheme iron.
Heme Iron
The nonvegetarian foods is available as hemoglobin
and myoglobin in meat, fish and poultry. It is the richest
source of iron. Heme iron is highly bioavailable, since
it is absorbed intact within the porphyrin ring and the
absorption of this is not affected by any another food
and is better absorbed than nonheme iron. It is the
richest source of iron containing 10 to 18 mg of iron
per 100 gm. But in developing countries like ours, the
intake of these products is generally low.
Nonheme iron is available in the form of ferric
complexes. Nonheme iron is markedly affected by
promotive and inhibitory iron binding ligands.
Foods rich in iron are cereals, pulses, legumes, Bajra,
nuts, dates, jaggery, green leafy vegetables, and meat,
fish and liver preparations.
Milk is a poor source of iron: Breast milk, the primary
source of infant nutrition is poor in iron, containing
0.28 to 0.73 mg/L. Whereas the bioavailability of iron
in cows milk is just 10 percent and that of breast milk
is 50 percent (2080%) making it a good source of iron.
Hence, iron deficiency rarely occurs in exclusively
breastfed infants till the age of 4 to 6 months. Breast
feeding does not protect against iron deficiency after
the age of 6 months, unless iron containing weaning
foods are introduced.
Factors affecting iron absorption: Heme iron is not
affected by presence of any factors in the gut. The
absorption of nonheme iron is retarded by alkaline
pH, presence of phosphates, phytates, bran, starch,
tannins, calcium, antacids, other metals (Co, Pb),
etc. Phytates, which constitute 1 to 2 percent of
many cereals, nuts and legumes, play a major
role in the causation of nutritional anemia in the
developing world.
It is enhanced by ascorbic acid, free hydrochloric acid,
presence of sugars and amino acids in the diet, presence
of heme iron (nonvegetarian source of iron) and EDTA.53-56
The bioavailability of iron from a particular dietary
source affects the amount absorbed. Ferrous iron is
better absorbed compared to ferric iron. It is estimated
that in wheat based diet, iron absorption is around
2 percent and in rice based diet, it is 5 to 13 percent.53,54 Poor
bioavailability of iron in largely cereal-based diet is major
cause of IDA in most developing countries. Fish, meat
and poultry are good sources of iron and bioavailability is
around 20 to 30 percent. Increasing the dietary intake to
meet the caloric needs will also increase the dietary intake
of iron by one- third. Calcium in the form of milk, cheese or

(calcium added to the bread), depresses iron absorption.
Administration of 50 mg of vitamin C increases iron
absorption by two fold.
An average adult has about 3 to 5 g of iron and children
have 55 mg/kg/body weight. It is more in males as
compared to females. Seventy percent of iron in the body is
in the form of Hb. 3.9 percent is incorporated in myoglobin
and various other iron containing enzymes. Plasma iron
forms only 0.1 percent of the body iron. Iron balance in the
body is achieved mainly by control of absorption of iron
rather than its excretion, most of the iron is recirculated
in the body. Only 1.15 mg of irons is excreted daily. Thus a
daily requirement is minimum. Absorption of iron mainly
depends upon dietary content of iron.
Mucosal Cell Control

Site of absorption is the 1st and 2nd part of the duodenum,
and at times jejunum. Maximum absorption of iron occurs
from the duodenum.
Two steps are involved in the absorption of iron:
1. Entry of iron from the intestinal lumen into the mucosal
cell.
2. Its passage from the mucosal cell into the plasma.
Appropriate iron balance in the body is achieved by
mucosal cell control through transferrin and apoferritin
receptors. The iron molecule that is taken into the
mucosal cell across the brush border, can bind either to
the apoferritin molecule or the ferroportin molecule in the
mucosa. Iron status of the body at the time of the formation
of the mucosal lining cells determines the amount of iron
that is absorbed.
If iron in the plasma is adequate, or increased iron
stores, there is increased messenger iron in the mucosal
cell. This messenger iron stimulates the production of
apoferritin. Iron binds to apoferritin, which remains in the
mucosal cell. There is increased transferrin saturation.
Thus, whenever there is increased transferrin satu
ration or, serum iron is normal and adequate, a larger
fraction of the iron entering the mucosal cell is held back
as ferritin and discarded, as the cell is desquamated and
ultimately excreted after 3 to 4 days, and gets denuded with
the cell within 3 to 4 days. If iron is required in the body, it
is bound to the ferroportin, which is then transferred to the
transferrin (produced in the liver), which carries it across
the mucosa. It is then utilized in the bone marrow for
hemoglobin production, in the muscle tissue for myoglobin
and in the body for various other enzymes. Any excess
iron is stored in the form of ferritin in the liver. The RBCs
circulate for their life span of approximately 120 days and
are then destroyed in the spleen, liberating the free iron,

which is then retransported to the bone marrow and other
tissues for its reutilization. Thus, most of the iron is cycled
continuously in the body, with only 1 to 1.5 mg/day of iron
being excreted through the intestinal epithelial cells after
completion of their life span. Since 10 percent of ingested
iron is absorbed and the daily loss is only 1 to 1.5 mg, one
needs to ingest about 10 mg of iron daily, except during
periods of extra needs. Iron is stored in the body in the
form of ferritin and hemosiderin.
In iron deficiency state, the mucosal cell transports
the iron rapidly to the circulation, where it combines with
transferrin and is transported to the site of utilization and
storage. Only 1/10th of the dietary iron is absorbed by the
GI mucosa.
Hepicidin and its Role in Iron Metabolism57,58

Hepicidin plays a key role in the regulation of iron
metabolism and iron deficiency. Hepatocytes produce
hormone peptide (cysteine rich) hepicidin. Hepicidin
controls the release of iron from variety of cell such as
macrophages, hepatocytes enterocytes, etc. to plasma. It
primarily controls iron absorption. The recycling of the
iron from red cell lysis and release of iron from tissue
iron stores is carried by interaction of hepicidin with
ferroprotein which is a cellular iron exporter. Release of
ferroprotein is controlled by hepicidin.
Iron Transport and Storage

Transferrin helps in transport of iron from the intestines to
the site of its utilization.
Transport of Iron Across the Placenta

The transport of iron across placenta occurs against a
gradient, thereby protecting fetus against iron deficiency.
Babies with low iron stores may be born, to mothers
who are severely iron deficient during pregnancy. Most
of the placental transfer of the iron occurs during the
3rd trimester of pregnancy. As a consequence of this,
all preterm babies invariably develop anemia unless
supplemented by iron and iron deficiency in the mother
may cause preterm labor.
Normal infants at birth have about 75 mg of iron
per kg body weight, two-third of which is present in red
blood cells. Once the iron is assimilated in the body it
is not excreted. Normal body losses of iron are about
20 ug/kg/day. Most of these loss occur by shedding of cells
from intestinal mucosa. Average loss of iron per day in
children is 0.9 mg/day or 0.5 mg/m2/day. 0.6 mg/day is lost
in the GIT in the form of RBCs, bile or exfoliated mucosal
cells. The rest is lost from the sweat, desquamated cells of
the skin and the urinary tract.
Causes of Iron Deficiency

Decreased iron stores: Preterms, small for date babies
Decreased intake/assimilation and reduced absorption
Prolonged breastfeeding and delayed introduction
of iron rich, complementary feeds after the age of
6 months adds fuel to the fire
Diet containing low iron or nonbioavailable dietary
iron: It is estimated that in the wheat millet based
diet, iron absorption is around 2 percent and in rice
based diet, iron absorption is around 5 to 8 percent.
Low over all dietary intake
Nonbreastfed infants on cows milk
Malabsorption of iron: Chronic diarrhea, celiac
disease, cows milk allergy, GI surgery, giardiasis,
etc.22
Rarely genetically determined absorptive defect
specific for iron.
Increased requirement:
During periods of growthpreterm infants, tod
dlers, puberty
During reproductive age in females
Pregnancy
Lactation.
Increased losses: Blood loss due to any cause/chronic
blood loss. In gastrointestinal bleeding the chronic loss
of few milliliters of blood daily is sufficient to deplete
iron stores and lead to iron deficiency.
Gastrointestinal bleeding
Diverticulitis
Polyps
Fetomaternal hemorrhage
Repeated blood sampling
Blood losses in the menstrual cycle (Menorrhagia).
Females loose 40 mL blood per month in the
menstrual cycle, this increases the daily iron losses
to 1.5 mg/day.
Intestinal-parasiteshookworm-infestation
giardiasis:59-65 Infants are exposed to intestinal
helminths from the time they crawl. Such infants
suffer repeatedly from gastroenteritis, and other
infections further depleting their iron stores.51,52
Particularly for those from rural areas. Four
hundred fifty million people all over the world
harbor this parasite and about 0.2 mL of blood/
worm of ankylostoma per day may be lost and with
nector infestation each worm accounts for loss
about 0.1 to 0.5 mL/day. Female subjects harboring
more than 100 worms (5 mL/day blood loss) and
male subjects harboring more than 250 worms
(12.5 mL/day blood loss) tend to become anemic.
Chakma T, et al.62 from Madhya Pradesh reported
intestinal parasite in 50 percent of adolescents
(Hook worm 16.3% lumbricoid 18.5%).

Adolescents: Adolescence, is a period of rapid growth,
weight gain and blood volume expansion. Iron
requirement increases from preadolescent level of
0.7 mg to 0.9 mg iron per day to as much as 2.2 mg
iron per day or more particularly heavily menstruating
women
In pregnancy, 4 mg of iron is lost per day in the last two
trimesters. During lactation 0.5 to 1 mg of iron is lost
per day
False concern about the body figures, food fads: During
adolescence false concern about the body figures,
food fads, ignorance, particularly in girls lead to iron
deficiency. Lack of knowledge of nutritional factors
further adds to the problem particularly in adolescent
girls
Poor iron absorption:
Malnutrition/iron poor diet/malabsorption syndro
mes chronic infection/chronic diarrhea celiac
disease/giar
diasis/helminthiasis, sprue,
hypopro
teinemia, cows milk allergy also contribute to a
high prevalence of anemia
Gastrointestinal surgery: Polyps/Meckels diverti
culum/hemorrhagic telangiectasia/peptic ulcer,
diverticulitis are other causes of bleeding diathesis
and iron loss
Milk-induced enteropathy is the most common
cause of occult GI bleeding seen in approximately
more than 50 percent of infants with IDA seen in
the western world
Rarely genetically determined absorptive defect
specific for iron.
Fetomaternal hemorrhage: Among the other causes
of blood loss leading to anemia in newborn. In about
50 percent of all pregnancies there is some degree of
fetomaternal hemorrhage. Eight percent are significant
(0.5 40 mL fetal blood loss)
Repeated venipunctures for investigations, hemo
dialysis, and regular blood donations are important
iatrogenic causes of iron deficiency due to chronic
blood loss
Inadequate transport:
Atransferrinemia
Antitransferrin receptor antibodies.
PATHOGENESIS
Stages of Iron Deficiency
Iron deficiency anemia (IDA) is the end stage of a relatively
long drawn process of deterioration in the iron status of an
individual.
The spectrum of iron nutrition status can be divided
into three stages:
Iron deficiency stage: This refers to lack of iron of sufficient

severity to restrict production of hemoglobin.
1. First stagestorage iron depletion: Iron reserve is
decreased or absent. It is characterized by reduced
serum ferritin, reduced iron concentration in marrow
and liver tissue. Hb, serum iron, transferrin levels and
saturation are within normal limits
2. Second stageiron limited erythropoiesis (Iron defici
ency without anemia): Refers to a milder form of iron
deficiency where Hb has not fallen enough to meet the
criteria of anemia. It may be transient and consists of
a decrease in the transportation of iron Hb level may
still be normal or in the low normal range. Serum iron
is low and total iron binding capacity (TIBC) increased
with low transferrin saturation and low serum ferretin
levels
3. Third stageiron deficiency anemia: It represents the
more severe form of iron deficiency. The supply of
iron to erythroid cells in marrow is impaired, causing
a reduction in Hb concentration, with progressive
microcytic hypochromic anemia. Hb concentration has
fallen and decreased serum iron, transferrin saturation
and serum ferritin levels. There is an increase in the FEP
(free erythrocyte protoporphyrin) detectable anemia,
microcytosis, hypochromia on the peripheral smear
with low MCV and MCH and high RDW.
Clinical Features of IDA

Iron deficiency an isolated hematological condition
associated with anemia. It is a systemic disease involving
multiple systems. The appearance of symptoms depends
upon:
Hemoglobin level
The rate of fall of hemoglobin
Hemostatic adjustment of various organs systems
Age of the child
Maturity of various organs
Underlying cause.
If the fall of hemoglobin is gradual as in iron deficient
anemia, then the onset of symptoms is insidious and may
go unnoticed till Hb drops to as low as 4 to 5 gm/dL. Child
may not have any obvious symptoms. Gradual onset of
pallor may escape notice even when the hemoglobin falls
to 4 to 5 gm.
However, if the drop of Hb is rapid, child may be
brought in serious conditionstachycardia, signs of
congestive cardiac failure and even gasping conditions as
it some times occur in G6PD deficiency or autoimmune
hemolytic anemia. Initial symptoms include pallor,
tiredness, lassitude, easy fatigability, anorexia, weakness,
lack of concentration, breathlessness, irritability, puffi
ness, edema feet, etc.

However, all cases of anemia may not have pallor,
especially in mild cases of anemia, and associated with
icterus, cyanosis, dark pigmentation, may mask pallor.
Pallor can also be seen in nonanemic conditions as
color of the skin not only depends on the Hb content, but
on the state of blood vessels of the skin (Vasoconstriction
as seen in vasovagal syncope), presence of edema as seen
in nephrotic syndrome, myxedema, congestive cardiac
failure, even in absence of anemia. Hence, it is always
prudent to rely on Hb or HCT estimation to detect anemia.
Later hyperdynamic circulation leads to palpitation,
shortness of breath, easy fatigability, reduce exercise
tolerance and heart failure
Changes in epithelial cells: These include koilonychias,
platonychia, atrophic glossitis, angular cheilosis are
uncommon in children, however may be observed,
especially with long standing anemia and in adolescent
children (Fig. 2). The triad of dysphagia due to esophagal
webs, koilonychias (Fig. 1) and splenomegaly in a child
with IDA is known as PlummerVinson or Paterson
Kelly syndrome and are not common in children
Mild hepatosplenomegaly is also not uncommon in
children with iron deficiency anemia
Pica: Pica usually is the manifestation of iron deficiency
and is relieved when condition is treated. Pica is a
habitual ingestion of unusual substances like:
Geophagia:83 Mud or clay and can decrease absor
ption of iron and aggravate IDA
Fig. 2 Adolescent child with IDA
Amylophagia: Eating laundry starchuncooked

rice
Pagophagia-ice: It is unexplainable symptom.
Often seen in pregnant women.
Other common causes of pica are lead poisoning and
psychological disturbances
Clay84 can behave in the gut as an exchange resin and
can interfere with iron absorption.
Pica though may be a manifestation of iron deficiency,
is also considered to be a predisposing factor. It is both
effect and cause of IDA.
Clinical features may be due to anemia or in addition
due to underlying etiology of anemia28,29,66-70
In mild anemia: There may be no signs and symptoms but
a definite sense of well being and better exercise tolerance
is observed following treatment. All the symptoms of the
anemia like fatigue, breathlessness, irritability, anorexia,
etc. may be seen. Spleen is often enlarged slightly in
children, but is of normal consistency.
Patients with Mild to Moderate Anemia

(Hb 610 gm%)1,71
Fig. 1 Koilonychia and puffiness of face and eyes and severe

pallor in a case of IDA (Rare in children)
May or may not have any symptoms

They are usually diagnosed during routine laboratory
testing
This is because of compensatory mechanisms like
increase in 2,3 DGP levels and a shift of O2 dissociation
curve.
Severe IDA < 5 gm%

May present with fatigue, breathlessness, tachycardia,
systolic murmur and later on, signs of CCF may develop
Anorexia, loss of appetite
Increased infections
Irritability
Other features: Depletion of nonheme iron containing
tissue proteins is responsible for various other mani
festations.
cases. However, oral iron therapy only minimally

changes saturation of transferrin and hence practically
it does not have any adverse effect on incidence of
infection. In several studies, results show that infants
who receive iron supplementary formulae have fewer
episodes of respiratory and gastrointestinal infections
than those who receive unsupplemented formula.
Reduced myeloperoxidase can also lead to altered
white cell function.
Growth Retardation
Diet History
A detailed diet history is very important, especially in
infant with anemia.
Exclusive breastfeeding for 4 to 6 months
Introduction of good home made weaning food con
taining iron thereafter
Iron deficiency develops where there is poor breastfeeding, prolonged breastfeeding beyond 1 to 2 years
especially with introduction of improper weaning food
is also a cause of nutritional anemia
Iron deficiency has a wide range of clinical and
functional consequences:
Behavioral changes: These changes occur due to
diminished activity of aldehyde oxidase, required for
serotonin catabolism, thus leading to increased levels
of serotonin and 6-hydroxy nidole compounds. MAO
which is also required for catabolism of catecholamine
is also reduced.
Short attention span, irritability, stubbornness, dec
reased cognition and scholastic performance and
conduct disorders are common in children with iron
deficiency, leads to learning disabilities and scholastic
backwardness. These neurological changes that
occur due to iron deficiency may be long term or even
irreversible. Anemic children have poorer endurance
capacity and lack physical fitness.72-81
Breath holding spasms in less than 3 years child.
Altered immune response: It is believed that IDA
children have increased susceptibility to infec
tions due to immunosuppression. Humoral, cellmediated and nonspecific immunity and the
activity of cytokines which have an important role
in various steps of immunogenic mechanisms
are influenced by iron deficiency anemia.82 Iron
deficiency affects both cell mediated as well as
humoral immunity, though phagocytic activity
may be normal.
Some studies state that immunity is enhanced in iron
deficient state. This is due to increased unsaturated
transferrin which inhibits bacterial growth and hence
high dose IV iron therapy could be harmful in such
There is marked reduction in weight of iron deficient

children, though height seems to be unaffected.
Exercises Intolerance80,81
Maximum work capacity, work output and endurance are
impaired in iron deficiency state. This is due to reduction
in the mitochondrial enzyme a-glycophosphatase dehy
drogenase besides due to anemia.
Effects on Pregnancy Outcome42-46,48,50,51

Estimates from the World Health Organization report
that from 35 to 75 percent (56% on average) of pregnant
women in developing countries, and 18 percent of women
from industrialized countries are anemic. However,
many of these women were already anemic at the time
of conception, with an estimated prevalence of anemia of
43 percent in nonpregnant women in developing countries
and of 12 percent in women in wealthier regions. Even for
women who enter pregnancy with reasonable iron stores,
iron supplements improve iron status during pregnancy
and for a considerable length of time postpartum, thus
providing some protection against iron deficiency in the
subsequent pregnancy.
Maternal iron deficiency in pregnancy reduces fetal
iron stores, perhaps well into the first year of life. Iron
deficiency anemia in pregnancy is a risk factor for preterm
delivery and subsequent low birth weight and possibly for
inferior neonatal health.
Regulation of Iron Transfer to the Fetus

Most iron transfer to the fetus occurs after week 30 of
gestation. Serum ferritin usually falls markedly between
12 and 25 weeks of gestation, probably as a result of iron
utilization for expansion of the maternal red blood cell
mass. Serum transferrin carries iron from the maternal
circulation to transferrin receptors located on the apical
surface of the placental syncytiotrophoblast, holotrans
ferrin is endocytosed, iron is released, and apo-transferrin
is returned to the maternal circulation. The free iron then
binds to ferritin in placental cells where it is transferred

to apotransferrin, which enters from the fetal side of
the placenta and exits as holotransferrin into the fetal
circulation. This placental iron transfer system regulates
iron transport to the fetus.
When maternal iron status is poor, the number of
placental transferrin receptors increases so that more iron
is taken up by the placenta. Excessive iron transport to
the fetus may be prevented by the placental synthesis of
ferritin. There is a substantial amount of evidence showing
that maternal iron deficiency anemia early in pregnancy
can result in low birth weight subsequent to preterm
delivery.
Diagnosis of Iron Deficiency Anemia

(Flow Chart 1)84-90
Laboratory tests in iron deficiency anemia are required to
diagnose IDA and to establish its cause. Iron deficiency
anemia, should initially be suspected clinically by taking
proper detailed history, dietic history, socioeconomic
status, and proper clinical detailed examinationlooking
at tongue, mucosa of inner side of lip and palate, conjunc
tiva or nails, paleness around the crease of the palm and
thorough systemic examination to detect underlying
cause.
It is desirable that anemia and its severity are then

quantified through the accurate laboratory tests.
Screening Tests85-91
Manual determination of these red cell indices are time
consuming and not very reliable and not reproducible.
With the availability of electronic particle counters
estimation of RBC parametersHb, PCV, MCV, MCHC,
RBC count, RDW, has become easy to perform, accurate,
reproducible and practical.
Evaluation of peripheral smear examination is must.
The changes in these parameters include:
Red cell count, hemoglobin and hematocrit are all
decreased in IDA. MCV, MCH and MCHC are also
decreased.
The peripheral blood film shows hypochromic,
microcytic red cells (Fig. 3).
If anemia is severe, morphological abnormalities such
as poikilocytosis and target cells. Pencil cells may be
seen.
When iron deficiency is associated with deficiency of
other hematinics like vitamin B12 or folate, there may
be a dimorphic picture with hypochromic, microcytic
red cells along with macrocytic red cells. These routine
Flow chart 1 Approach to IDA-hypochromic microcytic anemia

Child is said to be anemic when the hemoglobin and/or
hematocrit is two standard deviation (SD) below the mean
for that particular age and sex.
Reticulocyte count is usually normal unless the
child has an acute or recent blood loss or has received
hematinics. However in mild iron deficiency, RBC
morphology and indices are not altered.
Confirmatory Tests (Table 3)
Fig. 3 Peripheral smear examination showing microcytic

hypochromic anemia
investigations may not be useful to diagnose early iron

deficiency state.
Reticulocyte count is normal unless the patient has had
a recent acute blood loss or the patient has received.
Hematinics, in which case it may be increased.
Following iron therapy there is reticulocytosis which
peaks at 1 to 2 weeks.
In severe IDA, reticulocyte count may be decreased.
Low levels of Hb, MCV< 80 ug/dL, MCH < 27 Pg and
high levels of RDW with low SI, TS, TIBC and FEP
indicate IDA.
Klee92 G in his study showed that more than half of the
62 patients with IDA had a MCH value clearly within a
normal range and nearly 70 percent of cases exhibited
distinct microcytosis, suggesting that MCV is much
more sensitive than MCH in determining changes of
iron deficiency. MCHC < 33 percent and is the last of
the indices to be affected and is the least important in
diagnosis of IDA. MCV is more sensitive than MCH in
diagnosis of IDA. RDW is the quantitative measure of
anisocytosis. It is increased in IDA and normal or low
RDW values are unlikely to be present with IDA.
Microcytosis also may be seen in other conditions.
Differential Diagnosis of Microcytic

Hypochromic Anemia (Table 4)
Anemia of chronic infection and inflammation
Thalassemias and abnormal hemoglobinopathies traits
Lead poisoning
Sideroblastic anemia.
Serum iron is reduced (N = 50180 ug/dL)

TIBC is increased, more than 470 mcg/dL (N = 250450
ug/dL)
Transferrin saturation is lowless than 16 percent
suggestive and less than 7 percent diagnostic of severe
IDA.
Serum ferritin is less than 10 to 12 ng/mL. However,
when infectious or inflammatory diseases like rheuma
toid arthritis, collagen disorders, liver disorders,
chronic renal disease or malignancy are also present,
the serum ferritin level is usually higher, but less than
50 to 60 ng/mL as ferritin is an acute phase reactant.
The test still lacks sensitivity and normal value does not
reliably exclude iron deficiency.
Free Erythrocyte Protoporphyrin

Free erythrocyte protoporphyrin (FEP) and protoporphyrinheme (PH) ratio: Erythrocyte protoporphyrin, the
precursor of heme accumulates in red blood cells when
it has insufficient iron to combine with the form of heme.
The blood can be conveniently tested by putting drop of
blood on a cover slip and reading the result directly. The
FEP can be measured by a simple fluorescence assay per
formed directly on the thin film of blood. Both FEP and PH
ratio is elevated in iron deficiency. Normal values of FEP
are 30 to 40 ucg/dL RBC and PH ratio 16 (+5.3). FEP values
above 70 mcg/dL RBC and of PH ratio above 32 is consid
ered to represent iron deficiency.
FEP/Hb ratio increases when iron reserve is exhausted,
even before anemia becomes apparent
Table 3 Confirmatory tests
Age in
years
Serum ferritin
ng/dL
Transferrin
saturation
percent
RBC/FEP ug/dL
0.54
< 10
<12
>80
510
< 10
<14
>70
1114
< 10
<16
>70
>14
< 12
<16
>70

Table 4 Differential diagnosis of microcytic/hypochromic anemia
Iron
deficiency
Thalassemia
minor
Chronic
infection
Age
624 months
Any
Any
Community
Any
High risk
Any
Pica
++++
Diet
Milk/bottle
feeding
Behavior
Irritable/listless
Breath holding
+++
Epithelial/nails
Koilo/
Platonychia
Low
High
Low
Clinical
Laboratory
RBC count
MCV
Low
Low
N-Low
RDW
High
High
Hemolysis
++
RBC count
Low
High
Low
TIBC/FEP
High
High
Ferritin
Low
High
sTfR/serum ferritin
High
Low
ESR
High
HbA2
High
Iron trial response
Good
Poor
Poor
The ratio is normal in thalassemia trait and renal

anemia
FEP/Hb ratio remains elevated during iron therapy and
returns to normal only after majority of cells containing
FEP formed during iron deficiency are replaced
FEP/Hb ratio is not subject to daily fluctuations and
sudden changes as in transferrin saturation
The highest value of FEP is seen in lead intoxicationa
level of FEP greater than 160 ug/dL of RBC is taken as
cut-off value for detection of lead intoxications.
FEP/Hb ratio in the range of 5.5 to 17.5 ug of Hb may
be attributed to either IDA or lead intoxication with
or without associated iron deficiency. This is not
used regularly due to the cost of the machine and
problems of standardization. Advantage of FEP is that
unlike serum iron studies, FEP values are not altered
immediately after iron therapy.
Soluble transferrin receptor (sTfR) measures the severity
of IDA and values more than 9 mg/L are considered
abnormal. Transferrin receptors (TfR) facilitate the
entry of transferrin-bound iron into cells by a process

of endocytosis. sTfR increases with enhanced red cell
production but iron deficiency is the only disorder in
which there is increased serum receptor combined with a
low level of red cell production. Unlike the serum ferritin,
which only identifies iron deficiency, sTfR measures its
severity. The normal reference value is 2.8 to 8.5 mg/L.
Values above 9 mg/L are considered abnormal. Unlike
many other iron measurements, the level remains normal
in patients with anemia of chronic inflammation or
infection.
The most sensitive method available to distinguish
IDA from anemia of chronic disease is a combination of
plasma sTfR and the log of plasma ferritin concentration,
i.e. sTfR-ferritin complex. If it is high (>4) it indicates IDA;
if <1 it indicates chronic disease.
Molecular genetics of iron deficiency: Human transfer in
gene has been reported that human transferrin G2775
mutation is a risk factor for iron deficiency.
Depletion of stainable iron from bone marrow:
(Routinely bone marrow examination not required) Bone
marrow aspirates can be stained for hemosiderin by Perls
reaction and iron content is graded from 0 to 4. Although
is the most accurate technique to evaluate iron status, it is
an invasive procedure and therefore impractical.
Response to Therapy
In uncomplicated IDA, administration of iron shows a
predictable reticulocytosis and a rise in Hb. A positive
response to therapy can be defined as a daily increase
in Hb concentration of 0.1g/dL (0.3 or 1% rise in HCT)
from the fourth day onwards.
If the serum ferritin is low but the hemoglobin is
normal, the individual is at risk of iron deficiency,
while if the hemoglobin is low but the serum ferritin is
normal further hematological assessment is required
to identify the cause of anemia.
Laboratory Tests in Iron Deficiency Anemia

Low serum iron
Increased total iron
binding capacity
Low transferrin saturation
Serum ferritin
Less than 75 mg/dL

More than 470 mcg/dL
Less than 12% and 14% for
infant and children
< 10 g/L in children and
12 g/L in adults
Increased red cell

protoporphyrin
concentration
Depletion of stainable iron Graded from 0 to 4
from bone marrow
TESTS FOR THE STORAGE COMPARTMENT

Serum ferritin: A level of < 10 g/L in children and
12 g/L in adults is suggestive of iron depletion. Serum
ferritin is increased in infections, inflammation, liver
disease, parasitic infestations, enteric infections and
even upper respiratory tract infections
Bone marrow evaluation: Morphologically bone
marrow shows erythroid normoblastic hyperplasia
though the normoblasts may be smaller than normal
(micronormoblasts)
Bone marrow aspiration is not routinely indicated
in the diagnosis of IDA. The degree of cellularity and
the proportion of myeloid to erythroid cells on bone
marrow examination vary depending on the severity
as well as the duration of IDA
Prussian blue staining of the bone marrow is also used
for diagnosing IDA, though it is rarely indicated. The
iron content is graded from 0 to 4.
TESTS FOR PLASMA IRON COMPARTMENT

It includes:
Serum iron
Total iron binding capacity (TIBC), transferrin
saturation (SI).
It is a major drawback is diurnal variation after 3 years
of age. Morning samples show higher levels. Hence if
morning sample shows a serum iron < 30 ug/dL, it is
suggestive of IDA.
TIBC: It is less subject to biological variations. But
normal range is 250 to 400 ug/dL. An increase in TIBC
indicative of IDA.
Transferrin saturation: It is the ratio of above two
values and is consistent and hence is a very useful test
for IDA.

Serum iron
TS =

100

TIBC

In adults TS < 16 percent is suggestive of IDA. In infants
and children the diagnostic value is < 12 to 16 percent. TS <
6 percent is diagnostic of IDA at any age.
It is important to realize that one should collect fasting
sample (nonlipemic) and all forms of iron supplements
should be stopped for 48 to 72 hours before collection
while performing iron studies.
When to Suspect IDA?

Anemia during age of rapid growth, i.e. first 6 months
to 3 years of life and adolescence.
Child not breastfed but fed with faulty diet, diluted
artificial powder milk especially improper weaning,
prolonged breastfeeding, bottle feeding.
Irritable, cranky child, breath holding spasm, history of

pica, worms infestation, chronic bleeding.
Microcytic, hypochromic anemia on PS, relative decrease
in RBC count and increased RDW and low MCV
Leukocyte count is usually normal.
Hypersegmented neutrophils may be seen due to
concomitant B12 or folate deficiency or due to iron defi
ciency-induced interference with folate utilization, or due
to IDA-induced impairment of jejunal function leading
to poor absorption of B12 or folate. Thrombocytosis may
occur in patients with IDA, as a result of iron therapy per
se or due to underlying condition such as malignancy or
bleeding:
In infants and children the TS < 12 to 16 percent is
diagnostic. Ferritin value is < 12 to 16 ng/dL
Increase in FEP
Therapeutic test: Treat the child with 3 to 5 mg/kg of
elemental iron.
There is increase in retic count at 1 to 2 weeks and Hb
level reaches to normal by 2 to 3 months.
When to Suspect b-thalassemia Trait?

Community: Kutchi, Lohana, Punjabi, Sindhi, Neo

buddhist, Mahars and other high-risk communities
Microcytic/hypochromic anemia with target cells,
polychromasia, relative increase in RBC count and
normal RDW. Normal iron study including ferritin
level
Poor and inadequate response to iron therapy.
Screening Tests
NESTROFT,93,94 discriminant functions.93,94 PS exami
nation
Confirmatory tests: Increase in HbA2 more than 3.5
percent
b-chain synthesis (silent carrier).

Free erythrocyte protoporphyrin (FEP) and proto

porphyrinheme (PH) ratio: Erythrocyte proto
porphyrin, the precursor of heme, accumulates in red
blood cells when it has insufficient iron to combine
with to form heme. Elevation of FEP mainly EZP level
is an early and sensitive indicator of iron deficiency.
FEP can be measured by a simple fluorescence
assay performed directly on a thin film of blood on
a glass slide. Both FEP and PH ratio are elevated
in iron deficiency. Normal values of FEP are 30 to
40 mcg/dL RBC and PH ratio 16 (+5.3). FEP values
above 70 mcg/dL RBC and of PH ratio above 32 is
thought to represent iron deficiency. In uncomplicated
iron deficiency anemia, red cell FEP levels may range
from 100 to1000 g/dL. EZP is also elevated in chronic

lead poisoning and sideroblastic anemia
Serum iron: Normal serum iron level varies
considerably. It has a diurnal variation with a peak
in the morning and trough in the evening. Serum
iron concentration may also be affected by chronic
infection, malignancies and chemotherapy as well
as iron medication. Values below 40 mcg/dL (<12
mcg/dL in young children) are considered diagnostic
of iron deficiency (in absence of infection or other
disorders which affect iron metabolism)
Total iron binding capacity (TIBC) and transferrin
saturation (TS): TIBC is the measure of plasma
transferrin, which is free, not bound to iron. The
normal value of TIBC is 250 to 350 mcg/dL. Since
serum iron is about 100 mcg/dL, normally only onethird of transferrin is utilized to bind iron, giving a
normal transferrin saturation of 33 percent. In iron
deficiency states, TIBC is increased (> 350 mcg/dL)
and transferrin saturation is reduced to below 16
percent (<12% for children)
TIBC below 200 mcg/dL is characteristic of inflam
matory disease
Factors that affect serum iron concentration do not
alter values of TIBC
Serum ferritin: The serum ferritin is a sensitive
laboratory index of iron status. It is the best noninvasive test (gold standard with a high specificity
and adequate sensitivity) for evaluating iron status
in the body. It is estimated that each ng/mL of serum
ferritin is equivalent to 8 to 10 mg of storage iron. A
serum ferritin value of less than 12 ng/mL is highly
specific for iron deficiency but gives no information
about its magnitude.91 Ferritin levels are estimated
by radioimmunoassay (RIA), or ELISA techniques.
Serum ferritin is increased in chronic disorders, e.g.
chronic infection and inflammation, malignancies,
chronic liver disorders. In presence of any of these, a
coexisting iron deficiency anemia can be missed.
Soluble plasma transferrin receptor (sTfR): Transferrin
receptors (TfR) facilitate the entry of transferrin bound
iron into cells by a process of endocytosis in iron
deficiency anemia, transferrin receptors are increased
probably due to an increased turnover associated
with ineffective erythropoiesis and, an increase in
cellular transferrin receptor expression produced
by iron starvation. Unlike the serum ferritin, which
only identifies iron deficiency, the serum transferrin
receptors measure its severity. Value above 9 mg/L
are considered abnormal health level in healthy male
and female are 56 mg/L and is normal in anemia of
chronic infection and inflammation.95
Bone Marrow Examination

Bone marrow aspiration is not recommended for the
diagnosis of IDA, as there are simpler, noninvasive
and relatively inexpensive tests, which diagnose
IDA reasonably well. In contrast, bone marrow iron
staining, though a gold standard, is very painful,
expensive and cumbersome to perform. However, bone
marrow when done shows increased cellularity with
micronormoblastic erythroid hyperplasia. On staining
with prussian blue (Perls reaction), there is little or no
stainable iron seen.
Response to Therapy
In uncomplicated IDA, administration of iron shows a
predictable reticulocytosis and a rise in hemoglobin. Hb
concentration remains the most dominant predictor of
response to therapy in uncomplicated iron deficiency.
A positive response to therapy can be defined as a daily
increase in Hb concentration of 0.1 g/dL (0.3 or 1% rise in
HCT) from the fourth day onwards. Lower the initial Hb,
greater is the response following iron therapy.
Treatment of Iron Deficiency Anemia

Basic principles of management include:
1. Correction of anemia
2. Treatment of underlying cause
Management of IDA: If the patient is severely pale
and sick looking, breathless, has tachycardia, raised
JVP and tender hepatomegaly, it is suggestive of
congestive cardiac failure. Such a patient needs
immediate attention and prompt treatment including
admission, diuretics, anti-CCF measures and packed
cell transfusion. And other treatments depending on
underlying cause
One should not waste time in lengthy diagnostic tests
and do as minimum tests as required.
Even removing too much blood for various tests in
small infants, can be hazardous as it can precipitate
cardiac failure. Instead, one can arrange for packed
cell transfusion and remove blood for various tests just
before starting transfusion.
Other way if the patient is pale but comfortable and
not sick, there is neither need to give packed cell
transfusion nor start gun shot therapy without proper
investigations and establishing the diagnosis.
The management of iron deficiency anemia is consi
dered in two parts:
1. Treatment of the individual patient
2. Treatment at public health level.

The successful management requires:
Confirmation of the diagnosis
Thorough investigations to find out the etiology and to
treat the cause
Supplementation of iron.
It is important to find out the etiological factor for iron
deficiency to prevent failure of therapy and recurrence of
deficiency after treatment is stopped, especially in older
children who are likely to have a secondary IDA associated
with underlying cause. Treatment of worms, giardiasis,
bleeding from any site, recurrent infections is must to treat
the patient adequately besides iron.
Infants usually have poor dietary history. Lack of
breastfeeding associated with bottle feeding or prolonged
breastfeeding and improper weaning and poor intake of
iron containing food as a cause of iron deficiency.
Promotion of exclusive breastfeeding for first 4 to
6 months. Thereafter introduction of proper and age
appropriate food items after 6 months and continuing
breastfeeding for as long as possible, along with prop
hylactic iron supplementation will prevent iron defici
ency during infancy and early childhood. In older
children diet modifications to improve total calorie
intake and iron containing foods in diet will prevent iron
deficiency.
Management
of IDA consists
of
Iron therapyincluding
replenishment
of stores.
Oral
Parenteral.
Treatment of underlying causative factor
To prevent recurrence of deficiency preventive measures:
Diet counseling
Iron supplementation
Iron fortification.
IRON THERAPY
Aim is to give iron in enough dose, for enough number of
days so as to normalize the Hb levels and replenish stores,
in a convenient way with least number of side effects.

It can be given either:
Orally
Parenterally.
Oral Iron Therapy

Advantages of oral iron therapy are cheap, effective,
safe, convenient and well tolerated and preferred and
advocated route of therapy.
Best absorbed when given on an empty stomach or in
between the meals in divided doses.
It may be given at bed time as compliance is better

in children as child goes to sleep and vomiting and
pain abdomen is much less as intestinal activities are
slow during sleep. Compliance in the first month of
therapy is important as majority of iron absorption
occurs during this period. It is continued for at least
2 to 3 months after hemoglobin becomes normal, to
replenish stores.66,85
Dose
For infants and children: Iron store present at birth
and the highly bioavailable iron in breast milk protect
an infant from IDA up to 6 months. Supplementation
with medicinal iron has been recommended by WHO
for all children beyond 4 to 6 months of age and low
birth weight babies from 2 months onwards, for
preventive supplementation, iron dosage is 2 mg/kg
per day for children of all age groups. Children of 6 to
35 months of age should receive a daily uniform dose
of iron folic acid (IFA) supplement (20 mg elemental
iron + 100 mcg folic acid) in liquid from (36 mg/kg/
day of elemental iron). Although the desired Hb level
is usually reached in 2 months, iron therapy should
continue for another 3 months to build up iron
stores.
For women (15 years +) with severe anemia (Hb < 7 g/
dL): National Nutritional Anemia Control Program
(NNACP)96 recommends two tablets of iron-folate tablet
per day (each tablet containing 100 mg of elemental
iron and 500 mcg of folic acid) for a minimum of 100
days. Prolonged duration of treatment is required to
correct the anemia and replenish iron stores.
Restoration of Hb to normal with ferrous salts requires
3 to 6 months of Rx. Replenishment of body iron stores
requires further therapy for additional 2 to 4 months.
Risk of accidental iron poisoning in small children
In developed countries, tablet containing ferrous iron
are the second most common cause (after aspirin) of
accidental poisoning among small children leading to
hospitalization and several death.
Preparations of iron formulations.
All dietary iron has to be reduced to ferrous form to
enter the mucosal cells. Various iron salts available include
ferrous fumerate, ferrous gluconate, ferrous sulphatehydrous anhydrous form, etc.
Bivalent iron salts like ferrous sulfate, fumarate, gluco
nate, succinate, glutamate and lactate have been preferred
over ferric salt preparations.
Type of iron salt:
Ferrous sulfate (20% elemental iron) is commonly
used for tablet preparations.


Ferrous fumarate (33% elemental iron) is environ
mentally more stable.
When ferrous preparation is taken on empty
stomach absorption increases, however side effect
also increases.
Many new iron preparations are not affected by food
or milk enabling administrations without consideration of
the timing of feed. These are iron polymaltose complex and
carbonyl iron (highly purified metallic iron with a particle
size less that 5 mm). However, most of these preparations
have not been found to be effective in clinical setting.
Ferrous salt is the drug of choice as it is absorbed best
and is cheapest. Iron salts of carbonate, citrate, choline
citrate and pyrophosphate are not absorbed efficiently
(Table 5).
Other salts available are:
Ferrous fructose
Ferrous succinate
Ferrous lactate
Ferrous carbonate
Ferrous glycine citrate
Ferric ammonium citrate
Colloidal iron.
Various Forms of Iron Preparation

Uncoated tablets: Uncoated tablets are cheaper but have
more side effects. Enteric coated tablets have better
availability with less side effects but are expensive.
Flavored chewable tablets are available which have
better compliance but again are costly. And overdose is
more common.
Syrups and drops can lead to staining of tongue and
teeth and are costly, may not be stable.
Iron in hemoglobin form is also available but has
little advantage. Content of elemental iron is low and
is expensive and often fails to provide the required
amount of iron.
Side effects of oral iron therapy: Nausea, vomiting,
abdominal cramps, diarrhea, constipation, staining of
tongue and teeth, blackish discoloration of stools, etc.
are common side effects. By and large the side effects
Table 5 Percentage and amount of iron in some commonly

used iron tablets preparation of iron compounds97
Per tab
(mg)
Ferrous fumarate
200
Per tab
iron
66
Elemental %
iron (mg)
33
Ferrous gluconate
300
36
12
Ferrous sulfate (7H2O)
300
60
20
Ferrous sulfate
(anhydrous)
200
74
are less and well tolerable if proper counseling is done

and before starting therapy.
Rarely case of acute iron poisoning occurs by taking
accidental or suicidal overdose.
Once or twice a week oral iron therapy has been found
to be equally effective if not better with less side effects.
Daily versus Weekly Supplementation99-104

In humans, the intestinal mucosal turnover time is 5 to
6 days and serves as the basis for the weekly preventive
supplementation regimen:
Iron absorption from GI tract depends upon iron
content in the mucosal cells. Less the iron contents
more the absorption
One of the major problem with daily supplementation
regimen is that supplements must be taken for a long
period of time for achieving desired improvement in
iron status
It has been seen that iron deficient and anemic women
can absorb as much as 30 to 40 mg dose of iron ingested
on an empty stomach
Iron administration every 3rd day (intestinal mucosal
turn over time in rat is 34 days) was more efficient
in iron deficient rats than when administered daily.98
Indeed, in weekly dosing food iron absorption is also
better maintained. Weekly dose is considered as cost
effective with requirement of lesser number of doses,
with fewer side effects and better compliance. Recent
research in experimental animals and field studies
among the preschool children in China and other
countries have indicated that intermittent therapeutic
dosage can be as effective as daily dosage in correcting
the mild to moderate anemia and iron deficiency and in
anemia prophylaxis.96,97 A number of studies in Indian
setting have shown weekly iron supplementation is
effective
With daily administration of iron, gastrointestinal
complaints were more common in majority of the
studies and were rare with weekly dose. Serum
ferritin levels were nonsignificantly higher in daily as
compared to weekly supplement
In Bombay, Mehta et al.100 in a study of 1748 adoles
cent girls (10-18 years) from urban slums revealed
prevalence rate of anemia in 63.8 percent. Iron supple
mentation resulted in beneficial effect and prevalence
of anemia decreased to 61.16 to 26 percent in daily
group and 65 to 33.9 percent in weekly group and no
changes 64.8 to 58.4 percent in control group and there
was statistically significant increase in Hb levelrise of
mean 0.939 g. Hb in daily group as compared to 1.54 g
in weekly group. Rise in ferritin level was 5.04 ng/mL
in weekly group as compared to 4.69 ng/mL in the dai
ly group. Sheshadri et al. from Baroda101 in her study

reported rise in Hb in daily group was 0.749 percent as
compared to 0.44 gm% in the weekly group side effects
of iron supplementation were almost absent in weekly
regimen as compared to 15 percent in daily regimen
A WHO report based on 11 trials published involving
14000 subjects for a period of 4 to 7 months in school
children, adult, nonpregnant women and pregnant
women revealed weekly supplementation was as
effective as when given daily whereas in some studies
slightly less therapeutic effect was seen in weekly
supplementation as compared to the daily supple
mentation.

Based on these studies and recent multicentric study
in India has now recommended that adolescent girls on
attaining menarche should be given weekly dosage of the
IFA tablet containing 100 mg elemental iron and 500 ug
folic acid once a week accompanied by appropriate dietary
supplementation.97
Response to Therapy
The first response is the decreased irritability and a
subjective improvement
This is followed by a marrow response and reticulocytosis

peaking at 5 to 7 days.
Hb rises at a slower rate, i.e. 0.25 to 0.4 g/dL/day. It

normalizes by 6 to 8 weeks but it may take little longer.
Failure of oral iron therapy:
Wrong diagnosis
Inadequate dose, inadequate length of treatment
Poor compliance, etc. This can be easily tackled by proper
knowledge on part of physician and proper counseling of
parents
Having severe side effects
Decreased absorption as seen in various GI disorders
Gastrointestinal bleeding, which is aggravated by oral iron
therapy
Increased iron loss not met with oral therapy, e.g. ongoing
GI bleeds, or true intolerance. Such cases can be treated
with parenteral iron therapy
Chronic malabsorption syndromeschronic diarrhea,
cystic fibrosis, Crohns disease, etc.
Oral iron not sufficient to compensate the need for increasing
deficit as in persistent bleeding (Epistaxis).
Parenteral Iron Therapy

Intravenous Iron
Parenteral iron therapy should usually be avoided as
having severe side effects.
Indications
Oral iron not sufficient to compensate the need for
increasing deficit as in persistent /significant bleedinglike epistaxis (telangiectasia), gastrointestinal bleeding,
etc.
Decreased absorption as seen in various GI disorders
Chronic malabsorption syndromes: Chronic diarrhea,
cystic fibrosis, Crohns disease, surgery, gastrointesti
nal disease, etc.
True intolerance for oral iron therapy.
Having severe side effects on oral therapy.
For receiving recombinant erythropoietin therapy, or
for use in treating functional iron deficiency.
Noncompliance may make oral iron treatment in some
patients inadequate
Types of Parenteral Iron Preparations

Intravenous (IV)
Intramuscular (IM)
Parenteral iron products available are:
Iron dextran,
Ferric gluconate,
Iron sucrose.
Following parenteral administration of iron, the
iron carbohydrate complex is separated by the reticu
loendothelial system. Iron is gradually released into the
circulation.
Iron Dextran Complex

Iron dextran is a colloidal solution of ferric oxyhydroxide
complexed with polymerized dextran.
Total dose to be given as, divided intramuscular
injections or as full dose IV therapy.
The iron requirement can determine from the
equation:
Iron (mg) = weight (kg) Hb deficit (g/dL) 80/100
3.4 1.5 or
weight (kg) Hb deficit (g/dL) 4.
Dose: Dose of iron (mg) = weight (lbs) Desired
increment of Hb (g/dL) 3.
a. Intravenous route (IV): There are two methods:
Infusion of iron dextran diluted in ratio of 5 mL of
iron dextran complex in 100 mL of normal saline.
Initially flow rate should be kept at 20 drops/min
for 5 to 10 minutes and there are no reactions, then
rate can be increased to 40 to 60 drops/min.
Bolus injection of iron dextran: Bolus dose of iron
dextran diluted in 20 mL of saline.105-107 Both these
routes are however used after a prior sensitivity
testing where 1 mL of iron dextran solution is diluted in
20 cc of normal saline and injected slowly over 10 to

15 minutes following which one should observe for
reactions for 1/2 to 1 hour
Sodium ferric gluconate intravenous injection or
infusion.
Ferrlecit (sodium ferric gluconate complex in
sucrose injection) is indicated for treatment of iron
deficiency anemia in pediatric patients age 6 years
and older. Standard dose of 125 mg in 100 mL of
normal saline intravenously over 60 min. If the
patients serum ferritin is less than or equal to 100
ng/mL and the transferrin saturation is less than
or equal to 20%, the dose can be repeated over 8
weeks.
Iron sucrose injection Venofer
Iron sucrose cucrose injection (Venofer) is an
iron hydroxide sucrose complex in water.
Iron sucrose is administered by intravenous
injection or infusion. The recommended
schedule is to administer 100 mg intravenously
over 5 min, 13 times weekly upto 1,000 mg if
required.
The rate of administration should not exceed
20 mg per minute. Side effect includes hypotension,
nausea, and lower back pain.
Intramuscular route (IM): This is very painful and

may lead to serious allergic reactions and hence not used
in children. Intramuscular injections are best given into
the upper outer quarter of gluteal region using Z tract
technique. A dose of 0.1 mL should be given as test dose
intramuscularly and there are no reactions within 1 hour,
full dose (to a maximum of 0.5 cc) can be given.
Though most of the reaction are mild and tran
sient, anaphylactic reactions may be life-threatening
and hence one should always keep injection adrenaline,
hydrocortisone and resuscitative measures handy before
injecting.
Response to Therapy
Rapid hematologic response can be confidently
predicted in iron deficiency.
A positive response to therapy can be defined as a daily
increase in hemoglobin concentration of 0.1 g/dL (0.3
or 1 percent rise in hematocrit) from the fourth day
onwards.
Approximately 2 months are required to achieve a
normal Hb level.
Reticulocytes increase within 3 to 5 days and reach a
maximum at 5 to 10 days, reticulocyte counts being 8
to 10 percent in severe anemia.
The maximum rate of recovery from severe anemia in
a child may be 0.25 to 0.4 g/dL per day increase in Hb
or a 1 percent per day rise in hematocrit which is more

rapid than is anticipated in the adult.
Iron absorption is maximum during the initial phase of
therapy and declines from 14 percent in the 1st week to
7 percent in the 4th week to 2 percent after 4 months.
Blood transfusion may be needed in most severe cases
of IDA when the hemoglobin level is below 3 to 4 g/dL or
when superimposed infection may interfere with optimal
therapeutic response. Packed red cells may be slowly
given preferably 2 to 3 mL/kg at one time.
Side Effects
Reactions can occur with both IM and IV therapy and can
be either immediate or delayed.
Immediate reactions
Pain at the injection site
Vomiting, nausea, headache, malaise, flushing,
metallic taste, such reactions are brief in duration
and often are relieved by slowing the rate of
infusion.
Severe reactions like anaphylaxis, hypotension,
cardiac arrest, etc. should be contraindicated to
further doses.
Delayed reactions
Arthralgia, fever, myalgia, regional lymphadenitis
Prevention of IDA
The basic approaches to the prevention of IDA are:
Supplementation with medicinal iron
Dietary modification (Table 6)
Fortification of foods with iron
Other measures, which could play an indirect role in
improving the iron status are control of viral, bacterial
and parasitic infections (hookworm infestation-correct
ed by regular deworming measures), malaria. Improve
ment in poor health facilities, poor socioeconomic
status, faulty dietary patterns, the degree of urbaniza
tion, educational background, provision of safe water,
environmental sanitation, health education, vitamin A
deficiency and immunization, etc.
Protection and promotion of breastfeeding: Exclusive
breastfeeding till the age of 4 to 6 months and
promoting breastfeeding for as long as possible, even
up to 2 years. Human breast milk is low in iron about
0.5 mg/L. An infant taking 600 to 650 mL of breast
milk daily ingests approximately 0.3 mg of iron/day.
However, the bioavailability of this iron is quite high,
(50%) as much as 0.15 mg of iron per day is absorbed
which is sufficient for an exclusively breastfed baby.
Breast milk appears to be adequate to cover the dietary

Table 6: Iron content of food articles108-110
Food
Iron content Articles rich in iron (>10

(mg/100 g) mg/100 g)
Cereals
2.514.0
Bajra, wild barley, kangri

ragi, rice flakes, whole wheat
flour, kodra (Harik)
Pulses and
legumes
2.711.0
Bengal gram, cowgram,

soyabean
Leafy vegetables
0.940.0
Amaranth, beet greens,

Bengal gram leaves,
coriander, alu leaves,
pudina, neem, radish top
rajgira leaves, turnip greens,
all types of green bhajis
(spinach, methi, lettuce, etc.)
Roots and tubers
0.413.9
Other vegetables
0.222.2
Amaranth seeds, dhaincha

seeds
Nuts and oil

seeds
2.510.0
Garden cress, gingelly,

mustard,
Fruits
0.110.0
Dates, karvands, raisins
Seafood
1.011.5
Most Indian fish, crab
Meat
2.018.8
Beef
Milk
0.20.8
Miscellaneous
Jaggery, yeast
iron requirements of normal birth weight full term and

infants up to the age of 6 months. From 6 months of age
the iron requirement increases markedly and hence
the iron from breast milk alone is no longer sufficient.
Encouraging the timely introduction of iron containing
weaning food is an important step in prevention of
anemia in early infancy and childhood. As maternal
transplacental transfer of iron from mother to child
takes place during the last trimester of pregnancy,
iron storage in premature and low birth weight infant
is affected and low. Hence, low birth weight infant
require iron supplementation from the age of two
months.
Nutrition education and dietary modification: Food
based intervention: Anemia (IDA) is hardly ever
observed in exclusive breastfed infants till the age of
4 to 6 months even though mother is severely anemic.
Breast milk has high bioavailability for iron absorption.
Breastfeeding along with appropriate complimentary
feed, including iron rich or iron fortified foods where
possible through the second year of life is important
modality to prevent IDA.
Introduction of iron containing food after the age

of 4 to 6 months is the most important step in
prevention of anemia of infancy.
Commercially prepared iron rich weaning foods
though available in developed countries, are very
expensive and beyond the reach of the majority of
the families and so not recommended.
Encourage natural homemade food items, initially
semisolids and then solid items so that child should
consume normal family diet by 9 to 12 months of
age.
Home made weaning foods rich in iron and
vitamin C are cooked vegetables, raw fruits,
parents should be taught how to prepare mashed
vegetables? Thick palak soup with boiled dal and
vegetable, citrous fruit juices, egg preparation,
minced mutton, etc. and motivated to introduce
these to the infants in early life after 4 to 6 months
of age.
Foods rich in vitamin C like orange, citrous food,
guava, tamarind are seasonably available and
are however expensive particularly in developing
countries. In developing countries where meat
intake is low, vitamin C (ascorbic acid) is the single
most important enhancer of iron absorption.
Adding as little as 50 mg of ascorbic acid to a
meal will double the iron absorption (an orange
or lemon, or cabbage 100 g or 200 g of amaranth
will sufficient amount of vitamin C). The presence
of vitamin C 25, 50, 100, 250, 500 mg in given meal
is associated with 2, 3, 4, 5, 6, fold enhancement
of iron absorption respectively.5 Approximately
50 to 80 percent of vitamin C originally present in
food can be lost during cooking. And hence should
consumed a raw form. Inhibitors of iron absorption
such as phytate and tannin. (Phytates are present
in wheat and other cereals). Tannin present in tea
and to a lesser extent in coffee, nuts and legumens).
hence should not be consumed with meals or
shortly after meals.

Approximately 50 to 80 percent of vitamin C originally
present in food can be lost during cooking. Vitamin C
content of food cooked and left standing decreases,
reheating reduce still further. In poor households food
is cooked once and reheated 12 hours apart, in which
case difficult to ensure that enough vitamin C is retained.
Best would be to consume raw fruits but caution for
hygienic care for GI infections. Common household
strategy, processing methods, germination, malting and
fermentation, increases vitamin C content and lower

tannin and phytic acid content or both, e.g. germination of
some cereals and legumes for 24 to 48 hours is associated
with appearance of 10 to 70 mg ascorbic acid/100 gm and
reduction of 8 to 25 percent in tannin, 25 to 35 percent in
phytic acid and bioavailability increases 2 folds.
Heme containing food like red-meat, fish and other
sea-food have highly absorbable iron and promotes
the absorption of the iron more than other less
bioavailable food sources. However, it is a very
small fraction of the total iron intake particularly
in persons from developing poor countries. Heme
iron is directly absorbed (2030% absorption). Its
bioavailability is little affected by the nature and
composition of the meal, like other associated foods
such as phytate, etc.
Approximate ascorbic acid content: Fruits and vegetables
vitamin C mg/100 g of food109,110
Fruits
Guava
326
Lemon fresh (juice)
3750
Orange fresh
46
Pineapple fresh
37
Mango fresh
42
Vegetables
Cabbage raw
5460
Cabbage boiled
15
Cauliflower raw
60 96
Cauliflower boiled
20
Potato raw
21
Potato boiled
1218
Sweet potato raw
2537
Sweet potato boiled
15
Spinach boiled
725
Tomato raw
2026
Turnip boiled
17
Nonvegetarian foods not only have a rich amount of

heme iron, but they enhance the absorption of the nonheme iron contained in the rest of the meal. However,
enhancing meat consumption is not practical by
the poor rural people from developing and religious
objections to the consumption of meat also pose a
problem.
Some breast milk substitutes particularly cows milk
is prone to cause gastrointestinal bleeding in infants
leading to IDA.
Increasing total consumption of habitual food in
young children (Mothers should include to feed 45
meals per day for young children.) so that their energy
needs are fully met and ensure that total iron intake
is high even though the percentage of iron absorbed
from each meal remains low.
Dietary modification process like germination

(sprouting of green grams) and intake of green leafy
vegetables are also helpful in prevention of IDA.
Promotion of low viscocity, nutrient dense food for
infants is useful. Germinating, malting, fermenting also
increases iron absorption by increasing the vitamin C
content and lowering tannin and phytic acid which
inhibits iron absorption from the gut. Germination
increases the bioavailability by almost 2 folds. Just
inclusion of guava fruit/citrous food with lunch and
dinner have shown to raise Hb level by 2.2 g/dL.110
For older children and adult, iron supplementation
can be done by cooking of the food in iron pots may
increase the iron content of a meal several fold. This is
especially true for soups containing vegetables. Frying
in iron pans does not increase the foods iron content.
Health program and nutrition education on dietary
diversification are useful strategies to improve iron
intake in intervention area.
Strategies for iron fortification: Basic approach to
prevention of IDA:
Food based strategies: The problem of IDA in children
largely disappeared in North America when foods
fortified with iron and other micronutrients became
available for children. In this group, the prevalence of
IDA has fallen from 21 percent in 1974 to 13 percent in
1994.
Nonfood based strategies: Food based strategies are
important for raising the iron status of populations. They
will not be enough to improve the iron status rapidly.
Current Approaches to Food Based

Fortification with Iron
Exclusive breastfeeding
Avoid bottle-feeding
Introducing of iron containing weaning foods from
6 months of age
Older children: Encourage diet containing iron
cereals wheat, ragi, jowar sprouted cereals, green
and leafy vegetables, jaggery, nonvegetarian food like
mutton, chicken, fish, egg and liver preparations.
Commercially prepared iron rich weaning foods is not
affordable to our poor patients
Increasing utilization of iron in poor communities
Increasing total consumption of habitual food so that
their energy needs are fully met (Increased by 2530
percent when the energy shortage was corrected)
Enhancing the bioavailability of iron by germinating,
malting, fermenting by almost 2 folds
Enhancer heme iron, vitamin C, meat, fish
Avoiding inhibitors of iron absorption like phytic acid,
phytates in plant based diets, tannin in tea and coffee.
Supplementation of Medicinal Iron

Supplementation with oral iron tablet (syrup) is the most
widely used approach to control global problem of iron
deficiency anemia. For the past 150 years or more, oral
ferrous sulphate syrups have been the primary strategy to
control IDA in infants and young children.3
1. Although pockets of infants and children remain at
risk, generally, the eradication of iron deficiency in
developed countries is recognized as a successful
public health accomplishment. This solution has not
worked in developing countries where commercially
purchased fortified foods are not affordable or are not
used.
2. However, adherence to the syrups is often limited
owing to a combination of their unpleasant metallic
after taste, the dark stain they leave on the childs teeth,
and abdominal discomfort.
In the developing world, there are three major
approaches available to address iron deficiency:
1. Dietary diversification so as to include foods rich in
absorbable iron.
2. Fortification of staple food items (such as wheat flour),
3. The provision of iron supplements.
Dietary or fortification strategies are not logistically
or economically feasible, supplementation of individuals
and groups at risk is an alternative strategy.
For the past 150 years or more, oral ferrous sulphate
syrups have been the primary strategy to control IDA in
infants and young children.
The earths crust contains 4.5% iron whereas the
human body contains a mere 0.005% of iron. Accordingly
iron overload, should be more of a problem rather than
iron deficiency. However, this is not so, because the form
of iron in the environment as well as food is insoluble
and difficult to assimilate. In early times the earth had
a reducing atmosphere and an abundance of ferrous
iron was available for incorporation into biological
molecules. Later with an increase in the atmospheric
oxygen, iron existed largely in its less available ferric
form and special devices had to be developed by lifeforms, for the acquisition of iron. Bacteria for example
synthesize and excrete high affinity chelating agents
that extract otherwise unavailable iron from the
surroundings environments. Roots of the plants also
secrete substances that augment iron absorption. In
the mammalian species, mucosal transferrin appears to
perform this function.
The body had been genetically designed to absorb
hemoglobin iron, as then human beings were hunters
and carnivorous. The progressive change in diet that
began 10,000 years ago, with the cultivation of grain and
vegetables led to replacement of highly available iron in
meat, by the small amounts of iron from cereal diet. This

explains the high prevalence of iron deficiency.
Despite the fact that iron is one of the most abundant
metals on the earth crust, iron deficiency is the most
prevalent deficiency in the world. PARADOX IS
POVERTY IN THE MIDST OF PLENTY.
It is useful for rapid treatment as well as for prophylaxis
and prevention of anemia can be targeted at high-risk
group of becoming iron deficient, such as pregnant women
adolescent girls. Preschool and school and children,
infants and captive audience such as school children or
plantation workers who can receive the supplements at
school or work. Problems encountered include side effect
of the drug and lack of motivation to continue the drug
for a minimum 3 to 4 months in patients who perceive
themselves not to be ill.
Pregnant Women
Pregnancy creates a larger demand for iron which is
needed for the development of the fetus and placenta and
to expand the womans blood volume. Iron also is lost
with blood lost during delivery. About 100 mg of iron are
needed to cover the iron requirement of the mother and
the fetus during pregnancy. Dietary absorption of iron is
reduced during the first trimester and morning sickness,
nausea, vomiting adds to the problem. In most of the
developing countries 25 to 30 percent of women have little
or no iron stores even before conception. Particularly in
pregnant teen age mothers the situation is farther critical.
Supplementation should be done primarily during the
second half of pregnancy. Pregnant women are a priority
group for iron supplementation. A number of programs
National Nutritional Anemia Program 1970, National
Nutritional Anemia Control Program (NNACP)111 1989
have been implemented and dosage was revised from
60 mg elemental iron to 100 mg and 500 mg folic acid per
tablet. Poor compliance due to side effects like nausea,
vomiting, pain in abdomen, constipation, loose motions,
etc. and lack of awareness regarding the real need for iron
during pregnancy and the importance of iron for their
health, for the unborn fetus and the newborn.
Adolescent Girls31-40
Why Concentrate on Adolescents Girls?
The greatly elevated iron requirement of pregnant
woman indicates need for prepregnancy reserve. Daily
requirement of iron of pregnant women are three times
as compared to the need of nonpregnant women and total
requirement of iron during pregnancy is about 1000 mg.
Though food based strategies are important for raising the

iron status of population they will not be enough for many
iron deficient women who become pregnant. Hence there
is a higher requirement of iron during adolescent period
and reproductive age and during lactation. In developing
countries 24 to 30 percent women have no iron reserve.
As poor iron store before conception is one of the cause of
IDA during pregnancy, there is need to raise iron stores of
women (adolescents) before they become pregnant. Iron
loss during menstruation is estimated to be 16 mg/kg/day
and basal requirement during this period in both male
and females estimated to be 44 mg/kg/day or total of 3 mg/
kg/day in female97 and hence need for supplementation of
iron in adolescent girls (1018 years) 100 mg of elemental
iron daily to all adolescent girls every year for 100 days.
Addition of 25 mg of vitamin C to iron folate tablet has
shown a higher Hb response as compared to iron folate
tablet alone in adolescent girls.34 The most common form
of iron in iron tablet used are ferrous sulfate (20% iron)
fumerate (33% iron) and gluconate (12% iron).
Iron Supplementation
In breastfed term infants 1 mg/kg/ day of oral iron in
single dose starting from 5th month of life will prevent
IDA at later age.
In preterm and LBW babies one may give 2 to 3 mg/
kg/day of oral iron and start it early, i.e. by 2nd and 3rd
months of age.
Iron tonic to infants is more important than multi
vitamin drops!
Iron supplementation can also be given to pregnant
women, school children, and other high-risk groups.
Community level: Fortification of staple foods like
cereals, grains, sugar or salt will be effective.Vitamin C
or meat increase the iron absorption. Salt fortification
gives an iron content of 1 mg/g of salt in preparation.
Common112 salt fortified with iron orthophosphate and
sodium hydrogen sulphate with ascorbic acid has been
found stable and effective in field trials in India.
Similarly for infants fortification of formula feeds and
cereals have been successful in developed country.
Fortification of foods with iron constitute the most
desirable, cost effective and sustainable methods of
preventing iron deficiency and is a long-term measure
for improving the iron status of the entire population.
Fortify a staple food that is consumed in significant
quantity regularly by most people. Widely consumed
condimentsalt, sugar, fish sauce, curry powder113 and
have all been successfully fortified with iron. In South
America both dried and liquid milk and milk products
like yogurt, fortified infant food have been fortified with
iron. Ferrous fumerate, ferrous gluconate, lactate and
ferrous sulfate, ferric orthophosphate, sodium acid
sulfate, orthophosphoric acid have been extensively

used for the fortification of wheat flour, bread and other
bakery products, corn-soya-milk preparation (CSM)
salt, sugar, fish sauce, rice, etc. Iron salt EDTA (ethylene
diamine tetra-acetate)112-117 has been successfully used
to fortify sugar/wheat flour in Guatemala115 (13 mg of
iron/100 mg sugar). A formula for double fortified salt,
salt fortified with iodine and iron has been developed
and has been found effective.112
Home Fortification with Sprinkles112-123

The idea of sprinkles was formulated in 1996, when a
group of consultants determined that the prevention of
childhood. IDA was a United Nations Childrens Fund
priority, yet available interventions (syrups and drops)
were not effectivesingle-dose sachets containing
micronutrients in a powdered form, which are easily
sprinkled onto any foods prepared in the household. This
would be a successful method to deliver iron and other
micronutrients to children at risk .
In sprinkles, the iron (ferrous fumarate) is encapsulated
within a thin lipid layer (soya-based hydrogenated lipid
layer) to prevent the iron from interacting with food.
There are minimal changes to the taste, color, or texture
of the food upon adding sprinkles. Other micronutrients
including zinc, iodine, vitamins C, D, and A, and folic
acid may be added to sprinkles sachets. Any homemade
food can be fortified with the single-dose sachets, hence
the term home fortification. Two formulations have
been developed, a nutritional anemia formulation and a
complete micronutrient formulation.
Encapsulation prevents the micronutrients from
oxidizing the food. No change in the color and taste, fixed
dose sachet (1545 mg).
Home fortification can be done by, parents, health
care giver and can be given as Intermittent Fe therapy
under supervision or can be integrated into existing health
program. Sprinkles is a novel approach and this can be
sprinkled on any complementary food at containing
micronutrients in a powder form, which are easily sprinkled
onto any foods prepared in the household. Sprinkles have
been shown to be efficacious in the treatment of anemia in
many developing countries.
Periodic de worming should be considered in endemic
areas.
Administration of one pediatric (small) tablet contain
ing 20 mg of iron and 100 ug of folic acid daily for 100
days every year has been recommended by National
Nutritional Anemia Control Program.Various contact
points like measles (9 months) and DPT booster (16
18 months) in ICDS scheme should be utilized for the
distribution of iron folate.
Control of Viral, Bacterial and

Parasitic Infections
Effective, timely curative care could diminish the adverse
nutritional consequences of viral and bacterial disease.
Although the number of infective episodes is unlikely to
be reduced, the curative services reduce the duration
and severity of infections, thereby improving iron status
even if there is no increase in dietary iron consumption.
Preschool children who have such would benefit from such
improvements in health care. It is vital to educate families
frequent infections about proper feeding practices during
and after periods of infective illness, as the young children
are often semistarved when ill , either because of their
poor appetite because of illness and myth of parents about
restrictions of diet during illness. Breastfeeding must be
confined as it helps preventing infections apart from its
direct effect on iron status. Along with encouragement
for taking timely immunizations, primary health care
measures like improvement in personal hygiene, environ
mental sanitation, provision of safe water go a long way in
improving the nutritional status and indirectly iron status
of the children. The main culprits in causing anemia due to
chronic blood loss are parasites hookworm ankylostoma
and necator and schitosoma. Heavy giardial infestation
can reduce iron absorption. Although routine deworming
is recommended in actual practice, it becomes costly,
when advised to entire community and reinfections
are common. As it does not improve hemoglobin [Hb]
value significantly, addition of supplemental iron or food
fortification with iron has better results for rise in (Hb)
status even when deworming is not done. However, in
individual cases with heavy infestation deworming and
use of cheap footwear advised to prevent reinfestation.
CONCLUSION
Iron deficiency anemia is a public health problem of high
magnitude. Iron deficiency is the most common malady
known to mankind since ages, though iron is available
in plenty in environment. In early fetal life and young
children, iron deficiency could impair mental (intellectual
potential) and motor development irreversibly. Low intake
of iron rich food is a very important cause for developing
anemia. Hemoglobin, MCV, RDW and serum ferritin
estimation can identify most IDA cases correctly. The
reasons for IDA are mainly faulty dietary habits especially
during growth period. Exclusive breastfeeding and proper
weaning thereafter 6 months age, and measures taken
during last few decades like iron supplementation food
fortification. Education have reduced IDA, atleast its
severe forms. Iron supplementation in high risk group is
another alternative. All it needs realization of magnitude

of problem of IDA will and open eyes to prevent, detect
and treat IDA in time!
Did you Know!

Thirty percent of world population suffers from IDA.
Out of which > 80 to 90 percent in developing countries.
< 70 to 90 percent Indian children at 1 to 2 years of
age, adolescents, pregnant women, lactating mothers
suffer from IDA.
Pica is a common symptom of IDA but can also be seen
in lead poisoning.
Always suspect IDA in patient with breath holding
spasm.
Exclusive breastfeeding protects a full term infant from
IDA till 6 months of age.
Preterms can develop IDA as early as 2 to 3 months.
IDA early in life can reduce the intellectual potential
and cognitive functions of the child permanently.
Adding vitamin C (fruit juices) or meat can increase
iron absorption by 3 to 4 folds.
b-thalassemia is a common differential diagnosis of
IDA. RDW helps in differentiation as it is normal in
thalassemia minor and increased in IDA.
Simple way to prove IDA is by iron therapeutic test.
HbA2 levels can be low in patients with thalassemia
minor if they have coexisting IDA. Repeat HbA2 after
iron therapy and will show increased values.
Cheapest and best form of iron is ferrous sulfate tablets.
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15
Megaloblastic Anemia
INTRODUCTION
Nutritional anemia is one problem that has haunted the
developing world for ages now and still continues to do
so. Nevertheless the modern zero figure trends and the
resultant increase in the followers of vegan diets has lead to
a surge in the number of anemia cases in the western world
also. As science progressed, a better insight was gained
into the causes, pathogenesis and molecular details of the
biology of the various kinds of anemias consequent to which
tremendous advances in the diagnostics and treatment of
the same have been made. Much has been discussed and
spoken about the iron deficiency anemia which was so far
considered to be synonymous to nutritional anemia but
as has been realized over the last few decades cobalamin
and folic acid deficiency is an equally big problem
challenging the practicing pediatricians and hematologist,
if not more. This chapter intends to provide an overview
of megaloblastic anemia in the pediatric population, both
of the nutritional and other varieties with emphasis on
clinical approach, laboratory diagnosis as well as treatment
and preventive aspects of the disorder.
HISTORY1-3
In 1855, Thomas Addison at Guys Hospital described a
lethal, idiopathic anemia that in 1872 was given the name
pernicious anemia by Biemer. For years it was believed
that pernicious anemia was a result of the positive acting
deleterious influence of an unknown infectious agent or
biological product which caused increased destruction
of the red blood cells. Ehrlich was amongst the first to
describe megaloblastic bone marrow in 1891. In the 1920s
two milestones discoveries were made that changed the
way in which the medical fraternity treats anemia today.
While Dr George Whipple (1), a pathologist along with his

colleagues at the Rochester university firmly established
the fact that properties of food affected blood formation,
a concepted not previously accepted, George Minot and
William Murphy (2) at Harvard Medical School developed
a special diet that could reverse the pathology of pernicious
anemia and cure patients. These milestone discoveries
lead another prominent investigator of the era WB Castle
(3) to put in decades of investigation into uncovering the
complex pathophysiological mechanisms underlying
pernicious anemia.
Pernicious anemia is another example where an
effective treatment was found before an understanding
of the underlying pathogenic processes was found. Even
before the therapy for megaloblastic anemia was described
in 1926, it was known that marrow morphology could
return to normal with reticulocytosis and correction of
anemia even in a previously documented megaloblastoid
marrow. The observation that despite feeding the same
liver extracts to various subjects the response to the
pernicious anemia was variable lead Castle to think that
some intrinsic factor must also influence the absorption
of the yet not discovered deficient nutrient and that it
could be corrected by feeding beef stimulated gastric juice
from healthy patients along with the liver extracts. Later
on the fact that pernicious anemia was caused by inability
of the stomach to absorb vitamin B12 because of atrophy of
its mucosal lining was realized. A major clinical leap was
when it was acknowledged that cobalamin and folic acid
deficiencies could manifest as neurological symptoms
like peripheral neuropathies, SCDSC and NTDs in the
unborn child of a folic acid mother. With advances in the
science, details of the absorption and transport of these
compounds in the body, their role in the DNA synthesis
Chapter-15 Megaloblastic Anemia 127

and other single carbon transfer reactions in the body
have been elucidated and this has also allowed clinicians
to arrive at diagnoses in conditions with megaloblastosis
where the nutrition seems to be adequate. Elevated levels
of methyl malonic acid and homocysteine levels could be
used as a means of diagnosing subclinical deficiencies of
vitamin B12 and folic acid, that these two correlated with
the incidence arteriosclerotic diseases, bowel and other
cancers and that correcting these levels could decrease the
incidence of such events was also an outcome of elaborate
insights into the metabolism and physiological role of the
concerned nutrients.
DEFINITIONS
Megaloblastic anemia is used to describe a group of
disorders characterized by a distinct morphological pattern
in the hematopoietic cells most often macrocytosis of the
red blood cells often accompanied by leukopenia and
thrombocytopenia. The prominent feature is a defective
DNA synthesis with minimally altered RNA synthesis and
protein synthesis leading to a state of unbalanced cell

growth and impaired cell division. These cells in a vain
attempt to divide increase their DNA contents by two to
four times and often get arrested in the S phase of the cell
cycle. A larger than normal immature nuclei with finely
particulate chromatin afloat in the mature cytoplasm of a
large cells having unimpaired RNA and protein synthesis
is the hallmark of megaloblastosis. Thus in a nutshell,
megaloblastosis results in a cell whose nuclear maturation
is arrested while its cytoplasmic maturation proceeds
normally independent of the nuclear events. Although
megaloblastic hematopoiesis commonly manifests as
anemia, it reflects a global defect in DNA synthesis which
affects all the proliferating cells of the body.
CAUSES OF MEGALOBLASTIC
ANEMIA (TABLE 1)
Although cobalamin and folate deficiency is amongst the
major causes of megaloblastic anemia, it is not the sole
Table 1 Causes of megaloblastic anemia*4

Cobalamin deficiency
Folate inhibitors: Antifolates (methotrexate, pyrimethamine,
sulfones, trimethoprime)
Nutritional cobalamin deficiency: Vegetarians, breastfed infants of Hereditary folate malabsorption (PCFT mutations)
mothers with pernicious anemia.
Abnormal intragastric events: Atrophic gastritis, hypochlorhydria, Damage to the ileal mucosa: Tropical and nontropical sprue,
PPI, H2 blockers
regional enteritis, infiltrative disorders of the small bowel
(lymphoma)
Loss/atrophy of gastric oxyntic cells: Total or partial gastrectomy,
Defective CSF transport
pernicious anemia, caustic damage
Insufficient pancreatic secretions: ZE syndrome
Inherited disorders of folate utilization: Methylenetetrahydrofolate
reductase deficiency, methionine synthase deficiency18,19
Usurping of luminal cobalamin: By bacterial overgrowth in cases of Other causes
blind loop syndrome, diverticulosis; infection by D latum
Defects in purine and pyrimidine synthesis
Disorders of ileal mucosa/Cobalamin-IF receptors: Ileal bypass,
Orotic aciduria
nontropical sprue, Crohns disease
Myelodysplasia and leukemia, HIV
CUBAM receptor defects: Imerslund-Grsbeck syndrome
Drug-induced
Drug effects: Metformin, neomycin
Congenital TCII deficiency
Thiamine responsive megaloblast anemia
Metabolic disorders (cells not able to use vit B12 ): CbIA to CbIG
Scurvy
disorders, nitrous oxide intoxication
Pyridoxine responsive anemia
Folate deficiency
Decreased dietary intake: Poverty, psychiatric illnesses, maternal
deficiency affecting fetus or infant, prolonged feeding of goats
milk
Increased requirements: Pregnancy, lactation, hemolysis,
hyperthyroidism, anticonvulsant therapy, Lesch-Nyhan
syndrome, prematurity, homocystinuria, psoriasis
*modified from ref no. 4

reason for a megaloblastic picture. Other conditions are
also enumerated in the Table 1.
COBALAMIN (VITAMIN B12)

Chemistry:5 Cobalamin, a member of the corrin family
has a structure described below in the Figure 1. A planar
corrin ring similar to heme, coordinates with a central
cobalt atom, with a 5, 6 dimethylbenzimidazole and
an upper axial ligand which varies in different biologic
and pharmacological cobalamins like cyano-, methyl-,
hydroxyl-, 5deoxyadenosylcobalamines. These axial
ligands are attached when the central Co is in its most
oxidized state, the cob(III) state. It can also exist in the
cob(II) and cob(I) states. These various forms confer a
distinct identity to the cobalamin while it participates in
the various one carbon metabolism reactions.
Nutrition:6-8 Cobalamin in the nature is produced only
by microorganisms and humans receive it solely from
diet. Certain bacteria and fungi produce this vitamin
in excess and form the major resources of cobalamin
for commercial purposes and therapy. Herbivores
(and humans) obtain their cobalamin from plants
contaminated with cobalamin-producing soil bacteria
found in the roots of legumes. For all practical purposes,
there is no uncontaminated plant source that could be
a source of vitamin B12. Nevertheless the colon of some
individuals contains cobalamin producing bacteria like
Klebsiella pneumoniae, which can be absorbed.
Animal protein especially parenchymal meat is a
major dietary source of vitamin B12 for non-vegetarians
(mcg/100 gm dry wt). Milk and milk products and eggs
contain 1 to 10 mcg/100 gm dry weight. While an average
non-vegetarian diet contains 57 mcg/day of cobalamin,
the average vegetarian consumes only 0.250.5 mcg/day
(Table 2).
Although heat does not influence the stability of
cobalamin, ascorbic acid readily changes the active forms
of cobalamin into inactive analogs. With the liver storing
1 mg of the total 45 mg of the adult stores and an obligatory
loss of 0.1 percent/day, it takes about 34 years to deplete
the stores even if the dietary cobalamin is abruptly
Table 2 Recommended daily allowance of vit B12

Recommended daily allowance (mcg)
Men
2.4
Nonpregnant women
2.4
Pregnant and
lactating women
2.6
Children 918 years
1.52
withdrawn. However a deficiency would take longer to

set in due to an efficient enterohepatic circulation which
accounts for a turn over of 510 mcg/day of cobalamin.
ABSORPTION AND TRANSPORT

OF VITAMIN B12
Cobalamin in the food is in the coenzyme form and
nonspecifically bound to protein. On reaching the
stomach, the low pH causes proteolysis and releases
the cobalamin which now preferentially binds to a high
affinity (>intrinsic factor) 150 kda cobalamin-binding
protein, R protein (a haptocorrin) from gastric juice and
saliva. The cobalamin-R protein (holo R protein) complex
along with IF.
Passes into the duodenum where the pancreatic
juices cleave the cobalamin from the complex. However
the IF does not undergo proteolysis and the cobalamin
is now transferred to this 45kDa glycoprotein secreted by
the oxyntic cells in the fundus and cardia of the stomach
in response to food ingestion by membrane associated
vesicular transport stimulated by vagal and hormonal
signals. IF is produced in an amount far access of that
required for absorption and only 24 mL of normal gastric
juice can correct cobalamin deficiency in adults lacking IF.
While R binder binds both active cobalamin and its inactive
analogs IF binds only the active forms. This property is
used in order to excrete the inactive analogs secreted in the
biliary secretions which are excreted along with R protein
while the active form attaches to IF and is reabsorbed thus
providing an efficient system of enterohepatic circulation
of cobalamin.
This stable cobalamin-IF complex now passes into
the jejunum and into the ileum where the IF through its
receptor binding site attaches to the receptors present on
the microvilli of the ileum. The functional IL cobalamin
receptors are composed of two proteins collectively
known as CUBAM-cubulin and amnionless.8 The cubulin
is the larger extracellular portion of this complex which is
anchored to the membrane by the smaller amnionless.10
These are very specific for the IF-cobalamin complex
and do not bind any of the components when presented
singly or in combination with the R protein. The human
ileum contains cubam receptors to bind 1 mg of IF bound
cobalamin. Once internalized into the enterocyte the
cubam is recycled back to the surface. The cobalamin is
now released from the IF in the lysosome and is attached to
the transcobalamin(II) either within the eneterocyte itself
or at the basal surface of the ileal enterocyte, while the IF
is degraded. Holo-TC appears in the portal circulation in
about 35 hours and reaches peak levels in about 8 hours.
Cobalamin when given in large doses can diffuse
passively through buccal, gastric and jejunal mucosa
and less than 1 percent of such orally administered drug
Fig. 1 Absorption and transport of cobalamin (Image9 Adopted from: Dr Joseph Mercola, Alexa Natural Health Website)
then appears in the circulation within few minutes. This

property has been utilized to treat patients with impaired
absorption with oral supplements instead of parenteral
therapy (Fig. 1).
In the blood the cobalamin is bound to three types of
proteins. Transcobalamin (TC) I, II and III.11,12 >90 percent
of recently absorbed cobalamin is bound to TCII which is
the specific transport proteins that delivers this important
nutrient to the tissues. The TCII-cobalamin complex is
rapidly cleared from the circulation in less than an hour as
it binds to the various cells with receptors for this complex
and is internalized. Major circulating form which is the
methyl form is never found free to in the plasma. The
major (70%) circulating form found in the plasma is that
bound to TCI which binds both active and inactive forms
and is largely considered to be a plasma-storage protein
for cobalamin. TCIII which is a asialoglycoprotein binds
all forms of cobalamin analogs with high affinity and
within minutes delivers them to the liver through the
asialoglycoprotein receptors present on the surface of
hepatic cells and from there into the bile for fecal excretion.
CELLULAR PROCESSING
The TCII-cobalamain complex is internalized13,14 via
conventional receptor mediated endocytosis and within
the lysosome, at the low pH the TC is cleaved off the
cobalamin and the cobalamin is transported into the
cytosol. Here it can have two fates. It either goes to the
mitochondria to participate in reactions involving methyl
malonyl-CoA or stays in the cytosol to be a part of the
methionine synthase complex (Fig. 2).
In the mitochondria, cob(I) alamin is converted to its
coenzyme form adenosyl cobalamin which along with
methylmalonyl-CoA mutase mediates transfer of a -CH
moiety to convert methylmalonyl CoA to succinyl-CoA
which can now take part in the Krebs TCA cycle and help
generate ATP.14-17
In the cytosol, cobalamin in its methylcobalamin form
acts as a coenzyme along with methionine synthase, a
complex enzyme requiring both folates and cobalamin
for carrying out one carbon metabolism reactions. First
a methyl group is transferred from 5-methyl-tetra
Fig. 2 Intracellular metabolism of cobalamin
hydrofolate to methionine synthasebound cob(I) alamin

to form methylcobalamin, followed by transfer of this
methyl group to homocysteine to form methionine and
regeneration of cob(I) alamin.14-17
During these reactions sometimes the cob(I) alamin
is spontaneously converted to the inactive form cob(II)
alamine which needs to be reduced back to the active form
cob(I) alamin before it can accept and transfer a methyl
group. This is carried out by the enzyme methionine
synthase reductase with the help of NADPH and SAM.
This enzyme is defective in people with cbIE mutations.
Intracellular reactions involving cobalamin: In vivo
substitutions include the replacement of hydroxocobalamin
or cyanocobalamin by a 5-deoxyadenosyl group attached by
a covalent bond, giving rise to adenosylcobalamin (AdoCbl).
Methylcobalamin (MeCbl) is the main form in plasma. In
vivo, 5-methyl-tetrahydrofolate readily donates its methyl
group to cob(I) alamin in a reaction involving methionine

synthase to form methylcobalamin. The approximate loci
for defects in cobalamin mutants, cblA to cblG, are shown.
MMCoA mutase, methylmalonyl-CoA mutase; SAH,
S-adenosylhomocysteine; SAM, S- adenosylmethionine
(Fig. 2).15
DEVELOPMENT OF COBALAMIN DEFICIENCY

Nutritional deficiency: People following vegetarian
diets can be either pure vegans who exclude all animal
products from their diets and need to be routinely
supplemented with cobalamin or they could be those
following lactovegetarian diets or lacto-ovo vegetarian
diets which incorporates milk and egg products into their
food also need external supplementation, even if they
are asymptomatic as they are too likely to suffer from
subclinical deficiencies.

Although severe cobalamin deficiency can often lead to
sterility, adverse pregnancy outcomes like preterm labor,
intrauterine growth retardation, neural tube defects and
recurrent miscarriages are also frequent manifestations of
undetected cobalamin deficiency in the potential young
mother.
There is a critical period in prenatal and early postnatal
neurodevelopment when sufficient folate and cobalamin
is required for the proper formation of neurologic circuits.
Any perturbation of neurodevelopment during this
period can give rise to subtle changes that can manifest
in behavioral abnormalities long after the folate and
cobalamin deficiency is reversed.
Cobalamin deficient mothers with low serum coba
lamin levels are not able to provide enough vit B12 stores to
their fetuses at birth neither are they able to compensate
for it when they breastfeed their child exclusively since
their breast milk cobalamin levels are also found to be
equally low, often below 362 pmol/L. In India the duration
of exclusive breastfeeding is longer than the western world
and hence the relevance of supplementing the mother
with B12 and folic acid supplements in order to prevent
deficiency in the infant cannot be emphasized less. The
maternal stores can exert a strong effect on the vit B12
stores of the infant for around 12 months.
Children of mothers who have been on macrobiotic
diets (nearly vegan with occasional serving of animal
protein in form of fish) are also at risk not only because
the cobalamin deficient mother is not able to provide the
child with enough cobalamin stores during her pregnancy
and lactation but she also tends to feed her child according
to the principles of macrobiotic diet. Elevated urinary
methylmalonic levels were found in 15 to 16 percent of
breastfed infants of vegetarian mothers who consumed
macrobiotic diets.18,19
Cobalamin deficient infants have also been found
to be born to mothers who are on apparently balanced
nonvegetarian diets highlighting the fact that pregnancy
places an additional stress on the mothers cobalamin
stores which needs to be corrected. This can negatively
affect their breastfed infants cobalamin status at 6 weeks;
indeed, over two-thirds of Norwegian infants of otherwise
healthy mothers had a metabolic profile consistent with
cobalamin deficiency, which reverted to normal after
cobalamin replenishment. This emphasizes that many
more breastfed infants may need cobalamin supplements
early in life than previously realized. Such studies raise new
questions as to whether the optimal intake of cobalamin in
women should be much higher than 2.4 mcg/day, and be
raised to 47 mcg/day.
The prevalence of cobalamin deficiency among older
children and adolescents is also high, ranging from
40 percent to 80 percent in various communities, because
of consuming monotonous diets low in animal-source

foods prepared by unaware parents or self-imposed by the
adolescent to keep up with the so called healthy vegan
diet trends and food fads. Low serum cobalamin levels
have also been found in adolescents infected with HIV
without having the frank immunodeficiency syndrome.
Treatment with HAART resulted in improved status in
these candidates.
Pernicious anemia:20-23 This lymphocyte mediate
destruction of the oxyntic cells of the stomach gives rise
to deficiency of the IF and constitutes one of the most
important causes of cobalamin deficiency in the adult
population. Autoantibodies are directed against the H+,
K+ ATPase of the parietal cells. Patients who lack IF after
gastric resection and those with genetic mutations yielding
defective or undetectable IF are not considered to have
pernicious anemia.
The annual incidence of pernicious anemia is
approximately 25 new cases per 100,000 persons older
than 40 years. Although the average age of onset is about
60 years, pernicious anemia dose not avidly comply with
the boundaries of age, race, or ethnic origin. Although a
genetic basis that predisposes one to develop pernicious
anemia has long been suspected, but neither the mode of
inheritance nor the initiating events or primary mechanism
is precisely understood. There is a positive family history
for about 30 percent of patients, among whom the risk for
familial pernicious anemia is 20 times as high as in the
general population.
Other autoimmune diseases, including Graves disease
(30%), Hashimoto thyroiditis (11%), vitiligo (8%), Addison
disease, idiopathic hypoparathyroidism, primary ovarian
failure, myasthenia gravis, type 1 diabetes mellitus, and
adult hypogammaglobulinemia have been found to have
significant associations with pernicious anemia.
Histologic features of stomach in pernicious anemia
compared to normal: The normal gastric mucosa (A) is
contrasted to that seen in pernicious anemia (B), in which
there is atrophy of gastric glands, intestinal metaplasia
with goblet cells, and loss of parietal cells (not visible at
this magnification) (Figs 3A and B).
Abnormal events in the small bowel: Insufficient or
inactivated pancreatic proteases as occurs in the ZollingerEllison syndrome, fail to cleave the cobalamin from the R
binder to allow it to bind to IF in order to get absorbed
through the ileal receptors which are highly specific for the
cobalamin-IF complex.
Bacterial overgrowth in the intestine as occurs during
bowel stasis in conditions like blind loop syndrome,
leads to usurpation of the cobalamin from the intestinal
lumen making less it available for absorption. This type of
deficiency has been corrected with a 710 days antibiotic
course which sterilizes the gut.

mutations (in 80% of cases) involving either the cubulin
(CUBN) or amnionless (AMN) genes that constitute the
functional IF-cobalamin receptor (i.e., cubam) resulting
in selective cobalamin malabsorption. Presentation is
commonly between ages of 310 years with hematological
and neurological manifestations with low serum cobala
min. Consequent to the role of cubam in the renal tubular
absorption of several other proteins, a persistent but
benign proteinuria is also found in Imerslund-Grsbeck
syndrome. Mutational analysis of gastric IF, CUBN and
AMN genes can give the diagnoses.
Nitrous oxide exposure: Nitrous oxide (N2O) by inacti
vating coenzyme forms of cobalamin by oxidizing the fully
reduced cob(I) alamin to cob(III) alamin causes a state
of functional intracellular cobalamin deficiency. First
identified in patients with tetanus who were given nitrous
oxide for up to 6 days, similar manifestations were also
found in persons exposed to nitrous oxide for open heart
surgery and through chronic exposure either accidental,
or occupational. These groups are considered to be at
high risk for developing megaloblastosis and cobalamindeficient neuromyelopathy. Megaloblastosis develops
within 24 hours and lasts less than 1 week after a single
exposure.
Inborn Errors of Cobalamin Metabolism20,21

B
Figs 3A and B (A) Histologic features of stomach in

normal mucosa; (B) Pernicious anemia24
Infestation by the fish tapeworm, Diphyllobothrium

latum, which avidly usurps cobalamin for growth, affects
around 3 percent of the population and such people can
develop frank cobalamin deficiency. Plerocercoids of this
parasite reach the human intestine when they consume
partially cooked or raw fish containing, where they
develop into adult worms in the jejunum in about 6 weeks,
growing to a length of 10 m, with up to 4000 proglottids;
when these worms lay eggs, the life cycle is repeated. Stool
examination showing the ova can give a diagnosis. This
followed by praziquantel (1020 mg/kg as a single dose
taken orally) which leads to expulsion of the worms and
cobalamin replenishment is curative.
Disorders of ileal IF-cobalamin receptors or mucosa:
Resection of only 12 feet of the distal ileum which has the
maximum density of the concerned receptors can cause
clinically significant cobalamin deficiency by reducing
the number of interactions between the IF-cobalamin
complex and its respective receptor.
Imerslund-Grsbeck syndrome25-28 is an autosomal
recessive disorder in children arising from biallelic
Inborn errors of cellular cobalamin metabolism can affect

synthesis of AdoCbl, synthesis of MeCbl, or synthesis of
both cobalamin coenzymes, depending on which step
in metabolism is affected. Essentially, defects that affect
AdoCbl synthesis or directly affect methylmalonyl-CoA
mutase result in isolated methylmalonic acidemia and
aciduria; defects affecting synthesis of MeCbl result in hy
perhomocysteinemia and homocystinuria; and defects re
sulting in deficiency of both cobalamin coenzymes results
in combined methylmalonic aciduria and homocysteine.
cblA: The cblA disorder is caused by mutations in the
MMAA gene on chromosome 4q31.1q31.2. It plays a role
in transfer of AdoCbl from cobalamin adenosyltransferase
to methylmalonylCoA mutase and in stabilization of
mutase-bound AdoCbl.
cblB: Caused by mutations in the MMAB gene on chro
mosome 12q24 encoding cobalamin adenosyltransferase,
it result in decreased synthesis of AdoCbl and therefore
decreased activity of the AdoCbl dependent enzyme
methylmalonyl CoA mutase.
Patients with the MUT disorder, caused by mutations
in the gene encoding methylmalonyl-CoA mutase itself
also have a similar clinical presentation although the
synthesis of AdoCbl is normal.
When compared to serum and urine MMA levels in
dietary cobalamin deficiency the levels here are very high.

Patients usually present in the first year of life, but late and
benign presentations along with silent carrier states of
these mutations are also known. Lethargy, failure to thrive,
hypotonia, recurrent vomiting and dehydration constitute
common presenting symptoms. Any stress including
infections and even dietary changes can precipitate fatal
metabolic acidotic crises.
cblC: This disorder with more than 500 documented
cases is the most common inborn error of cobalamin
metabolism is the most common inborn error of cobalamin
metabolism. Around 70 different types of mutations
affecting the MMACHC gene, which encodes a protein
that apparently plays a role as a cobalamin chaperone
and in removal of the upper axial ligand of exogenous
cobalamins are likely to be the cause of this disorder. It is
found that there is a problem not with the uptake but with
the retention of cobalamin in the fibroblasts from cblC
patients, perhaps because it does not become associated
with cobalamin-binding enzymes.
There is decreased synthesis of both AdoCbl and
MeCbl, and decreased activity of both cobalamindependent enzymes.
cblD: This disorder is caused by mutations in the
MMADHC gene, which encodes a gene of unknown
function. Affection of the N-terminal domain of the
MMADHC protein resulted in variant 2, while mutations
affecting its C terminal domain caused variant 1. Although
the exact defect is still to be found, it is suggested that the
MMADHC protein plays a role in partitioning of cobalamin
between the mitochondrial (methylmalonylCoA mutase)
and cytoplasmic (methionine synthase) compartments.
cblE: Mutations in the MTRR gene have been identified
in cblE patients locus on chromosome 5p15.3p15.2,
which encodes methionine synthase. Both the cblE and
cblG disorders show rapid improvement in biochemical
and neurological parameters when treated with intra
muscular OHCbl while such is not the case with most cblB
patients which respond poorly.
cblF: This disorder is the result of mutations in the
LMBRD1 gene on chromosome 6q13, which encodes a
lysosomal membrane protein containing 9 transmemb
rane domains which leads to inability to transfer cobala
min freed from transcobalamin in the lysosome across
the lysosomal membrane into the cytoplasm. Cells from
cblF patients accumulate large amounts of free cobalamin
within lysosomes, but there is a deficiency of both
cobalamin coenzyme derivatives and decreased activity of
methylmalonylCoA mutase and methionine synthase.
cblG: Mutations at the MTR locus have been identified
in cblG patients.
All the above disorders can present in various combi
nations as well.
Treatment of these disorders involves protein restric

tion, or feeding with formula deficient in valine, isoleucine,
methionine and threonine, to limit the levels of the amino
acids that are the major source of methylmalonylCoA
within cells. Supplementation with OHCbl or CNCbl may
be useful in cblA patients as well as some MUT and cblB
patients. Therapy with carnitine has been advocated,
as has treatment with lincomycin and metronidazole
to reduce generation of propionate (the precursor to
methylmalonylCoA) by gut bacteria. Even with treatment,
outcomes may be poor.
FOLATES
Chemistry:30,31 More than 100 compounds are known
which are together known as folates. Folic acid (pteroy
lmonoglutamate [PteGlu]) is the commercially available
parent compound. PteGlu consists of three basic compo
nents: a pteridine derivative, a p-aminobenzoic acid
residue, and an L-glutamic acid residue. This must be
first reduced at positions 7 and 8 to dihydrofolic acid
(H2PteGlu) and then to 5, 6, 7, 8-tetrahydrofolic acid
(THF; H4PteGlu), and one to six additional glutamic
acid residues must then be added by means of -peptide
bonds to the l-glutamate moiety (subscripted n in PteGlun
denotes polyglutamation) before it can play its part as a
coenzyme (Fig. 4). The major role of folate coenzymes is in
donation or acceptance of one-carbon units in numerous
reactions in amino acid and nucleotide metabolism.
Fig. 4 Folate structure29

Various substitutions in H4PteGlun occur at positions 5 or
10, or both; position 5 can be substituted by methyl (CH3),
formyl (CHO), or formimino (CHNH), and position 10
can be substituted by formyl or hydroxymethyl (CH2OH).
Positions 5 and 10 can be bridged by methylene (CH2) or
methenyl (CH=).
Nutrition: Vitamin B9 or folates are synthesized by
microorganisms and plants, including leafy vegetables
(spinach, lettuce, broccoli), beans, fruits (bananas,
melons, lemons), yeast, and mushrooms, and are also
found in animal meats.
Bioavailability of folates from various sources varies
greatly mostly as result of the following factors.
1. Food stability: The labile and susceptible reduced
natural folate is damaged by oxidative cleavage by
nitrates or light exposure and prolonged cooking/
boiling for over 30 minutes which can reduce the
bioavailabilty by 5080 percent. However folic acid
is much more stable. Similarly refrigeration of leafy
foods exposed to artificial fluorescent light in super
markets doubles the folate content and ascorbate
when consumed along with folates increases the
bioavailability.
2. Pureed foods allow easier access to the glutamate car
boxypeptidase II (also known as folate-polyglutamate
hydrolase), which converts folate polyglutamates to
simpler folate monoglutamates before absorption;
any perturbation of this enzyme by organic acids
(orange juice), sulfasalazine, or ethanol can preclude
absorption; conversely, folate-binding proteins in
human or cows milk can increase folate absorption for
infants and women.
3. Interference with jejunal absorption of folaes due to
intestinal disease.
4. Drugs that interfere with the proton-coupled folate
transporter (PCFT) can also compromise folate
absorption.
The recommended daily allowances of folate are as
follows (Table 3):
Table 3 Recommended daily allowance of folate
Recommended daily allowance
Adult men and nonpregnant
women
400 mcg
Pregnant women
600 mcg
Lactating women
500 mcg
Children 9-18 years
400 mcg
1-6 years
3.3 mcg/kg/day
Infants
3.6 mcg/kg/day
ABSORPTION AND TRANSPORT

First the dietary folate which is mainly in the polyglutamate
form is converted to folate monoglutamate form by glutamyl hydrolase at the enterocyte brush border.31,32
This is followed by their transport through the duodenal
and jejunal brush border by high-affinity membraneassociated, luminal surfacefacing proton-coupled folate
transporters (PCFT). At pH 5.5, they act most efficiently and
have equivalent affinity for transport of both physiologic
reduced folates and folic acid, but at pH 6.5, reduced
5-methyl-tetrahydrofolate is transported more efficiently.
PCFT being a folate-hydrogen symporter results in a net
translocation of positive charge along with every folate
molecule transported.
Within the enterocyte, after reduction to tetrahydro
folate and methylated before release into plasma as
5-methyl-tetrahydrofolate the efflux from the basolateral
membarane into the portal blood being aided by the
multidrug resistanceassociated protein 3 (MRP3). These
proteins with a low affinity but high capacity can be best
described to function as cellular sump pumps that eject
excess folates as well as antifolates out of cells. With the
help of MRP2, which mediates folate transport into the
bile, an efficient enterohepatic circulation is maintained
thereby allowing the body to retain folates.
Less than 5 percent of average folate requirement can
be derived from that produced by the intestinal bacteria
by absorption across the large intestine. However, this
fraction is largely used up by the colonocytes themselves
for purpose of nutrition.
At high pharmacological concentrations passive dif
fusion of folic acid is probably the primary mechanism of
intestinal mucosal folate. Peak folate levels in plasma are
achieved 1 to 2 hours after oral administration.
Unlike cobalamin, folates are not privileged with a
specific serum transport protein which enhances their
cellular uptake. In the plasma, one-third of the folate is free,
two-thirds is nonspecifically bound to serum proteins, and
a very small fraction binds high-affinity, hydrophilic 40kDa folate-binding proteins, which are structurally related
to hydrophobic (native) folate receptors. Specialized, highaffinity, glycosyl-phosphatidylinositol-anchored (mem
brane) folate receptor-, which takes up these folates at
physiologic concentrations found in serum and transfer
into the intracellular compartment of proliferating cells.
The folatefolate receptor complex is then endocytosed.
Acidification of the perinuclear endosomal compartment
to pH 6 cleaves the folate from folate receptor, thereby
releasing the folate to pass across the acidified endosome
into the cytoplasm by a trans-endosomal pH gradient,
mediated most often by the PCFT.33,34

Folate receptor- mediates the cellular uptake of
folates in proliferating normal and malignant cells
besides their transport across the placenta to the fetus,
into the brain, and in renal conservation of folates. While
receptors are expressed mostly in monocytes and
macrophages, receptors are found in abundance in
many kinds of malignant cells and these are now being
explored as potential diagnostic and therapeutic targets
for certain malignancies.
Placental Transport35
Fetal and newborn blood folate is invariably more
elevated than maternal blood folate which is proof
enough for existence of a placental mechanism for
preferential maternal-to-fetal folate transport. Transfer
receptors are abundant and polarized to the maternalfacing microvillous membrane of the syncytiotrophoblast
wherein they become the first to bind maternal folate
at physiologic concentrations and pH. For physiologic
transplacental folate transport a continued provision of
adequate dietary folate intake by the mother followed by
capture of maternal folate by placental folate receptors is
essential. This results in an intervillous blood concentration
that is three times that of maternal blood and subsequent
concentration gradient based transfer of the folate into the
fetal circulation. Inadequate intake of folate by the mother
thereby leads to reduction in maternal-to-fetal folate
transfer which in turn predisposes the embryo/fetus to
very serious developmental defects.
Folate Receptors in Embryonic and

Fetal Development36
Folate receptors- are among the earliest genes activated in
embryonic stem cells coinciding with the period when there
is the need for increased folate requirements to support DNA
synthesis during bursts of intense cell proliferation of initial
phases of organogenesis. They are abundantly expressed
in early stage neural tube cells and neural crest cells and
their experimental perturbation can lead to profound
abnormalities in neural tube closure and in heart, facial,
and eye development. A striking human correlate of such
experimental studies is the significant increase in blocking
autoantibodies against placental folate receptor- seen in
women with pregnancy complicated by neural tube defects.
Cerebral Folate Transport Across

the Choroid Plexus
As has already been mentioned folate receptor- and PCFT
are found in the basolateral membranes of the choroid
plexus. To maintain the normal cerebrospinal fluidto
blood-folate ratio in healthy humans of 3:1 the folate first

binds to the folate receptor- in the choroid plexus, and is
transported into the CSF with the assistance of the PCFT.
A syndrome of severe developmental regression in
early childhood associated with movement disturbances,
epilepsy, and leukodystrophy that is reversed by folinic
acid occurs due to cerebral folate deficiency consequent
to a mutation in folate receptor-, which perturbs folate
transport into the cerebrospinal fluid.
Similarly antifolate receptor- antibodies that can
prevent uptake of folate into the cerebrospinal fluid,
lead to either infantile acute cerebral folate deficiency
or one of two autism spectrum disorders (Rett syndrome
and infantile low-functioning autism with neurologic
abnormalities). High doses of oral folinic acid can lead
to partial or complete clinical recovery in 12 months by
normalizing CSF folate levels.
The role of PCFT in transport of folates across the
choroid plexus is supported by the fact that mutations in
PCFT result in hereditary folate malabsorption with low to
undetectable cerebrospinal fluid folate values.
Renal Retention of Folates (Cobalamin)

Once the folate reaches proximal tubule after filtration it is
bound to the folate receptor- in the brush border memb
ranes of these absorptive cells and is internalized rapidly
by folate receptor-mediated endocytosis followed by its
dissociation in the acidic environment of the lysosome. It
is then transported across basolateral membranes into the
blood, with recycling of apofolate receptor- back to the
luminal brush border membrane. Megalin, a large 550kDa membrane protein interacts found in renal proximal
epithelial cells interacts with cubulin and functions as
a multiligand receptor for a variety of macromolecules.
Beside it also specifically binds to and mediates endo
cytosis of TCII-cobalamin complexes as well as filtered
folate bound to soluble folate-binding proteins in kidney
proximal tubules.
Regulation of Folate Homeostasis37-39

Upregulation of cell surface folate receptor- in response
to low extracellular and intracellular folate concentrations
through transcriptional, translational, and post-transla
tional mechanisms allows it to bind all available folate and
thereby restore cellular folate homeostasis.
The basic molecular mechanism has now been deciphered. Intracellular deficiency of folates leads to accumu
lation of homocysteine which covalently binds to a protein
known as heterogeneous nuclear ribonucleoprotein-E1
(hnRNP-E1), which is already known to mediate the
translational upregulation of folate receptor-. Homo-

cysteinylation of hnRNP-E1 at specific cysteinecysteine
disulfide bonds leads to the unmasking of an underlying
messenger RNA (mRNA)-binding pocket for which folate
receptor- mRNA has a high affinity thereby triggering the
biosynthesis of folate receptors which ultimately results
in a net increase of cell surface folate receptors to bind
more available folate and thereby normalize cellular folate
levels.
Intracellular One-Carbon Metabolism

Polyglutamylation is important not only because it is the
folate form that can be retained within the cell but also
because, polyglutamylated folates are more efficient sub
strates for folate-dependent enzymes. In human eryth
rocytes, folate is accumulated at earlier stages within
the marrow by folate receptors;8 on maturation, more
than 90 percent of H4PteGlu(n) molecules interact with
hemoglobin, which, because of its high capacity, assists in
intracellular folate retention (Fig. 5).
Compartmentalization and Channeling

of Folate Metabolism
Folate metabolism and folate-dependent enzymes are
very strategically compartmentalized with a distribution
such that approximately 40 percent are in the mitochond

rial matrix, 50 percent in the cytoplasm, and 10 percent in
the nucleus.
After cellular uptake, 5-methyl-THF (which is the
major form that is transported intracellularly) it must
first be converted to THF via methionine synthase (in the
methylation cycle). This is because THF is the preferred
physiologic substrate for polylpolyglutamate synthase,
which adds multiple glutamate moieties to THF. Only
once this is accomplished the polyglutamylated form of
THF participate in one-carbon metabolism where it can
be converted to either 10-formyl-THFused in de novo
biosynthesis of purines, or to 5,10-methylene-THFused
for synthesis of thymidylate. Also 5, 10 -methylene-THF and
10-formyl-THF can be interconverted by intermediates.
The mitochondrial compartment contains its comple
ment of folate cofactors, and homologues of the major
cytosolic enzymes. Other one-carbon donors like serine,
glycine, dimethylglycine, and sarcosine also enter mito
chondria and ultimately generate formate that crosses
back into the cytoplasm. In the cytoplasm, C1-THF
synthase uses this mitochondria-derived formate with
THF to form 10-formyl-THF, which is required for the de
novo synthesis of purines; this enzyme can also catalyze the
interconversion of THF, 10-formyl-THF, 5, 10-methenyl-
Fig. 5 One carbon metabolism40 (Abbreviations: B2: Riboflavin; B6: Pyridoxal phosphate; B12: Cobalamin; DHF: Dihydrofolate; DHFR:
dihydrofolate reductase; DMG: Dimethylglycine; dTMP: Deoxythymidine 5-phosphate; dUMP: 2-deoxyuridin-5-phosphate; MS:
Methionine synthase; 5-MTHF: 5-methyltetrahydrofolate; MTHFR: Methylene tetrahydrofolate reductase; SAM: S-adenosylmethionine;
SAH: S-adenosylhomocysteine; SHMT: Serine hydroxymethyltransferase; THF: Tetrahydrofolate; TS: Thymidylate synthetase; UMFA:
Unmetabolized folic acid. Adopted from ref no. 40)

THF, and 5, 10-methylene-THF. Thus a continued delivery
of mitochondrial formate helps perpetuate cytoplasmic
one-carbon metabolism. Formation of 5, 10-methyleneTHF from serine (which is derived from glycolytic
intermediates) forms another major entry point of onecarbon units into cytoplasmic folate metabolism. After 5,
10-methylene-THF is converted to 5-methyl-THF by the
enzyme methylenetetrahydrofolate reductase, it can be
used in the methylation cycle that involves methylation of
homocysteine via methionine synthase to form methion
ine and tetrahydrofolate.
The methionine that is generated can be converted to
a methyl donor through its adenosylation to SAM which
in turn is a universal donor of methyl groups for critically
important biologic methylation reactions involving over
80 proteins, membrane phospholipids, the synthesis of
neurotransmitters.
5, 10-methylene-THF can be converted to 10-formylTHF, it can be used for de novo synthesis of purine
nucleotides for DNA and RNA or can also be used in the
thymidylate cycle via the enzyme thymidylate synthase to
generate thymidylate for DNA synthesis.
Methylfolate Trap41-45
The methylfolate trap is a normal physiological response
to impending methyl group deficiency resulting from a
very low supply of methionine which decreases cellular
S-adenosyl-methionine (SAM) thereby endangering im
portant methylation reactions, including those required to
maintain myelin. To protect against such catastrophy and
considering availability of SAM as its utmost priority the
cell behaves as explained as:
Decreased SAM causes the folate co-factors to be di
rected through the cycle involving 5-methyl-tetra
hydrofolate (5-methyl-THF) and methionine synthe
tase and away from the cycles that produce purines and
pyrimidines for DNA synthesis. This not only enhances
the remethylation of homocysteine to methionine and
SAM but by restricting DNA biosynthesis decrease
the requirement of methionine for protein synthesis
and with it cell, division thereby allowing the limited
methionine to be conserved for the vital methylation
reactions in the nerves, brain, and elsewhere.
Since in the absence of methionine homocysteine
cannot be formed which as discussed earlier is
essential to allow folate to be retained intracellularly,
there sets in a state of intracellular folate deficiency
which restricts the rate of mitosis in the cells and hence
decreases requirements of methionine further.
Vitamin B12 deficiency is mistakenly perceived as
methione deficiency by the cells, thus resulting in an
inappropriate response of downregulating the multi
plication of hematopoietic precursors and causing lethal

anemia. In these circumstances the methylation reactions
are also partly protected by the reduced rate of cell
division. Hence when only folic acid is administered in
cobalamin deficiency without simultaneous supplemen
tation of B12, cell division is induced and the subsequent
consumption of methionine in protein synthesis, impairs
methylation of myelin and precipitates or exacerbates
subacute combined degeneration (SCD).
The selective use of available folate to conserve
methionine, together with the ability of nerve tissue to
concentrate folate from the plasma, explains the absence
of SCD in folate deficiency.
Development of Folate Deficiency

Nutritional: The body stores of folate are adequate for
only about 4 months any additional stress that increase
folate requirements like illness, hemolysis, anorexia will
tip an individual who was chronically in a negative folate
balance to develop frank folate deficiency.
Socioeconomic status has a major impact as folate
deficiency often coexists with poverty, malnutrition, and
chronic bacterial, viral and parasitic infections. ignorance
about cooking practices like overheating food also contri
butes to the nutritional losses of folates.
In the economically well off countries food faddism,
alcoholism, or unbalanced slimming diets usually lead to
decreased folate intake in adolescents.
Pregnancy and infancy: Folate requirements (over 400
mcg/day) during pregnancy and lactation are increased
tremendously for growth of the fetus, placenta, breast,
and other maternal tissues. There is also increased urinary
loss of folate in pregnancy (about 14 mcg/day versus
approximately 4.2 mcg/day in nonpregnant women)
because of a lower renal threshold. Additional folate
during pregnancy is required to prevent both pregnancy
complications (pre-eclampsia, placental abruption or
infarctions, recurrent miscarriage) and poor pregnancy
outcomes (preterm delivery, NTDs, congenital heart
defects, and intrauterine growth retardation).
The rapidly proliferating tissues in children also have
an absolute requirement for exogenously supplied folate.
Although human milk can maintain folate balance in
breastfed infants, the breast milk content of folate is low
when the mothers folate status is poor.
Folates and neurodevelopment: All inborn errors
of folate metabolism, which result in reduced folate
availability to the developing brain, give rise to mental
retardation and related mental health problems. Since the
fetal brain is dependent on sufficient provision of maternal
folate during embryogenesis maternal folate deficiency
can compromise the delivery of folate to the developing

fetal brain, and depending on the degree of deficiency,
there could be a spectrum of neurologic abnormalities
ranging from full-blown NTDs to more subtle changes
that manifest in childhood as behavioral abnormalities.
Many studies have confirmed this theory and marked
improvement in pregnancy outcomes in form of reduced
incidences of NTDs as well as better neurocognitive
status in the offsprings of mothers who were adequately
supplemented with folate perinatally.
Folates and intrinsic hematologic disease: Because
folate is necessary for hematopoiesis, folate requirements
are increased when there is significant compensatory
erythropoiesis in response in hemolytic disorders, abnor
mal hematopoiesis, or infiltration by abnormal cells in
marrow. In fact folate deficiency developing in hemolytic
disorders can lead to an acute aplastic crisis and hence the
recommendation of routine prophylactic administration
of folate in all follow up cases of hemolytic anemias has
been laid down. An unexpected increase in transfusional
requirement or a fall in platelets can also suggest folate
deficiency.
Drugs and folates: Although trimethoprim and py
rimethamine bind to bacterial and parasitic dihydrofolate
reductase with much greater affinity than to human
dihydrofolate reductase, but patients with underlying
folate deficiency appear to be more susceptible to the
effects of these drugs. The megaloblastosis can be reversed
by folinic acid (5-formyl-tetrahydrofolate [5-formyl-THF];
leukovorin). Methotrexate binds with high affinity to human
dihydrofolate reductase and leads to trapping of folate as
a metabolically inert form (dihydrofolate). This leads to
a true depletion of THF within hours and consequently
to functional deficiency of 5, 10-methylene-THF and
reduced thymidylate synthesis. Although megaloblastosis
can develop rapidly, the toxic effects of methotrexate can
be avoided by rescue with 5-formyl-THF (leukovorin).
Sulfasalazine produces megaloblastosis in up to two-thirds
of patients taking full doses (over 2 g/day) by decreasing
absorption of folates and induction hemolytic anemia
(i.e. increased requirements). Anticonvulsants can induce
NTD, and guidelines have stressed the importance of
ensuring that pregnant women and children with epilepsy
be prescribed folates together with anticonvulsants. The
only caveat is to correct B12 deficiency before prescribing
long-term folates.
PATHOLOGY OF MEGALOBLASTIC ANEMIA

Hematological Manifestations46-48
Peripheral smear and bone marrow examination (Table 4):
Widening disparity in nuclear-cytoplasmic asynchrony as
a cobalamin- or folate-deficient cell divides, until the more
mature generations of daughter cells die in the marrow or
Table 4 Morphology49
Morphology in megaloblastosis from cobalamin and
folate deficiency
Peripheral smear
Increased mean corpuscular volume (MCV) with macroovalocytes (up to 14 mm), which is variously associated with
anisocytosis and poikilocytosis

Nuclear hypersegmentation of polymorphonuclear

neutrophils (PMNs) (one PMN with six lobes or 5% with five
lobes)
Thrombocytopenia (mild to moderate)
Leukoerythroblastic morphology (from extramedullary

hematopoiesis)
Bone marrow aspirate

General increase in cellutarity of all three major hemato
poietic elements

Abnormal erythropoiesisorthochromatic megaloblasts
Abnormal leukopoiesisgiant metamyelocytes and band

forms (pathognomonic), hypersegmented PMNs
Abnormal megakaryocytopoiesispseudohyperdiploidy
are arrested (as megaloblastic cells) at various stages of

the cell cycle is the hall mark. Although megaloblastosis
affects all proliferating cells including those of the
intestinal lumen, cervix, uterus, changes are most striking
in the blood and the bone marrow.
As the megaloblastic erythroid cells are prone to
programmed cell death, ineffective hematopoiesis extends
into long bones, and the bone marrow aspirate exhibits
trilineal hypercellularity, especially of the erythroid series.
This apparent exuberant cell proliferation seen within
the marrow with numerous mitotic figures is misleading
because these cells are actually proliferating very slowly.
Elevated LDH, increased bile pigments and iron are
outcomes of this ineffective erythropoiesis.
The mature erythrocytes are of various sizes with
higher mean corpuscular volumes (MCV). In fact increase
in (MCV) with macro-ovalocytes (up to 14 m) is one of
the earliest manifestations of megaloblastosis. Because
these cells have adequate hemoglobin, the central pallor,
which normally occupies about one-third of the cell, is
decreased. Poikilocytosis and anisocytosis are seen when
severe anemia is present. Cells containing remnants of
DNA (Howell-Jolly bodies), arginine-rich histone, and
nonhemoglobin iron (Cabot rings) may be observed.
Extramedullary megaloblastic hematopoiesis may give
rise to a leukoerythroblastic picture.
Nuclear hypersegmentation of DNA in PMNs is
found to be a strong and pretty consistent indicator of
megaloblastosis when associated with macro-ovalocytes.
In megaloblastosis greater than 5 percent PMNs with more

than five lobes or a single PMN with more than six lobes
supports the diagnosis and a formal lobe count/PMN (i.e.
lobe index) above 3.5 may be obtained.
Thrombocytopenia and neutropenia often accompany
severe anemia although they may be seen even in the
absence of anemia.
Erythroid hyperplasia reduces the myeloid-to-erythroid
ratio from 3:1 to 1:1. Proerythroblasts often do not exhibit
much abnormality except for a larger size but the later
precursors show many abnormalities. These megaloblasts
are not only larger but instead of having a densely packed
chromatin they have an open, finely stippled, reticular,
sieve-like pattern. The orthochromatic megaloblast, with
its hemoglobinized cytoplasm, continues to retain its
large sieve-like immature nucleus, in sharp contrast to the
clumped chromatin of orthochromatic normoblasts.80-90
percent of the potential progeny of proerythroblasts that
develop into later megaloblastic die in the bone marrow.
Effective scavenging dead or partially disintegrated
megaloblasts by the marrow macrophages forms the basis
for ineffective erythropoiesis (intramedullary hemolysis).
Leukopoiesis is hit as well. There is an absolute
increase in the myeloid precursors, which are large and
have similar sieve-like chromatin. Spectacular giant (20
30 m) metamyelocytes and band forms are often seen
and are pathognomonic for megaloblastosis. Their clinical
relevance lies in the fact that such giant metamyelocytes
and band forms are not seen in the megaloblastoid bone
marrow of leukemia and MDS. They may persist in the
marrow for 1014 days after the initiation of treatment for
megaloblastosis (Figs 6A to E).
Megaloblastosis50,51 when affects the rapidly prolifera
ting cells of the gastrointestinal tract leads to their atrophy
which in turn cause further malabsorption of cobalamin
and folate thereby fueling a vicious cycle wherein mega
loblastosis begets more megaloblastosis which can be
adequately interrupted by specific therapy with folates
and cobalamin.
process is a patchy demyelination affecting both the

brain and the spinal cord. It begins as a swelling of the
myelin sheath followed by its breakdown and eventual
axonal degeneration which is often followed by secondary
Wallerian degeneration of the long tracts. Lesions first
involve the dorsal columns in the thoracic segments
spreading contiguously to engulf the corticospinal tracts
and ultimately affecting the spinothalamic and spino
cerebellar tracts as well. Degeneration of the dorsal root
ganglia, celiac ganglia, the Meissner plexus, and the
Auerbach plexus also occurs. Demyelination may also
extend to the white matter of the brain. Whether the
peripheral neuropathy is caused by a distinct lesion or
results from spinal cord disease is still to be found.
Megaloblastosis versus Macrocytosis

The central pallor that normally occupies about one-third
of the normal red blood cell is decreased in macro-ovalocytes. This contrasts with the finding of thin macrocytes,
in which the central pallor is increased. This is because the
hemoglobinization in cobalamin and folate deficiency is
only increased as the cell now takes more time to mature
and hence the decrease in central pallor (Table 5).
Neurological Manifestations
Cobalamin deficiency can manifest as a myriad of

neurological defects. The basic underlying pathogenic
Figs 6A and B The peripheral smear (A) Hypersegmented polys;

(B) Macro-ovalocytes
CLINICAL FEATURES
History
History often reveals an exclusively breast fed infant born
to an apparently anemic mother who is either vegetarian
by choice or forced due to socioeconomic factors. The
infant would have gradually curtailed his activities and the
mother is unable to notice the gradually developing pallor
until it becomes severe enough that the child needs to be
taken to a doctor. Occasionally children may present with
shortness of breath and impending failure. Since this is a
chronically developing anemia such manifestations are
seen only when the hemoglobin falls below 5 gm/dL.
Gastrointestinal symptoms may predominate in some
including loss of appetite, weight loss, diarrhea, nausea,
vomiting, and glossitis aggravated by spicy foods.
The neurological symptomatology may vary from vague
complaints like decreased memory, lethargy, irritability,
mild degree of cognitive impairment to severe peripheral
neuropathies a subacute combined degeneration of the
spinal cord which is the most feared complication of this
nutritional deficiency. SCDSC may manifest as loss of
vibration sense, parestherias and weakness, all affecting
the lower limbs much more than the upper.
Further enquiry regarding parity of the mother, birth
history and dietary details as well as past illnesses and
surgeries, drug ingestions (antiepileptics, pyrimethamine),
worm infections and affection of other family members
may aid in coming to an etiology of the present condition.
Figs 6C to E Microscopic picture of megaloblastosis49 (C). Giant

metamyelocyte (Band form cell) Details from the cells in the
aspirate (D) compared with normal hematopoiesis at same
magnification (E)
Table 5 Macrocytosis versus megaloblastosis51

Macrocytosis without megaloblastosis
Reticulocytosis
Liver disease
Aplastic anemia
Myelodysplastic syndromes (especially 5q-)
Multiple myeloma
Hypoxemia
Smokers
Spurious increases in MCV without macro-ovalocytosis51
Cold agglutinin disease

Marked hyperglycemia
Leukocytosis
Older individuals
Physical Examination
Physical examination reveals different features in wellnourished patients and poorly nourished individuals. The
latter show evidence of significant weight loss or other
stigmata of multiple deficiencies due to broadspectrum
malabsorption. Angular cheilosis, bleeding mucous mem
branes, dermatitis, and chronic infections hint to associated
vitamin A, D, E, K deficiency with PEM. Various degrees of
pallor with lemon-tint icterus (i.e. a combination of pallor
and icterus best observed in fair-skinned individuals) are
common features of megaloblastosis.
The skin may be diffusely pigmented or have abnor
mal blotchy tanning. A macular hyperpigmentation41
with follicular accentuation may be observed in the axilla
and groin; hyperpigmentation can also involve the dorsal
acral distal interphalangeal joints with special emphasis
on pigmentation of the nail beds and skin creases. Unlike
Addisons disease there is no staining of the mucous
membranes. Premature graying, observed in light-and
dark-haired individuals, is reversible within 6 months of

cobalamin therapy. These pigmentation changes often
resolve within 2 months of cobalamin replacement.
Glossitis with a smooth (depapillated), beefy red tongue
with occasional ulceration of the lateral surface or gingival
hyperplasia are found on oral examination. Increased
jugular venous distention along with gallop, cardiomegaly
(with or without pericardial effusions), pulmonary basal
crepitations, pleural effusion, tender hepatomegaly, and
pedal edema should alert the clinician towards a cardiac
failure due to severe anemia. Very rarely nontender
hepatomegaly, but more often splenomegaly may hint
towards extrameduallary hematopoiesis (Table 6).
Also look for signs of associated hypo-or hyperthyroid
ism like neck swellings and loss of eyebrows, etc.
Anemia and neurological signs52-56 are found to be
inversely related. SCDSC can have all or few of the features
which include decreased vibration sense below the iliac
crests (mobile phone sign), loss of position sense in feet
and ataxia all due to affection of posterior spinal columns.
Weakness and progressive spasticity with increased
muscle tone, exaggerated deep tendon reflexes with
clonus, extensor plantar response, and in-coordinate
or scissor gait, which may progress to spastic paraplegia
indicate UMN type of lesion because of pyramidal tract
involvement. The involvement of peripheral nerves may
markedly modify these signs to include flaccidity and
the absence of deep tendon reflexes. A positive Romberg
sign as well a positive Lhermitte sign may be elicited.
Loss of sphincter and bowel control, altered cranial nerve
dysfunction with altered taste, smell, and visual acuity
or color perception, and optic neuritis are other rare but
proven manifestations of cobalamin deficiency.56
Data suggests that changes of SCDSC is a result of
decreased remethylation of homocystiene as a result of
Table 6 Clinical features of B12 and folate deficiency57
changes in the activity of AdoMet-dependent methyltransferase.
Subclinical Cobalamin Deficiency57-59

The issue of subclinical cobalamin deficiency has been
a semantic dilemma. Many persons present with subtle
symptoms including fatigue, cognitive changes, lower
quality-of-life measures, and subtle symptoms of neuro
p
athy that cannot be directly attributed to cobalamin
deficiency, despite the fact that these very symptoms
are often seen in symptomatic cobalamin deficiency;
often this triggers testing with a serum cobalamin test,
and a borderline result generates a new set of problems,
including the need to label this entity and thereby make
clinical decisions. The incidence of subclinical cobalamin
deficiency is found to be 10 times higher in the US
population than the classical overt type of megaloblastic
anemia. Demonstration of an increase in metabolites (i.e.
serum homocysteine and MMA test results), helps pick-up
many individuals having subclinical cobalamin deficiency,
provided they had no subtle cognitive abnormalities.
A cut-off value of 148 pmol/L (less than 200 pg/mL) is
consistent with 3 standard deviations (SDs), and will miss
about 3 to 5 percent of patients with clinical cobalamin
deficiency.
However, the literature does not provide the clinician
with set guidelines about how to manage the entity of
subclinical cobalamin deficiency, which is defined as
biochemical evidence for cobalamin deficiencyreflected
by a low cobalamin value (and increased MMA and
homocysteine) but without overt clinical manifestations.
Although some experts do not feel obliged to treat,
preferring to wait until there are overt symptoms, there
is another school that feels ethically bound to treat even
without overt clinical manifestations rather than allow
them to develop and make the patient suffer.
System
Manifestations
Hematologic
Pancytopenia with megaloblastic marrow
DIAGNOSTIC ISSUES AND INVESTIGATIONS
Cardiopulmonary
Congestive heart failure
Gastrointestinal
Beefy-red tongue and added stigmata of

broadspectrum malabsorption in folate
deficiency
Peripheral Smear and Bone Marrow Aspirate
Dermatologic
Melanin pigmentation and premature

graying
Genital
Cervical or uterine dysplasia
Reproductive
Infertility or sterility
Psychiatric
Depressed affect and cognitive dysfunction
Neuropsychiatric
Unique to cobalamin deficiency with

cerebral, myelopathic, or peripheral
neuropathic disturbances, including optic
and autonomic nerve dysfunction
Macro-ovalocytes, although not specific for megaloblastic

anemia are the hallmark of megaloblastosis. Similarly,
though the importance of MCV values in suspecting mega
loblastic anemia is immense only half of the patients with
MCVs greater than 105 fL may have vitamin deficiency.
Macrocytosis per se is not associated with megaloblastosis
in around 50 percent of the cases and a complete diagnosis
may be reached only after carrying out several other
additional tests.
The frequency of hypersegmented neutrophils
(5 percent with five lobes or 1 percent with six-lobed PMNs)
in patients with megaloblastic hematopoiesis is 98 percent

with the specificity of this finding being approximately 95
percent. Hypersegmented PMNs and macro-ovalocytosis,
together give results that are much more accurate with
a specificity of 96 percent to 98 percent, and the positive
predictive value of folate or cobalamin deficiency of about
94 percent.
Diagnostic features of a megaloblastoid marrow have
been mentioned in previous sections. A question now
being frequently raised is that whether a bone marrow
examination always necessary to make a diagnosis of
folate and cobalamin deficient megaloblastic anemia.
There are many schools of thought. With highly sensitive
serum tests for the specific diagnosis of cobalamin and
folate deficiency now available, it would be reasonable
to say that the urgency of the diagnosis should dictate the
need for a bone marrow. For example, an urgent bone
marrow aspirate examination showing megaloblastosis
for immediate diagnosis is indispensible in a case of florid
hematologic disease with or without neurologic disease
suggestive of cobalamin or folate deficiency. However, in
stable and non-urgent cases with characteristic peripheral
smear, or for a patient with a primary neuropsychiatric
presentation, proceeding with measurement of serum
levels of vitamins or metabolites without a bone marrow
aspiration is a reasonable option.
Masked Megaloblastosis60
Conditions wherein true cobalamin or folate deficiency
with anemia is not accompanied by classic findings of
megaloblastosis in the peripheral blood and bone marrow
constitute the phenomenon of masked megaloblastosis
any condition that compromises a cells capacity to carry
out hemoglobinization such as iron deficiency anemia
and thalassemia will simultaneously decrease the ten
dency to form megaloblastic cells. However certain
points can help unveil this occult megalblastosis. A
wide RBC distribution width (RDW) with a normal MCH
and/or MCV on the Coulter counter readout may reflect
megaloblastic anemia 9 or dimorphic anemia (macroovalocytes plus microcytic hypochromic RBCs). Since
hemoglobinization has got no business with the white
blood cells and their pecursors, these pathognomonic
findings (giant myelocytes and metamyelocytes, and
hypersegmented PMNs) remain unaltered and can be of
great help in suspecting an underlying folate or cobalamin
deficiency. The latter may persist for up to 2 weeks after
replacement with cobalamin or folate. Once masked
megaloblastosis has been recognized investigations to
rule out iron deficiency, anemia of chronic disease, or
hemoglobinopathies is indicated. Without correction of
the iron deficiency, cobalamin or folate will not elicit a
maximal therapeutic benefit. Conversely, treating with
iron alone would unmask the megaloblastosis.
Biochemical Evidence56,61
Serum levels of cobalamin: The sensitivity of cobalamin
concentration less than 200 pg/mL (or less than 148
pmol/L) exceeds 95 percent when the clinical spectrum
suggests and smear examination reveals megaloblastosis.
A serum cobalamin level of more than 300 pg/mL
predicts folate deficiency or another hematologic or
neurologic disease while 99 percent of patients with occult
deficiencies will have levels less than 300 pg/mL. In view of
lack of transparency related to these tests, poor validation,
and poor tracking of assay performance, if the clinical
picture is consistent with cobalamin deficiency, and the
serum cobalamin level is normal or borderline low, it is
entirely appropriate to treat as for a cobalamin deficiency.
Cobalamin deficiency can falsely raise serum folate by
20 to 30 percent via methyl-folate trapping. In patients
with megaloblastic anemia, the finding of a normal to
increased level of serum folate, along with a reduced
ratio of RBC to serum folate provides strong although an
indirect evidence of cobalamin deficiency (Table 7).
Serum folate levels: When negative folate balance
continues, hepatic folate stores are depleted in about
4 months. This leads to tissue folate deficiency, which
clinically correlates with a decrease in RBC folate (less
than 150 ng/mL) by the microbiologic assay.
Serum MMA and Homocysteine Level

Basis: Perturbation of methionine synthase activity by
cobalamin deficiency results in substrate (homocysteine)
buildup and elevated serum levels of homocysteine,
which can be measured by a sensitive assay. Additionally
cobalamin deficiency also affects the activity of methyl
malonyl-CoA mutase negatively, which leads to elevated
Table 7 Cobalamin levels and B12 deficiency56
Falsely low serum cobalamin in the absence of true56
cobalamin deficiency
Folate deficiency (one-third of patients)
Multiple myeloma
TCI deficiency
Megadose vitamin C therapy
Falsely raised cobalamin levels in the presence
of a true deficiency62
Cobalamin binders (TCI and II) increased (e.g.
myeloproliferative states, hepatomas, and fibrolamellar
hepatic tumors)
TCII-producing macrophages are activated (e.g.
autoimmune diseases, monoblastic leukemias and
lymphomas)
Release of cobalamin from hepatocytes (e.g. active liver
disease)
High serum anti-IF antibody titer

serum MMA levels. Thus homocysteine and MMA are
sensitive tests for cobalamin deficiency. Early manifes
tations of negative cobalamin balance are increased serum
methylmalonic acid (MMA) and total homocysteine
levels. This occurs when the total cobalamin in serum is
still in the low-normal range. Normal levels of MMA and
homocysteine rule out clinically significant cobalamin
deficiency with virtually 100 percent certainty.
Values: The normal value for serum homocysteine is
5.1 to 13.9 M and serum MMA is 73 to 271 nM, and in
general the higher the values, the more severe the clinical
abnormalities.9 However age-, creatinine-, gender-, diet-,
and race-dependent can cause the values to fluctuate over
a wide range.
Application: When cobalamin and/or folate defi
ciency is suspected strongly and the cobalamin levels
are suggestive but not definitive, then the MMA and
homocysteine tests are an excellent means to confirm
a clinical diagnosis. Patients with clinical cobalamin
deficiency usually have MMA values over 1000 nM and
homocysteine values that are over 25 M. The MMA and
homocysteine test results exceed cobalamin levels by
quite an amount when sensitivities are compared as they
increase much earlier and more consistently than the
drop in cobalamin levels.
Since running serum cobalamin and folate levels
compared with serum MMA and homocysteine levels
is more cost effective it is recommended to first use the

cheaper tests that can assist in the diagnosis of cobalamin
and folate deficiency (Table 8).
Tests to Assess Absorption and Transport

Schilling test: This test is rarely used these days since less time
consuming and less tedious ways of diagnosing pernicious
anemia are now available. However for historical purposes
the principle of this test is mentioned in brief. It is important
to remember that this test intends to define an etiology of
cobalamin deficiency already established by other tests and
not to diagnose cobalamin deficiency per se.
In the first part of the test, the patient is given radio
labeled vitamin B12 orally followed by an intramuscular
injection of unlabeled vitamin B12 given an hour later
which is only enough to temporarily saturate B12 receptors
in the liver with enough normal vitamin B12 to prevent
radioactive vitamin B12 binding in body tissues (especially
in the liver). Normally, the ingested radiolabeled vitamin
B12 will be absorbed into the body. Since the body already
has liver receptors for vitamin B12 saturated by the
injection, much of the ingested vitamin B12 will be excreted
in the urine.
A normal result shows at least 10 percent of the
radiolabeled vitamin B12 in the urine over the first 24
hours.
Table 8 Interpretation of serum levels62

Cobalamin*
(pg/mL)
Folate (ng/mL)
Provisional diagnosis
Proceed with metabolites?
>300
>4
Cobalamin or folate deficiency is unlikely
No
<200
>4
Consistent with cobalamin deficiency
No
200300
>4
Rule out cobalamin deficiency
Yes
>300
<2
Consistent with folate deficiency
No
<200
<2
Consistent with (1) combined cobalamin plus folate

deficiency or (2) isolated folate deficiency
Yes
>300
24
Consistent with (1) folate deficiency or (2) an anemia Yes

unrelated to vitamin deficiency
Test results on metabolites: serum methylmalonic acid and total homocysteine

Methylmalonic
acid (Normal,
70270 nM)
Total
homocysteine
(Normal, 514 mM)
Diagnosis
Increased
Increased
Cobalamin deficiency confirmed; folate deficiency still possible (i.e. combined

cobalamin plus folate deficiency possible)
Normal
Increased
Folate deficiency is likely
Normal
Normal
Cobalamin and folate deficiency is excluded
*Table adopted from ref no. 62

In patients with pernicious anemia or with deficiency
due to impaired absorption, less than 10 percent of the
radiolabeled vitamin B12 is detected.
If an abnormality is found, i.e. the B12 in the urine is
only present in low levels, then in the second part the
test is repeated, with additional oral intrinsic factor.
A normal urine collection shows a lack of intrinsic
factor production, i.e. pernicious anemia.
A low result on the second test also implies other
causes of malabsorption, including infestation with D
latum or giardia, celiac disease, Whipples disease, etc.
Singlesample stool excretion test: Labeled cobalamin
was fed with a nonabsorbable dye together with nonab
sorbable chromium chloride (Cr51). A sample of such
stained stool was counted for Cr51 and Co57 and the
ratio of the counts compared with that of the sample that
was fed. Normally 3688 percent of the dose should be
absorbed. This test is not readily available.
Miscellaneous
Increase LDH, serum bilirubin and serum iron levels
reflect ineffective erythropoiesis-non-specific.
Serum lipid, cholesterol and immunoglobins may be
decreased-non-specific.
Increased serum gastrin and pepsinogen levels.
Antibodies to IF in the serum is highly specific and
indicates either present or imminent cobalamin
deficiency.
Serum transcobalamin II levels: As an early marker
of cobalamin homeostasis, as a surrogate for the
Schilling test, or to diagnose cobalamin deficiency in
lieu of serum cobalamin values is still in the process of
validation.
Positive Therapeutic Response63-66

Clinical, hematological and biochemical response to
therapy with cobalamin and folic acid is another way to
diagnose the deficiency in retrospect. A single injection
of cyanocobalamin is given and disappearance of
megaloblastoid changes in the bone marrow is looked for
in the next 48 hours besides two of the following, in order
to call the test positive (Fig. 7).
50 percent decrease in serum iron or LDH within 48
hours.
Increase in retic count 5 to 10 days after treatment.
Correction of neutropenia and thrombocytopenia over
a period of 2 weeks.
Once reticulocytosis subsides MCV is decreased by 5 fL
or more.
Plasma MMA and homocysteine in 2 weeks.
Correction of anemia of 2 to 4 weeks.
Fig. 7 Therapeutic response
Decrease in the neutrophil lobe count to normal over a

4 weeks period.
Accelerated turnover of normal DNA in erythroid
precursors also increases serum rate level, peaking by the
fourth day along with increased cellular phosphate uptake
for nucleotide synthesis. These together may precipitate
an attack of gout if the patient has a gouty predisposition.
If by the end of the third week, the RBC count is not
above 3 106/mm3 additional causes of underlying
iron deficiency, hemoglobinopathy, chronic disease, or
hypothyroidism should be considered.
TREATMENT OF MEGALOBLASTOSIS67-74
Principles
Routinely, treatment with full doses of parenteral
cobalamin (1 mg/day) and oral folate (15 mg)
before knowledge of the type of vitamin deficiency
is established should be reserved for the severely ill
patient.
Patients with vitamin B12 deficiency despite a normal
absorption, such as vegetarians and vegans, only
need a daily supplement in the form of a vitamin pill
containing at least 6 g of vitamin B12.
Patients with an irreversible cause of vitamin B12
deficiency are destined to lifelong treatment with a
pharmacological dose of vitamin B12.
Severe deficiency: When a patient of suspected mega
loblastic anemia presents in failure either due to anemia
itself, due to sodium retention or due to myocardial
hypoxia the treatment includes oxygen administration
with slow transfusion of packed cells under cover of
diuretics to avoid disastrous conditions of fluid overload.
Giving high initial doses of vitamin B12 can cause severe
metabolic disturbances like hypokalemia by shifting

extracellular potassium intracellularly in response to
the sudden increase in the cell replication. This is also
exaggerated further by the delay in renal potassium
retention. A clinician should anticipate such complications
and keep a watch on the potassium levels besides starting
prophylactic potassium supplements in such cases. Hence
it is recommended to give small doses of 10 g (0.2 g/kg for
severely deficient children) CNbl subcutaneously for first
2 days which should suffice to normalize serum LDH as
well as iron levels besides inducing reticulocytosis within
approximately a week. However, more is needed before
serum MMA and homocysteine levels are normalized and
body stores are replenished.
Conventional therapy:75-78 In a stable child it is advisable
to collect samples of bone marrow aspirate, those for
serum folate and cobalamin levels. Conventional therapy
includes once daily injection 1000 g for a week which is
succeeded by 100 g of cyanocobalamin injection for a
month and then monthly injections.
Different forms of vitamin B12 can be used, including
cyano-, hydroxy-, and methylcobalamin.
Hydroxycobalamin may have advantages due to a
slower metabolism however, the depot preparation of
cyanocobalamin (cyanocobalamin-tannin complex sus
pended in a sesame oil-aluminium monostearate gel) is
metabolized even slower than hydroxycobalamin.
All inborn errors of cobalamin metabolism adequately
justify use of parenteral therapy with cobalamin. There
is no major advantage of other preparations over generic
cyanocobalamin. Oral 2 mg cobalamin tablets consumed
daily is found to be equivalent to traditional monthly
parenteral treatment with 1 mg of intramuscular/subcu
taneous cobalamin among those requiring long-term
cobalamin as at such high doses cobalamin is absorbed
passively across the mucous membranes of oral cavity and
stomach. This option is especially helpful in patients in whom
parenteral therapy becomes less feasible due to refusal for
daily injection, those with coagulation disorders and in them
cobalamin (12 mg/day as tablets) can be recommended
despite cobalamin malabsorption. Meals can decrease the
bioavailability of cobalamin by 40 percent and taking the
same doses empty stomach decreases the losses in stool.
Certain points should be emphasized when initiating
treatment with vitamin B12. Once vitamin B12 has been
administered, the increase in red cell production will
increase the demand on iron stores and, therefore, it
is important to monitorand correctany signs of iron
deficiency. A drop in plasma folate after initiation of
vitamin B12 treatment is a sign of unmasking of hitherto
occult folate deficiency.
Even when malabsorption is a problem oral folate
(folic acid) at doses of 1 to 5 mg/day results in adequate
absorption. Therapy should be continued until complete
hematologic recovery is documented although if the

underlying etiology for the folate deficiency is not corrected
a lifelong folic acid supplemented is also warranted for.
Folinic acid (i.e. 5-formyl-THF [leukovorin]) should be
reserved only for rescue protocols involving antifolates
(methotrexate or trimethoprim-sulfamethoxazole), for
5-fluorouracil modulation protocols, after nitrous oxide
toxicity, or in pediatric cases involving cerebral folate
deficiency or inborn errors of folate metabolism.
Prophylaxis
Prophylaxis with Cobalamin
5 to 10 mcg for nutritional causes and 1000 mcg/day for
problems of malabsorption
Infants on specialized diets
Premature infants
Infants of mothers with pernicious anemia
Infants and children of mothers with nutritional
cobalamin deficiency
Vegetarianism and poverty-imposed near-vegetari
anism
Total gastrectomy.
Prophylaxis with Folic Acid

4 g/day periconceptionally
All women contemplating pregnancy (at least 400
mcg/day)
Pregnancy and lactation, premature infants
Mothers at risk for delivery of infants with neural tube
defects
Hemolytic anemias/hyperproliferative hematologic
states
Patients with rheumatoid arthritis or psoriasis on
therapy with methotrexate
Patients on antiepileptic drugs
Patients with ulcerative colitis.
Thiamine-responsive Megaloblastic
Anemia Syndrome79
It is caused by mutations in SLC19A2, encoding a thiamine
transporter protein. It is usually associated with diabetes
mellitus, anemia and deafness. With an onset generally
seen during infancy or at early childhood and most of
the thiamine-responsive megaloblastic anemia (TRMA)
patients are originated from consanguineous families
and is thus an autosomal recessive disease whereby
active thiamine uptake into cells is disturbed. Thus, at
physiological concentrations (food as the only source),
thiamine is not transported normally and intracellular
thiamine deficiency leads to decreased activity of enzymes

associated with thiamine pyrophosphate. The role of
thiamine in DNA metabolism and heme synthesis explains
the megaloblastic anemia. Thrombocytopenia has been
less commonly reported in TRMA patients. The rarity of
leukopenia is in these patients is probably accounted for
by the different needs of the hematopoietic progenitor
cells to the intracellular thiamine. Diabetes mellitus in
TRMA patients is a consistent finding and is most likely
secondary to impairment of islet cell function by the
intracellular thiamine deficiency.
While the costs for health care delivery move farther
and farther out of the reach of the common man, and
the ongoing debate on ways to reduce these costs, few
instances in internal medicine and hematology yield
more satisfying dividends than diagnosing and treating
cobalamin and folate deficiency using generic vitamins
that are dirt-cheapcosting only one or two cents a
day. These conditions are devastating when undiagnosed
or misdiagnosed or when cobalamin deficiency is treated
with folate alone. Recognition of various populations at risk
and the clinical scenarios in which folate and cobalamin
deficiency are likely to be present, and the availability of
sensitive and specific tests, should reduce uncertainty in
diagnosis.
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16
Anemia of
Chronic Disease
Anemia of chronic disease (ACD), the second most prevalent anemia after anemia caused by iron deficiency, occurs in patients
with acute or chronic immune activation. The condition has thus been termed anemia of inflammation.1 ACD is an anemia of
underproduction that usually is normocytic, normochromic, and relatively mild, with a hemoglobin level greater than 10 g/L.
However, the anemia can be severe, and the mean corpuscular volume may be reduced. Hypochromia (mean corpuscular hemoglobin
concentration, 26 to 32 g/dL) is more common than microcytosis.
The most frequent conditions associated with anemia of

chronic disease are listed in Table 1.
ANEMIA
Microcytosis in ACD is usually not as striking as that
commonly associated with iron deficiency anemia;
values for MCV <72 fL are rare. Another distinction
from iron deficiency is that hypochromia typically
precedes microcytosis in ACD but typically follows
the development of microcytosis in iron deficiency.2
The hematocrit usually is maintained between 0.25
and 0.40, but significantly lower values are observed in
20 to 30 percent of patients.2,3
The percentage of reticulocytes is normal or
reduced; although on rare occasions, it may be slightly
increased.
Red cell distribution width may be normal initially but
is typically elevated to a moderate degree, and generally
does not help in distinguishing iron deficiency and ACD.
The degree of anemia is proportional to the severity of
the underlying disease. The severity of the anemia and
the activity of rheumatoid arthritis are judged by fever,
severity of joint swelling and inflammation, and the erythrocyte sedimentation rate (ESR). In patients with malignant disease, anemia is more severe when metastases are
widespread than when the disease is localized. Serum
iron concentration and total iron binding capacity (TIBC)
is decreased. Transferrin saturation is subnormal.2
Table 1 Causes of anemia of chronic disease

Chronic infections
Tuberculosis
Pulmonary infections
Subacute bacterial endocarditis
Pelvic inflammatory disease
Osteomyelitis
Chronic urinary tract infections
Chronic fungal disease
Human immunodeficiency virus infection
Chronic noninfectious inflammations
Rheumatic fever
Severe trauma
Thermal injury
Malignant diseases
Lymphoma
Leukemia
Multiple myeloma
Autoimmune
Rheumatoid arthritis
Systemic lupus erythematosus
Vasculitis
Miscellaneous
Chronic renal disease
Chronic liver disease
Endocrine disorders
Graft rejection

The abbreviation sTfR/log ferritin denotes the ratio of
the concentration of soluble transferring receptor to the
log of the serum ferritin level in conventional units.
In patients with ACD, however, the serum ferritin level
indicative of adequate reticuloendothelial iron stores
requires upward adjustment. Serum ferritin values usually
increase in patients with inflammatory diseases and
extreme elevations of serum ferritin may be a nonspecific
indicator of significant underlying disease.4 When iron
deficiency coexists, the serum ferritin level falls but do not
reach values as low as those found in uncomplicated iron
deficiency. A patient with chronic inflammatory disease
and a serum ferritin <30 g/L is certainly iron-deficient,
and a patient with a serum ferritin >200 g/L is certainly
not iron-deficient. Examination of a Prussian bluestained
marrow specimen can confirm the ferritin status. Flow
chart 1 shows differences between anemia due to iron
deficiency from anemia of chronic disease.
A determination of the levels of soluble transferrin
receptors by means of commercially available assays
can be helpful for differentiating between patients with
anemia of chronic disease alone (with either normal or
high ferritin levels and low levels of soluble transferring
receptors) and patients with anemia of chronic disease
with accompanying iron deficiency (with low ferritin levels
and high levels of soluble transferrin receptors).5
The concentration of free protoporphyrin in the
erythrocytes (FEP) tends to be elevated in patients with
Flow chart 1 Algorithm for the differential diagnosis among iron
deficiency anemia, anemia of chronic disease, and anemia of
chronic disease with iron deficiency
ACD.6 However, FEP increases more slowly in anemia of

chronic disorders than it does in iron deficiency.
PATHOGENESIS
The pathogenesis of anemia of chronic disease has been
attributed to following:
Shortened erythrocyte survival
Impaired marrow response
Disturbance in iron metabolism.
The shortening of the erythrocyte survival creates an
increased demand for red cell production on the marrow
and the marrow is unable to respond fully because of a
combination of a blunted erythropoietin response, an
inadequate progenitor response to erythropoietin, and
limited iron availability.
ACD is one manifestation of the systemic response to
immunologic or inflammatory stress, which results in the
production of various cytokines: the cytokines most often
implicated in the pathogenesis of ACD are TNF7, IL-18, IL69, and the interferon,10,11 concentrations of which have
been reported to be increased in the serum or plasma of
patients with disorders associated with ACD.11,12
Shortened Erythrocyte Survival

The rate of survival of cells from patients with arthritis,
when transfused into normal subjects, is normal, and
the survival of red cells from normal individuals in the
circulation of patients with arthritis is less than the normal
rate. Therefore, shortened red cell survival in patients
with chronic inflammatory disorders is attributed to an
extracorpuscular mechanism. IL-1 levels and shortened
red cell survival are correlated in anemia patients with
rheumatoid arthritis, and mice that become anemic after
exposure to TNF in vivo also exhibit a shortened red cell
survival.
Neocytolysis, a selective hemolysis of newly formed
erythrocytes associated with erythropoietin deficiency,
can also contribute to shortened red blood cell (RBC)
survival in ACD.
IMPAIRED MARROW RESPONSE

The bone marrow which normally should compensate for
decreased erythrocyte survival does not show increased
marrow response.
The three proposed possible mechanisms are:
1. Inappropriately low erythropoietin secretion
2. Diminished marrow response to erythropoietin
3. Iron-limited erythropoiesis.
The erythropoietin response to anemia is blunted. This
impaired erythropoietin response is cytokine-mediated.
IL-1, TNF-, and transforming growth factor- inhibit
Chapter-16 Anemia of Chronic Disease 151

production of erythropoietin by various hepatoma cell
lines. This reduces the tissue oxygen consumption so
that normal oxygenation is maintained despite reduced
hemoglobin levels. There is also increased erythrocyte
2, 3-diphosphoglycerate levels along with decreased
hemoglobin oxygen affinity
TNF, IL-1, and interferon have all been reported to
inhibit erythropoiesis in vivo and in vitro. TNF induces IL-1
production by macrophages, IL-1 induces interferon-
production by T-lymphocytes, and interferon- can
exhibit positive or negative feedback on production of IL-1
and TNF.
Treatment with recombinant human erythropoietin
can correct ACD in many cases.
ABNORMAL IRON METABOLISM

A hallmark of anemia of chronic disease is the develop
ment of disturbances of iron homeostasis, with inc
reased uptake and retention of iron within cells of the
reticuloendothelial system. This leads to a diversion of iron
from the circulation into storage sites of the reticuloendo
thelial system, subsequent on-restricted erythropoiesis.
It has been proposed that lack of iron for erythropoiesis
contributes to the inadequate marrow response in ACD.
Evidence of a functional iron deficiency in this syndrome
includes erythrocyte microcytosis, increased FEP, reduced
transferrin saturation, and decreased marrow sideroblasts.
The major contributor to hypoferremia in patients
with ACD is probably a shift of iron from a transferrinbound, available state to a ferritin-incorporated
storage state. Iron absorption appears to be normal,
but iron tends to remain in the mucosal cell and in
hepatocytes and there is a limited availability of iron
for erythroid progenitor cells. Macrophages, the major
site from which iron is obtained for erythropoiesis, also
exhibit increased iron storage.
Macrophage iron becomes available for erythropoiesis
through two mobilization pathways:
Rapid pathway, associated with almost immediate
return of the iron retrieved from senescent red cells;
Slower pathway, consisting of iron mobilized from
storage13
In ACD, the slower pathway predominates, and
iron tends to accumulate. The acquisition of iron by
macrophages most prominently takes place through
erythrophagocytosis and the transmembrane import of
ferrous iron by the protein divalent metal transporter 1
(DMT1). Recent studies of the role of the liver-produced
antimicrobial peptide hepcidin strongly suggest that it
is the dominant factor in this process.14
Hepcidin is an acute-phase-reacting peptide, which
is induced by IL-6, lipopolysaccharides and inhibited
by TNF-. Hepcidin appears to promote macrophage

iron retention by causing internalization of the iron
transport protein ferroportin.15 Also causes decreased
duodenal absorption of iron. Under certain conditions,
hepcidin may be associated with impaired erythroid
colony formation in vitro.16 The mechanisms leading
to anemia in anemia of chronic disease are given in
Figure 1.
Apoferritin is normally synthesized in response to
increased intracellular iron concentration.17 It has
been suggested that excess apoferritin is made in infla
mmatory and malignant conditions, and the surplus
binds a larger-than-usual amount of iron entering the
cell.18 In effect, such a mechanism would divert iron
from the rapid to the slow pathway of iron release.
Rodents injected with recombinant TNF developed a
hypoferremic anemia associated with impaired storage
iron release and incorporation into erythrocytes.19
IL-1 increases translation of ferritin messenger RNA
and this additional ferritin act as a trap for iron that might
otherwise be available for erythropoiesis.20

Nitric oxide, which is a common mediator of cytokine
effects, has similar effects on ferritin expression.21

Lactoferrin is a transferring like protein in neutrophilspecific granules,22 released from the neutrophil during
phagocytosis or stimulation by IL-1.23 Lactoferrin-bound
iron is not immediately available for erythropoiesis as it
transfers iron from its transferrin-bound, circulating state
to a storage state.
In Panel A, the invasion of microorganisms, the
emergence of malignant cells, or autoimmune dysregu
lation leads to activation of T cells (CD3+) and monocytes.
These cells induce immune effector mechanisms, thereby
producing cytokines such as interferon- (from T cells)
and tumor necrosis factor-a (TNF-), interleukin-1,
interleukin-6, and interleukin-10 (from monocytes or
macrophages).
In Panel B, interleukin-6 and lipopolysaccharide
stimulate the hepatic expression of the acute-phase
protein hepcidin, which inhibits duodenal absorption of
iron.
In Panel C, interferon-, lipopolysaccharide, or both
increase the expression of divalent metal transporter
1 on macrophages and stimulate the uptake of ferrous iron
(Fe2+). The anti-inflammatory cytokine interleukin-10 up
regulates transferrin receptor expression and increases
transferrin receptormediated uptake of transferrin
bound iron into monocytes. In addition, activated macro
phages phagocytose and degrade senescent erythrocytes
for the recycling of iron, a process that is further induced
by TNF- through damaging of erythrocyte memb
ranes and stimulation of phagocytosis. Interferon a
and lipopolysaccharide down-regulate the expression
Fig. 1 Pathophysiological mechanisms underlying anemia of chronic disease
of the macrophage iron transporter ferroportin 1, thus

inhibiting iron export from macrophages, a process that
is also affected by hepcidin. At the same time, TNF-,
interleukin-1, interleukin-6, and interleukin-10 induce
ferritin expression and stimulate the storage and retention
of iron within macrophages.
In summary, these mechanisms lead to a decreased

iron concentration in the circulation and thus to a limited
availability of iron for erythroid cells.
In Panel D, TNF- and interferon-g inhibit the
production of erythropoietin in the kidney.
In Panel E, TNF-, interferon-g and interleukin-1 directly
inhibit the differentiation and proliferation of erythroid

progenitor cells. In addition, the limited availability of iron
and the decreased biologic activity of erythropoietin lead
to inhibition of erythropoiesis and the development of
anemia. Plus signs represent stimulation, and minus signs
inhibition.
Treatment Options
Moderate anemia warrants correction, especially in
patients with additional risk factors (such as coronary
artery disease, pulmonary disease, or chronic kidney
disease), or a combination of these factors. In patients
with renal failure who are receiving dialysis and in
patients with cancer who are undergoing chemotherapy,
correction of anemia up to hemoglobin levels of 12 g per
deciliters is associated with an improvement in the quality
of life.
In a retrospective review of nearly 100,000 patients
undergoing hemodialysis, levels of hemoglobin of 8 g per
deciliters or less were associated with a doubling of the
odds of death, as compared with hemoglobin levels of
10 to 11 g per deciliter. Guidelines for the management of
anemia in patients with cancer or chronic kidney disease
recommend a target hemoglobin level of 11 to 12 g per
deciliter.
Transfusion
Transfusions are particularly helpful in the context of
either severe anemia (in which the hemoglobin is less than
8.0 g per deciliter) or life-threatening anemia (in which the
hemoglobin is less than 6.5 g per deciliter), particularly
when the condition is aggravated by complications that
involve bleeding.
Iron Therapy
Oral iron is poorly absorbed because of the down
regulation of absorption in the duodenum. Only a fraction
of the absorbed iron will reach the sites of erythropoiesis,
owing to iron diversion mediated by cytokines, which
directs iron into the reticuloendothelial system.
In addition, iron therapy for patients with anemia
of chronic disease is controversial. By inhibiting the
formation of TNF-, iron therapy may reduce disease
activity in rheumatoid arthritis or end-stage renal disease.
In addition to possible absolute iron deficiency
accompanying the anemia of chronic disease, functional
iron deficiency develops under conditions of intense
erythropoiesis24 during therapy with erythropoietic agents,
with a decrease in transferrin saturation and ferritin to
levels 50 to 75 percent below baseline.24
Iron supplementation should also be considered for
patients who are unresponsive to therapy with erythropoietic agents because of functional iron deficiency.
Erythropoietic Agents
The therapeutic effect involves counteracting the antipro
liferative effects of cytokines,25 along with the stimulation of
iron uptake and heme biosynthesis in erythroid progenitor
cells. Accordingly, a poor response to treatment with
erythropoietic agents is associated with increased levels
of proinflammatory cytokines, on the one hand, and poor
iron availability.24
Three erythropoietic agents are currently available:
1. Epoetin alfa
2. Epoetin beta
3. Darbepoetin alfa.
These differ in terms of their pharmacologic com
pounding modifications, receptor-binding affinity,
and serum half-life, thus allowing for alternative
dosing and scheduling strategies.
The long-term administration of epoetin has been
reported to decrease levels of TNF-a in patients with
chronic kidney disease; reportedly, those who respon
ded well to epoetin therapy had a significantly higher
level of expression of CD28 on T cells and lower levels of
interleukin-10, interleukin-12, interferon-, and TNF-a
than did those with a poor response. Such anti-infla
mmatory effects might be of benefit in certain diseases
such as rheumatoid arthritis, a disease in which combined
treatment with epoetin and iron not only increased
hemoglobin levels but also resulted in a reduction of
disease activity.
The production of erythropoietin receptors by cancer
cells appears to be regulated by hypoxia, and in clinical
cancer specimens the highest levels of erythropoietin
receptors were associated with neoangiogenesis, tumor
hypoxia, and infiltrating tumors. Erythropoietin increases
inflammation and ischemia-induced neovascularization
by enhancing the mobilization of endothelial progenitor
cells.26, 27
Monitoring Therapy
Before the initiation of therapy with an erythropoietic
agent, iron deficiency should be ruled out. Hemoglobin
levels should be determined after four weeks of therapy
and at intervals of two to four weeks thereafter. If
the hemoglobin level increases by less than 1 g per
deciliters, the iron status should be reevaluated and iron
supplementation considered.28 If iron-restricted erythro
poiesis is not present, a 50 percent escalation in the
dose of the erythropoietic agent is indicated. The dose
of the erythropoietic agent should be adjusted once the
hemoglobin concentration reaches 12 g per deciliter.29 If
no response is achieved after eight weeks of optimal dosage
in the absence of iron deficiency, a patient is considered
nonresponsive to erythropoietic agents.
ANEMIA OF CHRONIC RENAL INSUFFICIENCY

The term anemia of chronic renal insufficiency refers to
that anemia resulting directly from failure of the endocrine
and filtering functions of the kidney. The kidney is the
major source of erythropoietin and the ability to secrete
this hormone is lost as the kidney fails. Renal failure is
also associated with other pathologic processes that either
inhibit erythropoiesis or shorten erythrocyte survival. Lack
of sufficient erythropoietin is the most important factor
in causing anemia; consequently, the hypoproliferative
features of the anemia tend to predominate.In clinical
settings, in chronic renal failure, additional factors may
also contribute to the development of anemia such as :
The presence of infection or inflammation
Iron deficiency anemia due to blood loss from the
gastrointestinal tract or hematuria or from retention of
blood in the hemodialysis apparatus tubing30
The megaloblastic anemia because of folate deficiency
in patients on dialysis31
Certain types of renal disease, including the hemolyticuremic syndrome or thrombotic thrombocytopenic
purpura, are associated with microangiopathic hemo
lytic anemia
Aluminum intoxication can cause microcytic anemia
in dialysis patients.32
Reticulocyte count: The reticulocyte count often is within

normal limits,35 but it may be moderately increased.36
The highest values were observed with extreme azotemia
(BUN, 300 to 350 mg/dL).
Leukocyte count: The leukocyte count typically is normal,
but slight neutrophilic leukocytosis may be observed.35
Platelet count and function: The platelet count is either
normal or slightly increased,35 but platelet function may
be severely impaired resulting in defective hemostasis
disease (1500).
Bone marrow examination: The bone marrow tends to
be hypercellular and slight erythroid hyperplasia may
be observed. The myeloid-to-erythroid ratio averaged
2.5:1.0.35 Erythroid maturation remains normal. In some
instances, especially when renal failure is relatively acute,
hypoplasia of erythroid elements is noted.
Liver function test: The serum bilirubin level is usually
within normal limits but the hemolytic index (a measure
Clinical Description
The nature of the underlying disease has little relation to
the degree of anemia, although anemia may be less severe
in patients with hypertensive renal disease and with
polycystic disease.33
The severity of the anemia bears a rough relationship
to the degree of renal insufficiency.
Anemia is not routinely observed until the creatinine
clearance falls to <40 mL/minute, which corresponds
roughly to a serum creatinine of 2.0 to 2.5 mg/mL in
an average-sized adult. At creatinine clearance rates
below that, a statistically significant correlation between
creatinine clearance and hematocrit has been reported.34
Laboratory Findings
Hemoglobin and PCV: Anemia tends to become more
severe as renal failure worsens, but in most patients the
hematocrit ultimately stabilizes between 0.15 and 0.30.2
The apparent degree of anemia may be exaggerated or
minimized by alterations in plasma volume.
Peripheral blood film (PBF): The erythrocytes usually are
normocytic and normochromic. The majority of red cells
appear normal on blood smears. Occasionally, burr cells
(Figs 2A and B) are observed along with some triangular,
helmet-shaped, or fragmented cells.
B
Figs 2A and B (A) Crenated cells in renal; (B) Burr cells in renal
disease (X 3000)

of urobilinogen excretion in relation to total circulating
hemoglobin) may be increased in ~40 percent of patients.37
Serum iron: It is normal in mild renal failure. Serum
iron decreases in severe disease, or hyperferremia. The
gastrointestinal absorption of iron is also reduced in
patients with chronic renal failure.38 FEP may be normal
or moderately increased, but the increased values seem to
occur only in patients with hypoferremia.39 The erythrocyte
lactate dehydrogenase level is within normal limits.
HbA1c: The glycated fraction (A1) of hemoglobin tends to
increase in chronic renal failure. Hemoglobin A1 value
averaged 10.8 percent in patients with uremic patients
compared with 7.1 percent in nonuremic individuals.40 In
uremic patients treated with dialysis, the value averaged 8.8
percent. The increase is thought to result from carbamylation
of the hemoglobin molecule by urea-derived cyanate; it
can be detected by using column chromatography. The
increase in the A1 fraction may continue after successful
renal transplantation has brought the azotemia under
control because of disturbed carbohydrate metabolism.41
Pathogenesis
The three factors involved are:
1. Erythropoietin deficiency
2. Suppression of marrow erythropoiesis
3. Shortened red cell survival.
As renal function deteriorates, renal erythropoietin
secretion decreases.42 Measured erythropoietin values
may be lower than normal, higher than normal, or
normal.42
Suppression of bone marrow
Retained uremic toxins depress erythropoiesis
directly.36,43
Hyperparathyroidism may also contribute to
marrow suppression. It is effects by causing marrow
fibrosis.
Cytokine-mediated anemia mechanisms typically
associated with ACD may be active in renal failure.
20 to 70 percent of uremic patients show shortened
red cell survival related to degree of azotemia.36 In
some patients, splenic sequestration of red cells
may be a contributory factor.
In 20 percent patients, red cell pentose phosphate
pathway is impaired.44
Oxidant drugs, such as primaquine or sulfonamides,
produce a Heinz body hemolytic anemia in patients
with the pentose phosphate pathway defect.
Contamination of dialysate water by chloramines,
which inhibit phosphoglyceromutase and thus
cause accumulation of glycolytic intermediates,
may worsen this defect.44,45
Impaired erythrocyte glycolysis has been found

in uremic patients. Hemoglobin oxygen affinity
is reduced,46 because of increased erythrocyte
adenosine triphosphate and 2, 3-DPG levels.
Neocytolysis, the selective hemolysis of newly
formed red cells, has been reported after
erythropoietic with-drawal in dialysis patients
and may contribute to shortened red cell
survival in dialysis patients.
Management and Course

Recombinant erythropoietin: Recombinant human
erythropoietin has been available for treatment of
anemia of renal disease which has revolutionized
the approach to this disorder. Erythropoietin can
be administered intravenously or subcutaneously.
Although erythropoietin was originally given three
times weekly (to coincide with dialysis schedules),
single weekly doses are similarly efficacious if the total
weekly dose is increased appropriately.48 A standard
starting dose would be 100 to 150 U/kg/week, given
as a single or in divided doses. Higher doses generally
result in faster correction of anemia; target hemoglobin
is typically attained within 6 to 8 weeks.47 Iron
supplementation is necessary, particularly in patients
on hemodialysis. The target hemoglobin/hematocrit
range is usually 12 g/dL/0.360.
Recombinant human erythropoietin (rHuEPO): Deter
mine the baseline serum erythropoietin and ferritin
levels prior to starting rHuEPO therapy. If ferritin is
less than 100 ng/mL, give ferrous sulphate 6 mg/kg/
day aimed at maintaining a serum ferritin level above
100 ng/mL and a threshold transferrin saturation of
20 percent.
Start with rHuEPO treatment in a dose of 150 units/kg/
day subcutaneous three times a week.
Monitor blood pressure closely (increased viscosity
produces hypertension in 30 percent of cases) and
perform complete blood count (CBC) weekly.
Titrate the dose:
If no response, increase rHuEPO to 300 units/kg/day SC
three times a week.

If hematocrit (Hct) reaches 40 percent, stop rHuEPO until

Hct is 36 percent and then restart at 25 percent dose.

If Hct increases very rapidly (>4% in 2 weeks), reduce dose

by 25 percent.
Folic acid 1 mg/day is recommended because folate is
dialyzable.
Side Effects/Adverse Reactions

Erythropoietin is generally safe. When used for
anemia in renal disease, hypertension is an important
complication which is transient, confined to the first
3 to 6 months of treatment.49 Rarely, the hypertension is
abrupt and severe with encephalopathy and seizures.
The pathogenesis is multifactorial. An increase in
peripheral vascular resistance because of decrease in
cardiac output, heart rate and stroke volume due to
correction of anemia may be responsible.
Anaphylaxis in response to erythropoietin has been
described but is extremely rare.
Erythropoietin Resistance
The failure of patients to respond optimally to erythro
poietin therapy or a requirement for unusually high doses
is referred to as an erythropoietin resistance.
Iron deficiency is the most common cause.50 Patients
with serum ferritin levels <100 to 200 g/L or with transferrin
saturation values <20 to 25 percent50,51 require iron supple
mentation. The best early predictors of erythropoietin
response are serum TfR and serum fibrinogen. Response
rates approaches 100 percent when both are low and
29 percent when both are high, reflecting both the patients
iron status and the presence or absence of inflammation.
Inadequate hemodialysis is associated with erythro
poietin resistance.52 As discussed earlier, secondary hyper
parathyroidism often accompanies renal failure and the
associated marrow fibrosis may contribute to the anemia
and to erythropoietin resistance.
Treatment with vitamin D3 can decrease recombinant
erythropoietin requirements and improve hemoglobin
values.53 If erythropoietin resistance is associated with an
increased MCV, folate supplementation is warranted.
The use of angiotensin-converting enzyme inhibitors
in renal failure patients may exacerbate erythropoietin
resistance.54 Splenectomy may be required in case of
erythropoietin requirement increases in a patient with
splenomegaly.
Anti-erythropoietin antibodies, including production
of pure red cell aplasia, have rarely been reported.55
Darbepoetin (novel erythropoiesis-stimulating protein):
The long-acting erythropoietin analog Darbepoetin
(novel erythropoiesis-stimulating protein) appears to
be safe and effective in the anemia of renal failure.56
The recommended starting dose is 0.45 g/kg/week.
Iron: Iron repletion and maintenance is the second
pillar of anemia management in kidney disease. The
current NKF-KDOQI recommendation for targets of
iron therapy is to maintain serum ferritin at >100 ng/
mL and TSAT at >20 percent in pediatric HD, PD and
non-dialysis CKD patients.
Oral iron supplements, though cheap, are often

insufficient to maintain iron stores, especially in HD
patients, due to excessive blood loss, poor absorption,
poor compliance with medications and gastrointestinal
side effects.
The current NKF-KDOQI guidelines recommend oral
iron therapy to be given in doses ranging from 2 to 3 mg/
kg up to 6 mg/kg of elemental iron per day in two to three
divided doses per day. Maintenance therapy aims to
provide 12 mg/kg of elemental iron per week to achieve a
TSAT between 20 and 50 percent and serum ferritin levels
of 100 to 800 ng/mL.
RENAL REPLACEMENT THERAPY

Renal replacement approaches (transplantation and
dialysis) aim to restore or substitute for lost renal function.
As such, they may have some effects on anemia associated
with renal failure.
RENAL TRANSPLANTATION
Renal transplantation is the complete and satisfactory
treatment for renal insufficiency. Anemia is usually
corrected over an 8- to 10-week period due to erythropoietin
secretion by the grafted kidney.57
Two peaks of erythropoietin secretion have been
documented. An early peak at 7 days and a second
more sustained increase in erythropoietin levels, on
approximately day 8, accompanied by reticulocytosis and
a gradual increase in hemoglobin levels. Erythropoietin
values return to normal when the hematocrit reaches 0.32.
Approximately, 80 percent of patients experience an
increase in blood hemoglobin concentration after renal
allograft.57 Improvement in erythropoiesis occurs earlier
when cyclosporin is used for immunosuppression rather
than with antilymphocyte globulin (ALG).
DIALYSIS
Red cell production increases slightly in patients on
hemodialysis, with small increases in hematocrit and
decreases in transfusion requirement.58
As a general rule, anemia is less severe in patients
receiving peritoneal dialysis, with consequently lower
erythropoietin and transfusion requirements.59,60
Anemia in Cirrhosis and Other Liver Diseases

Certain degree of anemia is commonly seen in patients
with liver disease like alcohol-induced cirrhosis, biliary
cirrhosis,61 hemochromatosis, postnecrotic cirrhosis,
and acute hepatitis.62
The term anemia of liver disease refers to mild or
moderate anemia associated with liver disease in the
absence of any complicating factors such as blood
loss, marrow suppression by exogenous agents or

nutritional deficiency.
Some of the pathogenetic mechanisms of anemia
include:
Shortened red cell survival and red cell fragmen
tation (spur cell anemia) in cirrhosis.
Hypersplenism with splenic sequestration in the
presence of secondary portal hypertension
Iron deficiency anemia secondary to blood loss
from esophageal varices in portal hypertension
Chronic hemolytic anemia in Wilsons disease
secondary to copper accumulation in red cells
Aplastic anemia resulting from acute viral hepatitis
(particularly hepatitis B) in certain immunologically
predisposed hosts
Megaloblastic anemia secondary to folate defi
ciency in malnourished individuals.
Individuals with cirrhosis of any etiology are at
increased risk for hemorrhage. Blood loss occurs in
24 to 70 percent of patients with alcoholic cirrhosis. The
upper gastrointestinal tract is the major site of bleeding,
but loss of blood from the nose, hemorrhoids, and uterus
often occurs in association with coagulopathy of hepatic
origins.
PREVALENCE AND CLINICAL

MANIFESTATIONS
Approximately 75 percent of patients with chronic liver
disease develop anemia as defined by a reduction in
the hematocrit or hemoglobin level.63 The whole blood
volume in liver disease averages 10 to 15 percent greater
than normal; thus, hemodilution tends to exaggerate the
prevalence and degree of anemia.64 Patients with more
severe liver disease and bleeding tend to have reduced
red cell mass.
The anemia is usually mild-to-moderate and hemo
globin level averages 12 g/dL or the hematocrit 0.36.64
The hemoglobin level rarely falls below 10 g/dL in the

absence of bleeding or severe hemolysis. Approximately,
5 percent of liver disease patients, with severe liver disease
develop spur cell hemolytic anemia and hemoglobin
concentrations <10 g/dL.65 Episodic hemolysis when
accompanied by jaundice and hyperlipidemia is known as
Zieves syndrome.
HEMATOLOGIC FINDINGS
PBF: Anemia of liver disease is mildly macrocytic.
Target cells and cells with increased diameters are
evident on blood smear (Figs 3A to C). The cells
appear hypochromic. These morphologic changes are
accompanied by increased resistance to hemolysis
in osmotic fragility tests.66 When spur cell hemolytic
anemia supervenes, characteristic acanthocytes
erythrocytes covered with five to ten spike like
projections are evident.
Reticulocyte count: The reticulocyte count often is
increased, but sustained reticulocytosis of 15 percent
or more is unusual in the absence of hemorrhage or
spur cell anemia.
Platelet count: Approximately 50 percent of patients
with cirrhosis have mild thrombocytopenia, but values
less than 50 109/L are uncommon.63
Total leukocyte count (TLC): A variety of leukocyte
abnormalities may be observed. Severe pancytopenia
associated with splenomegaly in liver disease is known
as Bantis syndrome.
Bone marrow aspiration: Bone marrow cellularity
is normal or increased.63 Erythroid hyperplasia is
observed. Red cell precursors have been described
as macronormoblasts, a term that implies their size
is increased, but their nuclear chromatin appears
normal.63,67 Frank megaloblastosis is seen in <20
percent of patients.
Figs 3A to C Anemia of liver disease. (A) Crenated cells in renal failure; (B) Burr cells; (C) Macrocytes and target cells in liver disease
PATHOGENESIS
Darbepoetin (also called novel erythropoiesis-stimula

ting protein) is an erythropoietin analog with modified
glycosylation permitting a longer half-life. The results of
studies comparing Darbepoetin and erythropoietin in
anemic cancer patients vary depending on specific study
endpoints, but both appear to be effective.73
It is debated whether or not to administer iron routinely
to patients receiving therapy with erythropoietin products.
Although there are reports of correction of ACD by
intravenous iron without erythropoietin,74 normalization
of hemoglobin was only described in patients who were
clearly iron-deficient. Anemic cancer patients treated
with concurrent intravenous iron and recombinant
erythropoietin appear to have a better response than
those treated with no iron supplementation or with iron
supplementation alone.75
Shortened erythrocyte survival: Red cell survival is

decreased in 33 percent of patients with alcoholic liver
disease. Various causes are congestive splenomegaly,
abnormal erythrocyte metabolism and hypophos
phatemia with reduced erythrocyte adenosine tripho
sphate levels and consequent hemolysis.
Characteristic alterations in red cell membrane
lipids are found in patients with hepatitis, cirrhosis,
and obstructive jaundice and may also be another
contributor to shortened red cell survival.68
In spur cell hemolytic anemia, the erythrocyte
membrane accumulates excess cholesterol without
a corresponding increase in lecithin, resulting in the
characteristic morphologic abnormality. This change is
accompanied by pronounced reduction in erythrocyte
survival, probably because the distorted cells are less
deformable than normal and thus become trapped by
splenic macrophages.
Inadequate erythropoiesis: The marrow response
to the anemia in patients with liver disease may
be inadequate. Serum from cirrhotic patients can
suppress hematopoietic colony formation in vitro,69
and cytokines implicated in inhibition of erythropoiesis
have been found to be increased in patients with
liver disease.70 Dyserythropoiesis with morphologic
abnormalities and intramedullary hemolysis has also
been reported in severe liver disease.71
A mild-to-moderate anemia commonly accompanies

disorders affecting the thyroid, adrenals, parathyroids,
gonads, or pituitary. It is usually not associated with
symptomatology and in fact may reflect a physiologically
appropriate hemoglobin concentration because the
hormone deficiency often results in reduced oxygen
requirements. Most individuals present as referrals for
evaluation of moderate anemia with normal iron, B12, and
folate studies.
ANEMIA IN PATIENTS WITH CANCER
Hypothyroidism
Much of the anemia commonly observed in patients with

cancer can be attributed to the mechanisms involved
in ACD. Erythroid precursors may be displaced from
marrow by metastatic tumor, tumor-induced fibrosis,
or tumor-associated marrow necrosis. The treatment
of cancer can also produce or exacerbate anemia by a
variety of mechanisms, including impaired erythropoietin
production and cytotoxic effects of therapy on erythroid
progenitors.
Typically, the serum transferrin is either low or low
normal. The major differential diagnosis is iron deficiency
anemia.
A mild anemia with no other apparent etiology occurs

in 10 to 25 percent of patients with hyperthyroidism.82,83
Anemia is associated with severe or prolonged hyper
thyroidism. Hemoglobin value falls but remains within
normal limits.82 MCV is either normal or modestly
decreased. Hemoglobin A2 levels are slightly increased but
not as much as in thalassemia.79 Both the anemia and the
microcytosis are corrected when the hyperthyroidism is
successfully treated. Erythropoiesis usually is accelerated
but ineffective along with increased plasma erythropoietin
levels.
Anemia is observed in 21 to 60 percent of hypo
thyroid patients. The anemia may be normocytic and
normochromic, hypochromic and microcytic, or macro
cytic. Hypochromic microcytic anemia found in asso
ciation with hypothyroidism should be considered iron
deficiency.76,77 The microcytic anemia responds to iron
therapy, even if thyroid hormone is not administered, but
does not typically respond to thyroid hormone without
iron.76 Hypothyroid individuals are more likely to become
iron-deficient because of predisposition to menorrhagia
Treatment
Fewer than 30 percent of patients have anemia sufficiently
severe to necessitate transfusion, and assessment of the
symptomatic state should always be considered before
administration of blood products.
Recombinant erythropoietin is effective and safe but
expensive.72
ANEMIA ASSOCIATED WITH

ENDOCRINE DISORDERS

and achlorhydria77 and because thyroid hormone itself
may be essential for normal iron absorption.76 Severely,
macrocytic anemia usually results from complicating
deficiency of vitamin B1277 or folate.
Anemia usually affects children whose height is below
the third percentile. The anemia usually is mild, with the
hematocrit rarely falling below 0.35. The plasma volume
often is decreased, which tends to make the reduction in
hematocrit less than might be expected for a given decrease
in red cell mass.77 The degree of anemia is related to both
the severity and the duration of the hypothyroidism.78 The
MCV may be increased in hypothyroid patients, even in
the absence of anemia.76 Acanthocytes are apparent in 20
percent of patients. Usually, the leukocyte and platelet counts
are within the normal range, although both may be slightly
reduced.78 The bone marrow may be mildly hypoplastic, but
the myeloid-to-erythroid ratio is not significantly altered.
Hemoglobin A2 levels are reduced slightly.
Pathogenesis
The anemia of hypothyroidism results from decreased red
cell production. Plasma iron transport and erythrocyte
iron turnover rates are reduced, indicating subnormal
red cell production.79 Erythropoietin secretion is reduced
in hypothyroid patients,80 and 2, 3-DPG levels are not
increased81 as occurs in most anemic and hypoxic states.
The response of anemia of hypothyroidism to thyroid
hormone is gradual. No striking reticulocytosis occurs, and
the hematocrit returns to a normal value only gradually
over approximately a 6-month period.76,77
Hyperthyroidism
A mild anemia with no other apparent etiology occurs in 10
to 25 percent of patients with hyperthyroidism.82,83 Anemia
is associated with severe or prolonged hyperthyroidism.
Hemoglobin value falls but remains within normal limits.82
MCV is either normal or modestly decreased. Hemoglobin
A2 levels are slightly increased but not as much as in
thalassemia.79 Both the anemia and the microcytosis are
corrected when the hyperthyroidism is successfully treated.
Erythropoiesis usually is accelerated but ineffective along
with increased plasma erythropoietin levels.
Adrenal Insufficiency
Although anemia is common and nearly universal in
adrenal insufficiency, it may be masked by the dehydration
characteristic of this syndrome.83 The red cells were
normocytic and normochromic. Pernicious anemia is
observed in 3 to 16 percent of cases of nontuberculous
adrenal insufficiency and may complicate 13 percent
of adrenal insufficiency cases associated with the

polyglandular autoimmune syndrome type I.84
Androgen Deficiency
After puberty, values for the hematocrit, blood hemoglobin
concentration, and red cell count average 10 to 13 percent
higher in men than in women. In castrated men, these
values fall to within the normal female range.85 This is due
to a difference in erythropoietin production. After the sixth
decade, male hemoglobin values fall back toward those
observed in women.86 The anemia in these patients is
corrected by androgen replacement.The differences in red
cell parameters between the sexes are accounted for chiefly
by the stimulating effect of androgens on erythropoiesis.
The administration of androgens to castrated males restores
male values for hemoglobin concentration. Androgens can
also stimulate erythropoiesis in normal subjects. In normal
men, testosterone enanthate induced an average red cell
mass increase of 1.7 to 2.3. The increase in hematocrit
was of smaller magnitude (from 0.456 to 0.494), probably
because the plasma volume also increased. Androgens
act by increasing renal synthesis of erythropoietin.85
Estrogens produce anemia when given in large amounts
which suggest that this effect results from suppression of
hepatic synthesis of erythropoietin, but it may also simply
represent opposition to androgen effects in general.
Hypopituitarism
Moderately severe anemia is seen as a feature of all
types of pituitary insufficiency. Reduced hemoglobin
levels are seen in Simmonds disease, pituitary neoplasms
and prepubertal pituitary dwarfs. The anemia usually is
normocytic and normochromic and the red cells appear
normal morphologically. Studies demonstrate reduced
red cell production.87
The anemia of hypopituitarism results chiefly from
deficiencies of the hormones of target glands controlled by
the pituitary, especially the thyroid and adrenal hormones,
but also from deficiency of androgens. In addition, lack
of other pituitary factors, such as growth hormone,87,88
prolactin, or factors characterized less clearly, may be of
importance.
As suggested for the anemia of hypothyroidism,
panhypopituitarism produces its effects on erythropoiesis
chiefly by reducing tissue oxygen consumption.88 The
organism reacts to this decreased need for oxygen by
secreting less erythropoietin and the red cell mass
diminishes until a new equilibrium between oxygen
supply and demand is established.
Treatment with a combination of thyroxine, cortisone,
and growth hormone corrects both the anemia and the

marrow hypoplasia88 and is more effective than any single
hormone by itself. Administration of recombinant human
erythropoietin (6,000 IU/day) was followed by correction
of the anemia.
Hyperparathyroidism
Anemia is a rare complication of primary hyperpara
thyroidism.89 The anemia is normocytic and normochromic
and no evident reticulocytosis. Some authors conclude
that parathyroid hormone decreases proliferation of
erythroid precursors in culture. Marrow fibrosis may also
be a result of excess hormone levels. Myelofibrosis is a
common finding in bone marrow biopsy specimens, but
the usual morphologic signs of myelophthisis are lacking.89
When hyperparathyroidism is secondary to renal
disease, it is difficult to ascertain the relative importance
of the hormone excess versus the erythropoietin deficit
characteristic of renal failure as a contributor to the
observed anemia. Medical treatment of hyperparathyroi
dism with vitamin D3 can bring about improvement in
anemia and decreased requirement for erythropoietin in
some patients.53
Anorexia Nervosa
Anemia is observed in as many as 84 percent of patients

with anorexia nervosa admitted to the hospital.90 A mode
rate degree of leukopenia or thrombocytopenia may also
be observed. The peripheral blood smear shows a striking
composite process, and bone marrow examination
shows gelatinous transformation with necrosis, as well
as decreased cellularity in most cases.90,91 These are
essentially the findings observed in starvation, and they
return to normal with improved nutrition.90,91
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17
Thalassemia Syndromes
Mamta Vijay Manglani, Ambreen Pandrowala, Ratna Sharma, MR Lokeshwar
Thalassemia syndromes are a heterogeneous group of single gene disorders, inherited in an autosomal recessive manner, prevalent
in certain parts of the World posing a major health problem. In populations from the Mediterranean basin, Indian subcontinent
and South-East Asia, -Thalassemia is the most common genetic variant associated with Thalassemia major. However population
migration these days has, no longer, restricted the gene frequency to above tropical areas in which it was first observed, and hence
it is seen all over the world.1- 4
HISTORICAL REVIEW1-6
Thalassemia was first described by Cooley and Lee in
1925,1 (Fig. 1) cases of severe anemia occurring in Italian
children with hepatosplenomegaly, growth retardation,
discoloration of skin and sclera, with peculiar bony
changes, during the Transactions of American Pediatric
Society. It was then called as Cooleys anemia.1
The term thalassemia was first used in 1932, by
Whipple and Bradford.2 The word was taken from the
Greek language which means great sea (anemia around
the sea). As it was first described around Mediterranean
countries. It was also called as Mediterranean anemia.1,2
However, it was soon realized that it also occurs in SouthEast Asia, Indian subcontinent and Middle-East and not
only around Mediterranean regions. The first case from
India was reported by Dr M Mukherjee5 from Campbell
Medical School Calcutta India in 1938.4 Dr PK Sukumaran5
from Mumbai did pioneering work in the field of diagnosis
of thalassemia syndromes in India.
Currently, as the life span of affected patients has been
considerably prolonged by improvement in supportive
care, the age distribution of patient population has dramatically altered. Furthermore, in many countries, the
use of DNA based prenatal diagnosis has substantially
reduced number of births of affected individuals, accentuating the trend of increasing age of thalassemia patients.
Fig. 1 Dr Thomas Cooley
EPIDEMIOLOGY3,7-17
Thalassemia Incidence: World Scenario
All over the world there are more than 250 million (1.5% of
world population) carriers of b-thalassemia gene, and in
South-East Asia, there are 40 million carriers of this gene
(50% of these are in India alone, i.e. 20 million).1-4

Thalassemia syndrome: Indian scenario
The mean prevalence of the carrier status in India is 3.3%
(ranging from 1% to 17% in various communities). If you draw
a line between Mumbai (Bombay) and Kolkata (Calcutta) on
the map of India, the region above the line has an incidence of
317 %, where as the region below the line has an incidence of
less than 3%.
Thalassemia is more common in the following communities
North India
Sindhis, Punjabis, Khatris, Kukrejas, migrants

from Pakistan
Gujarat
Maharashtra
Bhanushalis, Kutchis, Lohanas Mahars,

Chamars, Buddhas, Navabuddhas, Kolis,
Agris, Kunbis
Andhra Pradesh
and Karnataka
Reddys, Gowdas, Lingayats, Kurgs
Goa
Other
Goud Saraswats
Certain Muslim and Christian communities
Fig. 2 Thalassemia BeltWorld Scenario
Flow chart 1 Pathophysiology of -thalassemia
It is estimated that every year approximately 100,000

children with thalassemia major are born world over.
With the birth rate of 22.8 per 1000 in India, it
is estimated that there are about 65,000 to 67,000
b-thalassemia patients in our country and about 9,000 to
10,000 cases being added every year.
The prevalence of thalassemia varies in different
communities, religions and ethnics groups.
The thalassemia belt stretches across the African
continent, the Mediterranean regions, Middle-east,
Indian subcontinent, South-east Asia, Thailand, Cambodia, Laos, Vietnam, Malaysia, Singapore, Southern China,
and Melanesia1 which is the same as malaria belt. The
observation that the prevalence of thalassemia and falciparum malaria was similar, suggested the hypothesis that
nature developed genetic mutation to overcome mortality
and morbidity of malaria (Fig .2).
PATHOPHYSIOLOGY (FLOW CHART 1)18-21

Normally hemoglobin consists of two pairs of amino acid
chains:
Adult hemoglobin HbA consists of two pairs of
-chains and -chains each.
HbA2 consists of two pairs of -chains and -chains.
HbF fetal hemoglobin is constituted by two pairs of
-chains and -chains.
Thalassemia is an inherited disorder of hemoglobin.
Thalassemia syndromes refer to a group of blood
diseases characterized by defects in the synthesis of one
or more of the globin chains that form the hemoglobin
tetramer. This results in reduced or complete absence
of production of one or more of the globin polypeptide

chains of the hemoglobin molecule leading to imbalance
in and non- chains of hemoglobin.
In -thalassemia, decreased (+) or absent (0)
chains lead to excess of unpaired chains, that have no
complementary non--chains with which to pair, form
insoluble inclusions that precipitate on red cell membrane
to form insoluble inclusion bodies, leading to damaged
cell membranes, perturbed internal ionic environment of
Chapter-17 Thalassemia Syndromes 165

the cells, decreased red cell deformability and interference
with egress from the bone marrow spaces. This leads to
premature destruction of RBCs in bone marrow (Ineffective
erythropoiesis) and in peripheral circulation, particularly
in reticuloendothelial system of spleen (Extravascular
hemolysis) resulting in progressive anemia.
To compensate for the reduced hemoglobin, the
synthesis of gamma chains persist after fetal life even
beyond 6 months of age. The normal switch mechanism
leading to reduction in -chain synthesis does not occur.
This leads to higher fetal hemoglobin 22(HbF) in
postnatal life.
Increased fetal hemoglobin (HbF) with its high affinity
for oxygen leads to tissue hypoxia, which in turn stimulates
erythropoietin secretion leading to both medullary and
extramedullary erythropoiesis (expansion of bone marrow
space) causing characteristic hemolytic faces with frontoparietal and occipital bossing, malar prominence and
malocclusion of teeth and complications that include
distortion of ribs and vertebrae and pathological fractures
of the long bones, splenomegaly and its complication
hypersplenism, hepatomegaly, gallstones and chronic leg
ulcers, etc.
The precise mechanism controlling the switch from
fetal to adult hemoglobin (2b2) is not fully understood.
CLASSIFICATION3,22,23
Thalassemias are classified depending on, which globin
chain is defectivea(alpha), b(beta), g(gamma), d(delta),
etc.
a-thalassemia trait, HbH disease and hydrops fetalis due

to 1,2,3 and 4 gene defects respectively.
The b-globin genes are represented one on each
chromosome 11.
The b-thalassemias also include four clinical synd
romes of increasing severity:
1. Silent carrier
2. Thalassemia trait
3. Thalassemia intermedia
4. Thalassemia major (Table 3)
The former two result from a single gene defect
(heterozygous) whereas the latter two from both genes
affected (homozygous).
Molecular Genetics
(Figs 3 and 4 and Table 4) 5,24-43
More than 200 mutations have been described that are
responsible for thalassemia. The -globin genes are
clustered on chromosome 11 and are arranged over
approximately 60,000 nucleotide bases (Fig. 3). These
mutations occur in both introns and exons, and outside the
coding regions of the genes. Most types of -thalassemia
are due to point mutation affecting the globin gene but
some large deletions are also known. However, within
each geographical region, few common mutations are
responsible for over 90 percent of -thalassemia.
Table 1 Classification based on the chain affected
a-thalassemia
a-chain is affected
b-thalassemia
b-chain is affected
Classification of -thalassemia (Tables 1 and 2)
b0-thalassemia
b-chain is absent
The gene for a-globin chains is duplicated on chromosome

16 with each diploid human cell containing four copies
of the a-globin gene. The four a-thalassemia syndromes
with increasing clinical severity include silent carrier,
b + thalassemia
If b-chain is partially present
D
ouble heterozygous
states
S ickle cell thalassemia, HbE

thalassemia, HbD thalassemia,
etc.
Table 2 Classification of a-thalassemia syndromes18,22,23

Syndrome
Clinical features
Hemoglobin pattern
Silent carrier
No anemia, normal red cells
12% Hb Barts ( ) at birth
a-thalassemia trait
Mild anemia, hypochromic

microcytic red cells
510% Hb Barts (4) at birth
HbH disease
Moderate anemia,
hypochromic, microcytic, red
cells
530% HbH (4)
Hydrops fetalis
Death in utero caused by

severe anemia
Mainly Hb Barts, small

amounts of HbH
-globin genes affected

Table 3 Classification of b-thalassemia18,22,23
Syndrome
Clinical features
Hb pattern
-globin genes
Inheritance
Silent carrier
No anemia, normal, asymptomatic
Normal
Heterozygous state
Thalassemia trait
Mild anemia, hypochromic, microcytic red cells
Elevated HbA2
Heterozygous state
Thalassemia
intermedia
Moderate anemia, requires some transfusion

occasionally and not dependent on blood
transfusion for their survival
HbF elevated
Homozygous state/
Double heterozygous
Thalassemia
major
Severe anemia, dependent on regular blood

transfusion for survival
HbF elevated
Homozygous state
Table 4 Various mutations have been found in the Indian

population with -thalassemia
5 most common mutations in
Indian population
Newer mutations
1.619 bp deletion
Codon 15 (TGGTAG)
2.IVS 1-5(G-C)
C
odon 4/5 and 6 (ACT CCT
GAGACA TCTTAG)
3.IVS 1-1(G-T)
Codon 47/48 (+ATCT)
4. FS 8/9 (+G) and
Codon 55 (+A)
5. FS 41/42 (-CTTT)
IVS 2-837 (T to G)
Codon 88 (+T)
Fig. 3 The globin gene cluster on short arm
Codon 5 (-CT)
IVS 1-110 (G-A)
Clinical Heterogenecity of Thalassemia due to

Diversity of Mutations
Fig. 4 Timing and normal development switching of

chromosome human hemoglobin
Inheritance of Genes (Figs 5A and B)

Inherited by autosomal recessive pattern
If the child inherits one normal and one abnormal gene
from each parent, child will have no disease (carrier/
minor)
If both parents are carriers, i.e. thalassemia minor
(single gene affected), there is a 1 in 4 (25%) chance of
having a thalassemia major child in each pregnancy.
This is depicted in Figures 5A and B.
In populations in which thalassemia is prevalent, different

types of mutations, affecting genes of either a- or b- or
both globin clusters, may co-exist. Frequently, patients are
compound heterozygotes for these mutations. The relative
degree to which globin chain synthesis is impaired reflects
this genetic heterogeneity and determines the clinical
phenotype.
Mild b-thalassemia
Silent carrier: Silent carriers of b-thalassemia have
normal levels of HbA2. However, they often reveal mild
microcytosis, or a slight impairment in the b-globin
synthesis in the peripheral blood reticulocytes.
Several patients who are homozygous for the silent
carrier b-thalassemia gene have been described.
These children rarely require transfusions. They have
significant hepatosplenomegaly and have HbF of 10
to 15 percent with an elevated HbA2 (as seen in traits).
B
Figs 5A and B Inheritance of thalassemia
Two point mutations in the b-globin gene regions have

been linked to the silent carrier phenotype.
The -101 promoter mutations seen in Italians,
Bulgarians and Turkish population.
+1 Cap site Inv mutation in an Indian family.
b-thalassemia trait: Individuals with thalassemia trait
are heterozygous for b-thalassemia, i.e. expression of
one b gene is impaired by mutation, whereas that of
the other gene is normal. Individuals with thalassemia
trait exhibit mild microcytic, hypochromic anemia
with basophilic stippling, target cells and elliptical cells
on peripheral blood smear. Characteristically, HbA2
and/or HbF are elevated in b-thalassemia trait, though
various combinations may result depending upon the
genetic mutation.
High HbA2 b-thalassemia trait: This is the most
common form of b-thalassemia trait. HbA2 levels
vary from 3.5 to 8.0 percent whereas HbF from 1 to 5
percent.27
Thalassemia trait: Individuals heterozygous for these
mutations have increased HbF levels (515%) and low
HbA2 levels.
High HbA2 high HbF b-thalassemia: This form of
thalassemia trait is associated with deletions of the
globin gene that leave the d- and b-goblin genes intact.
Normal HbA2 b-thalassemia trait: This should be
distinguished from the silent carrier state. Both have
normal HbA2, however, individuals with normal
A2 b-thalassemia trait have red cells which are
hypochromic, microcytic in contrast to near normal
red cells in a silent carrier.25
Severe b-thalassemia
Thalassemia major suggests severe homozygous
b-thalassemia requiring regular transfusion to sustain life.
Patients who are homozygous for b-thalassemia mutations,
based on family studies, but maintain a hemoglobin
concentration of 6 to 10 g% without transfusions are termed
as thalassemia intermedia.
Various factors affect the severity of b-thalassemia.
But the most important factor is the imbalance between
a- and total non-a-globin synthesis.
Four factors determine this ratio:
1. The mutations (b0 or b+) in both globin genes.
2. Abnormalities in the a-globin gene cluster that
increase or decrease a-globin gene expression.
3. The genetic capacity to produce HbF.
4. Co-inheritance of Xmn1 polymorphism.
Dominant b-thalassemia: Rarely, heterozygote state
of b-thalassemia may be associated with severe
transfusion-dependent disease. Mutations involving
the Exon 3 of the b-globin gene have been associated
with such thalassemia.
Severe b-thalassemia trait: Increased production
of a-chains may lead to severe expression of
b-thalassemia trait due to increase in unbalanced
a-chains. Co-inheritance of triplicated a-globin gene
chromosomes may result in severe b-thalassemia trait
manifesting like thalassemia intermedia.25
Increased HbF synthesis: b-globin gene deletions
with mutations in g-globin promoters are associated
with increased HbF production and are shown to
ameliorate the clinical course of thalassemia. This has

led to pharmacologic manipulation of HbF production
to manage thalassemia patients.
Management of Thalassemia: Principles

of Therapy
Confirmation of diagnosis
Transfusion therapypacked red cell transfusions
Management of complications
Transfusion related complications
Iron overload: Removal of iron with iron chelating agents
Hypersplenism: Role of splenectomy
Transfusion transmitted infections: Hepatitis B and C HIV,
Yersinia spp, malaria, CMV
Gallstones and leg ulcers
Curative treatment: Bone marrow transplantation
Future treatment: Pharmacologic manipulation of HbF/Gene
therapy
Prevention of the disease by antenatal diagnosis and
genetic counseling
remain undiagnosed and are not given red blood cell

transfusions. Whereas at the other end of the spectrum
is a heterozygous form (Thalassemia minor) in which the
patient can lead a practically normal life except for a mild
persistent anemia not responding to hematinics. They
have a normal life span.
In between these two extremes are forms with varying
degrees of clinical manifestations of anemia, spleno
hepatomegaly and bony changes who maintain their
life fairly comfortably and are not dependent on blood
transfusions for their survival and are called thalassemiaintermedia (they are also homozygous).
Untreated or irregularly treated children develop signi
ficant hemolytic faces including frontoparietal bossing
with a hot-cross-bun appearance of the skull (caput
quadratum with hair-on-end appearance on X-ray
skull), depressed bridge of nose, malar prominences and
malocclusion of teeth with protrusion and malocclusion
of maxillary teeth.
LABORATORY DIAGNOSIS OF
b-THALASSEMIA SYNDROMES (TABLE 5)
Confirmation of Diagnosis
Clinical manifestations of -thalassemia:1-4,6,7,9,11-17
Children with thalassemia major are generally
diagnosed between 6 and 18 months of life. In
India, many children born with thalassemia major
die undiagnosed due to lack of facilities or ideal
treatment. The spectrum of clinical manifestation of
-thalassemia varies widely. Severe b-thalassemia
usually becomes manifest in the first year of life when
the fetal hemoglobin (a2,g2) starts declining and adult
stable Hb cannot be formed.
The clinical syndromes associated with thalassemia,
arise from the combined consequences of:
Inadequate hemoglobin production
Unbalanced accumulation of one type of globin chain.
The former causes anemia with hypochromia and
microcytosis whereas the latter leads to ineffective
erythropoiesis and hemolysis.
The high affinity of HbF for oxygen leads to tissue
hypoxia, which in turn stimulates erythropoietin secretion
leading to both characteristic hemolytic facieswith
frontoparietal and occipital bossing, malar prominence
and malocclusion of teeth.
At one end of the spectrum is the serious homozygous
form (Thalassemia major) that presents in early infancy
(618 months) with progressive pallor, failure to thrive,
irritability, intercurrent infections and bony changes
and hepatosplenomegaly. Ninety percent thalassemia
children do not survive beyond 3 to 5 years of age if they
For a reliable diagnosis of thalassemia, it is advisable to

correlate clinical profile and ethnicity of the individual
with various laboratory investigations to confirm the
diagnosis. Hemoglobin electrophoresis is the confirmatory
test for diagnosis of most cases of thalassemia syndromes.
However, a complete blood count and examination of the
peripheral smear provide very vital information and are an
important primary screen in thalassemia syndromes.
Thalassemia Major/Intermedia (Figs 7A and B):

Complete Blood Count
Complete blood count (CBC), examination of PBF and a
reticulocyte count can help in suspecting and identification
of hemoglobinopathies. CBC reveals generally severe
anemia, a high leukocyte count (due to immature myeloid
cells as well as nucleated red cellsalso known as a
leukoerythroblastic reaction). WBC and platelets may
decrease if there is accompanying hypersplenism.
The red cell indices reveal a severe hypochromia
with microcytosis. Patients in whom diagnosis is delayed
there is significant macrocytosis due to relative folate
depletion.
The red cell distribution width (RDW) in thalassemia
major is significantly high (ranging from 30 to 40% for a
normal value of 1216%), suggesting a very high degree of
anisocytosis. The peripheral smear shows a striking and
characteristic bizarre picture with hypochromic, microcytic

Table 5 Clinical and hematological features of the b-thalassemia syndromes1-4,6,7,9,11-17
Major
Intermedia
Severity of manifestations
genetics
++++
Homozygotes, double heterozygotes
Homozygotes, double
++
heterozygotes, rarely heterozygotes Heterozygotes
Splenomegaly
++++
++, +++
+, 0
Jaundice
++
++, +
Skeletal changes
++++, ++
+,0
+,0
Anemia (Hb, g/dL)
<7
710
>10
Hypochromia
++++
+++
++
Microcytosis
+++
++
Target cells
1035%
++
Basophilic stippling
++
Reticulocytes (%)
515
310
25
Nucleated red cells
+++
+, 0
Minor
B
Figs 6A and B Peripheral smear showing (A) Reticulocyte; (B) Target cell and normoblast
as well as macrocytic red cells, anisopoikilocytosis, target

cells, polychromasia (more common in thalassemia
intermedia), basophilic stippling, nucleated red cells and
sometimes immature myeloid cells (Figs 6A and B) .
Thalassemia Minor
The CBC in thalassemia trait is associated with high red
cell count relative to hemoglobin concentration and
hematocrit, resulting in a marked fall in mean cell volume
(MCV), mean cell hemoglobin (MCH) as well as mean cell
hemoglobin concentration (MCHC). RDW is normal in
thalassemia trait.
Reticulocyte count: Reticulocyte count is generally low
to normal in thalassemia major, whereas in thalassemia
intermedia, it is increased to 3 to 6 percent. The reason

for a low reticulocyte count in thalassemia major is
significant ineffective erythropoiesis preventing the
precursor red cells from maturing to reticulocyte stage
to be thrown into peripheral blood. In thalassemia
intermedia, since the ineffective erythropoiesis is milder,
the reticulocytes are increased in peripheral blood due to
the anemia.
Naked-eye Single Tube Red Cell Osmotic

Fragility Test (NESTROFT) for Thalassemia
Minor44-46
Many investigators have studied naked-eye single tube red
cell osmotic fragility test. The test has a high sensitivity of

In children with thalassemia major, the values of ferritin are
proportionate to iron overload due to multiple transfusions.
Serum ferritin estimation is used as the most common test
for diagnosing iron overload. However, ferritin can be
affected by various clinical situationsit may be elevated
in acute infections as an acute phase reactant, in chronic
diseases and chronic inflammatory disorders, etc.
Quantitation of Various Hemoglobins (Figs 8 and 9)

Separation of hemoglobins either by electrophoretic mobility
or chromatographic separation is the confirmatory investi
gation for diagnosis of thalassemia syndromes.
Quantitation of various hemoglobins can be done by the
following methods
Isoelectric focussing
Microcolumn chromatography
High performance liquid chromatography
Both anion and cationexchange HPLC
Cellulous acetate electrophoresis (Fig. 8A)
Paper electrophoresis (Fig. 8B)
In untransfused patients with thalassemia major, hemo
globin pattern reveals 20100% HbF, 27% HbA2 and 080%
HbA, the quantities varying depending upon the genotype.
Thalassemia minor is characterized by elevated HbA2 of
more than 3.4% on paper electrophoresis, and more than
4% by certain other method.
B
Figs 7A and B (A) Thalassemia major on irregular treatment;
(B) Thalassemia intermedia
95 percent, but its poor precision, interobserver variability

and low specificity has precluded it from becoming a
robust test.
Iron Studies47
Serum iron and transferrin saturation would be normal
to increased (increased especially in multiply transfused
children) in thalassemia major, whereas the total iron
binding capacity (TIBC) would be decreased. It is generally
normal to high even in thalassemia minor. Though iron
deficiency is extremely uncommon in thalassemia minor,
in our country, due to a high incidence of IDA, concomitant
iron deficiency may be present in children with thalassemia
minor. In such patients, serum iron level would be low with
reduced transferring saturation and a high TIBC.
Serum ferritin is high in children with thalassemia major
and normal to increased/decreased when concomitant
iron deficiency associated in those with thalassemia minor.
Microcolumn chromatography and HPLC,48,49 by

auto
mated machines (Fig. 9A) are now becoming
increasingly popular due to the ease of performing the
test, less time consumption and greater reliability and
reproducibility. It has thus become the gold standard
for diagnosis of thalassemia syndromes and other
hemoglobinopathies. It generates graphs depicting
various abnormal and normal hemoglobins with
quantification. HbA2 value of > 9 percent indicates
the presence of a co-eluting abnormal hemoglobin
such as Hb E, Hb D Iran and Hb Lepore. Microcolumn
chromatography and HPLC are currently used in most
laboratories. Hemoglobins are separated graphically
and quantified by photometer utilizing sophisticated
computer (Fig. 9B).
Radiological findings include widening of medulla due
to bone marrow hyperplasia, thinning of the cortex and
trabeculations and fracture are seen in long bones, metacarpals and metatarsals. X-rayskull AP and lateral views
show hair on endappearance (Figs 10A to C).
Tests Used for Estimating Iron Overload50-53

Liver iron concentration (LIC): This is done on a liver
biopsy tissue collected on a filter paper. Any level above
B
Figs 8A and B (A) Cellulose acetate electrophoresis; (B) Paper electrophoresis
Figs 9A and B (A) BIO RAD variant machine; (B) Pattern of hemoglobin in thalassemia minor/trait
Figs 10A to C (A and B) Thalassemia major X-ray skull; (C) Widening of medulla, thinning of the cortex and trabeculations,
and fracture in the long bones
7 mg/g of dry liver tissue is indicative of significant

iron overload. Levels above 15 mg/g is associated with
cardiac iron overload.
Superconducting quantum interference device
(SQUID)54,55 is a non-invasive method of estimating
liver iron and has proven to be more accurate than serum ferritin in quantifying the total body iron overload.
T2 weighted cardiac magnetic resonance imaging56-60
helps in accurately determining the cardiac iron
overload.

Bone marrow examination not indicated for the
diagnosis of thalassemia major but if done, it shows
normoblastic erythroid hyperplasia with excessive
iron on iron staining with Prussian blue.
Periodic tests for organ dysfunctions. While diagnosis
of thalassemia major can be achieved by the tests, it
is also mandatory to do baseline screening of various
parameters:
Liver function tests (LFT) especially serum bilirubin,
SGOT, SGPT, GGT, GTC (glucose tolerance curve).
Baseline HBsAg, HIV and HCV antibody test
Hormonal assays as and when required
DEXA scan for density of the bones.
Clinical Consequences, Diagnosis

and Management
Most of the complications of b-thalassemia are attributable
to iron overload. Excess iron is toxic to the heart, liver, and
various endocrine glands. In b-thalassemia, 70 percent of
deaths are due to cardiac complications. Growth failure
is seen in 30 percent of patients in the Western world and
nearly all patients in our country, and is due to various
factors including endocrine dysfunction. The other
factors responsible for growth failure include: anemia,
hypersplenism, desferrioxamine, and liver disease.
ENDOCRINE DYSFUNCTION61-64
The commonly affected endocrine glands include pituitary
gland, thyroid gland, parathyroid gland, pancreas, gonads.
Clinically, they may remain latent. Investigations should
be done in all patients at regular intervals to detect these

disorders and treat them appropriately.
Diabetes may be seen as early as 5 years of age
Short stature is commonly noted at 10 to11 years of age.
A glucose tolerance test, thyroid functions, serum
calcium and phosphorus should be monitored every
year, beginning at the age of 5 years and evaluation of
height velocity, 10 years age onwards, goes a long way
in early detection and treatment of these complications.
Management would depend upon the specific abnormality
found.
BONE DISEASE: OSTEOPENIA

AND OSTEOPOROSIS (FIG. 11)65-68
Osteopenia and osteoporosis are major causes of morbidity
in the aging thalassemic population, and it is suggested
that prevalence is higher in men than in women. It is more
severe in the spine than in the femoral neck.
Osteoporosis as defined by WHO as a progressive
systemic skeletal disease characterized by low bone mass
and microarchitectural deterioration of bone tissue, with
consequent increase in bone fragility and susceptibility to
fracture.
DEXA SCAN (Fig. 11) for assessing bone mineral
density (BMD)helps in identifying various bones
with osteopenia and osteoporosis.
Biochemical evaluation like serum calcium, serum
phosphorus, serum alkaline phosphatasehelp in
identifying vitamin D deficiency as well as hypo
calcemia, which may be due to hypoparathyroidism
Fig. 11 DEXA scan in a child with thalassemia

in addition to calcium deficiency related to vitamin D
deficiency.
Urinary calcium/Creatinine ratio >0.2 as well as urinary
Phosphorus/Creatinine ratio >0.6 are useful screening
parameters for suspecting osteopenia and osteoporosis.
Genetic factors also play a role in bone mineralization,
regulated by estrogen receptor gene, vitamin D receptor
(VDR) gene, COLIA1 and COLIA2 genes. Furthermore,
TGF-b1 has also been implicated as a possible mediator
of coupling between bone resorption and formation.
Testosterone, estrogen and progesterone are involved in
the regulation of bone mineralization and contribute to
the osteopenia and osteoporosis in thalassemic children.
Though studies have demonstrated iron deposition
along the mineralizing perimeter of the bone, there are
other factors influencing, such as anemia, which affects
erythroid activity.
Cardiac Complications69-71
Most of the complications of -thalassemia are attributable
to iron overload. Excess iron is toxic to the heart, liver,
and various endocrine glands. Iron overload causes
deposition of iron in the ventricular walls, mainly in the
left, relatively sparing the atria and the conduction system.
In the ventricular wall, the epicardium contains most of
the iron, the endocardium moderate with least iron in the
intermediate layer. When iron accumulation increases,
free iron damages the cells of the layers of the heart,
inducing lipid peroxidation and lysosomal rupture.When
iron accumulates in the cardiac tissue, free iron damages
the cells of the layers of the heart, due to lipid peroxidation
and lysosomal rupture. Cardiac failure and ventricular
arrhythmias are the main cause of death in patients with
b-thalassemia major and account for 70 percent of the
deaths.
Cardiac iron overload related heart disease may be
divided into three stages:
1. Preclinical
2. Early clinical
3. Advanced disease.
Early detection of cardiac involvement can be done
by evaluation of serum ferritin level regularly and then
doing the various tests to evaluate the cardiac functions
like ECG, 2D echocardiogram, stress test, etc. However,
these tests do not quantitate the cardiac function. T2
weighted cardiac MRI weighted cardiac MRI is the only
method of assessing accurately the severity of cardiac iron
overloading. In acute cardiac failure and arrhythmias,
continuous subcutaneous desferrioxamine can reverse
the ventricular dysfunction, whereas intravenous
desferrioxamine can improve complicated arrhythmias
and progressive heart failure.
In a study done at LTMG Hospital in 28 children with

thalassemia major above the age of 10 years, 3 children
had evidence of overt cardiomyopathy. Abnormalities
such as left atrial dilatation, aortic root dilatation, reduced
left ventricular internal dimension in systole and diastole
were seen in 20 (71.42%), 11 (39.28%), 6 (21.42%) and 10
(35.7%) children respectively.
Ejection fraction was decreased in 16 out of the 28
(57.14%) patients. Of these, 33.3 percent were chelated
adequately using deferiprone and 84.6 percent were
unchelated. Four (14.28%) of the 28 children had decrease
in fractional shortening.
Kaya SB et al.80 also reported 3 out of 28 patients between
the age group of 7 to 23 years with abnormalities on ECG.51-53
Since cardiac function has strong correlation with
chelation early institution of appropriate and regular
chelation and regular transfusion therapy to maintain pretransfusion Hb above 10 gm% will lead to better cardiac
function in these children. Early detection of cardiac
involvement can be done by evaluation of ferritine level
regularly and then doing the various tests to evaluate the
cardiac functions like ECG, 2D echocardiogram, stress
test, etc. However, these tests do not quantitate the cardiac
function. T2 cardiac MRI is the only method of accessing
accurately the severity of cardiac iron overloading.
Management of Thalassemia Major72-76

The management of thalassemia has undergone tremen
dous changes over the last 3 decades.
If untreated, patients of thalassemia major die by the
age of 3 to 4 years due to severe anemia.
With transfusion therapy alone, patients with thalas
semia major children died due to cardiac compli
cations (related to iron overload) as early as 10 to 12
years of age. However, with the advent of chelation
therapy as well as better screening procedures for
transfusion related infections as well as leukodepletion
through prestorage/bedside filtration, the lifespan
of these children have improved considerably. If no
complications occur, they live for an almost normal
span with an improved quality of life.
Management of thalassemia involves a multidiscipli
nary therapeutic team approach and should be preferably
done at a comprehensive thalassemia children care center
with outdoor transfusion facilities (Table 6).
Transfusion Therapy in Thalassemia77-79

Packed red cell transfusions remain the cornerstone of
therapy in thalassemia major. The decision to initiate
lifelong regular transfusions in patients with -thalassemia
should be based on the molecular defect, severity of
symptoms, and clinical criteria such as failure of growth,
development and bone changes.

Table 6 Thalassemia outdoor center
Team Members
Goals of Transfusion
To obviate anemia
To reduce
hepatosplenomegaly
by reducing ineffective
erythropoiesis
To reduce hemolytic faces
To improve tissue
oxygenation
To improve growth
Pediatric hematologist
Pediatrician
Dedicated nurses
Transfusion medicine
specialist
Physiotherapist
Endocrinologist
Psychologist and social
worker
without transfusions. If the hemoglobin drops to below

7 gm% without transfusion, in absence of any concurrent
illness, it is imperative to put the child on a regular
transfusion program. If the child maintains hemoglobin
above 7 gm%, the diagnosis of Thalassemia Intermedia
has to be considered.
Whenever possible, it is equally important to know
the compete genotype of the red cells to prevent red
cell alloimmunization following repeated transfusions.
However, this is not feasible in India and the alternative
to this is Coombs cross-match for each transfusion to
prevent alloimmunization.
TYPE OF TRANSFUSIONS (FIGS 12 AND 13

AND TABLE 7)
Progress in the Concept of Transfusion

Therapy for Thalassemia
In the 1960s, Wolman et al. proposed a palliative
transfusion therapy77 for children with thalassemia
major. It was aimed at maintaining the hemoglobin at
the level of 8.5 gm%. This led to improved survival, but
the chronic illness, bone disease and cardiomyopathy
persisted.
To overcome these problems, Piomelli and workers
suggested maintaining the hemoglobin.78 A above
minimum of 10 gm%. These vigorous regimens were
termed as hypertransfusion, although Normo-trans
fusion may be a more descriptive term. Hypertransfusion
promotes normal growth and development, prevents
the onset of severe hepatosplenomegaly and hemolytic
facies, lowers the absorption of gastrointestinal iron
and reduces the anemic cardiomyopathy changes.
In 1980, Propper and colleagues introduced a further
improvised regimen79 called supertransfusion, and
main
tained a pretransfusion hemoglobin of above
12 gm%. However this did not prove significantly
superior to hypertransfusions and was given up.
Hypertransfusion remains the most accepted regimen
in most parts of the world. However, in Europe, a yet
newer regimen termed the moderate transfusion
regimen has been adopted and recommended by the
Thalassemia International Federation. In this regimen,
pretransfusion hemoglobin is maintained between
9 and 10.5 gm%.
The most ideal way to transfuse thalassemics is using group

and type specific packed red cells that are compatible
Fig. 12 Cold centrifuge
INITIATION OF TRANSFUSION THERAPY

Before embarking on a lifelong transfusion therapy,
it is essential to establish the diagnosis firmly with
DNA analysis. This would help to know the severity of
thalassemia as well as would help in prenatal diagnosis for
future pregnancies.
One can ascertain the diagnosis of thalassemia
Intermedia by observing the rate of fall of hemoglobin
Fig. 13 Leukodepleting filters at bedside

Table 7 Various transfusion regimens (Progress in transfusion therapy)
Year of regimen
Transfusion regimen
Pretransfusion Hb
1960s
Palliative
Hb to 8.5 gm% (Wolman et al.)
1970s
Hypertransfusion
Hb 1012 gm% (Piomelli and workers)
1980
Supertransfusion
Hb > 14 gm% (Propper and colleagues)
2005
Moderate transfusion
Hb 910.5 gm% (European regimen)
by direct antiglobulin test. The hematocrit should be

standardized to 65 to 75 percent. This maintains the desired
viscosity as well as aids in calculating the yearly requirement
in a given patient. It is ideal to use prestorage leukodepleted
blood, however, the next best is to use leukodepleting filters
at bedside but they are also costly. An alternative to this is
use of triple saline washed red cells. The red cells should be
fresh, not more than 4 to 5 days old to maintain adequate
levels of 2,3-DPG. Various other methods of leukodepletion
are available, including use of frozen red cells (highly
expensive and impractical in developing countries), filtra
tion in the blood bank, use of apheresis, etc.
Neocyte transfusions to improve the survival of red cells
after transfusion, have been tried but with limited success.
Amount and Rate of Transfusions

Approximately 180 mL/kg of red cells are required to be
transfused per year in nonsplenectomized, nonsensi
tized patients to maintain the hemoglobin above 10 gm%,
whereas splenectomized patients require 133 mL/kg per
year. Even without hypersplenism, the requirement is 30
percent higher in nonsplenectomized patients (Table 7).
Rate of Transfusion
These red cells should be transfused 10 to15 mL/kg at the
rate of 3 to 4 mL/kg/hour every 2 to 4 weeks to maintain
the hemoglobin. Patients with cardiac decompensation
should be given red cells at the rate of not more than 1 to
2 mL/kg/hour.
Advances in Transfusion Therapy

Daycare Transfusion Center
Transfusions are given on an outdoor basis and hence
no hospitalization is required.
Children are more comfortable with the familiar staff
members.
There is less school absenteeism and parents lose
fewer work days.
The cost of the hospital stay is almost 5 times less.
There is no threat of contacting infections from other
patients in the wards.
Parents and children are happy to be with other
children and parents and discuss common issues of
thalassemia management.
Management of Complications of
Transfusion Therapy
A major problem encountered in the management of
thalassemia is iron overload. Regular red cell transfusions
to maintain hemoglobin and increased iron absorption
from GI tract due to ineffective erythropoiesis and conse
quent low hemoglobin in irregularly transfused children is
responsible for iron overload.
Transfusion Related Complications

Iron overload
Transfusion transmitted infections.
Adequacy of Transfusions
Iron Overload and Chelation Therapy
It is important to check the adequacy of transfusions to

achieve best results and manage thalassemics ideally.
In the first decade of life, normal growth confirms
adequate transfusions.
Also the number of normoblasts should be <5/100
WbCS in well-transfused children. This may be an
indicator in older children. However, this is not
applicable to those children who have not been
initiated on therapy early and adequately in early life.
Clinical Consequences, Diagnosis and Management

Most of the complications of b-thalassemia are attributable to iron overload. Excess iron is toxic to the heart, liver,
and various endocrine glands. In b-thalassemia, 70 percent
of deaths are due to cardiac complications. Growth failure
is seen in 30 percent of patients in the western world and
nearly all patients in our country, and is due to various
factors including endocrine dysfunction.
Iron Chelation Therapy80-112

The aims of chelation therapy are to reduce the serum
ferritin to below 1000 ng/mL and hepatic iron concentra
tion below 268 mmol/g of dry weight of liver. In addition,
iron chelation also promotes growth and gonadal function.
Established iron induced dysfunction of heart and liver
may improve with effective chelation therapy, however,
pituitary failure does not reverse. Improvement in thyroid
and glucose tolerance is seen.
Chelation therapy should be started when:
Serum ferritin level > 1000 ng/mL or above.
More than 10 transfusions
Hepatic iron concentration > 3.2 mg/g dry weight.
The standard available chelators used are:
Desferrioxamine (Desferal, DFO) (Figs 14A and
B): This was introduced in the early 1960s,82-90 but
its impact on the survival curves in thalassemic
patients was recognized 15 to 20 years later. This is
a hexa-dentate chelator and cannot easily mobilize
iron from intracellular compartment due to its
high molecular weight. It slowly binds iron to form
Ferrioxamine and does not bind with iron from
transferrin. 1 g of desferrioxamine binds 93 mg of iron.
Desferrioxamine (DFO) is the gold standard therapy
and is the most effective and safe iron chelator. Though,
desferrioxamine is the gold standard it has not become
popular particularly in the developing countries and
is preferred by only 10 to 15 percent of thalassemia
patients in our country. This is mainly due to its
high cost and the need for continuous subcutaneous
injection over 6 to 8 hours with the desferal pump.
Hence, many of the thalassemic children develop
complications related to iron overload and may

require to be given high dose intravenous desferal,
through the port or central line. This again is beyond
the reach of many children in developing countries.
The dose is 20 to 40 mg/kg/day given subcutaneously
over 8 to 10 hours for 6 nights a week with the help of
subcutaneous desferal infusion pump. In recent times,
methods of administration have improved with better,
more convenient smaller, lighter infusion pumps with
LCD display. Balloon pumps, pre-filled syringes of
desferal are available though they are prohibitively
costly.
Sixty percent of DFO chelated iron is excreted in
urine and 40 percent in stool.
Adverse effects include local reactions, auditory
and visual toxicity, growth retardation, severe Yersinia
spp. infections, etc. Rarely, pulmonary infiltrates and
renal toxicity has been encountered.
Intravenous desferal (Table 8): Intravenous desferal
can be given particularly in those with very high iron
overload through port-a-caths (central line). However,
it is not easy to maintain the central catheter and
infections are extremely common. However, high dose
desferal (100 mg/kg, 39 g/day) can be given in severe
hemosiderosis to prevent/reverse cardiac toxicity of
iron overload.
The dose for intravenous desferrioxamine is 50
to 100 mg/kg body weight. With depot preparation
of desferal there is slow release of desferrioxamine
leading to substantial plasma level of desferrioxamine
in the blood for longer period and hence urinary iron
excretion is sustained for longer period. This is more
effective than the conventional subcutaneous infusion.
B
Figs 14A and B Desferal infusion pumps

Table 8 Indication for intravenous desferrioxamine is indicated
in the following conditions
Cardiac complications
Very high ferritin level
During pregnancy
Prior to stem cell transplantation
Rarely in patients with persistent local reaction at injection site
Toxicity of Desferrioxamine
Minimal or no tachyphylaxis has been observed
When given parenterally there may be liberation of
histamine leading to bradycardia, hypo/hypertension,
rigors, headache, photophobia, feeling cold and hot,
etc.
When given subcutaneously local pain, indurations,
irritability and redness may occur
Visual abnormality may occur in 4 to 10 percent of
patients and includes decreased acuity of vi
sion,
peripheral field vision defects
Defective dark adaptation, thinning of retinal vessels,
retinal stippling, abnormal visual evoked responses
and cataract
High frequency sensory-neural hearing loss has been
reported in 4 to 38 percent of patients
Delayed linear growth accompanied by mild skeletal
abnormalities such as short trunk, sternal protrusion
and genu valgum.
As the auditory and visual toxicities are reversible, yearly
slit-lamp examination and audiometry are mandatory to
detect them early (Fig. 15).
Role of vitamin C: Ascorbic acid deficiency increases
insoluble iron90 (hemosiderin). Vitamin C helps in
conversion of hemosiderin into ferritin, from which iron
can be chelated. High doses of vitamin C can lead to
increased free radical liberation and lipid peroxidation,
resulting in tissue damage and rapid cardiac decompen
sation and even death. Addition of 100 mg of vitamin C
daily, prior to DFO therapy increases iron excretion.
Oral Chelator
Deferiprone (L1) (Fig. 16) or 1,2-dimethyl-3-hydroxypyridin-4-one (Kelfer)91-98 is a water soluble, bi-dentate molecule. It mobilizes iron from transferrin, ferritin and
hemosiderin. It has been licensed for use in India since
1995. It is used orally and is less expensive. The recommended dose for deferiprone for effective iron chelation
is 75 to 100 mg/kg body weight/day. Deferiprone/L1 has
a better protective effect on myocardial tissue as shown
in various studies. It also chelates zinc in addition to iron
Fig. 15 Slit-lamp examination of eye
Fig. 16 Kelfer capsules
and therefore, zinc supplementation is mandatory in those

receiving deferiprone.
Side-effects of Deferiprone
GI symptoms like nausea and vomiting
Pain in abdomen and diarrhea
Arthropathy
Neutropenia/Agranulocytosis.
Patients on deferiprone should be monitored with
monthly CBC, LFT, RFT besides clinical monitoring for arthralgia/arthropathy. It should be stopped in children who
develop arthropathy and cytopenias. It may be restarted
once the counts recover. In children with arthropathy, it
should be cautiously be restarted in a lower dose of 50 mg/
kg/day. If symptoms and signs recur, it should be discon-

tinued permanently. There are some controversial reports
of increased hepatic fibrosis due to L1.
Deferasirox99-101 or ICL670 (4- [3,5-bis (2-hydro
xyphenyl) -1,2,4-triazol-1-y1] benzoic acid), (Asunra,
Desirox, Deferijet, Desifer) is a new class of tri-dentate
chelators65-72 with a high specificity for iron. It is an orally
active chelating agent developed for the treatment of
chronic iron overload. The compound is an N-substituted
bis-hydroxyphenyl-triazole that was selected from more
than 700 compounds that were screened as part of a drug
development program. Deferasirox is able to mobilize
iron from both the hepatocellular and reticuloendothelial
source. It has ability to prevent myocardial cell iron uptake
and removes iron directly from myocardial cells, the liver
cells, the intracellular labile iron pool and the surface of
reticuloendothelial cells where iron is handed over to
transferrin. Iron is excreted predominantly in the bile and
hence in the feces.
This novel agent is well tolerated, with no major safety
concerns at doses up to 80 mg/kg/day. Iron excretion
is dose-dependent. The plasma half-life (1119 hours)
supports the once daily oral dosing regimen used in
subsequent clinical studies.
It is also approved by the US FDA for use in nonthalassemia related transfusional iron overload. The
drug is given orally as a single dose preferably in the
morning on empty stomach. The recommended dose
varies based on the serum ferritin levels and ranges
from 20 to 40 mg/kg once daily and requires monthly
monitoring of CBC, liver functions, renal functions,
urine protein estimation and annual audiometry and
ophthalmic examination.
Adverse Events
Include gastrointestinal disturbances causing abdo
minal pain, nausea, vomiting, diarrhea and occasio
nally constipation.
Headache, fever, anxiety and sleep disorders.
Hearing loss has been reported.
Nephropathy in patients with compromised renal
function can be life-threatening.
Hydroxybenzyl-ethylenediamine-diacetic Acid103,104
Hydroxybenzyl-ethylenediamine-diacetic acid (HBED)
was able to clear radiolabeled iron when administered
parenterally and that it remained active after oral adminis
tration. However, further evaluation in both iron-loaded
primates and humans revealed that the oral activity was
too small to be of value in the treatment of iron overload.
Recently Bergeron et al. continued the preclinical
evaluation of the efficacy and safety of HBED monosodium
salt for the treatment of both transfusional iron overload
and of acute iron poisoning in animals. Na-HBED was
as efficacious as DFO in iron-loaded monkeys, either as
a subcutaneous (SC) bolus or a 20-minute intravenous
infusion (IV). Na-HBED was about twice as efficient
as DFO in excreting iron. Safety evaluation showed no
systemic toxicity.
Pyridoxal Isonicotinoyl Hydrazone105

Pyridoxal isonicotinoyl hydrazone (PIH) was identified as
an effective iron chelator in 1979. PIH is a tridentate chelator
with a selectivity for iron comparable to that of DFO. Over
the years, various PIH analogs have been synthesized and
some of them, such as pyridoxal-benzoyl hydrazones, were
as much as 280 percent more effective than PIH. Studies
in iron-overloaded patients treated with 30 mg/kg/day of
PIH have much less than required iron excretion. However,
recently investigators have examined the chelating
potential of two additional PIH analogs, alone or in
combination with DFO in hypertransfused rats. The latter
studies have shown that the orally administered analogs
are about 2 to 6 times more effective than intraperitoneally
administered DFO in mobilizing liver iron in rats.
GT56-252106,107
Newer Iron Chelators
GT56-252 is a novel orally available iron chelator derived

from DFT that forms a 2:1 complex with Fe3+. Eighteen adult
patients with b-thalassemia received 3 to 8 mg/kg in 2 doses
with food or fasting. The compound was well tolerated,
with no related serious adverse clinical events, laboratory
abnormalities or changes in the electrocardiogram (ECG).
Further studies are in progress to define the effect of GT56252 on iron balance.
Desferrithiocin102
40SD02 (CHF1540)108,109
Desferrithiocin (DFT) caused kidney damage in rats on

prolonged oral DFT. The damage was believed to be due
to toxic effects of the Fe3+ complex, ferrithiocin. One of its
analogs, 4-OH-desaza-desmethyl-desferrithiocin, appears
to be less toxic while remaining biologically active as an
orally administered iron chelator in animal studies. This
analog may enter Phase I human trials shortly.
40SD02 is a new entity synthesized by chemically attaching

DFO to a modified starch polymer. The resulting high
molecular weight chelator has a prolonged half-life. A
Phase I study in 10 patients with thalassemia and chronic
iron overload showed that single doses of up to 600 mg/
kg of the compound were safe and well tolerated, and
stimulated a clinically significant amount of iron excretion.
Combination Therapy:
The Shuttle Hypothesis110,111
Additive and synergistic effects of combination of iron
chelators have been explained by the shuttle hypothesis.
The theory is that a bidentate (L1) or tridentate ligand with
access to a variety of tissues acts as a shuttle to mobilize
the iron from tissue compartments to the bloodstream,
where most exchanges with a larger hexadentate (DFO)
sink. The sink binds this iron irreversibly, promoting
its excretion. Experiments using a DCI assay showed that
simultaneous administration of L1 and DFO produced
shuttling of iron from L1 (shuttle) to DFO (sink).110,111
Clinical studies using DFO and L1 in combination have
confirmed this hypothesis. Several other combinations
exhibiting shuttle mechanism have been tried with
successHBED and L1 as well as ICL670A and DFO (in
experimental cells).
Management of Bone Disease in Thalassemia

Major: Osteopenia and Osteoporosis (Intervention
Recommended Based on BMD Result) (Table 9)65-68
Hormone replacement therapy with estrogen in females
and hCG for males improves bone density parameters.
Calcitonin, an inhibitor of osteoclasts, can reduce osteo
porosis and increase cortical thickness in thalassemic
children. Hydroxyurea, oral biphosphonates or injectable
pamidronate are other useful modalities.
Prevention of Osteopenia/Osteoporosis
Children with b-thalassemia should be encouraged to
indulge in moderate- and high-impact activities such
as walking, ballet dancing, aerobics, climbing, mild
sports, jogging, running, etc. to prevent bone changes.
The diet should be rich in calcium and vitamin D may
be supplemented. Hormone replacement therapy for
endocrine abnormalities needs to be administered.
Table 9 Management of osteopenia/osteoporosis

Category
Treatment
Normal
Diet + exercise
Osteopenia
Diet + exercise + calcium
Osteoporosis
Diet + exercise + calcium +

bisphosphonates
Established osteoporosis
Diet + exercise + calcium +

bisphosphonates + treatment
of fractures
Management of Cardiac Complications69-71

Investigations such as Holter monitoring, 2D-echo
cardiography and stress test assist in evaluating, but do
not quantitate, the cardiac function. T2 weighted cardiac
MRI58-62 is the only method of assessing accurately the
severity of cardiac iron overloading.
In acute cardiac failure and arrhythmias, continuous
subcutaneous desferrioxamine can reverse the ventricular
dysfunction, whereas intravenous desferrioxamine can
improve complicated arrhythmias and progressive heart
failure.
Transfusion Transmitted Infections113-126

The common transfusion transmitted infections seen in
these multiply transfused thalassemic children include
the following:
Hepatitis B and C
HIV
Yersinia spp.
Malaria
CMV.
Hepatitis B has been reported in 5 to 30.6 percent
amongst multiply transfused individuals in various
studies.
A study at LTMG hospital have reported hepatitis B
infectionrecent or past in 85 percent of cases at LTMG
Hospital, Mumbai, Maharashtra, India.
Stringent screening of donors and testing of all blood
bags for HIV, HBsAg and Anti-HCV has reduced the
rate of these transfusion-transmitted infections.
Additionally, it has been possible to effectively control
hepatitis B through transfusions by vaccinating with
hepatitis B vaccine, all children at diagnosis, with
double dose, intense regimen (0, 1, 2 and 12 months).
Boosters may be given at 5-year intervals.
Hepatitis C
The prevalence of hepatitis C is quite high in thalassemics
the world over, and more so in our country. Hepatitis C has
been reported in 39 percent of transfused thalassemics
(before it was mandatory to screen all blood bags for
HCV antibodies), whereas Narang et al.115 from Delhi
have reported it in 69 percent, on the other hand, Wonke
et al.116 reported HCV positivity in 11.1 percent and Sarin
et al.117 in 53.3 percent of cases. Agarwal et al.118 from
Mumbai, have reported hepatitis C in 16.7 percent of
cases.
Treatment of these patients is difficult, as it is highly
expensive. Interferons and Ribavirin are the commonly

used therapies. Pegylated interferons are obtained by
conjugating Intron A with polyethylene glycol. This pro
longs the activity of interferon allowing weekly dosing
instead of the conventional thrice weekly dosing.
Human Immunodeficiency Virus (HIV)

The occurrence of transfusion transmitted HIV has ranged
from 0 percent by Chaudhary et al.113,114 to 70 percent by
Currimbhoy et al. It has been reported in 10 percent of
children in one study by Manglani and Lokeshwar24 from
LTMG Hospital, Mumbai. Children with transfusion
transmitted HIV progress to AIDS over a period of 5 to 10
years unlike perinatally infected children, who progress quite
rapidly. They can be managed with antiretroviral therapy, as
per the national guidelines for children and adults.
Other infections commonly seen in these children
include malaria and CMV infections.123,124 CMV infection
can be prevented by reducing the leukocyte content of
packed red cells, either by pre storage filtration or using
bedside leukocyte filters. Also, use of red cells from CMVnegative donors and frozen red cells are other alternatives
in the developed world. Malaria has to be treated as
and when it occurs, as despite screening blood bags for
malaria, it would not be possible to identify all donors
harboring the parasite due to a low sensitivity and interobserver variability of peripheral blood smear evaluation.
Yersinia spp. infection is known to occur in iron
overloaded125,126 and desferrioxamine-treated patients.
If a patient on desferrioxamine comes with symptoms of
abdominal pain, diarrhea and vomiting, desferrioxamine
should be stopped immediately, appropriate stool culture
or blood serology undertaken and treatment with cotrimoxazole or aminoglycoside given.
Hypersplenism (Fig. 18)130-133

Hypersplenism may occur due to inadequate trans
fusions, alloimmunization, rarely autoimmune hemo
lysis complicating thalassemia major and chronic
liver disease. Splenectomy is recommended when the
transfusion requirement exceeds 200 to 250 mL/kg/
year of packed red cells.
Splenectomy should be deferred till 5 years of age.
Following vaccines should be given 3 to 6 weeks prior
to procedure
Meningococcal
Pneumococcal
H. influenzae type b
Lifelong penicillin prophylaxis should be advised.
Fig. 17 Leg ulcer in thalassemia
Gall stones127,128: With better management of thalassemia

with regular and adequate transfusions, the incidence of
gallstones has considerably decreased. However, those
who do not receive optimal treatment, may develop gallstones. Prophylactic cholecystectomy during splenectomy
has been recommended as a safe, standard procedure for
these patients.
Leg ulcers (Fig. 17)129: Ulceration around the ankles
is commonly seen in thalassemia intermedia and
inadequately transfused thalassemia major. This occurs
due to venous stasis, vaso-occlusion, anemia, and
local trauma. Treatment includes bed rest, increased
transfusions, wound care, and the use of local tissue
factors. Local irrigation of the wound with granulocytecolony stimulating factor (G-CSF)1 vial diluted in
normal saline has been found beneficial.
Fig. 18 Splenectomy

Hospitalize promptly whenever required for cultures
and antibiotic sensitivity and for IV antibiotics.
Treat the infection promptly with appropriate anti
biotics.
Curative Treatment
Stem Cell Transplantation (Fig. 19)134-139
Bone marrow transplantation offers the potential perma
nent cure, if an HLA-matched sibling donor is available.
Though expensive, it is cost-effective when compared with
the long-term ideal treatment.
Multiple pricks, blood transfusion hospitalization, can
be averted. The outcome of this procedure depends upon
the three factors:
1. Hepatomegaly
2. Hepatic fibrosis
3. Irregular chelation.
According to these factors, patients are classified into
three classes as follows:
1. Class I: None of the above factors.
2. Class II: One or two factors.
3. Class III: All of the above.
For those with none of these factors (Class I), the
success rate is about 93 percent, with one or two factors
(Class II), it is 85 percent and with all three factors (Class
III), it drops to a very low figure of 60 percent.
Umbilical Cord Stem Transplantation140-142

Umbilical cord stem cells collected from the cord of
unaffected fetus at delivery, can be used for transplantation,
even if partially matched. This has yielded better results in
some centers.
BMT in utero (Fig. 20)143,144: Research is underway
on BMT in utero, at 14 weeks of gestation. Since the
immune system is not developed at that time, there
would be no rejection and mothers purified stem cells
could be used, although the risk of GVHD would have
to be looked into.
Pharmacologic manipulation of HbF145,146: Various
drugs, which induce production of HbF, have been
tried in hemoglobinopathies with variable success.
These include butyrates, hydroxyurea, 5-azacytidine,
erythropoietin, etc.
Hydroxyurea147-150,154,155: Few studies on effect of
hydroxyurea in b-thalassemia major have been
published and have shown variable responses.
However, its efficacy in thalassemia intermedia has
been established. Similarly, in double heterozygotes,
the usefulness has been established.
Butyrates151-155: Similar results, as seen with hydroxyurea,
were seen with butyrates in b-thalassemia. Though
an increase in HbF has been documented, no sub
stantial increase in total hemoglobin or decrease in the
transfusion requirement has been reported.
Fig. 19 Stem cell transplantation (Courtesy: MR Lokeshwar)

lives for 50 years, then he would require 2000 units of
packed red cells, 15,000 desferrioxamine injections, which
translates into 1.5 lac hours of a needle in his body and ` 90
lacs for chelation alone (personal communication). This is
besides the cost incurred by the hospital where he receives
his regular treatment including packed red cell transfusions
and other medical care.
The birth of a thalassemic child thus places consi
derable strain not only on affected child and family but
on society at large. Therefore there is an emphasis for shift
from treatment to prevention of birth of such children in
future. This can be achieved by:
Fig. 20 BMT in utero
Erythropoietin156-158: It has shown no benefit when

used alone, but in combination with hydroxyurea, an
additive effect has been found, resulting in increase in
HbF as well as total hemoglobin.40
Gene Therapy159-161
Inherited disorders of hemoglobin remain desirable
targets for genetically based therapies. These genetically
based strategies aim at addition of a normal copy of the
human globin gene along with key regulatory sequences
to autologous hematopoietic stem cells. But this approach
has been impeded by a difficulty of attaining hightiter vectors. Recent advances in vector construction
have circumvented some of the problems limiting gene
transfer efficiency and regulation of transgene expression.
However, it will be some time before clinical application of
this therapy becomes a reality.
Prevention162-166
The cost of treatment of an average weight 4-yearold thalassemic child is around ` 90,000 to 100,000
annually in a private set-up. Therefore, not more than
5 to 10 percent of thalassemic children born in India
receive optimal treatment. Stem cell transplantation as
a curative treatment, which costs between 6 and 16 lac
rupees is out of reach for majority of children.
Besides bearing the cost of treatment, the psychological
stress to both the patient and the parents/family is
phenomenal.
It may be starling to know from a 15-year-old
thalassemic child the account of what he has undergone
so far. He has received around 250 units of packed red cells
and 4000 injections of desferrioxamine. He has had a needle
in his body for over 40,000 hours of his life. His family has
already spent ` 16,20,000 for chelation alone. If this child
Population Education167
Mass screening of high-risk communities for thalas
semia minor
Genetic counseling of those who test positive for
thalassemia minor.
Prenatal Diagnosis168,169
The question that arises in the mind is whether prevention
at a national level is cost-effective.
The answer to this is Yes, it is cost-effective and we
should strive to prevent the birth of a thalassemic child.
Prevention of thalassemia, is practical, feasible and
the answer to the agony of so many children, families and
nations.
The methods would include creating awareness
amongst high-risk communities about the prevalence and
the difficulties in management of this condition. Screening
young people amongst all high-risk communities before
marriage is the right way to go. If screening is performed
in childhood, it is often forgotten around the time, they get
married. Hemoglobin electrophoresis is the confirmatory
test to diagnose thalassemia minor or carrier status. All
at-risk couples need to be counseled about the prenatal
diagnosis to confirm the thalassemic status of the fetus.
Thus, every baby born to two carriers of thalassemia trait
should be screened in utero and termination should be
advised for those fetuses who are found affected, so that
no child or parent has to suffer the agony of management
of thalassemia.
Future research is directed at improving the prevention
strategies by diagnosis before the embryo is formed,
to reduce the psychological trauma of termination of
pregnancy. These newer methods include:
Preimplantation Diagnosis170-174
Biopsy of blastula: By washing uterine cavity after in vivo
fertilization. Analysis of a single blastomere from an eight
cell embryo after in vitro fertilization.
Preconception Diagnosis175
Analysis of the first polar body of an unfertilized egg and
then. Distinguish between eggs which carry the defective/
normal gene in vitro fertilization of normal egg.
SUMMARY
During the approach of a case with thalassemia, it is
necessary to suspect thalassemia by clinical evaluation and
doing simpler hematological parameter like CBC, Nestrof
test and confirm the diagnosis by estimating HbF and HbA2
and other abnormal hemoglobins by doing various test like
hemoglobin electrophoresis, column chromatography,
isoelectric focusing or microcolumn chromatography
and high performance liquid chromatography using
various instruments like Bio-Rad Variant. It is important
to anticipate complication due to iron overload involving
various organs and due to transfusion complications. It is
therefore necessary to evaluate organ functions at regular
intervals for early detection of complications.
Management of thalassemia involves a multi-disci
plinary therapeutic team approach and should be prefer
ably done at a comprehensive thalassemia children care
center with outdoor transfusion facilities..
Packed red cell transfusions remain the cornerstone
of therapy in thalassemia major. The decision to initiate
lifelong regular transfusions in patients with -thalassemia
should be based on the molecular defect, severity of
symptoms and clinical criteria such as failure of growth,
development and bone changes.
Hypertransfusion remains the most accepted regimen
in most parts of the world. Moderate transfusion regimen
has been adopted and recommended by the Thalassemia
International Federation. In this regimen, pretransfusion
hemoglobin is maintained between 9 and 10.5 gm%
(Pretransfusion Hb). The most ideal way to transfuse
Thalassemics is using group and type specific packed red
cells that are compatible by direct antiglobulin test. The
hematocrit should be standardized to 65 to 75 percent.
Best is to use leukodepleting filters at bedside.
Most of the complications of b-thalassemia are attribu
table to iron overload. Excess iron is toxic to the heart, liver,
and various endocrine glands. The goal of iron chelation
is to reduce the iron overload and subsequently maintain
ferritin levels below 1000 ng/mL. The standard available
chelators used are: Desferrioxamine (Desferal, DFO),
given by subcutaneous route, with the help of Desferal
pump over 6 to 8 hours 6 days in a week: Though ideal, its
cost and mode of administration lead to non-compliance,
especially in the developing world and more than 90
percent do not comply.
Oral iron chelators are available now deferiprone (L1)
or 1, 2-dimethyl-3-hydroxypyridin-4-one,or kelfer and
deferasiroxor, icl670(4-[3,5-bis (2-hydroxyphenyl) -1,2,4triazol-1-y1] benzoic acid), (asunra, desirox), with minimal toxicity, can be given orally in multiple dose or single
dose, thus improving compliance.
Stem cell transplantation is curative but out of reach
of many because of cost and nonavailability of matching
donor. Gene therapy for thalassemia is still under research.
Until last few decades, thalassemia was regarded as a uniformly
fatal disease and death was expected during the second
decade of life before adulthood. However, progress in the
understanding and management of the disease in last 3 decades
has improved prospects of survival such that they survive now
into 3rd and 4th decades of life. This is possible provided, they
receive the ideal treatment with good compliance. Thalassemia
should no longer be, therefore, seen as a disease of childhood.
Better management and improved survival has opened a new
chapter in the management of thalassemia beyond transfusions
and chelation therapy. Problems of adolescence, growth and
development, attainment of puberty and full sexual potential,
bone mineralization, proper education, suitable employment,
marriage and parenthood are some of the concerns that
require attention.
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Reprod. 2002;17:1158-65.
171. De Rycke M, Van de Velde H, Sermon K, Lissens W, De
Vos A, Vandervorst M, Vanderfaeillie A, Van Steirteghem
A, Liebaers I. Preimplantation genetic diagnosis for sicklecell anemia and for beta-thalassemia. Prenat Diagn.
2001;21:214-22.
172. Kanavakis E, Vrettou C, Palmer G, Tzetis M, Mastrominas M,
Traeger-Synodinos J. Preimplantation genetic diagnosis
in 10 couples at risk for transmitting beta-thalassaemia
major: clinical experience including the initiation of six
singleton pregnancies. Prenat Diagn. 1999;19:1217-22.
173. Varawalla NY, Dokras A, Old JM, Sargent IL, Barlow

DH. An approach to preimplantation diagnosis of betathalassaemia. Prenat Diagn. 1991;11:775-85.
174. Yesilipek MA, Karasu G, Erelen N, Uygun V, Akcan M,
Kupesiz A, et al. Successful hematopoietic SCT from nonidentical twins to two sisters with -thalassemia major by
using preimplantation genetic diagnosis and HLA typing.
Bone Marrow Transplant. 2011;46:1581-2.
175. Verlinsky Y, Ginsberg N, LifchezA, Valle J, Moise J, Charles
M. Strom. Analysis of the first polar body: preconception
genetic diagnosis. Hum Reprod. 1990;5(7):826-9.
18
Sickle Cell Anemia in Children
Sickle cell disease is a group of commonly inherited hematologic disorders. It is a single gene disorder, caused by a single point
mutation in the globin chain of hemoglobin leading to defective hemoglobin synthesis. Sickle cell disease involves the red blood
cells or hemoglobin and their ability to carry oxygen, hemolytic anemia, painful crisis, end-organ failure and various complications.
Sickle cell anemia is the first disease, described to be due to a molecular mutation. It is characterized by relentless pain and so the
African tribes chose different names for sickle cell disease; chwechweechwe, hemkom, nuidudim all describing the relentless pain.
HISTORICAL ASPECT
Sickle cell anemia has been prevalent in Africa for the 5,000
years or more. It was first described in 1910, by Dr James
Herrick in a dental student from Grenada who noticed
abnormally shaped RBCs under the microscope. These
cells looked like a sickle and so the name.1 He also coined
the term crisis to describe the acute episodes of pain.
Sydenstricker described the first pediatric case and
recognized that this disorder was a hemolytic anemia.2 It
was only in 1952 that sickle cell anemia was reported in the
tea garden laborers of Assam in India.
Types of Sickle Cell Gene Mutations

Sickle-cell gene mutation probably arose spontaneously
in different geographic areas, as suggested by restriction
endonuclease analysis.
There are five major mutations of the sickle cell gene.
In Africa, four of the major sickle haplotypes are associated
with different geographical areas:3,4
1. Senegal is located in Atlantic West Africa (515%)
2. Benin in central West Africa (5070%)
3. Bantu (also known as CAR) is in central Africa (15
30%)
4. Cameroon
5. In India and parts of Saudi Arabia, the African
haplotypes are not seen, but a unique ArabianIndian haplotype is found.5
Their clinical importance, arises from the fact that

some of them are associated with higher HbF levels, e.g.
Senegal and Saudi-Asian variants, and tend to have milder
disease.6
In Caribbean and in North American sickle cell
patients of African origin, 50 to 70 percent of chromosomes
are Benin, 15 to 30 percent of chromosomes are BantuCAR and 5 to 15 percent are Senegal.7,8 In Los Angeles,
38 percent of patients are Benin homozygotes (Benin/
Benin), 25 percent are Benin/Bantu CAR, 13 percent are
Benin/Senegal, 5 percent are Bantu CAR homozygotes
and 3 percent are Bantu CAR/Senegal.
Sickle cell disease is more commonly found in people
from tropical regions particularly sub-Saharan Africa,
India and Middle East which are endemic for malaria.9
Disease is found with equal frequency in males and
females.
Incidence and Prevalence of Sickle Cell

Disease
The prevalence of the disease in the United States is
approximately 1 in 5000, mostly affecting Americans of
Sub-Saharan African descent, according to the National
Institutes of Health.10 One in 600 African-Americans
will have homozygous sickle cell disease, one in 800 will
have hemoglobin SC disease and one in 1700 will have
Sickle- Thalassemia Syndrome. The sickle gene has an
Chapter-18 Sickle Cell Anemia in Children 191

incidence of 8 percent in African-American individuals.
The frequency of the gene can be higher in certain areas of
Africa. In the US, it has been estimated that 1,000 children
are born each year with sickle cell disease. One in twelve
African-Americans has sickle cell trait.10,11
Sickle cell disease primarily affects those of African
descent and Hispanics of Caribbean ancestry, but the trait
has also been found in those with Middle Eastern, Indian,
Latin American, Native American and Mediterranean
heritage.
Sickle cell disease is prevalent in many parts of India,
where the prevalence has ranged from 9.4 to 22.2 percent
in endemic areas.12
Sickle Cell Anemia and Malaria

Sickle cell anemia is closely related to malaria. It is
well known that sickle cell disease (SCD) is seen in
those regions of the world where malaria is endemic.
The presence of a sickle trait in an individual provides
natural protection against malaria.13 In persons with AS
(heterozygotes), when the parasite infects the RBC, it
causes the abnormal hemoglobin to sickle. This leads to
preferential phagocytosis of the parasitized RBCs by the
spleen14,15 leading to a decrease in the parasitemia and
therefore less severe disease, with a relative protection
from dying of malaria. It is believed that this mutation
arose by the process of natural selection.
Pathophysiology
The sickle mutation is a GAG-GTC conversion. The
resultant sickle hemoglobin differs from normal adult
hemoglobin by alteration of one amino acid in the -globin
subunit at the sixth position of the b-globin chain.16 Sickle
chain has hydrophobic valine instead of hydrophilic
glutamic acid in the sixth position of the -globin chain.
The properties of hemoglobin S result in the clinical
manifestations of sickle cell disease.
Normal red blood cells, owing to their elasticity, can
deform while passing through the capillaries. In sickle cell
disease, presence of hypoxia, acidosis, deoxygenation,
high percent of Hb S, high MCHC, dehydration, fever,
acidosis promote red cell sickling due to formation of gellike substance containing Hb polymers called tactoids.
Repeated episodes of sickling, damage the cell membrane
and decrease the elasticity of the red blood cell.
Thus, the pathophysiology of sickle cell disease can be
based on:
1. Hb S polymerization
2. Increased adhesion of sickle RBC to endothelium
3. Hemolysis
Hb S Polymerization
As the RBC passes through the microcirculation there is
deoxygenation which causes conformational changes
in the Hb molecule. Due to the hydrophobic valine, and
interactions between two valine molecules, a polymer
is formed which later progress into helical fibers which
group together, stiffen and give rise to the characteristic
sickle shape. So, the polymerization of hemoglobin S is the
primary event in the molecular pathophysiology of sickle
cell disease and results in distortion of the shape of the red
blood cell and a marked decrease in the deformability of the
red blood cell. The resulting loss of red blood cell elasticity
plays a key role in the clinico-pathologic manifestations of
sickle cell disease. These cells thus assume a rigid sickle
shape and are unable to regain the normal biconcave
shape even after reoxygenation. Consequently, these rigid
blood cells are unable to deform while passing through
narrow capillaries resulting in vascular occlusion and
ischemia and are also hemolysed. These rigid sickle cells
are responsible for the vaso-occlusive phenomenon and
hemolysis which are characteristic of this disorder.
Data regarding the initial trigger for vaso-occlusive
crisis shows that there is contribution of the vascular
endothelium, complex cellular interactions and a global
inflammation mediated cell activation. The presence
of anemia is due to hemolysis of abnormally shaped
red blood cells. The presence of other hemoglobins in
the red blood cell, such as hemoglobin F, hemoglobin
A, hemoglobin C, and hemoglobin O, has an effect on
the sickling phenomenon and on the polymerization of
hemoglobin S. Hemoglobin F has the most profound antisickling effect, followed in order by hemoglobin A, C, and
O. Elevated levels of hemoglobin F can modify the clinical
and hematological effects of sickle cell disease and prevent
polymerization of hemoglobin and thereby sickling of red
cells.
Increased Adhesion of RBCs to Endothelium

Abnormal adhesion of sickle RBCs is initiated by young
RBCs called stress reticulocytes. These cells are thrown out
prematurely into the circulation from the bone marrow.
By virtue of their surface receptors, alpha 4 beta1 integrin
or VLA-4 (very late antigen 4), these cells bind directly to
the VCAM1 on the endothelial surface. CD 36 on the RBC
as well as on the endothelium are bound via a molecular
bridge the plasmatic thrombospondin.
It is not only the RBCs but the polymorphs and
platelets also that participate in the slowing of blood in the
microcirculation.
Hemolysis
In addition to causing anemia, it also has other deleterious
effects. Heme is the most powerful scavenger of NO or
nitric oxide which is a vasodilator. Hemolysis also releases
erythroid arginase in plasma, which degrades L arginine,
the substrate of NO producing enzyme endothelial NO
synthetase. Thus, NO levels are reduced by increase in
scavenging as well as a decrease in production all leading
to vasoconstriction and slowing of blood. Hemolysis of
abnormally shaped red blood cells during their passage in
the microcirculation results in anemia. The bone marrow
production of red blood cells does not match the rate of
destruction. The sickle cells have a shortened life span of
10 to 20 days as compared to the normal RBC lifespan of
90 to 120 days.
Genetics of Sickle Cell Anemia

Sickle cell disease is an autosomal recessive disorder
caused by a point mutation in the sixth codon of the
-globin gene found on chromosome 11 coding for
valine instead of glutamine. The disease includes various
genotypes containing at least one sickle gene where Hb S
constitutes > 50 percent of all hemoglobin.
Sickle Cell Syndromes

The common sickle cell syndromes are:
Heterozygous sickle cell anemia (AS)
Homozygous sickle cell disease (SS)
Sickle-beta thalassemia (0 or +)
Compound heterozygotes sickle cell disease
SD Punjab disease
SO Arab disease
Sickle E syndromes
Sickle syndrome
Sickle C syndrome.
Sickle Cell Trait or Carrier State

Heterozygous form (HbAS), where only one -globin gene
is affected, i.e. one parent is a carrier of Hb S mutation and
the other is normal, all the children will be phenotypically
normal, however 50 percent will have sickle trait or will be
carriers. Sickle cell trait is usually asymptomatic with Hb S
constituting 40 percent of the total hemoglobin.
Homozygous Sickle Cell Disease

Sickle cell anemia is the homozygous form (Hb SS) where
both -globin genes carry the mutation. It is the most
severe type and Hb S is as high as 90 percent of the total
hemoglobin. Thus, if both parents are carriers, they are at
risk for passing the gene on to a childthere is a 25 percent

chance of having sickle cell anemia, 50 percent chance of
being a carrier like the parents and a 25 percent chance
of being unaffected. This means that there is a three in
four chance or 75 percent chance for the child to not have
sickle cell disease.
Compound Heterozygotes
Where one -globin gene is affected with sickle cell
mutation and the other gene includes mutations associated
with Hb C (HbSC), Hb -thalassemia (Hb S-thal/Hb S+ thal, Hb D, Hb O Arab, hereditary persistence of fetal Hb
with variable clinical manifestations.
Sickle- Thalassemia Syndrome

Has two forms, Sickle- thalassemia and Sickle-+
thalassemia. The sickle- thalassemia individual is not
able to produce any hemoglobin A due to a complete
deletion of the beta-globin gene. In sickle-+ thalassemia,
there is a partial deletion of the hemoglobin gene and the
patient is able to make a variable amount of hemoglobin A.
The amount of hemoglobin A will be less than the amount
of hemoglobin S.
In general, hemoglobin SS disease is the most severe
of the sickle syndromes followed by hemoglobin S-0
thalassemia, hemoglobin SC and finally hemoglobin S-+
thalassemia. The typical hematological values of these
sickling syndromes are shown in Table 1.
Diagnosis of Sickle Cell Anemia

CBC and Routine Laboratory Testing
Mild to moderate anemia (59 g/dL) with decreased
hematocrit (2030%). The anemia is usually normocytic
normochromic unless associated with alpha or beta
thalassemia or iron deficiency in which case microcytosis
and hypochromia may be present. MCV may be on the
higher side due to reticulocytosis.
Peripheral smear: The peripheral blood smear may
show sickled red cells, typically irreversibly shaped
sickle cells, polychromasia indicative of reticulocytosis,
target cells and Howell-Jolly bodies (RBCs with nuclear
remnants) indicative of asplenia.
Reticulocyte count is elevated (Fig. 1.1) (315%).
Table 1 Sickle cell syndromes hematological values
Type
Hb (g/dL)
MCV
Severity
SS
78
nL
++++
S-thal
810
<70
+++
SC
1011
nL
++
S thal
1112
<70
+

However both these tests cannot distinguish between
sickle cell disease and trait.
Hemoglobin Electrophoresis
Fig. 1 Peripheral smear showing reticulocytes

(Courtesy: MR Lokeshwar, India)
There is unconjugated hyperbilirubinemia.

Decreased serum haptoglobin.
Increased plasma hemoglobin levels.
Increased serum lactate dehydrogenase levels.
Hemoglobin Solubility Test

Hb S is an insoluble hemoglobin molecule. It forms tactoids
or crystals when in the reduced state in high phosphate
buffer solution. These crystals refract and deflect light rays
and produce turbidity.
Sickling Test
Addition of sodium metabisulfite induces sickling of red
cells, on the blood film (positive sickling test). It is done to
diagnose sickle cell anemia or when there is an abnormal
electrophoretic or chromatographic hemoglobin fraction
in the position of Hb S, e.g. Hb D or G.
Method of sickling test: Sodium metabisulfite reduces the
oxygen tension inducing the typical sickle shape of red
blood cells.
The method is as follows: A drop of fresh anticoagulated
blood is mixed with 1 drop of 2 percent sodium
metabisulfite solution on a microscope slide. The solution
is freshly prepared each time. A cover slip is placed and
the edge is sealed with wax/vaseline mixture or with nail
varnish. It is allowed to stand at room temperature for
1 to 4 hours. Under the microscope, in positive samples
the typical sickle-shaped red blood cells are seen. False
negative results may be obtained if the metabisulfite has
deteriorated or if the cover slip is not sealed properly. It
is important to examine the preparation carefully and in
particular near the edge of cover slip.
It helps to differentiate individuals who are homozygous

for Hb S (Hb SS) from those who are heterozygous by
demonstrating either a single band of Hb S (in Hb SS) or
Hb S with another mutant hemoglobin (in compound
heterozygotes). This is the definitive test for sickle cell
anemia. HbePP on cellulose acetate electrophoresis is the
usual method for Hb electrophoresis. However Hb S, G
and D have the same electrophoretic mobility. On citrate
agar electrophoresis, at ph 6.2, Hb S is separated. The most
commonly used method is by the variant machine.
Only Hb S with an HbF concentration < 30 percent
Sickle cell anemia. A homozygous patient will have
hemoglobin SS (8090%), hemoglobin F (220%) and
hemoglobin A2 (24%).
A carrier patient will have Hb S (3540%) and
hemoglobin A (6065%).
Hb S is predominant, Hb F < 30 percent, Hb A2 is
elevated - Hb Sbeta-0 thalassemia.
Hb S > A and Hb A2 is elevatedHbSbeta+thalassemia.
Hb A2 level is normalto consider the possibility of
concomitant Hb SS and iron deficiency.
Hb S and Hb C concentration in roughly equal amounts
Hb SC disease.
The test may be inaccurate in a patient who has
recently received blood transfusions.
Newborn Sickle Cell Disease Screening

The introduction of newborn screening has been a great
advancement in the management of sickle cell disease
as infants with sickle cell disease are healthy at birth and
develop symptoms only after decline of fetal hemoglobin.
Such programs help in early recognition of affected
infants, early intervention to reduce morbidity and
mortality and to provide anticipatory guidance for parents.
The most commonly used techniques for newborn
diagnosis are thin layer/isoelectric focusing and highperformance liquid chromatography.
Repeat hemoglobin electrophoresis, if found abnormal
and again at six months, to confirm the hemoglobinopathy.
It is recommended to conduct a complete blood count and
hemoglobin analysis on the parents to confirm diagnosis
and offer genetic counseling. In newborn screening, the
patterns of hemoglobin are reported in decreasing order
according to the quantities detected.
FS pattern: Newborns with sickle cell anemia (Hb SS)
have this pattern with predominant Hb F and small
amount of Hb S and no Hb A. It may also be found in

newborns with sickle cell-beta-0 thalassemia, sickle
cell-hereditary persistence of fetal hemoglobin. Family
studies help confirm diagnosis, in case of sickle cellbeta-0 thalassemia, one parent has sickle cell trait and
the other beta thalassemia minor.
FSA pattern: This pattern is supportive of sickle cellbeta+ thalassemia.
FAS pattern: Newborns with sickle cell trait have this
pattern.
FSC pattern: This is supportive of a diagnosis of Hb SC.
AFS pattern: This is suggestive of transfusion prior to
the test or an error.
All patients screened to have either sickle cell disease
or trait must be started on penicillin prophylaxis until the
final diagnosis is determined. Due to clinical implications
of a diagnosis of either sickle cell disease or trait, the need
for repeat hemoglobin analysis at a later age must be
emphasized.
Imaging Studies
Radiological abnormalities and stroke evaluation are
carried out as and when required to evaluate extent of
the lesion. If a CT scan is ordered, it is preferable not
use contrast until the hemoglobin S concentration
can be reduced below 30 percent. If available, MRI is
preferable.
Ultrasonography: This can be used to visualize stones
and detect signs of thickening gallbladder walls or
ductal inflammation, indicating possible cholecystitis.
Prenatal Diagnosis
Parents with a child suffering from sickle cell disease or
those at risk of having a child with sickle cell disease, often
seek prenatal diagnosis and termination of pregnancy in
case of an affected fetus. However, patients with sickle cell
disease have a great variation in the symptoms despite
having the same mutation and therefore, it is as yet not a
very useful test.
Clinical Features of Sickle Cell Disease

There are great variations in the manifestations of sickle
cell disease (Fig. 2). Clinical features of sickle cell disease
are due to the intermittent episodes of vascular occlusion,
tissue ischemia/reperfusion injury and hemolysis, all
of which lead to multiorgan dysfunction as well as pain.
Hypercoagulability, hyposplenia and infections also
contribute to the clinical spectrum of sickle cell disease.
Symptoms do not develop in the first 6 to 12 months of
age due to elevated levels of hemoglobin F, in circulation.
After infancy, the red cells of a patient with sickle cell
anemia will have 90 percent hemoglobin S (Hb S), 2 to

10 percent of hemoglobin F (Hb F) and normal amounts
of minor fraction of adult hemoglobin A2 (Hb A2). Adult
hemoglobin A (HbA), which increases at 3 months of age,
is absent.
The most common clinical manifestation of sickle
cell anemia is vaso-occlusive crisis. It occurs due to the
sickled red blood cells obstructing the capillaries causing
ischemic injury to the organ. Factors precipitating vasoocclusive crisis include hypoxia, acidosis, dehydration,
infection, changes in body temperature.
The clinical features of sickle cell anemia occur
secondary to the physiological changes in the RBCs leading
to various acute and chronic complications. When Hb S is
deoxygenated the Sol (soluble) form of Hb changes to Gel
form of Hb to form rigid, sickle shaped tactoids, and they
polymerise forming insoluble structure. RBC membrane
becomes more fragile. Upon reoxygenation the sickle cell
initially resumes normal configuration, but with repeated
cycles of sickling and unsickling, fixation of membrane
occurs leading to irreversible sickle cell formation and
hemolysis.
Manifestation of Sickle Cell Anemia

Anemia
Patients are well compensated due to chronic nature of
anemia. Anemia may be complicated by secondary folate
deficiency. This is due to increased RBC turnover and
folate utilization. Periodic episodes of hyperhemolysis
may occur. All patients are universally anemic and are
hemolytic in nature. Repeated cycles of deoxygenation
and morphologic sickling irreversibly damage the red
cell membrane and result in hemolysis. Bone marrow
increases red cell production but is unable to compensate
for the rate of hemolysis. This results in moderate-tosevere anemia. Thus patients may simply be found to be
jaundiced or pale. Patients may show few manifestations
of anemia as they readily adjust by increasing their heart
rate and stroke volume (compensated). Though they may
be able to carry out daily activities in a normal fashion,
their tolerance for exertion is limited.
Splenic sequestration is an anemic crisis. It is a life
threatening medical emergency in children with
sickle cell anemia. It occurs due to pooling of blood
and trapping of deformed RBCs in the narrow splenic
vessels. This causes rapid, painful enlargement of
spleen, precipitous fall in hemoglobin, hypovolemic
shock and persistent reticulocytosis. It tends to
occur with higher frequency in infants and has been
reported as early as few weeks of age. Spleen suddenly
becomes enlarged and traps blood cells. The platelet
Fig. 3 Sickle cell anemia with hepatosplenomegaly

Fig. 2 Site of manifestations of sickle cell disease

(Courtesy: Swati Kanakia, India)
count often is slightly decreased. It occurs due to

pooling of blood and trapping of deformed RBCs in
the narrow splenic vessels. Hypovolemic shock occurs
if a large volume of blood is trapped or sequestered.
Hemoglobin levels dramatically drop from baseline
values and the reticulocyte count is elevated. In
Figure 3, a child showing the sickle cell anemia with
hepatosplenomegaly.
Treatment includes early diagnosis and aggressive
management in the form of intravenous fluids and
blood transfusion. The mortality rate may be up to 10
to 15 percent before transfusion therapy. Sequestration
crisis may be recurrent in 50 percent of the survivors
and hence splenectomy is recommended after the first
acute event.17 Parents should be educated about the

signs and symptoms of sequestration and to palpate
the spleen to recognize sudden increase in the size of
the spleen so that early treatment may be sought.
Aplastic crisis is also an anemic crisis. This is a serious
complication leading to worsening of anemia resulting
in pallor, tachycardia and fatigue. Aplastic crisis is
precipitated by parvovirus B-19 infection which infects
the red blood cell precursors in the bone marrow
thereby affecting red blood cell production. Impaired
red blood cell production that lasts for a few days can
cause an abrupt life threatening crisis in patients with
sickle cell anemia due to decreased lifespan of RBCs
(1020 days). Initial reticulocytopenia is followed by
brisk reticulocytosis as bone marrow spontaneously
recovers in a few days to a week. The spleen usually
is not enlarged over baseline. Management includes
packed red cell transfusion.
Vaso-occlusive Crisis
Pain resulting from vascular occlusion and ischemia and
can occur abruptly. Pain may be accompanied by malaise,
fever, and leukocytosis. It is the leading cause of emergency
department visits and hospitalizations, causing disruption
of daily life with pain lasting for several hours to days and
occurs in any part of the body particularly extremities,
bones, chest, abdomen. Bone pain occurs due to bone
marrow infarction particularly due to obliteration of
nutrient arteries of bone. Hence the site of involvement
changes with the site of maximum bone marrow activity.
Factors precipitating vaso-occlusive crisis include hypoxia,
acidosis, dehydration, infection, changes in body, bone
marrow infarction, etc. and since marrow activity changes
with age, site of infarction also changes.
Fig. 4 Dactylitis (Hand-foot syndrome)

Dactylitis (Hand-foot syndrome) (Fig. 4): The usual

presentation is symmetric or unilateral swelling of the
hands and/or feet which may be relieved with pain
medication such as acetaminophen and codeine and
supportive measures. Osteomyelitis must be ruled
out in all cases as they may have similar presentation
but require different line of management. It is one of
the earliest clinical manifestations of pain in children
with sickle cell anemia. Up to 18 months of age,
the metacarpals and metatarsals are active part of
erythropoiesis and are involved presenting as dactylitis
or hand-foot syndrome. Occurs in 50 percent of the
children by 2 years of age. Episodes are frequently
recurrent. Clinical involvement may be limited to a
single phalanx or metacarpal or may involve all small
bones of all small extremities.
Radiologic changes become evident after a
few days and include patchy areas of osteoporosis
and sclerosis, periosteal new bone formation, and
occasionally apparent disappearance of a bone.
Resolution is usually complete both radiologically
and clinically although occasionally premature fusion
occurs causing permanently shortened, deformed
small bones. The long bones of the extremities which
retain marrow activity as the child grows older are
affected during childhood. During adolescence, as
the marrow activity recedes further, pain involves the
vertebral bodies of the lumbar region.
Abdominal pain: Patients may present with acute

abdomen due to severe pain which may be due to
mesenteric vein thrombosis, referred pain or secondary
to underlying organ or soft tissue infarction.
Majority of the pain episodes are short lived and can
be managed at home with pain medications and other
comfort measures (heating blanket, relaxation technique
and massage). Specific therapies for pain include
acetaminophen and NSAIDs in conjunction with oral/
IV opioids and their derivatives. Optimal maintenance
oral/intravenous fluids to maintain hydration must
be initiated in hospitalized children. The 2003 BCSH
guidelines recommend use of oral analgesia for treatment
of pain although severe pain is best managed with
parenteral analgesics.18 Morphine is the drug of choice
and dosing must be individualized for each patient. It
should be given hourly followed by three hourly dosing
once effective analgesia is achieved. Patient-controlled
analgesia may also be helpful. Sleeping through the night
may be an indication to decrease dosing by 20 percent
the next morning. Decreasing analgesia dose at night is
not advisable as pain is often worse at night. After 24 to
48 hours, when pain is controlled, patient may be shifted
to sustained-release oral morphine and discharged from
the hospital with gradual tapering of dose over several
days. Pain must not be undertreated due to fear of opioid
addiction or dependence as they seldom occur due to brief
duration of painful episodes (57 days). Blood transfusion
does not help to decrease intensity or duration of a painful
episode and is indicated in patients with hemodynamic
instability due to decreased hemoglobin. Hydroxyurea
may decrease frequency and severity of pain episodes.
Neurological Complications
It is most prevalent in childhood and adolescence though
it may be found as early as 1 year of age. Involvement of the
nervous system due to sickle cell anemia may have a varied
presentation such as headaches, seizures, cerebral venous
thrombosis and reversible posterior leukoencephalopathy
syndrome of which stroke is the most serious manifestation
in 10 to 15 percent patients of SCD. Infarcts are usually
ischemic in children and hemorrhagic in adults.19 While
it is unusual for children to have strokes, approximately
11 percent of patients with sickle cell anemia have strokes
before they reach the age of 20 years. Hemiparesis is the
usual presentation.
Overt stroke, occurring in 11 percent of the children, is
defined as the presence of focal neurological deficit lasting
for > 24 hours and/or evidence of a cerebral infarct on T2
weighted MRI of the brain corresponding to the deficit.
The presence of a cerebral infarct on T2 weighted MRI
of the brain in the absence of a focal neurological deficit

lasting for > 24 hours is defined as a silent stroke. These
silent infarcts occur in 20 percent of the children and tend
to cause progressive decline in cognitive function, affect
learning and behavior and increased risk of epilepsy as
compared to general population.20
Management of a patient presenting with focal
neurological deficit includes:
Oxygen administration to maintain saturation > 96
percent.
Blood transfusion initiated within 1 hour of
presentation to increase hemoglobin up to 10g/dL.
Transfusion therapy to maintain Hb S level < 30
percent is the mainstay of therapy for primary and
secondary prevention of strokes.21 This strategy results
in 90 percent reduction in the rates of overt strokes.
Transfusion therapy must be continued indefinitely for
there is increased risk of stroke on stopping.22
Convulsions frequently are associated with stroke.
Primary prevention of strokes can be achieved by
transcranial Doppler (TCD) measurement of the
blood velocity in the circle of Willis and values of
> 200 cm/sec suggest a high risk of stroke even before
lesions become evident on MRI.
Chelation therapy must be given after 2 to 3 years for
iron overload from repeated transfusions.
Acute Chest Syndrome

Acute chest syndrome (ACS) is defined as combination
of respiratory symptoms, along with fever, cough,
respiratory distress, chest and/or back pain, and new
lung infiltrates.23,24 It is the second most common cause
for hospital admission in children with sickle cell anemia
and a common cause of death.23,25 In young children, it is
usually due to infection. Older children and adults have
infarction more often. ACS is most frequently preceded by
a painful episode requiring opioids.
Emergency management of ACS includes supplemen
tal oxygen and simple or exchange transfusion.
Continuous pulse oximetry monitoring is required and
oxygen therapy is initiated when room air saturation is <
90 percent. The aim of blood transfusion is to reduce Hb S
level < 30 percent and when administered early may help
prevent further respiratory complications and need for
supplemental oxygen.
The etiology of ACS is multifactorial including pulmonary
infarction, fat embolism due to bone marrow infarction
and more commonly infection. Due to similar clinical
presentation of pneumonia and ACS and infection being
a common causative factor, it is essential to start empiric
antibiotic therapy with a third generation cephalosporin
and a macrolide. S.pneumoniae, Mycoplasma and
Chlamydia species are common organisms.26 Other
treatment measures include adequate analgesia and fluid
management. Patients with coexistent asthma should

be treated promptly with bronchodilators and steroids.
Incentive spirometry and chest physiotherapy can help
to reduce the frequency of episodes of acute chest pain.
Prevention of recurrent episodes of ACS can be achieved
with chronic transfusions and hydroxyurea which reduces
the rate of episodes by 50 percent.
Avascular Necrosis of the Femoral or Humeral Head

Avascular necrosis (AVN) of the femoral head presents a
greater problem due to weight bearing (Fig. 5). Vascular
occlusion can result in avascular necrosis and subsequent
infarction and collapse at either site. Subjects with highbaseline hemoglobin are at increased risk. Approximately
30 percent of all patients have hip pathology by age 30
years.
Infection
Infection is a major cause of morbidity and mortality in
patients with sickle cell anemia. These children are prone
to life threatening infections as early as 4 months of age due
to hyposplenia or functional asplenia. These patients are
more prone to infections by encapsulated organisms such
as Streptococcus pneumoniae and Haemophilus influenzae
type b and Salmonella responsible for osteomyelitis.
Sickling of red cells within the spleen results in multiple
episodes of splenic infarction, leading to functional
asplenia (autosplenectomy) which occurs in most
children by 5 years of age. In addition, they may also have
abnormal IgM and IgG responses, defects in the alternate
pathway complement fixation and opsonophagocytic
dysfunction.27,28
The two major measures in preventing infections
in these children are penicillin prophylaxis and
immunization for all patients.
Fig. 5 Avascular necrosis (AVN) of the femoral head


Oral penicillin V in a dose of 125 mg twice daily should
be started at 2 months and given till 3 years of age after
which it is increased to 250 mg twice daily till 5 years of
age.
Most clinicians stop prophylaxis at 5 years of age
provided the child has not had prior pneumococcal
infection or splenectomy and has received pneumococcal vaccine.29
Patients who are allergic to penicillin should be given
erythromycin 10 mg/kg twice a day.
Children with sickle cell anemia should receive all
the routine childhood immunizations including
those against Streptococcus pneumonia, Haemophilus
influenzae type b, Neisseria meningitidis, seasonal
influenza, hepatitis B. Fever may be the first sign of
bacterial infection in these children prone to fulminant
and life threatening infections.
Thus, fever must be considered a medical emergency
requiring prompt medical attention and antibiotic
therapy. The factors with high risk for invasive infection
requiring inpatient management:30
Children younger than 2 years with hemoglobin SS
(Hb SS) or hemoglobin S- thalassemia
Temperature >40C
WBC > 30,000 mm or < 5000 mm
Hemoglobin < 5g/dL
History of previous bacteremia (due to increased risk
of recurrence)
Presence of indwelling catheter.
Signs of systemic toxicity, hemodynamic instability
and/or meningitis
Prior treatment with vancomycin or clindamycin
instead of ceftriaxone due to short half life of these
medications.
All patients must be immediately started on empiric
antibiotic therapy with a 3rd generation cephalosporin and
may be discharged after a 24 to 48 hours afebrile period
with duration of antibiotic therapy titrated as per culture
reports. Outpatient management may be considered in
those without risk factors. Another distinct infection in
these patients is osteomyelitis, most commonly caused
by Salmonella spp. Hence all patients with persistent pain
and fever or bacteremia due to Salmonella spp. must be
evaluated for osteomyelitis with a definitive bone scan.
Unhealed Ulcers (Fig. 6)

Skin Ulcers (Unhealed Ulcers)
Skin ulcers are relatively infrequent. The most common site
of skin ulcers is over the lateral malleoli. The ulcerations
often have no clear-cut antecedent trauma and progress
over a period of weeks. Lesions in children occur most
commonly around malleoli where poor circulation along
with sickling and microinfarcts leads to poor healing and
infection.
Fig. 6 Unhealed ulcers

Rest, elevation and dry dressings with antimicrobial

ointments are the best approach to this problem. Attempts
at skin grafting are frequently not successful due to poor
blood flow to the affected region. Healing usually takes
weeks to months.
The area should be protected against trauma. Socks
or other clothing that cover the area should be avoided,
to reduce friction injury. A simple dry dressing provides
additional protection. Zinc supplementation has been
traditionally thought to aid wound healing.
Other Complications
Priapism (Fig. 7)
It is defined as sustained, painful and involuntary erection
of the penis lasting longer than 30 minutes. Priapism is
not uncommon problem in sickle cell anemia and most
patients experience their first episode by 12 years of age
and by 20 years of age as many as 90 percent of the patients
have experienced one or more episodes of priapism. Minor
recurrent episodes are common during adolescence.
Occasionally, the problem is seen in pre-pubertal
boys. Pain becomes severe if erection persists longer
than 3 hours. Episodes may be described as stuttering or
refractory. Stuttering episodes last for a few minutes but
less than 3 hours and resolve spontaneously. Refractory
episodes are prolonged, lasting longer than 3 hours.
Acute therapy of prolonged episodes includes aspiration
of blood from corpus cavernosa followed by irrigation
with dilute epinephrine to sustain detumescence to be
done in consultation with pediatric urologist. Supportive
measures like sitz bath and pain medications may be tried.
Hydroxyurea may help to prevent recurrent episodes.A
sympathomimetic drug with mixed alpha and beta actions,
etilefrine seems promising for secondary prevention of
episodes.31 Evidence for the role of transfusion therapy for

occlusive episodes. Various studies have found that more
than 40 percent of adults with SCD have pulmonary
hypertension that worsens with age and is a major risk
factor for death.
Cholecystitis
Fig. 7 Priapism
acute or preventive therapy is lacking.32,33 Prolonged and/

or recurrent episodes of priapism may lead to fibrosis and
impotence.
Renal Disease
Renal involvement is common in sickle cell anemia and
contributes to the morbidity of the disease with renal
failure in up to 18 percent of the patients. The primary
event is occlusion of vasa recta capillaries in renal medulla
where there is low oxygen concentration and high
osmolarity thereby increasing the concentration of Hb S.
The renal manifestations of sickle cell anemia:
Enuresis secondary to hyposthenuria.
Painless hematuria due to papillary infarcts.
Proteinuria and hypertension. Asymptomatic
albuminuria is a precursor of progressive renal
disease.34,35
Renal infarction, papillary necrosis, and renal colic.
Nephrogenic diabetes insipidus that can lead to
polyuria.
Focal segmental glomerulosclerosis that can lead to
end-stage renal disease; dialysis is well tolerated and
increasing numbers of patients are being treated with
renal transplantation.
Renal medullary carcinoma is a malignancy found
almost exclusively in black patients with Hb SC disease
or sickle cell trait.
Pulmonary Hypertension
Pulmonary hypertension occurs due to formation of
microinfarcts and microthrombi in the pulmonary
vasculature due to circulation of deoxygenated blood
which promotes sickling. Depletion of nitric oxide may
also contribute to the pathogenesis independent of vaso-
Due to chronic hemolysis, cholelithiasis is common in

children and 40 percent of adolescents with sickle cell
anemia are affected with cholecystitis or common duct
obstruction can occur. Consider cholecystitis in a child
who presents with right upper quadrant pain, especially if
associated with fatty food.
Consider common bile duct blockage when a child
presents with right upper quadrant pain and dramatically
elevated conjugated hyperbilirubinemia.
Retinopathy
The retina is primarily affected with manifestations such as
proliferative retinopathy, retinal artery occlusion, retinal
detachment and hemorrhage.36,37 The vaso-occlusions
may begin in childhood and progressively lead to loss of
visual acuity. Prophylactic photocoagulation may have a
role in the treatment of proliferative sickle retinopathy.
Regular eye checkups are recommended.
Growth and Development

Growth failure and sexual maturation are delayed in
patients with sickle cell anemia. Normal height may be
achieved by adulthood but weight remains lower for age
as compared to controls. Neurodevelopment and skeletal
maturation are also delayed.38,39
Cardiac Involvement
The heart is involved due to chronic anemia and
microinfarcts. There is chamber enlargement due to
compensatory increase in cardiac output. Arrythmias may
be an important cause of death in older patients. As per
a study, coronary artery dilatation is common in children
with sickle cell anemia.
Cardiac complications are usually related to high
output stress due to anemia and manifest in the form
of congestive cardiac failure and hemosiderosis due
to iron overload because of chronic blood transfusion.
Chelation therapy must be given after 2 to 3 years for iron
overload from repeated transfusions. There is no specific
cardiomyopathy in sickle cell anemia.
Pregnancy
Pregnancy in patients with sickle cell anemia is associated
with fetal and maternal complications.

Fetal complications are related to compromised
placental blood flow and include spontaneous abortion,
intrauterine growth restriction, fetal death in utero, and low
birth-weight. Maternal complications occur in as many as
one-half of pregnancies, including acute chest syndrome,
bacteriuria, urinary tract infection, pyelonephritis,
endometritis, pre-eclampsia, thromboembolic events,
and the use of cesarean section.
As a result of these complications, careful monitoring
during the antenatal period to ensure maternal and fetal
well-being is essential.
Treatment
Comprehensive medical care must be provided to these
patients with the team effort of physician, disease specific
specialist and pediatric hematologist to treat the clinical
symptoms and complications.
Hydroxyurea Therapy
Sickle cell disease (SCD) is a potentially devastating
condition, which results in the vaso-occlusive phenomena
and hemolysis. The severity of the complications that
occur with this disorder are widely variable, but overall
mortality is increased and life expectancy decreased when
compared to the general population.
Hydroxyurea is a chemotherapy agent (myelosup
pressive agent) currently approved by US Food and Drug
Administration (FDA) for the treatment of sickle cell
disease. It acts by increasing the fetal hemoglobin as its
metabolism leads to NO related increase in cGMP which
increases gammaglobin synthesis.40 This in turn decreases
sickling of red blood cells. These effects have been found
to reduce the incidence of pain episodes, acute chest
syndrome episodes and blood transfusions by 50 percent.41
History of other severe vaso-occlusive events

Severe symptomatic anemia
Severe unremitting chronic pain that cannot be
controlled with conservative measures
History of stroke or a high risk for stroke.
Transfusion Therapy
Chronic transfusion with red blood cells decreases the
concentration of HbS in patients with sickle cell disease by
three mechanisms:42,43
Addition of Hb A from the blood of normal donors
dilutes the Hb S in the blood
The rise in hematocrit following blood transfusion
suppresses erythropoietin release thereby reducing
the production of new RBCs containing Hb S
Longer circulating lifespan of Hb A containing normal
RBCs as compared to sickle RBCs decreases the levels
of Hb S.
Transfusion therapy for individuals with sickle cell
disease can be categorized as therapeutic or prophylactic.
Accepted indications for transfusion therapy in individuals
with SCD include:44,45
Therapeutic: Acute use of transfusions for acute stroke,
acute chest syndrome, acute multi-organ failure, sudden
severe drop in hemoglobin (splenic sequestration, aplastic
crisis, hyperhemolytic crisis), acute symptomatic anemia
(e.g. onset of heart failure, dyspnea, hypotension, marked
fatigue).
Prophylactic: Use of periodic red cell transfusions for
primary or secondary stroke prevention.
Indications for Hydroxyurea Therapy
Transfusion: Related complications include alloimmunization, infection and iron overload. Matching for minor
antigens such as C, E, Kell, JKB (Kidd) and Fya (Duffy) antigens can significantly reduce alloimmunization.
A decision of simple versus exchange transfusion must
be made on case to case basis.
Simple blood transfusion is used when the aim is
to restore blood volume or oxygen carrying capacity in
an acutely ill child. Partial exchange transfusions are
recommended when an acute or chronic reduction in
the concentration of Hb S is required without an increase
in viscosity and iron burden (e.g. for acute emergencies
such as multi-organ failure, suspected stroke, acute chest
syndrome, primary and secondary prevention of stroke
and prevention of recurrent painful episodes). The upper
limit of hemoglobin should be kept at 10g/dL to prevent
hyperviscosity and decreased oxygen delivery.
Patients who are hospitalized more than 4 or 5 times

per year with painful vaso-occlusive crises
History of acute chest syndrome
Transfusion and surgery: In patients with sickle cell

disease undergoing surgery, events like hypoxia,
dehydration, hypothermia may result in intra or post
Starting dose: Hydroxyurea can be started at a dose of 10

mg/kg orally, on a daily basis. The patients hematological
status should be monitored to rule out fall in the neutrophil
count to less than 2,500 per cubic millimeter or platelet
count to less than 80,000 per cubic millimeter.
Dose escalation: The dose of hydroxyurea can be increased
at a rate of 5 mg/kg/week as long as the hematological
values remain in an acceptable range, and the patient
shows no other evidence of side-effect from the HU.
Maximum dose is 25 mg/kg/day. Higher doses have been
given at some institutions 35 mg/kg/day.

operative complications. Blood transfusion with the aim
of maintaining hemoglobin concentration at 10g/dL and
HbS concentration < 30 percent given preoperatively may
help to reduce complications. An exchange transfusion
may be required in cases with Hb > 10g/dL.
Chelation Therapy
Iron overload occurs as a result of repeated transfusions
in patients with sickle cell disease resulting in heart and
liver failure along with other complications. MRI is a
more accurate and non-invasive method of estimating
tissue iron load and response to chelation. The chelating
agents commercially available and approved for use are:
desferrioxamine, deferasirox.
Desferrioxamine needs to be given parenterally or
subcutaneously by prolonged infusion and nearly every
day (5 days a week), which has limited its effectiveness in
many patients. Deferasirox is an effervescent tablet that is
dissolved in liquid and taken orally daily.
Erythrocytapheresis
This technique involves automated red cell exchange that
removes blood containing Hb S from the patient while
simultaneously replacing that same volume with packed
red cells free of Hb S. Transfusion usually consists of sicklenegative, leuco-reduced, and phenotypically matched
blood for minor red cell antigens C, E, K, Fy and Jkb.
The procedure is performed on a blood cell processor
(pheresis machine) and is a better technique than manual
exchange transfusion. This technique has the advantage of
minimum iron accumulation; however it is less commonly
performed due to requirement of expertise and equipment.

Allogenic bone marrow transplantation (BMT) is the
only known cure for sickle cell disease. Many risks are
associated with BMT, and the risk-to-benefit ratio must
be assessed carefully. The lack of availability of a matched
donor may limit the utility of BMT.
Novel Therapies
New agents have been developed which are now in clinical
trials based on the pathophysiology of sickle cell anemia.
Induction of hemoglobin F
Decitabine: It is a nucleoside analoge that
hypomethylates cellular DNA without cytotoxicity.
This results in re-expression of -globin genes and
induces -globin synthesis.46,47
Butyrate: It is a short chain fatty acid that inhibits
histone deacetylase (HDAC) thereby affecting
chromatin structure and transcription rates of

-globin gene.48
Trichostatin A: HDAC inhibitor which significantly
inhibits pulmonary vein expression of vascular cell
adhesion molecule (VCAM) and tissue factor (TF)
in mouse models.49
Pomalidomide: Thalidomide derivative that
stimulates erythropoiesis, F cell production, total
hemoglobin and Hb F synthesis in human CD34+
cells.50
Prevention of red blood cell dehydration: Senicapoc is
a potent and selective blocker of the Gardos channel
(potassium efflux pathway) which prevents the loss
of solutes and water maintaining the hydration of
sickle RBCs which is critical to the rate and degree of
polymerization.51
Nitric oxide (NO): Sickle cell anemia is characterized
by a state of NO resistance, NO inactivation and
reduced NO availability. Options under investigation
to increase the supply of NO include direct
administration of inhaled NO, increasing the substrate
availability with arginine supplementation, treatment
of phosphodiesterase-5 inhibitor sildenafil to prevent
breakdown of endogenous NO.
Anti-inflammatory agents: Statins have potent antiproliferative and anti-inflammatory actions and
stabilize endothelial barrier function. Steroids have
been reported to reduce the duration of severe pain
episodes and severity of acute chest syndrome in
children and adolescents, however more studies are
required to assess the benefits and risk of this therapy.
Treatment with tinzaparin (LMWH) may help in
painful episodes as it decreases coagulation activation
and adhesion of cell to vessel wall. Use of eptifibatide
(glycoprotein IIb/IIIa inhibitor) in acute pain episodes
are currently being studied.
Other agents: Nix-0699 (Niprisan), a phytomedicine
has shown to inhibit RBC sickling and produce a
left shift of the oxygen dissociation curve of HbS on
in vitro studies.52 Safety and efficacy of intravenous
immunoglobulin (IVIg) in these patients with acute
pain episodes is being studied. Studies to evaluate
the use of Bosentan (endothelin receptor antagonist)
which have shown results in mouse models must be
considered.
Supportive Therapy
Supplementation with folate (1 mg/day), multivitamin
without iron, oral calcium and vitamin D along with
nutritional management are recommended.
Addressing psychological issues like depression,
scholastic backwardness, neurocognitive dysfunction
with appropriate therapy and rehabilitation.
Morbidity and Mortality

The following three prognostic factors have been identified
as predictors of an adverse outcome:53
Hand-foot syndrome (dactylitis) in infants younger
than 1 year
Hb level of less than 7 g/dL
Leukocytosis in the absence of infection
The mortality rate in infants and young children who
have access to comprehensive health care has decreased
dramatically. Due to routine use of antibiotic prophylaxis
and immunization, acute chest syndrome and multi-organ
failure are replacing bacterial sepsis as the leading cause of
death. In regions where comprehensive care is available,
the disease has shifted from a fatal pediatric illness to
a chronic disease often associated with progressive
deterioration in quality of life and organ function.
Patient Education
Patient education regarding the nature of the disease is
essential. They must be taught to recognize early signs of
complications to obtain prompt treatment and identify
environmental factors that may precipitate a crisis.
The importance of hydration, prophylactic penicillin,
immunization and drug therapy and regular follow-up
must be emphasized. Patients (including asymptomatic
heterozygous carriers) must be explained the genetic basis
of the disease and made aware of genetic counseling and
prenatal diagnosis. Genetic testing can identify parents
at risk for having a child with sickle cell disease. Families
must be encouraged to join support groups for information
of newer drugs and therapy such as of gene therapy, bone
marrow transplantation and the usage of cord blood stem
cells and psychosocial support.
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19
Antenatal Diagnosis of
Hemoglobinopathies
BACKGROUND
The hemoglobinopathies and thalassemia syndromes
are a group of autosomal recessively inherited disorder
resulting from either the qualitative (structurally abnormal
globins-hemoglobinopathies) or quantitative defects
(abnormal synthesis of one or more of the globin chainthalassemia syndromes). It is one of the common group
of single gene disorder with a carrier frequency of >5%. In
India, the carrier frequency varies from 3% to 17%, highest
being in Pakistani Sindhi and Punjabi populations.
Thalassemia is an example of a best studied disease of a
known molecular mechanism, and one of the first human
genes cloned and sequenced. It is classified according to
the abnormal synthesis of the globin chain. It is known
as -thalassemia or -thal if the chain is affected or the
b-thalassemia/bthal if b chain is affected. b-thalassemia
affects HbA whereas -thalassemia affects both HbA and
HbF. Hemoglobins with any of the four identical globin
chains are completely unstable and incompatible with
life for example HbH disease with four b chains (b 4) or
Hb Barts disease with four chains (4). Until 1970s,
prenatal diagnosis for hemoglobinopathies was possible
by analyzing globin chain levels on fetal cord blood, but
with gradual advancements in DNA based technology the
testing gradually shifted to the more reliable and efficient
PCR based studies on chorionic villi DNA to provide earlier
fetal diagnosis. Recent technological advancements have
lead to the possibility of fetal diagnosis on maternal blood
as well.
MUTATIONS IN GLOBIN GENES

Although globin gene is one of the small gene, till date
more than 1000 hemoglobin variants with single amino
acid substitutions in one of the globin chains are known.

Many of them are associated with hemoglobin disorders
of different types and severity. Interaction of various
thalassemia mutations and abnormal hemoglobins
produces complex genotypes and an extremely wide
spectrum of clinical and hematological phenotypes.
The three main categories of these interactions that are
associated with severe disease states and require further
genetic counseling and prenatal diagnosis are as follows:
b-thalassemia syndromes (includes b thalassemia and
E/b mutations)
Sickle cell disease (HbSS and variant interactions e.g.
Hb S/C, Hb S/b thalassemia, Hb S/D Punjab, Hb S/O
Arab, HbS/Lepore, Sbd)
Hb Barts and HbH hydrops fetalis syndrome.
Alpha Thalassemias
The thalassemias are a group of disorders characterized
by reduction in a globin synthesis. They can be divided
into the severe types (1 or thalassemias) with typical
microcytic hypochromic blood picture in heterozygotes,
and the milder form (2 or + thalassemias) which is
usually silent. Deletion mutations are the common in
thalassemia, although + thalassemia can also be caused
by point mutations (nondeletional thalassemia or T).1
Deletion of all 4 globin chains results in the most severe
type of 0 thalassemia which is known as Hb Barts hydrops
fetalis syndrome. In the absence of globin, HbF and HbA
are not synthesized and fetal blood contains abnormal
hemoglobin Barts (4) leading to severe anemia, hydrops
fetalis and fetal death. Alpha0 thalassemia is particularly
common in South East Asia whereas + thalassemia
predominates in Africa and India. The compound
Chapter-19 Antenatal Diagnosis of Hemoglobinopathies 205

heterozygous condition of /1 thalassemia (- - / - ), 0
thalassemia and nondeletion + thalassemia (- - / T) or
homozygous nondeletion + thalassemia (T/T) results
in moderately severe to severe HbH (4) disease. In India,
HbH traits have been reported among Bengalis, Malayalis,
and Tamils, Gujaratis and Sindhis in Singapore. Other
common structural hemoglobin variants are hemoglobin
Constant Spring and Koya Dora from the populations of
Southeast Asia2 and Andhra Pradesh3 in India respectively.
High prevalence of hemoglobin Constant Spring (both
heterozygotes and homozygotes) have also been reported
among the coastal people of Orissa.4
Box 1 Disorders of globin chain synthesis warranting

prediction in a fetus and prospective parents
Disorders of globin chain synthesis that should be predicted in a
fetus
b-thalassemia major (including E/b0 mutations)
b-thalassemia intermedia (including E/b0 mutations)
Sickle cell disease
Hb Barts hydrops fetalis syndrome (Homozygous 0
thalassemia) and (rarely) HbH hydrops fetalis syndrome (0/
T )
Compound heterozygous sickle cell states (including Hb
S/C, Hb S/b-thalassemia, Hb S/D Punjab, Hb S/O Arab, HbS/
Lepore).
b-Thalassemia5
The b-thalassemia are a heterogeneous group of disorder.
These can be classified either as b0 thalassemia with the
absence of b globin chain synthesis or b+-thalassemia
with reduced rate of beta chain synthesis. More than 200
mutations have been identified majority of them being
the point mutations. About 10% of mutations are deletion
mutations of varying size. Homozygous or compound
heterozygous state of most b+ or b0 type of severe
mutations result in b-thalassemia major, a transfusion
dependent anemia. That usually present in later part of
infancy or second year of life. Thalassemia intermedia
is the milder clinical condition that present usually after
second year of life. The type of mutation in the b globin
gene determines the phenotype. Thalassemia intermedia
too can be of varying severity depending upon the type of
mutations and its interaction with other variant forms. In
authors experience, due to the complex gene interactions
and unpredictability of the phenotype prenatal diagnosis
is often requested by the parents.
Sickle Cell Disease5

The sickle cell disease (SCD) is widely prevalent in India
and has a variable clinical course. It is characterized by
hemolytic anemia with acute crises due to infection or vaso
occlusive episodes. An A to T substitution in codon 6 of the
beta globin gene is responsible for SCD. Variable severity
in SCD occurs due to the interaction with beta thalassemia
and other structural hemoglobins. Homozygosity for
HbS, HbS/HbDPunjab, HbS/HbOArab; and HbS/thalassemia (severe mutations) results in moderate to
severe clinical disease.
Box 1 summarizes the various globin chain disorders
associated with severe disease states that requires prenatal
diagnosis and genetic counseling. Clinically asymptomatic
states are b thal trait, thal trait ( -/ or /--) or silent
carrier state ( /-), HbE trait, homozygous HbE, HbC,
HbD, deletional or nondeletional hereditary persistence

of hemoglobin and b trait or Hb lepore trait.
Inheritance of hemoglobinopathies: In most of the
common hemoglobinopathies like alpha, beta
thalassemias and sickle cell anemia the mode of
inheritance is autosomal recessive. Autosomal
recessive disorders manifest if both the parents are
carrier of the mutant gene. The disease usually occurs
in one generation only. The risk of occurrence and
recurrence is 25% in such cases (Fig. 1). Identification
of mutation in such couples or proband is the
prerequisite for prenatal diagnosis. There is no risk of
having an affected child if only one partner is a carrier
or is affected (Figs 2 and 3). If only one partner is a
carrier there is a 50% chance of the baby being a carrier
and all babies will be carriers if one partner is affected
with an autosomal recessive hemoglobinopathy.
Identification of carrier status is easy and is possible by
measurement of HbA2 which is almost always high in
carriers except in a rare situation of silent carrier status
when HbA2 may be normal and carrier status can only
be confirmed by molecular studies.
Diagnosis of hemoglobinopathies5-7: Hematological
and biochemical investigations are basic screening
investigations that are widely available for diagnosis
as well as carrier screening. DNA studies are important
for fetal diagnosis and making genotype phenotype
correlation.
Basic hematological parameters:
i. Complete blood count including Hb, RBC,
MCH, MCV, and RDW
ii. Hemoglobin electrophoresis at pH 8.6 using
cellulose acetate membrane for common
hemoglobin variants i.e. HbS, C, DPunjab, E,
OArab and Lepore Hb
iii. Hemoglobin electrophoresis at pH 6 using
acid agaroseDistinguishes between C, E, and
Fig. 1 Twenty-five percent risk of affected child if both parents

are carrier
Fig. 2 No risk of affected child if only one parent is carrier
Fig. 3 No risk of affected child if one parent is affected
OArab from each other and also HbS and,

DPunjab from each other.
iv. HPLC for simultaneous detection and quanti
tation of hemoglobin fractions.
Supplementary hematological methods
i. S, Fe and Ferritin, transferrin saturation
ii. Globin chain synthesis
iii. Immunological measurement of fetal cells for
HPFH. Distinguishes between heterocellular
and pancellular distribution
DNA analysis: An analysis or the research
conducted at various places across the globe reveals
that hemoglobinopathies are caused due to the
result of a broad spectrum of mutations (N>1000).

These include point mutations, frame shift
mutations, large deletions and rearrangements.
Various techniques such as oligonucleotide
specific hybridization, oligonucleotide specific
amplification, oligonucleotide specific ligation,
gap-PCR, restriction endonuclease analysis
of amplified product, and real-time PCR are
being used to identify these alterations. Each of
these techniques has its inherent advantages
and disadvantages. Every laboratory selects its
approach of mutation detection on the basis of
the mutation that is prevalent in that particular
population, ethnicity of that particular family and
running cost, suitability to routine diagnosis and
reliability of the technique.
Some laboratories have started using direct sequencing
as the first approach to identify a large number of different
mutations in at-risk populations. Indirect mutation
tracking using restriction enzymes having polymorphic
sites linked to mutations becomes the second choice
where mutations are not identified in previous affected
child and family has requested for prenatal diagnosis in
next pregnancy.
Source of DNA: For molecular diagnosis in parents and
in affected child, preferable source of DNA is blood. The
5 mL blood in EDTA can be transported to the laboratory at
room temperature within 2448 hours for further testing.
However blood spots and buccal swabs can also be used
in case the child is very young or parents are apprehensive
of venipuncture.
On the other hand, for prenatal diagnosis fetal DNA
can be obtained from chorionic villi sample, amniotic fluid
and cord blood. Chorionic villi sample is usually preferred
over amniotic fluid and cord blood because it can be
done at earlier gestation and gives better yield of DNA.
The 2025 mg of tissue in heparinized saline provided by
laboratory/RPMI culture medium can be transported to
the laboratory within 2448 hours at room temperature,
where fetal tissue is carefully separated from maternal
tissue by looking under inverted microscope.
Antenatal screening followed by prenatal diagnosis
in carrier couples and selective termination of affected
pregnancies is the only modality available which could
significantly reduce genetic load of hemoglobinopathies
in various countries. Cyprus for instance, has reduced
their incidence of thalassemia and thus stands as an ideal
for other countries. It has progressed from reporting the
highest occurrence of thalassemia in the world to nil
within an impressive span of just 11 years (19912002).8 In
addition to the incidence, the carrier frequency has also
been reduced by 1.89% in 24 years.9 Today, in India also

many centers have opened up which are actively involved
in providing prenatal diagnosis.
Carrier screening and prenatal diagnosis: The best way
to decrease the burden of hemoglobinopathies is to
perform carrier screening followed by prenatal diagnosis
and selective termination of affected pregnancies.
Before prenatal diagnosis was available, premarital
screening and counseling did not affect the marriage and
reproductive behavior in Greece and Cyprus, countries
with very high carrier frequency. With the introduction
of prenatal diagnosis along with mandatory premarital
screening had a tremendous effect on reducing the birth
of affected babies to almost zero. This was only possible
by mass education program with involvement of religious
leaders. The screening protocol which is usually followed
is outlined in the Flow chart 1.
Prerequisites for prenatal diagnosis:
Confirmation of carrier status in both partners and
identification of disease causing mutations/informa
tive linkage
Counseling about recurrence risk of disease (25% in
each pregnancy) and medical termination of affected
pregnancy
Explanation about procedural risk (i.e. chances of fetal
loss).
Prenatal diagnosis is increasingly becoming available
world over. Across India, many centers are now offering
prenatal diagnosis using molecular techniques.6,7 Once
the carrier status of the partners is confirmed, it is followed
by DNA studies to identify the mutant allele in both the
Flow chart 1 Thalassemia carrier screening protocol for
thalassemia
partners. If the family has a previously affected child then

the most important step in prenatal diagnosis is to first
determine the mutation status of the affected child in the
pretransfusion state along with the parents genotyping. If
proband is not available then, parental DNA can be tested
for thalassemia mutation followed by prenatal diagnosis.
There are five common mutations reported in Indian
population along with about 12 rare mutations. According
to our experience mutations are identified in 9597% of
North Indian families.
The technique used for identification of mutations
is based on allele specific amplification and is called
amplification refractory mutation system (ARMS) PCR in
most centers in India and abroad and is very reliable.10
If the mutations are identified chorionic villus sampling
(CVS) is offered around 10-12 weeks of pregnancy after
counseling. CVS is the most widely used sample as it gives
good DNA yield and can be done early in pregnancy. The
risk of fetal loss with CVS is around 2-3%. It usually takes
about a week for initial mutation screening and the same
time for CVS reporting. In situations when the mutations
are not identified, use of linkage studies or cord blood
analysis for globin chain synthesis or HPLC can be useful
for prenatal testing.
Flow chart 2 shows the strategy being followed in our
laboratory for prenatal diagnosis.
Flow chart 2 Thalassemia prenatal diagnosis protocol
DNA Techniques Required for

Hemoglobinopathies
Detection of Known Mutations
There are numerous PCR based techniques which are being
used to detect known mutations, other than large deletions
and rearrangements causing hemoglobinopathies.
Commonly used techniques are amplification refractory
mutation system, restriction enzyme PCR (RE-PCR) and
reverse dot blot analysis with allele specific oligonucleotide
probes.
Reverse Dot Blot Analysis

Reverse dot blot analysis is a nonradioactive technique
in which allele-specific oligonucleotide (ASO) probes
are immobilized on a nylon membrane. Separate probes
complementary to each known mutant normal allele
are spotted on a nylon membrane and subjected to
hybridization with patient DNA. Signals are generated
only for those particular mutations which are present in
patient DNA. These strips are commercially available and
can be customized according to mutation spectrum of any
population. Prior knowledge of common and uncommon
mutations in a population and simplicity of the technique
make it affordable and suitable for routine diagnostic labs.
In India, this technique is commonly used to detect five
common mutations and other variants like HbS, HbD and
HbE in HBB gene. Whereas in other countries like Sicily
it is also used to detect -thalassemia and -thalassemia
point mutations.
Amplification Refractory Mutation System

Amplification refractory mutation system (ARMS) is
the most commonly used technique throughout the
world to detect known common and few rare mutations
causing beta-thalassemia. Its principle is based on the
quality of perfectly matched primer over mismatched
primer resulting more efficiency in annealing and primer
extension. The 3 terminal nucleotide of these primers
is specific to the desired allele. Hence annealing of this
primer is possible only if the desired (Mutant/normal)
allele is present in the tested DNA. So, for every patient
two parallel reactions in two separate tubes containing
normal and mutant primer each are set up. A homozygous
mutant and wild sample shows amplification only in the
tube containing mutant and normal primer respectively
whereas a heterozygous sample shows amplification in
both tubes.
Two modifications are generally practiced in most of
ARMS PCRs. First modification is done at the time of primer
designing. This includes the incorporation of a mismatched
nucleotide at the -2/-3 position from 3 end to increase the

specificity of these primers. Second modification is addition
of another set of primers amplifying a different gene locus
which acts as an internal control. This modification is
introduced while setting up an ARMS PCR reaction. To
detect five common Indian mutations the general practice
is to set up four different reactions containing one mutant
primer for each mutation naming IVS1-5(G>C), IVS11(G>T), Cdn8-9(+G) and Cdn41-42(-CTTT), a common
reverse primer and also a set of primer specific to 5th
common mutation (619 bp deletion). This primer set for
619 bp deletion serves dual purpose. First it serves as an
internal control by amplifying a region of 861 bases and
second it also detects patients having this deletion of 619
bases from that region by showing an additional band
of 242 bp size. Figure 4A depicts the principle of ARMS
PCR and Figure 4B shows an agarose gel photograph of a
common beta-thalassemia mutation.
ARMS PCR is mostly preferred to detect known point
mutations, small insertions and deletions over RFLP
and direct gene sequencing due to its simplicity, cost
effectiveness and less labor intensive nature.
Restriction Enzyme PCR

Restriction enzyme PCR (RE-PCR) is less preferred
technique for molecular diagnosis of hemoglobinopathies
because consumption of restriction enzyme for a large
set of samples make it comparatively expensive than
ARMS PCR and there are very few mutations in the
list of hemoglobinopathies which creates or abolish
a pre-existing restriction site. It was previously used
very commonly for the detection of HbD, HbS and HbE
mutations. Flanking sequence of a particular mutation is
first amplified by PCR before cutting a mutant DNA with a
restriction enzyme resulting in a different restriction map.
For example, a missense mutation (A > T) at codon 6
of HBB gene causing the substitution of glutamic acid by
valine resulting in sickle cell anemia the most common
hemoglobinopathy of tribal population abolishes a
specific recognition site for the restriction endonucleases
Dde I and Mst II.
Gap PCR
Detection of large genomic rearrangements, gross
deletions causing deletional HPFH, -, -,
thalassemia and thalassemia was previously based on a
nonPCR technique called southern blot. But with time and
technical advancements this technique has been totally
replaced by Gap PCR.
If the deletion is less than 1 Kb then only two primers
flanking deleted sequence are needed which generate
Figs 4A and B (A) ARMS PCR; (B) gel photograph of ARMS
two fragments of different sizes in heterozygous patients.

The smaller one is due to deletion. But in case of larger
deletions one more primer complementary to a part of
deleted sequence is needed which gives an amplification
in normal individuals, as distance between primers
flanking deleted sequence is too large to amplify normal
allele. On the other hand, in the presence of deletion these
flanking primers produce an amplified product.
Gap PCR is much faster, simpler, cost effective and less
labor intensive in comparison with southern blot hence
most suitable for a routine diagnostic set up.
MLPA is another technique which is gaining in
reputation day by day. The technique has an advantage over
gap PCR because of its ability to detect unknown deletions
and rearrangements in addition to the previously reported

in literature. But its high cost limits its use in populations
where frequency of large deletions and rearrangements is
very low.
Detection of Unknown Mutations

Detection of unknown mutations was previously based
on few screening techniques like denaturing gradient
gel electrophoresis/single stranded conformation
polymorphism/heteroduplex analysis followed by
sequencing of that particular exon where a change
was suspected by any of above mentioned screening
technique.

However, these days, most laboratories resort to
direct gene sequencing as a first hand test since the rapid
advancement and competition within the biotechnology,
sector has led to a significant fall in the cost of gene
sequencing. This has made the process of reporting
faster and high throughput. Direct sequencing analysis
is particularly applicable to the globin genes which are
compact and relatively small (1.21.6 kb) with the majority
of the point mutations within the gene or its flanking
sequences. Mutations in the HBB gene are not limited to
the exons and their direct splice sites so the primers are
designed in the manner that they cover deep intronic
region and regulatory sequence.
Diagnosis Using Indirect Methods

Restriction Fragment Length Polymorphism (Fig. 5)
Linkage analysis can be an approach for prenatal
diagnosis in families at risk where mutations could not
be identified by using direct mutation detection methods.
Before offering PND to these families it is mandatory to do
heterozygosity screening of different intragenic markers

like AVA II, BamH I, etc. in family members including
parents, previous affected child/normal child. By
establishing heterozygosity of these markers and following
their patterns in parents and affected child mutated allele
can be tracked indirectly in fetal DNA with no knowledge
of causal mutations. The -globin gene cluster is known
to characterize at least 18 restriction fragment length
polymorphism (RFLP). But nonrandom association of
these sites result in only few haplotypes. Application of
this technique is limited to only those families where at
least two intragenic markers are informative and previous
affected child/normal childs sample is available. The
diagnostic error of this technique is a little higher (0.3%)
than direct mutation detection methods due to chance of
recombination between RFLP site and mutation locus.
Laboratories having no access to relatively advanced
and expensive techniques of direct mutation analysis
(e.g. gene sequencing and MLPA) can make use of this
technique in families at risk of producing children with
hemoglobinopathies.
Cord blood high performance liquid chromatography
or globin chain synthesis in fetal blood may be useful in
rare situations if the mutation is not identified.
PRECAUTIONS TAKEN WHILE DOING DNA

ANALYSIS
Fig. 5 Use of linkage studies for prenatal testing
A lab following reasonably good standards can also result

in 1-2% diagnostic error. This can arise due to several
technical reasons such as maternal DNA contamination,
cross contamination causing false amplifications
leading to false positive results, false paternity, genetic
recombination, deficient endonuclease digestion, allele
drop out, undiagnosed hemoglobinopathy in compound
heterozygote state in parents leading to misdiagnosis of
fetus and also due to human errors like sample exchange,
mislabeling of samples, etc.
Following guidelines can help in minimizing these
errors:
Chorionic villus sample should be washed in saline to
get rid of maternal blood and it should also be dissected
under microscope to get rid of maternal decidua before
sending to the fetal diagnostic laboratory
Appropriate positive and negative controls should
always be analyzed with fetal sample
Fetal sample should always be run in duplicate
PCR program should have a limited number of cycles
to minimize amplification contaminating DNAs
VNTR analysis using different polymorphic markers
should always be run in parallel to rule out maternal
contamination

Every sample should have more than one identification
code e.g. full name, lab number, date of birth, sample
date, etc.
The test that involves gene sequencing should always
be done in both directions
The type of DNA analysis method used and its inherent
risk of misdiagnosis should be clearly mentioned in
prenatal diagnosis report.
Noninvasive Methods
Owing to abortion risk to the fetus and the anxiety experi
enced by mothers undergoing any prenatal diagnostic
procedure done to rule out hemoglobinopathies, focus
has been shifted towards development of noninvasive
tests which are not only accurate but rapid, and can be
performed early in pregnancy for prenatal diagnosis.
There are two noninvasive approaches which have
been followed till today. One involves analysis of cell free
fetal DNA in maternal plasma and serum and the other
approach utilizes fetal cells within maternal circulation as
a source of fetal DNA. Determination of fetal gender and
RhD status of the fetus with in RhD-negative pregnant
women by using maternal plasma and serum has already
been established in European countries.11,12
This approach, however is not suitable for the analysis
of fetal loci that do not differ largely from the maternal allele
(e.g. beta-thalassemia), due to the vast predominance of
cell-free-maternal DNA in maternal samples.
To overcome this problem researchers have used
size fractionation as a possible enrichment technique to
enrich fetal DNA molecules. Use of peptide nucleic acids
followed by allele specific real time PCR to suppress the
amplification of wild type maternal allele is another
approach which has been used extensively and has given
promising results in detection of paternally inherited
fetal point mutations of beta-thalassemia and sickle cell
disorder.13
MS-SABER (mass spectrometry-based singleallele base extension reaction) and MS-ASBER (mass
spectrometry-based allele-specific base extension
reaction) have also been used in this field and have enabled
sensitive differentiation of fetal specific alleles down to a
single nucleotide level and has shown to be useful for the
detection of certain beta-thalassemia mutations and HbE
disease respectively.14
Moreover Gaibiati, et al. explored the applicability
of COLD PCR (coamplification at a lower denaturation
temperature polymerase chain reaction) to enrich
paternally inherited mutated allele in maternal plasma
which was then detected on a sequencer.15
Applicability of above mentioned techniques is limited
to only those families where partners carry different
mutations. To overcome this problem now focus is

towards finding new SNPs which are linked to known
beta-thalassemia mutations and can be used later as a
marker for NIPD of beta-thalasssemia in couples carrying
same mutations. Papasava, et al. used this approach
in combination with arrayed primer extension (APEX)
method in genetically homogenous population of Cyprus
and screened 34 families to know the most informative
paternally inherited single nucleotide polymorphisms
(SNPs). Only 11 families were infomative for more than
two SNPs.16
More recently a group in Netherland assessed
the possibility of using pyrophosphorolysis-activated
polymerization (PAP) technique for noninvasive prenatal
diagnosis (NIPD) of -thalassemia major and sicklecell disease (SCD). Phylipsen, et al. developed this assay
to detect SNPs specifically inherited from the father by
linkage to the normal or mutant allele to determine the
risk of having an affected fetus. This approach can provide
NIPD to the families where both partners carry same
mutation.17
Tracking associated SNP to the paternal allele is
an indirect approach of knowing presence of fathers
mutation and has its own limitations. For instance, the low
heterozygosity of these markers make the analysis more
time consuming and allows only few families suitable for
NIPD. Secondly, it does not give any direct information of
the genotype of the fetus.
The introduction of massive parallel sequencing in the
field of NIPD and recent demonstration of deep sequencing
of maternal plasma genome augmented the applicability of
CFF DNA to many more diseases unlike before. Applicability
of this technique in screening aneuploidies has already
been established but in the field of hemoglobinopathies
research is limited to very few reports and world is still
waiting for an accurate, safe, rapid, noninvasive tests
for prenatal diagnosis of hemoglobinopathies. More
recent technologies such as next generation sequencing
(NGS) and whole genome sequencing (WGS) although
have potential to replace currently practiced invasive
procedures for both pre- and postnatal diagnosis in the
near future. Although highly useful, these techniques will
not be suitable to all laboratories performing prenatal
diagnosis of hemoglobinopathies given their high cost and
sophistication.
Full range of genetic disorders including
hemoglobinopathies can be diagnosed noninvasively
through examination of intact fetal cells circulating with
in maternal blood. But due to scarcity of fetal cells within
maternal blood, procedures to enrich the cells and enable
single cell analysis with high sensitivity are the complexities
associated with this technique. Recent advancements like
lectin-based method to separate fetal cells from maternal

blood and autoimage analysis have reported better
sensitivity. The noninvasive prenatal testing is already in
clinical practice for aneuploides and the progress in the
field of single gene disorders is promising.
COUNSELING
Counseling for hemoglobinopathies include exact
determination of parental genotypes, proper understanding
of their interaction and assessment of clinical severity of the
disease in the fetus. It should also be accompanied with the
available treatment and the overall prognosis. One should
offer the prenatal diagnosis by available methods along
with the adequate pretest and post-test counseling.
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minimal set of SNPs for the noninvasive prenatal diagnosis
of -thalassaemia. Ann Hum Genet. 2013;77(2):11524.
17. Phylipsen M, Yamsri S, Treffers EE, et al. Non-invasive
prenatal diagnosis of beta-thalassemia and sicklecell
disease
using
pyrophosphorolysis-activated
polymerization and melting curve analysis. Prenat Diagn.
2012;32(6):57887.
20
Red Cell Membrane Disorders
(Spherocytosis, Elliptocytosis,
Stomatocytosis)
Normal RBC survival span is 110 to 120 days (half life, 5560 days). The plasma membrane of the red blood cell (RBC) consists of a
complex ordered array of lipids and proteins stretched over the outer surface of the cell in the form of a lipid bilayer that is dotted by
penetrating or surface proteins. Specialized interactions occur between specific membrane proteins or lipids, or both, to maintain the
stability of the membrane. Various red cell membrane proteins are necessary to maintain the normal shape of an erythrocyte, which
is a biconcave disc.1,2 A deficiency of any of the components of this membrane can lead to distorted red cell morphology (Fig. 1),
increased breakdown of red cells and anemia, i.e. intracorpuscular (intrinsic) hemolytic anemia (Table 1).
Common red cell membrane defects include:

Hereditary spherocytosis
Hereditary elliptocytosis
Hereditary stomatocytosis
Table 1 Major human erythrocyte membrane proteins

SDS gel band
Protein
Location of
protein in red cell
membrane
Alpha spectrin
Peripheral
HEREDITARY SPHEROCYTOSIS
Beta spectrin
Peripheral
It is a genetically-transmitted form of spherocytosis, an

autohemolytic anemia characterized by the production of
red blood cells that are sphere-shaped rather than donutshaped, and therefore more prone to hemolysis.
2.1
Ankyrin
Peripheral
2.9
Alpha adducing
Peripheral
AE1
Integral
4.1
Protein 4.1
Peripheral
Prevalence
It is the most common red cell membrane defect and
is especially common in people of North European or
Japanese descent, where the prevalence may be as high as
1/5000.
Etiology
Hereditary spherocytosis is an autosomal dominant trait,
although sometimes the mode of inheritance can be
recessive, and an estimated 25 percent of cases are due to
spontaneous mutations. A patient has a 50 percent chance
of passing the disorder onto his/her offspring, presuming
that his/her partner does not also carry the mutation.
4.2
Peripheral
4.9
Demantin
P55
Peripheral
Peripheral
Beta actin
Tropomodulin
Peripheral
Peripheral
G3PD
Peripheral
Stomatin
Tropomyosin
Integral
Peripheral
Protein 8
Peripheral
PAS-1
Glycophorin A
Peripheral
PAS-2
Glycophorin B
Peripheral
PAS-3
Glycophorin C
Glycophorin D
Glycophorin E
Peripheral
Peripheral
Peripheral
Fig. 1 The structural composition of the red cell membrane in vertical and horizontal interactions
Table 2 Common gene mutations in hereditary spherocytosis

Mutation
Protein-coded
Inheritance
ANK1
Ankyrin
Dominant/Recessive
AE1 (SL4A1)
Band 3
Mostly dominant
SPTB
-Spectrin
Dominant
SPTA1
-Spectrin
Recessive
EPB42
Protein 4.2
Recessive
Hereditary spherocytosis is caused by a variety of

molecular defects in the genes that code for red cell
membrane. The protein that is most commonly
defective is ankyrin (dominant and recessive defects).
A recessive defect has also been reported in -spectrin;
dominant defects have been reported in -spectrin
and protein 3.
Table 2 depicts the common gene mutations seen
in hereditary spherocytosis. These defects lead to loss
of membrane surface area while the mean corpuscular
volume is normal, and a consequent sphering of red blood
cells is seen. An increased permeability of the red cell
membrane to sodium occurs, which is compensated by an
active transport of sodium out of the cell by a cation pump
mechanism. There is an increased glycolysis to generate
the adenosine triphosphate needed for the active transport
of sodium out of the red cells. The spherocytes are also less
deformable and hence are destroyed in the spleen during
passage through the splenic cords to the splenic sinuses.3,4
Clinical Features
It has a varied clinical presentation, ranging from
asymptomatic to severe hemolysis.3,4 Anemia, jaundice
and splenomegaly are the common clinical features
of hereditary spherocytosis. The degree of anemia is

extremely variable and may be absent, mild, moderate, or
severe to the point of threatening life. The clinical severity
of this condition is generally classified into three forms, as
shown in Table 3.
Mild: It occurs in 20 to 30 percent of cases. These
patients have no anemia, modest reticulocytosis, and
little splenomegaly or jaundice, and may not be detected
until adolescence or adult life. Increase in erythropoiesis
is maintained via erythropoietin despite accelerated
hemolysis. The stimulus for increased production of
erythropoietin is not known but does not appear to be
hypoxia.
When detected in the neonatal period, it is commonly
accompanied by jaundice, requiring.
Treatment with phototherapy or exchange transfusion
Hemolysis can be marked in the neonate due to an
increased level of Hemoglobin F. Hemoglobin F binds
2,3-diphosphoglycerate poorly, consequently increased
levels of 2,3-diphosphoglycerate destabilizes spectrinactin-protein 4.1 interactions in the red cell membranes.
However, most neonates have little or no anemia,
reticulocytosis, or spherocytosis on the peripheral blood
smear; this is followed by a reduction in the hemo
globin concentration over the ensuing three weeks
that is transient, but may be severe enough to require
transfusions.5
In infancy and childhood the presentation is variable.
Some children present with pallor, acholuric jaundice,
icterus, exercise intolerance, and progressive splenomegaly
(Minkowski-Chauffard syndrome). Pigmentary gallstones
appear starting from 4 to 5 years of age. Hemolytic facies
may be seen but are less marked than in thalassemia
major. Radiography may show widened diploe of skull
bones and oxycephaly. Chronic leg ulcers may be seen.
Chapter-20 Red Cell Membrane Disorders (Spherocytosis, Elliptocytosis, Stomatocytosis) 215

Table 3 Clinical severity of hereditary spherocytosis
Trait
Mild
Moderate
Severe
Hemoglobin (g/dL)
Normal
1115
812
68
Reticulocyte count (%)
3.16
10
Bilirubin (mg/dL)
1.02.0
2.0
3.0
Spectrin per erythrocyte
100
80-100
6080
4060
Osmotic fragility:
Fresh blood
Normal
Normal/slightly increased
Increased
Increased
Slightly
Increased
increased
Increased
Increased
Autohemolysis
without glucose (%)
<10
10
10
10
Correctability (%)
>60
>60
080
50
Splenectomy
Not
needed
Usually not needed during

childhood and adolescence
Necessary during school

age before puberty
Necessary, delay till 6 years,

if possible
Symptoms
None
None
Pallor, erythroblastopenic Pallor, erythroblastopenic

crisis, hyperbilirubinemia, crisis, hyperbilirubinemia,
gallstones
gallstones
Incubated blood
These patients are particularly prone to aplastic crisis due

to parvovirus infections.
Diagnosis
The diagnosis of hereditary spherocytosis is established
by a combination of clinical examination, detailed history
including family history, and laboratory tests.
A positive family history is seen in up to 75 percent of
patients.
Fig. 2 Spherocytes, lacking, central pallor
The red blood cells appear sphere shaped and lack the
central pallor (Fig. 2).
Peripheral blood smear shows microspherocytes and
polychromasia. The percentage of microspherocytes usu
ally correlates with the severity of hereditary spherocy
tosis. The mean corpuscular volume is normal, and the
mean corpuscular hemoglobin concentration is raised
(3638 g/dL). The red cell distribution width (RDW) is
increased.
Evidence of hemolysis is in the form of reticulocytosis
(315%), decreased haptoglobin, indirect hyperbiliru
binemia and ultrasonic detection of gallstones may be
seen. Coombs test is negative. Increased red cell osmotic
fragility is seen. Spherocytes lyse in higher concentrations
of saline than normal red cells. This feature gets
accentuated when RBCs are deprived of glucose for 24
hours at 37C (Incubated osmotic fragility test). However,
this test is not specific for hereditary spherocytosis, but may
be positive in hereditary elliptocytosis. Also, the test may
be negative in presence of iron deficiency, during recovery
from aplastic crisis or in presence of obstructive jaundice.
Also osmotic fragility cannot differentiate the immune
and non immune causes of spherocytosis. The eosin-5maleimide (EMA) binding dye test, which requires a flow
cytometer is also positive, and may be used as a screening
test in addition to cryohemolysis test. Gel electrophoresis
analysis of erythrocyte membrane proteins may be used as
confirmatory diagnostic test in selected cases.

Complications
Hemolytic crisis
Erythroblastopenic crisis
Folate deficiency
Gallstones
Hemochromatosis
Leg ulcers
Growth retardation
Treatment
Transfusion: Continued transfusion dependence is unu
sual and it is important to avoid repeated transfusion
whereas possible. Many older children with Hb levels of
5 to 6 g/dL do not require transfusion. Children who
require one or two transfusions early in life frequently
become transfusion independent.
A regular follow-up is to be done once a child is
diagnosed to have hereditary spherocytosis (HS). An
annual visit to the physician is recommended even in
the absence of symptoms. A hemogram is unnecessary
in the absence of symptoms but a clinical examination
including a general assessment, measurement of
splenic size, growth, and exercise tolerance is needed.
An ultrasonogram of abdomen, every 3 to 5 years is
needed to look for gallstones, starting from the age of
5 years.
In the presence of chronic anemia, there may be
increased iron absorption in these patients, necessita
ting estimation of iron load during follow-up visits.
Folic acid supplementation (2.5 mg/day up to 5 years
age and 5 mg/day thereafter) is needed to meet the
increased bone marrow requirements. In presence
of erythroblastopenic crisis, leukocyte-depleted red
blood transfusions are needed. Erythropoietin may be
of benefit in reducing or avoiding transfusion, and can
usually be stopped by the age of 9 months. Splenectomy
is needed in moderate and severe cases.46
Indications for Splenectomy

Severe anemia
Reticulocytosis > 10 percent
Repeated hypoplastic or aplastic crisis
Faltering growth
Following splenectomy, there are chances of septi
cemia, and thrombosis. Therefore, where possible,
splenectomy should be deferred till six years. Even in severe
cases of HS who are transfusion dependent, it should not
be done till 3 years of age to avoid risk of septicemia. Some
people recommend partial splenectomy, where around
85 to 90 percent of spleen is removed, while 10 to 15
percent of spleen is left behind to preserve the immune
functions of spleen. Usually the lower pole is removed

while the upper pole is left in situ.7 Sometimes, there is a
failed splenectomy, when the child continues to be pale
and transfusion dependent even after splenectomy. This
is usually due to the presence of accessory spleens in the
body.
Two to Three Weeks Prior to Splenectomy

Children should be vaccinated against pneumococcal,
meningococcal, and Halmophilus influenza B infec
tions.
Children should receive prophylaxis with penicillin
(age < 5 year: 125 mg BD, age 5 year: 250 mg BD).
Following splenectomy.
There is disappearance of jaundice, anemia, and
reticulocytosis.
Peripheral smear shows the presence of Howell-Jolly
bodies, target cells, acanthocytes and siderocytes
Mean corpuscular volume of RBCs rises, while the
mean corpuscular hem oglobin concentration falls.
Pigment gallstones usually develop in patients of HS. In
case of symptomatic gallstone disease, it is preferable
to remove the gallbladder at the time of splenectomy.
HEREDITARY ELLIPTOCYTOSIS
Hereditary elliptocytosis are a heterogeneous group
of inherited erythrocyte disorders, most of which are
autosomal dominant that have in common the presence
of elongated, oval, or elliptically shaped red blood cells
(1550% of RBCs) on the peripheral blood smear. Some
conditions like thalassemias, and iron deficiency anemia,
are also characterized by the presence of elliptocytes on
peripheral smear but they constitute less than 10 percent
of RBCs.
Prevalence
The prevalence of hereditary elliptocytosis in the United
States is not greater than 2.5 to 5 per 10000. However,
in West Africa and South-east Asia, where malaria is
endemic, it may reach 1.6 and greater than 30 percent of
the population, respectively. The hereditary pyropoikilocytosis variant of hereditary elliptocytosis is more frequent
among black population, while the spherocytic elliptocytosis variant is reported only in Caucasians.
Etiology
It is usually inherited as, however, hereditary pyropoi
kilocytosis is a severe variant where there are two defective
alleles. Usually, there is a defect in spectrin leading to
defective spectrin heterodimer self-associations. Rarely,
there may be abnormalities in protein 4.1 or glycophorin C.
Chapter-20 Red Cell Membrane Disorders (Spherocytosis, Elliptocytosis, Stomatocytosis) 217

jaundice with presence of poikilocytes and pyknocytes
on peripheral smear.
The bone changes appear later.
South-east Asian Ovalocytosis is characterized by
presence of ovalocytes in the peripheral smear, which are
less elongated than elliptocytes. It is due defective protein
3. This condition offers protection from Plasmodium falci
parum malaria. Hereditary pyropoikilocytosis is the most
severe form characterized by presence of microspherocytes
in blood smear whose mean corpuscular volume is
decreased (MCV: 5060 fL). This condition as the name
suggests is characterized by increased thermal lability of
RBCs and they lyse at 45 to 46C, instead of 49 to 50C.
Treatment
Fig. 3 Stomatocytes showing a slit-like gap in center of red cells
Elliptocytic RBCs are the characteristic finding on

the peripheral smear (Fig. 3). The elliptocytic shape is
conferred by the red cell membrane skeleton, as shown
by persistence of the shape change in red cell ghosts and
in skeletons prepared from ghosts by removal of the lipid
bilayer. Elliptocytes form as the mature RBC ages in vivo,
since RBC precursors in the HE syndromes are round and
do not exhibit morphologic abnormalities. The elliptocytic
shape change is thought to result from repeated episodes
of elliptocytic deformation that all RBCs experience during
each circulatory cycle, as they pass through capillary beds.
Whereas normal RBCs regain a discocytic configuration
by a process of elastic recoil, hereditary elliptocytosis
RBCs appear to have disruption of the connections
between the various cytoskeletal components, followed
by the formation of new contacts that lock the cell into the
elliptocytic configuration.
Treatment is needed only if there is chronic hemolysis.8,9

Folic acid supplementation (1 mg/day) is needed.
Splenectomy may be indicated, if the hemoglobin is
below 10 g/dL or there is reticulocytosis >10 percent.
HEREDITARY STOMATOCYTOSIS
Hereditary stomatocytosis is a group of autosomal
dominant conditions which are characterized by the
presence of cup-shaped red blood cells (Fig. 4). The red
cell membrane leaks sodium and potassium ions. There
is a defective protein 7.2 or stomatin on chromosome 9.
A variety of variants of this condition have been described:
Overhydrated Hereditary Stomatocytosis

Most severe variety, stomatin gene may be defective.
Dehydrated stomatocytosis (Hereditary Xerocytosis/
Hereditary hyperphosphatidylcholine hemolytic anemia): It is the most common variety of stomatocytosis
caused by defective protein 7.2 or stomatin gene.
Types of Hereditary Elliptocytosis

The clinical features in generally fall into one of five
categories:
1. Silent carriers
2. Common HE
3. Hereditary pyropoikilocytosis
4. Spherocytic elliptocytosis
5. South-east Asian ovalocytosis.8,9
Hemolytic anemia in these disorders ranges from
absent to life-threatening. Severe hemolysis is usually
a consequence of homozygosity or compound hetero
zygosity for one or more of the various membrane protein
mutations associated with this disorder.
Usual features of hereditary elliptocytosis like anemia,
splenomegaly, cholelithiasis and In the newborn,
hereditary elliptocytosis may manifest as hemolytic
Fig. 4 Elliptocytes seen on peripheral smear

Dehydrated stomatocytosis with perinatal ascites.
Cryohydrocytosis: It is the mildest type where the
RBCs lyse on cooling in vitro and it is associated with
pseudohyperkalemia.
Blackburn variant.
Treatment
Usually no treatment is needed. Splenectomy is not

indicated as there is a greater tendency to life-threatening
thrombosis following splenectomy due to thrombocytosis
post-splenectomy coupled with abnormal adherence of
stomatocytic RBCs to vascular endothelium.8,9
REFERENCES

1. Delaunay J. Genetic disorders of the red cell membrane.

Crit Rev Oncol Hematol. 1995;19:79-110.
2. Gallagher PG, Lux SE. Disorders of erythrocyte membrane.
In: Nathan DG, Orkin SH, Ginsburg D, Thomas Look A (Eds).
Nathan and Oskis Hematology of Infancy and Childhood,
6th edn, volume 1, Saunders, Philadelphia. 2006.pp.560-682.
3. Bolton-Maggs PHB. Hereditary spherocytosis: New

Guidelines. Arch Dis Child. 2004;89:809-12.
4. Bolton-Maggs PHB, Stevens RF, Dodd NJ, Lamont G,
Tittensor P, King MJ. Guidelines for the diagnosis and
management of hereditary spherocytosis. Br J Hematol.
2004;126:455-74.
5. Trucco JI, Brown AK. Neonatal manifestations of hereditary
spherocytosis. Am J Dis Child. 1967;113:263.
6. Bolton-Maggs PHB. The diagnosis and management of
hereditary spherocytosis. Baillieres Best Pract Res Clin
Haematol. 2000;13:327-42.
7. Tracy ET, Rice HE. Partial splenectomy in hereditary
spherocytosis. Pediatr Clin N Am. 2008;55:503-19.
8. Martin PL. Hemolytic anemias. In McMillan J, Feigin RD,
DeAngelis CD, Jones MD (Eds). Oskis Pediatrics, 4th
end. Lippincot Williams and Wilkins, Philadelphia; 2006.
pp.1700-7.
9. Gallagher PG, Forget BG. Hereditary spherocytosis,
elliptocytosis and related disorders. In: Beutler E,
Lichtman MA, Coller BS, Kipps TJ, Seligsohn U (Eds).
Williams Hematology, 6th edn. Mc Graw Hill: New York.
2002.pp.501-16.
21
Red Cell Enzymopathy
The hereditary hemolytic anemia resulting from altered red blood cell (RBC) metabolism due to defects in various enzymes associated
with glycolytic pathway, hexose monophosphate shunt or pentose phosphate pathway are described as red cell enzymopathy or
erythro-enzymopathy (EEP). These hereditary anemias are distinguished from hereditary spherocytosis by absence of spherocytosis
in the peripheral blood. The most well known and widely distributed EEP is the deficiency of G6PD, which is involved in the initial
reaction of pentose phosphate pathway.1,2 Deficiency of pyruvate kinase and other enzymes of glycolytic pathway also result in
hemolytic anemia but the magnitude of clinical problem resulting from deficiency of these enzymes is considerably less compared
to G6PD deficiency.
G6PD DEFICIENCY
The main role of pentose phosphate pathway is related
to metabolism of glutathione (GSH) through production
of reduced form of nicotinamide adenine dinucleotide
phosphate (NADPH). GSH is important for preservation of
sulfhydryl group in many proteins including hemoglobin
and to prevent the damage from oxidative radicals in
general. Thus, GSH should be constantly available in the
reduced form which is effected by, GSH reductase through
NADPH, the later is provided by G6PD.1 G6PD catalyses
nicotinamide adenine dinucleotide phosphate (NADP)
to its reduced form, NADPH (Fig. 1). NADPH protects
cells from oxidative damage. As red blood cells (RBCs)
do not generate NADPH in any other way, they are more
susceptible than other cells to destruction from oxidative
stress. Therefore deficiency of G6PD in red cells leads to
various clinical manifestations in human beings. The level
of G6PD activity in affected RBCs is lower than in other
cells in the body.
Majority of mutations cause this enzyme deficiency
in RBC by decreasing enzyme stability. The polymorphic
mutations affect amino acid residues throughout the
enzyme and decrease the stability of enzymes in the RBC,
possibly by disturbing protein folding.2
Fig. 1 Pentose phosphate pathway
Prevalence
G6PD deficiency is the most common EEP affecting
approximately 400 million people worldwide.3 The dis
order is transmitted as a x-linked recessive trait. Though
the distribution of G6PD deficiency is worldwide, highest
prevalence is observed in Mediterranean countries,
Africa and Asia. In south-east Asia, the prevalence varies
widely in different ethnic groups10 to 20 percent in
certain Combodian groups to 1 to 3 percent in Vietnamese
population groups.4

Table 1 Frequency distribution of G6PD deficiency in India
S.
no.
Authors
Area/Caste/Tribes
studied
Frequency
1.
Thakur and
Verma,19928
Bastar (Central India),

Muria Gond tribes
M12.3%
F3.7%
2.
Handa et al, 19929
Punjab, Bania
2.8 %
3.
Ramadevi et al,
199410
Bengaluru (neonates)
7.8%
4.
Kaeda et al, 199511
Odisha
315%
5.
Balgir et al, 1999
Odisha (Mayurbhanj)
7.79.8%
6.
Sukumar et al,
20047
Mumbai
5.727.9%
7.
Gupte et al.13
Gujarat, Surat, Vataliya 22%

Prajapati
12
In India, G6PD deficiency was first reported almost 40

years ago.5 Prevalence in India varies from 0 to 27 percent
in various castes, tribes and ethnic groups.6 A recent series
from Mumbai including a large number of individuals from
various population groups reported overall prevalence of
10.5 percent the variation in various castes and linguistic
groups being 5.7 to 27.9 percent.6
Table 1 shows the prevalence rates of G6PD deficiency
in various reports over the last 15 years from different parts
of country and in different ethnic groups.7-13
MALARIA HYPOTHESIS
Variation in prevalence of G6PD deficiency has led to the
hypothesis that G6PD deficiency is a polymorphism that
confers protection from falciparum malaria. This hypo
thesis has been called G6PD/malaria or simply malaria
hypothesis.1,3 Malarial parasite grows less well in red
cells deficient in G6PD. Decreased parasitemia has been
documented in these individuals.14-16 A recent series by
Mohanty et al. has reported good correlation between
prevalence of Plasmodium falciparum malaria and G6PD
deficiency.17 Thakur and Verma have also observed inc
reased prevalence of antimalarial antibodies and higher
titers among those with normal G6PD levels compared to
G6PD deficient persons.8 Mohanty et al. have referred to an
interesting observation that among Parsees in India who
migrated from Iran approximately 1300 years ago, preva
lence of G6PD deficiency is 15.7 percent which is considerably
higher as compared to prevalence among Zorasstrians in
Iran who belong to the same community. An explanation
offered is that at the time of migration, Gujarat and Mumbai
were endemic for malaria where Parsees settled.3
Clinical and Biochemical Variants

Based on biochemical and other characterization,
442 different variants of G6PD have been identified.
Of them, 299 have been characterized with the methods

recommended by WHO.3,18 Molecular characterization
is considered more important as different variants based
on biochemical studies alone have been found to be
same on molecular characterization. From India, 13
different biochemically characterized variants have been
reported.3 A large series with biochemical and molecular
characterization reported G6PD-Mediterranean to be
the most common variant in India (60.4%) followed by
G6PD-Kerala-Kalyan (24.5%) and G6PD Odisha (13.3%).
Frequency distribution of various biochemical variants
is different in tribal and urban population. Kaeda et al.
observed that G6PD-Odisha is responsible for most cases
in tribal population but is not found in urban population
groups where most of the G6PD-Mediterranean is the
most prevalent variant. G6PD-Chatham with undetected
enzyme activity and G6PD-Insuli with normal G6PD
activity are very rare among Indian population groups. 3,7,11
Clinical Features
WHO has provided a classification of G6PD deficiency
which is based on residual activity of the enzyme and other
characterization and clinical presentation (Table 2).19 The
patients with G6PD deficiency can present clinically in
following ways: acute hemolytic anemia (AHA), neonatal
jaundice (NNJ) and chronic non-spherocytic hemolytic
anemia (CNSHA).
Acute Hemolytic Anemia

Children with certain variants of G6PD deficiency are
clinically in a steady state till they develop anemia of
sudden onset under the effect of some oxidative stress.
Within 24 to 48 hours of exposure to such stress, the child
suddenly becomes pale and has discoloration of urine
which is described as cola colored, strong tea colored
or simply brown in color. Other symptoms and clinical
findings correspond to degree of anemia and hypoxia.
Table 2 Categorization of G6PD variants

Class Clinical expression
Residual G6PD
activity (% of normal)
Variants
reported
Severe (CNSHA)
< 20%*
94
II
Mild
< 10%
114
III
Mild
1060%
110
IV
None
100%
52
None
>100%
*Severe enzyme deficiency with CNSHA. The enzymes levels are usually
less than 20% of normal. To classify in this group, the variant must be
associated with CNSHA
Chapter-21 Red Cell Enzymopathy 221

Mild jaundice, breathlessness and tachycardia are often
present. Occasionally features of frank congestive cardiac
failure, backache and abdominal pain are observed.20,21
Urinary discoloration is on account of intravascular
hemolysis but hemolysis is entirely not intravascular.
Depending upon degree of extravascular hemolysis,
splenic enlargement may be noticed. Hemolysis occurs
after exposure to stressor but does not continue with
continued exposure. This is thought to be on account of
older RBCs being damaged first as they have most severe
deficiency of enzyme. Once the population of deficient
RBC are hemolyzed, the juvenile RBC and reticulocytes
withstand the stress as they have typically higher levels
of enzyme.2 Hemoglobinemia and hemoglobinuria may
result in azotemia and/or acute renal failure. In one Indian
series on acute renal failure in children, G6PD deficiency
accounted for 6 percent cases. Azotemia occurred in 20
percent of 35 patients with G6PD deficiency in another
series.20,22
Laboratory findings during intravascular hemolysis
and AHA include moderate to severe anemia which is
usually normocytic-normochromic. RBC morphology
shows anisocytosis due to increased number of juvenile
red cells and contracted cells. Poikilocytosis with
presence of bite cells (as if some portion of red cell has
been bitten away) may be seen. Intense reticulocytosis
is present. Plasma hemoglobin level is increased and so
is unconjugated bilirubin level. Haptoglobin and other
hemoglobin binding proteins are decreased.1
Pathogenesis of such events involves oxidation
of glutathione (GSH) to GSSG. On account of G6PD
deficiency, the red cells of these patients have limited
capacity to regenerate GSH and the reserve gets depleted
soon. Exhaustion of GSH allows oxidation of sulfhydryl
group of hemoglobin (and other proteins) resulting
in denaturation of hemoglobin. Coarse precipitates of
hemoglobin lead to damage of red cell membrane and
hemolysis. As is evident, the prerequisite for such a series
of events is oxidative stress which occurs in the form of
exposure to various drugs and triggers. In fact, G6PD
was first described during investigation for primaquin
sensitivity. Since then many drugs have been incriminated
to result in intravascular hemolysis in individuals with
G6PD deficiency. Table 3 lists the drugs which can cause
such hemolysis.23-25 Other than drugs, ingestion of fava
beans (favism) and various infective agents have been
identified as triggers. In an Indian series bacterial sepsis,
malaria and hepatitis were identifiable triggers other
than drugs.20 Hepatitis results in very high levels of serum
bilirubin and increased morbidity.20,26 Mehta et al. have
reported AHA following ingestion of soft drink containing
ascorbate.27
Table 3 List of drugs known to cause hemolysis in G6PD

deficient patients (In alphabetical order)
Actyl salicylic acid
Ascorbic acid
Chloramphenicol
Chloroquine
Ciprofloxacin
Colchicine
Dapsone
Diphenhydramine
Dopamine
Doxorubicin
Furazolidone
Isobutyl nitrite
Isoniazid
Menadiol sod.
sulfate
Menadione
Menadione sod.
bisulfate
Mepacrine
Nalidixic acid
Naphthelene
Niridazole
Nitrofurazone
Nitrofurantoin
Norfloxacin
Paracetamol
Para amino-benzoic
acid
Phenacetin
Phenytoin
Phenylbutazone
Phytomenadione
Primaquine
Probenecid
Procainamide
Proguanil
Pyrimethamine
Quinidine
Quinine
Streptomycin
Sulfadiazine
Sulfadimidine
Sulfaguanadine
Sulfmethoxazole
Sulfanilamide
Astemizole
Azatidine
Cetirizine
Chlorpheniramine
Cyproheptadine
Diphenhydramine
Loratadine
Promethazine
Terfenadine
Trimethoprim
New Drugs added in
2002
NEONATAL JAUNDICE
Other than AHA, neonatal jaundice (NNJ) is a common
manifestation of G6PD deficiency. Almost one-third
of male neonates have been described to have NNJ.
NNJ resulting from G6PD deficiency has worldwide
distribution occurring in Mediterranean countries, Africa
and Asia. In an Indian series, in 12 out of 100 neonates
with jaundice, G6PD deficiency was the cause, of them10
being G6PD Mediterranean type.28 In another large series
of 551 cases of NNJ, G6PD deficiency was the largest
single identifiable cause accounting for 17.1 percent.28
Among neonates with severe jaundice requiring exchange
transfusion, G6PD deficiency has accounted for a large
number of cases.29,30 In a review of cases of kernicterus
in world literature, G6PD deficiency was the cause in 13
out of 88 cases which is next in frequency to only Rh and
ABO incompatibility.31 Severe intrauterine hemolysis and
hydrops fetalis have been reported following maternal
ingestion of oxidative agents and hemolysis has been
observed in breastfeeding neonates following maternal
ingestion of fava beans.32

Why only some and not all neonates with G6PD
deficiency develop NNJ is not easily explained. It was
postulated that NNJ is associated with only certain
variants of G6PD (just like CNSHA) but occurrence of
cases from various parts of the world does not support
this hypothesis. Similarly, correlation with residual
level of enzyme activity has also not been proven.1,30
NNJ occurring due to some other insult or trigger is
another explanation offered and is supported by higher
rates of exposure to naphthalene observed in neonates
with NNJ compared to those without NNJ.1 Infants with
G6PD deficiency and associated mutation of uridine
diphosphoglucoronate glucoronosyltransferase-1 gene
promoter (UDPGT-1) have been found to be particularly
susceptible to hyperbilirubinemia secondary to impaired
hepatic clearance of bilirubin. UDPGT-1 is the enzyme
affected in Gilbert disease.33
CHRONIC NONSPHEROCYTIC
HEMOLYTIC ANEMIA
The term CNSHA in relation to deficiency of G6PD and
other enzymes is used to describe chronic anemia with
normal/near normal red cell morphology, particularly
to differentiate it from hereditary spherocytosis. CNSHA
develops in a minority of cases with G6PD deficiency (Class
I variants). Clinical picture is quite variable. Unlike NNJ
which can affect female children, CNSHA affects only male
patients. Generally patients have had NNJ which might have
required therapeutic intervention. The patient presents
later with anemia and jaundice. Splenomegaly initially is
small but later it may increase in size. Anemia is normocytic
normochromic, slight macrocytosis may be observed due
to reticulocytosis. Unconjugated hyperbilirubinemia, inc
reased levels of lactate dehydrogenase and decreased
levels of haptoglobin are present. As most of hemolysis
is extravascular, hemoglobinemia and hemoglobinuria
is not present. Continuous hemolysis in these patients is
thought to result from red cell membrane damage due to
oxidation of sulfhydryl group of hemoglobin resulting in
its precipitation. This is supported by observation of high
molecular weight aggregates in the red cell membrane of
patients with CNSHA. This phenomenon is not seen G6PD
deficient individuals without CNSHA. G6PD deficiency
has been found to be associated with sickle cell disease
and other hemoglobinopathies. Diop et al.34 found that
prevalence of G6PD deficiency was higher in sickle cell
disease patients (21.6%) than in normal subjects (12.3%)
(p = 0.001). Will this association influence the severity of
sickle cell diseases is an obvious question because of the
nature of the two diseases. However, no difference was
found in the two groups of male sickle cell disease patients
concerning number of vaso-occlusive crisis, number of
transfusion, frequency of infectious episodes, number of

chronic complications, disturbances on patients activity
and total index severity.34 In an earlier report on this
association from India, decreased prevalence of painful
crisis was observed possibly due to poor survival of RBC
with HbS due to associated G6PD deficiency leading to
decreased chances of sickling of cells. Hemolytic crisis
was observed to be more when sickle cell disease was
associated with G6PD deficiency.35
Diagnosis
Various tests are available for diagnosis of G6PD deficiency.
Fluorescent spot test and dichlorophenol indophenol
(DPIP) de-colorization method and quantitation of
enzyme are suitable methods for routine use.
The tests are likely to be negative during episodes
of AHA as the neocytes are rich in G6PD which are in
abundance during AHA compared to steady state. Thus,
a negative test does not exclude but a positive test will
confirm the diagnosis. If negative, it is recommended
to repeat the test after three months of acute episode.3,21
G6PD genotyping can be performed using PCR but the
test is not routinely available. Quantitative methods are
available for estimating enzyme levels.
ELISA based method have been developed for field use.
A recent article reported a good sensitivity and specificity
of this test and recommended for use in resource limited
settings.
Another test for field studies is NADPH fluorescence
test on paper (NFP test). This test was compared with
polymerase chain reaction (PCR)-based G6PD genotyping
also using blood samples on filter papers. There was good
agreement between the NFP test results and the PCR
findings. The estimate of the sensitivity of the NFP test
was 98.2 percent (95.899.6%) and the specificity was 97.1
percent (94.299.2%).36,37
PREVENTIVE STRATEGIES AND TREATMENT

Management issues in cases with G6PD deficiency
include prevention of AHA and NNJ and treatment of
acute and chronic anemia and NNJ. Prevention of NNJ
is based on neonatal screening for enzyme defect and
then taking precautions in cases with enzyme deficiency.
Such a screening strategy has to be considered taking
into account the prevalence of G6PD deficiency in the
population group as is being followed in Sardinia and
some of the Mediterranean countries.1 WHO recommends
screening all newborns for G6PD deficiency I population
groups with prevalence rates of 3 to 5 percent or more in
males. Prevention of AHA centers around avoiding the
known trigger drugs in these patients.

The list in Table 3 shows that many antihistaminic
drugs are incriminated in AHA in G6PD deficiency, hence
it would be useful to avoid the cough and cold medicines
in general which otherwise are of unproven efficacy in
treating the upper respiratory infections. Some of the
known offending drugs have been successfully used in
certain population groups.38
Management of NNJ is like any other cause of uncon
jugated hyperbilirubinemia including phototherapy and
exchange transfusion. Phototherapy in these neonates
may be started at a lower level than otherwise recom
mended.31,39
A novel approach is use of heme-oxygenase inhibi
tor-tin-mesoporphyrin (Sn-MP) which reduces bilirubin
production. It has been found to be extremely useful in
preventing the development of significant hyperbiliru
binemia in G6PD deficient neonates.40-42
Treatment of acute episode of intravascular hemolysis
includes transfusion support for anemia and supportive
care. Fluid therapy during such episodes is important for

prevention and treatment of acute renal failure.22,22
Patients having CNSHA require meticulous monitor
ing. In most cases occasional exacerbation will require
blood transfusion. During steady state, administra
tion of folic acid is recommended as the requirement is
increased due to increased red cell turnover. Very few cas
es will need to be started on chronic transfusion therapy
like patients with thalassemia and hemoglobinopathies.
Splenectomy may be required due to large size, devel
opment of hypersplenism or to decrease the transfusion
requirement.1
Deficiency of Pyruvate Kinase and Other

Enzymes of Glycolytic Pathway
As compared to G6PD deficiency, the defects of glycolytic
pathway are very uncommon. Of them, pyruvate kinase
deficiency is most well recognized and along with G6PD
deficiency it is the most common cause of CNSHA.43,44 In
Table 4 Deficiency of enzymes of glycolytic pathway

S.
no.
Enzyme, inheritance
Clinical features
Hematological/other
laboratory findings
Treatment
1.
Hexokinase deficiency, AR
22 cases reported, NNJ, anemia,

splenomegaly, CNSHA, gallstones,
hyperhemolytic episodes
Red cell morphology

unremarkable
Transfusions
Folic acid
Splenectomy
2.
Glucose phosphate isomerase,

AR
46 cases from 34 pedigree, 30% NNJ,

hydrops, CNSHA, hyperhemolytic episodes
Very high reticulocyte

count, MCV increased
Same as above
3.
Phosphofructokinase
deficiency, AR
Involves red cells, muscle related symptoms

predominateexertional myopathy, easy
fatiguability (Type VII Glycogen storage
disease), mild hemolytic anemia
No lactate production
in ischemic arm test,
muscle biopsy
Unsatisfactory
4.
Aldolase deficiency, AR
Very few cases, severe CNSHA, mental

retardation
Normal red cell

morphology
Undefined
5.
Triose phosphate isomerase

deficiency, AR
Moderate to severe CNSHA, neonatal

anemia, progressive neurological disease
(unrelated to kernicterus)
Very high reticulocyte

count
Transfusions, folic
acid, splenectomy
6.
Glyceraldehyde-3-phosphate
dehydrogenase deficiency, AR
(Autosomal recessive)
Need not result in anemia, associated with

other defects like hereditary spherocytosis
Nonspecific
7.
Phosphoglycerate kinase
deficiency, X-linked recessive
CNSHA, NNJ, seizures, movement disorders,

psychomotor retardation, aphasia,
tetraplegia
Reticulocytosis
? Splenectomy
8.
2,3-Bisphosphoglycerate
mutase deficiency, AR
Complete absence may be associated with

polycythemia, neonatal onset of progressive
anemia described with 50% activity
9.
Enolase deficiency
Shortened red cell survival not necessary,

nitrofurantoin induced hemolysis
10.
Pyruvate kinase deficiency, AR
See text
11.
Lactate dehydrogenase
deficiency
Decreased levels not associated with anemia
Phlebotomy for
symptomatic
polycythemia
Spherocytosis
Undefined

Indian population, the deficiency of these enzymes has only
sparingly been studied.45,46 In contrast to G6PD deficiency,
patients with deficiency of enzymes of glycolytic pathway
usually have CNSHA with onset in neonatal period. Drug
induced hemolytic anemia- is not a common problem
in them. Most cases benefit from splenectomy. Pyruvate
kinase deficiency is described in the following section.
Rest of the conditions with their common clinical findings
are listed in Table 4.
PYRUVATE KINASE DEFICIENCY

Deficiency of pyruvate kinase (PK) is the most common
enzyme deficiency of glycolytic pathway with over 350
cases reported.47
It is transmitted as autosomal recessive trait and is
seen in patients of north European descent. PK enzyme
is a tetramer with four tissue specific subunitsR (RBC),
L (liver), M1muscle and M2 platelets and leukocytes.
Genetic control is separate for RL subunit and M1 M2
subunits.43,47 Prevalence of PK deficiency has varied from
0.14 to 6 percent.38
The hallmark of PK deficiency is CNSHA Cases with
neonatal anemia and hydrops have occurred. NNJ requiring
exchange transfusions have been described. Patients
with CNSHA have unconjugated hyperbilirubinemia
and splenomegaly which at times may become massive.
Chronic leg ulcers are a complication in some individuals.
Aplastic crisis due to parvovirus infection can occur. Gall
stones are increasingly seen after first decade.43,47,48
Table 5 describes the clinical and laboratory features
in a large series of 61 patients (all ages).
Red cell morphology is normocytic normochromic.
Macrocytosis due to active regeneration and acantho
cytosis may be observed. Reticulocyte count is increased
but not proportionate to hemolysis as in other hemolytic
anemias. This is on account of selective sequestration of
young RBCs and reticulocytes by spleen. A paradoxical
rise in reticulocytes after splenectomy therefore is a
known phenomenon. On account of hepatic PK defi
ciency, liver enzymes are elevated and coupled with
presence of hyperbilirubinemia may appear to be the
clinical picture with chronic liver disease. Iron overload
disproportionate to transfusions is an important observ
ation in certain cases and has been explained on the
basis of associated hemochromatosis mutations.43, 47-50
Treatment of PK deficiency includes transfusion
support, folate supplementation, splenectomy and chole
cystectomy for gallstones. Use of salicylates has resulted in
hyperhemolytic crisis and should be used with caution in
PK deficient patients having juvenile rheumatoid arthritis.47
Table 5 Clinical characteristics in pyruvate kinase deficiency

Clinical feature
Number
Consanguinity
4/56
Anemia
55/61
Jaundice
43/61
Neonatal jaundice
33/56
Splenomegaly
47/58
Splenectomy
18/61
Cholecystectomy
14/56
Aplastic crisis
1/61
Transfusions
18/59
Exchange transfusions
25/56
Desferrioxamine treatment
16/58
Clinical Approach to a Child Suspected to

have Enzyme Deficiency
Clinical diagnosis of erythroenzymopathy requires a high
index of suspicion. In cases presenting with acute intravas
cular hemolysis, history of exposure to trigger drugs helps
in the diagnosis. Family history of jaundice, anemia,
splenectomy and cholelithiasis may also point towards
such a disease.2,50 In absence of such history, the diagnosis
may be difficult. Other causes like autoimmune hemolytic
anemia and malaria (blackwater fever) can be excluded by
appropriate tests.
Cases with chronic hemolytic anemia pose a diagno
stic problem. In our country, common causes of hereditary
hemolytic anemia include b-thalassemia syndrome and
sickle cell disease. Both these conditions can be diagnosed by
hemoglobin electrophoresis. The diagnosis of enzymopathy
should be suspected in all cases with chronic hemolysis
and unexplained unconjugated hyperbilirubinemia parti
cularly if red cell morphology is unremarkable. Intense
reticulocytosis supports the diagnosis of various enzymo
pathies (see Table 4). The diagnosis can be confirmed by
appropriate enzyme assay. Unfortunately, the tests are
not widely available. Demonstration of accumulation of
proximal or depletion of distal intermediary compounds of
glycolytic pathway supports the diagnosis.
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Spectrum of neonatal hyperbilirubinemia: An analysis of
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Diakhate L. Prevalence and morbidity of G6PD deficiency
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38. Mandi G, Witte S, Meissner P, et al. Safety of combination
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40. Kappas A, Drummond GS, Valaes T. A single dose of
Sn-mesoporphyrin prevents development of significant
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42. Valaes T, Drummond GS, Kappas A. Control of hyperbili
rubinemia in glucose-6 phosphate dehydrogenase-defi
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47. Mentzer WC. Deficiency of Pyruvate Kinase and other
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22
Autoimmune Hemolytic Anemia
Rajiv Kumar Bansal
Immune hemolytic anemia (IHA) is the clinical condition in which IgG and/or IgM antibodies bind to RBC surface antigens and initiate
RBC destruction via the complement system and the RE system.1 Autoimmune hemolytic anemia (AIHA) refers to a collection of
disorders characterized by the presence of autoantibodies that bind to the patients own erythrocytes, leading to premature red cell
destruction. The antigens targeted often have a high incidence so that both native and transfused RBCs are destroyed. In contrast
to AIHA, in alloimmune hemolytic anemia exposure to allogenic RBCs leads to formation of alloantibodies which do not react with
autologous RBCs. A positive direct antiglobulin test (DAT, also known as the Coombs test) is essential for diagnosis.
Specific characteristics of the autoantibodies, especially

the type of antibody; its optimal binding temperature;
and whether complement is fixed, influence the clinical
picture. In all cases of AIHA, however, the autoantibody
leads to a shortened red blood cell survival (i.e. hemolysis)
and, when the rate of hemolysis exceeds the ability of the
bone marrow to replace the destroyed red cells, to anemia
and its attendant signs and symptoms. Subjects of all ages
are affected by AIHA: from infants in the first few months
of life to the elderly. Although, it occurs less frequently
than in adults, AIHA in the young is not a rarity. AIHA in
children presents some differences from those of adults.
Three types of AIHA can be distinguished based on
their serologic properties and clinical characteristics.
Most patients with AIHA (80%) exhibit warm-reactive
antibodies of the immunoglobulin IgG isotype on their
red cells. Most of the remainder of patients exhibit coldreactive autoantibodies. Two types of cold-reactive
autoantibodies to RBCs are recognized: cold agglutinins
and cold hemolysins. Cold agglutinins are generally of
IgM isotype, whereas cold hemolysins usually are of IgG
isotype. IgG warm autoantibodies bind to erythrocytes at
37C (99F) but fail to agglutinate the cells; cold agglutinins,
almost always of the IgM isotype, clump RBCs at cold
temperatures and occasionally lead to hemolysis; and the
IgG Donath-Landsteiner antibody (cold hemolysins) binds
to RBC membranes in the cold and activates the hemolytic

complement cascade when the cells are warmed to 37C
(99F).2 All three can occur as an idiopathic (primary)
disorder or can coexist with another disease (secondary)
(Table 1).
EPIDEMIOLOGY
It is a relatively uncommon but certainly not rare disorder,
with an estimated incidence of 1 to 3 cases per 100000
population per year. There is no evidence that AIHA is
confined to any particular race. It is less common than
immune thrombocytopenia. In teenagers and adults,
AIHA is more common in women than in men. The peak
incidence in pediatric patients occurs in preschool-age
children.2 Boys are 2.5 times more likely to be affected than
girls.3 In children, occurrences in patients younger than
2 years and older than 12 years are more likely to have a
chronic unremitting course.2 However, the majority of
pediatric cases are acute in onset and self-limiting. Often
these cases resolve within 6 months without treatment,2
and the decision to treat is based on the degree of anemia
and physiologic compromise. Some reports suggest
that in childhood, secondary cases are more common
than idiopathic forms. Viral and bacterial agents are
frequently the only recognizable stimuli; in fact, AIHA
follows viral infection or vaccination much more often

Table 1 Classification of autoimmune hemolytic anemia (AIHA)*
Warm active antibodies: Autoantibody maximally active at body temperature (37C)
Warm autoimmune hemolytic anemia:
Primary or idiopathic
Secondary (autoimmune disorders, lymph proliferative disorders)
Drug-induced immune hemolytic anemia
Autoimmune type
Drug adsorption type
Neoantigen type
Nonimmune type (first generation cephalosporins)
Cold active antibodies: Autoantibodies optimally active at temperature < 37C
Mediated by cold agglutinins:
Primary or idiopathic chronic cold agglutinin disease
Secondary cold agglutinin hemolytic anemia
Acute transient (infections, e.g. Mycoplasma pneumonia or infectious mononucleosis)
Chronic (lymphoproliferative disorders)
Mediated by cold hemolysins:
Primary or idiopathic: Paroxysmal cold hemoglobinuria
Secondary
Donath-Landsteiner hemolytic anemia: Acute transient (various viral infections)
Chronic (syphilis)
Mixed-type (cold and warm) autoimmune hemolytic anemia
Primary or idiopathic
Secondary (autoimmune disorders, lymphoproliferative disorders)
*Modified from Gehrs and Friedberg. Autoimmune hemolytic anemia. American Journal of Hematology. 2002;69:258-71.
in children than in adults. When it is associated with

infections in the former, AIHA is usually acute and of short
duration. Immunodeficiency or malignancy (especially
malignancies of the lymphoreticular tissues), systemic
lupus erythematosus (SLE), and other types of collagen
vascular diseases are most commonly associated with
immune hemolysis in children. Drugs are less commonly
associated with AIHA. The reason for this finding is
probably that the common inducers of immune hemolysis,
such as -methyldopa in the past, are not normally
prescribed for children. When drug-induced AIHA occurs,
it is usually due to immunoglobulin G (IgG) antibodies and
it is associated with antibiotics such as penicillin. Biphasic
hemolysin (historically related to syphilis) is, nowadays,
associated with viral infections such as measles, rubella,
and chickenpox.4
deLuca et al. reported 29 children with autoimmune
hemolytic anemia (AIHA) in 1979 from Rome, Italy. Patients
were divided into two groups, i.e. patients with transient AIHA
(15 cases) and patients with the chronic form of the disease
(14 cases).5 The criterion for this distinction was based on
the episode of increased hemolysis which was either shorter
or longer than 3 months. If a relapse of AIHA occurred, the
case was considered to be chronic by them. There were no
patients with cold autoagglutinins or biphasic hemolysins
in this study. Associated diseases were found in 27 patients

and included infectious diseases, immunodeficiency, autoimmune related disorders.
Lymphoproliferative Disease and

Rh-hemolytic Disease
Oliveira et al 2006 evaluated 17 patients younger than
15-years-old admitted from 1988 to 2003 in Brazil.6 The
median age at diagnosis was 10.5 months. The direct
Coombs polyspecific test was positive in 13 patients
and negative in four patients. Monospecific testing was
performed for 14 patients. The most frequent red cell
autoantibody was IgG (five patients), followed by IgM in
two. Thirteen patients had severe anemia and needed
blood transfusions. Underlying diseases were identified
in four patients: systemic lupus erythematosus, Hodgkins
lymphoma, autoimmune hepatitis and Langerhans cell
histiocytosis. The remaining patients were classified as
having primary disease. The median follow-up period
was 11 months (523 months). Three children died, two
after splenectomy and one with complications of the
underlying disease.
Vaglio et al. published one of the largest studies of
AIHA in children in 2007.4 A retrospective review of 100
cases of childhood AIHA (age range 6 months16 years)
Chapter-22 Autoimmune Hemolytic Anemia 229

Table 2 Distribution of 100 patients with AIHA based on disease association and serologic findings (Vaglio et al)4
Condition
Warm AIHA
Cold AIHA
PCH*
Mixed AIHA
Idiopathic AIHA
38
Autoimmune diseases
Idiopathic thrombocytopenic purpura

(ITP)
Systemic lupus-erythematosus (SLE)
Infectious diseases
Neoplasia
Sickle cell anemia
Thalassemia major
Myelodysplasia
Non-Hodgkins lymphoma
Chronic myelogenous leukemia
Acute myelogenous leukemia
Acute lymphoblastic leukemia
Liver and kidney transplant
Total
64
26
Hematologic disorder
* PCH: Paroxysmal cold hemoglobinuria.
by them, diagnosed over a 20-year-period revealed a

peak incidence in the first 4 years of life (Table 2). No sex
predilection was observed. The majority of patients (64%)
were diagnosed with warm AIHA, whereas cold agglutinin
disease and PCH accounted for 26 percent and 6 percent
of children, respectively. A mixed type of AIHA was
observed in four subjects. Overall, 54 percent of children
had coexisting disease, including hematologic disorders,
autoimmune disease, infection, and neoplasia. All cases of
PCH were associated with a recent viral illness.
There are no large studies on AIHA in Indian literature.
Sporadic case reports have been published from time to
time. Naithani et al. 2007 published one of the largest
pediatric series from India.7 A series of 26 cases were seen
by them over a period of 5 years in Delhi, India. Of the 26
patients, 11 were males and 15 females. Patients were in
the age group of 2 months to 17 years (median; 11 years).
Nine (35%) children had secondary AIHA in this series.
Of them 5 had autoimmune conditions, 2 had Evans
syndrome, 2 had SLE, 2 had JRA, 1 had nephritis, 1 had
endocrinopathy and 4 had various infections.
In a study of twelve children diagnosed with autoimmune hemolytic anemia over a period of four years
Gupta et al. (2008) from BHU, Varanasi found 9 had
primary disease and 3 had secondary disease.8 Tubercular
infection was seen in 2 patients with secondary disease.
Drug-induced immune hemolytic anemia (DIIHA)

is rare.9 The incidence is around 1 in 1 million of the
population. The number of drugs and the suggested
mechanisms associated with DIIHA has changed over the
last 40 years. In 1967, only 13 drugs were implicated; in
1980, 32 drugs were reported and in 2007, 125 drugs were
reported.10 Three groups of drugs predominated: 42 percent
were antimicrobials; 15 percent were anti-inflammatory; 11
percent were anti-neoplastics.10 The specific drugs mainly
implicated have changed dramatically. In the 1970, the
most common drug, by far, to cause DIIHA was methyldopa,
which caused a true AIHA with no drug antibody involved
and accounted for 67 percent of all DIIHA. High-dose
intravenous penicillin accounted for 25 percent of DIIHA.
When these therapies became less commonly used,
the most common causative group of drugs became
the cephalosporins, which, from the 1990s, account for
70 percent of the DIIHA. The drugs most frequently
associated with DIIHA at this time are cefotetan (more than
50 percent cases of DIIHA), ceftriaxone, and piperacillin.
Ceftriaxone is the second most common drug to cause
DIIHA.9 Some children have dramatic HA; 50 percent are
reported as fatal HA.11,12 Analysis of 21 patients (15 children
and 6 adults) showed that 40 percent of the children
started hemolyzing 1 hr after receiving ceftriaxone.
Hemoglobin levels fell to 5 g/dL in 62 percent and to

1 g/dL in 20 percent of the patients. Fatal HA occurred
in 38 percent of the patients. The children have always
received ceftriaxone previously, the DAT is usually
positive (all have RBC-bound complement and most have
IgG in addition), and ceftriaxone antibodies are detectable
in the patients serum. The HA is usually not as dramatic
in adults. The fall in hemoglobin is much less and does not
occur in a few hours; fatalities are less common.
Piperacillin can cause DIIHA and/or positive DATs.
Although a semi-synthetic penicillin, unlike other semisynthetic penicillins (e.g. ampicillin), it reacts differently
than penicillin G. In contrast to penicillin, the in vivo RBC
destruction can be complement-mediated; most of the
DATs are positive due to RBC-bound complement and IgG.13
Hydrocortisone can also cause DIIHA.14 This adds
another possible explanation for poor responses to steroid
therapy in some cases of AIHA, where steroid-induced
DIIHA may be masked by the autoimmune process.
PATHOGENESIS
AIHA is an autoimmune disease in which there is loss of self
tolerance. Self tolerance refers to a lack of responsiveness to
an individuals own (self) antigens. In the case of AIHA, the
antibodies are directed against self RBC antigens, leading
to their enhanced clearance through Fc-receptormediated
phagocytosis (extravascular hemolysis) or complementmediated breakdown (intravascular hemolysis). There is
some evidence that AIHA may be in large part due to selfreactive antibodies against erythrocyte band 3, an anion
transporter found in erythrocyte membranes. In AIHA,
autoantigenic T-cell epitopes have recently been mapped
for the RhD autoantigen. The degree of hemolysis in AIHA
depends on the characteristics of the bound antibody (e.g.
quantity, thermal amplitude, specificity, complement
fixing ability and the ability to bind tissue macrophages)
and also the characteristics of target antigen (density,
expression, patient age).15,16
The cause of autoimmune hemolytic anemia is
unknown. In about one-third of cases, the autoantibodies
have specificity for an antigen in the Rh system. In
another third, the antibodies target proteins in membrane
glycoproteins (glycophorins) of the red cell; in other cases,
the antibodies have specificity for antigens in the Kell or
Duffy blood group system (very rarely for ABO antigens)
or for structures in the membrane that are not blood group
antigens (e.g. band 3, an anchor point in the membrane for
the red cell cytoskeleton). In all these cases, the patients
own erythrocytes display the relevant antigen.17 In primary
AIHA, the autoantibodies of any one patient often are
specific for only a single RBC membrane protein. The
narrow spectrum of autoreactivity suggests the mechanism
underlying AIHA development in such patients is not
secondary to a generalized defect in immune regulation.

Rather, these patients may develop warm-antibody AHA
through an aberrant immune response to a self-antigen or
to an immunogen that mimics a self-antigen. In patients
with secondary AIHA, the disease may be associated with
a fundamental disturbance in the immune system.
During fetal life, developing lymphocytes that come
into contact with antigen are eliminated or silenced.
This effect is one of the mechanisms of immunologic
tolerance of endogenous antigens. The extreme rarity of
autoimmune hemolytic anemia secondary to anti-A or
anti-B antibodies indicates the deletion from the immune
repertoire of B cells with the capacity to produce anti-A or
anti-B antibodies. Such clones are probably eliminated
or inactivated early in ontogeny because the embryo
can synthesize A and B substances within 5 weeks of its
implantation in the uterine wall.
A population of CD4+/CD25+ T cells that express the
transcription factor Foxp3 restrains immune responses
against autoantigens in adults. There is evidence that a
deficiency of these regulatory T cells plays a role in the
pathogenesis of autoimmune hemolytic anemia.
Warm antibodies-pathogenic effects: IgG antired cell
autoantibodies mediate the destruction of red blood
cells outside the circulating blood in a process called
extravascular hemolysis (Figures 1A to D). By contrast,
when lytic components of the complement system enter
the mechanism, destruction of red cells occurs directly
within the circulating blood (intravascular hemolysis).
The participation of lytic complement components in IgGmediated autoimmune hemolytic anemia is, however,
rare. IgG antibodies are relatively poor activators of the
classical complement pathway, but they, especially the
IgG1 and IgG3 antibodies are recognized readily by Fc
receptors on various phagocytic cells. The IgG sensitized
RBCs generally are eliminated by the phagocytes of the
R-E system. Presence of complement factors C3 (C3b
and iC3b) potentiates extravascular hemolysis by the
R-E cells in these patients as they have receptors for
these complement components. Autoantibody-coated
RBCs are trapped by macrophages in the Billroth cords
of the spleen and, to a lesser extent, by Kupffer cells in
the liver. The process leads to generation of spherical
RBCs (Spherocytes) and fragmentation and ingestion of
antibody-coated RBCs. Spherical RBCs are more rigid and
less deformable than normal RBCs. As such, spherical
RBCs are fragmented further and eventually destroyed
in future passages through the spleen. Spherocytosis is
a consistent and diagnostically important hallmark of
AHA, and the degree of spherocytosis correlates well with
the severity of hemolysis. Direct complement-mediated
hemolysis with hemoglobinuria is unusual in warm-
Figs 1A to D IgG anti-red cell autoantibodies. (A) Structure of an

IgG molecule demonstrating its variable and constant regions
and the heavy and light chains; (B) Agglutination of red cells by
pentameric IgM antibodies, which can join the cells into a lattice;
(C) Coating of red cells by IgG antibodies. The antibodies are
unable to agglutinate the cells; (D) Agglutination of IgG-coated
red cells by an anti-IgG antibody
antibody AHA. Cytotoxic activities of macrophages and

lymphocytes also may play a role in the destruction of
RBCs in warm-antibody AHA.
Warm autoantibodies are panagglutinins, i.e. they
react with all the RBCs in the diagnostic panel. Of the
reported specificities, Rh is by far the most common (70%),
including all but the Rhnull erythrocytes.
The degree of anemia in AIHA depends not only on the
rate of red cell destruction but also on the ability of marrow
to increase erythrocyte production. With an adequate
supply of nutrients and growth factors, bone marrow can
overcome a hemolytic rate of about three times normal;
anemia does not appear until the half-life of the red
cell population drops to about 10 days (the half-life of a
population of normal red cells is about 30 days as measured
with 51Cr-labeled red cells). A half-life of 5 or 6 days is not
unusual in autoimmune hemolytic anemia. The marrow
can compensate for accelerated red cell destruction by
increasing the number of red cell precursors by upto
10 times the normal number (erythroid hyperplasia),
accelerating the release of reticulocytes, and in some cases,
allowing nucleated red cells to enter the blood.
Cold Agglutinins and Hemolysins

Pathogenic Effects
Cold-active antibodies exhibit increasing titer and RBCbinding activity as the temperature decreases toward 0C
and occur in two forms: (1) Cold agglutinin disease (CAD)associated with IgM antibodies usually directed at the RBC
I antigen, typically occurs in adult patients and may be
primary or secondary to another disease process, usually
infectious, and (2) Paroxysmal cold hemoglobinuria
(PCH)-caused by the so-called Donath-Landsteiner
antibody, an IgG hemolysin.
The great preponderance of cold agglutinin molecules
are IgM antibodies. Most cold agglutinins are unable to
agglutinate RBCs at temperatures higher than 30C. The
highest temperature at which these antibodies cause
detectable agglutination is termed the thermal amplitude.
Generally, patients with cold agglutinins with higher
thermal amplitudes have a greater risk for cold agglutinin
disease. For example, active hemolytic anemia has been
observed in patients with cold agglutinins of modest titer
(e.g. 1:256) and high thermal amplitudes. More than 90
percent of cold-active antibodies have the I antigen as their
target on the RBC, and the I antigen is the binding site for a
significant portion of the remaining 10 percent. The closely
related I/i antigens are high-frequency carbohydrates
similar to the ABO antigens. Neonatal RBCs exclusively
expressing large amounts of i antigen, converting to
exclusively I antigen by 18 months of age. Other uncommon
but reported antigen targets include Pr. The fact that M.
pneumoniae induces anti-I antibodies in the majority of
patients is potentially related to the finding that sialylated
I/i antigens serve as specific Mycoplasma receptors. Minor
modification of this antigen may incite autoantibodies.
The pathogenicity of a cold agglutinin depends upon
its ability to bind host RBCs and to activate comple
ment. IgM sensitized RBCs generally are associated
with a combination of intravascular and extravascular
hemolysis. The pentameric structure of IgM enables
efficient complement activation. Destruction of erythro
cytes sensitized with IgM antibodies is mediated by
the complement system. Complement mediates RBC
destruction either directly by cytolysis or indirectly via
interaction of RBC-bound activation and degrad
ation
fragments of C3 with specific receptors on reticuloendo
thelial cells, principally liver macrophages (Kupffer cells).
Due to the presence of regulatory RBC proteins such as
decay accelerating factor (DAF, CD55) and membrane
inhibitor of reactive lysis (MIRL, CD59), overwhelming
complement activation usually is required to produce
clinically evident intravascular hemolysis. However, in
most clinical situations, IgM antierythrocyte antibodies
are present in sublytic quantities. Under these conditions,
DAF (CD55) and MIRL (CD59) are able to prevent direct
RBC lysis. More commonly, IgM sensitized RBCs undergo
extravascular hemolysis. While RE cells do not have
receptors for the Fc fragment of IgM antibodies, they do
have receptors for the abundant RBC-bound C3b and iC3b

resulting from complement activation. The principal site
of IgM mediated extravascular hemolysis is liver and not
the spleen.
Cold agglutinins may bind to RBCs in superficial
vessels of the extremities, where the temperature generally
ranges between 28 and 31C, depending upon ambient
temperature.18 Cold agglutinins of high thermal amplitude
may cause RBCs to aggregate at this temperature, thereby
impeding RBC flow and producing acrocyanosis. In
addition, the RBC-bound cold agglutinin may activate
complement via the classic pathway. Once activated
complement proteins are deposited onto the RBC surface,
the cold agglutinin need not remain bound to the RBCs
for hemolysis to occur. Instead, the cold agglutinin may
dissociate from the RBCs at the higher temperatures
in the body core and again be capable of binding other
RBCs at the lower temperatures in the superficial vessels.
As a result, patients with cold agglutinins of high thermal
ampli
tude tend toward a sustained hemolytic process
and acrocyanosis.19 In contrast, patients with antibodies
of lower thermal amplitude require significant chilling
to initiate complement-mediated injury of RBCs.
This sequence may result in a burst of hemolysis with
hemoglobinuria.19 Combinations of these clinical patterns
also occur.
In contrast to cold agglutinins, cold hemolysins the so
called Donath and Landsteiner (D-L) antibodies, are IgG
antibodies and are polyclonal. They were first described
by Donath and Landsteiner in 1903 in patients with a
characteristic syndrome-paroxysmal cold hemoglobinuria
(PCH).20 The Donath and Landsteiner (D-L) antibody is
a hemolysin that binds to RBCs at low temperatures and
fixes complement. When the RBCs are warmed, they are
destroyed by complement lysis. The D-L IgG antibody is
a potent hemolysin, causing significant RBC destruction
even in low titers. The D-L antibody is classically described
as a biphasic hemolysin. The antibody requires the cooler
temperatures (04o C) to bind to the RBC, but complementmediated lysis does not proceed until the temperature
is raised (37o C). The antibody in PCH is directed against
the P antigen, found on the RBCs of most individuals. The
P antigen is similar to the Forssman glycolipids present
in many micro-organisms. This similarity suggests that
infectious agents, may elicit D-L antibodies as a result of
crossreactivity.
The D-L antibody occurs in three clinical syndromes:
(a) chronic PCH associated with late-stage or congenital
syphilis, (b) acute transient PCH occurring after an infectious
illness, and (c) chronic idiopathic PCH. An increasing
proportion of Donath-Landsteiner autoantibody-mediated
hemolytic anemias occurs as a single postviral episode
in children, without recurrent attacks (paroxysms). The
prognosis for such cases is excellent. Thus, rather than
paroxysmal cold hemoglobinuria, a proposed term for this

latter entity is Donath-Landsteiner hemolytic anemia.21, 22
DRUG-INDUCED IMMUNE
HEMOLYTIC ANEMIA
The most common drugs associated with DIIHA and the
hypotheses for the mechanisms thought to be involved
have changed during the last few decades. There are
two types of drug-related antibodies. Drug-independent
antibodies are those antibodies that can be detected in
vitro without adding any drug; thus, in vitro and in vivo
characteristics are identical to cell red blood cell (RBC)
autoantibodies. Drug-dependent antibodies are those
antibodies that will only react in vitro in the presence
of drug (e.g. bound to RBCs or added to the patients
serum in test systems to detect drug antibodies); these
are antibodies directed at epitopes on the drug and/or its
metabolites, or a combination of drug plus RBC membrane
protein. The mechanisms involved in the serological and
clinical findings are controversial. It is still unknown why
or how some drugs can affect the immune system to cause
RBC autoantibody formation, with or without HA.23
Clinical Features
Preschool children have the peak incidence of AIHA in
pediatric age group. It is 2.5 times more common in boys
as compared to girls. The clinical findings in WAIHA are
variable. They are determined by the rate of hemolysis and
the ability of the body to process breakdown products and
mount a reticulocytosis. Two general clinical patterns are
seen. In 70 to 80 percent patients mostly in the age group
of 2 to 12 years the disease has an acute transient pattern
lasting for 3 to 6 months. It is frequently preceded by an
infection, usually respiratory.
Onset may be acute, with prostration, pallor, jaundice,
pyrexia, and hemoglobinuria, or more gradual, with
primarily fatigue, dyspnea on exertion and pallor. The
spleen is usually enlarged. Hepatomegaly, and lympha
denopathy may also accompany the anemia.
Mild, chronic hemolytic anemia with exacerbations in
the winter is the general rule for cold agglutinin disease.
Rarely, does the hemoglobin drop below 7 g/dL. Pallor
and jaundice may occur, if the rate of hemolysis is greater
than the endogenous capability to metabolize bilirubin.
Some patients have intermittent bursts of hemolysis
associated with hemoglobinemia and hemoglobinuria on
exposure to cold and may be forced to move to warmer
climates to prevent attacks. Acrocyanosis can occur from
agglutination of RBCs in the cooler vessels of the hands,
ears, nose, and feet. Digits may become cold, stiff, painful,
or numb and may turn purplish. Limbs may manifest

livedo reticularis, a mottled appearance that is readily
reversible upon warming of the affected area. Only rarely
does actual gangrene of digits develop. If hemolysis does
occur after Mycoplasma infections, it typically begins
when the patient is recovering from the pneumonia and
titers for cold autoantibodies are at their peak. Hemolytic
anemia in infectious mononucleosis develops either at the
onset of symptoms or within the first 3 weeks of illness.
In children <5 years, paroxysmal cold hemoglobinuria
accounts for almost 40 percent of the patients. The onset
of the disease is sudden with fever (even up to 40oC),
back or leg pain, and hemoglobinuria after exposure
to the cold even of a few minutes. Symptoms may
follow shortly or several hours later. Abdomen cramps,
headache, nausea, vomiting, and diarrhea may also
occur. Dark red-to-black color urine is voided after the
onset and typically clears in a few hours. Rarely, it persists
for a few days. The spleen may be palpable during an
attack and shortly thereafter, and mild jaundice may
appear. Systemic symptoms may appear without the
hemoglobinuria and vice versa. Reports of Vasomotor
phenomena manifest as cold urticaria, tingling of hands
and feet, cyanosis, and Raynaud phenomenon are there
in the literature.
An antecedent upper respiratory infection in children is
usually identified in PCH. Measles, measles vaccinations,
mumps, Mycoplasma pneumoniae, influenza A, adenovirus,
varicella, cytomegalovirus, Haemophilus influenzae, and
infectious mononucleosis have been identified as ante
cedent illnesses. The original chronic PCH associated with
syphilis has all but disappeared.
A careful history of drug exposure should be obtained
from all patients with hemolytic anemia and/or a positive
DAT. In drug, induced AIHA, clinical manifestations are
the same as above except there is history (taken carefully)
of use of the offending drug and absence of hepatomegaly
and significant lymphadenopathy. Cefotetan or quinidine
(by ternary complex mechanism) has been implicated in
many severe hemolytic reactions. Fatal reactions may
occasionally occur. Cefotetan and ceftriaxone have been
associated with fatalities. Patients with hapten/drug
adsorption (e.g. penicillin) and autoimmune (e.g. alphamethyldopa) types of drug-induced hemolytic anemia
exhibit mild-to-moderate hemolysis, with insidious
onset of symptoms developing over a period of days to
weeks.
LABORATORY FINDINGS24-27
Anemia
By definition, patients with AHA present with anemia, the
severity of which ranges from life-threatening to very mild.
In fulminant cases, in which the RBC lifespan is less than
5 days, the anemia is severe, and erythropoiesis increases

8-10 fold. The reticulocyte count may rise, sometimes
upto 40 percent. Reticulocytes may be depressed early
in the course. Reticulocytopenia may be because of
marrow shutdown from intervening infection, malignancy
myelophthisis, parvovirus B19 infection, or the possibility
of the autoimmune antibody being directed at antigens in
great concentration on the reticulocytes themselves.
On PBF examination, polychromasia indicates reticu
locytosis. Spherocytes are seen in patients with moderateto-severe hemolytic anemia. RBC fragments, nucleated
RBCs, and occasionally erythrophagocytosis by monocytes
and rarely neutrophils may be seen in severe cases.
Most patients have mild leukocytosis and neutrophilia.
Leukopenia and neutropenia may also occur sometimes.
Patients with severe hemolytic anemia and markedly
increased erythropoiesis occasionally develop folate
deficiency and frank megaloblastosis with raised MCV
levels.
Platelet counts typically are normal but may be low in
systemic lupus erythematosus or in Evans syndrome.
The combination of a high MCV (because of reticulo
cytosis), a high RDW (because of the dimorphic population
of reticulocytes and spherocytes), and a high reticulocyte
count points to hemolytic anemia.
Clumping from the cold agglutinins complicates both
the peripheral blood smear and the calculation of the red
cell counts and red cell indices in cold agglutinin disease.
Disolution of the clumping upon warming indicates
the presence of a cold agglutinin rather than Rouleaux
formation or fibrin clumping.

Not recommended routinely. Indicated if uncommon
findings or in cases where lymphoma is suspected.
The characteristic finding in bone marrow is erythroid
hyperplasia.
Biochemical Tests Suggesting Increased

Destruction of Erythrocytes
Raised serum bilirubin levels, rarely >5 mg/dL with
conjugated (direct) fraction constituting less than 15
percent of the total. Increased urinary urobilinogen,
hemoglobinemia and depressed or absent haptoglobin
can be seen in rapid hemolysis rarely in warm AIHA but
more commonly in patients with cold agglutinin disease,
and characteristically in patients with paroxysmal cold
hemoglobinuria and with drug-immune hemolytic anemia
mediated by the ternary complex mechanism, even if
extravascular. Hemoglobinuria and hemosiderinuria may
be seen after severe hemolysis. Serum haptoglobin levels
are low, and lactate dehydrogenase levels are elevated.
Antiglobulin (Coombs) DAT Test

and Indirect Antibody Test (IAT)
Diagnosis of AIHA or drug-immune hemolytic anemia
requires demonstration of immunoglobulin and/or
complement bound to the patients RBCs outer membrane
by DAT, also known as the Coombs test (first described in
1945 by Robin Coombs) which is pathognomonic for this
disease. It is a screening procedure. If agglutination is
noted with this broad-spectrum reagent, antisera reacting
selectively with IgG (the gamma Coombs) or with C3
(the nongamma Coombs) are used to define the specific
pattern of RBC sensitization. Monospecific antisera to IgM
or IgA also have been used in selected cases.
Nevertheless, a positive antiglobulin test requires
cautious interpretation when there are no other features
of autoimmune hemolytic anemia. False-positive test
results are not unusual. The reported incidence of positive
antiglobulin tests in normal blood donors and general
populations of hospitalized patients varies widelyfrom
1 in 100 to 1 in 15000. Differences in the technique used
in performing the test account for this variation. The most
common reason for a false-positive direct antiglobulin test
is low-avidity adherence of nonspecific IgG to red cells. In
rare cases, however, the result is not a false-positive but a
harbinger of the development of autoimmune hemolytic
anemia. False-negative tests are usually due to low-affinity
autoantibodies that spontaneously elute from the red cell
in vitro or amounts of erythrocyte-coating antibodies
that are below the limit of detection by the antiglobulin
test. The distinction between a true-positive and a falsepositive direct antiglobulin test can be made by eluting
the antibody from the red cells and testing its ability to
bind to normal red cells. In a false-positive reaction, the
eluted antibody does not bind to normal red cells, whereas
binding occurs in a true-positive test.
In >95 percent of warm AIHA cases, the DAT is positive:
Series vary in their DAT results. Between 20 and 66 percent
have only IgG on the surface, 24 to 63 percent have IgG
and C3, 7 to 14 percent have only C3, and 1 to 4 percent
are DAT-negative. Patients with SLE are particularly
prone to positive tests for complement on their RBCs. IgG1
predominates, either alone or in combination with other
subclasses (Table 3).
Free autoantibody may be detected in the plasma
or serum of these patients by the IAT. In general, patients
whose RBCs are heavily coated with IgG more likely exhibit
plasma autoantibody. Patients with a positive IAT as a
result of a warm-reactive autoantibody should also have
a positive DAT. A patient with a serum anti-RBC antibody
(positive IAT) and a negative DAT probably does not
have an autoimmune process but rather an alloantibody
stimulated by prior transfusion.
Table 3 Results of DAT in 100 pediatric patients with different

serologic type of AIHA
AIHA
DAT
Warm
(n = 64)
Cold
(n = 26)
DAT neg
11
DAT pos
59
15
Compl (C)
15
IgG
19
IgG + C
31
IgG + IgA
IgG + IgA + C
IgG + IgA
+ IgD + C
IgA
Mixed
(n = 4)
PCH
(n = 6)
5
1
1
3
1
Vaglio et al. 2007
Patients with cold agglutinin disease have a more

homogeneous DAT results than patients with warm AIHA.
Since IgM antibodies are involved in this disease DAT is
positive almost exclusively with anti-C3 and polyspecific
reagents and negative with anti-IgG.
PCH is caused by Donath-Landsteiner antibody
a biphasic IgG antibody. It fixes complement at low
temperature and ultimately dissociate at higher tempera
tures. As a result, DAT is positive with anti-C3, but is
generally negative with anti-IgG unless performed at colder
temperature. Biphasic IgG autoantibodies bind RBCs
efficiently at 04oC and subsequently, fix complement C1
at that temperature.
D-L antibodies are potent, so even a small titers can
produce hemolysis.
THERAPY17,22, 24,28
General principles of treatment are guided by the severity
of hemolysis. Severe cases with very low hemoglobin
may warrant immediate blood transfusion while mild-tomoderate cases may either need only observation or else
need to modulate the immune systems production of
autoantibody and destruction of antibody-coated RBCs.
Blood Transfusion in Autoimmune

Hemolytic Anemia
In AIHA, the decision to transfuse does not depend on
compatibility test results and, instead depends on an
evaluation of the patients need for transfusion. The
indications for transfusion in patients with AIHA are not
significantly different than for similarly anemic patients

without AIHA. Patients with autoimmune hemolytic
anemia (AIHA) frequently have anemia of sufficient
severity as to require a blood transfusion. It is impossible
to find compatible blood when, as is frequently the case,
the autoantibody in the patients serum reacts with all
normal red blood cells.
Because the antibody in this disease is usually a
panagglutinin, reacting with nearly all normal donor
cells, compatible cross-matching is impossible. The goal
in selecting blood for transfusion is to avoid administering
RBC with antigens to which the patient may have
alloantibodies.
A common procedure is to adsorb the panagglutinin
present in the patients serum with the patients own
RBC from which antibody has been previously eluted.
Serum cleared of autoantibody can then be tested for the
presence of alloantibody to donor blood groups. ABOcompatible RBC matched in this fashion are administered
slowly, with watchfulness for signs of an immediate-type
hemolytic transfusion reaction.
Physicians should provide as many RBCs as may be
reasonable because the autoadsorption procedure is
the most effective method for detecting alloantibodies
in patients with warm autoantibodies. The warm
autoadsorption test is not useful in patients who have
been transfused recently (within about the last 3 months)
because even a small percentage of transfused cells may
adsorb the alloantibody during the in vitro adsorption
procedure, thus invalidating the results. An alternative
approach, which may be about as effective in avoiding
the effects of alloantibodies, but which is not widely
implemented in transfusion services, is to perform
extensive RBC phenotyping of the patient and the donor
units. Other simple tests that provide safety include routine
testing of the patients serum against a red cell panel and
diluting the patients serum before doing compatibility
testing.
However, one need to remember that only a few percent
of all hospitalized patients have RBC alloantibodies so
that if transfusion is extremely urgent, the lesser risk
may be to transfuse rather than waiting for completion
of the compatibility testing. In very urgent situations,
the quickest, but least reliable, techniques for detection
of alloantibodies are the dilution technique and partial
RBC phenotyping. Warm autoadsorption test should
be performed if there is adequate time, since it is highly
effective for detection and identification of alloantibodies
and only requires one to three adsorptions of the patients
serum with the patients (ZZAP-treated) RBCs. Allogeneic
adsorption, which is the most time consuming, is indicated
if the patient has been transfused recently or if the patients
RBCs are not available for autoadsorption.
Alleviation of signs and symptoms of anemia usually
can be accomplished with relatively small quantities
of RBCs, as little as 0.5 to 1 units. Transfusion should be

given when indicated even before all serological tests are
completed.
Compatibility testing in cold antibody AIHAs is
less labor intensive. In cold agglutinin syndrome, the
autoantibody does not often react upto a temperature of
37C, whereas clinically significant RBC alloantibodies will
react at this temperature. Accordingly, the compatibility
test can be performed strictly at 37C (Petz & Garratty,
2004). If the transfusion service is not able to perform
testing strictly at 37C, one or two cold autoadsorptions
should be done, which will not remove a high titer cold
agglutinin completely, but are likely to eliminate reactions
that occur at 37C.
GLUCOCORTICOIDS
Glucocorticoids are the main stay of treatment in
warm AIHA. If the disease is mild and compensated, no
treatment is needed. However, if the hemolysis is severe
with significant anemia with its antecedent signs and
symptoms, glucocorticoid treatment is started.
Glucocorticoids decrease the rate of hemolysis by
blocking macrophage function by downregulating Fc
receptor expression and thus may suppress RBC seques
tration by splenic macrophages, decreasing the production
of the autoantibody, and perhaps by enhancing the elution
of antibody from the RBCs. The standard of practice is
administration of prednisone in a dose of 1.0 to 2.0 mg/kg/
day. In some patients with severe hemolysis, doses upto 6
mg/kg/day may be required to reduce the rate of hemolysis.
A response, manifested by a rise in the hematocrit and a fall
in the reticulocyte count usually within 3 to 4 weeks. The
duration of treatment at this dose is an unsettled question.
A patient who fails to improve within this time is unlikely to
respond to further treatment with prednisone. In a patient
who responds, slow reduction of the dose of prednisone
is essential to avoid a relapse. The dose is tapered only
when the rate of hemolysis decreases significantly and
then reduced to 5 to 15 mg/day. Thereafter, slow, cautious
tapering over a period of at least 4 months is the rule. A
rise in the reticulocyte count or a fall in the hematocrit
should prompt an increase in the dose, usually to the
previous level. The disease tends to remit spontaneously
within a few week or month. The Coombs test result may
remain positive, even after hemolysis has subsided. About
25 percent of patients treated with corticosteroids enter
a stable, complete remission; half the patients require
continuous, low-dose prednisone; and the remaining 25
percent respond only transiently or not at all or are unable
to tolerate continuous corticosteroid treatment. There
is no reliable evidence that alternate-day maintenance
treatment is superior to daily treatment, but some patients
tolerate this schedule better than daily prednisone.

Very high doses of intravenous methylprednisolone
may be tried in cases who do not respond to oral
prednisolone before other treatments are initiated or are
critically ill.
SPLENECTOMY
Because the spleen is the major site of red cell destruction
in autoimmune hemolytic anemia, splenectomy should
be considered for patients who have not responded to
corticosteroids or who have maintained a stable, but
corticosteroid-dependent remission. A complete, durable
remission follows splenectomy in half to two-thirds of
cases. Attempts to predict responsiveness to splenectomy
with measurement of splenic sequestration of 51Cr-labeled
erythrocytes are not reliable. However, the relapse rate
following splenectomy is disappointingly high. Many
patients require further glucocorticoid therapy to maintain
acceptable hemoglobin levels, although often at a lower
dose than required prior to splenectomy. The only way of
knowing the effectiveness of splenectomy in a given patient
is to perform the procedure. Laparoscopic splenectomy, a
safe method of removing the organ, is now the preferred
surgical technique. In most cases, a reasonable approach is
to continue glucocorticoids for 1 to 2 months while waiting
for a maximal response. However, if no response is noted
within 3 weeks, the patients condition deteriorates, or the
anemia is very severe, splenectomy should be performed
sooner.
Splenectomy removes the primary site of RBC
trapping. The beneficial effect of splenectomy may be
related to several factors interacting in complex fashion.
The spleen is also believed to be a major producer
of IgG antibodies. Continuation of hemolysis after
splenectomy is partly related to persisting high levels
of autoantibody, favoring RBC destruction in the liver
by hepatic Kupffer cells. Splenectomy has little effect on
the clearance of IgM-coated RBCs and therefore would
not be indicated in the unusual patient with a warmactive IgM antibody.
Splenectomy is complicated by a heightened risk of
infection with encapsulated organisms, particularly in
patients younger than 2 year. Prophylaxis is indicated with
appropriate vaccines (pneumococcal, meningococcal, and
Haemophilus influenzae type B given atleast 2 weeks before
splenectomy) and with oral penicillin/amoxicillin after
splenectomy. The usual dose of penicillin for prophylaxis
is 250 mg twice daily for 2 to 3 years after splenectomy
(or at least until the age of 5). Education of the patient
concerning the risk for serious infection after splenectomy
is also important. Subsequent to splenectomy, patients
should be given antibiotics promptly with any febrile
illness preferably after sending a blood culture.
A rise in the platelet count occurs after splenectomy in

almost all patients. The increase rarely exceeds 500000/
L and usually subsides within 3 to 5 months. Routine
antithrombotic prophylaxis is not indicated for postsplenectomy thrombocytosis as there is a low risk for
thromboembolism.
Immunosuppressive Therapy
Patients who have failed to respond to splenectomy or
have relapsed after splenectomy, when splenectomy poses
an unacceptable risk, and for patients who cannot tolerate
steroid therapy, are the candidates for immunosuppressive
therapy.
Cytotoxic and immunosuppressant drugs, such as
cyclophosphamide, azathioprine and cyclosporine A, give
a 40 to 60 percent response rate. However, these treatments
may be associated with serious side effects, such as bone
marrow suppression, nephrotoxicity and secondary
malignancies, while the effectiveness of other options, such
as IVIG, plasmapheresis and, danazol, is controversial.
A reasonable immunosuppressive regimen might
include azathioprine (80 mg/m2/day) or cyclophosphamide
(60 mg/m2/day), concomitantly with prednisone (40 mg/
m2/day). Prednisone may be tapered over 3 months or
so, and the cytotoxic agent continued for 6 months before
reducing the dose gradually. Bone marrow suppression
may dictate minor dose adjustments. Rapid withdrawal has
led to rebound immune response. Alternatively, high-dose
cyclophosphamide (50 mg/kg/day 4 days) has produced
a complete remission in 66 percent of patients who were
refractory to other therapies. Severe myelotoxicity and
its attendant potential for complications are expected.
Hemorrhagic cystitis, bladder fibrosis, secondary malig
nancies, sterility, and alopecia are some of the major side
effects.
RITUXIMAB29,30
Rituximab is a monoclonal antibody directed against the
CD20 antigen expressed on B-lymphocytes and is used for
treatment of B-cell lymphoma. Its use for treatment of AHA is
based on the antibodys ability to eliminate B lymphocytes,
including presumably those making autoantibodies to
RBCs. However, the mechanism of action is more complex
than that, as the effect of rituximab can occur very early,
before the autoantibodies can recede. Rituximab (375 mg/
m2 weekly for a median of 4 weeks) is effective in treating
both warm AIHA and CAD, with an overall response rate
ranging from 40 to 100 percent (median with 60%), and with
patients of all ages responding. Moreover, many of these
responses were durable, lasting >3 years in some patients.
In a large prospective series,30 13 of 15 (87%) children with

warm-antibody AHA responded to rituximab 375 mg/
m2 weekly for 2 to 4 weeks. Twenty-three percent of the
responders relapsed, but subsequent courses of rituximab
induced additional remissions in this series. Thus far, few
side effects have been reported, but rare reactions to the
infusion have been documented. B-cell counts remain low
for months after treatment, raising the risk of infections due
to poor immune response. If remissions remain durable
and potential side effects are less harmful than other
treatments for warm AIHA, such as prolonged steroid use
or splenectomy, its use may become more common.
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23
Paroxysmal Nocturnal
Hemoglobinuria
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired clonal disorder of hematopoetic stem cells. The molecular defect in
PNH is a somatic mutation in the PIG-A gene causing defect in glycosyl phosphatidyl inositol (GPI) anchored proteins. Deficiency of
these GPI-anchored proteins (GPI-AP) on the membrane of hematopoietic cells lead to the various manifestations of PNH.
The clinical manifestations of PNH are characterized by

a triad of cytopenias, intravascular hemolysis and venous
thrombosis at unusual sites. PNH can be broadly classified
into hypoplastic and classical type. The predominant
manifestation of hypoplastic type is bone marrow failure
with a small clone of PNH cells.
The classical type is characterized by:
Intravascular hemolysis
Thrombosis
With or without cytopenias.
The disease is insidious in onset and causes significant
morbidity due its prolonged natural course. Management
of PNH depends upon proper classification, as the
treatment differs in different subgroups.
MOLECULAR GENETICS OF PAROXYMAL

NOCTURNAL HEMOGLOBINURIA
Glycosyl Phosphatidyl
Inositol Anchor (GPI-anchor)
Although most membrane proteins traverse the lipid
bilayer one or more times, certain membrane proteins
(i.e. GPI-anchored proteins) adhere to the cell surface by
means of a glycolipid moiety. In PNH cases, the defect is
attributed to mutations in the PIG-A gene.
PIG-A Gene and its Significance in PNH

PIG-A is an endoplasmic reticulum membrane protein.
In PNH, there is a somatic mutation in the PIG-A gene in
the hematopoetic stem cell, resulting in a deficiency in

the surface expression of all GPI anchored proteins due to
defective synthesis of GPI in the endoplasmic reticulum.
The defect in PIG-A gene is always in the somatic cells and
is never identified in the germ line; thus it is always acquired.
Effect of the Defect

The mutation in PIG-A gene leads to little or no GPI anchor
being made. This leads to lot of proteins missing on the
membrane of these cells which are GPI anchored.
INCIDENCE AND NATURAL HISTORY

PNH is a rare disease whose incidence is reported to be
15/million population in United States. As a result of
improved diagnostic tools, more and more patients are
suspected and screened for PNH.
Indian Perspective
Koduri PR, Gowrishankar S et al. from Apollo Hospital
Hyderabad, in their series of 11 patients of PNH in
1992 reported that the Indian patients were younger
and showed a marked male preponderance. Severe
thrombocytopenia with its hemorrhagic manifestations
and infectious complications were not seen. However,
thrombotic complications were common. Parab RB et
al. in 1990 presented a retrospective study of 17 patients
of PNH diagnosed on positive sucrose lysis. Anemia was
present in all of them, whereas about 50 percent of the
patients had jaundice, fever and bleeding tendency.
Chapter-23 Paroxysmal Nocturnal Hemoglobinuria 239

Agarwal MB, Mehta BC et al. also reported a study of
20 PNH patients in 1981. Neelam Verma et al. from PGI
Chandigarh found that 9.6 percent and 30.7 percent of the
Aplastic anemia patients were positive for PNH on flow
cytometry on diagnosis and on follow up respectively. The
conventional tests, however, diagnosed only 4.6 percent
patients on follow up. None of the MDS patients tested
positive by any of these means, on diagnosis or at follow up.
CLINICAL MANIFESTATIONS (TABLE 1)

The clinical presentation of PNH is variably overlapped by
three features:
I. Intravascular hemolysis
II. Thrombosis
III. Hematopoiesis deficient.
Intravascular Hemolysis
It is one of the most important manifestations of PNH and
the disease derives its name from this symptom.
Pathophysiology of Intravascular Hemolysis

The cause of the hemolysis is the deficiency of 2 GPI-AP
in the RBC membrane, that is CD55 (Decay accelerating
factor-DAF) and CD59 (Membrane Inhibitor of Reactive
Lysis-MIRL). CD55 and CD59 protect the RBCs from
complement mediated hemolysis, especially CD 59. PNH
cells are divided into three types (Table 2).
Aggravating factors for hemolysis:
1. Nocturnal hemolysis: The nocturnal pattern of hemolysis, initially thought to be a consequence of systemic
acidosis due to retention of CO2 during sleep is now
attributed to the nocturnal absorption of lipopolysacchrides (LPS), a byproduct of bacterial cell wall from
the gut. LPS markedly activates complement system.
LPS is normally bound by monocytes through a GPI
linked protein, CD14, which is missing in PNH.
2. Concurrent inflammation or immune reactions to
infections: Complement is also activated by con
current inflammation or the immune reaction to
infections. Most viral disorders will result in a burst
Table 1 Clinical manifestations of PNH

Due to intravascular hemolysis
Anemia, hemoglobinuria, fatigue
Acute/chronic renal failure, recurrent urinary tract infection
Back pain, headache
Abdominal pain, bloating
Esophagospasms
Cholelithiasis
Erectile dysfunction
Rare
Choledocho dyskinesia
Acute pancreatitis
Ischemia and ulceration of duodenum or colon
Due to thrombosis
Venous thrombosis
Abdominal vein thrombosis
Budd-Chiari
Splenic vein
Mesenteric veins
Portal hypertension, esophageal varices, caput medusae
(dilated abdominal veins)
Renal vein thrombosis
Cerebral vein thrombosis
Headache
Hemorrhagic infarct
Retinal vein thrombosis
Loss of vision
Deep vein thrombosis
Pulmonary emboli
Rare
Cutaneous vein thrombosis
Pyoderma gangrenosum
Arterial thrombosis (less common)
Stroke
Myocardial infarction
Due to bone marrow failure
Anemia, infections, bleeding
Myelodysplastic syndrome
Bone pain
Rare: Transformation to acute myeoloid leukemia (AML)
Table 2 Types of PNH cells

Type
CD55/CD59
Complement
sensitivity
Erythrocyte survival (t1/2)
Cell of origin
Normal
Normal
120 days
Normal stem cell
II
1050% of normal
315 times
3060 days
Defective clone with limited ability to

make GPI anchor
III
Absent
1525 times
46 days
Clone unable to make GPI anchor

of hemolysis. The most serious hemolysis results
from gastrointestinal inflammation, usually due to
viral gastroenteritis. This may be due to increased
absorption of LPS and the effect of the immune
reaction against the virus.
3. Immune reactions, which otherwise cause minimal
hemolysis in normal persons, can cause severe hemolysis
in PNH patients, e.g. infectious mononucleosis.
Immunizations and vaccinations: Special precau
tion should be taken while giving repeated doses of
polysaccharide containing vaccine against Strepto
coccus pneumoniae.
Blood transfusion in a PNH patient can lead to a
burst of hemolysis, due to the activation of comple
ment by immune reactions involving leukocytes or
plasma proteins. This can be avoided by washing of
RBCs prior to transfusion, in a susceptible patient.
Few reports suggest that intravenous hematinics
and injection erythropoietin may aggravate hemo
lysis.
3. Other manifestations: The free hemoglobin in

plasma diffuses in the tissues and binds to nitric
oxide (endothelial derived relaxing factor) causing
a local deficiency of nitric oxide in the tissues. This
leads to contraction of smooth muscles leading to
various clinical manifestations such as early morning
substernal tightness, dysphagia (esophageal contrac
tion), penile erectile dysfunction in males, sense of
fatigue and weakness, abdominal pain, Jaundice due to
indirect hyperbilirubinemia. The patients of PNH may
be chronically jaundiced due to the ongoing hemolysis
in the circulation. This is sometimes aggravated in
acute hemolysis.
Clinical Effects of Intravascular Hemolysis
The pathophysiology of thrombosis in PNH is not clearly

understood. Various mechanisms are postulated:
Absence of CD59 on the platelets may play a role in the
hypercoagulable state of PNH.
The PNH platelets are more sensitive to aggregation by
thrombin than normal platelets.
The abnormal monocytes of PNH lack the receptor
for plasminogen activator and thus are less efficient in
fibrinolysis.
Thrombosis in PNH is mostly venous, and at unusual
sites. Preference for these sites may be due to the locally
retarded blood flow, sufficient for the formation of platelet
aggregates. This also permits activation of complement on
the surface of RBC that can be transferred to the neighboring
endothelial cells resulting in the expression of tissue factor
and initiating clotting. The common sites for thrombosis are:
1. Hemoglobinuria: It is due to the excretion of globin

dimers in urine as the reabsorption capacity of proximal
tubules is exceeded. The incidence of hemoglobinuria
presenting anytime during the course of the disease
ranges from 27 to 84 percent.
2. Renal dysfunction: PNH patients can develop renal
complications in the form of either acute renal failure
or chronic kidney damage.
a. Acute renal failure: This occurs when the
concentration of hemoglobin in the tubular filtrate
becomes sufficiently high to impair renal function,
and acute renal failure sets in. This situation is
usually seen with gastrointestinal illnesses and is
complicated by the inability of the patient to take
sufficient amount of water orally. Although there
is usually good recovery if the condition is treated
with hydration and careful monitoring of blood
pressure, there often is residual renal impairment.
b. Chronic renal damage: Hemoglobinuria can lead to
chronic damage to the kidney. It manifests in two
forms.
c. Proximal renal tubular acidosis: This happens
when the concentration of globin dimers in the
glomerular filtrate becomes so great that the
resorption capacity of the proximal tubule for other
molecules normally resorbed by this epithelium is
impaired.
d. Chronic renal failure: This is usually slowly
progressive and may result in death. It is the cause
of death in 8 percent of the PNH patients.
Thrombosis
Thrombosis has been reported to be a leading cause of
morbidity in PNH patients.
Pathophysiology of Thrombosis
Hepatic veins and veins of portal system: These are

particularly affected. Hepatic and portal vein thrombosis
in PNH can present in either of the forms:
Acute onset of thrombosis: This results in the classic
Budd-Chiari syndrome, often seen in the setting of
severe hemolysis, leading to
Tender hepatomegaly
Ascites
Jaundice
Elevation of serum enzymes indicative of liver
damage.
Gradual hepatic vein thrombosis
Pain in the right upper quadrant
Hepatomegaly
Gradual onset of ascites
Signs of portal hypertension

Radiological diagnosis can be made in both instances.
Inferior vena cava thrombosis:
Can lead to lower body anasarca
Renal vein thrombosis can cause renal dysfunction
in the form of proteinuria and renal failure.
Splenic vein thrombosis:
Causing massive splenic enlargement and even
rupture.
Splanchnic vein thrombosis:
Results in a syndrome of recurrent abdominal pain
sometimes bowel necrosis
Cerebral venous thrombosis:
Common in PNH patients
Sagittal sinus is most frequently involved
Patients have headache, signs of raised intracranial
tension and focal neurological deficits
Retinal vein thrombosis:
Manifests as diminution of vision.
These are the common sites of venous involvement in
PNH. In addition to this rarely there can be
Thrombosis of dermal and epididymal veins:
In the former, there is necrosis of the skin
The later results in a syndrome that is confused
with epididymitis, orchitis or torsion of the testis
Thrombosis of the veins of the uterus can cause a
syndrome resembling pelvic inflammatory disease.
It is postulated that the PNH granulocyte clone size is
predictive of the risk of thrombosis. The overall incidence
of thrombosis in patients with granulocytic clone size
larger than 50 percent is 53.5 percent, as compared to an
incidence of only 5.8 percent in patients with a small PNH
granulocytic clone. Thrombosis as a complication predicts
poor survival.
Factors associated with high-risk of thrombosis during
the disease course:
Thrombosis at diagnosis
Age over 54 years
Presence of infection at diagnosis.
Thrombosis in PNH mostly involves the venous system.
However, there are few case reports of arterial thrombosis
also.
Hematopoiesis Deficient
Many patients of PNH have a history of aplastic anemia
and diminished hematopoiesis to a greater or smaller
extent. Nearly 50 percent of patients of aplastic anemia
have a readily detectable PNH clone, particularly during
or after recovery with antithymocyte globulin therapy.
Many patients of PNH develop aplastic anemia in
the final stage. PNH like cells are found in 20 percent
of patients of MDS. Anemia and hemorrhage are more
common in pediatric than in adult PNH patients.
Classification
PNH is a disease of varied clinical presentations. It is
classified into subtypes, based on predominant clinical
manifestations and laboratory features.
There are various proposed systems of classification of
PNH.
Clinically PNH can be divided into two types:
1. Classical PNH: Patients have predominant hemolytic
and thrombotic manifestations and some degree of
hematopoietic deficiency.
2. Hypoplastic PNH: Patients have features of bone
marrow failure with a PNH clone which may or may
not have hemolytic or thrombotic manifestations.
Wendell P et al. divided PNH into five groups:
1. Aplastic anemia with detectable PNH cells [AA-PNH]:
This group is characterized by bone marrow failure with
detection of fewer than 5 percent PNH granulocytes in
the peripheral blood by flow cytometry. These patients
may not develop overt PNH symptoms in future.
2. Aplastic anemiaPNH [AA-PNH]: In this group the
predominant syndrome is bone marrow failure, but
with presence of >5 percent PNH cells which can lead
to some clinical features.
3. PNH-aplastic anemia [PNH-AA]: In this group the
predominant clinical syndrome is PNH with significant
evidence of bone marrow hypoplasia including
granulocytopenia and thrombocytopenia.
4. Classic PNH [PNH]: Syndrome of PNH without bone
marrow hypoplasia.
5. MDS-PNH or PNH-MDS: In this group, PNH cells are
present in a patient with predominant myelodysplastic
hematopoiesis in the former or when the clinical
syndrome is predominantly due to the abnormal
PNH cells with some elements of MDS as in the later
(Table 3).
WHO SHOULD BE SCREENED FOR PNH?

(TABLE 4)
PNH is a rare disease with varied clinical manifestations.
The International PNH interest group has suggested
screening for PNH in the following patients (Table 3):
Patients with hemoglobinuria
Patients with Coombs-negative intravascular hemo
lysis (based on abnormally high serum LDH), especi
ally patients with concurrent iron deficiency.
Patients with venous thrombosis involving unusual
sites:
Budd-Chiari syndrome
Other intra-abdominal sites (e.g. mesenteric or
portal veins)
Cerebral veins
Dermal veins.

Table 3 The International PNH interest group (Parker et al. Dec. 2005) classification
Types
Hemolysis/Thrombosis
Bone marrow
Cytogenetic
abnormality
Flow cytometry
Hams/Sucrose
lysis test
Classical
Yes
Erythroid hyperplasia
Absent
Positive
Positive
PNH/SAA*-MDS**
Yes
Associated disorder
(SAA, MDS, MF)
May be seen
Positive
Positive
Subclinical
No
Associated disorder
(SAA*, MDS**, MF***
May be seen
Positive
Negative
*SAA: Severe aplastic anemia; **MDS: Myelodysplastic syndrome; ***MF: Myelofibrosis
Table 4 Who should be tested for PNH and how often?

Once
Repeatedly#
All patients with PNH

All patients who have aplastic anemia
All patients who have had aplastic anemia (except after bone
marrow transplantation)
All patients with myelodysplastic syndrome (MDS)
All patients with hemoglobinuria

All patients with unexplained hemolysis (increased LDH)
All patients with abdominal and cerebral vein thrombosis
All patients with thrombocytopenia and macrocytosis or signs
of hemolysis
Initially once every 6 months; then annually
Patients with aplastic anemia (screen at diagnosis

and once yearly even in the absence of evidence of
intravascular hemolysis).
Patients with refractory anemiaMDS.
Patients with episodic dysphagia or abdominal pain
with evidence of intravascular hemolysis.
LABORATORY DIAGNOSIS (TABLE 5)

Laboratory workup of a patient suspected of PNH includes
the essential tests to diagnose and classify PNH as well
as some ancillary tests to determine the prognosis and
treatment.
This discrepancy reflects underlying marrow dysfunc

tion that is invariably a component of the disease.
Urine Hemosiderin
Due to intravascular hemolysis, there is continuous
presence of hemoglobin in the glomerular filtrate in the
kidney. This excess of hemoglobin is deposited in cells
of the proximal convoluted tubule as hemosiderin and
can be detected in urinary sediments. At least 3 samples
of urine should be tested for hemosiderinuria which
indicates chronic intravascular hemolysis.
The various laboratory tests include:
CBC
Morphologic analysis of the bone marrow aspirate and

biopsy and cytogenetics are needed for proper classi
fication, as PNH is often observed in association with
marrow failure syndromes.
Bone marrow cellularity may vary from hypo, normo to
hypercellular.
In classic PNH it is normo to hypercellular with
erythroid hyperplasia.
It is usually hypocellular in hypoplastic PNH.
The presence of dysplasia other than in erythroid
series and cytogenetic abnormalities (present in 20%)
suggest associated hematological disorder.
The bone marrow iron stain shows decreased iron in
case of iron loss due to hemolysis and increased iron in
case of transfusion dependency.
The blood picture varies. There may be:

Severe pancytopenia
Bicytopenia
Normal counts
Virtually all patients are anemic with mild macrocytosis
Occasionally, when urinary iron loss is considerable,
the red cells may appear microcytic and hypochromic
In addition polychromasia, normoblasts and fragmen
ted red cells may be seen on peripheral smear
Relative reticulocytosis.
This may be marked but the absolute reticulocyte count
is often lower than that found in association with other
hemolytic disorders at comparable degrees of anemia.

Table 5 Laboratory tests for the diagnosis of PNH
Diagnostic tests
Traditionally
Ham test (acidified serum lysis)
Sucrose lysis test
Thrombin lysis test
The lysis of PNH red blood cells exposed to activated complement

tests for the deficiency of CD59 and CD55 on red blood cells. The
tests vary in the pathways activating complement.
Advantage: Cheap and simple to perform.
Disadvantage: Labor intensive, decreased sensitivity due to the
short half-life of circulating PNH red blood cells.
Today
Flow cytometric analysis
CD59 and/or CD55 peripheral blood red cells
Advantage: Useful to determine the degree of GPI anchor

deficiency (PNH type I, type II, type III).
Disadvantage: Decreased sensitivity due to the short half-life of
circulating PNH red blood cells.
CD59, CD24, CD16, or any other GPI-linked proteins expressed on Advantage: The deficiency of at least 2 linked proteins is sensitive
peripheral blood granulocytes
and specific for the diagnosis of PNH.
Disadvantage: Might be difficult to perform in severe aplastic
anemia when the number of circulating granulocytes is very low.
FLAER (fluorescently labeled inactive toxin aerolysin) binding of FLAER binds the GPI anchor.
peripheral blood granulocytes
Advantage: The lack of FLAER binding on granulocyte is sufficient

for the diagnosis of PNH.
Disadvantage: Cannot be used for the analysis of red blood cells or
platelets. Might be difficult to perform in severe aplastic anemia
when the number of circulating granulocytes is very low.
PIGA gene mutation analysis
Serum Iron Studies and Ferritin

Due to chronic urinary iron loss in patients with hemolytic
PNH, they may have iron deficiency. In contrast, patients
of aplastic anemia with a clone of PNH may have normal or
sometimes even increased serum iron due to transfusion
dependency.
Complement Based Assays

Principle
PNH cells are unusually susceptible to lysis by complement.
This can be demonstrated in vitro by a variety of tests.
Acidified Serum Lysis Test (Ham Test)

The principle of this test is that patients red cells are
exposed at 37C to the action of normal or patients own
serum, suitably acidified to the optimum pH for lysis (pH
6.57.0). In PNH, 10 to 50 percent lysis is usually obtained.
The Ham test is relatively specific but less sensitive. The
only disorder, other than PNH that may appear to give a
clear cut positive test is a rare congenital dyserythropoietic
anemia CDA Type II or HEMPAS. In contrast to PNH,
however HEMPAS red cells undergo lysis in only a
proportion (about 30%) of normal sera, do not undergo
Although very specific is NOT used for diagnosing PNH
lysis in the patients own acidified serum, sucrose lysis test

is negative and the expression of GPI-AP is normal.
The standard Ham test can be negative when there
are less than 5 percent PNH Type III cells or less than 20
percent PNH Type II cells.
Sucrose Lysis Test

The sucrose lysis test is based on the fact that red cells absorb
complement from serum at low ionic concentrations. PNH
cells, because of their greater sensitivity will undergo lysis
but normal red cells do not. In PNH, lysis usually varies
from 10 percent to 80 percent, but exceptionally may be
as little as 5 percent. Sucrose lysis test is more sensitive
and less specific than the Ham test, as red cells from some
cases of leukemia or myelofibrosis may undergo a small
amount of lysis, almost always less than 10 percent. In
these cases the Ham test is usually negative.
GPIAnchor-based Assays
Today these tests are the mainstay of the diagnosis of PNH.
Principle
It involves the use of monoclonal antibodies against
specific GPI-anchored proteins in conjunction with flow
cytometry to diagnose PNH.
Advantages
Flow cytometry offers several advantages over complement
based assay for diagnosing PNH:
It is more sensitive and specific
Measures the size of the PNH clone
It is less affected by blood transfusions.
RBCs are the easiest to deal with but are not the most
sensitive cell type to test because hemolysis or transfusion
may decrease or even eliminate the PNH clone. Assaying
granulocytes is better, assuming there is not severe granu
locytopenia, but not all GPI-anchored surface antigens
expressed granulocytes will give identical results. The
recommendation is that more than one GPI-AP must
be demonstrated to be abnormal and depending upon
circumstances, more than one cell line should be evaluated.
Flow cytometry can be useful to know the extent
of involvement and monitoring therapy in PNH. The
standard flowcytometer can detect a PNH clone of
>3 percent. The best estimate of clone size is given by
CD55, CD59 and CD66b in granulocytes and CD55, CD59
and CD14 in monocytes.
Aerolysin Based Assays

A fluorescently labeled aerolysin, FLAER, is now the gold
standard for diagnosis of PNH. These flow cytometry test
are now done in many centers.
TREATMENT OF PNH
Treatment of PNH is under evolution. It aims at:
Supportive treatment
Definite treatment
Supportive treatment is as follows:
Anemia: It is invariably present in PNH patients. It may be
either due to hemolysis or bone marrow failure.
Anemia due to Hemolysis

If anemia is predominantly due to ongoing hemolysis, it
needs to be treated. The various treatment options are:
Eculizumab
This is a recombinant humanized monoclonal antibody
against the terminal complement components and is an
effective therapy in PNH. It is a remarkably safe drug and
has been approved for the treatment of PNH. However,
there is a slightly increased risk of developing infections
with encapsulated organisms especially meningococcal
infections. Thus, all patients should receive appropriate
vaccinations and early therapy as required.
Effects
Stabilization of hemoglobin levels, reduction or
cessation of transfusion requirement
Reduction of the intravascular hemolysis, cessation of
hemoglobinuria
Clinically significant improvement in the quality of life
Significant reduction in the rate of thrombosis.
Corticosteroids
The use of corticosteroids in treating chronic hemolysis
is debated because of the empiric nature of therapy
and no experimental data to support the explanation in
ameliorating complement mediated hemolysis. It may
have a role in attenuating acute hemolytic exacerbation
given in a dose of 0.25 to 1 mg/kg of prednisolone. A
rapid response (within 24 hours) suggests complement
inhibition either by directly inhibiting alternate pathway
or dampening the inflammation.
Androgens
The mechanism of the amelioration of anemia in PNH
is thought to be complement inhibition and stimulating
erythropoiesis. Danazol is usually used in these cases. A
starting dose of 400 mg twice a day is recommended, but
a lower dose (200400 mg/d) may be adequate to control
chronic hemolysis. Benefit of danazol was attributed to
reduced hemolysis rather than enhanced erythropoesis.
Lack of venous thrombotic complications is an advantage
of danazol over other androgens. Danazol has been shown
to increase fibrinolytic activity thus offering protection
against thromboembolism.
Folate
Supplemental folate (5 mg/d) is recommended in all
patients to compensate for increased utilization associated
with heightened erythropoiesis that is a consequence of
hemolysis.
Chronic Transfusion Therapy

Transfused red cells are CD55 and CD59 positive and thus
have normal survival. It also suppresses erythropoesis
in addition to increasing hemoglobin. Iatrogenic hemo
chromatosis is delayed in PNH patients due to iron loss.
Iron Replacement Therapy

Patients of PNH often become iron deficient as a result of
hemoglobinuria and hemosiderinuria. Iron replacement,
both oral and parenteral causes exacerbation of hemolysis.

However, iron therapy should not be withheld because of
this and the exacerbation should be treated with steroids,
androgens and blood transfusion.
Splenectomy
There are only anecdotal reports of amelioration of
hemolysis and improvement of cytopenias by splenectomy,
but there is an increased risk of postoperative thrombosis;
therefore it is not recommended in the treatment of PNH.
Treatment of Nonhemolytic Anemia

Pancytopenia with low reticulocyte count indicates anemia
due to bone marrow failure. Thus treatment should aim at
the underlying disease (Aplastic anemia, myelodysplastic
syndrome). Hence, when immunosuppressive therapy is
used in a patient of PNH, therapy is aimed at the treatment
of bone marrow failure. Androgens may also be beneficial
in patients with PNH who have a hypoproliferative
component to their anemia.
Thrombosis: Thrombosis is the leading cause of mortality
in patients of PNH. The occurrence of thrombosis has
been related to the size of the granulocytic clone.
Prophylaxis: Prophylactic anticoagulation in PNH patients
is a matter of debate in the International PNH Interest
Group and not yet a standard recommendation.
Management of Thromboembolic Disease

Patients of PNH usually present with venous thrombosis.
Any acute thromboembolic event requires anticoagulation
with heparin.
Patients presenting with acute Budd-Chiari syndrome
should be managed with thrombolytic therapy and/or
radiological intervention.
Thrombocytopenia should not come in way of
anticoagulant treatment. It is a relative but not an absolute
contraindication for anticoagulation. It can be managed
with repeated platelet transfusions. However this may not
always be possible.
Patients with a thrombotic episode require life-long
anticoagulation. Long-term anticoagulation should be
reassessed in any patient who undergoes a spontaneous
remission or in whom the PNH clone size falls to below 50
percent.
Stem cell transplantation is indicated in recurrent life
threatening thrombotic complications.
Definitive Treatment of PNH

The definitive treatment of PNH includes stem cell
transplantation and gene therapy.
Stem Cell Transplant for PNH

This is the only definite treatment for PNH. The overall
survival for PNH patients who undergo transplantation
using an HLA-matched sibling donor is in the range of 50
percent to 60 percent.
Indications for consideration of transplantation: Inter
national PNH Interest Group recommendations:
Bone marrow failure
Decision on transplantation is based on underlying
marrow abnormality (e.g. aplastic anemia)
Major complications of PNH
Recurrent, life-threatening thromboembolic disease
Refractory, transfusion-dependent hemolytic anemia. The availability of new treatment options (e.g.
eculizumab) may influence the decision to recommend transplantation.
PEDIATRIC PNH
PNH can occur in the young (about 10% of patients are
younger than 21) but is often misdiagnosed and mismanaged. A retrospective analysis of 26 cases underscored
the many similarities between childhood and adult PNH.
Signs and symptoms of hemolysis, bone marrow failure,
and thrombosis dominate the clinical picture, although
hemoglobinuria may be less common in young patients.
A generally good response to immunosuppressive therapy
may be seen. However, based on the lack of spontaneous
remissions and poor long-term survival (80% at 5 years,
60% at 10 years, and only 28% at 20 years), sibling-matched
stem cell transplantation is the recommended treatment
of childhood PNH. A recent Dutch study confirmed the
common presentation of bone marrow failure in 11 children with PNH, and reported that 5 patients eventually underwent bone marrow transplantation (BMT; 3 matched
unrelated donors and 2 matched family donors), of whom
4 are alive. Mortality appears high in young patients with
PNH treated with transplantation using unrelated donors
although surviving cases have been reported.
BIBLIOGRAPHY

1. Agarwal MB, Mehta BC. Paroxysmal nocturnal hemo

globinuria: (a report of 20 cases). J Postgrad Med. 1981;27:
231-4.
2. Brodsky RA. New Insights into Paroxysmal Nocturnal
Hemoglobinuria. In: Berliner N, Linker C, Schiffer CA
(Eds). Hematology 2006, American Society of Hematology
Education Program Book, Orlando, Florida. 2006.pp.24-8.
3. Brodsky RA. Paroxysmal Nocturnal Hemoglobinuria.
In: HematolgyBasic Principles and Practice. Hoffman
R, Benz EJ, Shattil SJ, Furie B, Cohen HJ, Siberstein LE,
McGlave P. (Eds) 4th Edn. Elsevier Churchill Livingstone.
2005.pp.419-27.

4. Gabrielle Meyers, Charles J Parker. Management Issues

in Paroxysmal Nocturnal Hemoglobinuria. Int J Hematol.
2003;77:125-32.
5. Ghosh K, Madkaikar M, Gupta M, Jijina F. Evaluation of
danazol, cyclosporine, and prednisolone as single agent or
in combination for paroxysmal nocturnal hemoglobinuria.
Turk J Hematol. 2013;30:66-370.
6. Hall SE, Rosse WF. The use of monoclonal antibodies and
flow cytometry in the diagnosis of paroxysmal nocturnal
hemoglobinuria. Blood. 1996;87:5332-40.
7. Hill A, Stephen J, Hillmen P. Recent developments in
the understanding and management of paroxysmal
nocturnal hemoglobinuria. British Journal of Hematology.
2007;137:181-92.
8. Hillmen P, Hall C, Marsh JC, et al. Effect of Eculizumab on
hemolysis and transfusion requirements in patients with
paroxysmal nocturnal hemoglobinuria. N Engl J Med.
2004;350:552-9.
9. Koduri PR, Gowrishankar S. Paroxysmal nocturnal haemo

globinuria in Indians. Acta Haematol. 1992;88(2-3):126-8.
10. Madkaikar M, Gupta M, Jijina F, Ghosh K. Paroxysmal
nocturnal haemoglobinuria: diagnostic tests, advantages,
and limitations. Eur J Haematol. 2009;83:503-11. Review.
11. Parab RB. Paroxysmal nocturnal hemoglobinuria: a study
of 17 cases. J Postgrad Med. 1990;36:23-6.
12. Parker J Charles. Historical aspects of Paroxysmal
Nocturnal Hemoglobinuria: Defining the disease. British
Journal of Hematology. 2002;117:3-22.
13. Rosse Wendell F, Nishimura J. Clinical manifestations of
paroxysmal nocturnal hemoglobinuria: present state and
future problems. International Journal of Hematology.
2003;77:113-20.
14. Varma N, Garewal G, Varma Subhash, Vohra H. Flow
cytometric detection of PNH defect in Indian Patients with
Aplastic anemia and Myelodysplastic Syndromes. Letters
and correspondence. American Journal of Hematology.
2000;65:263-6.
24
Diagnosis and Management of Acquired

Aplastic Anemia in Children
Nitin K Shah
Aplastic anemia (AA) is defined as pancytopenia caused by bone marrow failure with bone marrow hypocellularity without infiltration
or fibrosis.1,2 It is a difficult proposition to treat in resource crunched set-up lie in developing countries and carries high mortality. It
accounts for 20 to 30 percent cases presenting with pancytopenia2,3 and pediatric AA accounts for nearly 16 percent of all AA.4 In
USA and Europe, incidence of childhood AA is estimated at 2 to 6/million.1 Incidence in India is not known exactly but is perceived as
higher than in the West by Indian pediatric hematologists. A recent study from Canada has reported increased incidence in children
of east and south-east Asian descent (7.3/million/year) compared to white or mixed ethnic groups (1.7/million/year).5 In Western
countries, AA has been reported with equal frequency in boys and girls. However, in Indian studies AA is reported to occur three to
four times more frequently in boys compared to girls.6,7 It can be inherited (Inherited bone marrow failure syndromes like Fanconis
anemia) or acquired which may be then primary or idiopathic; or secondary to some insults like drugs, etc. It is also classified as mild
to moderate, severe and very severe depending on the severity of pancytopenia. In large series, nearly 70 percent cases have been
reported to be severe/very severe and almost 70 to 80 percent of acquired aplastic anemia cases to be idiopathic.4,8
DIAGNOSIS OF APLASTIC
ANEMIA IN CHILDREN
As in any other disease diagnosis involves detailed clinical
history, head to toe clinical examination and laboratory
investigations; and in that order!
Clinical Presentations
Clinical presentation will include effects of depressions
of all three peripheral blood cell lines, viz anemia,
neutropenia and thrombocytopenia; and effects of the
cause of AA.
It will include effects due to anemia like pallor, easy
fatigability, tiredness, headache, breathlessness,
puffiness of face and edema of the feet, tachycardia,
tachypnea, frank cardiac failure.
Effects due to neutropenia like fever, sepsis, oral ulcers.
Effects due to thrombocytopenia like petichea, pur
pura, ecchymosis, mucosal bleeds like epistaxis, gum
bleeds, gastrointestinal (GI) hemorrrhage, hematuria,
intracranial bleeds, etc. One should carefully look for
one of the secondary causes in any case of AA as shown

in Table 1.
One should also look for findings suggestive
of inherited bone marrow failure syndromes like
skeletal anomalies, mental retardation, short stature,
peri-oral hyperpigmentation, nail dystrophy, renal
anomalies on ultrasound and a strong family history
like consanguinity, other sibs affected in family and
cousins and some family members having some of the
anomalies without frank AA.
One should also look for findings like presence of
lymphadenopathy, hepatosplenomegaly, bone pains
and weight loss which may suggest pancytopenia
due to other causes like leukemia, lymphomas,
myelodysplastic syndromes, myelofibrosis, megaloblastic anemia, osteopetrosis, etc.
Laboratory Investigations
Basic tests done in a case of suspected AA include
complete blood count (CBC), PS examination and
corrected reticulocyte count. CC will show different

Table 1 Classification of aplastic anemia in children

Acquired:
Viruses
i. EBV
ii. Hepatitis
iii. HIV
Immune diseases
Eosinophilic fascitis
Hypoimmunoglobulinemia
Thymoma
Pregnancy
Paroxysmal nocturnal hemoglobinuria (PNH)
Inherited:
Fanconi anemia
Dyskeratosis congenital
Shwachman-Diamond syndrome
Reticular dysgenesis
Amegakaryocytic thrombocytopenia
Familial aplastic anemia
Nonhematological syndromes
Down syndrome
Dubowitz syndrome
Seckel syndrome
severity of pancytopenia with anemia, neutropenia and

thrombocytopenia.
Corrected retic count will be lower than 1 percent.
Mean corpuscular volume (MCV) is usually high with
normal differentiating it from megaloblastic anemia
where MCV is high but red cell distribution width
(RDW) is also high.
The PS will confirm macrocytosis without aniso
cytosis, neutropenia and thrombocytopenia. Presence
of some changes would suggest other diagnoses
like blasts (leukemia), leukcoerythroblastic changes
(osteopetrosis), etc.
Bone marrow aspiration and bone marrow trephine
biopsy: Diagnosis is confirmed by bone marrow
aspiration as well as bone marrow trephine. On aspirate
smears, one will see hypocellularity with increased fat
spaces, however, this could also be due to technically
dilute marrow or a hypocellular myelodysplastic
syndrome (MDS). On the other hand, a hypercellular
marrow does not necessarily rule out aplasia on bone
marrow aspirate alone as it could have hit one of the
few persisting cellular foci. Hence, a trephine biopsy,
which gives a wider area to look at, is mandatory for
diagnosis of aplastic anemia. A hypocellular MDS
should be kept in mind, even if hypocellular marrow
is found on trephine biopsy, if there are dysplastic
changes present. In such cases a repeat bone marrow
test is required after 2 to 3 weeks to see for evolution

of changes of hypocellular MDS. When hypocellular
MDS is suspected, heparinized bone marrow should
be also sent for cytogenetic study.
Lastly, one should also do stress cytogenetic study to
rule out Fanconis anemia in all cases of pediatric AA
and irrespective of presence of physical anomalies as
some cases of Fanconis anemia may be phenotypi
cally absolutely normal. It is important to rule out
Fanconis anemia in all cases of pediatric AA as the
treatment for Fanconis anemia is totally different
and immunotherapy has no role in these patients.
Stress cytogenetic study can be done on peripheral
blood lymphoctyes. Recently, even genetic study for
Fanconis anemia is available in some centers which is
useful to confirm Fanconis anemia in rare cases where
there is strong suspicion clinically but repeated stress
cytogenetic studies are inconclusive.
Other tests that are required include:
Liver function tests as a baseline before starting
androgenic steroids.
Renal function tests before starting cyclosporine.
Serum lactate dehydrogenase (LDH) and uric acid
which, if high may suggest leukemia as diagnosis.
HbF levels which, if high may suggest Fanconis
anemia.
One should also look for secondary causes like
HIV/HCV/HBsAg/Parvovirus as aplastic anemia
can follow one of these viral infections.
PNH study by flow cytometry for CD 55 and
CD 59 cells or HAMs test or sucrose lysis test, if flow
cytrometry is not available.
RISK STRATIFICATION OF APLASTIC

ANEMIA IN CHILDREN
International Aplastic Anemia Study Group takes in to
consideration three peripheral blood criteria, i.e. absolute
neutrophil count (ANC) below 0.5 109/L, platelet count
below 20 109/L and corrected retic count below 1 percent
(or absolute retic count below 20 109 /L); and two bone
marrow criteria, i.e. bone marrow biopsy showing severe
hypocellularity < 25 percent; or moderate hypocellularity
(2550%) with hematopoietic cells representing less than 30
percent of residual cells.9 Based on these AA is classified as:
Severe aplastic anemia (SAA) when any 2 of the
3 peripheral blood criteria and either marrow criterion
are present.
If ANC is below 0.2 109/L, then it is labeled as very
severe aplastic anemia (vSAA).
All other cases are classified as mild-moderate AA.
It is important to classify AA as inherited vs. acquired
and acquired AA as severe, very severe or mild-moderate
Chapter-24 Diagnosis and Management of Acquired Aplastic Anemia in Children 249

as the outcome and treatment needed are different for
different severity. Most inherited causes need stem cell
transplant (except TAR which normally resolves by 1 year
and Diamond-Blackfan syndrome which has 25 percent
chances of spontaneous regression) whereas many
mild-moderate and some severe AA may resolve with
immunosuppressive therapy or sometimes even with
supportive care alone; and many severe and all very severe
AA will need stem cell transplant.10,11
The number of days taken for ANC to improve with
G-CSF and non-response to any specific therapy at
6 months have also been proven to be risk factors in one
study.12 Certain cytogenetic changes at diagnosis like
presence of telomerase gene mutations leading to short
telomeres make the prognosis unfavorable.14 Presence
of cytogenetic abnormalities after diagnosis also alter
prognosis like trisomy 8, chromosome 13 abnormalities,
chromosome Y deletion, etc. suggest favorable outcome,
whereas monosomy 7 and complex abnormalities depict
an unfavorable outcome.13
Supportive Care
Supportive care is the main stay besides definitive
therapy, and for many ill affording patients it is the only
treatment available. It includes use of blood components
to control anemia and thrombocytopenia, management of
infections, psychosocial support and financial help.
Transfusion Support
Packed red blood cell: Target is to keep hemoglobin
in near physiological range of about > 9 gm% so as
to improve quality of life. One should do complete
antigen phenotype before first transfusion so as to
use a particular rare blood group donor should there
be sensitization after multiple transfusions. It is
mandatory to use leukodepletion by using white blood
cell (WBC) filters with each transfusion so as to avoid
HLA sensitization as well as prevent febrile transfusion
reactions. It is preferable to use irradiated blood
products to prevent transfusion associated graft versus
host disease, especially in post-transplant period.
One should also always avoid relative donors for any
transfusion, especially if the patient is for a potential
transplant candidate. Cytomegalovirus (CMV) negative
donor is desirable but not practicable as most of the
donors in India are CME positive. In presence of
bleeding and infection, packed red blood cells (PRBCs)
are used more liberally.
Platelets: Platelet transfusion is reserved for patient
with mucosal bleeds. It is not required for only skin
bleeds, howsoever grotesque they may look. It is also
Table 2 Indications of using prophylactic platelets in AA

Prophylactic platelets (without bleeding)

< 50010000/cumm in a non-sick child

< 20000/cumm in a sick child with:
Severe mucositis
DIC
Platelet likely to fall < 10,000/cumm before next evaluation
Associated coagulopathy/anticoagulation
Before surgery
Bone marrow aspiration/biopsy can be without platelet
support
Lumbar puncture < 30,000/cumm
Other surgeries < 50,000/cumm
Surgery at critical sites like CNS, eyes < 100,000/cumm
< 50,000/cumm with acute bleeding, massive hemorrhage,
head trauma, multiple trauma
not required prophylactically unless platelets counts

are less than 500 to 10,000/cumm in a non-sick child,
<20,000/cumm in a sick febrile child or patient is
undergoing some surgical procedure as shown in
Table 2. Platelets may be liberally used in presence of
sepsis and DIC with platelets < 20,000/cumm as there is
a lot of consumption of platelets in these conditions. For
minor mucosal bleeds (except hematuria) one can use
platelets sparing drugs like tranexamic acid in the dose
of 75 mg/kg/day in 3 divided doses orally. Similarly,
menorrhagia may be a problem in adolescent girl who
can benefit with hormonal replacement therapy.14,15
Care of Infections
Infections are the most common problems and cause of
death in untreated severe and very severe AA patients, and
are difficult to eradicate in spite of effective antimicrobials.
Infections are also related to use of immune suppressive
therapy as well as in post-transplant period. Bacterial
infections are the most common infections in AA patients
followed by fungal, parasitic and of course viral infections
which are otherwise also so common in children in general.
Gram negative sepsis is more common than gram positive
sepsis in India. Recently several hospitals are facing
extended spectrum beta lactamase (ESBL) producing
gram-negative organisms as well as methicillin resistant
Staphylococcus aureus sepsis in neutropenic patients.
Partly, this is because of haphazard use of antimicrobials
in general. Initial choice of antimicrobials in a patient with
suspected sepsis in AA patients will depend on the recent
local experience with the type of microorganisms grown
and treatment failure with a particular antimicrobial.
Initially, broadspectrum antimicrobials that will cover

gram negative as well as gram positive organisms will
be 1st line choice like third generation cephalosporins
like ceftriaxone plus aminoglycoside like amikacin. In
case, ESBL producing organisms are common in a local
set-up, one may have to start cefaperzone-sulbactum
or piperacillin-tazobactum plus amikacin as the 1st line
therapy. Drugs will be the changes based on cultures
and antimicrobial sensitivity. However if there is no
growth and patient is not responding, one will have to
add vancomycine to cover for MRSA on day 3 to 5. If
patient still fails to respond or deteriorates, one may
have to switch to carbapenums like meropenum with
vancomycine. Lastly, in desperate ELBS producers which
are carbapenum resistant one will have to add IV colistin.
Anti-fungals will be added either empirically on day 5 to 7
when patient does not respond to second line antibiotics
or if culture grows a specific fungus.16 Recently several
hospitals are faced with problems of fluconazole resistant
candida species sepsis or increasing trends of infection
with Aspergillus, especially if some construction work is
going on in near vicinity.17 There is no role of prophylactic
antimicrobials or antifungals as it will only add to the
problem of drug resistance. Lastly unlike in patients with
leukemia, there is no role of giving Pneumocystis carinii
pneumonia (PCP) prophylaxis to AA patients, and sulfa
drugs will be contraindicated in patients with AA.
Prevention of Infections
Various measures are required to prevent infections
which include chlorhexidine mouth washes after every
major meals, chlorhexidine bath, betadine application
to groins and axillae after bath, sterile or well-cooked
diet, avoidance of contaminated, uncooked and open or
overnight left over food, hand sanitization by care taker
before handling patients, cleaning well fruits and eating
only well preserved or fully skin covered fruits after
peeling, avoiding going to crowds, etc.
General Measures
No drugs should be administered per rectally due to
fear of infection and bleeding. Avoid contact games
and injuries
Avoid altogether brushing or brush with soft tooth
brush, especially if patient is thrombocytopenic.
Psychological support to the patient and family
members is of utmost importance like in any other
chronic life-threatening illnesses stressing the chronic
nature of disease and slow response to treatment.14,15
All vaccinations should be avoided during the active
disease as live vaccines can lead to vaccine induced
infection and killed may not be efficacious. OPV should
be avoided even in siblings and inactivated poliovirus

vaccine (IPV) could be used in to stead. Live vaccines
are especially contraindicated in transplant patients.
Intramuscular injections are contraindicated in
patients with severe thrombocytopenia due to fear of
bleeding.
IV access may be difficult in patients due repeated
infections and use of peripheral lines, hence central
lines or a port may be a better option especially for
patients on immune suppressive therapy or transplant
patients as they will need prolonged supportive care.
SPECIFIC THERAPY IN APLASTIC ANEMIA

Options available: There are several options available to
offer a cure to patients with AA. Several mild-moderately
severe AA patients may need supportive care alone or with
immune suppressive therapy (IST). Severe and very severe
AA patients will need either immune suppressive therapy
or stem cell transplant (SCT). Many patients in India
cannot afford IST or SCT and would receive only supportive
care that too haphazardly leading to high mortality. Such
patients are often treated with corticosteroids, androgenic
steroids alone. There are also anecdotal reports of use of
danazol, cyclophosphamide, splenectomy, etc. which are
sort of given up now with the advent effective IST and SCT.
Immunosuppressive Therapy for

Aplastic Anemia
Immunosuppressive therapy (IST) currently comprises
use of anti-thymocyte globulin (ATG) and cyclosporine
(CsA) as standard first line therapy along with short course
low dose steroids. Clinical experience and laboratory data
suggests that the mechanism leading to bone marrow
failure is probably secondary to activated cytotoxic
lymphocytes, which produce T-helper type 1 (Th1)
cytokines including interleukin-2, interferon gamma and
tumor necrosis factor. These cytokines in turn induce
apoptosis of the hematopoietic stem cells. Immuno
suppressive agents exert their action by inhibiting T cell
activation and dose dependent lympholytic activity as well
as stimulation of hematopoietic growth factors.
Indications
Children tolerate hematopoietic stem cell transplantation
(HSCT) exceedingly well with excellent outcome making
it as the modality of choice for all severe and very severe
aplastic anemia cases. However, a large chunk of children
with SAA/vSAA in developing countries cannot afford
HSCT or do not have a matched donor ; for them IST is the
only alternative. For non-severe aplastic anemia cases IST

is the first modality of choice as it is associated with less
risk than HSCT.
Eligibility
All patients should have a stress cytogenetics test done
to rule out Fanconi anemia as IST is of no use in patients
with Fanconi anemia. Patient should be relatively well
and free of serious infections. Central venous access is
required as ATG can cause peripheral venous sclerosis.
Platelet and packed red cell transfusion should be given
to keep platelets above 20,000/cumm and Hb above 7 g/
dL before and during ATG course. Post-ATG transfuse
packed red cells to maintain Hb >7 g/dL. It is desirable to
use leukodepleted blood products. Even use of irradiated
blood products is desirable post IST as there is profound
immune suppression following IST. Immunosuppressive
therapy should be instituted with facilities for resuscitation
and intensive life support under care of a qualified medical
team familiar with this treatment.
ATG/ALG
Horse and Rabbit ATG is available in India containing
100 to 250 mg in 5 mL vial. ALG is used in the dose of
40 mg/kg/day for 5 to 10 days, and ATG is used in the
dose of 15 mg/kg/day for 5 to 10 days, however one
should follow manufacturers instructions. Chances
of serum sickness go up when given for more
than 7 to 10 days. Lyophilized powder is reconstituted
in normal saline shaking it vigorously, avoiding plastic
bottles as ATG tends to stick to the sides, looking for
visible contamination, discoloration or precipitation,
and given over 8 hours under close monitoring after
obtaining informed written consent. Reconstituted
solution should be used as early as possible. Premedication in form of paracetamol, chlorpheniramine
and hydrocortisone or dexamethasone is given prior
to starting ATG/ALG infusion daily to prevent allergic
reactions. First vial should be administered slowly.
Look for toxicities like allergic reactions, anaphylaxis,
urticaria, etc.
Abandon ATG/ALG infusion if patient develops
anaphylaxis as suggested by development of reactions
like hypotension, dyspnea, poor peripheral circulation,
etc. and immediately start standard measures of
resuscitation.1,18
Patient may develop serum sickness by 10 to 14
days after ATG infusion presenting with fever, rash,
arthralgia and arthritis. Hence observe the patient in
hospital for 2 weeks after ATG course for the same.
Steroids in form of prednisolone in dose of 1 mg/kg/
day in 3 divided doses should be given along with ATG

infusion and continued for 2 weeks and then tapered
over next one week to prevent serum sickness. One has
to use IV hydrocortisone or dexamethasone to treat
serum sickness should it occur and then switched to
oral course thereafter. Requirements of PRBc, platelets
may go up after IST course and even infections may
increase post-IST.
Cyclosporine (CsA)
Oral cyclosporine is given in the dose of 5 to 10 mg/kg
per day in 2 divided doses and the dose is adjusted by
keeping trough levels at 100 to 150 ng/mL by testing the
levels 15 days after starting the dose and any increments
done thereafter. CsA is usually started on day 21 after
stopping prednisolone, as combined administration
often leads to hypertension. Common side effects of
CsA include hirsuitism and gum hypertrophy. Toxicities
include hypertension, liver function abnormality, and
renal toxicity; hence monitor liver function tests and renal
functions, and blood pressure weekly. CsA is continued
for a minimum 3 to 6 months before any response can be
seen. The oral liquid is highly concentrated and comes as
100 mg/mL. Hence a small child may need fraction of an
milliliter as the dose and patient should be taught how to
measure tiny doses using 1 mL syringe.
Response to IST (ATG Plus CsA)

It takes 3 to 6 months for response to be seen, hence,
one should not stop therapy before 6 months. Patient is
assessed after 3 to 4 months and periodically thereafter for
response as well as toxicities.
Response is defined as complete when patient main
tains hemoglobin levels normal for age, ANC above 1500/
cumm and platelets > 150,000/cumm on two occasions
1 month apart without any transfusion support. In case
patient where the counts improve but is still transfusion
dependent to maintain normal counts it is taken as partial
response.
If patient satisfies all criteria of AA and is completely
transfusion dependent for PRBCs and platelets it is taken
as failure of first course of IST in which case either HSCT
should be considered or if that is not feasible, a second
course of IST can be given using a different brand of ATG/
ALG than what was used in the first course. When giving
second course patient should be closely monitored for
anaphylaxis as there might have occurred sensitization
with first course. Chances of response to first course
are 40 to 50 percent and that with a second course is
around 60 percent in moderate cases.
Other Drugs
Various drugs like corticosteroids including high dose
methylprednisolone, androgenic steroids, cyclopho
sphamide, danazol, stanozolol, etc. have been in past with
anecdotal response.
Nandrolone enanthate is used in a dose of 2 to 5 mg/
kg/day of injectable form once in 10 days and continued
till response is evident. Efficacy is doubtful and the
outcome may be in fact adverse due to side effects like
masculanization, stunted growth, hepatotoxicity, Ca liver,
etc. Though these are currently not the ideal choice of
treatment, they can be tried in those children with AA who
cannot afford HSCT or IST.
Corticosteroid stimulates erythropoiesis. It also
stabilizes capillary membrane and decreases bleeding.
They are useful to counteract side effects of androgenic
steroids on growing epiphysis and the serum sickness of
immunotherapy. Oral prednisolone is used in the dose of
0.5 to 1 mg/kg/day and tapered to a minimum effective
dose. High dose IV methylprednisolone was popular in
Europe in past and probably effective in patients treated
within few weeks of diagnosis, this therapy is reserved
for occasional patients due to tremendous toxicity. It is
used in the dose of 15 to 20 mg/kg/day for 5 days followed
by tapering doses over next 15 days. Side effects include
hypertension, fluid electrolyte imbalance, infections,
suppression of neuroendocrinal axis, psychosis, avascular
necrosis of head of femur, etc.19
Danazol 100 mg BD/TDS for girls, stanozolol 10 mg BD
for boys have shown some response in children with nonsevere AA.
HEMATOPOIETIC STEM CELL

TRANSPLANTATION IN APLASTIC ANEMIA
In young patients hematopoietic stem cell transplantation
(HCST) is the best modality of therapy as it is quite safe
at that age, has almost 80 to 90 percent cure rates and
except for initial period of profound neutropenia related
infections, and graft-versus-host disease (GVHD), there
are not many long term complications.7 Most of the patients
are free from transfusion support and medications within
1 year or so. This is in contrast to IST which has lesser cure
rates, more toxicities, slower response, need for prolonged
support with blood products and quite a cost.20 However
HSCT needs a HLA matched donor and less than 40 percent
of the patients will be lucky to find such a matched sibling
donor from the family. This is a big problem now with
smaller family size. Unrelated matched donor is difficult to
get in India and is prohibitively expensive to get from the
Western registry. Besides, HSCT itself is quite expensive
and not many centers offer such a therapy at an affordable
price in public health set-up. As such very few centers

have invested for HSCT even in private set-up and hence
the patient has to travel long distance to get HSCT done
outside major metro cities. In elderly patients HSCT has
its own complications rates especially due to GVHD and
success rates are less with higher mortality making IST as
the first choice especially for > 40 years of age.21
Ideal is HLA matched sibling or family donor. Partial
matched family donor or unrelated matched donor are
less desirable as complications like GVHD and graft
rejection are higher in this settings. Donor need not be
ABO compatible, but should be healthy. Best experience
is with bone marrow or peripheral blood stem cells as the
source of HSCT. Umbilical cord blood stem cells are nor
preferred. For peripheral blood stem cells donor is given
G-CSF for 4 to 5 days and then subjected to apheresis to
collect enough stem cells from peripheral blood.
Most protocols would use non-myeloablative condi
tioning based on combination of ATG, cyclophosphamide
and fludarabine.22-25 Engraftment would occur normally
in 10 to 15 days and till then patient will need effective
supportive care. All aseptic precautions should be
taken to avoid infections during the critical neutropenic
period that includes chlorhexidine bath, chlorhexidine
mouth washes, sterile drinking water, sterile diet or well
cooked food, avoiding of crowds, sterile cloths or at least
clean ironed cloths. And hand sanitizer for the contacts.
Only irradiated blood products should be used to avoid
transfusion associated GVHD which has very high fatality
should it occur. Once engraftment is well established and
patient has no infection, patient can go home and followup on outdoor basis for further management and usually
is kept under follow-up for 3 to 6 months.
COMPLICATIONS AFTER SUCCESSFUL

ENGRAFTMENT
Graft-versus-host disease (GVHD) and rarely graft
rejection are two main complications of HSCT.22
Acute GVHD can occur up to 100 days post-transplant
and will characterize with skin rash, diarrhea and
liver disease with jaundice and sometimes fever.
Treatment includes immune suppression with steroids
and cyclosporine. Chronic GVHD develops after
100 days and is characterized by scleroderma with
skin rash, sicca complex, hepatic dysfunction, and
sclerosing bronchiolitis. Management includes again
immunosuppressive agents. Most patients develop
tolerance after 1 year or two and are able to stop
immune suppression thereafter. Other complications
include viral infections like CMV, EBV, HSV; fungal
infections, bacterial infections with encapsulated
organisms, etc.

Immunization: Revaccination with routine childhood
vaccines against polio, diphtheria, tetanus, pertussis,
Hib, and pneumococcal vaccines is carried out at 1 year
after successful HSCT and when the patient is off
all immune suppression. Typically 2 doses of Tdap,
IPV, Hib, hepatitis B, and PCV13 are given at one
month interval followed by 3rd dose after 6 months.
These children also receive age appropriate doses of
inactivated influenza vaccine which is then continued
annually. In India they will also receive hepatitis A 2
doses at 6 months interval and Vi typhoid vaccine one
dose to be repeated every 3 to 5 years. Live vaccines like
MMR and Varicella are given as 2 doses 8 to 12 weeks
apart starting at 2 years after HSCT.
ROLE OF PEDIATRICIAN IN SHARED CARE

Before HSCT primary pediatrician should encourage
the patient to take proper treatment, treat infections
vigorously, discuss options of IST and HSCT with parents,
refer the patient to appropriate referral center for further
management, avoid unnecessary transfusions, and avoid
any transfusion from family members. After discharge
primary pediatrician can continue to follow-up patient for
minor ailments and carry out immunization as advised.
FOLLOW-UP AND PROGNOSIS

Patient, if followed clinically for regression or reappearance
of symptoms that may suggest response or graft failure like
pallor, bleeding, fever. They are followed for complication
like skin rash, diarrhea, jaundice, skin changes, dryness
of mucosal surfaces which may suggest acute or chronic
GVHD. If patient is on immune suppression like steroids
or cyclosporine, patient is monitored for side effects like
hypertension, renal toxicities, hyperglycemia, etc. In a sick
child, follow-up is on a daily basis and in a well child, it
could be once in 2 to 3 weeks. Laboratory tests are also
done periodically including CBC, LFT, RFT depending
presence of complications. CBC are usually done weekly
initially and then monthly once patient shows successful
engraftment.26,27
LONG-TERM COMPLICATIONS
Patient may develop long-term complications like relapse
of disease, leukemia, PNH, etc. Check bone marrow
aspiration and bone marrow biopsy are done after 6 to 12
months.
REFERENCES

1. Davies JK, Guinan EC. An update on the management

of severe idiopathic aplastic anemia in children. Br J
Haematol. 2007;136:549-64.
2. International Agranulocytosis and Aplastic Anaemia

Study. Incidence of aplastic anemia: relevance of
diagnostic criteria. Blood. 1987;70:1718-21. PubMed.
3. Kumar R, Kalra SP, Kumar H, Anand AC, Madan H.
Pancytopenia-a six year study. J Assoc Physicians India.
2001;49:1078-81.
4. Bhatnagar SK, Chandra J, Narayan S, Sharma S, Singh V,
Dutta AK. Pancytopenia in children: etiological profile. J
Trop Pediatr. 2005;51:236-9.
5. Mary JY, Baumelou MG and the French cooperative
group for epidemiological study of aplastic anemia.
Epidemiology of aplastic anemia in France: A prospective
multicentric study. Blood. 1990;75:1646-53.
6. McCohan E, Tang K, Rogers PC, McBride ML, Schultz KR.
The impact of Asian descent on the incidence of acquired
severe aplastic anemia in children. Br J Haematol.
2003;121:170-2.
7. Marwaha RK, Bansal D, Trehan A, Varma N. Androgens in
childhood acquired aplastic anemia in Chandigarh, India.
Trop Doctor. 2004;34:149-52.
8. Chandra J, Naithani R, Narayan S, Sharma S, Ravi R,
Singh V, Pemde H, Dutta AK. Antithymocyte globulin plus
ciclosporin in children less than 12 years with acquired
aplastic anemia. Br J Haematol. 2006;133(suppl 1):118.
9. Shimamura A, Guinan EC. Acquired Aplastic Anemia.
In Nathan and Oskis Hematology of Infancy and
Childhood Vol I. Nathan DG, Orkin SH, Ginsburg D, Look
AT eds; WB Saunders Co 6th Edn. 2003.pp.256-79.
10. Camitta B, OReilly RJ, Sensenbrenner L, Rappeport J,
Champlin R, Doney K, et al. Antithoracic duct lymphocyte
globulin therapy of severe aplastic anemia. Blood. 1983;62:
883-8.
11. Fhrer M, Rampf U, Baumann I, Faldum A, Neimeyer C,
Janka-Schaub G, et al. Immunosuppressive therapy for
aplastic anemia in children: a more severe disease predicts
better survival. Blood. 2005;106:2102-4.
12. Alter BP. Bone marrow failure: A child is not just a small adult
(But an adult can have a childhood disease). Hematology
Am Soc Hematol. Educ Program. 2005.pp.96-103.
13. Kojima S, Ohara A, Tsuchida M, Kudoh T, Hanada R,
Okimoto Y, et al. Risk factors for evolution of acquired
aplastic anemia into myelodysplastic syndrome and acute
myeloid leukemia after immunosuppressive therapy in
children. Blood. 2002;100:786-90.
14. Maciejeweski J, Risitano A, Sloand E, Nunez O, Young N.
Distinct clinical outcomes for cytogenetic abnormalities
evolving from aplastic anemia. Blood. 2002;99:3129-35.
15. BCSH General Haematology Task Force. Guidelines for the
diagnosis and management of acquired aplastic anaemia.
Br J Haematol. 2003;123:782-801.
16. BCSH Transfusion Task Force. Guidelines for the use of
platelet transfusions. Br J Haematol. 2003;122:10-23.
17. Weinberger M, Elatta L, Marshall D, Steinberg SM, Redner
RL, Young NS, Pizzo PA. Patterns of infection in patients
with aplastic anemia and the emergence of Aspergillus as
a major cause of death. Medicine. 1992;71:24-43.
18. Ascioglu S, Rex JH, de Pauw, et al. Defining opportunistic
invasive fungal infections with cancer and hematopoietic
stem cell transplants: an international concensus. Clin
infectious Dis. 2002;34:7-14.

19. Aplastic Anaemia in childhood management guidelines.
UK Childhood Leukaemia working party. 2005.
20. Young NS, Calado RT, Scheinberg P. Current concepts in
the pathophysiology and treatment of aplastic anemia.
Blood. 2006;108(8):2509-19.
21. Frickhofen N, Heimpel H, Kaltwasser JP, Schrezenmeier H.
Antithymocyte globulin with or without cyclosporin A: 11year follow-up of a randomized trial comparing treatments
of aplastic anemia. Blood. 2003;101(4):1236-42.
22. Marsh J. Making therapeutic decisions in adults with
aplastic anemia. Hematology Am Soc Hematol Educ
Program. 2006.pp.78-85.
23. Copelan EA. Hematopoietic stem-cell transplantation. N
Engl J Med. 2006;354(17):1813-26.
24. Kumar R, Prem S, Mahapatra M, et al. Fludarabine,
cyclophosphamide and horse antithymocyte globulin
conditioning regimen for allogeneic peripheral blood

stem cell transplantation performed in non-HEPA
filter rooms for multiply transfused patients with
severe aplastic anemia. Bone Marrow Transplant.
2006;37(8):745-9.
25. George B, Mathews V, Viswabandya A, Kavitha ML,
Srivastava A, Chandy M. Fludarabine and cyclopho
sphamide based reduced intensity conditioning (RIC)
regimens reduce rejection and improve outcome in Indian
patients undergoing allogeneic stem cell transplantation
for severe aplastic anemia. Bone Marrow Transplant.
2007;40(1):13-8.
26. Guidelines for the diagnosis and management of aplastic
anemia. British J of Hematology. 2003;123:782-801.
27. Neal S. Young: Acquired Aplastic Anemia: Annals Int.
Medicine. 2002;136:534-46.
25
Inherited Bone Marrow
Failure Syndromes
Revathi Raj
Inherited bone marrow failure syndromes (IBMFSs) are rare genetic disorders characterized by defective production of red cells, white
cells and platelets. This results in a single cell line failure or pancytopenia depending on the gene mutation inherited.
Based on the cell lines affected IBMFS can be classified as Table 1.

Table 1 Classification of inherited bone marrow failure syndrome
Disorder
Cell line
affected
Gene mutation
Mode of inheritance
Chromosome affected
Fanconi anemia
Pancytopenia
FANC A to G
Autosomal recessive
Several 16, 9,13,3,6,11
Dyskeratosis congenita
Pancytopenia
DKC1/TERC
X linked or autosomal Xq28, 3 q26

recessive
Pearson syndrome
Pancytopenia
Mitochondrial DNA
Maternal
Maternal
Pancytopenia
Unknown
Unknown
Unknown
Congenital amegakaryocytic
thrombocytopenia
Pancytopenia
cmpl
Autosomal recessive
1p34
Diamond-Blackfan anemia
Anemia
RPS19
Autosomal dominant
19q
Congenital dyserythropoietic anemia
Anemia
CDAN1
Autosomal recessive
15q, 20q
Congenital sideroblastic anemia
Anemia
ALAS2
X-linked recessive
Xp11
Kostmann syndrome
Neutropenia
ELA2
Autosomal dominant
19p
Shwachman-Diamond syndrome
Neutropenia
SBDS
Thrombocytopenia absent radii
Thrombocytopenia Unknown
Fanconi Anemia
Children with Fanconi anemia (FA) present with distinct
dysmorphic features and can be diagnosed even at
birth before the onset of cytopenias. REFAINRegistry
for Fanconi anemia in India has followed up over 150
children with FA over 15 years. The main somatic features
noticed in the Indian FA registry are growth retardation,
Autosomal recessive
7q11
Autosomal recessive
Unknown
hyperpigmentation, microphthalmia, caf-au-lait spots,

renal anomalies like horse shoe kidney, cardiac anomalies
like atrial or ventricular septal defects, cryptorchidism and
radial ray defect with hypoplastic thumb. Hypopigmented
spots appeared in the palms with the onset of pancytopenia.
Fanconi anemia results from multiple defects in FANC
proteins and the incidence is high in South India due

to high consanguinity. FANC proteins help in monou
biquitination that helps DNA repair. Mutations in FANC
proteins thus result in defective DNA repair and increased
chromosomal fragility which is the hallmark of FA. Gene
complementation studies have helped in antenatal
diagnosis and prevention of new births and this is possible
in our country through the FA registry.
The children present with cytopenia from the age of
3 years. Peripheral blood testing to assess chromosome
breakage with mitomycin C or diepoxybutane helps confirm
the diagnosis. Bone marrow aspiration and karyotyping
are required as the presence of an abnormal clone such as
monosomy 7 heralds the onset of acute myeloid leukemia.
The children initially respond to androgenic steroids such
as stanzolol or oxymetholone. Careful monitoring of liver
enzymes is required during drug therapy.
Hematopoietic stem cell transplantation offers the
sole chance of cure. Outcomes are better when children
are referred early as multiple transfusions increase the
chance of graft rejection and graft-versus-host disease.
Transplantation is done using low dose conditioning as
the children are extremely sensitive to chemotherapy.
Overall survival after transplantation for FA approaches
90 percent survival with sibling donors and 60 percent
with matched unrelated cord blood transplantation. All
children need long-term surveillance for malignancies,
especially head and neck cancers.
Dyskeratosis Congenita
Dyskeratosis congenita can present at any age from
preschool to late thirties with pancytopenia. There are
characteristic nail changes with dystrophy and a bald
tongue with skin hyperpigmentation especially around the
neck. These children are particularly prone to pulmonary
fibrosis and transplantation carries a higher risk of mortality
due to lung complications. Mutations in the DKC gene or
TERC genes are pathognomic of this condition. Cancer
predisposition is high as in other marrow failure syndromes.
Pearson Syndrome
Pearson syndrome is a mitochondrial cytopathy that
causes failure to thrive, pancreatic insufficiency and pan
cytopenia. Bone marrow aspiration shows characteristic
changes with vacuolation in the marrow precursor cells.
Death in infancy results from infections and the role of
transplantation is not clearly defined.
Reticular Dysgenesis
This is a severe defect in the lymphohematopoietic system
with features of severe combined immune deficiency and
marrow failure.
Congenital Amegakaryocytic
Thrombocytopenia (CAMT)
Defects in thrombopoiesis ultimately result in pancy
topenia due to marrow failure. Children can also present
with developmental delay and cardiac defects such as
ASD/VSD. Treatment is with hematopoietic stem cell
transplantation although rejection rates are high. Cancer
predisposition is also noted in CAMT.
Diamond-Blackfan Anemia
Pure red cell aplasia can present at birth or later in life. The
children show dysmorphic features such as craniofacial
anomalies and thumb anomalies often in association
with deafness and growth retardation. The majority of
children respond to prednisolone starting at 2 mg/kg/
day and then tapered over 8 to 12 weeks. Steroid dose is
kept at a minimum required to sustain hemoglobin levels.
Prednisolone dependent or refractory children need to
be treated as per guidelines for thalassemia major with
transfusion and oral chelation. Transplantation helps
achieve cure and children need long-term follow-up for
screening for malignancies.
Kostmann Syndrome
Severe mutations in the ELA2 gene causes Kostmann
syndrome whilst milder mutations result in cyclical
neutropenia. Management consists of aggressive treat
ment of infections and GCSF at a dose between 5 and
20 mcg/kg/day or more is needed to keep the neutrophil
count above 500. Clonal evolution and transformation to
myelodysplasia or acute myeloid leukemia is known to
occur after the second decade.
Thrombocytopenia Absent Radii (TAR)

Most children show spontaneous regression of throm
bocytopenia following the first birthday. Orthopedic
procedures to correct hand anomalies are best postponed
till there is platelet recovery above 75,000. Children with
TAR have the best outcome of all the inherited marrow
failure syndromes.
Key Points in Management of Children with

Cytopenias
Always suspect and screen for inherited marrow failure
syndrome even when single cell line is involved as the
disease may progress to pancytopenia
Avoid marrow suppressive drugs for treatment of
infections
Preserve DNA for future counseling and guiding
families through subsequent pregnancy
Chapter-25 Inherited Bone Marrow Failure Syndromes 257

Early referral to a transplant center results in improved
outcomes
Careful screening of sibling donors prior to
transplantation is important as they may be affected
asymptomatic individuals
There is an increased risk of malignancies in all forms
of IBMFS and cancer surveillance is an important
aspect of follow-up
Test for Fanconi anemia before ATG is given as part of
immunosuppressive therapy for aplastic anemia.
BIBLIOGRAPHY
1. Alter BP. Cancer in Fanconi anemia, 19272001. Cancer.
2003;97:425-40.
2. Alter BP. Inherited bone marrow failure syndromes.
In: Nathan DG, Orkin SH, Ginsberg D, Look AT (Eds).
Hematology of Infancy and Childhood. Philadelphia: WB
Saunders. 2003.pp.280-365.
3. Ball SE, McGuckin CP, Jenkins G, et al. DiamondBlackfan
anaemia in the UK: analysis of 80 cases from a 20-year
birth cohort. Br J Haematol. 1996;94:645-53.
4.
Butturini A, Gale RP, Verlander PC, Adler-Brecher B, Gillio
AP, Auerbach AD. Hematologic abnormalities in Fanconi
anemia: an International Fanconi Anemia Registry study.
Blood. 1994;84:1650-5.
5. Dokal I. Dyskeratosis congenita in all its forms. Br J
Haematol. 2000;110:768-79.
6. Dror Y. Shwachman-Diamond syndrome. Pediatr Blood
Can. 2005;45(7):892-901.
7. Freedman MH, Bonilla MA, Fier C, et al. Myelodysplasia
syndrome and acute myeloid leukemia in patients with
congenital neutropenia receiving G-CSF therapy. Blood.
2000;96:429-36.
8. Gluckman E, Auerbach AD, Horowitz MM, et al. Bone
marrow transplantation for Fanconi anemia. Blood.
1995;86:2856-62.
9. Gluckman E, Vanderson R, Ionescu I, et al. Results of
unrelated cord blood transplants in Fanconi anemia.
Blood. 2004;104:2145.
10. King S, Germeshausen M, Strauss G, Welte K, Ballmaier M.
Congenital amegakaryocytic thrombocytopenia (CAMT):
A detailed clinical analysis of 21 cases reveals different
types of CAMT. Blood. 2004;104:740A.
26
Benign Disorders of Neutrophils
Bharat R Agarwal
This chapter describes benign disorders of neutrophils

(Malignant disorders are described elsewhere). Disorders
of neutrophils can be quantitative (Neutropenia and
neutrophilia) or qualitative (Cytoplasmic or nuclear
abnormalities). All these various conditions are considered
in the following sections as follows:
Neutrophilia
Neutropenia
Neutrophils: cytoplasmic anomalies
Neutrophils: nuclear anomalies.
NEUTROPHILIA
Except for the first weeks of life, the upper limit of normal
is approximately 7.5 109/L. Rarely, artifactually high
counts may be obtained by automated particle counters:
Precipitation of cryoprotein on cooling. Error revealed
by examination of stained film. Examine fluid
preparation by subdued light or phase contrast for
crystals.
Incomplete lysis of erythrocytes. Examination of
stained film will reveal error.
Neutrophilia (Table 1) has little value in specific
diagnosis, with some exceptions considered below.
Infection
As a general rule, neutrophilia is more likely in bacterial
than in viral infection. However, neutrophilia is not infre
quent in the early stages of viral infection and neutropenia
may occur in severe bacterial infection. The neutrophil
count (and other routine characteristic) is of value
in assessing the likelihood of appendicitis in children
admitted to surgical wards with abdominal pain (Table 2).
All characteristics examined in this study were useful in
discrimination, i.e. they were reasonably common in,

and reasonably specific for, appendicitis. The most useful
and easily obtained is the neutrophil count a value of
15 109/L is a useful cut-off. The difference in frequency
of atypical (viral) lymphocytes is an indication of the high
frequency of viral infection in non-surgical abdominal
pain.
Substantial neutrophilia (< 50 109/L) is not infrequent
in bacterial infection, especially bacterial pneumonia,
empyema, bacterial meningitis, septicemia, urinary tract
infection and bacterial endocarditis, and is characteristic of
the rare genetic deficiency of integrin adhesion molecules
on neutrophils and lymphocytes (delayed separation of
umbilical cord, severe bacterial infections, periodontitis,
gingivitis, poor pus formation).
Sweets Syndrome (Acute Febrile

Neutrophilic Dermatosis)
A rare syndrome of unknown cause, characterized by
high neutrophilia, raised, tender, erythematous plaques
and bullae in the skin, spiking fevers and often arthralgia,
myalgia and headache. It may occur without underlying
disease or in association with leukemia, usually myeloid
(in remission and not in a neutropenic phase). Diagnosis
requires skin biopsy (dermal infiltration with mature
neutrophils, edema, vesiculation). Without treatment,
resolves spontaneously in weeks; no response to anti
biotics, but prompt relief from steroids.
Familial Neutrophilia
A familial, lifelong, substantial (to 62 109/L) neutrophilia
of segmented and, to a lesser degree, stab forms. Neutro
phils are normal in morphology and function. NAP may
Chapter-26 Benign Disorders of Neutrophils 259

Table 1 Benign neutrophilia
Artifact
Infection1
Inflammation
Kawasaki
Inflammatory bowel disease
i. Crohns
ii. Ulcerative colitis
SLE
Histiocytosis
Tissue necrosis (e.g. hepatic)1
Leukemoid reactions1,2
Viral infection (may mimic e.g. AML M2, M3, M4)
TAR syndrome
Randalls syndrome
Disseminated tuberculosis
Nonhemopoietic malignancy
Postsplenectomy
Drugs
Steroid
Ranitidine
Leukocyte stimulating factors1
i. Colony stimulating factors
ii. Interleukins
Lithium
Stress
Vomiting
Convulsions
T Hypoxia, near-drowning
Acidosisdiabetic, other
Postoperative
Sweets syndrome
Familial1
1
2
Count often exceeds 50 x 109/L

Nonleukemic shifts to left, including myeloblasts
Note: Placement of some disorders, e.g. Kawasaki, histiocytosis

is tentative.
be increased. Associated features include increased

incidence of chromatid breaks in blood chromosomes,
Gaucher-like cells in marrow and spleen, thickening of
skull bones (widening of diplo) and hepatosplenomegaly.
Regarded as inherited, autosomal dominant.
QUALITATIVE CHANGES IN LEUKOCYTES IN

INFECTION
Appraisal of leukocyte numbers and morphology usually
gives some indication of the likelihood of infection, its broad
nature (bacterial vs viral) and occasionally the precise cause.
Changes in morphology (Table 3) are considered here.
Toxic Change in Neutrophils

Toxic change is characterized by various combinations of
the abnormalities listed in Table 3. When an apparently
toxic change occurs in isolation, e.g. shift to left or heavy
granulation, suspicion should be raised of mimicry
(Table 4).
Toxic change in neutrophils, in combination with other
abnormalities in the film, is a useful guide in distinction
of bacterial from viral infection (Table 5). However,
toxic change per se is not specific for infection (Table
8). A quantification of toxic change has been devised
(Table 6); this may be combined with other leukocyte
changes and the platelet count to produce a score for risk
of sepsis in the neonate, in whom (more so than in older
children) infection is likely to produce rapid deterioration
(Table 7). However, C reactive protein levels on 2 succes
sive days appear to be more useful than morphologic
assessment (if readings can be obtained rapidly); sepsis
is likely if values are raised on day 1 and/or day 2, and
can be confidently excluded if values are normal on both
days.
Each feature has a score of 1. A total score of > 3 is
strong evidence for, and < 2 is strong evidence against
sepsis. If no mature neutrophils in film, score 2 rather than
1 for abnormal total count.
Phagocytosis by Neutrophils
Of cells (leukocytes, erythroblasts, erythrocytes): Phago
cytic neutrophils are less conspicuous than phagocytic
monocyte, which accompany them (see below).
Of organisms: Careful and systematic examination
of the film with a low to medium power objective
(1025) for 5-10 minutes will detect organisms
in a significant proportion of cases of septicemia,
especially those with severe effects such as circulatory
shut-down. On the other hand, blood from an
indwelling venous line may contain a profusion of
organisms (from colonization) with surprisingly mild
accompanying symptoms.
Optimal parts of the film for search are edges and tails.
Infected leukocytes are more numerous in films of the first
drop of blood from the previously unmanipulated earlobe (because of trapping in capillary bed), and in films
of buffy coat. Densely-staining organisms (e.g. cocci) are
more readily visible than the pale-staining organisms
(Gram-negative rods).
Criteria for acceptability of organisms in films as
genuine evidence of septicemia are summarized in
Table 9A; descriptions are given in Table 9B.

Table 2 Hematology of appendicitis (n=50)1 vs nonsurgical abdominal pain (n=50)2

Sensitivity3
Specificity4
9
Total leukocytes, x 10 /L
>15.0
29/50
43/50

> 20.0
15/50
48/50

> 25.0
7/50
50/50

> 30.0
1/50
50/50
Neutrophils, x 109/L
>15.0
25/50
48/50

> 20.0
7/50
49/50

> 25.0
3/50
50/50

> 30.0
1/50
50/50
Neutrophils, shift to left, %
>10.0
17/49
37/50

> 20.0
11/49
50/50

> 30.0
4/49
50/50
Atypical lymphocytes: 0 in 200 leukocytes
13/50
48/50
ESR, mm in 1 h
> 30.0
5/31
38/38
1
Histologically proven
2
Admitted to surgical wards with abdominal pain 46 with various diagnoses discharged without laparotomy. 4 with histologically
normal appendix removed
3
Sensitivity = proportion of patients with positive test
4
Specificity = proportion of controls with negative test
Table 3 Qualitative changes in leukocytes in infection

Neutrophils
Shift to left
Toxic granulation
Degranulation
Dhle bodies
Vacuolation
Pelgeroid change
Chromomeres
Gigantism
Phagocytosis of:
i. Leukocytes
ii. Erythroblasts/cytes
iii. Organisms
Cell death, fragmentation
Agglutination
NAP usually in bacterial infection, in viral
Lymphocytes
Monocytes/macrophages
Vacuolation, enlargement, activation, Dhle-like bodies
Phagocytosis of:
i. Leukocytes
ii. Erythroblasts/cytes
iii. Organisms
Chromomeres
Transformation to histiocytes
Infection-associated hemophagocytosis (marrow, blood)
Giant cells with intranuclear inclusions (marrow, CMW
infection)
Cell Death
Death (apoptosis) of leukocytes is common in infection.
Because anticoagulation and storage also cause damage,
cell death is most reliably assessed in films made directly
from vein, finger or ear.
The process affects leukocytes in general. Whole
cells as well as fragments may be observed. Though
phenomenon may be noted in non-infective conditions
such as malignancy and SLE, in childhood it almost
always is a result of infection and may be striking in viral
infections such as infectious mononucleosis, measles and
neonatal herpes in viral infection death may affect atypical
lymphocytes as well as normal leukocytes.
Possible mechanisms include immune effect, inter
leukin-2 starvation as a result of cell hyperactivity and
invasion by virus. Dead cells are a stimulus to phagocyto
sis by monocytes/macrophages and neutrophils.
TRANSIENT NEUTROPENIA
Neutropenia is occasionally spurious.
Clotting in sample (likely to depress counts of all cell
types rather than neutrophils only)
MPO deficiency (neutropenia wrongly identified by
counters, e.g. Hemalog D, which recognize neutrophils
cytochemically)
Aggregation, in some cases EDTA-induced
Cell fragility (smudging) in chylomicronemia.
Neutropenia in childhood (Table 10) is most commonly
due to infection, especially viral. Neutropenia is usually

Table 4 Differential diagnosis of toxic changes in neutrophils
Changes
Table 7 Hematologic scoring system for sepsis in the neonate
Differential diagnosis
Toxic granulation
Alder granulation
Degranulation
Genetic disorder
Myeloid leukemias
Dhle bodies
Dhle-like bodies in MayHegglin, Fechtner and

Sebastian syndromes
Vacuolation
Anticoagulant/storage artifact
Jordans anomaly
Giant neutrophils
Pseudo-Pelgerization
Cell death
Hereditary giant neutrophils

Anticoagulant/storage artifact
Total neutrophil count

Immature/total neutrophil
ratio
Immature/mature neutrophil
ratio
Immature neutrophil count
Total leukocyte count
Toxic change in neutrophils

Platelets
Table 5 Common changes in leukocytes in bacterial and viral

infection
Bacterial infection
Viral infection
Neutrophilia
Common
Uncommon
Neutropenia
In severe infection
Common
Toxic change in
Common, often
Slight; marked in
neutrophils
severe
some infections,
e.g. measles
Atypical
Small numbers or
Increased
lymphocytes
absent
Organisms in
Sometimes
0 (zero)
leukocytes
Table 6 Quantitation of toxic change in neutrophils1

% cells affected
Score
Vacuolation
0
0
Dhle bodies
<25
+
2550
2+
5175
3+
>75
4+
Toxic granulation
Normal granulation
Slight toxic granulation
Approx 50% cells affected
Toxic granules most cells
gross; nucleus obscured by
toxic granules
1
For use with (Table 7)
0
+
2+
3+
4+
not severe (>0.2 x 109/L) and usually begins to recover

within 5 days, rarely not for 2-3 weeks. Destruction may be
due to direct effect or immune mechanism. Morphologic
Abnormality
or
0.3
or
( 5.0 x 109/L or 25.0,
30.0 or 21.0 at birth,
12-24 h and day 2 onward
respectively
3 + for vacuolation, toxic
granulation or Dhle bodies
150 x 109/L
Table 8 Toxic changes in neutrophils. Some causes other than

infection
Collagen disease
SLE
Other vasculitides
Kawasaki
Stevens-Johnson
Crohns
Ulcerative colitis
Near-drowning1
Heat stroke
Tissue necrosis
Hepatic
Necrotizing enterocolitis2
Burns1
Drugs
Colony-stimulating factors
Cytotoxics
1
Added infection common
2
Septicemia from normal gut flora a significant component
evidence in blood films of antibody/opsonic effect

includes agglutination and phagocytosis of neutrophils
by monocytes or rarely neutrophils. The marrow appears
normal or shows maturation arrest at the myelocyte/
stab stage or, rarely, destruction. In a high proportion the
organism is not identified (or sought). Recovery of count
after treatment with antiviral agents, e.g. ganciclovir,
suggests a viral cause.
Mechanisms for neutropenia in sepsis include
destruction by endotoxin or phagocytosed organisms
and agglutination by activated complement components,
e.g. 5a. The marrow may be depleted of granulocytes,

Table 9A Organisms in blood films: acceptability as genuine
evidence of septicemia
At least a proportion intracellular; appearances must be typical.
Intracellular organisms are unequivocal evidence of septicemia
only in films of capillary blood or films of venous blood made
directly from needle (skin organisms may rarely be phagocytosed
by leukocytes in venous samples in the interval before films are
made)
Disregard
Inclusions in lymphocytes
Infected skin squames, epidermal cells
Granules in basophils: More variable in size and shape than
cocci, often hollow, no characteristic grouping, no capsule,
paler than most cocci, no or minimal staining with Gram toxic
granules.
Differential diagnosis
Granules in basophils: More variable in size and shape than
cocci, often hollow, no characteristic grouping, no capsule,
paler than most cocci, no or minimal staining with Gram toxic
granules
Coarse azurophil granules
Nuclear appendages
Chromomeres (detached, pyknotic nuclear fragments)
Phagocytosed nuclear fragments
Table 9B Characteristics of bacteria in Romanowsky-stained

blood films1
N. meningitides
Plump cocci, a proportion in pairs, with some

flattening of opposed faces, intense blueblack. N. gonorrhoeae indistinguishable in
morphologyrare in childhood and clinical
features different. Gram negative
S. pneumoniae
Fine cocci, some slightly elongated, most

in pairs, with clear space (capsule) around;
intense, almost black staining. Infection may
be heavy postsplenectomy
S. aureus
Coarse cocci, usually in small groups, but

may be single, in Pairs or short chains (to
about 4), redbrown to violet or almost black,
no capsule
b-hemolytic
streptococci
Fine cocci in groups or chains, intense violet

to almost black
Coliforms
Small to large rods, gray to gray-pink,

Klebsiella often encapsulated. Organisms
usually not profuse in individual cells and
infected cells usually sparse
H. influenzae
Small rods or coccobacilli, often encapsulated,

usually not profuse
Clostridia
Large rods, often square ended; gray to graypink, no capsule
Gram and PAS stains may be useful on spare films if infected

cells plentiful.
1
Table 10 Neutropenia transient

Infection
Viral (including HIV)
Bacterial
i. Pyogenic infection Staphylococcus, Streptococcus,
Coliforms, Meningococcus, Haemophilus, if severe
ii. Brucella, typhoid, paratyphoid1
Tularemia1
Malaria, occasional cases1
Burns
Hemodialysis
Drugs
1
Neutropenia may be chronic
especially in neonate. Transient neutropenia associated

with burns and hemodialysis is attributed to agglutination
by activated C5.
NEUTROPENIA, CHRONIC (MORE THAN 3

MONTHS)
Less frequent than transient neutropenia. An empiric
classification has been given (Tables 11 to 14), as in many
cases the mechanism is unknown. As suggested schema
for initial investigation is given in Table 11A.
Cyclic Neutropenia
Periodicity of infections, especially upper respiratory and
oral, should suggest the diagnosis. The cycling period is
usually 1921 days; neutropenia lasts for 36 days, with
complete absence for 13 of these. In neutropenic phases,
patients feel unwell from fever and infection, especially
staphylococcal with streptococcal. Oral infection may be
associated with cervical lymphadenopathy. Monocytes
are usually increased in neutropenic phases, but infection
is nevertheless a problem, as monocytes are less efficient
than neutrophils in tracking and destroying bacteria.
Monocytes, lymphocytes, eosinophils and platelets
also show some cycling (usually from normal to above
normal), while reticulocytes cycle above to below normal.
An increase in large granular lymphocytes is often noted
in cases of adult onset.
In neutropenic phases the marrow shows maturation
arrest at the myelocyte stage. Increase in mature forms
and paucity of precursors preceded by some days increase
in neutrophils in blood.
In some cases oscillations tend to dampen over the
years and evolve to chronic neutropenia. The condition
does not appear to predispose to leukemia, though
cyclic neutropenia may rarely be a harbinger of ALL or
myelodysplasia.
In most cases, especially those of adult onset, inheri
tance cannot be discerned. In familial cases (about one
Table 11A Chronic neutropenia: initial assessment

Clinical history, age at onset, physical examination
Blood values
Blood film
Neutrophil count, once or twice weekly for 6 weeks
Bone marrow
Aspirate
- Morphology
- Karyotype
Trephine biopsy
Electron microscopy
Serum
Immunoglobulins
Complement components
Autoimmune screen
B12, folate
Viral serology
Antigranulocyte antibodies
Lymphocyte subsets
As appropriate: Tests for disorders in Tables 1214
Table 11B Chronic isolated neutropenia in childhood

inherited1
No other anomalies
Cyclic
Kostmann
Lazy leukocyte syndrome
With abnormal marrow neutrophils: Myelokathexis and
others
As part of genetic syndrome
With visible somatic anomalies (Table 12)
Without visible somatic anomalies (Table 13)
1
Neutropenia usually congenital
third), transmission is autosomal dominant with variable

penetrance.
The defect appears to reside in the stem cell/committed
progenitor cell, as it is transmissible by transplantation in
humans and can be cured in affected animals (Collie dogs)
by transplantation of normal marrow.
Differential Diagnosis
A degree of cycling may be noted in neutropenias such as
Shwachmans syndrome and monosomy 7 MPD. Cycling,
however, does not have the predictability of true cyclic
neutropenia.
Kostmanns Syndrome (Infantile Genetic

Agranulocytosis)
Neutrophils are persistently lower than 0.3 109/L; bac
terial infections are frequent and severe and are the
Table 12 Genetic syndromes with visible somatic anomalies

which may be associated with neutropenia
Shwachman
Exocrine pancreatic insufficiency, metaphyseal

dyschondroplasia, growth retardation.
Fanconi
Abnormal pigmentation short stature, thumb
and radius anomalies, abnormal head/face,
hypogonadism.
Dyskeratosis
Reticular hyperpigmentation, depigmen
congenita skin
tation, atrophy; hair loss, nail dystrophy,
leukoplakia, dental dystrophy.
Chediak-Higashi Partial oculocutaneous albinism, bacterial
infections, esp. S. aureus, gingivitis and perio
dontitis, cranial and peripheral neuropathies,
hepatosplenomegaly.
Cartilage-hair
Short-limbed dwarfism, fine hair, infections,
hypoplasia
esp. varicella
Cohen
Nonprogressive psychomotor retardation,
microcephaly, short stature, delayed puberty,
hypotonia, joint hypermobility, peculiar faces
and teeth, myopia, narrow hands and feet, not
infection-prone
Hernandez
Dystrophy of nails and hair, mild mental
retardation
Microcephaly, psychomotor retardation, reti
nitis pigmentosa, marrow normal by light
microscopy
usual cause of death. There is often a compensatory

monocytosis which, even if striking (in a personal case
to 14.6 109/L), assists little in ameliorating infection
because of the inefficiency of monocytes in handling
infection. The marrow is cellular usually with maturation
arrest at the promyelocyte/myelocyte stage, or in some
cases normal maturation. Electron microscopy shows
dysgranulopoiesis in some cases.
A deficiency in responsiveness to granulocyte colony
stimulating factor (GCSF) is likely, which can however be
overridden in vivo by administration of GCSF. Evolution to
(myeloid) leukemia may occur. Inheritance is autosomal
recessive.
Lazy Leukocyte Syndrome

A rare, chronic neutropenia (<0.2 109/L) with mor
phologically normal marrow and severe curtailment of
chemotaxis and random mobility of neutrophils. Neutro
penia shows no response to intravenous adrenaline and
subnormal response to Pneumococcus polysaccharide. An
abnormality of surface configuration may make the cell
rigid. A similar disorder may occur as a temporary (< 12
months) phenomenon.

Table 13 Genetic syndromes without visible somatic anomalies
which may be associated with neutropenia
Neutropenia with
immunodeficiency1
X-linked
agammaglobulinemia
dysgammaglobulinemia
type
-
O lgG, IgA, n to IgM
Hyper-IgA, eosinophilia, defective

neutrophil chemotaxis, T, B cell
function
Hypogammaglobulinemia,
lymphopenia (imperceptible
tonsils, impalpable lymph nodes,
no thymus on X-ray). Marrow
depleted of granulocytes.
Lymphocytes. AR
mild variant described
Lymphopenia, T cell deficit, partial
Pelgerization, benign course,
X-linked recessive
Organic acidemias:
Recurrent metabolic acidosis,
Isovaleric
often with vomiting, variable
Propionic
mental retardation, odor of
Methylmalonic
sweaty feet in isovaleric acidemia;
thrombocytopenia/pancytopenia
in acidotic episodes of isovaleric
acidemia
Glycogen storage 1b
Hypoglycemia, convulsions, failure
to thrive, infections, bleeding,
hepatomegaly
Abbreviations: AR: Autosomal recessive; n: Normal.
1
Neutropenia may be a result rather than a cause of infection,
as neutropenia appears to be infrequent in those treated with
immunoglobulin
Neutropenias with Abnormal Marrow

Neutrophils
Myelokathexis (Kathexis = Retention)
A rare neutropenia (chronic, non-cycling) associated with,
and attributed to, abnormality of segmented neutrophils in
marrow which are abundant but show signs of degeneracy
(nuclear pyknosis, hypersegmentation with slender con
necting filaments, cytoplasmic vacuolation). Neutrophils
show variable impairment of function (decreased NAP,
impaired dye exclusion, mobility and phagocytosis). MPO
is normal. Count increases in infection and after injection
of GCSF. Possible variants include familial occurrence
(father, daughter) with hypogammaglobulinemia, and as
sociation with growth retardation and dysmorphism.
Table 14 Chronic isolated neutropenia in childhoodacquired

Alloimmune
Autoimmune1
Infection
Virus
Other2
Brucellosis
Typhoid, paratyphoid
Malaria
Leishmaniasis
Marrow pathology2
Leukemia
- Monosomy 7 MPD
- Pre-ALL
Neuroblastoma
Hypoplasia
Myelosclerosis
Osteopetrosis
Deficiency of hematinics2
Folate, B12
Copper
Drugs
Immune
Nonimmune
Sequestration
Spleen2
Marrow macrophages
1
In neonates passive transfer may occur from a mother with
autoimmune disease
2
Usually with other cytopenias
Neutropenia with Gigantism and

Multinuclearity of Marrow Neutrophils
Marrow promyelocytes contain up to 4 nuclei, and seg
mented neutrophils up to 16. Some cells are hypogranular
and others hypergranular. Cells are severely deficient in
lactoferrin (specific granules). The abnormalities impair
survival in marrow and are attributed to aberration of
centrioles. Karyotype is normal.
Blood neutrophils by contrast are normal. Increase is
inconstant in infection and minimal after adrenaline and
dexamethasone.
Neutropenia with Large, Binucleate,

Tetraploid Neutrophils and Monocytes in
Marrow
The proportion of binucleate cells increases with maturity
(metamyelocytes 42%, segmented 100%). Other leukocytes
are normal. Neutropenia is attributed to impaired egress
of abnormal cells from marrow. Binucleate cells are rare
(< 1%) in blood.

In a personally observed case, neutropenia was
associated with abnormal granule structure and pancreatic
fibrosis.
Neutropenia as Part of a Genetic Syndrome

(Tables 12 and 13)
Neutropenia in these disorders is due to a variety of
mechanisms.
Precursor cell deficiency, e.g. Fanconi, Shwachman,
cartilage-hair hypoplasia
Intramedullary destruction, e.g. Chediak-Higashi
(abnormal myeloid precursors in marrow, increased
serum muramidase in absence of monocytosis or
decreased survival of blood neutrophils)
Suppression of myeloid maturation, e.g. by organic
acids and glycine in organic acidemias.
Antibody-induced Neutropenias
Antibodies to neutrophil-specific antigens are an impor
tant cause of neutropenia (Minchinton & Waters 1984).
Antigens shared with other cells types (e.g. HLA) do not
appear to be significant in neutropenia. Serum may be
tested against a panel of neutrophils of known phenotype
or against films of marrow aspirate. Serum should be tested
fresh, but if delay in transport to a reference lab is likely,
blood should be taken into citrate-phosphate-dextroseEDTA solution. Serum or plasma should be heated before
application; to remove complement with interferes with
antibody binding. Marrow films should be fresh, or stored
at -30C till and fixed with paraformaldehyde at time
of testing. Antibody is demonstrable on more mature
stages (metamyelocyte onward) in mild to moderate
neutropenias, and on myelocytes and promyelocytes as
well, in severe neutropenias.
Alloimmune Neutropenias
It is two important types in childhood:
1. Alloimmune neutropenia of infancy: Estimates of
incidence vary from 1/200 to 3 percent of neonates.
Neutropenia is severe (0-0.5 109/L, often with a
compensatory monocytosis. In infected infants anti
body should be sought if neutropenia is excessive for
the infection (neutropenia is unlikely unless bacterial
infection is severe).
Antibodies (IgG) are directed against one of the
normal cell-specific antigens (well represented on
cord neutrophils), most commonly NA1, NA2, NB1,
NC1 and 9a. Rarely, the mother has no NA specific
neutrophil antigens (NA null, CD16 negative) and as a
consequence reacts to any NA (NA1, NA2) antigens on
Table 15 Alloimmune neonatal neutropenia : diagnosis

Combination
Result
Maternal serum + paternal granulocytes
pos
Maternal serum + maternal granulocytes1
neg
Baby serum2 + paternal granulocytes
pos
Baby serum2 + baby neutrophils3
pos
Maternal serum + baby neutrophils3
pos
1
To exclude maternal autoimmune neutropenia, e.g. SLE
2
Collected while neutropenia
3
Collected when numbers become normal
Table 16 Autoimmune neutropenias of childhood

Combination
Autoimmune neutropenia of infancy (chronic benign)
Viral infection
Autoimmune disease
SLE
Feity
Passive transfer from mother with autoimmune disease, e.g.
SLE
With autoimmune hemolysis and thrombocytopenia (Evans
syndrome)
Bone marrow transplantation
Drugs (some)
T lymphocytosis with neutropenia
fetal neutrophils. Immunization is usual with the first

child.
Because of paucity of cells, realistic testing can
be done only for antibody in the mothers serum
which reacts with the fathers but not with her own
neutrophils (Table 15).
Marrow examination excludes the unlikely occur
rence of leukemia as the cause of isolated neutrope
nia. Cellularity is variable. Stages from metamyelocyte
onward may be normally represented, deficient or
absent. Maturation arrest is due to destruction of
mature forms and not to suppression of maturation.
Neutropenia persists for 3 weeks to 3 months
depending on rate of catabolism of antibody. Mortality
(bacterial septicemia) is about 5 percent.
2. Autoimmune neutropenias (Table 16): The most
common in childhood is autoimmune neutropenia of
infancy.
Autoimmune Neutropenia of Infancy

(Chronic Benign)
Neutropenia is severe (0-0.5 109/L); however there is no
excess of infections compared with normal children of the
same age. The count increases with infection and urticaria,

especially in the recovery period; there is little or no response
to adrenalin (draws cells from marginating pool), variable
response to steroid (enhances release from marrow), and
good response to intravenous immunoglobulin (usually
temporary occasionally permanent, effect attributed to Fc
receptor blockade and decreased synthesis of antibody).
Compensatory monocytosis is common, so that usually
total leukocyte count is within normal limits.
Marrow examination is recommended to exclude
the rare possibility of leukemia as a cause of isolated
neutropenia. Myeloid hyperplasia is usual; mature forms
(bands and segmented) are normally represented or
deficient (maturation arrest).
Median age at detection is approximately 8 months
(range 3-30). Blood counts shortly after birth have been
normal. Girls are more often affected than boys (1.5/L).
The antibody is IgG, with some IgM in occasional cases.
Specificity is usually for NA1 or NA2; in some cases the
target antigen cannot be identified. Evidence of parvovirus
infection (PCR on marrow cells, serology) was obtained in
a majority of cases; the occurrence of neutropenia rather
than the usual erythroblastopenia may be due to altered
immune response, the antibody recognizing myeloid cells
as well as virus.
Neutropenia is self-limiting with a median duration of
30 months (range 6-60), 95% recovering by 4 years. There
are no known long-term or other effects.
Viral Infection
Antineutrophil antibodies have been detected in some
viral infections, e.g. infectious mononucleosis, HIV and
parvovirus infection. Neutropenia, however, occurs in
only a minority of those with antibody. The target antigen
is not clearit does not appear to be one of the known
polymorphous, neutrophil-specific antigens, NA1, NA2,
etc. Neutropenia is only occasionally (< 1%) severe and
prolonged enough in itself to predispose to bacterial
infection.
Autoimmune Disease
SLE: Antineutrophil antibodies are detectable in about
50% of patients. The antibody does not have specificity
for known polymorphous neutrophil-specific antigens
and is distinct from the anti-DNA present in most
cases.
Neonatal lupus syndrome is a risk if the mother has
SLE (not necessarily symptomatic in the pregnancy).
Major manifestations are cutaneous lupus (not
manifest at birth but becoming so within 2 months)
and complete heart block (at birth), usually one or the
other, occasionally (< 10%) both. Skin lesions resolve
usually within 6 months, but the heart block almost
always is permanent. Some infants have, singly or

in combination, neutropenia, thrombocytopenia or
autoimmune hemolysis.
Feltys syndrome (rheumatoid arthritis, splenomegaly
and neutropenia): Rare in childhood. The neutropenia
is of complex causation:
Neutrophil antibodies demonstrable in most cases
Hypersplenism, most patients showing sustained
improvement in count after splenectomy
Inadequate compensatory marrow production.
Evans Syndrome
Autoimmune thrombocytopenia and hemolysis is without
detectable underlying cause such as viral infection or
SLE. Autoimmune neutropenia also occurs in some cases.
Antibodies to the various cell lines are different.
Marrow Transplantation
Antibodies to neutrophils (and platelets) occur frequently
after marrow transplant (allogeneic or autologous).
Antibodies post-allogeneic transplant can be shown by
immunoglobulin allotyping to be of donor origin, i.e.
antibody against engrafted cells is autoimmune, whether
allogeneic or autologous.
Drug-immune Neutropenia (Table 17)

Rare in childhood.
In most cases the condition is drug-specific; in contrast
to drug-specific hemolysis, antibody will not simply
react with pretreated granulocytes, but only when
serum, drug and neutrophils are incubated together.
True autoantibody, comparable to methyl dopa immune
hemolysis; though autoimmune, antibody cannot be
detected in serum after withdrawal of the drug.
Usually antibody is active against both mature and
immature cells, in a minority against only precursor or
only mature cells. The nature of the target antigen/s is
for the most part unknown; the specific neutrophil series
(NA1, NA2, etc.) is not involved. For quinine, at least it is a
membrane glycoprotein. Antibodies from different drugs
occasionally cross-react (e.g. quinine, quinidine).
Neutropenia affects only a minuscule proportion of
those exposed, and is unpredictable in occurrence and
course. Usually onset is abrupt, 1-5 weeks after start of
treatment, sooner (or immediately) after re-exposure.
Neutropenia lasts usually for 1-4 weeks after withdrawal of
the drug, occasionally as briefly as 1 day. It may be severe
enough to cause serious infection.
Marrow may be grossly depleted of neutrophils in
general or show maturation arrest at the myelocyte/
metamyelocyte stage, with or without hyperplasia of
precursor cells.

Table 17 Pediatric drugs which may be associated with
immune neutropenia
Antiarrhythmic
Aprinidine HCl
Flecainide acetate
Procainamide
Quinidine
Antibiotics
Penicillin and derivatives
- Ampicillin
- Amoxycillin
- Dicloxacillin
- Nafcillin
- Oxacillin
Cephalosporins
- Cephradine
- Cefotaxime
- Ceftazidime
- Cefuroxime
Sulphonamides
Sulphamethoxazole
Sulphathiazole
Sulphafurazole
Sulphapyridine
Antimalarial
Amodiaquine
Chloroquine
Quinine
Analgesic/anti-inflammatory
Amidopyrine
Aminosalicylic acid
Diclofenac
Ibuprofen
Propyphenazone
Antithyroid
Propylthiouracil1,2
Carbimazole
Methimazole
Other
Phenytoin
Chloral hydrate
Gold thiomalate
Levamisole
1
Neutropenia may not occur till months or years after exposure
2
True autoimmune in some cases
T-Lymphocytosis with Neutropenia

Rare in childhood. Neutropenia (antibody demonstrable
in some cases) with substantial is increase in normal
mature lymphocytes (CD8 suppressor/cytotoxic; large
granular lymphocytes in some cases). Lymphocytosis
may first manifest or become more obvious after sple
nectomy (for other reasons) and may affect marrow.
Karyotype normal. It may be associated with polyclonal
hyperimmunoglobulinemia. Blood is otherwise normal,
no anemia or thrombocytopenia. Chronic (years) is with
little effect on health. Spleen may be moderately enlarged.
Evidence of EBV infection is found in some cases.
Marrow Infiltration/Replacement (Table 14)

Neutropenia is rarely the only finding. In monosomy 7
MPD, however, neutropenia, with or without macrocytosis,
may be a prodrome over many years to overt disease.
Rarely, neutropenia is a prodrome to ALL.
Deficiency of Hematinics
Folate, B12 deficiency
Copper deficiency.
A rare cause. Neutropenia is an important and early
characteristic, usually severe (<0.5 109/L); marrow usually
shows vacuolation of precursor cells and maturation
arrest at myelocyte/metamyelocyte stage. Anemia is
usually severe (to about 4.5 g/dL) and macrocytic, with
megaloblastosis, vacuolated erythroblasts and ringed
sideroblasts (10-15% of cells) in marrow. The genesis of
these changes obscure; they do not occur in the best-known
copper deficiency in man (Menkes kinky hair syndrome).
Possible mechanisms include defective synthesis of
cytochrome oxidase and ascorbic acid oxidase; which
keep copper in the reduced state. Treatment with copper
produces rapid and striking response.
Deficiency is most likely to occur in infants with
prolonged diarrhea and malnutrition, and in those on
prolonged total parenteral nutrition without copper
supplementation. Deficiency may, however, occur without
obvious cause in infants who are thriving.
Drugs and Neutropenia

In some cases antibody is generated against platelets
as well as neutrophils (different antibodies), and rarely
against other cells, e.g. erythrocytes and T lymphocytes in
a hemolytic-uremic-like syndrome attributed to comple
ment-mediated activation and adhesion of neutrophils to
endothelium.
Selective granulocytopenia as an idiosyncratic, unpre

dictable effect of drugs is rare in childhood, though it is
possible with a large variety of drugs. Mechanisms include
personal idiosyncrasies in pharmacokinetics, sensitivity
of myeloid precursors and immune response. Drugs with
potential for immune destruction are listed in Table 17. The
same drug may produce granulocytopenia by different

mechanisms in different patients and possibly even at
different times in one patient.
Neutropenia due to Sequestration

Hypersplenism (e.g. biliary atresia, liver cirrhosis,
cavernous transformation of portal vein).
Hyperphagocytosis of band and segmented forms by
marrow macrophages is a rare cause of isolated neutro
penia; e.g. hemophagocytosis, in which macrophages
contain a variety of inclusions. There is no evidence
of neutrophil antibody, no or slight increase in serum
muramidase, no response to adrenalin (marginating
pool) but good response to hydrocortisone (marrow
reserve).
GRANULOCYTES: CYTOPLASMIC ANOMALIES

(TABLE 18)
Qualitative changes in leukocytes in infection are des
cribed in Tables 3 to 9.
Alder Anomaly (Table 19)

Coarse, densely-staining granulation in neutrophils,
anomalous staining of eosinophil granules (violet,
Table 18 Anomalies of granulocyte cytoplasm
Alder anomaly
Sparse coarse azurophilic granules
Vacuolation
Vacuolation of granulocyte precursors and erythroblasts
Dhle-like bodies
Neutrophil specific granule deficiency
Eosinophil specific granule deficiency
Peroxidase deficiency in neutrophils
Giant granulation in granulocytes and monocytes
Amorphous rounded gray bodies
Hemosiderin
Bilirubin
Table 19 Alder granulation
MPS VI (Maroteaux-Lamy)1
MPS VII (Sly)
Multiple sulphatase deficiency
Infantile free sialic acid storage disease2
Asymptomatic3
Granules metachromatic and birefringent

Partially developed Alder granulation
3
Existence doubted
1
2
green or gray-black, may resemble basophil granules),

and unusually coarse or densely staining granules in
basophils, monocytes and mast cells. Precursor cells in
marrow are also affected. To be distinguished from toxic
granulation (finer, often associated with other signs of
toxicity, temporary).
Sparse, Coarse Azurophil Granules

A minority of neutrophils contains a light sprinkling of
coarse granules. Rare granules may be metachromatic.
Other granulocytes are normal.
Characteristic of MPS IV (Morquio) type A (early
onset). Main features: Normal intelligence, gross and
distinctive skeletal change, mild facial coarsening and
corneal clouding, risk of spinal cord compression from
odontoid hypoplasia; valvular heart disease. Onset
1-3 years survival beyond 30 years is unusual auto
somal recessive. Definitive diagnosis is by galactose6-sulphatase (arylsulphatase A) assay in leukocytes or
cultured fibroblasts. Milder forms occur, with no excess of
mucopolysaccharide in urine and longer survival.
Vacuolation
Vacuolation is uncommon as a genetic anomaly. More
common causes are toxic states (infection, inflammation
and cytotoxics) and artifact of anticoagulation.
Vacuoles of Neutral Lipid (Jordans Anomaly)

Vacuoles are ORO and Sudan III positive, stain red with
Nile blue sulphate and occur in most to all neutrophils,
eosinophils, basophils and monocytes and in a proportion
of plasma cells, but not in other hemopoietic cells. Absent
from myeloblasts and increase with cell maturity from
promyelocyte onward.
Ichthyosis and Neutral Lipid Storage Disease

Triglyceride droplets also in other tissues, e.g. muscle, liver.
Main features: Ichthyosis, myopathy, ataxia, sensorineural
deafness, cataracts, liver dysfunction, variable mental
retardation, evident at birth, autosomal recessive.
Carnitine Deficiency
A heterogeneous and incompletely characterized group of
disorders is in which carnitine deficiency may be genetic
or acquired (e.g. renal Fanconi syndrome, hemodialysis,
total; parenteral nutrition). The defect/s in some of the
genetic deficiencies is unidentified and the traditional
distinction between muscle and systemic deficiency

may be artificial. In some there is a defect in carnitine
transport across mitochondrial membranes, in others
a defect in carnitine synthesis. Jordans anomaly is
associated with muscle carnitine deficiency (skeletal and
cardiac), less so with systemic deficiency.
Wolmans Disease
Lipid vacuoles are inconsistent and infrequent.
May-Hegglin Anomaly
Inclusions usually easily seen, but may be inconspicuous
in some cases; occur in granulocytes and monocytes but
not lymphocytes; pyroninophilic (reaction abolished by
ribonuclease), with distinctive ultrastructure of 7-10 nm
filaments oriented in parallel in long axis. It is associated
with enlarged platelets and, in about one quarter, mild
thrombocytopenia autosomal dominant.
Neonatal Hemochromatosis
Fechtners Syndrome (Alports Syndrome

Neutrophils with ORO positive vacuoles may occur Variant)
in neonatal hemochromatosis. In infants vacuolation
may be associated with nuclear pyknosis/cell death,
and vacuolated cells contained (between the vacuoles)
fine Perls positive granulation (finer than in adults with
hemochromatosis).
ORO positive neutrophils may occur transiently in biliary

atresia and following GCSF treatment.
Dohle-like inclusions, giant platelets, nephritis (micros

copic hematuria to renal failure), sensorineural deafness
and congenital blue-spotted (cerulean) cataracts. The
Dhle-like bodies occur in most neutrophils and some
eosinophils, are smaller and less intensely staining than in
MayHegglin and consist of segments of rough endoplas
tic reticulum and ribosome clusters but no filaments.
Platelets are large, moderate to severe thrombocytope
nia common autosomal dominant.
Pearsons Marrow-Pancreas Syndrome
Sebastian Platelet Syndrome
Vacuolation of granulocyte and erythroid precursors,

ringed sideroblastosis, increased storage hemosiderin,
transfusion-dependent macrocytic anemia, reticulocy
topenia; variable neutropenia, thrombocytopenia and
splenic atrophy. It may evolve to marrow aplasia or leuke
mia. A deletion of mitochondrial DNA has been identified
with possible maternal inheritance.
It presents in infancy with growth failure and refractory
steatorrhea (pancreatic fibrosis). About half die before the
age of 3 years, others improve with age.
Differential diagnosis is from other marrow-pancreas
syndromes and from hereditary sideroblastic anemia.
Shwachman syndrome: No vacuolation or sidero
blastosis; marrow hypoplasia earlier and more pro
minent than in Pearsons.
Hereditary sideroblastic anemia: A proportion of eryth
rocytes are microcytic. No vacuolation or pancreatic
insufficiency.
Atypical cystic fibrosis with marrow hypoplasia: No
vacuolation or sideroblastosis.
It is similar to Fechtners syndrome but without the clinical

abnormalities.
Other
Dhle-like Bodies
These are usually more sharply defined and larger than
Dhle bodies, are not accompanied by toxic changes and
are permanent.
Neutrophil Specific Granule Deficiency

Specific granule deficiency is usually acquired (myeloid
leukemias, burns, infection, normal neonate). The genetic
deficiency is never severe and is rare.
Main features:
In stained films cells appear poorly granulated and
washed out (MPO-deficient cells appear normal).
NAP decreased or absent. NAP is not a constituent
of specific granules but plasma membrane linked,
deficiency being attributed to an anomaly common to
both plasma membrane and specific granules.
Granules ultrastructure consists only of the enveloping
vesicle.
Deficiency of specific granule components, e.g. lacto
ferrin, TCII, can be shown by biochemical or immuno
logic methods. Deficiency of TCII in serum may be
associated.
Deficiency of defensins (normal component of sub
population of azurophil granules) accompanies the
specific granules defect.
Pelgeroid changesbilobed nuclei of uneven size;
micronuclei in some cells.

Cells are defective in chemotaxis (specific granules
produce chemotactic receptors) and in bactericidal
capacity (deficiency of lactoferrin, defensins).
Neutropenia due to intramedullary destruction may
occur.
Manifests as pyogenic infections, which may be indolent.
Probably autosomal recessive.
Peroxidase Deficiency and Monocytes

The peroxidase in neutrophils and monocytes (MPO)
differs from that in eosinophils and is under different
genetic control. In neutrophils MPO is localized to azuro
phil (primary) granules.
Acquired deficiency occurs in myeloid leukemias (M2,
M3 and M4 especially) and myelodysplasias. Usually
a proportion of neutrophils is completely lacking in
enzyme. The gene for MPO lies in 17q in the vicinity of
the breakpoint for the t(15;17) of AML M3.
Activity is diminished by some drugssulphonamides,
antithyroid drugs, phenothiazines, ascorbic acid.
MPO deficiency is the most common inherited disorder
of neutrophils (complete deficiency about 1/4000,
partial about 1/2000. The partial deficiency affects all
or almost all neutrophils, though not necessarily to the
same degree. Identification is by standard cytochemical
methods (MPO, SBB) or, for partial deficiency especi
ally, automated flow cytometry using 4-chloro-1naphthol as substrate (e.g. Hemalog D counter).
MPO-deficient bloods will be wrongly identified as
neutro
penic by automated counters which identify
neutrophils cytochemically. EPO is normal.
Morphology of neutrophils and monocytes in stained
films is normal.
Surprisingly, bactericidal capacity of MPOdeficient
granulocytes is only mildly diminished; killing of fungi
(candida, aspergillus) however is severely affected.
Patients have little susceptibility to bacterial infection,
but there is a risk of disseminated candidiasis if MPO
deficiency is associated with diabetes mellitus. Mode of
inheritance is uncertain. Simple Mendelian genetics are
unlikely and polygenic inheritance has been proposed.
Giant Granulation in Granulocytes and

Monocytes
Chediak-Higashi Syndrome
An unidentified membrane abnormality results in
fusion of azurophil and specific granules to form giant
granules. These are positive for MPO, SBB AchPh and
CAE (constituents of azurophil granules) and contain

lactoferrin (specific granules). Normal specific granules
are sparse and azurophil granules absent. Defects in
chemotaxis, mobilization and degranulation are attributed
to mechanical impediment imposed by granule size. These
defects, together with neutropenia and deficient natural
killer cell activity, contribute to susceptibility to infection.
Neutrophil precursors (marrow) contain large, MPO
positive, pink to purple staining inclusions, often within
vacuoles. Neutropenia and increase in serum muramidase
are attributed to intramedullary destruction of precursor
cells. Eosinophil precursors may contain giant, densely
staining azurophil granules.
A minority of platelets may contain large granules.
Bleeding is due to deficiency of dense bodies and, in the
accelerated phase, thrombocytopenia.
The main clinical features are partial oculocutaneous
albinism, cranial and peripheral neuropathy (muscle
weakness, ataxia, sensory loss, nystagmus), infection
(especially S. aureus) and bleeding. In the accelerated
phase (usually preterminal, first or second decade),
organ enlargement and pancytopenia are due to
lymphohistiocytic proliferation and hemophagocytosis.
Autosomal recessive. Heterozygotes may show giant
granulation in occasional leukocytes, but this is an
unreliable test for the carrier state.
Pseudo-Chediak-Higashi Granulation
Giant granulation in granulocytes, but not lymphocytes,
may occur in myeloid leukemias. Abnormal granules are
formed by fusion of azurophil granules and may contain
Auer-like microcrystals, which differ from true Auer rods
in periodicity of ultrastructure.
Gray-staining Bodies
Amorphous, rounded, gray-staining bodies have been
noted in:
Granulocytes of the three types, monocytes and mast
cells in an infant with livedo reticularis of the skin and
extrahepatic biliary atresia. Leukocyte morphology
in both parents was normal. Inclusions negative by
routine cytochemical procedures. The anomaly is not
a result of the biliary atresia.
Eosinophils and basophils only, as a dominantly inheri
ted, apparently asymptomatic anomaly. Inclusions
absent from other hemopoietic cells, including mast
cells; mildly positive with some cytochemical procedures
(e.g. PAS), distinctive in ultrastructure. (Charcot-Leyden
crystals, which may also occur in eosinophils, are not
latticed).

Granulocytes (all types), monocytes, lymphocytes
and plasma cells, from birth in an infant with hepato
spleno
megaly, spherocytic hemolysis, thrombocy
topenia, neutropenia and infections. These features
disappeared and the child is apparently well at the age
of 2 years. Inclusions negative with routine cytochemis
tries. Electron microscopy showed ribosomal type
composition without identifiable organelles.
In a (possibly) similar case, inclusions identified
as collections of actin microfilaments occurred in
all hemopoietic cells, but mainly granulocytes in a
13-month-old boy with transfusion-dependent ane
mia, splenomegaly, gray skin discoloration and inter
mittent neutropenia and thrombocytopenia. Clinical
abnormalities resolved spontaneously at about 18
months but inclusions have persisted.
intermediate degree of pelgerization in one parent

available for study
iii. A syndrome of leukopenia and infections, probably
X-linked.
The homozygous state appears to be usually lethal
in utero. Pelgerization is conspicuous in inherited
neutrophil specific granule deficiency.
Excessive Tags
Neutrophils and/or monocytes may contain hemosiderin

(brown-yellow staining, often refractile, and bilirubin
(yellow-green to green black).
Short projections, with head as wide as or slightly wider

than the attachment stalk, to be distinguished from
drumsticks (larger mass of dense chromatin, attached by
short filament) and clubs (larger than drumstick, longer
filament). The chromatin may be coarse and lumpy and
separation of lobes indistinct.
Occurrence of 2 or more tags in > 15% of neutrophils
is characteristic of trisomy 13, whether isolated or as part
of triploidy. Hereditary persistence of nuclear appendages
is descried as an autosomal dominant, asymptomatic
defect, but its status as a genuine, independent anomaly is
uncertain.
GRANULOCYTES: NUCLEAR ANOMALIES

(TABLE 20)
Hypersegmentation of Neutrophil Nuclei

(Table 21)
Pelger-Huet Anomaly
The normal mean lobe count, after the neonatal period

is 2.8 (2.53.1). Only the last 2 in Table 21 are considered
here. Others are discussed elsewhere.
Hereditary constitutional hypersegmentationmean
lobe count approximately 4 but cells normal in size.
Asymptomatic, autosomal dominant.
Hereditary giant neutrophils (macropolysytes)5-15%
of neutrophils abnormally large, with 6-10 lobes (prob
ably tetraploid. Normally up to 2 cells per 1000, slight
ly more in a variety of illnesses, including cytotoxic
exposure. Asymptomatic, autosomal dominant, but
only the heterozygous state is known.
Other Inclusions
Pelgerization is most commonly acquired, occurring

especially in myeloid leukemias, myelodysplasias,
bilineage ALL, toxic states and colchicine poisoning.
The inherited anomaly may be heterozygous or
homozygous and affect all or only some (5-20%) cells.
In the common, heterozygous state, neutrophil nuclei
have rod, dumb-bell, peanut or pince-nez shapes, and
eosinophil nuclei > 2 lobes; abnormality is not readily
recognizable in basophils. In the rare homozygote,
most cells have rounded nuclei.
Inheritance is autosomal dominant, with some rare
exceptions (following). The common, heterozygous state is
not convincingly linked to any clinical illness. Associations
have however been suggested with:
i. Muscular dystrophy
ii. A syndrome of episodic fever and abdominal pain
(thought to be autosomal recessive because of an
Table 20 Abnormalities of granulocyte nuclei

Pelger-Huet and like anomalies
Excessive tags
Hypersegmentation of neutrophil nuclei
Hypersegmentation of eosinophil nuclei
Chromomeres
Toxic states
Table 21 Hypersegmentation of neutrophil nuclei

Toxic states
Megaloblastosis1
Triploidy
Myelokathexis
Neutropenia and hypogammaglobulinemia with abundant
Abnormal neutrophils in marrow
Lightsey anomaly2
Iron deficiency (uncommon)
Hereditary constitutional hypersegmentation
Hereditary giant neutrophils (macropolycytes)
1
Benign or as a part of myeloid leukemia/myeloidysplasia
2
Neutropenia with gigantism and multinuclearity of marrow
neutrophils
Nuclear Changes in Toxic States

Infection, treatment with cytotoxics
Heat stroke, hyperpyrexia Botryoid nuclei (shrinkage,
pyknosis, clustering of lobes), often with fragmentation
and chromomere formation, may occur in heat stroke
and hyperpyrexia. Changes disappear within 24 hours
after removal from injury.
Colchicine poisoning
Extrusions, chromatin damage and Pelgerization may
be noted.
BIBLIOGRAPHY

1. Dacie JW, Lewis SM. Practical hematology, 7th edn.

Churchill Livingstone, Edinburgh. 1991.
2. Dale DC, Hammond WP. Cyclic neutropenia: a clinical
review. Blood reviews. 1988;2:178-85.
3. Harmon DC, Weitzman SA, Stossel TP. The severity of
immune neutropenia correlates with the maturational
specificity of antineutrophil antibodies. British Journal of
Haematology. 1984;58:209-15.
4. Kozlowski C, Evans DIK. Neutropenia associated with
X-linked agammaglobulinaemia. Journal of Clinical
Pathology. 1991;44:388-90.
5. Lyall EGH, Lucas GF, Eden OB. Autoimmune neutropenia

of infancy. Journal of Clinical Pathology. 1992;45:431-4.
6. McClain K, Estrov Z, Chen H, Mahoney DH. Chronic neu
tropenia of childhood: frequent association with parvovi
rus infection and correlations with bone marrow culture
studies. British Journal of Haematology. 1993;85: 57-62.
7. Minchinton RM, McGrath KM. Alloimmune neonatal
neutropeniaa neglected diagnosis? Medical Journal of
Australia. 1987;147:139-41.
8. Pui CH, Williams J, Wang W. Evans syndrome in childhood.
Journal of Pediatrics. 1980;97:754-8.
9. Rodwell RL, Leslie AL, Tudehope DI. Early diagnosis
of neonatal sepsis using a hematologic scoring system.
Journal of Pediatrics. 1988;112:761-7.
10. Schooley RT, Dolin R. Epstein-Barr virus (infectious
mononucleosis). In: Mandell GL, Douglas RG, Bennett JE
(Eds) Principles and practice of infectious diseases, 3rd
edn. Churchill Livingstone, New York. 1990.
11. Shastri KA, Logue GL. Autoimmune neutropenia. Blood.
1993;81:1984-95.
12. Stroncek DF. Drug-induced immune neutropenia.
Transfusion Medicine Reviews. 1993;7:268-74.
13. Young GAR, Vincent PC. Drug-induced agranulocytosis.
Clinics in Haematology. 1980;9:485-504.
14. Zipursky A, Palko J, Milner R, Akenzua GI. The haematology
of bacterial infections in premature infants. Pediatrics.
1976;57:839-53.
Bleeding Disorders
CHAPTERS OUTLINE
27. Approach to a Bleeding Child

28. Diagnosis and Management of Hemophilia Patients

Farah Jijina
29. von Willebrand Disease and Other Rare Coagulation Disorders

30. Acquired Inhibitors of Coagulation

31. Immune Thrombocytopenic PurpuraDiagnosis and Management

32. Platelet Function Disorders

Shanaz Khodaiji
33. Pediatric Thrombosis

Rashmi Dalvi
34. Disseminated Intravascular Coagulation in Neonates

VP Choudhary
27
Approach to a Bleeding Child
Hemostasis is maintained by many processes in the

circulating blood and the blood vessels designed to stop
hemorrhage. These functions are delicately balanced
so that we will neither clot nor bleed to death. Clotting
reactions are initiated in response to injury to vessels and
leads to formation of a fibrin platelet plug that stops the
blood loss but ultimately results in elimination of the clot,
repair of any damage to the vessels and normal blood flow
through the affected site.
Hemostasis involves a complex interplay between the
vessel wall, platelets, and coagulation factors.
The main three components of hemostasis are:
1. Vascular and extra vascular factors
2. Platelets
3. Plasma factorscoagulation factors, fibrinolytic factors,
natural inhibitors of coagulation and fibrinolysis.
Successful management of an acute bleeding episode in
a child depends on:
Detailed history and clinical examination leading to
appropriate diagnostic tests.
Ordering an array of available diagnostic tests without
a clinical diagnosis is neither economically viable nor
therapeutically ideal.
Prompt implementation of therapeutic measures.
HISTORY

Significance of bleeding
Nature and site of bleeding
Local vs generalized causes
Acquired or hereditary disorder
Vascular, platelet or factor deficiency
Is it due to a local cause?
Local Versus Systemic

Local cause should be suspected when:
Bleeding even if recurrent from the same site, e.g.
recurrent epistaxis from one nostril may be due to
excoriation of a superficial vessel in the Kisselbach
triangle.
Nose picking, polyps, foreign bodies (Fig. 1A) or rarely
vascular anomalies may cause frequent nose bleeds.
Profuse prolonged, bilateral nose bleeds that occur
spontaneously without any trauma and are difficult
to stop are suggestive of a coagulation defect. Rarely
an angiofibroma or Rendu-Osler-Weber (Hereditary
hemorrhagic telangiectasia) may cause profuse epis
taxis (Figs 1A and B).
Generalized petechiae, purpura, bruising, hematuria
especially if associated with past history of bleeding
from dental extractions or circumcision should arise
suspicion of a bleeding disorder.
IS THE DEFECT INHERITED OR ACQUIRED?

Inherited Disorders
Inherited disorders usually present in infancy and
early childhood.
Family history of bleeding disorder.
Inherited disorers in milder forms may not be seen in
early infancy and may present later in life with bleeding
following injury or during surgerymild hemophilia,
von Willebrand disease.
The development of bleeding later in childhood usually
indicates an acquired disorder.
276Section-4Bleeding Disorders
liver dependent factors. Medication can also exacerbate
bleeding in those with existing coagulation defectsuse
of aspirin in patient with hemophilia or low platelets.
INDICATIONS FOR EVALUATION
Figs 1A and B (A) Persistent recurrent bleeding from left nostril

due to foreign body; (B) Bleeding from both nostrils and over the
skin (DIC) (Courtesy: MR Lokeshwar)
Acquired Disorders
Usually present later in life. Immune thrombocyto
penic purpura (ITP) may however present during early
childhood, i.e. 3 to 5 years of age.
Have a negative family history.
Underlying medical disorder that may affect hemo
stasis.
Hepatic disorders, malabsorption syndrome, may
be associated with vit. K dependent coagulation
factors.
Renal disease: Uremia can interfere with platelet
function.
Low-molecular-weight coagulation proteins (factors
IX and XI) are lost through the kidney in children
with nephrotic syndrome.
Cyanotic congenital heart disease with polycy
themia may have thrombocytopenia and hypofibri
nogenemia with risk of bleeding and or thrombosis.
Infections: Meningococcemia with DIC
A detailed menstrual history should be obtained when
applicable. The prevalence of bleeding disorders
in women with menorrhagia is as high 20 percent
conversely; menorrhagia is a common initial symptom
in women with VWD and has been reported to occur
more than 90 percent of patients.
Past surgical procedures, serious injuries, fractures
and tooth extractions without any abnormal bleeding
is good evidence against the presence of a congenital
hemorrhagic disorder.
Medications: Aspirin and other nonsteroidal antiinflammatory agents affect platelet aggregation. Pro
longed use of antibiotics can lead to decreased levels of
vitamin K deficiency leading to decreased production of
Investigations for bleeding disorders are done when there is:

Recent bout of bleedingunusual, spontaneous, pro
longed, or delayed bleeding. Postsurgical and trau
matic bleeding that is unexpected, prolonged or
disproportionate to extent of injury.
Family history of bleeding
Abnormal coagulation test results obtained as a part
of preoperative evaluationpreparation for surgery or
invasive procedures
Systemic diseases known to be associated with bleed
ing disorders, e.g. liver disorder, renal disorder, DIC
and sepsis, etc.
Is the Bleeding due to Vascular, Platelet or a

Coagulation Abnormality or a Combination of
these?
Vascular disorder, thrombocytopenia or functional platelet
disorders:
Usually in the form of subcutaneous and mucus
membrane bleeds like petechiae, purpura (Fig. 2C),
ecchymoses, epistaxis and subconjunctival hemorrhage
(Fig. 2B)
Mucous membrane bleeding and menorrhagia can
occur in von Willebrand disease also.
Factor deficiency:
Hematomas (Fig. 3): Intramuscular, soft tissue bleeding
Hemarthrosis, retroperitoneal bleeds
Post-traumatic bleeds are often delayed, some times
hours after the injury.
Mucous membrane bleeding (epistaxis, excessive
menorrhagia, bleeding from gums) is often the conse
quence of a problem with primary hemostasis. Namely a
platelet disorder or von Willebrand disease (VWD).
Hereditary hemorrhagic telangiectasia may also be
manifested as mucosal bleeding
Umbilical stump bleeding is typically seen with factor
XIII deficiency, but it may also occur with deficiencies
of prothrombin, factor X, and fibrinogen
The immediate history often provides useful clues
to diagnosis. A sick child with fever, shock, mucocu
taneous purpura frequently has intravascular coagu
lation (DIC) (Fig. 6) associated with bacterial infection.
Family History of Bleeding

History of unusual bleeding in family members is present
in hemophilia, von Willebrand and platelet function
Chapter-27 Approach to a Bleeding Child 277
Figs 2A to C (A) Bleeding in the knee joint; (B) Subconjunctival hemorrhage; (C) Purpura (Courtesy: MR Lokeshwar)
Proper pedigree chart, covering at least 2 to 3 genera

tions also should take note of members who have expired,
especially due to bleeding.
X-linked Recessive Pattern
Fig. 3 Cephalhematoma in bleeding disorder

(Courtesy: MR Lokeshwar)
Maternal brothers, cousins, uncles and maternal grand

father may be affected with X-linked transmission while
the females remain asymptomatic carriers.
Bleeding disorders which have a sex-linked recessive
inheritance are:
Hemophilia A (factor VIII deficiency)
Hemophilia B (factor IX deficiency)
Wiscott-Aldrichs syndrome.
Autosomal recessive disorders: In autosomal recessive
disorders, the parents of affected person are heterozygote
and hence have a 50 percent plasma concentration of the
relevant clotting factors. History of consanguinity should
be asked for. This genetic pattern is typical of disorders
of factor II, V, VII, X, XI, XII, XIII, prekallikrein and high
molecular weight kininogens.
However, lack of plasma factor XII, prekallikrein or
high molecular weight kininogens do not usually cause
any clinically significant bleeding.
Autosomal Dominant Pattern of Inheritance

Fig. 4 Hemorrhagic disease of newborn
disorders. Approximately a third of infants and young

children with newly diagnosed hemophilia have a negative
family history.
Von Willebrand disease

Qualitative platelet defects
Dysfibrinogenemia
Hereditary hemorrhagic telangiectasia.
This type of inheritance may show a variable pene
trance and expressivity. Many members in different gene
rations of the family may be affected.
Figs 5A to C (A and B) Bleeding in the joints in hemophilia; (C) Glanzmanns thrombasthenia (Courtesy: MR Lokeshwar)
A well-looking child covered with petechiae often has

immune thrombocytopenia (Figs 2C and 9)
Hematuria with bruising localized to the gluteal region,
ankles, and feetHenoch-Schnlein purpura (Figs
10A and B).
ASSOCIATED UNDERLYING DISORDERS
Fig. 6 Intravascular coagulation (DIC) (Courtesy: MR Lokeshwar)
Negative family history does not rule out the possibility

of inherited bleeding disorders.
Family history might be negative, if the coagulation
defect is mild.
Spontaneous mutation, as is seen in 20 percent of
patients with hemophilia A
Exsanguinating bleeding is uncommon due to bleeding
disorders and is more likely to be due to injury to major
vessels.
History and physical examination can often help
you make a specific diagnosis and point one to the right
diagnostic tests.
A male toddler who has just started crawling exhibits
extensive bruising and or joint bleedingdiagnosis
hemophilia A or B (Figs 2A, 5A and B)
A girl who has had severe menorrhagia with frequent
nose bleedspossible VWD
Certain characteristic hemostatic defects are associated

with specific clinical conditions.
Liver diseases with factor II, VII, IX and X deficiency and
fibrinolysis due to decreased clearance of activators
and hypercoagulable state because of antithrombin III
and protein C deficiency.
Malabsorption states may be associated with multiple
factor deficiencies, i.e. Vitamin K dependent factors.
Acute promyelocytic leukemia is known to be associ
ated with DIC due to increased cellular procoagulant
activities.
Myeloproliferative disorder may have platelet defects,
thrombocytopenia and thrombocythemia.
Amyloidosis may be associated with factor X deficiency
and capillary fragility.
Systemic lupus erythematosisantibody to acidic
phospholipase, autoantibodies to coagulation proteins
and glycoproteins may be present, resulting in lupus
inhibitors, factor deficiency, thrombocytopenia and
thrombocytopathy.
CERTAIN SYNDROMES KNOWN TO BE

ASSOCIATED WITH BLEEDING DISORDERS
Hereditary hemorrhagic telangiectasia is associated
with characteristic telangiectatic lesions in the
mucus membrane and skin and may manifest with
Fig. 7 von Willebrand disease (Courtesy: MR Lokeshwar)
Figs 10A and B Henoch-Schnlein purpura

Fig. 8 Qualitative platelet defects (Glanzmanns thrombasthenia)

Fig. 9 Immune thrombocytopenic purpura
epistaxis, melena and bleeding per rectum. Presence

of telangiectasia in the mucous membrane of nose,
bulbar conjunctiva, tongue, lips and tips of fingers is
the hallmark of diagnosis.
Keloids may be seen in children with afibrinogenemia
and factor XIII deficiency.
Cigarette paper scar, hyperextensible joints suggest
Ehler-Danlos syndrome.
Presence of syndactyly with history of bleeding episode
is known to be due to factor V deficiency.
Wiskott-Aldrich syndrome (Fig. 11A) is associated with
thrombo
cytopenia, recurrent infection, otitis media,
and eczema.
Children with albinism may have qualitative functional
defects of platelets.
Thrombocytopenia with absent radius (TAR syndrome)
is easy to diagnose because of skeletal anomaly.
Kasabach-Merritt syndrome is characterized by giant
hemangioma associated with evidence of clinical
and subclinical DIC and thrombocytopenia (Figs 11B
and C).
Figs 11A to C (A) Wiskott-Aldrich syndrome; (B and C) Kasabach-Merritt syndrome (Courtesy: MR Lokeshwar)
Hemarthrosis (spontaneous), bleeding in the muscles

without significant trauma points towards inherited
coagulation disorders.
LABORATORY ASSESSMENT (TABLE 1)

Sample Collection and Technique
A properly drawn blood sample is crucial for
interpretation of the results of coagulation test.
For coagulation assays blood should be obtained by
clean venipuncture without air bubbles and without
contamination by tissue fluids
Drawing of samples from catheter often results in
sample contamination or intravenous fluids and
spuriously abnormal values
Improper sample collection is one of the most common
reasons for abnormal coagulation test
Samples should be tested within 2 hours of collection
if maintained at room temperature or within 4 hours if
kept cold
Plasma samples must be frozen if not tested within
this time frame. When they are to be analyzed, frozen
samples should be rapidly thawed at 37C and tested
immediately
A panel of screening tests should be ordered, including
a complete blood count with evaluation of platelet
number, morphology-smear examination, PT, APTT,
PFA (Platelet function analysis).
Though a thorough history and clinical evaluation
helps in suspecting the nature and type of bleeding
disorder, laboratory investigations are required to make a
specific diagnosis, they can be conveniently divided into
screening tests and special tests.
Table 1 Screening laboratory tests in hemostatic disorders

Platelet
BT
PT
APTT
Interpretation
Normal Normal Thrombocytopenia
DIC
Normal
Type 2A vWD
Normal
Normal
vWD
Platelet
Normal
Normal Normal
Dysfunction
Normal
Normal
Normal Factor VII deficiency
Normal
Normal Normal
XII, XI, IX, VIII
Liver disease, Vit K
Normal
Normal
def, Combined def
Normal
Normal Normal Normal XIII def, vascular
Screening tests are done after evaluating the nature

and clinical circumstances of bleeding and prior to
surgery if indicated
Specific tests need to be done to confirm the diagnosis
after the history, physical examination and screening
test point to a possible diagnosis.
Screening Tests
These are the tests for the initial assessment for bleeding
tendency and include:
CBC and PS examination
Platelet count
Bleeding time/PFA
Clot retraction
Prothrombin time/INR
APTT.
CBC can reveal involvement of other cell lines in cases
suspected to have leukemia, aplastic anemia, etc.
Proper Smear Examination also helps in Evaluating

Extent of Thrombocytopenia if Present
Presence of clumps of platelets rules out platelet
deficiency and absence of platelets indicates severe
thrombocytopenia usually less than 10,00020,000/
cumm
Presence of platelets but not in clumpsindicates
absence of aggregation, suggesting platelet functional
disorder
Large platelets simulating size of the lymphocytes
suggest possibility of Bernard-Soulier syndrome
Large platelets also indicate younger platelets as seen
in regenerative type of thrombocytopenia where there
is peripheral destruction of platelets
Large platelets are also seen in the hereditary giant
platelet syndromes
Small platelets are characteristic Wiskott-Aldrich
syndrome.
Platelet Count
It is a simple first step in evaluating the cellular aspect
of hemostasis
However, manual count is not reliable and not
reproducible and hence platelet count should be
done on particle cell counter or using phase contrast
microscope
A spuriously low automated platelet count (pseudo
thrombocytopenia) may result from ethylene diamine
tetra acetic acid (EDTA) anticoagulant plus an IgG or
1gM platelet antibody, platelet cold agglutinins, or
platelet clumping from a partially clotted sample. The
normal platelet count (for all ages) ranges from 150,000
to 450,000/uL
In the setting of thrombocytopenia increased or
decreased platelet size may suggest platelet turnover
or decreased production, respectively
If platelet type of bleeding (petechiae, purpura,
mucosal bleeding) is seen with normal platelet count or
marginally low platelet count, then platelet functional
disorders should be kept in mind.
Electronic particle counters also provide a mean
platelet volume and (size) distribution.
Bleeding Time
The bleeding time (BT) is a measure of the interaction
of platelets with the blood vessel wall. This test evaluates
primary hemostatic stage. It has major drawbacks and has
been discarded in children by most hematologists.
The BT is an approximate measure of the relationship
between platelet number and function.
The most widely used method is the modified ivy BT

performed with a template. The BT is performed with a
tourniquet maintained at 40 mm Hg and placement of the
template device on an area of the forearm (Just below the
elbow), blade makes a linear cut 1 to 2 mm deep.
With a stop watch and filter paper, the blood coming
from the cut is gently blotted away while taking care to not
touch the filter paper to the cut (which would remove the
fragile platelet plug). A normal BT is 3 to 9 minutes with
normally functioning platelets. The BT is an approximate
measure of the relationship between platelet number and
function.
Prolongation of bleeding time usually occurs at platelet
count of < 50,000/cumm to 100,000/uL. At counts below
10,000/cumm, bleeding time is usually prolonged and is
often 15 minutes or longer and hence BT should not be
performed when platelets are low.
The BT can also be prolonged with congenital and
acquired platelet defects.
Prolonged Bleeding Time with Nearly

Normal Platelet Count
Qualitative Platelet Disorders (Table 2)

Glanzmanns thrombasthenia (Figs 5C and 8)

Bernard-Soulier syndrome
Storage pool disorder
Wiskott-Aldrich syndrome
Acquired defects, uremia and cyanotic congenital
heart disease
Vasculitis (e.g. Henoch-Schnlein purpura)
Connective tissue disorders such as Ehlers-Danlos
syndrome
Drugs like aspirin and nonsteroidal anti-inflammatory
agents
Von Willebrand disease (Fig. 7).
Bleeding time has been replaced by the platelet
function analyzer (PFA) which is a rapid and automated
form of platelet function assessment.
Clot retraction: This is not any more a commonly
ordered test as a screening or diagnostic test any more.
Retraction and exudation of the serum after one hour
is observed in the clotting tube. Normally, 50 percent
exudation at the end of one hour of the original blood
volume is taken as normal retraction.
Prothrombin Time
Normal (reference) range varies depending on the labora
tory (its instrumentation and the lot of thromboplastin),
but it is generally 10 to 11 seconds.
PT measures extrinsic clotting system and the common
pathway, the activities of factors I (fibrinogen), II
Table 2 Platelet aggregation response
Condition
Platelet
Count
Size
ADP
Col
Ri
AA
A23187
IIb/IIa
expression
Low
Large
Gp1b expression
1/0
ATP: ADP pools
1/N
Responds to
endoperoxide
1/N
R/0
R/0
N/R
0/R
Thrombasthenia N
Bernard-Soulier
syndrome
Storage pool
defect (d)
Cyclooxygenase
deficiency
Thromboxane
synthetase
deficiency
Aspirin
ingestion NSAID
and retest
Ehlers-Danlos
syndrome
von Willebrand
disease
Comment/
Further tests
Aggregation with
(prothrombin), V, VII, and X. PT is prolonged with

deficiencies of plasma factor VII, X, V, II and fibrinogen
and inhibitors of these factors
Prolongation of the PT beyond the reference range is
not generally seen until the functional level of one of
these factors is less than 30 percent or until fibrinogen
is less than 100 mg/dL
A prolongation of PT with normal PTT indicates factor
VII deficiency OR early in the course of anticoagulant
therapy, Vitamin K deficiency (Fig. 4) or liver diseases
The PT is also used to monitor the effect of coumarintype anticoagulants.
Activated Partial Thromboplastin Time

Activated partial thromboplastin time (APTT) is an
excellent screening test for determining abnormality of
intrinsic and common pathway.
It should be noted that the sensitivity and repro
ducibility of the APTT are highly dependent on the
specific reagents used (particularly the activator in the
partial thromboplastin reagent)
With most APTT reagents, the APTT will not he
prolonged until the amount of factor VIII is less than
35 percent (0.35 U/mL).
The reference range will generally be approximately
20 to 35 seconds for children and adults but longer (30
Stop aspirin
Assay vWF:Ag
and RiCoF
to 54 seconds) in term infants (and often even longer in

premature infants).
The APTT measures factors I (fibrinogen), II (pro
thrombin), V, VIII, IX, X, XI, and XII; prekallikrein; and
high-molecular-weight kininogen.
Activated Partial Thromboplastin Time is

Prolonged
During deficiency or abnormalities of high molecular
weight kininogen, prekallikren, factor XII and XI, IX,
VIII, X, V, II and fibrinogen
By inhibitors of blood coagulation such as lupus inhib
itors, heparin, fibrin/fibrinogen degradation product
Deficiency of any of the latter three factors (prekal
likrein; and high-molecular-weight kininogen) can
result in a markedly prolonged APTT in the absence of
clinically significant bleeding
Isolated prolongation of the APTT in a patient with
clinical bleeding is likely to result from a deficiency of
factor VIII, IX, or XI.
Mixing study in prolonged PTT: The presumption
is that addition of normal plasma to a 50 percent mix
should correct the PTT if it is due to factor deficiency.
Among hospitalized infants or children, unintentional
contamination of patient samples with heparin is a
common cause of an unexpected prolongation of the APTT

that does not correct on mixing. Failure to correct after
a mix of 50 percent of normal plasma is indicative of the
presence of inhibitors or antibody that indiscriminately
(not specific against any factor) suppresses fibrin formation
in patients and normal plasma. Lupus anticoagulant (a
misnomer as it is not necessarily associated with SLE) is a
very common cause of isolated prolonged PTT in children
with adenotonsillar hypertrophy and infections.
Thrombin Clotting Time

The thrombin clotting time (TCT or TT) measures the
thrombin-induced conversion of fibrinogen to fibrin and
is performed by adding bovine thrombin to the patients
citrated plasma and recording the clotting time.
An extremely prolonged TT usually indicates a heparin
effect. Reptilase, a snake venom protease, clots fibrinogen
in the presence of heparin and thus can be used to
identify heparin as the cause of a prolonged TT. Thus, in
the presence of heparin the TT is prolonged, whereas the
reptilase time is normal.
Thrombin Clotting Time is Abnormal in Patients

with
Hypofibrinogenemia whether acquired or congenital or
Dysfibrinogenemia
In presence of inhibitors like heparin, myeloma
proteins and fibrin degradation products which block
either thrombin cleavage of fibrinopeptide or fibrin
monomer polymerization.
A normal or minimally low platelet count with
prolonged BT or abnormal PFA and poor clot retraction
indicates the possibility of platelet functional disorders
Platelet aggregation studies: Low and high concen
tration of ADP, epinephrine, collagen and Ristocetin
are used for aggregation studies. First phase of aggre
gation is induced by low concentration of ADP and by
direct effect of certain agents notably epinephrine and
thrombin. Second phase is mediated by thromboxane A2
and endogenous ADP released in response to numerous
pharmacological and naturally occur
ring substance
like ADP itself. Absence of first phase of aggregation
unresponsiveness to ADP in any concentration is
characteristic of Glanzmanns disease. Deficiency of
platelet fibrinogen and specific glycoproteins GP-II
and GP-III confirm the diagnosis
von Willebrand disease has characteristic lack of
aggregation with ristocetin alone
The classical laboratory findings in Bernard-Souiler
syndrome areprolonged bleeding time, throm
bocytopenia, very large platelets on peripheral smear,
deficient platelet adhesion and normal platelet
aggregation with ADP, epinephrine and collagen but

absence of platelet aggregation with ristocetin but with
normal levels of von Willebrand factor.
In Glanzmanns thrombasthenia, the patients platelets
will agglutinate normally with ristocetin but not at all with
the addition of adenosine diphosphate, epinephrine,
collagen, or arachidonic acid. In Bernard-Soulier synd
rome, platelet agglutination will occur normally on addi
tion of each of these agonists except ristocetin.
Bleeding disorders not associated with any abnor-
malities in screening tests are:
Factor XIII deficiency
Alpha 2 antiplasmin deficiency, amyloidosis (may or
may not be associated with factor X deficiency)
Vascular disorders like hemorrhagic telangiectasia
(Rendu-Osler-Weber syndrome)
Scurvyprolonged BT
Ehlers-Danlos syndromeprolonged BT
Henoch-Schnleins purpuraprolonged BT
Mild factor deficienciesfactor assay
Battered baby syndrome (Figs 12A and B).
Special Confirmatory Tests

Specific coagulation factors: Each of the coagulation
factors of the intrinsic pathway (prekallikrein, highmolecularweight kininogen, and factors VIII, IX, XL, and
XII) can be measured by one stage, APTT based method
FDPs are usually measured in serum samples because
these degradation products consist predominantly of
nonclottable derivatives that remain in solution after clot
The D-dimer assay will identify only cross-linked FDPs
(indicating that fibrin has formed intravascular, has
been cross-linked, and has then been cleaved into
D-dimers by plasmin
Euglobulin clot lysis time.
The euglobulin clot lysis time (ECLT) is a screening
test for excessive fibrinolysis. The normal ECLT is 60 to
300 minutes. It is shortened in conditions characterized
by increased fibrinolysis (e.g. antiplasmin deficiency,
plasminogen activator inhibitor 1 deficiency or systemic
fibrinolysis).
Lupus anticoagulant: Abnormal mixing study followed
by dilute russel vipor venom test (DRVVT) and platelet
neutralization procedure (PNP) and for confirmation.
Solitary thrombocytopenia may be due to either:
Reduced production or increased destruction of the
platelets
Idiopathic thrombocytopenic purpura is characterized
by acute onset of isolated thrombocytopenia in other
wise healthy children. Other cell lines are normal and
the smear reveals normal RBC, white cells with low
number of platelets and occasional macrothrombocytes
Figs 12A and B Battered baby syndromehematoma over the forehead and punch mark over the thigh (Courtesy: Raj Warrier)
Thrombocytopenia due to decreased production may

be either due to involvement of only megakaryocytes
as seen in TAR syndrome or in amegakaryocytic
thrombocytopenic purpura and is characterized by
thrombocytopenia and platelet type of bleeding.
CONCLUSION
Detailed history, thorough clinical examination and
screening tests usually give sufficient information to
decide, whether bleeding is due to local causes or a
generalized bleeding disorder.
Depending upon type and nature of the bleeding
disorder, further tests such as factor assay, aggregation
tests, etc. have to be carried out to confirm the diagnosis
before planning therapy.
BIBLIOGRAPHY

1. Blanchette V, Bolton-Maggs P. Childhood immune

thrombocytopenic purpura: diagnosis and management.
Pediastr Clin N Am. 2008;55:393-420.
2. James AH, Manco-Johnson MJ, Yawn BP, Dietrich JE,
Nichols WL. von Willebrand disease: key points from the
2008 National Heart, Lung, and Blood Institute guidelines.
Obstet Gynecol. 2009;114(3):674-8. Review.
3. Petrini P, Seuser A. Haemophilia care in adolescentscompliance and lifestyle issues. Haemophilia. 2009;15
(Suppl 1):15-9. Review.
4. Rodeghiero F, Kadir RA, Tosetto A, James PD. Relevance
of quantitative assessment of bleeding in haemorrhagic
disorders. Haemophilia. 2008;14(Suppl 3):68-75. Review.
5. Rossbach HC. The rule of four: a systematic approach to
diagnosis of common pediatric hematologic and oncologic
disorders. Fetal Pediatr Pathol. 2005;24(6):277-96. Review.
28
Diagnosis and Management
of Hemophilia Patients
Farah Jijina
Hemophilia is an X-linked hereditary bleeding disorder. Hemophilia A is the most common of these, with an annual incidence of 1/5000
male births worldwide. Hemarthrosis is the most common, most painful, physically, economically, and psychologically debilitating
manifestation of hemophilia. It occurs in 90 percent of severe hemophiliacs. Prompt replacement therapy with the required factor
remains the mainstay of treatment of a bleed.
The dose and choice of the product are influenced by the

severity of the disease, the site and severity of the bleeding,
inhibitor antibody status and the clinical scenario.
However, the adjuvant role of antifibrinolytic agents
and expert physical therapy in the treatment cannot be
undermined in an economically burdened society like ours.
It is possible to carry out any procedure on a hemophilic
patient provided adequate factor is given. Outcome is
directly related to the intensity of treatment and the level of
compliance. Improvements translate into decrease absence
from school or work, fewer bleeds and days spent in the
hospital, increased personal and professional productivity,
improved overall performance status and a healthier self
image. Carrier testing and prenatal diagnosis can be offered
to women who are interested in children bearing.
CLINICAL FEATURES

haracteristically deep/internal bleeding

C
Usually spontaneous or following minimal trauma
Occurs in frequent unpredictable episodes
Delayed bleeding due to failure of secondary hemo
stasis.
Grades of Severity
Severe
Factor levels < 1%
Moderate Factor levels 25%
Bleeds following minor

trauma or after procedures
Mild
Usually do not bleed except

following major trauma or
surgery
Factor levels 640%
INTRODUCTION
The most prevalent of the hereditary disorders of
coagulation are:
Types of hemophilia
Spontaneous bleeds
Diagnosis
When to suspect?
Hemophilia A
Factor VIII deficiency
If any of the following are present:
Hemophilia B
Factor IX deficiency
Recurrent spontaneous bleeds
von Willebrand disease
von Willebrand factor deficiency
Bleeding following trauma out of proportion to the injury
Hemophilia C
Factor XI deficiency
Positive family history
Investigations
To Avoid
A patient who is clinically suspected to have hemophilia

should be subjected to coagulation tests.
In hemophilia, the APTT is prolonged and corrects on
addition of normal pooled plasma. The PT and TT are
characteristically normal.
However, in case of combined deficiencies for example,
combined factor V and VIII deficiency, the PT will also
be prolonged.
Factor assay is then done to confirm the diagnosis and
document the severity of the disease.
One of the problems, we face in our country is the lack
of adequate laboratory facilities at all places to carry
out all the tests. Therefore a clinician suspecting a
bleeding disorder should refer the patient to a center
that specializes in carrying out these investigations to
ensure an early accurate diagnosis. Now, most of the
major cities have these diagnostic facilities.
Once the patient is accurately diagnosed, further
treatment can be given by the local treating physician
with some guidance from a specialist center. The
patient may then be referred to a higher center only
for complicated problems. A wrong diagnosis at the
beginning would result in the patient being given
inappropriate treatment and the development of
complications.
IM injections
All contact sports
Aspirin and other nonsteroidal anti-inflammatory
drugs (NSAIDs); all drugs that affect platelet function.
Treatment of Hemophilia
In the Western world today, it is possible for a child with
hemophilia receiving adequate treatment to live a near
normal life. An accurate diagnosis is quickly established,
the family is educated on the management, and the child is
put appropriate factor therapy. With this type of treatment
most children with hemophilia (apart from the small
number who develop inhibitors) can go to school, enjoy
sports, and expect to have minimal or no joint bleeding.
This is however expensive and not feasible for us. Thus
we need to have our own strategies to treat our patients at
lower costs.
GENERAL PRINCIPLES
Before we discuss the definitive therapy of hemophilia
there are certain general precautions, dos and donts which
the treating physician, the parents of the patient and the
patient himself can follow. All patients and their relatives
need to be educated about the disease, precautions and
preventive strategies for bleeding.
To Do
E
arly factor correction; prompt treatment of a bleed.
This prevents subsequent damage and deformity.

Ice application at the site of bleed.
All procedures to be done under appropriate factor
cover, including dental procedures.
Getting all vaccinations is recommended, including
hepatitis A and B; these need not be given intramuscular
but can be given subcutaneously.
Maintaining a healthy body weight is important to
avoid extra stress on joints. Thus mothers need to be
educated on a proper diet for these children.
Regular supervised physical therapy and exercises
should be taught to children from an early age. This
helps to develop strong muscles and thereby prevent
bleeding into the joints. This is one of the most
important preventive measures that the child and his
parents can do.
Very often the local physicians and dentists are not
aware of the problem or the relatives tend to hide the
problem and the patient comes to us with complications
of an avoidable bleed. Thus, it is important to educate
the parents and the patient.
It is also worthwhile to inform the principal and
teachers of the school, regarding the problems faced
by these children.
This ensures immediate institution of measures to
control the bleed when it occurs.
It should be highlighted to the caretakers that no form
of physical punishment be given to the child. We have
had many children coming to us with muscle bleeds
following physical punishment in school. This is highly
unfortunate and all efforts should be made to prevent it.
Definitive Treatment
Prompt replacement therapy with the required factor
remains the mainstay of treatment of a bleed.
The dose of factor replacement (in units) is calculated
as follows:
Hemophilia A:
Each unit of factor VIII infused/kg body weight is
assumed to yield a 2 percent rise in plasma factor
VIII complains of fever since 1 day back levels.
Chapter-28 Diagnosis and Management of Hemophilia Patients 287

Units of factor VIII to be given = (Desired level
patients level) weight in kg/2. This dose is given
stat and is followed by half the dose at 12 hourly
intervals as required, as the biological half life of
factor VIII is 8 to 12 hours
In case cryoprecipitate is used, the number of bags
to be given is calculated according to the amount
of factor VIII in each bag of cryoprecipitate. This
information is available with the respective blood
bank.
Hemophilia B:
Each unit of factor IX infused/kg body weight, is
assumed to yield a 1 percent rise in plasma factor
IX levels
Units of factor IX to be given = (Desired level
patients level) weight in kg
This dose is given stat and is followed by half the
dose at 24 hours intervals as required, as the
biological half life of factor IX is 18 to 24 hours.
HEMOPHILIC ARTHROPATHY
Hemarthrosis is the most common, most painful and most
physically, economically and psychologically debilitating
manifestation of hemophilia, occurring in 90 percent of
severely affected patients.
In fact most of the physical, psychosocial and financial
problems in a severe hemophilia patient are caused by the
effects of recurrent hemarthrosis and chronic arthritis.
This hemorrhage may occur spontaneously or as a result
of trauma.
Pathophysiology
There is a complex relationship between recurrent
bleeding, synovitis and the development of arthritis in a
patient with hemophilia.
Bleeding into the joint originates from the richly
vascular synovial plexus, developing spontaneously or
as a result of imperceptible/trivial trauma. Following the
development of the hemarthrosis, the synovial space is
distended with blood; the joint becomes swollen, hot, tense
leading to muscular spasm and restriction of movement.
This hemorrhage will ignite an inflammatory response with
the release of kinins and macrophage interleukin-1 (IL-1).
Absorbance of the intra-articular blood is usually
incomplete, as the synoviocytes can absorb only a limited
amount of iron and their capacity is reached easily. The
excess clot formed is, therefore, unlikely to be totally removed
by the fibrinolytic system and organization of the remaining
clot leads to development of fibrous adhesions. The retained
blood produces a chronic inflammation and hyperemia of
the synovial membrane and the joint may remain swollen,
painful and tender even in the absence of bleeding.
Acute hemarthrosis invariably recurs from time to

time. The first episodes are generally relatively mild and
the joint may regain normal function. However, with
each recurrence, the synovium becomes invariably more
thickened and vascular. Synovial folds and frond like villi
form, which become trapped and crushed by joint action,
leading to further bleeding and synovial enlargement.
There is a simultaneous weakening of the periarticular
supporting structures which leads to joint instability and
further predisposes the joint to recurrent bleeding.
Thus a vicious cycle of bleedingsynovitisbleeding
sets in, because of the profusion and fragility of the vessels
within the tissue.
Ultimately, there is a gradual conversion of the
synovium from friable hyperemic tissue to fibrotic scar
tissue.
This is followed by subchondral and synovial ischemia
which results in progressive loss of hyaline cartilage. As
the joint cartilage progressively degrades, deterioration
of joint function occurs leading to limited and painful
movements.
Finally, the stage of chronic hemophilic arthropathy
is reached. The cartilage becomes pitted and destroyed.
There is loss of joint space; bony necrosis and cyst formation
may occur. This may lead to complete destruction of the
joint with fibrous or bony ankylosis.
Over a period of time, osteoporosis may develop as a
result of disuse and immobilization of the joint.
Clinical Features
Hemarthrosis occurs in 90 percent of patients with
severe hemophilia. Though any joint may be affected,
weight bearing joints are more prone to bleed. The knee
joint is the most commonly involved and the most often
permanently crippled.
The joints affected in order of frequency are knee >
elbow > ankle > shoulder > wrist > hip. The spine is rarely
involved.
The first episode of hemarthrosis usually occurs when
the child begins to walk or crawl. There is often a target
joint, one which is more prone to repetitive bleeding. The
onset of bleed is often heralded by an aura, which may
be a feeling of vague warmth/tingling sensation/a sense of
mild restlessness/or anxiety.
A hemophilic patient may present in various ways:
Acute Bleed in a Relatively Normal Joint

The earliest definitive symptom is excruciating pain in
the affected joint. It is swollen, warm and tender, with
restriction of movement and muscle spasm.
Subacute or Chronic Synovitis

In these patients, in spite of no active bleed, the joint
appears swollen, tender and inflamed with a boggy
synovium and some restrictions of movement (Figs 1A
and B).
Chronic Hemophilic Arthropathy

If untreated, symptoms of chronic arthropathy typically
develop by the second or third decade. In chronically
damaged joints due to the thickening of the articular
capsule, external evidence of bleeding may not show.
These patients may present with pain in the joint due to:
The degenerative arthritis
Referred pain due to bleeding in adjoining structures
Actual bleeding in the joint, which may not be apparent
clinically
It is also important to keep in mind that HIV positive
hemophiliacs are prone to develop septic arthritis, the
features of which may mimic an acute bleed.
Practical Approach to Management of

Hemophilia Patients in India
Optimal treatment of acute hemarthrosis involves:
Factor replacement
Relief of pain
Rest
Supervised rehabilitation
Factor replacement: Early factor replacement is the main

stay of treatment
Prompt replacement.
Prompt Replacement
It reduces duration of bleed
It reduces joint damage, absenteeism
It reduces overall amount of factor required and cost.
Doses: 25 to 30 percent correction, with factor VIII is
given IV, 12 hourly. Though these are standard textbook
recommended doses, one can generally use less. Often
10 u/kg can be given, and repeated if required.
The duration is decided on the basis of the patients
symptoms. Once the pain subsides and there is no increase
in the swelling, further factor need not be given. Thus most
patients may require 1 to 3 doses only. It is important to
note that the swelling itself may take a while to subside
and in situations where there is a shortage of factor and
finances are tight, one need not continue with the factor.
Home Therapy Programs

Wherever possible it is advantageous for the patient or a
family member to be taught to administer the factor.
Advantages
Improved preservation of joint function, as no time is
wasted in getting the factor
Figs 1A and B Severe hemophilia showing chronic synovitis of the knee joint

Decreased hospital care and cost

Decreased absenteeism from school and work
Patient is more active, mobile and independent
Self-reliance improves the patients confidence and
family interaction.
However, energetic physiotherapy should be done only

in conjunction with small doses of factor replacement
Orthopedic devicessplints/braces/traction/corrective
footwearmay be used as per the patients needs (Figs 2
to 4).
Relief of Pain
Prophylactic Therapy
Analgesics
Ice application
All patients should be given analgesics to relieve
the pain. The drugs which can be safely used in these
patients are dextropropoxyphene (proxyvon), paraceta
mol (crocin), opiods and Cox 2 inhibitors. Nonsteroidal
anti-inflammatory drugs (NSAIDs) which affect platelet
function should be avoided.
We usually recommend that the patient applies
crushed ice or an icepack to the joint, over a wet towel
intermittently for periods of 5 minutes to achieve a 10 to
15C lowering of temperature in the deeper tissues. The
efficacy of this however, is not definitely proven.
Prophylaxis is the treatment by intravenous injection

of factor concentrate to prevent anticipated bleeding.
The goal of prophylactic therapy is to convert a severe
hemophilia patient to a moderate hemophilic by
maintaining trough levels of factor above 1 percent
and thereby preventing spontaneous bleeds.
This prevents bleeding and joint destruction and helps
to preserve normal musculoskeletal function.
In patients with repeated bleeding, particularly into
target joints, short-term prophylaxis for 4 to 8 weeks
can be used to interrupt the bleeding cycle. This
may be combined with intensive physiotherapy or
synoviorthesis.
Prophylactic administration of clotting factor
concentrates is advisable prior to engaging in activities
with higher risk of injury.
Prophylaxis is best given in the morning to cover
periods of activity.
Physical and Rehabilitative Therapy

Early physical therapy should be instituted as soon
as the acute hemarthrosis subsides, i.e. once the pain
subsides. Exercises should be increased gradually.
Figs 2A and B Severe hemophilia A with chronic synovitis undergoing dual force stretching and exercise.
The patient recovered completely in two weeks time
Fig. 3 Customized device for footdrop. This patient also

developed this drop as a result of compartment syndrome
Figs 4A and B Customized traction system for Volkmanns ischemic

contracture in a patient of severe hemophilia A. The patient is now
fully functionally and is an active member of the society
Primary Prophylaxis
Administration and Dosing Schedules
Regular continuous treatment initiated in the absence of

documented osteochondral joint disease, determined by
physical examination and/or imaging studies, and started
before the second clinically evident large joint bleed and
age 3 years
Prophylactic Therapy Dose
Secondary Prophylaxis
Regular continuous treatment started after 2 or more
bleeds into large joints and before the onset of joint
disease documented by physical examination and imaging
studies.
Tertiary Prophylaxis
Regular continuous treatment started after the onset of
joint disease documented by physical examination and
plain radiographs of the affected joints.
Intermittent (Periodic) Prophylaxis

Treatment given to prevent bleeding for periods not
exceeding 45 weeks in a year.
Continuous is defined as the intent of treating for 52
weeks per year and receiving a minimum of an a priori
defined frequency of infusions for at least 45 weeks (85%)
of the year under consideration.
Large joints = ankles, knees, hips, elbows and
shoulders.
Factor VIII 25 to 40 u/kg thrice a week

Factor IX 25 to 40 u/kg twice a week
These dosage schedules are expensive. Therefore,
different countries follow different protocols for prophy
laxis, and the optimal regimen remains to be defined.
Thus we now have the concept of low dose prophylaxis,
using 10 u/kg twice a week, which is gaining popularity in
developing countries.
Muscle Bleeds and Hematomas (Figs 5 and 6)

Seventy-five percent of patients present with soft tissue
bleeds
The most common site is the ileopsoas muscle
This leads to reflex muscle spasm and joint flexion
deformity
It may lead to complications such as compression of
adjacent nerves, vessels; muscle atrophy; contractures
Large bleeds may produce fever, hyperbilirubinemia
and neutrophilia.
Treatment
Factor correctionsoft tissue bleeds generally require
more factor correction, about 50 to 60 percent. One
can try with lesser doses if availability or finances are a
problem.

They may be subdural, intracranial or subarachnoid
They require full factor replacement for a longer
duration.
Treatment
It should be noninvasive as far as possible; surgical
intervention is rarely required except in those patients
with neurological deficit or an altered sensorium.
Aggressive 100 percent factor correction should be
given and continued for at least 8 to 10 days.
Antifibrinolytic drugs such as trenexamic acid, may be
given for 6 to 8 weeks.
Gastrointestinal Bleeds
Fig. 5 Muscle hematoma in a severe hemophilia patient.
Responded to conservative management
They are seen in 15 to 20 percent of patients

Bleeding may be exacerbated by an underlying peptic
ulcer; in fact peptic ulcer disease is more common in
hemophiliacs than in the general population
The patient must also be investigated for an underlying
disease such as ulcer, chronic liver disease, GI
malignancy, etc. especially in patients who are HbSAg
or HCV positive.
Treatment
Factor concentrates of about 40 to 60 percent correction
may be required
They are given till the bleeding stops
H2 receptor blocking agents may be given simul
taneously
Antifibrinolytic drugs can also be given.
Urinary Tract Bleeding

Fig. 6 Scrotal hematoma in a severe hemophilia patient.
Responded to conservative management
Patients may require the factor to be given for at

least 3 to 4 days or more, depending on the response.
However, once the patient responds, further factor
need not be given.
Once the pain subsides the patient must be given
supervised physical therapy to prevent complications.
CNS Bleeds
CNS bleeds are a frequent occurrence in hemophiliacs
and one of the major causes of mortality.
They develop in 10 to 20 percent of patients
However less than 50 percent give history of trauma
Sixty-six to ninety percent of patients will experience at

least one episode of hematuria
Most patients present with spontaneous painless
hematuria
All patients must also be investigated to rule out an
underlying organic cause, e.g. calculus, malignancy.
Treatment
R
ecommended first line treatment for hematuria is to
increase fluid intake to 2 to 3 liters per day, either oral
or parental
Most patients will respond to conservative therapy
If hematuria persists, factor correction 50 to 80 percent
should be given, till bleeding stops
Antifibrinolytic drugs are contraindicated in hema
turia.
Mucous Membrane Bleeds

These commonly present as epistaxis, gum bleeds,
tongue bleeds or from the frenulum in infants, and in
children following loss of decidous teeth, etc.
Whenever a clot forms, the body attempts to break
it down within the vessel so that blood flow can be
restored. This process of clot breakdown called fibrino
lysis is very active on mucous membrane surfaces. In
people with hemophilia, this process can prevent a
bleed from stopping.
Thus these bleeds especially those following injury are
often difficult to treat and may end up consuming a lot
of factor.
The problem is worse in children as they tend to
continuously disturb the clot with their tongue.
Treatment
Fibrinolysis can be inhibited by drugs, and tranexamic
acid is the most widely used drug for this.
It is advisable to treat with local measures such as
EACA application to the site of bleeding or fibrin glue
where feasible since the drug is absorbed from the
buckle mucous membrane and then secreted into the
saliva
Oral EACA tablets or a mouthwash prepared by
crushing or dissolving the tablets can be used
If this does not arrest the bleed, then factor replacement
30 to 40 percent correction is given till the bleed stops.
Chronic Hemophilic Arthropathy

This is a common problem we face in our country, due to
inadequate treatment of an acute hemarthrosis. Patients
often come with deformed joints and marked restriction
of movement. Treatment of this can be conservative or
surgical, depending on the individual patient.
Conservative Treatment
Factor replacement with gradual supervised physical
therapy
Synovectomy to control bleeding and prevent pro
gressive destruction of the articular cartilage.
Types of Synovectomy
Conventional arthrotomy: Articular debridement and
synovectomy
Disadvantage: Loss of range of motion.
Arthroscopic synovectomy:
Low morbidity
Early rehabilitation
Better range of motion
Both the above procedures are not recommended

today as nonsurgical synovectomy is a much better
treatment option.
Nonsurgical synovectomy: This is done by the intra-
articular injections of drugs or radioactive material

Chemical: Rifampicin
Radioactive: Au 198 colloidal gold, Y colloidal yttrium,
Re colloidal rhenium, P 32 colloid
Of these using intra-articular rifampicin is a safe and
effective means of causing a chemical synovectomy.
Pseudotumors (Figs 7A to D)
Hemophilic pseudotumors are large encapsulated
hematomas that represent progressive cystic swelling
from persistent bleeding and incomplete resorption. This
serious complication is evident in approximately 1 to 2
percent of severely affected patients. The pseudotumor is
composed of clot and necrotic tissue.
Three types of pseudotumors predominate in hemo
philia.
1. The most common type arises from repeated hemorr
hage and inadequate clot resorption. They are
usually confined within facial and muscle planes.
Radiologically, they appear as simple cysts.
2. The second type involves large muscle groups, such as
the gluteus maximus and iliopsoas. These lesions are
especially problematic because they may gradually
enlarge, develop a fibrous capsule, and eventually
destroy adjacent underlying structures by pressure
necrosis. Skeletal fractures and bony deformities
produced by cortical erosion may result.
3. The third and rarest type of pseudotumor arises from
within bone itself, often secondary to subperiosteal
bleeding. This lesion typically is observed in the long
bones of the lower extremities and pelvis but has been
reported to occur within the calcaneus, cranium, and
mandible.
Most such pseudotumors arise in adults and occur
in proximal skeletal structures; distal lesions occur more
frequently in children before skeletal maturity and are
associated with a better prognosis.
Treatment
Distal pseudotumors respond well to conservative treat
ment consisting of aggressive clotting factor replacement
and cast immobilization. Because conservative treatment
has not been nearly as successful for lesions of the proximal
musculoskeleton, and because complete regression is
very rare, this approach has been reserved primarily for
patients with high-titer inhibitors.
High- and low-intensity radiotherapy regimens have
been successful in eradicating pseudotumors in the long
bones and may offer an alternative conservative approach.
Figs 7A to D Pseudotumors of hand and foot in hemophilia A
Surgical extirpation is the most effective therapy for

pseudotumors and is the treatment of choice when it can
be carried out in major hemophilia centers. Nevertheless,
the operative mortality rate approaches 20 percent.
Depending on the size and location of the pseudo
tumor, percutaneous evacuation of the cavity and sub
sequent introduction of fibrin sealant or cancellous bone
can be considered.
Surgery in Hemophilia
Surgeries in hemophilia patients are a major challenge
in our country due to the poor availability of factor and
the expense, as majority of our patients may not have
access to it or are unable to afford the factor.
Optimal care requires cooperation between the
hematologist, surgeon, blood bank and physical ther
apist
Thus it is best to carry out surgeries in hemophilia

patients only at specialized centers where all facilities
are at hand.
Before operating on a patient certain pre-requisites must
be ensured:
Accurate diagnosis
A baseline factor level
Rule out presence of an inhibitor
Adequate stocks of factor
It is best to do the surgery in the morning as that
gives adequate time to take care of any unforeseen post-
operative complications.
Recommended Dose of Factor

Using 100 percent factor correction as recommended
is not always financially feasible for our patients. Thus,
we need to modify our strategies of treatment to suit the
patients finances and also give him optimum treatment.
Depending on the type and site of the operation one
would preoperatively raise the factor levels to 70 to 100
percent and try to continue the dose for about 48 hours
in the perioperative period.
Subsequently, levels may be maintained around 50
percent or even less, for 7 to 15 days, depending on the
type of surgery.
There is generally no need to routinely measure factor
levels in the postoperative period. Factor levels should
be measured only, if required.
Adjuvant use of antifibrinolytic drugs where possible,
considerably reduces the requirement for factor.
Also intraoperative use of local agents such as anti
fibrinolytic drugs/fibrin glue can minimize bleeding.
Use of DDAVP in Hemophilia A

Infusion of desmopressina synthetic analog of vaso
pressin causes a 3 to 5 fold rise in factor VIII levels by
release of von Willebrand factor (vWF) from endog
enous stores in the endothelial cells.
It is effective in mild/moderate hemophilia and there
fore it can only be used in patients those patients.
Disadvantages
Variability in response, and needs to be individually
assessed in each patient
Transient flushing/headaches/palpitations
Fluid retention, hyponatremia
Tachyphylaxis
Seizure activity in infants
Thrombocytopenia in Type 2B and platelet type vWD
It is contraindicated in patients with hypertension/
CAD/elderly persons.
Route of Administration
Spray: The intranasal dose for patients <50 kg is 150 g
and for patients over 50 kg300 g.
IVThe usual dose is 0.2 to 0.3 g/kg IV in a volume of
50 to 100 mL infused over 30 minutes.
Increase in factor levels is seen within 15 to 60 min
Effect intranasal lasts for 6 to 8 hours
It may be given daily for 2 to 3 days.
Pharmacologic Options for

Controlling Bleeding
Tranexamic acid: Tranexamic acid is an antifibrinolytic
agent that inhibits the activation of plasminogen to
plasmin. It promotes clot stability and is useful as
Fig. 8 Hematoma following

tooth extraction without factor correction
the adjunctive therapy in hemophilia. It is especially

valuable in controlling bleeding from mucosal surfaces
(e.g. oral bleeding, epistaxis, menorrhagia).
Dose: Oral tablets are freely available.
For an adult 1 g is administered every 6 hours
For a child is 20 mg/kg.
Fibrin sealant: Fibrin sealant has hemostatic, sealing,
and healing properties. It is made by mixing fibrinogen
and thrombin, which mimics the last step in the blood
coagulation cascade. A semirigid to rigid fibrin clot
consolidates and adheres to the application site and
acts as a fluid-tight sealing agent able to stop bleeding.
Fibrin sealant can be used for:
Dental extraction (Fig. 8)
Circumcision
To stop bleeding from mucous membranes
Postoperatively over suture lines, etc.
Commercially available fibrin sealants are prohi
bitively expensive.
Cryoprecipitate and plasma: Cryoprecipitate, fresh
frozen plasma (FFP), and cryo-poor plasma are
sometimes the only affordable treatment options in
many developing countries. However, they are usually
not treated to eliminate blood-borne viruses. Because
of the risk of transmitting disease, the use of plasma and
cryoprecipitate which has not been viral inactivated
should be considered a temporary measure until
adequate amounts of factor can be made available.
PREVENTION
Carrier Detection and Prenatal Diagnosis
In developed countries, where hemophilia care has
progressed to such an extent that a child can live a near

normal life with safe and effective therapy, the need
for carrier detection and prenatal diagnosis may not be
important.
However, these services are necessary in developing
countries so that individuals and families can be evaluated,
informed of their carrier status, and be allowed to make an
informed choice on whether they will risk having a baby
with hemophilia or not.
If there is an affected family member then the antenatal
diagnosis for hemophilia A and B is now available for
those parents who wish to opt for it and has more than 99%
accuracy. It can be done at 1011 weeks of gestation on
chorionic villous samples or at 1819 weeks on cord blood
samples.
Take home message
The key to success in hemophilia management lies in early
diagnosis and treatment. This will reduce the morbidity and
mortality from a disease which is treatable. Though factor
accessibility remains a major issue due to financial constraints,
even with a limited amount of factor concentrates, it is
possible to improve the lives of people with hemophilia
in developing countries through education, prevention,
and ancillary care. Hemophilia services must emphasize on
education, physiotherapy, laboratory diagnosis, and simple
measures to manage bleeds, along with a supply of safe
concentrates.
BIBLIOGRAPHY

1. Agarwal MB, Patnaik M. Recombinant activated factor VII

japi.org/august 2005/U-717.
2. Beutler E, et al. Williams Hematology; 5th edn. McGraw
Hill, Inc. 1995.p.1413.
3. Chandy, Mammen: Management of Hemophilia with
Minimal Factor Replacement in Developing Countries:
Role of Ancillary Therapy Semin Thromb Hemost. 2005;
31:495-500.
4. G Richard Lee, et al. Wintrobes Clinical Hematology.

11th edn. Inherited coagulation disorders. Williams and
Wilkins 1999.p.1619.
5. Ghosh K, Shetty S, Jijina F, Mohanty D. Role of epsilon
amino caproic acid in the management of hemophilia
patients with inhibitors. Hemophilia. 2004;10:58-62.
6. Ghosh K, Jijina F, Pathare AV, Mohanty D. Surgery in
hemophilia: experience from center in India. Hemophilia.
1998;4:94-7.
7. Ghosh K, Jijina F, Shetty S, Madkaikar M, Mohanty D. First
time development of Factor VIII inhibitor in hemophilia
patients during postoperative period. Hemophilia. 2002;
8(6):776-80.
8. Ghosh K, Nair AP, Jijina F, Madkaikar M, Shetty S, Mohanty
D. Intracranial hemorrhage in severe hemophilia: pre
valence and outcome in a developing country. Hemophilia.
2005;11:459-62.
9. Jijina F, Ghosh K, Madkaikar M, Mohanty D. Ophthalmic
surgery in Hemophilia. Hemophilia. 2001;7:464-7.
10. Madkaikar M, Ghosh K, Jijina F, Gandhi S, Shetty S,
Mohanty D. Open heart surgery with mitral valve replace
mentordeal of an undiagnosed hemophilia patient.
Clinical and Laboratory Hematology.
11. Ronald Hoffman, et al. Hematology Basic Principles
and Practice, 5th edn. Clinical aspects and therapy of
hemophilia. p. 1883.
12. Shetty S, Colah R, Gorakshakar A, Bhide A, Ghosh K,
Pathare AV, Jijina FF, Mohanty D. Prenatal diagnosis of
HemophiliaA preliminary report. The National Medical
Journal of India. 1998;11(5):218-9.
13. Seminars in thrombosis and hemostasis (Impact factor:
4.22). 2005;31(5):495-500.
14. Srivastava A, Chuansumrit A, Chandy M, Duraiswamy G,
Karagus C. Management of hemophilia in the developing
world. Department of Hematology, CMC Hospital, Vellore,
India. Hemophilia. 1998;4(4):474-80.
15. Srivastava A, Brewer AK, Mauser-bunschoten EP, Key NS,
Kitchen S, Llinas A, Ludlam CA, Mahlangu JN, Mulder
K, Poon MC and A. Street; treatment guidelines working
group on behalf of the world federation of hemophilia.
Guidelines for the management of hemophilia.
29
von Willebrand Disease and
Other Rare Coagulation Disorders
Among the hereditary coagulation disorders, hemophilia

is the most common in which one of the clotting factors has
either quantitative deficiency or absent or has qualitative
(functional) abnormality, as a result of other medical
conditions, it can also be acquired.
COMMON HEREDITARY COAGULATION

DISORDERS
The three most common hereditary bleeding (coagulation)
disorders are:
1. Hemophilia A (factorVIII deficiency)
2. Hemophilia B (factor IX deficiency)
3. von Willebrand disease.1
Factors other than factor FVIII, FIX and von Willebrand
factors are classified as rare coagulation factor disorders2
apart from inherited deficiencies of coagulation.
Rare coagulation factor (deficiencies) disorders include:
Fibrinogen
FII
FV (parahemophilia)
FV+FVIII
FVII
FX
FXI (Hemophilia C)
FXIII
Kashyap et al.3 reported a comprehensive study of 24 cases
with rare coagulation disorders from India of which factor
X deficiency was found in 8 patients, 7 had factor XIII
deficiency, fibrinogen and factor VII deficiency was found
in 4 cases each and factor V deficiency was found in 1 case.
von WILLEBRAND DISEASE (VWD)

In 1926, Erik von Willebrand first described a unique
bleeding disorder, in a 5-year-old girl from Finland,
inherited as an autosomal dominant or recessive pattern

in patients with normal platelet counts which is due to an
abnormality, either of quantitative (Type 1 and Type 3)
and/or qualitative (Type 2)of the von Willebrand factor.4
Pathophysiology
Bleeding occurs due to abnormalities in platelet adhesion
and aggregation, and decreased factor VIII levels, because
of decrease in quantity or a dysfunction of von Willebrand
factor (vWF) in this disease.
Extremely large multimeric glycoprotein complex; low,
intermediate, and high molecular weights of multimers are
the constituents of von Willebrand factor. It is synthesized
in endothelial cells and megakaryocytes and after cleavage
of a large propeptide, is released as a series of multimers,
including ultralarge forms that are rapidly cleaved to a
slightly small size.
Type of Hemostasis
Primary hemostasis: vWF in the subendothelium and
plasma bind to the platelet receptor glycoprotein Ib (GPIb)
and to subendothelial structures, such as collagen, during
normal hemostasis consequent to an injury, and serve as a
bridge between platelets and subendothelium in damaged
vessels.
Higher the molecular weight of the multimer, higher
would be the number of platelet-binding sites and
adhesive properties. Each multimeric subunit has binding
sites for the receptor glycoprotein Ib on nonactivated
platelets and the receptor glycoprotein IIb/IIIa on
activated platelets, this facilitates both platelet adhesion
and platelet aggregation, making high molecular weight
multimers most important for normal platelet function.
Chapter-29 von Willebrand Disease and Other Rare Coagulation Disorders 297
Secondary hemostasis: von Willebrand factor protects
factor VIII from degradation in secondary hemostatis
and delivers it to the site of injury. Binding enhances the
localization of platelets as fibrin is formed at the site of the
injury promoting aggregation.
The small multimers function mainly as carriers for FVIII:
The size of the multimers determines the binding of vWF.
Patient might have a bleeding diathesis in spite of a normal
concentration of vWF when there is a decrease in the more
functional large vWF multimers. Thrombus formation
as in thrombocytopenic purpura can happen when the
ultra large vWF forms that initially released are sticky
and are capable of binding the platelets in the circulation
spontaneously.
Due to decrease in quantity or a dysfunction of von
Willebrand factor (vWF) there will be abnormalities in
platelet adhesion and aggregation and decreased factor
VIII levels, thus causing bleeding in this disease. The small
multimers function mainly as carriers of FVIII.
Prevalence
The prevalence of clinically significant cases of vWF in
humans are 1 per 10,000. It is detected more in women and
adolescent girls whose bleeding tendency shows during
menstruation. Most forms of vWF are mild. The level of
vWF varies depending upon the blood group, for instance
people with type O are approximately 25% less affected
than those of the other blood groups.5 vWF is reported
to affect animals including dogs (especially Doberman
Pinschers), rarely it affects wine, cattle, horses and cats.
Other end of the spectrum when associated with

angiodysplasia vWD, serious gastrointestinal bleeding can
occur.7 Abnormally heavy bleeding during menstruation
(menorrhagia), blood loss during childbirth, hematuria,
hemarthroses,
intramuscular,
intracerebral
and
retroperitoneal hemorrhages, cephalhematomas in
newborns (more common in Type 3 vWD). 8 Severe internal
or joint bleeding is uncommon (except for in vWD type III).
In between are the children who present with symptoms
usually involving skin and mucosal bleeding like: Easy
bruising, excessive nose bleeds (epistaxis) bleeding
from the gums, bleeding during procedures like tooth
extractions, tonsillectomy, menorrhagia, etc.
Classification
International Society on Thrombosis and Haemostasiss
(ISTH) classification.
There are four types of hereditary vWD, described are
type 1, type 2, type 3 and pseudo or platelet-type.
vWD Type I
vWD Type II-4 subtypes-A, B, M, and N
vWD III
Pseudo or platelet-type
Within the three inherited types of vWD there are
various subtypes
Platelet type vWD is also an inherited condition
Most cases are hereditary, but acquired forms of vWD
have been described.
Type 1 vWD
In types I and II of von Willebrand disease is inherited in

an autosomal dominant pattern. In type III and sometimes
in type II it is inherited in autosomal recessive pattern.
However penetrance may widely vary in a single family.
Also on different occasions even the clinical and laboratory
findings may vary in the same patient.2
This is the most common type which accounts for

approximately 7580% of patients and is characterized
by quantitatively decreased and qualitatively and
structurally vWF
Many patients are typically asymptomatic or may have
mild to moderate bleeding
Often incidentally identified when other medical
procedures requiring, a blood work-up is done.
CLINICAL PRESENTATION
Laboratory Assays
Clinical symptoms have a wide spectrum. One end of the

spectrum many children with von Willebrand disease
(vWD) are asymptomatic and are diagnosed as a result
of a positive family history or during routine preoperative
screening. vWD is of various types and each type is
presented with varying degree of bleeding tendency.
Due to its wide range and severity of symptoms, vWD
patients may present at any age. In majority of the cases
the bleeding is of mild to moderate severity reflecting the
predominance of type 1 vWD.6 Individuals with decreased
or qualitatively abnormal vWF function, usually present
earlier in life. Type 3 vWD is more serious in nature.
Decrease in vWF activity and antigen levels

Decrease in the ristocetin-inducecl platelet aggregation
and vWF multimers show normal distribution, due
to lower vWF concentration their intensity may be
diminished
Decreased binding of vWF to platelets factor VIII is
decreased or in the low normal range
A normal multimer size distribution, though vWF
bands with abnormal migration may be present.
Abnormal multimers may be seen (Vicenza variant)
Caused by a defect in the von Willebrand factor
gene that produces decreased or absent binding to
Inheritance
platelet glycoprotein 1b. The vWF gene is located
on chromosome twelve (12p13.2). It has 52 exons
spanning 178 kb
By performing a binding assay for factor VIII that uses
the patients vWF as the binding partner, the diagnosis
is established.
von Willebrand Disease Type 2

Type 2 vWBD is associated with primarily qualitative
defects of von Willebrand protein and is most common. Its
incidence is 2030% and vWBF levels are normal. Bleeding
tendency can vary between individuals as it is a qualitative
defect, however subgroups of large or small multimers
may be absent or structurally abnormal multimers are
present.
Type 2A von Willebrand Disease Includes Four

Subtypes (A, B, M and N)
Type 2A. In type 2A vWD the qualitatively defective
vWFs ability to bind to glycoprotein 1 receptor on the
platelet membrane is enhanced abnormally, leading
to spontaneous binding to platelets and rapid and
subsequent clearance of the bound platelets and
of the large vWF multimers. There are chances for
thrombocytopenia. vWF antigen assay is normal but
qualitatively defective and decreased capability at
multimerization. Large vWF multimers are reduced or
absent from the circulation
Large vWF multimers are reduced or absent and
ristocetin cofactor activity is low. Substitution within a
normal cleavage site in the A2 domain of vWF is the
effect of the majority of mutations in 2A. Some make
it more susceptible to proteolysis by the vWF cleaving
protease (ADAMTS13)
The mutations in type 2A vWD may either cause a defect
in intracellular transport (2A, type 1) or render the
molecule more susceptible to proteolysis (2A, type 2).
Laboratory Findings
Its ability to bind to the glycoprotein 1 (GP1) receptor
on the platelet membrane is reduced. This results
in abnormally low ristocetin cofactor activity and
decreased platelet adhesiveness and aggression. The
defective vWFs ability to coalesce and form large
vWF multimers is also impaired which would lead
to decreased quantity of large vWF multimers and
detected in the circulation are only small multimer
units
Because of the loss of high molecular-weight multimers
which are more functional there is a decrease in
vWF activity assays compared with antigen. There is

an absence of high-molecular weight multimers on
agarose gels
Decreased RIPA
The factor VIII may be normal or decreased.
TYPE 2B von WILLEBRAND DISEASE

Type 2B accounts for approximately 5% of vWD
Inherited either autosomal dominant or autosomal
recessive pattern
The removal of platelets aggregates with bound vWF
may result in hemostatic defect caused by qualitatively
abnormal vWF and intermittent thrombocytopenia.
The ability of the qualitatively defective von Willebrand
factor to bind to glycoprotein 1 (GP1) receptor on the
platelet membrane is abnormally enhanced, leading
to its spontaneous binding to platelets and subsequent
rapid clearance of the bound platelets and of the
large vWF multimers. From the circulation, large vWF
multimers are reduced or absent.
Laboratory Assays
Low concentrations of ristocetin in ristocetin-induced
platelet (RIPA) show an increased reactivity, similar to
type 2A, vWF ristocetin cofactor activity shows marked
decrease than in antigen level and high molecular
weight multimers of vWF are decreased
Thrombocytopenia may be present in some patients.
Low or normal factor VIII
Bleeding symptoms may be moderate to severe
Platelet-related vWF function is normal
Type 2M von Willebrand Disease

Type 2M is very rare type of vWF and is a qualitative
defect. In this type of vWD there is normal capability
at multimerization and a decreased ability to bind to
glycoprotein (GP1) receptor on the platelet membrane.
This is characterized by a decreased platelet-directed
function which is not because of the decrease of highmolecular weight multimers. Though vWF bands with
abnormal migration may be present and abnormally large
multimers may be seen, there would be a normal multimer
size distribution (Vicenza variant).
Caused by a defect in the von Willebrand factor gene
that produces decreased or absent binding to platelet
glycoprotein 1b characterized by its decreased ability
to bind to glycoprotein 1 (GP1) receptor on the platelet
membrane and normal capability at multimerization.
This results from mutations affecting the A1 domain in a
different area from those mutations in type 2B.
Decreased ristocetin cofactor activity and decreased
vWF antigen and activity, and high molecular weight large
vWF multimers are present in the circulation.
Laboratory studies show that there is normal vWF
function and antigen, and RIPA and multimer distribution,
however shows decreased factor VIII which is between 2%
and 10%.
Type 2N von Willebrand Disease

The cause of type 2N vWD is by mutations in the amino
terminus of the mature vWF monomer and this is an
uncommon variant. This may be initially confused with
hemophilia A as patients may have mild to moderate
bleeding which is related to the decreased factor VIII.
The presence of affected females in the family is a vital
indication that this diagnosis should be considered
Decrease binding for factor VIII result in rapid clearance
of factor VIII. This is a deficiency of the binding of vWF
to coagulation factor VIII. Soft tissue and joint bleeding
are apparent symptoms, as expected with decreased
factor VIII
Normal platelet-related vWF function
Laboratory studies show decreased factor VIII (210%)
and normal vWF function and antigen, RIPA and
multimer distribution
Performing a binding assay for factor VIII that uses the
patients vWF as the binding partner is the diagnosis to
establish type 2N vWD.
Type 3 von Willebrand Disease

Type 3 vWD is characterized by complete absence of
production of vWF and it is the most severe and rare
form of von Willebrand disease. Manner of inheritance
of type 3 vWD is homozygous or doubly heterozygous.
Consanguinity is common. A variety of mutations,
including larger deletions are the causes of type 3 vWD
From proteolytic degradation, the vWF protects
coagulation factor VIII, extremely low factor VIII level
is caused due to total absence of vWF, severe clinical
bleeding which is similar to severe hemophilia, e.g.
hemarthrosis, intramuscular bleeding, etc., would be
the clinical presentation
It is identified by marked deficiencies of both FVIIIc
in the plasma and vWF, the absence of vWF from both
endothelial cells and platelets and lack of response to
DDAVP, therefore platelets cannot clot. It is difficult to
stop bleeding in patients with type 3 vWD as bleeding is
severe. Patients may present with cephalohematomas in
newborns, hemarthroses, hematuria and intramuscular,
intracerebral and retroperitoneal hemorrhages.
Platelet-type vWD (pseudo-vWD)6

Pseudo-vWD is another name of platelet type vWD
It is a genetic defect of the platelets which is autosomal
dominant
The vWF is qualitatively normal
No mutational alteration is revealed while genetically
testing the von Willebrand gene
Thrombocytopenia, and diminishing or absence of
large vWF multimers result as large platelet aggregates
and high molecular weight vWF multimers are
removed from the circulation. The ristocetin cofactor
activity and loss of large vWF multimers are similar
to vWD type 2B and can be distinguished from type
2B vWD by mixing studies with patient platelets and
normal plasma using RIPA
Because of the genetic mutation in factor VIII binding
region of vWF it is characterized by a marked decrease
affinity of vWF for FVIII. Bleeding is related to the
decreased factor VIII. Symptoms include as soft tissue
and joint bleeding and with decreased factor VIII
may initially be confused with hemophilia A. This is
suspected when patients with mild FVIII deficiency and
a bleeding disorder which is not clearly transmitted as
X-linked disorder or when patients do not completely
respond to hemophilia.
A significant indication is the presence of affected females
in the family. It is usually presented before adulthood with
symptoms such as moderate to severe bleeding in affected
patients.
Laboratory Findings
Due to the loss of the more functional high molecular
weight multimers, laboratory testing shows more marked
decrease in vWF activity assays as compared with antigen.
Decreased RIPA
High molecular weight multimers on agarose gels are
absent
Normal-to-reduced plasma levels of factor VIIIc and
vWF (in moderate/severe disease it is abnormal).
DIAGNOSIS OF von WILLEBRAND DISEASE

Accurate Personal and Family Bleeding
History

Increased or easy bruising and bleeding from wound

Gingival bleeding and recurrent epistaxis
Menorrhagia, postpartum bleeding
Postoperative bleeding (particularly after tonsillectomy
or dental extractions):
Clinical Evaluation
Laboratory Assays Tests for vWD Include
Routine screening test for coagulation disorders like
CBC, platelet count
Bleeding time: Bleeding time tests are not sensitive and
are not done as often as they once were
Prothrombin time, APTT: Characteristically there is
marked prolongation of the PTT, PT and the thrombin
time (TT)
vWF antigen level: vWF antigen (vWF Ag) is a
quantitative test that is usually carried out in an ELISA
format using antibodies specific for vWF
vWF multimer distribution by gel assays and RIPA: This
occurs in type 2B vWD
The patients plasma which is the source of vWF and
platelets are used in RIPA. To assess whether the
platelet aggregation is present or absent, different
concentrations of ristocetin are added to aliquots of
the platelet-rich plasma of the patient. Aggregation will
cause in patients with type 2B vWD if, concentrations of
ristocetin is approximately below 0.6 mg/mL, but will
not cause aggregation in normal subjects. The gain of
function can be assessed primarily through RIPA
Ristocetin-induced platelet aggregation (RIPA), collagen
binding: Ristocetin is the antibiotic that promotes the
binding of vWF to platelets. In the presence of ristocetin
the vWF have the functional ability to bind to platelets.
If concentration of ristocetin is approximately below
0.6 mg/mL, it will cause aggregation in patients with
type 2 vWD. Gain of function mutation in patients
vWF is primarily assessed through RIPA.
Factor VIII Activity

In moderate and severe disease factor VIII would be
abnormal, otherwise it would be normal or decreased.
Factor VIII activity is usually performed in the traditional
coagulation factor assay.
vWF multimer study and ristocetinAdditional tests
useful in classifying the type of vWD includeristocetin
induced platelet aggregation (RIPA) performed in a
platelet function analyzer. In this test, the patients
own platelets and vWF are employed, so the test is not
specific for vWF abnormalities.9
To assess whether high molecular weight multimers
are decreased or absent, vWF multimer gels are used
as they provide visualization of the size distribution of
vWF multimers in plasma
vWF is visualized using antibodies to vWF and
immunofluorescence end point by performing
electrophoresis on diluted plasma in agarose gels and
the proteins are transferred to a membrane.10
Genetic TestingMutation in the Patients

vWF
The gene defect in the majority of type 1 patients is
unknown. Specific gene defect in type 2 and type 3 vWD
patients is available in specialized laboratories and
research centers.
Specialized laboratories and research centers are
available where genetic testing for diagnosis of specific
gene defect in type 2 and type 3 vWD patients are available.
Direct sequencing of the suspect area of the patients gene
is done to identify the specific defect. Usually genetic
testing is not usually performed in type 1 patients as it is
unknown at that time.
Medical Care
Treatment for von Willebrand disease depends on type
and severity of the disorder. vWD, the patient has dual
defect of hemostasis, i.e.
Defect in platelet adhesiveness and aggregation which
can be corrected by raising the level of von Willebrand
factor
Low factor VIII activity.
Treatment
The three major treatment modalities used for patients
with vWD is detailed in Table 16
Desmopressin acetate (DDAVP)
Replacement therapy with plasma-derived factor VIII
vWF concentrates
Adjunctive therapies such as antifibrinolytic agents
and topical therapies.
Specific treatment is not required if there is minor
bleeding problems, such as bruising or a brief nose bleed,
etc., in patients with vWD. The main aim in case of serious
bleeding is to limit the patients bleeding, by medications
that can raise the vWF level.
Desmopressin Acetate (DDAVP)

Desmopressin is a synthetic analog of antidiuretic
hormone. It is considered that for patients with mild
vWD, the primary treatment and mainstay of therapy
is desmopressin [1-deamin-8-d-arginine vasopressin
(DDAVP)]. It stimulates the release of vWF from the
Weibel Palade bodies of endothelial cells (storage site). In
type 1 vWD patients who have normal vWF in storage sites
DDAVP (desmopressin acetate) is most effective.
It may not be effective in vWD type 2M and is hardly
effective in vWD type 2N and in severe forms of vWD 1 and
2. It is totally ineffective in vWD type 3.
Table 1 Classification and treatment of von Willebrand disease
Type
Description
vWF activity
Ag
RIPA
Multimer pattern
Treatment
Type 1
Partial quantitative deficiency

of vWF
Uniform
DDAVP 0.3 g/kg IV in 50 mL

saline over 20 minutes, or
nasal spray 300 g for weight
>50 kg or 150 g for <50 kg.
Replacement vWF concentrate
at 2030 IU/kg q12h
Type 2
Qualitative vWF defect
2A
Decreased vWF-dependent
platelet adhesion with
selective deficiency of high
molecular weight
multimers
Large and
intermediate
DDAVP as in type 1.
2B
Increased affinity for platelet

GPIb
Large
Possibly DDAVP (may worsen

thrombocytopenia) as in type 1.
2M
Decreased vWF-dependent
platelet adhesion
without selective deficiency of
high molecular weight
multimers
Normal
DDAVP as in type 1.
2N
Markedly decreased binding

affinity for FVIII
Normal
DDAVP as in type 1.
Type 3
Virtually complete deficiency

of vWF
Undetectable
Replacement vWF concentrates

platelet transfusions if
inadequate response to vWF
replacement
Abbreviations: DDAVP: Desmopressin acetate; N: Normal; IV: Intravenous; RIPA: Ristocetin-induced platelet aggregation; vWD: von Willebrand disease;
vWF: von Willebrand factor.
DDAVP indirectly causes release of vWF and factor

VIII from storage sites, increasing the levels of both factors
2- to 5-fold within 45 minutes following intravenous
administration; the effect usually lasts about 6 hours.
Route and Mode of Administration and Dose

Administration of DDAVP can be either intravenously
or intranasaly or subcutaneously. If administered slowly
through intravenous infusion or subcutaneous mode, the
recommended dosage is 0.3 g/kg.
Intranasal Preparation
If DDAVP is administered through intranasal mode in
the form of nasal spray the levels peak approximately 2
hours after intranasal delivery.12 A high concentration
preparation (i.e. stimate 1.5 mg/mL) available and this
allows home treatment for bleeding symptoms. At the start
of the bleeding episode, through intranasal dosing the

patient can have rapid access to medication at home. It is
recommended that DDAVP be administered at 812 hours
interval for 23 doses and then at intervals of 48 hours in
case of tachyphylaxis and serious hyponatremia, where
bleeding can occur even after repeated doses.
Dosage: Fixed doses of 300 g in adults and 150 g in
children by intranasal spray.11
Common Side Effects Include

Frequent side effects of intranasal spray include transient
headache, facial flushing and mild tachycardia, but are
usually well-tolerated by patients. More often in infants
and in young children severe symptoms such as cerebral
edema and seizures are reported as a result of water
intoxication. Water retention and dilutional hyponatremia
with consequent convulsion can occur due to over use of
DDAVP.
Type 2B patients are at risk for worsening
thrombocytopenia after DDAVP and in type 2B patients,
platelet count should be evaluated along with vWF levels.
vWF Concentrates
When there is more severe bleeding and could not
controlled by DDAVP then vWF concentrates should be
used. They are also given prophylactically and following
surgery or trauma for 214 days, as dictated by the clinical
situation.
Intermediate-purity plasma-derived factor VIII
concentrates, administered intravenous mode in an
interval time of approximately 12 hours, contains vWF
(not recombinant or monoclonally purified factor VIII
concentrates).
Cryoprecipitate
Due to lack of viral inactivation, this product is generally
not recommended.
Nonreplacement Therapy
Aminocaproic acid and tranexamic are both drugs
that steady the clots formed by platelet by preventing
fibrinolysis. The antifibrinolytic agents epsilon amino
caproic acid and tranexamic acid are useful adjuncts in
the management of vWD complicated by gum bleeding,
bleeding from mucous membrane, menorrhagia, etc.
Common side effects include nausea, vomiting, and clot
complications.
Estrogen-containing oral contraceptive medications
are effective in reducing the frequency and duration of
the menstrual periods for women with heavy menstrual
bleeding. Estrogen compounds available for use in the
correction of menorrhagia are:
can be used as prophylaxis to treat patients with vWD

who do not respond to DDAVP. It can also be used for
patients with vWD scheduled for surgery, patients with
rare types 2B or 3. vWD and cases of vWD complicated
by clinically significant hemorrhage
However, most available FVIII concentrates do not
contain sufficient von Willebrand factor to be used
in von Willebrand disease e.g. Humate-P, Alphanate,
Wilate Alphanate and Koate also contain vWF in
high molecular weight form. These concentrates
are especially useful in types 2B and 3 vWD and are
available commercially for prophylaxis and treatment
of vWD. Insignificant quantity of vWF is present in
monoclonally purified factor VIII concentrates and
recombinant factor VIII, hence are not clinically useful.
In 1015% of patients receiving human derived
medium purity factor VIII concentrates development of
alloantibodies occur. Other side effects include allergic
reactions including anaphylaxis and increased risk of
venous thromboembolic complications.
Cryoprecipitate Contains Multimeric von

Willebrand Factor
In general, the dosage of cryoprecipitate or FVIII to
be used is calculated on the basis of FVIII units. Other
blood products are rarely required for patients with von
Willebrand disease.
Type 3 vWD patients or platelet-type vWD who do not
respond to vWF containing concentrates or cryoprecipitate
may be benefitted by platelet transfusion.
Other supportive line of treatments includes blood
transfusions for hypotension secondary to hypovolemia to
correct anemia. For correction of hemorrhage associated
with platelet type vWD, infusion of platelet concentrates is
recommended.
Ethinyl Estradiol and Levonorgestel (Levona,

Nordette, Lutera, Trivora)
Adjunctive Therapies
Stabilization of the endometrial surface of the uterus is

done by administration of ethinyl estradiol which in turn
diminishes the secretion of luteinizing hormone and
follicle stimulating hormone from the pituitary.
Antifibrinolytic agents such as epsilon amino caproic acid

and topical agents such as topical thrombin, gelfoam, and
fibrin sealant are used as adjunctive therapies.
For dental procedures, epsilon amino caproic acid
may be helpful.
Use of Topical Thrombin

Are effective adjuncts for correction of hemorrhage from
wounds.
Replacement Therapy Plasma Products

Plasma derived-derived factor VIII (FVIII) concentrates
Human derived medium purity factor VIII
concentrates, contain von Willebrand factors. This
Acquired von Willebrand Disease

Acquired von Willebrand syndrome (AvWS) is a rare
bleeding disorder and is distinguished from the congenital
form by several factors such as age at presentation, absence
of personal and family history of bleeding disorders.13
Acquired vWD can occur in patients with
autoantibodies.
Antibodies,
binding
mechanism
responsible for decreased vWF, proteolysis, decreased
production of vWF are the mechanisms responsible
for decreased vWF.14 There is a rapid clearance of vWF
antibody complex from the circulation.
Often Associated with Underlying Diseases

Like

Lymphoproliferative (48%)
Myeloproliferative disorders (15%)
Neoplasia (5%)
Immunological (2%)
Cardiovascular (21%), aortic valve stenosis, left
ventricular assist device (LVAD)
Miscellaneous disorders including hypothyroidism
(9%), Wilms tumor and mesenchymal dysplasias.
Laboratory Findings
Laboratory features are the same as in congenital von
Willebrand disease. Only the measurement of vWF
propeptide (also known as vWF Ag II) has been suggested
as helpful to discriminate between congenital and
acquired vWD. In AvWS, the propeptide levels remain
normal because vWF synthesis is normal or higher and it
is not targeted by antibody and not consumed or bound.
In less than one-third of the cases, antibodies are found
and are difficult to demonstrate in the laboratory.
Treatment
Treatment of vWS has two main objectives:
1. To control the bleeding episode.
2. To treat the underlying associated disease.
Initial treatment is usually administration of
DDAVP, however, if the response is not adequate, either
replacement therapy (FVIII/vWF concentrates) or
intravenous immunoglobulin (IVIg) is used.14 Despite the
possible presence of antibodies to vWF, the response to
replacement therapy is usually satisfactory.
Drugs to Avoid
As aspirin and nonsteroidal anti-inflamattory drugs can
increase bleeding complications, these drugs are to be
avoided. These children must inform about their health
problems to health providers, including their dentists of
their condition as well as teachers in the school, family
members and close friends.
Rare Coagulation Disorders

Rare coagulation disorders due to deficiencies of
coagulation factors other than factor FVIII and FIX and
von Willebrand disease, include deficiency of coagulation
factors like fibrinogen, FII, FV, FV+FVIII, FVII, FX, FXI,

FXIII.
FIBRINOGEN DEFICIENCIES (F1-5)

Fibrinogen deficiencies are inherited disorders of
fibrinogen defect.2 They may be classified as:
Quantitative Defect
Hypofibrinogenemia, with fibrinogen levels lower than
1.5 g/L
Afibrinogenemia, characterized by the complete
deficiency of fibrinogen.
Qualitative Defect of the Circulating

Fibrinogen
Dysfibrinogenemia
or
Both hypo/dysfibrinogenemia
Congenital fibrinogen disorders are relatively rare.
Clinical Features
Symptoms in afibrinogenemia are not as severe as
those seen in classic hemophilic disorders
Congenital afibrinogenemia is an autosomal recessive
disorder. Hereditary dysfibrinogenemia are usual
autosomal dominant
It may manifest in the neonatal period with
gastrointestinal
hemorrhage
or
hematoma
(cephalhematoma) after normal vaginal delivery
Thrombosis is another cause of concern. Patients with
congenital fibrinogen disorders may paradoxically
suffer from severe thrombotic episodes. The
etiopathogenesis is poorly understood except for a
few cases having a severe thrombophilic disorder
concomitantly.15
The clinical complication which is common in case of
fibrinogen deficiency is pregnancy loss.
DIAGNOSIS16,17
There is marked prolongation of the PT, PTT and the
thrombin time (TT)
Fibrinogen is the ligand for the glycoprotein IIbIIIa receptor which enables platelet aggregation.
In fibrinogen deficiency, the bleeding time and the
platelet aggregation tests are abnormal
The best screening tests are the TT and the reptilase
time, which measures the time required for the
conversion of fibrinogen in plasma to a fibrin clot.
Unlike the TT, the reptilase time is unaffected by
heparin treatment
The bleeding phenotype is difficult to predict even by the
characterization of the molecular defects responsible
for afibrinogenemia or hypofibrinogenemia
Congenital fibrinogen disorder patients may
paradoxically suffer from severe thrombotic episodes,
at times independent of any fibrinogen substitution.
Few cases having a severe thrombophilic disorder
concomitantly.
Clinical Phenotypes
Management
During bleeding due to congenital fibrinogen deficiency,
fibrinogen levels should be increased and maintained
above 1.0 g/L until hemostasis is secured and it should
be maintained above 0.5 g/L until wound healing is
complete.18,19 A dose of 50 mg/kg is required to increase
the fibrinogen concentration to 1 g/L.
Hemarthrosis and muscle hematomas are most

frequent bleeding manifestations in this group of
patients
Intracranial bleeds and umbilical bleeding have been
reported in neonates
Postoperative bleeding and mucosal bleeding are
other manifestations.
Fresh Frozen Plasma or Cryoprecipitate
Diagnosis
The plasma half-life of fibrinogen is between 2 days and

4 days and the availability of fibrinogen concentrates is
rare. Treatment with either fresh frozen plasma (FFP) or
cryoprecipitate is effective. Each bag of cryoprecipitate
contains 100150 mg of fibrinogen. Efficiency of viral
inactivation process is not that effective as it is for
fibrinogen concentrates. Transfusion-related acute
lung injury or TRALI complication can be caused due
to cytotoxic antibodies contained in the infused plasma
To treat mucosal bleeding and to prevent bleeding
following procedures, e.g. dental extraction,
antifibrinolytic agents may be given
Agents such as tranexamic acid should also be
considered
For treating superficial wounds or wounds following
dental extraction fibrin glue will be useful
For selected patients gene therapy could be the future.20
High index of suspicion and family history helps in

early diagnosis. Prolonged PT and a normal TT is
diagnostic criteria although both PT and APTT may
be prolonged in FII deficiency. It should also be noted
that the degree of abnormality may be minimal and
results can be within the normal range
A specific FII assay confirms the diagnosis
In premature and young neonates where vitamin K
deficiency may complicate assessment, the diagnosis of
mild prothrombin deficiency is difficult. Reassessment
after vitamin K replacement may be necessary.
FACTOR IIPROTHROMBIN DEFICIENCY

Factor II (FII) deficiency also called hypoprothrombinemia
or prothrombin deficiency and is a rarest coagulation
disorder first, identified in 1947 by Dr Armand Quick.
Prevalence of 1:2,000,000 in the general population.21
The mode of inheritance is autosomal recessive. At
least 32 different mutations have been identified.
FXa activates prothrombin on the surface of platelets
in the presence of FV and calcium.
Two clinical phenotypes are recognized.

1. Hypoprothrombinemia (type I deficiency), in which
prothrombin antigen and activity levels are reduced
concomitantly.
2. Dysprothrombinemia (type II deficiency), in which
prothrombin activity is reduced but antigen levels are
normal.
Clinical Features
Management22,23
There are no specific prothrombin concentrates available.
Prothrombin Complex Concentrates are

therefore Treatment of Choice
As a basis for dosage usually approximately 1 unit of
prothrombin per unit of FIX and can be used. Doses
of 2030 IU/kg seem to be effective as relatively low
levels are required for normal hemostasis. The plasma
prothrombin level is estimated to rise by 1 IU/dL with
one unit of prothrombin
An alternative source of prothrombin is fresh frozen
plasma (FFP). Around 72 hours is the half-life period
of prothrombin. This eases comparatively occasional
dosing, usually every 23 days. Depending on the
frequency and type of bleeding, prohylaxis should be
used in older children. To prevent the development
of chronic arthropathy, prophylaxis should be used in
cases where recurrent joint bleeding is a feature.
FACTOR V DEFICIENCY (PARAHEMOPHILIA)

In 1943, a Norwegian patient was found to have factor V
deficiency and was reported by Dr Paul Owren in 1947.
Factor 5 deficiency is also called as parahemophilia,
Owrens disease, labile factor deficiency and proaccelerin
deficiency.
Clotting factor: FV is a large glycoprotein of molecular
weight 249 kDa, is synthesized by hepatocytes and
megakaryocytes. Encoded by a gene on chromosome 1,
hereditary FV deficiency is a very rare autosomal recessive
condition. The prevalence of the homozygous state is
approximately 1 per million.
FV is activated by thrombin and the resulting
heterodimer FVa acts as a cofactor for FXa in the conversion
of prothrombin to thrombin.
Clinical Features
Homozygous deficiency is associated with a moderately
severe bleeding disorder with easy bruising and mucous
membrane bleeding, epistaxis and oral cavity bleeding24,
postoperative, postdental extraction and postpartum
bleeding, etc. Hemarthroses and muscle hematomas are
often related to trauma rather than being spontaneous.
Gastrointestinal bleeding and hematuria may occur
rarely. Intracranial bleeding especially in the antenatal
and neonatal periods have been reported.25
Diagnosis
Factor V deficiency is characterized by prolongation of
both the PT and APTT but a normal TT. By mixing with
normal plasma, both PT and APTT are corrected. By
FV assay or by immunological assessment of FV levels,
deficiency of FV is confirmed. FV assay has to be performed
on individuals with reduced FV levels to exclude combined
FV and FVIII deficiency.
Management
There is no FV concentrate available
FV replacement is done in patients presenting with a
bleeding episode by administering a dose of 1520 mL/
kg of FFP
Use of agents such as tranexamic acid should also be
considered
In patients who are not responding to FPP, use of
recombinant activated factor VII (rFVIIa) should also
be considered26
A potential complication of hereditary FV deficiency is

the development of alloantibodies to FV in FFP
It is suggested that low-level inhibitors can be used to
neutralize large amounts of FFP in case of bleeding
problem27
Immunoglobulin administered intravenous may be
effective in eliminating FV inhibitor.28
COMBINED DEFICIENCY OF FACTORS

V AND VIII
In 1954, Oeri et al. first described combined FV and FVIII
deficiency, which is a rare autosomal recessive disorder.
History of consanguinity present. It is likely to be due to a
single gene defect (located on the long arm of chromosome
18), leading to deficiency of a transport protein, rather
than due to coinheritance of separate defects of the FV and
FVIII genes.
Affected individuals have reduced plasma levels of
both FV and FVIII.29
Shetty et al. from India reported nine patients from five
unrelated families of combined FV and FVIII deficiency,
youngest being an 8-year-old girl.20
Clinical Features
Mild bleeding symptoms, such as easy bruising and
epistaxis are present. In 9 patients from India, the most
common manifestations observed were prolonged
bleeding from cuts, easy bruisability, bleeding gums
and postdental extraction bleeding. Following a dental
extraction or a surgery, bleeding is common phenomena.
In affected woman menorrhagia and postpartum
hemorrhage is seen.
Diagnosis
The combined deficiency disorder is associated with
a prolongation of both the PT and APTT, with the APTT
prolongation disproportionate to that of the PT. By using
normal plasma, both the test times are corrected.
APTT-based activity assays and antigen assays reveal
levels of between 5 IU/dL and 20 IU/dL for both FV and
FVIII.
Management
Both FVIII concentrates and FFP are to be used
for treating patients with combined FV and FVIII
deficiency who have spontaneous bleeding episodes.
(as a source of FV)
FVIII levels should be raised to at least 30 IU/dL for
minor bleeding episodes and for more severe bleeding
atleast 50 IU/dL with rFVIII concentrate
FFP should be administered for patients with FV
deficiency, in order to increase the FV level to at least 25
U/dL.
Rather than intramuscular vitamin K, affected babies
should receive oral vitamin K.18
There is no indication for routine prophylaxis with
plasma and FVIII. Neonatal intracranial hemorrhage has
not been described in this condition.
FACTOR VII DEFICIENCY

Also known as proconvertin, deficiency, Alexanders
disease.
Among the rare inherited coagulation disorders
the most common is factor VII deficiency. Factor VII
is a vitamin K-dependent glycoprotein with a MW of
approximately 50 kDa.
FVII deficiency is inherited in an autosomal recessive
manner.
Estimated prevalence of FVII deficiency 1:300000
1:500000. First recognized in 1951, circulates in plasma
in two formsthe majority in a single chain inactive form
with a concentration of 10 nmoles/L (0.5 g/mL) and a
much smaller amount (approximately 10110 pmoles/L
as the active two-chain form.
happen if the blood samples collected for the determina

tion of FVII:C are stored at 4C. An enzyme-linked
immunosorbent (ELISA) assay or immunoradiometric
assay (IRMA) assay and monoclonal or polyclonal
antibodies are used frequently to measure FVII antigen
(FVII:Ag). Such assays can detect as little as 0.01 IU/dL
of FVII. Functional FVII assay should be preferred over
immunological assay. Due to the low physiological levels
of the neonate, diagnosis of factor VII deficiency may be
difficult in neonates. Age- and gestation-related reference
ranges must be used in such cases for this reason.
Management
Current therapeutic options to manage patients with FVII
deficiency include fibrinolytic inhibitors (tranexamic
acid), plasma, intermediate purity FIX concentrates
(prothrombin complex concentrates), FVII concentrates
and recombinant factor VIIa (rFVIIa).
Plasma FVII has a short in vivo half-life of approximately
5 hours; plasma infusions may not achieve adequate levels
for normal hemostasis. With levels of FVII:C in the range
of 1015 IU/dL, efficient hemostasis can be achieved.
For patients requiring replacement therapy due to FVII
deficiency, rFVIIa is recommended.22
Clinical Features
FACTOR X DEFICIENCY
Common manifestations include; epistaxis, gum

bleeding, menorrhagia and other mucous membranetype bleeding.30 Increased risk for developing
intracranial hemorrhage is reported in neonates who
are diagnosed with factor VII deficiency
Although it is not a consistent finding joint bleeds are
reported in some patients with severe FVII deficiency
Bleeding into the central nervous system is common in
patients with severe FVII deficiency (FVII:C <2 IU/dL),
and is reported to be between 15% and 60%
Although the mechanism is unclear, thrombosis in
association with FVII deficiency is also reported.31
It is an autosomal recessive disorder which is also

called severe (homozygous). In general population its
incidence is 1:1,000,000. Factor X or Stuart-Prower factor,
deficiency was first identified in the 1950s in the US and
England in two patients: Rufus Stuart and Audrey Prower.
Kumar et al. from India reported three pediatric cases
with FX deficiency and two out of them were product of
consanguineous marriage.32
In the coagulation cascade, factor X occupies a unique
position, as the first enzyme in the common pathway of
thrombus formation. Following secretion into plasma, FX
synthesis occurs in the liver, at a concentration of 10 g/
mL.
Either a quantitative deficiency or a dysfunctional
molecule can be the cause of this deficiency. Systemic
amyloidosis, although rare in children, may be associated
with factor X deficiency owing to the adsorption of factor X
on the amyloid protein.
Diagnosis
Characteristic features of factor VII deficiency is finding
of a prolonged PT, which corrects, unless an inhibitor is
present, in a 50:50 mix with normal plasma.
FI concentration, APTT and TT are found to be normal.
Before making the diagnosis of FVII deficiency, it is critical
to exclude vitamin K deficiency or any other clotting
disorder which is acquired.
A therapeutic trial of vitamin K may be of value.
Using a one-stage PT-based assay, the functional
FVII activity (FVII:C) is measured. Cold activation of FVII
and substantial overestimation of the true FVII level can
Clinical Features
FX deficiency may present at any age in individuals. With
umbilical stump bleeding, factor X deficiency may be
present in the neonatal period too. Easy bruising may be
experienced in patients who are mildly affected by factor
X deficiency. Epistaxis is the most frequent symptom
in patients with FX deficiency and other mucosal-type
bleeding is less frequent. Women of reproductive age may
present with menorrhagia. Rarely reported presentations
include central nervous system hemorrhage, hemarthroses
and severe postoperative hemorrhage. Severe arthropathy
may be due to recurrent hemarthroses.
Bleeding only after hemostatic challenge is seen
in moderately affected patients (FX:C 15 IU/dL), for
example, trauma or surgery.
During routine screening or family studies, mild
FX deficiency (FX:C 610 IU/dL) may be identified
incidentally.
Diagnosis
Following the finding of a prolonged PT and APTT, which
corrects in a 50:50 mix with normal plasma, the diagnosis
of FX deficiency is suspected. By measuring the plasma
FX levels, the FX deficiency diagnosis is confirmed. the
one-stage PT- and APTT-based assays, a chromogenic
assay, an assay employing Russell viper venom (RVV)
and an immunological assay are the five different assays
available for measuring plasma FX levels. However, for the
diagnosis of FX deficiency, one-stage PT- or APTT-based
assay are sufficient. Before the diagnosis of FX deficiency
is made, it is crucial to exclude other deficiencies such as
vitamin K and other acquired causes of a clotting disorder.
However, a therapeutic trial of vitamin K may be of value.
Management
Management of patients with FX deficiency includes
fibrinolytic inhibitors, plasma and intermediate purity
FIX concentrates (prothrombin complex concentrates).
To treat acquired FX deficiency secondary to amyloidosis
rVIIa is used.33 Even in the immediate postoperative
period, for hemostasis, factor levels of 1020 IU/dL are
generally sufficient. For management of the acute bleed
and the treatment of choice is prothrombin complex
concentrates. The biological half-life of FX is 2040 hour,
so infusion of approximately 20 mL of FFP per kg of body
weight followed by 6 mL/kg every 12 hours increases
the level FX sufficiently to achieve hemostasis for minor
bleeding episodes.34
FACTOR XI DEFICIENCY (HEMOPHILIA C)

Factor XI (FXI) deficiency or hemophilia C was described
for the first time in 1953 in a Jewish family in the United
States by Dr Rosenthal. It is particularly common in
Ashkenazi Jews in whom the heterozygote frequency is 8
percent. Factor XI deficiency is generally transmitted as
an autosomal recessive trait, and both sexes are affected;
however, cases of dominant transmission have also been
reported. FXI can be activated to FXIa by FXIIa, thrombin,
or by autoactivation. FXIa promotes coagulation by

activating factor IX (FIX).
This disorder is divided into two categories:
1. Type I deficiency, which corresponds with low activity
and levels of FXI antigen.
2. Type II deficiency, with low activity and normal FXI
antigen levels.35
FXI deficiency has been described in all racial groups.36
Gene defect is seen in the F11 gene, located on the
long arm of chromosome 4 [4q35]. This gene encodes
an 18-amino acid signal peptide and a 607-amino acid
mature protein. More than 100 mutations causing FXI
deficiency have been reported which are distributed all
over the gene.37
Clinical Features
It can affect both men and women and is associated with
mild to moderate bleeding, especially after trauma or
surgery.
There are no reports of presentation of spontaneous
bleeding in the neonatal period. No instances of neonatal
intracranial hemorrhage resulting from FXI deficiency
have been reported. Epistaxis, soft tissue hemorrhage,
and bleeding after dental extraction may occur, but
hemarthroses and concomitant arthropathy are not seen.
Diagnosis
The APPT is prolonged in factor XI deficiency, whereas the
PT is normal.
Management
Minor surgeries can be controlled with local pressure;
dental extraction can be monitored closely and the patient
treated only if hemorrhage occurs. Fibrinolytic inhibitors
(Tranexamic acid-15 mg/kg, 8 hourly) are useful. The IV
preparation is given orally in this situation although this is
not a licensed use of the product.18
Plasma infusion of 1 mL/kg body weight can increase
the circulating factor by about 1.5 U/dL.
A loading dose of 1520 mL of plasma/kg will result in
plasma level of 2030 U/dL, a level that is usually sufficient
to control moderate hemorrhage. The half-life of FXI is 48
hours or greater.
FACTOR XIII DEFICIENCY (FIBRIN

STABILIZING FACTOR DEFICIENCY)
Inherited factor XIII (FXIII) deficiency is an autosomal
recessive bleeding disorder, mostly because of defects in
the FXIII-A gene resulting in FXIII-A deficiency.38
Jayandharan et al. reported nine mutations in
coagulation factor XIII A gene in eight unrelated Indians
and five out of them were novel.39
Clinical Manifestations
dilute monochloroacetic acid or acetic acid. To determine

FXIII activity quantitatively, measuring the incorporation
of fluorescent or radioactive amines into proteins is
adopted. Specific ELISA tests are required to assess FXIII-A
and FXIII-B antigen lvels.
Factor XIII deficiency is charecterized by delayed

hemorrhage. Patients develop a bruise or hematoma
after delay of some time interval of injury. Bleeding
from the umbilical stump in the first few days of life with
delayed separation is common. It is characteristic that
prolonged bleeding following trauma, after an intracranial
hemorrhage, ecchymoses, hematomas.40 Hemarthroses
and bleeding into the muscles are less common than
in hemophiliacs. Delayed wound healing also occurs.
In affected females, habitual abortions are commonly
observed. It may either be due to intrauterine bleeding or
impaired formation of cytotrophoblastic shell leading to
detachment of the placenta and miscarriage.
Management
Diagnosis
CONCLUSION
The normal factor XIII deficiencies are PT and APTT.

Due to the failure of cross linking there is an increased
solubility of clot and screening tests for factor XIII
deficiency are based on this observation. FXIII deficiency
is demonstrated by increased clot solubility in 5 M urea,
The most frequent bleeding disorders are the von Willebrand

and disease, hemophilia A and B. Inherited deficiencies of
coagulation factors other than factor (F) VIII and FIX, the
so-called rare coagulatuion disorders (fibrinogen, FII, FV,
FV+FVIII, FVII, FX, FXI, FXIII deficiencies), generally leads
Replacement therapy for FXIII deficiency is highly

satisfactory because of the small quantities of FXIII
needed for effective hemostasis (5%) and the long halflife of FXIII (1014 days). Prophylactic therapy with
plasma-derived, virus-inactivated FXIII concentrate at a
dose of 1020 U/kg every 56 weeks has been successful
in achieving normal hemostasis.41 A new recombinant
FXIII-A2 (rFXIII-A2) concentrate appears to be safe and
appropriate for monthly prophylactic administration in
patients with FXIII-A deficiency42. Characteristic features
of rare coagulation disorders are shown in Table 2.
Table 2 Characteristic features of rare coagulation disorders

Disorder
Inheritance
Clinical features
APTT
PT
TT
Factor I
deficiency
Autosomal recessive
4q23-34
Predisposition to thrombosis; may suffer from

little, moderate or severe bleeding
Prolonged
Prolonged
Prolonged
Factor II
deficiency
Autosomal recessive
11p11-q12
Umbilical cord bleeding and intracranial bleeds Prolonged

in neonates; bleeding after trauma or surgery;
easy bruising
Prolonged
Normal
Factor V
deficiency
Autosomal recessive
1q21-25
Bleeding into the skin; nose bleeds; bleeding of Prolonged

the gums; prolonged/excessive bleeding with
minor injuries, surgery or trauma
Prolonged
Normal
Factor VII
deficiency
Autosomal recessive
13q34
Spectrum variable. Bleeding of mucous

membranes; excessive bruising; bleeding into
muscles and/or joints; CNS bleeding
Normal
Prolonged
Normal
Factor X
deficiency
Autosomal recessive
13q32
Umbilical stump bleeding. Mucous membrane

bleeding; bleeding into joints; muscle
bleeding; CNS bleeding
Prolonged
Prolonged
Factor XI
deficiency
Autosomal recessive
4q35
Mild-to-moderate bleeding. Prolonged/

excessive bleeding with surgery or trauma;
bruising; hematuria; delayed bleeding
Prolonged
Normal
Factor XIII
deficiency
Autosomal recessive
A-subunit- 6p24-25
B-subunit- 1q31-32
Delayed bleeding; bleeding from umbilical

stump after birth with delayed separation;
prolonged bleeding from trauma; delayed
wound healing
Normal
Normal
Normal
to lifelong bleeding disorders. These disorders are largely
inherited by autosomal recessive genetics. As these are not
well-characterized clinically in comparison to common
bleeding disorders, they do not have well-established
treatment strategies. High index of suspicion is required
to diagnose rare coagulation disorders and a sophisticated
laboratory support is essential to confirm the clinical
diagnosis.
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M, Hernandez-Navarro F. Acquired von Willebrand
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14. Veyradier A, Jenkins CS, Fressinaud E, Meyer D. Acquired
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15. Hayes T. Dysfibrinogenemia and thrombosis. Arch Pathol
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16.
Roberts HR, Stinchcombe TE, Gabriel DA. The
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17. Neerman-Arbez M, de Moerloose P. Mutation in the
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afibrinogenemia: an update and report of 10 novel
mutations. Hum Mutat. 2007;28:540-53.
18. Bolton-Maggs PHB, Perry DJ, Chalmers EA, et al. The
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19. Schuepbach RA, Meili EO, Schneider E, Peter U, Bachli
EB. Lepirudin therapy for thrombotic complications in
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1044-6.
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A, Ghosh K, Mohanty D. Combined Factor V and VIII
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of inherited factor V deficiency in 35 Iranian patients. Br J
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with intravenous immune globulin. J Pediatr Hematol
Oncol. 1997;19:226-31.
29. Peyvandi F, Tuddenham EG, Akhtari AM, Lak M,
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30. Peyvandi F, Mannucci PM, Asti M. Clinical manifestations
in 28 Italian and Iranian patients with severe factor VII
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689-700.
32. Kumar A, Mishra KL, Kumar A, Mishra D. Hereditary
coagulation factor X deficiency. Indian Pediatr. 2005;
42:1240-2.
33. Boggio L, Green D. Recombinant human factor VIIa in the
management of amyloid-associated factor X deficiency. Br
J Haematol. 2001;112:1074-5.
34. McMahon C, Smith J, Goonan C, Byrne M, Smith OP. The
role of primary prophylactic factor replacement therapy
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2002;119:789-91.
35. Franchini M, Veneri D, Lippi G. Inherited factor XI
deficiency: a concise review. Hematology. 2006;11:307-9.
36. Peyvandi F, Lak M, Mannucci P. Factor XI deficiency in
Iranians: its clinical manifestations in comparison with
those of classic hemophilia. Haematologica. 2002;87:512-4.
37. Fard-Esfahani P, Lari GR, Ravanbod S, Mirkhani F,
Allahyari M, Rassoulzadegan M, Ala F. Seven novel
point mutations in the F11 gene in Iranian FXI-deficient

patients. Haemophilia. 2008;14:91-5.
38. Greenberg CS, Sane DC, Lai T. Factor XIII and fibrin
stabilization. In: Colman RW, Marder VJ, Clowes
AW, George JN, Goldhaber SZ (Eds). Hemostasis and
Thrombosis, 5th edn. Philadelphia: Lippincott Williams
39. Jayandharan GR, Viswabandya A, Baidya S, Nair SC,
George B, Mathews V, Chandy M, Srivastava A. Mutations
in coagulation factor XIII A gene in eight unrelated Indians.
Thromb Haemost. 2006;95:551-6.
40. Lak M, Peyvandi F, Ali Sharifian A, Karimi K, Mannucci
PM. Pattern of symptoms in 93 Iranian patients with
severe factor XIII deficiency. J Thromb Haemost.
2003;8:1852-3.
41. Gootenberg JE. Factor concentrates for the treatment of
factor XIII deficiency. Curr Opin Hematol. 1998;5:372-5.
42. Lovejoy AE, Reynolds TC, Visich JE, et al. Safety and
Pharmacokinetics of recombinant factor XIII-A2
administration in patients with congenital factor XIII
deficiency. Blood. 2006;108:57-62.
30
Acquired Inhibitors of Coagulation
Acquired inhibitors of coagulation are antibodies that develop against coagulation proteins when there is either a congenital
deficiency of coagulation proteins or when there is an underlying disease process that precipitates the formation of these antibodies.
The resultant functional deficiency of coagulation factors causes altered coagulation profiles leading to, at times, severe bleeding
disorders.
Coagulation inhibitors are basically antibodies against naturally occurring clotting factors and may occur as alloantibodies in patients with congenital factor deficiencies or as
autoantibodies in patients with previously normal coagulation who have associated underlying diseases.1 Bleeding
occurs from multiple sites and is often compounded by the
simultaneous deficiency of natural clotting factors. As acquired inhibitors of coagulation are quite rare, a high index
of suspicion is required to recognize and treat the disorder
effectively. Multiple mechanisms are involved in the pathogenesis and hence treatment modalities need to attend to all
the mechanisms in order to be effective.

Among all the clotting factor inhibitors, the most
commonly occurring inhibitor is against factor VIII and
the resultant clinical syndrome is referred to as acquired
hemophilia.2 Autoantibody inhibitors against factor II,
factor V, factor VII, factor IX, factor X, factor XI, factor XIII
and the von Willebrand factor proteins have also been
reported.3
ACQUIRED HEMOPHILIA
Inhibitors to FVIII are the most common in clinical
practice, but the diagnosis of acquired hemophilia is
difficult owing to its rarity and because the patient does
not have the usual precedent personal or family history
of bleeding as seen in congenital hemophilia.2 Moreover,
the clinical signs and symptoms as well as the severity of
acquired hemophilia differs quite significantly from that of

hereditary hemophilia.
Pathophysiology
Acquired hemophilia is a spontaneous autoimmune
disorder in which patients with previously normal
hemostasis develop antibodies against clotting factors,
most frequently FVIII.4 The development of antibodies
against FVIII leads to functional FVIII deficiency, which
results in insufficient generation of thrombin through the
intrinsic pathway of the coagulation cascade (Flow chart 1).
Patients with this disorder are thus at an increased risk of
both spontaneous as well as post-traumatic bleeding.
At the chromosomal level, the most common sites
coding for the development of these offending antibodies
appear to occur in the A2 and A3 domain on the heavy
chain of FVIII and in the C2 domain on the light
chain.3,5,6 These sites when activated produce anti A2,
A3 and C2 antibodies which are alloantibodies in nature
in primary coagulation deficiencies and autoantibodies
when associated with underlying disease.
Anti-A2 and Anti-A3 antibodies impede the binding of
FVIII to activated factors X and IX of the Factor X activation
Complex in the intrinsic pathway while Anti-C2 antibodies
inhibit the binding of FVIII to phospholipids and may also
interfere with the binding of FVIII to Willebrand factor
protein.7
Flow chart 1 Coagulation cascade
cantly lower than reported with acquired hemophilia

A. There is no known association between the tendency
to develop these acquired antibodies and ethnicity and
these inhibitors have been seen with no specific genetic
inheritance pattern in all racial groups.
ETIOLOGY
Acquired hemophilia results from the development
of antibodies (mostly of the IgG1 and IgG4 subclasses)
directed against various clotting factors.3,8,11
Numerous conditions that have been associated
with acquired inhibitors to FVIII (Table 1) include:
Frequent blood transfusions (as in hemolytic anemias)
Pregnancy
Autoimmune disorders
Dermatologic disorders
Respiratory diseases
Diabetes mellitus
Infections
Malignancies
Rarely, FVIII antibodies arise as an idiosyncratic
reaction to medications.
However, in approximately 50 percent of cases, no
underlying or precipitating factor can be found.2,12
Among the antibodies, the mechanism of factor
VIII inactivation differs.8 For example, alloantibodies
inactivate FVIII activity in totality according to type 1
kinetics and this total inactivation is independent of the
titer or concentration of circulating antibody. In contrast,
autoantibodies typically exhibit more complex type II
kinetics causing an initial rapid inactivation of factor VIII
followed by a slower inactivation reaction and results in
some residual FVIII activity which can be detected in the
blood but is not useful clinically to prevent bleeding.8,9 The
end result is that severe or partial deficiency of Factor VIII
occurs leading to its associated clinical syndromes.
EPIDEMIOLOGY
Acquired hemophilia has a worldwide distribution. In
the United Kingdom, the incidence has been reported
to be 1.48 per million persons per year10 while in the
United States, it is 0.2 to 1.0 case per million persons
per year. These figures may, however, underestimate
the true incidence of the disorder given the difficulty
in making the diagnosis.2 Further, some patients with
acquired hemophilia and low titers of inhibitors may not
be diagnosed, unless they bleed after surgery or trauma.2

The incidence of acquired inhibitors to clotting
factors other than FVIII is unknown, although it is signifi
CLINICAL FEATURES
History
Unlike patients with hereditary hemophilia, patients
do not have a personal or family history of bleeding
episodes.2 About half of the cases are associated with other
conditions, such as autoimmune disease, and cancer2,12
and history may often reflect the underlying disease.
Physical Findings
In these patients, instead of the intra-articular bleeding
episodes, which are typical in congenital FVIII deficiency,
hemorrhages occur into the skin, muscles, soft tissues and
mucous membranes.2 Bleeding episodes are often more
frequent and severe than in congenital hemophilia.
On Examination
Typical signs include epistaxis, gastrointestinal and
urological bleeding and rarely cerebral hemorrhage.2,7,11
Spontaneous bruising and muscle hematomas are also
quite frequent.3 Other manifestations include prolonged
bleeding following trauma or surgery and iatrogenic
bleeding, particularly following attempts to insert
intravenous lines.2
Chapter-30 Acquired Inhibitors of Coagulation 313

Table 1 Conditions associated with acquired inhibitors to factor VIII
S. No. System involved
Disease state
1.
Frequent blood transfusions
Hemolytic anemias (Thalassemia)
2.
Systemic lupus erythematosus
Autoimmune hemolytic anemia
Goodpasture syndrome
Myasthenia gravis
Graves disease
Autoimmune hypothyroidism
3.
Ulcerative colitis
4.
Dermatologic disorders
Psoriasis
Pemphigus
5.
Respiratory diseases
Asthma
6.
Drugs
Penicillin and its derivatives

Sulfonamides
Phenytoin
Chloramphenicol
Methyldopa
Interferon-Alfa
7.
Malignancies and premalignant conditions Solid tumors

Chronic lymphocytic leukemia
Non-Hodgkin lymphoma
Waldenstrm macroglobulinemia
Myelodysplastic syndrome
Myelofibrosis
Erythroleukemia
8.
Infections and vaccinations
9.
Idiopathic
INVESTIGATIONS
An isolated prolongation of the activated partial
thromboplastin time (aPTT) that is not corrected when
the patients plasma is incubated with equal volumes
of normal plasma in a mixing study is pathognomonic
of acquired inhibitors to factor VIII.2,11 Because the
action of the inhibitor is often delayed, incubation for 2
hours at 37C is required before the correction study is
initiated.13
Bleeding time, prothrombin time, and platelet
counts are normal.
Reduced factor VIII levels and evidence of a factor
VIII inhibitor are diagnostic. Although acquired
hemophilia A is a rare condition, FVIII inhibitors in
very low concentrations and not typically detected
by screening coagulation assays have been detected
by specific assays in 17 percent of healthy individuals
Acute hepatitis B infection

Acute hepatitis C infection
BCG vaccination
with normal FVIII levels and no bleeding symptoms or

history.14,15
Acquired hemophilia can occasionally be confused
with disseminated intravascular coagulation because
of its clinical presentation and a prolonged aPTT;
however, the absence of a prolonged prothrombin
time (PT), low fibrinogen, elevated fibrin degradation
products and D-dimers and thrombocytopenia7
should help distinguish between the conditions.
Among the common causes of isolated prolonged
aPTT is lupus anticoagulant.16 Presence of lupus
anticoagulant is suggested when aPTT values during
the mixing study are similar at time zero and after
incubation at 37C8 and can be confirmed by specific
tests, such as the dilute Russell viper venom time and
the kaolin clotting time.17,8
As heparin administration can also prolong aPTT,
a thorough treatment history and relevant tests
for heparin effects are indicated. The presence of
heparin is suggested by a prolonged thrombin time in
association with a normal reptilase time.8
The levels of other intrinsic pathway factors (factors IX,
XI, and XII) may also be reduced by antibodies against
these factors in patients with acquired hemophilia A.14,12
Therefore, it is important to repeat factor assays8 using
increasing dilutions of patient plasma to establish the
specificity of the inhibitor. Once detected, the acquired
inhibitor should be quantified to assess the severity of
the disorder and the risk of hemorrhage. Methods used
for quantifying factor VIII inhibitors are the Bethesda
assay and the Nijmegen modification of the Bethesda
assay.18 One Bethesda unit (BU) is the quantity of
inhibitor that inactivates 50 percent of factor VIII in
normal plasma after incubation at 37C for 2 hours.
However, both the Bethesda assay and the Nijmegen
modification may underestimate the potency of
the inhibitor due to its nonlinear complex reaction
kinetics.18 As a result of its kinetic profile, the recovery
and half-life of exogenous FVIII may be considerably
reduced, even in patients with low inhibitor titers. This
has significant implications for therapy.
Imaging studies: MRI, CT scan, and ultrasound may
be needed to localize, quantify, and serially monitor
the location of bleeding and response to therapy.
Other imaging tests can be used as needed to diagnose
associated diseases.
Other tests: Testing patients with pregnancy-associated
acquired hemophilia, for autoimmune disorders such
as lupus and rheumatoid arthritis is recommended
because the presence of an autoimmune disorder may
require a change in therapeutic approach.19
DIFFERENTIAL DIAGNOSES

Lupus anticoagulant
von Willebrand disease
Dysfibrinogenemia
Heparin administration
Congenital hemophilia
MANAGEMENT
Management of acquired inhibitors involves three
strategies:
1. Management of acute bleeding
2. Eradication of the inhibitor
3. Management of the etiological cause
The approach to these objectives usually depends on
the natural history of the disease, the clinical presentation,
and the titer of the inhibitor. Frequently, treatment of the
underlying disorder or the discontinuation of an offending

drug may be all that is required.7
MANAGEMENT OF BLEEDING
Management of Mild Bleeding
Patients with mild or minimal bleeding rarely require
specific treatment to control bleeding and require only
immunosuppressive therapy for the inhibitors. Studies
have shown that there is no correlation between the titer of
the inhibitor and the severity of bleeding hence treatment
should be based on symptomatology rather than on the
inhibitor titers.10
Management of Moderate-to-Severe Bleeding

In patients with moderate-to-severe bleeding, the manage
ment depends upon the inhibitor titer.10 In patients
with very low titer inhibitors (<3 BU) treatment with
Desmopressin has been found to be useful in augmenting
residual factor VIII activity.7 IV infusion of desmopressin
(0.3 mcg/kg) may result in a 2- to 3- fold temporary increase
in plasma levels of FVIII and von Willebrand factor.19
However, in many patients, Desmopressin treatment
alone will not ensure hemostasis.7

In cases where the inhibitor titer is between 3 and
5 BU, increasing the levels of factor VIII in the plasma by
factor VIII infusions may suffice to control the bleeding.7,12
These patients may need a higher than usual dose of
factor VIII, as much as double or triple the dose compared
to patients of congenital hemophilia of the same body
weight.19,20 An arbitrary dose of FVIII 200 IU/kg IV bolus
every 812 hours has been recommended.21 There are no
published studies on the use of human FVIII in acquired
hemophilia to guide its dosing.14
Patients in whom the levels of Factor VIII inhibitor is
higher (> 5 BU) require other modalities of treatment to
control bleeding:
Recombinant activated factor VII (FVIIa): Here the
requirement of factor VIII in the coagulation cascade
is bypassed by FVIIa binding to activated platelets and
promoting thrombin synthesis, thereby controlling
bleeding. Studies have shown that there is dramatic
control of bleeding in more than 90 percent of cases
within a few hours of infusion.22 FVIIa has also been
found to have very few side effects, is free of anamnestic
reactions and does not transmit blood borne diseases.
Activated prothrombin complex concentrates:
Activated prothrombin complex concentrates (APCCs)
are also used to manage bleeding episodes in acquired
hemophilia. The mechanism of action is by bypassing
the requirement of factor VIII and promoting thrombin

synthesis in the coagulation pathway. Studies in adults
have shown a response rate of 86 percent.23 No studies
are yet available on children. There is a potential risk
of anamnestic reaction and transmission of bloodborne diseases with APCCs which has restricted their
universal use.
Immunoadsorption/plasmapheresis: Selective removal
of the inhibitor using immunoadsorption has been
found to be useful especially in cases where there
is severe hemorrhage, no response to the above
modalities of therapy or when the concentration
inhibitors is very high. After the inhibitors are removed,
factor VIII infusions are given to control the bleeding.
ERADICATION OF THE INHIBITOR

Eradication of the inhibitor is achieved by stopping
the production of the inhibitor by immunosuppressive
therapy.
The various modalities available are:
Steroids: These have been used as first line therapy in
the eradication of the inhibitors. Methyl prednisolone
(oral or IV) or oral prednisolone are the drugs of choice
and have shown response in 60 to 70 percent of adult
cases.
Cytotoxic drug therapy with cyclophosphamide
and azathioprine has been used to control inhibitor
production. However, the side effects of these drugs
and their low safety profiles restrict their universal use.
Other drugs which have also been used are mycophenolate mofetil, vincristine and 2-chlorodeoxyadeno
sine.
Cyclosporine has also been found to have good
immunosuppressive effect on the inhibitors, however
due to its toxicity and side effects, its use in children is
restricted. It has been tried both as monotherapy and
as an adjuvant drug to steroids, showing best results in
cases of systemic lupus erythematosus.7
Immunoglobulins have been used as a second
line treatment option in patients not responsive to
other modalities.7 However, studies have shown an
equivocal response of immunoglobulins in eradicating
inhibitors, and have found best response in those with
low titers of the inhibitor.15
Biological therapy-Rituximab, an anti-CD20
monoclonal antibody, has shown promising results
in eradicating inhibitors in acquired hemophilia.7,24-26
Given in the dose of 375 mg/m2 on D1 and D15, it has
shown excellent results in refractory cases.
Surgical management: May be required in cases
where there are life-threatening bleeding episodes.
Treatment options vary according to the site of bleeding
and can be mechanical (ligature placement, selective
embolization), thermal (electrocautery, cryotherapy)

or chemical (fibrin glues, micronized collagen). 27
ACQUIRED INHIBITORS TO
WILLEBRAND FACTOR
von
Acquired inhibitors to the von Willebrand factor (vWF)

are infrequently encountered and have been seen in
association with:
Autoimmune disorders, monoclonal gammopathies,
lymphoproliferative diseases
Epidermoid malignancies, Wilms tumor
Hypothyroidism
Myeloproliferative disorders
Certain medications.
The incidence of these acquired antibodies is
especially high in children with Wilms tumor, which
makes identifying such patients important due to the
inevitable associated hemorrhagic complications that
occur during surgery. The exact mechanism of synthesis
of this antibody is unclear, however, an interaction
between a plasma factor secreted by the tumor and the
naturally occurring vWF in the blood is thought to result
in premature clearance of the vWF.28 Treatment options
include Desmopressin, infusion of FVIII that contains
vWF (cryoprecipitate), platelet transfusions, intravenous
immunoglobulin and plasma exchange. Acquired antivWF antibody usually disappears after treatment of the
tumor.
ACQUIRED INHIBITORS TO FACTOR V

Acquired inhibitors to factor V are rare and are seen
in lymphoproliferative disorders, adenocarcinoma,
tuberculosis, prolonged aminoglycosides (particularly
streptomycin) usage and topical exposure to bovine
thrombin.29 The clinical presentation of children with this
inhibitor is varied, some children bleed while others do not
which is probably because patients with antibodies that
bind to the factor V present on the platelets bleed more
profusely than those where the antibody binds to factor V
present in the plasma.30 Treatment is by transfusing fresh
frozen plasma and recombinant factor VIIa.
ACQUIRED INHIBITORS TO PROTHROMBIN

Acquired inhibitors to prothrombin occur in patients
with systemic lupus erythematosus, in children treated
with bovine fibrin glue after surgery for congenital heart
disease or exposure to procainamide. A small number are
idiopathic in origin. In children in whom the concentration
of lupus anticoagulant is high, acquired inhibitors to
prothrombin are also present. These inhibitors are difficult
Table 2 Conditions associated with acquired inhibitors to other clotting factors11, 31
Coagulation factor
Associated disorders
VII
Bronchogenic carcinoma, idiopathic
IX
Systemic lupus erythematosus, acute rheumatic fever, hepatitis, collagen vascular diseases, multiple
sclerosis, and postpartum
Amyloidosis, carcinoma, acute nonlymphocytic leukemia, acute respiratory infections, fungicide exposure,
idiopathic
XI
Autoimmune diseases, prostate carcinoma, chronic lymphocytic leukemia, chlorpromazine
XIII
Idiopathic, isoniazid, penicillin
to measure as they do not neutralize coagulant activity in

activity dependent inhibitor assays and hence do not cause
clinically significant spontaneous bleeding. However,
they may cause bleeding during surgery or after trauma.
Treatment is by using fresh frozen plasma or activated
prothrombin complex concentrates. These inhibitors
usually disappear spontaneously within 7 to 21 days or
else can be treated using plasmapheresis, corticosteroids
and immunosuppression.
ACQUIRED INHIBITORS TO OTHER

FACTORS VII, IX, X, XI, XIII
Inhibitors to these factors occur in various conditions
(Table 2) and are not common in children. Treatment
options include fresh frozen plasma, activated prothrom
bin complex concentrates, recombinant factor VIIa along
with inhibitor eradication using plasmapheresis, corticosteroids and immunosuppression.
CONCLUSION
Acquired inhibitors to naturally occurring clotting factors
are commonly encountered in clinical practice and must
be considered in the differential diagnoses of any child
with an altered bleeding profile not responding to the
standard therapy. Acquired inhibitors are associated with
numerous common underlying conditions and require to
be managed aggressively in order to prevent mortality and
morbidity. Early recognition of the presence of inhibitors
helps to institute appropriate management to control the
bleeding as well as prevent further episodes.
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5. Knobe KE, Villoutriex BO, Tengborn LI, Petrini P, Ljung
RC. Factor VIII inhibitors in two families with mild
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6. Barrow RT, Healey F, Jacquemin MG, Saint Remy JM,
Lollar P. Antigenicity of putative phospholipid membrane
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7. Ma AD, Carrizosa D. Acquired factor VIII inhibitors:
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8. Franchini M. Acquired hemophilia A. Hematology. 2006;
11(2):119-25.
9. Green D, Blanc J, Foiles N. Spontaneous inhibitors of
factor VIII: kinetics of inactivation of human and porcine
factor VIII. J Lab Clin Med. 1999;133(3):260-4.
10. Collins PW, Irsch HS, Baglin TP, Dolan G, Hanley J, Makris
M, et al. Acquired hemophilia A in the United Kingdom:
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2007;109(5):1870-7.
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Haematol. 1996;9(2):331-54.
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13. Green D, Lechner K. A survey of 215 non-hemophilic
patients with inhibitors to Factor VIII. Thromb Haemost.
1981;45(3):200-3.
14. Collins PW. Management of acquired haemophilia A
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15. Algiman M, Dietrich G, Nydegger UE, Boieldieu D, Sultan
Y, Kazatchkine MD. Natural antibodies to factor VIII (antihemophilic factor) in healthy individuals. Proc Natl Acad
Sci, USA. 1992;89(9):3795-9.
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activated partial thromboplastin time in an acute care
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17. Kazmi MA, Pickering W, Smith MP, Holland LJ, Savidge
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18. Verbruggen B, Novakova I, Wessels H, Boezeman J,
van den Berg M, Mauser-Bunschoten E. The Nijmegen
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inhibitors: improved specificity and reliability. Thromb
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19. Delgado J, Jimenez-Yuste V, Hernandez-Navarro F, Villar
A. Acquired haemophilia: review and meta-analysis
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2003;121(1):21-35.
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21. Kessler CM. New perspectives in hemophilia treatment.
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29. Savage W, Kickler T, Takemoto C. Acquired coagulation
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acquired inhibitor of human coagulation Factor V. J Clin
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2004;10(5):593-628.
31
Immune Thrombocytopenic
PurpuraDiagnosis and Management
Immune thrombocytopenic purpura (ITP) in children is an acquired hemorrhagic disorder occurring in an apparently healthy child,
usually due to transient postviral autoimmune phenomenon, characterized by acute onset of petechiae, bruising and mucosal
bleeding. It is associated with isolated thrombocytopenia (platelet count <1,00,000/cumm) with normal or increased megakaryocytes
in an otherwise normal marrow without evidence of concurrent abnormality or disease process that might account for the
thrombocytopenia. Despite major advances in our understanding of the molecular basis of many blood disorders, despite major
advances in our understanding of basic underlying pathophysiology for more than 50 years, the diagnosis of ITP still remains one of
exclusion and currently no confirmatory clinical or laboratory diagnostic parameters exist.
There is no single simple test for the diagnosis of ITP. Hence, there are many unresolved issues pertaining to its diagnosis and
management of this disease.
Immune thrombocytopenic purpura (ITP) was first

described as Morbus hemorrhagicus maculosus by
German physician Paul Gottlieb Werlof in 1735.13
Immune thrombocytopenic purpura (ITP) is most
common acquired autoimmune bleeding disorder and is
characterized by a low platelet count and mucocutaneous
bleeding.1-9,3a
CLASSIFICATION
ITP may be classified as:4-9
Acute
Chronic
Recurrent.
These differ especially in respect to patients age at
onset, sex, medical events preceding the onset, duration
of thrombocytopenia and response to treatment. It
is not possible to distinguish them at the onset of
symptomatology. However, in the age group above 13
years, the incidence of chronic ITP is higher. In this age
group 80 to 90 percent cases continue to have active
disease for 6 months to one year.4-9
Acute ITP is common after the age of 3 months through

childhood with a peak incidence between 2 and 5 years
of age which also is the age at which children are most
susceptible to viral infections, a major etiological factor.4-9
Acute ITP is generally a benign and self-limiting
condition, with 90 percent of them making an uneventful
recovery within 3 weeks to 6 months with or without
specific treatment. Only 10 percent of ITP cases progress
to chronic ITP. 65-95 percent of prepubertal children who
develop ITP have the acute form of the disease. Of these
55 to 75 percent in < 1 month, 80 to 90 percent in < 4 to
6 months resolve, only 10 percent of ITP cases progress
to chronic ITP.2-6 ITP occurring for the first time before
the age of 10 years is predominantly acute whereas after
20 years of age chronic ITP is almost the rule, though the
disease is not limited to any age.7,9 Although there is no sex
predilection for ITP in childhood, in the adult form of the
disease, there is 3:1 predominance in women.
In recurrent ITP there is recurrence of thrombocy
topenia after a sustained normal platelet count. It is
precipitated each time usually following a viral infection.
Boys and girls are equally affected.
Chapter-31 Immune Thrombocytopenic PurpuraDiagnosis and Management 319
DIAGNOSIS OF ITP1-9,12-19
Table 1 Incidence of symptoms in ITP10
There is no single simple test for the diagnosis of ITP. The

diagnosis of ITP is still a clinical one, based on the patients
history, physical examination and complete blood cell
count as well as examination of peripheral blood smear and
bone marrow examination (If done.).12-16 There is no gold
standard test that can reliably establish the diagnosis.
The usual presentation is sudden onset of mucocutaneous
bleeds (Figs 1A and B) in an otherwise healthy child (the
child may be considered healthy in the absence of fever
and any systemic abnormality). The diagnosis is more by
exclusion. A typical case is a child with ITP, characterized
by isolated thrombocytopenia, with normal counts in
otherwise healthy child without any hepatosplenomegaly,
no lymphadenopathy and bony tenderness and may be
preceded by viral infection 2 to 3 weeks earlier. However,
patients with risk factors for human immunodeficiency
virus, should be tested for HIV antibodies.
It is usually a benign disorder.
ITP may be (Table 1):4-12
Asymptomatic: Incidentally detected low platelet
count. Systemic examination is usually normal. No
bleeding manifestations may be present.
Mild symptoms: Bruising/petechiae, minor epistaxis,
little/no interference with daily living.
Moderate symptoms: Skin bleed, epistaxis and menorr
hagia, mucosal bleeds more troublesome.
Severe symptoms: Severe bleeding episodes include
ICH requiring hospitalization and/or transfusions.
GI bleeding, severe epistaxis, hematuria, prolonged
menorrhagia.
Usually there is no hepatosplenomegaly; spleen may
be just palpable in 10 to 12 percent of the even normal
children.
Figs 1A and B Mucocutaneous bleeds (hematoma, petechiae

and purpura)
Common bleeds UK survey
Our series
Total 132
Bruising and
skin bleeds
386
(90%)
122
Nose bleeds
95
(20%)
31
ICH
1%
Mouth, gum,
tongue bleed
68
(16%)
35
GI bleed
10
(2%)
Conjuctival
hemorrhage
(2%)
Hematuria
(1%)
Heavy periods
(0.7%)
Bleeding ear/
eye
(0.5%)
No bleeding
symptoms
(2%)
Preceding
viral infection/
immunization
245
(57%)
30
If child is clinically ill, with moderate or massive

splenomegaly, sternal tenderness/bony tenderness
or joint pains then it suggests an alternative cause,
sinister causes like malignancy, leukemia.
Constitutional symptoms, such as fever or weight loss,
hepatomegaly or lymphadenopathy might indicate
underlying disorder such as HIV, viral infection, syste
mic lupus erythematosus (SLE), or a lympho-prolife
rative disease.
Anemia disproportionate to severity of bleeding, is
unlikely to be due to ITP and should consider aplastic
anemia, leukemia.
Atypical rash should lead to suspicion of an alternate
diagnosis like viral infections.
If child is clinically ill, then it is unlikely to be ITP,
and should consider other etiology like infection
meningococcal infection, septicemia and other sinister
diseases like aplastic anemia, leukemia, etc.
Presence of significant lymphadenopathy, hepatosplenomegaly should lead to the suspicion of infectious
diseases like EBV or CMV or any other alternative
diagnosis like leukemia.
Response to specic therapy, for example, intravenous
immunoglobulin (IVIg) and intravenous anti-D is
supportive of the diagnosis, but a response does not
exclude secondary ITP.
On examination, these children may have petechiae,
purpura and/or bruises. Serious bleeding is rare. Only 4
percent have serious symptoms such as severe epistaxis,
GI bleeding or hematuria. Less than 1 percent children
with ITP develop intracranial bleeds.
Presence of fever, weight loss, bony pains, hepato
splenomegaly or lymphadenopathy and anemia dispro
portionate to amount of bleeding, would suggest diagnosis
other than ITP (e.g. leukemia, lymphoma, viral infections,
malaria, aplastic anemia, etc.). However, a just palpable
spleen may be normally present in 10 percent of pediatric
population.
When platelets are reduced in number (Thrombocytopenia) or defective in function (thrombasthenia), bleeding
may occur. Bleeding typically involves skin and mucous
membranes including petechiae, purpura, ecchymosis
and epistaxis, hematuria and gastrointestinal hemorrhage. Intracranial hemorrhage can occur rarely.
Most thrombocytopenia in children are the result
of increased platelet destruction. The bone marrow in
such cases responds with compensatory increase in the
rate of production with increased number of immature
megakaryocytes. The increased mean platelet volume
provides supportive evidence of the larger size young
platelets, which are functionally very active, are more
prominent in the peripheral blood smear. The increased
mean platelet volume provides evidence of the larger
size. Normal MPV is 6.010 fL.
In disorders with decreased platelet production,
the decreased platelet number is associated with small
sized platelets, a decreased mean platelet volume and
a longer bleeding time relative to platelet number. The
megakaryocytes are decreased in number or absent in
bone marrow aspirate.
In the diagnostic evaluation of thrombocytopenia,
it is important first to determine whether other blood
components are involved. Co-existing abnormalities of
the white blood cells or red cells may indicate other causes
of diseases involving bone marrow like aplastic anemia
(Fig. 7), leukemia (Fig. 8).
Abnormalities in coagulation, in association with
thrombocytopenia, suggest disorders of consumption
including DIC, liver disorder.
Platelets are one of the important components in the
first phase of hemostasis and platelet plug formation.
The characteristics of platelets are (Figs 2 to 5):
Number: 150,000 to 400,000/mm3, out of which 2/3rd
circulate in blood stream and 1/3rd located in spleen. Life
span is 7 to 10 days.
Mean platelet volume (MPV)7.1 fL.
Most thrombocytopenia in children is the result
of increased platelet destruction. The bone marrow in
such cases responds with compensatory increase in the
Fig. 2 Normal blood smear with normal platelet count
Fig. 3 Blood smear with decreased platelet count
Fig. 4 Blood smear with increased platelet count
Fig. 5 Blood smear with increased platelet count and platelet in

clumps
Fig. 6 Bone marrow aspiration smearincreased

megakaryocytes
Fig. 7 Bone marrow aspiration smear in aplastic anemia
Fig. 8 Bone marrow aspiration smear in leukemia
rate of production with increased number of immature

megakaryocytes (Fig. 6). The large young platelets, which
are functionally very active, are more prominent in the
peripheral blood smear. The increased mean platelet
volume provides supportive evidence of the larger size.
In disorders with decreased platelet production,
the decreased platelet number is associated with small
sized platelets, a decreased mean platelet volume and
a longer bleeding time relative to platelet number. The
megakaryocytes are decreased in number or absent in
bone marrow aspirate.
Platelet count less than 100,000/cumm is called
thrombocytopenia
80 percent of children with acute ITP have platelet
count less than 40,000/cumm.
In chronic ITP, platelet count at the time of presentation
is usually higher (20,00075,000/cumm).
Thrombocytopenia is evident on peripheral smear
and is accompanied by bizarre shaped or giant forms of
platelets (Fig. 3).
In chronic ITP both mean platelet volume (MPV)
and number of large platelets are significantly increased
compared to control values. However, these values are
unchanged in acute ITP.
The presence of low or normal MPV in a case of
thrombocytopenia suggests aregenerative thrombocy
topenia, i.e. bone marrow suppression or marrow infil
tration.
Platelet distribution width (PDW) may be more
discriminating than MPV in detection of compensated
thrombocytopenic states.
Leukocyte Count
The total leukocyte count is usually normal though mild
to moderate lymphocytosis with increased number of
atypical lymphocytes may be seen especially when pre
ceded by viral infection. Mild peripheral eosinophilia may
be seen in 20 percent of children but is of no diagnostic or
prognostic value.2
Anemia
Anemia because of blood loss is seen in about 20 percent
of children with ITP. However, if the degree of anemia is
disproportionate to amount of bleeding seen then, other
sinister conditions like leukemia, aplastic anemia or occult
blood loss, Evans syndrome should be kept in mind. Bone
marrow aspiration, trephine biopsy, Coombs test, etc. are
of immense value in confirming the diagnosis and ruling
out above conditions.
Antiplatelet Antibody13-25
Understanding of pathophysiology and incite in the
clinical and laboratory aspect started with published series
of observation by Harington in 195113 which revealed
transferable plasma factor mediated the disease in many
patients. This was accomplished by infusion of plasma
from ITP patients into healthy volunteers which lead to
acute thrombocytopenia in recipient. Shulman et al. and
others subsequently confirmed that this factor as IgG
antibodies. Platelet associated with IgG antibody (PAIgG)
is present in 80 percent of thrombocytopenic children
with ITP. However, PAIgG is also found in other immune
thrombocytopenic states. Although these tests are highly
sensitive they have very low specificity as the patients with
both immune and non-immune thrombocytopenia have
elevated PAIgG. In Evans syndrome, as it is associated
with autoimmune hemolytic anemia, Coombs test is
helpful in the diagnosis.
Bone Marrow Examination27-29

In a typical case of ITP bone marrow evaluation is unneces
sary. Thus, acute onset of bruising following a viral infec
tion in a previously healthy child without any significant
hepatosplenomegaly, anemia not disproportionate to
amount of bleeding, bony tenderness or lymphadenopathy
and appearance of mega thrombocytes without any
abnormal premature cells on peripheral smear does not
need evaluation of bone marrow aspirate.
Indication for Bone Marrow Aspiration

In patients with atypical features: The clinical presen
tation suggests leukemia or aplastic anemia as a
differential diagnosis, associated with hepatospleno

megaly/Lymphadenopathy, (Sternal) bone tenderness
or painful joint, atypical rash
Abnormal leukocyte count (leukopenia and leuko
cytosis) and/or abnormal (premature) cells on peripheral smear
Anemia (Low Hb) disproportionate to amount of
bleeding.
Prior to the initiation of the corticosteroid therapy or
blood transfusion for presumed ITP as this may lead to
a temporary remission and may mask the presence of
blast cells
Lack of response to specific therapy like IVIg /Anti-D
globin.
Prolonged thrombocytopenia (> 6 months)
A possibility of missing the diagnosis of rare
conditions like a amegakaryocytic thrombocytopenic
purpura should be kept in mind if bone marrow
examination is not done.
It is not necessary to perform bone marrow aspiration
if IVIg therapy is contemplated.
Bone marrow examination in ITP will show normal or

increased megakaryocytes with normal erythroid and myeloid
maturation. Cytoplasm of megakaryocytes is decreased, often
vacuolated, less granular and stains more basophilic. They may
have increased nuclear lobe count. Platelet production and
turnover is increased up to 8 times the normal.
Other Investigations23,30,31
Plasma glycocalicin (a fragment of platelet membrane
glycoprotein Ib levels) are significantly below the normal
range (527%) in a regenerative thrombocytopenic
conditions like aplastic anemia and amegakaryocytic
thrombocytopenic purpura. The levels are above the
normal range (48261%) in thrombocytopenia associated
with normal or increased megakaryocytes in bone marrow.
Over the last few years platelet survival studies using the
radioisotope chromium-51, Indium-111 (In-111) have
become available. There are characteristic patterns of
platelet recovery and survival. Immune thrombocytopenic
disorders like ITP have nearly normal platelet recovery but
a very short platelet survival, whereas markedly reduced
platelet recovery with normal platelet survival is seen in
hypersplenism.
Glycoprotein specific acute antibody assay: Early studies
showed encouraging results with sensitivity of 75-85
percent and specificity of almost 100 percent. Unfortu
nately recent large studies showed low (4060%) sensitivity
but high specificity (7892%) However, patients with
myelodysplastic and lymphoma with thrombocytopenia
were also tested positive. Further studies perhaps using

new technology may give better sensitivity and specificity
and needs further study.24
Management of ITP2-9,32-53,57,58, 66,69,70-80

The main strategy of treatment of ITP is to administer
least amount of therapy In ITP treat the child and not
the platelet count. Why certain patients bleed but most
do not, remains unclear. Some patients may have marked
thrombocytopenia yet normal or near normal hemostasis,
because of increased young platelets having better
functional capacity.
On the other hand some patients (5% of all children
with ITP) may have impaired platelet function as a result
of antibodies and these children have prolonged bleeding
time and increased bleeding tendency in spite of having
near normal platelet count. Therefore, platelet count as
well as bleeding time estimation is recommended prior to
the decision regarding management of ITP.
Therapy depends on whether it is acute or chronic ITP.
Acute ITP2-9
In general 70 to 80 percent of children with acute ITP will
have complete remission and permanent recovery without
sequelae with or without treatment. 55 to 75 percent of
those who recover do so within the first month and 80 to 90
percent within 4 to 6 months of diagnosis and rest beyond
6 months to 1 year sometimes even beyond 10 years.
Chronic ITP
However, in chronic ITP only 1/3rd go into remission
spontaneously, that too usually late in the course of the
disease, i.e. between 1 and 10 years after the diagnosis.
ITP patients may not need any treatment but
reassurance. Children with chronic ITP whose platelet
count remains within a relatively safe range (more than
1030,000/cumm) and whose bleeding time is fairly
normal need no therapy except defensive management.
Remission is known to occur in about one-third of these
children, sometimes as late as 10 to 20 years postdiagnosis.
The treatment of a benign disease like acute ITP
should be decided after balancing the risk of treatment
vs no treatment. The mainstay of treatment in majority
of cases of childhood acute ITP hence is a Defensive
management and nonfrantic watchful waiting. During
the initial period following the onset of ITP, restriction of
physical activity and complete avoidance of all contact
sports and playground activities. Use of helmets to prevent
trauma especially head injury and using knee-cap during
the phase of thrombocytopenia are indicated.
Certain antiplatelet drugs like aspirin, phenacetin,

antihistaminics, phenothiazines, nonsteroidal anti-infla
mmatory drugs, etc. should be avoided.
Deep intramuscular injections should be avoided
and if has to be given, then pressure over the injection
site should be maintained minimum for 10 minutes,
continuously without trying to see in between whether
bleeding is present or not.
Immunization with live viral vaccines (polio, measles,
MMR) preferably should be avoided during the period of
severe thrombocytopenia.
Previous studies of ITP have not addressed the risk of
hemorrhage during various sport activities. Restrictions of
contact sports (football, soccer, kabaddi, etc.) advocated
until platelet count is above 100,000. Most noncontact
sports can be safely enjoyed with platelet count greater
than 30,000/cumm. Serious athletes may need frequent
platelet count measurement and treatment during their
participation.
SPECIFIC THERAPY IN ACUTE ITP

Corticosteroid Therapy (Oral)32-36
The use of corticosteroids in the management of ITP is a
matter of considerable controversy. In a heterogeneous
disease that usually sooner or later gets better on its own
and gives rise to little morbidity and low mortality, it is
difficult to evaluate the modality of the treatment. It has
been estimated that to have statistical significance, a
randomized trial of corticosteroid versus placebo, would
require some 14,000 patients. A double blind randomized
prospective study is more likely to give the truth and
eliminate both physician and patient bias. Normalization
of platelet counts as well as reduction in prolonged
bleeding time occurs earlier in the steroid treated group
as compared to the untreated group. However, it takes
8 to 10 days before significant changes are noticed. In a
randomized double blind and placebo controlled trial,
platelet counts reached a level of 30,000/cumm or more
(safe range) significantly earlier, with corticosteroids.
Platelet survival increased in ITP after steroids.17-21
Steroids in ICH
No proof exists that use of steroids reduces the incidence
of intracranial hemorrhage (ICH) or death.
Walker and Walker3 while reviewing the data of ITP in
children from England and Wales noted that 11/12 children
died of ICH, 8 of whom had received corticosteroids.
Lusher and Zuelzar4 reported ICH in only one child
who died despite immediate treatment with steroids.
Table 2 Controversies in ITP in children
Lokeshwar
et al.
Walker and
Walker3
Lusher4
et al.
Choi and
McClure5
Benham and
Taft62,63
Simon et al.7
Lammi and
Lovric6
Zerella et al.6a
Imbach et al.64
Total
No. of
patients
No. of
ICH ITP
Steroid
<1 M
16 M
>6 M
Not
known
Mortality
Platelet
count
History of
trauma
122
0.81
0/1
1/1
<20000
1/1
181
0.5
1/1
<20000
465
None
413
1.4
0/6
2/6
<20000
1/6
132
1.5
0/2
0/2
95
1.1
0/1
1/1
<20000
0/1
152
0.7
0/1
1/1
0/1
183
108
6
1
3.3
0.9
4/6
0/1
2
1
4
-
1
-
<20000
-
2/6
None
1851
19
1.02
10
2/6
1/1
8/19
42%
Benham and Taft62 reported 132 children with ITP,

with 2 cases having ICH, one each in steroid treated and
untreated group.
Review literature done in 1851 (Table 2) cases showed
19 cases with ICH (1.026%) and 6 cases had ICH when they
were on steroid therapy. Eight children had within 1 month
of diagnosis and 10 children had intracranial hemorrhage
after 1 month of onset of ITP. Few of precipitating factors
included hypertension, aspirin ingestion, platelet count
less than 20,000/cumm and trauma.
Table 2 shows the ICH in children with ITP.
Indications for Steroids in ITP

Though there is a lot of controversy whether steroids
should be given to children with acute ITP or not, there is
uniformity in the opinion that large doses of steroids for a
prolonged period should not be given, since steroids may
in fact, suppress platelet production.
Adverse effects of steroid include: Hyperglycemia,
hypertension, fluid electrolyte imbalance, psychosis, and
osteoporesis, etc. Hence, the clinician should balance the
benefits of the treatment against the risk.
The child and not the platelet count should be
treated. In children who present with mild illness no
therapy other than purely defensive management is
required.
A child with severe thrombocytopenia with a platelet
count of less than 10,000 to 30,000/cumm with generalized
petechiae and purpura, wet purpura with mucosal
bleeding, gastrointestinal hemorrhages and fundal hemor

rhages and ICH should be treated with steroids. Active
young children less than 3 to 4 years with low platelet
count also may be treated with steroids, because of fear of
trauma induced severe bleeds.
Dose of Steroids
Prednisolone is used in the dose of 2 mg/kg/day for two
to three weeks followed by tapering of dose over the next
week irrespective of platelet count. However, as steroids
are being tapered some patients may develop a drop in
their platelet count. This is usually transitory and not an
indication to step up the dose to previous levels since
clinically purpura often improves. In severe cases, for
initial 4 to 5 days, prednisolone may be given in a dose
of 4 mg/kg followed by reduction in the dose thereafter
to conventional levels.2 A small number of patients with
chronic ITP with recurrent mucosal bleeds or severe
thrombocytopenia can be managed successfully with
small maintenance dose (0.51.0 mg/kg/alternate day or
even less) of corticosteroids.
Intravenous Pulse Methylprednisolone

Pulse Therapy37,38,42
Pulses of few days durationsingle dose short course
of methylprednisolone 25 mg/kg/day on 3 consecutive
days resulted in early response lasting for 3 months or
more. Lusher et al. (1984)42 have used this therapy to raise

platelet counts prior to splenectomy. One of our patients,
16-year-old with chronic ITP for 8 years responded well to 3
doses of methylprednisolone and platelet count increased
from 5,000/cumm to 1,50,000/cumm following which
tooth extraction could be done. Similar results have been
reported by other authors. A short intravenous course of
high-dose methylprednisolone is effective as initial
treatment of ITP. Toxicity of long-term treatment with
prednisone can be avoided in a number of patients with ITP.
In patients refractory to treatment with methylprednisolone,
the response rate to second-line treatment with prednisone
was not negatively influenced, since two-thirds of these
relapsing patients subsequently responded to prednisone.
Both IVIgG and methylprednisolone produce a significant
early rise in platelet count that is somewhat greater with
IVIgG. However, the higher platelet counts produced by
IVIgG may not justify the additional cost and potential risks
of this agent.
Intravenous Immunoglobulin43-48
The major goal in the treatment of acute ITP is to restore the
platelet count to relatively safe levels as soon as possible so
as to prevent ICH and life-threatening hemorrhages.
Fifty-five to seventy-five percent children with ITP
recover within first month of illness, irrespective of
treatment. An increase in the platelet count to a safer
level of more than 30,000 to 1,80,000/cumm was noted
within 1 to 2 days following IVIgG therapy. Bussel et al.44
used 1 g/kg/day for 2 to 3 consecutive days followed
by maintenance infusion. Imbach et al.43 described
randomized multicentric trial in which IVIgG was
compared with steroids. Eighty percent of children in each
group responded to the therapy with mean time for the
peak platelet count being 12 days in the group receiving
corticosteroids versus 9 days in IVIgG. Thus, the effect of
corticosteroids and IVIgG were identical for children who
responded rapidly to the treatment and IVIgG does not
offer a major advantage over corticosteroids. However,
in steroid nonresponders, IVIgG can produce better
remissions. Reactions seen in 20 percent of children trivial
such as headache, fever, vomiting, fatigue, etc. But there
is a potential problem of transmission of plasma-borne
infections like hepatitis, AIDS and other viral infections. In
addition, the cost is prohibitive. (The total cost for a 10 kg
child for one course will be about ` 30,000/- onwards). As
the chance of spontaneous recovery is high and chances of
ICH are very low (03.3 %) routine administration of IVIgG
is not recommended. IVIgG should be considered for any
patient with ITP in whom rapid rise in platelet count is
deemed essential such as before surgery, after significant
trauma, especially a child with head injury, menorrhagia,
delivery, life-threatening bleeds like gastrointestinal
bleeding and ICH and during pregnancy as steroids are

contraindicated. In addition, young children below the
age of 5 years with severe, recurrent hemorrhage may
be given IVIgG to postpone/avoid splenectomy. Bussel44
etal. were able to avoid splenectomy in about 75 percent
of patients with ICH. IVIgG acts by causing temporary
reticuloendothelial blockade. This might be due to two
separate effects, a decrease in Fc receptor affinity for
platelet associated IgG and competition for Fc receptors
by the increased serum IgG.
IVIgG in Chronic ITP

IVIgG is effective for temporarily raising the platelet count
in 70 to 80 percent of children with chronic ITP. Platelet
count rises within 1 to 3 days of infusion. Permanent
remission occurs only in minority (020%) of these
children. A safe count however (above 20,00030,000/
cumm) may be achieved with periodic booster doses.
However, for the child with bleeding symptoms and
not responding to steroid therapy as whose platelet count
remain precariously low (less than 10,000/cumm) IVIgG
now has become the initial therapy of choice prior to
splenectomy in about 70 percent of patients with chronic
ITP.
Anti-D in ITP49-53
Rh anti-D globulin has been recommended as an
alternative to IVIgG in treatment of chronic ITP. Rh anti-D
globulin have been tried in varying doses intravenously.
Responses are usually slower in onset when compared
to IVIgG and are transient. However, in some patients
sustained responses have been seen, lasting for 6 months
to 3 years.
Splenectomized and Rh-ve patients respond less well
Though occasionally a complete remission has been
observed after a single course of anti-D globulin,
repeated booster doses at intervals of more than 3 weeks
may be required to maintain platelet count at a safe level.
A number of children are able to discontinue the
therapy during the first year of treatment.
The drug is administered slowly in 20 to 50 cc of saline
over 2 hours or can be administered fast over 3 minutes.
Though the peak platelet count occur at a mean of 8
days following initial infusion, platelet counts increase
significantly in 72 hours.
Hypersensitive reactions like for any other plasma
product are known and may cause shaking and chills.
Transmission of HIV and hepatitis after infusion of
anti-D is uncommon.
Hemolysis has been observed and patient may need
blood transfusions due to anemia caused by IV anti-D
globulin.
IV anti-D appears to be useful in treatment of ITP as it
is cheaper and effective in steroid-refractory patients
prior to splenectomy.
Splenectomy in ITP54-65
Spleen is the most important site for the destruction of
antibody coated platelets (Graveyard of platelets.). It is
one of the major sites of antiplatelet antibody production.
Reported efficacy rate in regard to achieving a stable
increased platelet count have varied for 40 to 86 percent.
With most reporting approximately 60 percent platelet
count increased to normal range of 150,000 to 400,000 in
5 to 60 days. No response was observed in 21 percent (6
40%) of patients, morbidity of splenectomy 10 percent and
mortality less than 2 percent.
Indication of Splenectomy ITP

As an emergency measure for life-threatening ICH, and
in adolescent girls with chronic disabling menorrhagia.
If patient do not afford or failure to IVIg therapy
Some clinicians prefer to perform an emergency
splenectomy during life-threatening hemorrhages
because they believe surgical procedure produces
more rapid rise in platelet count than IVIgG and occasionally patient may fail to respond to IVIgG within
first 24 hours
Less convincingly perhaps, in those with persistent
thrombocytopenia to avoid prolonged disruption of
lifestyle caused by limitation of activity and avoidance
of contact sports
Non responding chronic ITP.
For children with bleeding symptoms whose count
remains precariously low (less than 10,000/cumm) or
with recurrent mucosal bleeds and who do not respond
to steroids and IVIgG (medical line of treatment),
splenectomy is the alternative. Response rate to splenec
tomy in chronic ITP is about 65 to 88 percent.2,5,6,9,10 There
is no definite test by which one can predict response
to splenectomy. But some authors have found that the
initial response to steroids and thrombokinetic studies
could demonstrate predictive relationship.2,26 At the time
of splenectomy the surgeon should look for accessory
spleens which if missed may result in relapse of ITP.
Administration of platelet transfusions prior to surgery
usually is not required as platelet count starts rising
immediately following surgery (Clamping splenic radicles)
reaching as high as 3,00,000/cumm in the immediate postoperative period and reaching a peak within 1 to 2 weeks
and then gradually dropping to normal values by 4 to 8
months. Though platelet count can rise as high as 1 to 2
millions, there are no reported cases of thrombosis and
hence routine administration of antiplatelet drugs like

aspirin or dipyridamole is not recommended.
Problems after Splenectomy

Risk of postsplenectomy infection is related to age; it is
very high in early infancy and in those with underlying
disorders. As compared to ITP, the risk of infection is more
when splenectomy is done for diseases like thalassemia
major, sickle cell disease and Hodgkins disease. A detailed
review in 1973 estimated the risk of fatal sepsis following
splenectomy for ITP to be 1 to 4 percent. Pneumococcus
was the most common infecting organism with adrenal
hemorrhages occurring in over 25 percent of fatal cases.
Most deaths occur within first 2 to 3 years following
splenectomy, though deaths are reported as late as 30 years
after splenectomy. Children rapidly develop progressive,
overwhelming sepsis presenting initially with acute onset
of fever, nausea, vomiting and then rapidly progressing
with altered sensorium, confusion and leading to coma
and death within few hours. It may be associated with DIC,
electrolyte imbalance, shock, etc.
Parents of splenectomized children should be educated
and instructed to seek immediate medical attention
whenever child develops febrile illness. Broad spectrum
antibiotics by intravenous route are recommended after
collecting blood for cultures. Combination of ampicillin/
amoxycillin or 3rd generation cephalosporins should
be administered. Prophylactic antibiotics, particularly
during infancy, are recommended for several years
after splenectomy. Pneumococcal vaccine should be
administered at least 2 to 8 weeks prior to the surgery.
Revaccination after 2 to 5 years is recommended. Other
vaccinations such as H. influenzae and meningococcal
vaccine also may be given.
Thus, splenectomy should not be first treatment
initiated in the management of patients with ITP
particularly in children. It should be performed only after
all other therapeutic modalities have been exhausted and
patients have platelet count less than 10 to 25,000/cumm
and has mucosal bleed. It has fairly favorable response
rate of 60 to 80 percent. Acute and late morbidity of
splenectomy, low rate of mortality of ITP and the chance
of late spontaneous remission of thrombocytopenia have
lead to differ splenectomy indefinitely particularly in
childhood ITP. Splenectomy is thus differed for as long as
possible in pediatric population.
Role of Nonsteroidal Immunosuppressant

Drugs in Chronic ITP
A small percentage of children (less than 2%) with severe
chronic ITP do not respond either to steroids, IVIgG, anti-D

globulin or splenectomy and continue to have bleeding
tendencies with a platelet count of less than 10 to 30,000/
cumm. In these patients immunosuppressive therapy is the
alternative. Nonsteroidal immunosuppressive agents used
are vincristine, vinblastine, azathioprine, 6-mercaptopurine, cyclophosphamide67,68,68a and cyclosporine,69 etc.
Vinca alkaloids act more quickly but cyclophos
phamides have a more lasting effect. Vincristine (0.025
mg/kg not over 2 mg) or vinblastine (0.125 mg/kg) IV
is given at weekly intervals for 3 to 4 doses. Recently a
constant infusion of vincristine has been tried, however,
overall advantage of this method has not been established.
Target delivery of the drug by infusing platelets
incubated with vinblastine has not been found to be
effective as binding of vinblastine is easily reversible. Our
observations are discouraging with none out of 5 patients
in the age group of 3 to 8 years showing any significant
response to Vincristine therapy. Only one child showed
marginal rise in platelet count and did not show a lasting
improvement in the course of the disease.
Studies using azathioprine in chronic ITP refractory
to splenectomy show marked variation in the rate of
remission. The dose used ranged from 1 to 4 mg/kg/day
which may cause mild neutropenia. Three to six months
of treatment may be necessary before maximum response
is observed. The major side effects which are encountered
relate to granulocytopenia and other features of bone
marrow suppression.
Cyclophosphamide67,68 has been used in ITP with
variable success rates. It may be given either orally 1 to 2
mg/kg/day or intermittently intravenously in a dose of 750
to 1000 mg/m every three weeks. Response occurs 2 to 10
weeks after the initiation of therapy.
Cyclosporin69 has been recently tried in refractory
ITP with transient increase in platelet counts after the
treatment. It is known to modulate cell-mediated immunity
or alter T-helper cell aspect of humoral immunity. It is
given in the dose of 8 to 10 mg/kg/day in 2 divided doses
continued over 2 to 3 months. The drug is usually tolerated
well without major side effects but a significant rise in
glutamine transpeptidase may be present. Nonsteroidal
immunosuppressive drugs should be used with greater
caution in children as alkylating agents are known to be
mutagenic and increase the risk of subsequent malig
nancy. Secondary lymphomas have been reported. Close
monitoring of these patients, including WBC count is
necessary.
Alpha Interferon70,71
Alpha interferon has recently been used to treat refractory
ITP. Interferon alpha-2b therapy is indicated to treat
patient with life-threatening hemorrhage and those patient
not responding to steroids, IVIgG or splenectomy. Alpha2b interferon is a nontoxic alternative that may modify
B-cell activity involved in antibody production. Responses
were similar in splenectomized and non-splenectomized
patients.
Dose used is 2.5 mu/m 3 times a week given subcuta
neously for 12 weeks. The course may have to be repeated
in some cases. The response is usually transient with a
mean duration of fewer than 14 days. Alpha interferon
therapy is well-tolerated and side-effects are mild. It may
cause increase in tendency of clinical bleeding. There may
be a significant fall in granulocyte count. Fortunately this
has not been associated with an increase in the incidence
of bacterial infections. Flu-like symptoms may develop
particularly in older patients for which acetaminophen
may be used.
Monoclonal anti-FcR III antibody has been found to be
effective in 6 to 10 patients with long-term response.54
Rituximab72-76
Rituximab binds to the transmembrane antigen CD20
located on Pre B and mature B lymphocytes. CD20 antigen
found on both normal and malignant cells but not on
hematopoietic stem cells, Pro B Cells, normal plasma cells
or any other normal tissue.
Rituximab in ITP available as Mabthera (Roche) 1 vial
contain 10 mg in 10 mL or 500 mg in 50 mL.
Rituximab dose 375 mg per meter square was
administered as IV infusion at weekly interval for 4 doses.
Methods of administration: IV infusion should be
administered through a dedicated line. Administration
IV push or bolus should not be done.Infusion should
be administered where full resuscitation facilitates are
immediately available.
Premedication consisting of an analgesic/antipyretic
(paracetamol) and an antihistaminic drug (e.g. diphen
hydramine) should always be administered before giving
each infusion of Rituximab.
Initially start in micro drip 10 drops/min for 15 minutes
then 15 drops/min for 15 minutes then 20 drops/min be
continued.
Adverse events: Common symptoms are fever, chills
rigor, flushing, nausea, vomiting, urticaria, rash, pruritus,
angioedema headache, throat pain, abdominal pain,
myalgia, rhinitis, hypotension, bronchospasm, arthalgia.
Prepared solution is stable for 24 hours at 2 to 8 C and
subsequently 12 hours at room temperature. Store the
vials in refrigerator in the carton do not freeze.
Brox et al.75 in 1988 reported beneficial response to
ascorbic acid in 3 out of 11 patients with chronic ITP.56 But,
this has not been confirmed by others.
Since children with chronic ITP can have a spontaneous
remission even many years after their initial diagnosis, it is
important to reduce or withdraw the drugs periodically.
It has been reported that approximately 0.5 to 3 percent
of children with chronic ITP will eventually develop autoimmune diseases and hence it is necessary to evaluate
children with chronic ITP particularly adolescent females,
for evidence of concomitant autoimmune disease.
Thrombopoietin in ITP
AMG 531 (Romiplostim, Nplate) and Eltrombopag
(Promacta).77,78
Stimulating the thrombopoietin (TPO) receptor
increases the platelet production has been successful by
drugs or various agents.79
First-generation agentsrecombinant human thrombopoietin (rHuTPO) and pegylated recombinant human
megakaryocyte growth and development factor (PEG
rHuMGDF).
First-generation agents
Recombinant human thrombopoietin (rHuTPO)
and pegylated recombinant human megakaryocyte
growth and development factor (PEG rHuMGDF)-showed promise, however antibody formation to PEG
rHuMGDF led to the discontinuation of both agents.
Second-generation agents
TPO agonist antibodies--have been developed to
reduce or eliminate the problem of antigenicity.
TPO peptide mimetics
TPO non-peptide mimetics.
AMG 531 (romiplostim, Nplate) and
Eltrombopag (Promacta).
AMG 531 and eltrombopag are able to stimulate platelet
production in patients with ITP.
Clinical studies for some of these agents, such as AMG
531 (romiplostim, Nplate) and eltrombopag (Promacta),
are demonstrating their relative safety and efficacy in
increasing platelet counts in patients with ITP. There are
currently seven second-generation TPO receptor agonists
that have been reported in the literature, representing the
potential advantages.
Dose
AMG 531 (romiplostim, Nplate) and eltrombopag
(Promacta) (0.2 to 10 microg - 1 or 3 ug per kilogram of
body weight six weekly subcutaneous injections).
No major adverse reactions.
CONCLUSION
ITP in children constitutes 90 percent cases which
are acute and most of them go into remission in 1 to 6
months period. Since practically none of them in ones

experience go into ICH (less than 1% cases) and morbidity
is minimum, the dictum of the treatment of ITP should be
the too frequently forgotten maxim first do not harm.
In mild ITP with cutaneous bleeding and a platelet
count of more than 50,000/cummno drug therapy
defensive managementnonfrantic watchful waiting is
the rule.
In severe ITP with mucosal bleeding and platelet count
of less than 20,000/cumm, prompt vigorous treatment
with steroids should be started.
In nonresponders, and during emergency, IVIgG
should be given. If IVIgG is not available or if the patient
cannot afford, in life-threatening conditions, splenectomy
may be done, particularly in children above 6 to 7 years.
Intravenous anti-D globulin and intravenous methy
lprednisolone bolus dose may be tried before splenectomy.
In Chronic ITP
Treat the child and not the platelet count. No treatment
is required for cutaneous purpura and ecchymosis with
a platelet count above 20 to 30,000/cumm. For platelet
counts less than 20,000/cumm and mucosal bleeding, 1 to
2 courses of steroids may be given for 3 to 4 weeks each
time. Low minimum required maintenance doses may
be continued in partial responders. Avoid long-term high
dose steroids. Nonresponders may be treated with IVIgG
and booster dose if required or anti-D globulin may be
given intravenously along with maintenance booster dose
if required. Pulse methylprednisolone therapy is other
alternative for nonaffording patients. Avoid splenectomy
in children below 5 to 6 years and before 1 year of onset
of the disease. In 2 percent of cases who do not respond
to above therapy, immunosuppressive drugs may be used
with caution.
ITP in children are generally benign conditions leading
to only in few patients, serious complications and long
term squeal. 10 to 20 percent of children ultimately develop
chronic ITP whose platelet count majority of times remains
in relatively safe range more than 30,000/cumm and whose
bleeding time is fairly normal hence needs only defensive
management and nonfrantic watchful waiting. IVIg or high
dose steroid may benefit some patients who have evidence
of clinical bleeding and severe thrombocytopenia and
splenectomy may be of value in patients with chronic
ITP with recurrent manifestations of bleeding or very low
count. In acute ITP with severe bleeding like intracranial
hemorrhage or severe menorrhagia, splenectomy may be
indicated above the age of 5 years amongst those children
who cannot afford IVIg or are nonresponsive to steroids. In
some children with recurrent thrombocytopenia periodic
booster dose of IVIgG or methylprednisolone may be

required so as to keep the platelet count in the safe range.
However, there is no way to predict which patients are at
high-risk for the development of ICH/severe hemorrhage
and which patient will respond to which type of therapy
and hence the decision to treat the child with ITP is more
often based on entire clinical picture and severity of the
bleeding and experience of the clinician rather than only
the platelet count.
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53. Tarantino MD, Young G, Bertolone SJ, et al. Single dose
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32
Platelet Function Disorders
Shanaz Khodaiji
Platelet function disorders are difficult to diagnose

because the laboratory assays are time-consuming, and
require skilled technical staff to standardize and perform.
Mild platelet function disorders such as primary secretory
defects are rare and are a diagnostic challenge. They may
be missed due to their heterogeneity and failure to perform
the appropriate tests for their diagnosis.
The latest guidelines on platelet function testing have
been published in 2011, a long time after the previous
guidelines, which were published by the British Committee
for Standards in Hematology (BCSH) in 1988.1 Lack of
standardization of platelet function tests necessitated the
publication of the new guidelines. The gold standard for
platelet function testing is platelet aggregometry, which
was first described in the 1960s.2
In Germany, Austria, and Switzerland, it is estimated
that 2 children per million are affected by this disorder.
Ethnicity and consanguinity have a role to play in this
condition. A study carried out by Israels et al. has shown
that abnormalities of platelet function are as common
as von Willebrand disease (vWD) in patients with mucocutaneous bleeding.3 Platelet function disorders are more
common than previously diagnosed as has been reported
by a Canadian registry having 577 cases since 2004 (http://
www.fhs.mcmaster.ca/chr/data.html). Many of these
patients have incompletely characterized platelet defects,
thus suggesting that these disorders are not as rare as
previously believed.
PLATELET STRUCTURE
Platelets are discoid smooth surfaced cells, 34 m in
diameter that are present in whole blood in a concentration
of 150,000400,000/L.
The major structural features of platelets include:

Cell membrane which is a bilipid membrane and is
the site of some complex coagulation activities (Fig.
1). It contains several glycoproteins that function as
surface receptors. The two membrane systems are the
endoplasmic reticulum or dense tubular system and
the plasma membrane-derived, surface connected
canalicular system (Fig. 1).
The glycoprotein Gp Ib is a binding site for von
Willebrand (vWF). It is an intrinsic transmembrane
protein with a molecular weight of 140 kilodaltons. The
vWF is necessary for platelet adhesion, an important
first step in platelet function.
The other glycoprotein GpIIb/IIIa is a prominent
calcium dependent membrane protein complex that
functions as a fibrinogen receptor. Fibrinogen binding
is necessary for platelet aggregation to occur.
Circumferential microtubular system and micro
filaments: Microtubules lying just beneath the platelet
membrane form a circumferential band round the
platelet (Fig. 1). The microtubules are composed of
tubulin which plays a role in cytoskeletal support
and in contraction of the stimulated platelet.
Closely associated microfilaments contain actin and
participate in platelet pseudopod formation
Dense tubular system is so named because of the
presence of an amorphous electron-dense material.
This system selectively binds divalent cations and
serves as the platelet calcium reservoir (calcium flux
is critical to platelet function). The dense tubular
system is also the site of platelet cyclo-oxygenase and
prostaglandin synthesis (Fig. 1).
Platelet granules: Granules store various substances
that are secreted during platelet aggregation or are
Chapter-32 Platelet Function Disorders 333
Fig. 2 Interaction between vessel wall and platelets following

injury (adhesion and aggregation)4
Fig. 1Schematic diagram of morphology of a platelet.
Abbreviations: AG: a granules; CM: Cell membrane; DG: Dense
granule; DT: Dense tubule; GLY: Glycogen; M: Mitochondria; MT:
Microtubule; OC: Open canaliculus.
instrumental to aggregation. The four types of granules

are:
1. granules store a variety of proteins that are
secreted by stimulated platelets. These include
platelet factor IV, factor V, vWF, fibrinogen,
-thromboglobulin, and platelet derived growth
factor (PDGF). Various glycoproteins important
to adhesion are also contained in these granules
e.g. osteonectin, fibronectin and thrombospondin
(Figs 1 and 2).
2. Dense granules are electron dense particles that
contain high concentration of ADP and Ca2+ as well
as serotonin and other nucleotides. It also contains
ATP. These substances are released upon platelet
stimulation and enhance platelet aggregation (Figs
1 and 3).
3. Lysosomes contain hydrolytic enzymes.
4. Peroxisomes contain catalase.
Externally communicating open canalicular system
(Fig. 1).
Platelets perform many functions and are therefore
associated with many pathological processes.
Platelet function in bleeding and clotting: When platelets
come in contact with a damaged vessel wall, they undergo
shape change, adhesion, release of secretory granules
and aggregation leading to exposure of the procoagulant
surface. As a result, a hemostatic plug is formed that
prevents further blood loss by occluding blood vessels at
the site of injury. If this sequence of events is disturbed,
clot formation is impaired and patient is at increased risk
of bleeding.
Sequence of events occurring when platelets come in

contact with injured vessel wall
1. Collagen and endothelial proteins are exposed on the
internal surface of the affected vessel (Fig. 2).
2. Platelet adhesion is initiated when vWF binds to
collagen (from exposed endothelium) and Gp Ib/V/IX
complex on the platelet surface (Fig. 2). Simultaneously
platelets bind directly to collagen via Gp VI membrane
receptor complex and the Gp Ia/IIa integrin which is
a collagen receptor (Fig. 2). This in turn binds to the
G chain of fibrinogen and links the platelets to one
another (Fig. 2). The platelets form a layer on the
breached surface of the vessel wall causing platelet
activation, which leads to the next step of primary
hemostasis (Fig. 2).
Since BernardSoulier syndrome (BSS) is
characterized by the absence of the platelet membrane
GP Ib complex, normal adhesion to the vWF-A1
domain cannot take place.
3. The platelets change shape rapidly from discoid to
round and spread with filopodia and lamellipodia
(stellate form). Platelet adhesion initiates intracellular
signaling and platelet activation, by which substances
such as ADP are released from platelet granules and
thromboxane, (TXA2) are generated (Fig. 3).
4. Platelets stagnate and transiently stick to (adhere) or
roll along the vessel wall.
5. Platelet aggregation occurs when vWF and fibrinogen
bind to activated platelets through the Gp IIb/IIIa
complex (Fig. 2). Calcium ions are necessary for this
process. This is the final step in the formation of the
platelet plug. Absent or severely reduced platelet
aggregation is seen in glanzmann thrombasthenia
(GT), which is due to decreased levels/function of the
Gp IIb/IIIa complex.
such as the lumiaggregometer, which can assess platelet
function from whole blood and flow cytometry, which can
detect the presence or absence of antigens on the surface
of the platelet as well as some secretory pathway defects.
These are also used for monitoring antiplatelet therapy in
patients of coronary artery disease.
Initial Approach to Diagnosing Platelet

Dysfunction
Fig. 3 Platelet response to activation4
Though there are not many studies comparing platelet

function in pediatric age group and adults, all studies
conclude that with the exception of neonates, there is no
difference in aggregation patterns between the two groups.3
The first step in investigating a suspected bleeding
disorder is to take a detailed personal and family history
followed by examination and ordering of appropriate lab
tests.
Clinical Features of Platelet Defects
Fig. 4 Formation of a procoagulant surface4
6. The hemostatic plug is stabilized (Fig. 4) by reactions

such as activation of Gp llb/IIIa complex, exposure
of anionic phospholipids on the platelet surface and
production of procoagulant microvesicles.
7. As the activation process proceeds, the actin-myosin
complexes within each platelet shorten and draw the
platelet mass together, which results in clot retraction.
8. TXA2 generation induces further platelet aggregation
(Fig. 2) and vasoconstriction, slowing the flow of blood
and increasing the shear forces.
9. Platelet function is regulated in vivo by the presence of
nitric oxide.
While coagulation screening tests such as the PT and
the APTT are standardized in all labs, and not costly, there
are no easy diagnostic screening tests for platelet function
defects. Owing to the heterogeneity of these disorders it
is difficult to find a platelet function test which is 100%
sensitive. Moreover, these tests are laborious, expensive
and require trained and experienced persons to perform
and interpret. Newer instruments are now available
Primary hemostasis involves formation of the platelet plug

and secondary hemostasis is represented by the initiation
of the coagulation process up to formation of the fibrin clot.
Defects of both these functions have characteristic features,
which can distinguish these 2 conditions (Table 1).
In addition, mucosal membrane bleeding can occur
from the gastrointestinal and genitourinary tracts and
pulmonary sites in patients with platelet functional defects.
The petechiae and purpura are usually symmetrical
and found on the extremities as well as the torso, unlike
the vascular disorders where petechiae and purpura are
seen in dependent areas.
Platelet Function Defects may be Hereditary,

Acquired or Drug-Induced
Acquired platelet function defects are associated with
many diseases and are more commonly seen than the
hereditary disorders. They often cause clinically significant
bleeding.
Table 1 Characteristic bleeding patterns seen in primary and

secondary hemostatic defects
Primary/platelet defect
Secondary/coagulation defect
Immediate excessive
bleeding after trauma
Delayed bleeding
Petechiae, epistaxis,
menorrhagia, gingival
bleeding (mucocutaneous
bleeds) accompanied by a
history of easy, spontaneous
bleeding
Bleeding in the deeper

tissues, joints (hemarthrosis),
and intramuscular
hematomas are seen
commonly

Flow chart 1 Approach to diagnosis of platelet function disorders in children3
Key: Gray boxes Investigations; hatched boxes results; circles diagnosis; dotted circles - suspected diagnoses.
Abbreviations: BSS: BernardSoulier syndrome; CAMT: Congenital amegakaryocytic thrombocytopenia; ATRUS: Amegakaryocytic
thrombocytopenia with radio-ulnar synostosis; FPD/AML: Familial platelet disorder and predisposition to acute myelogenous leukemia;
GT: Glanzmann thrombasthenia; GPS: Gray platelet syndrome; SGD: Storage granule disorder; TAR: Thrombocytopenia with absent radii;
THC2: Autosomal dominant thrombocytopenia; XLT: X-linked thrombocytopenia.
An algorithm for evaluation of children with suspected

platelet disorders is described in flow chart 1.
CLASSIFICATION OF HEREDITARY
PLATELET FUNCTION DEFECTS3
Receptor abnormalities affecting platelet adhesion
Gp IbIXV abnormality causing BernardSoulier
syndrome or platelet-type vWD.
Gp IIb-IIIa (IIb3) defect causing Glanzmann
thrombasthenia
Gp Ia-IIa (21) defect
Gp VI defect
Gp IV defect
Abnormalities of receptors for

Thromboxane A2
P2Y12
2-adrenergic receptor
Platelet granule defects
Dense granule defects leading to -storage
pool deficiency, HermanskyPudlak syndrome,
ChediakHigashi syndrome, thrombocytopenia
with absent radii (TAR) syndrome
Alpha granules defects such as Gray platelet
syndrome ARC syndrome, Quebec platelet
disorder, ParisTrousseauJacobsen syndrome
and granules storage pool deficiency
Abnormalities of signal-transduction
Primary secretion defects
Abnormalities of the AA or TXA2 pathway
Gq deficiency
Partial selective PLC-2 deficiency
Defects in pleckstrin phosphorylation
Defects in Ca2+ mobilization
Cytoskeleton related abnormalities
Disorders of MYH9 e.g. MayHegglin anomaly,
Fechtner syndrome, Epstein syndrome, Sebastian
syndrome
WiskottAldrich syndrome
X-linked thrombocytopenia
Membrane phospholipid abnormalities
Scott syndrome
These disorders also have thrombocytopenia in addition
to functional defects.3
Secondary aggregation defects occur more frequently
than primary or hereditary platelet disorders. Storage pool
defects are the most common in the hereditary as well as
acquired groups.
Other rare disorders are:
Quebec platelet syndrome characterized by delayedonset bleeding, impaired epinephrine induced platelet
aggregation. The diagnosis is confirmed by presence of
platelet urokinase by immunoblotting or ELISA
Scott syndrome presenting with mucocutaneous
bleeding but normal aggregation with all agonists.
The confirmatory test is by demonstrating absence
of annexin A5 binding to activated platelets by flow
cytometry
Thromboxane A2 receptor defect presents with mucocutaneous bleeding, absent or decreased aggregation
with AA and U46619. The molecular assay used for
confirmation of this disorder is mutational analysis of
TBXA2R gene.
Secondary or acquired defects of platelet function are
encountered more frequently than hereditary disorders,
the most common being storage pool defects (SPD).
These divisions are somewhat arbitrary but are
convenient for categorizing the defects and interpreting
laboratory tests.
The hereditary disorders are discussed below:
von Willebrand disease (vWD): von Willebrand
disease can present in children with mucocutaneous
bleeding in the absence of a family history, in which
case it is difficult to differentiate it from platelet
function disorders. Testing for both vWD, and
platelet function defects is helpful. Both conditions
are common specially in children, and combined
disorders may be present. Quiroga et al. demonstrated
that in 11.5% of 113 individuals (ages 450 years) with
mucocutaneous bleeding and laboratory evidence
of primary hemostatic defects both vWD and platelet

dysfunction are found. VWD can also present with
thrombocytopenia. Macrothrombocytopenia can be
seen in patients of type 2B vWD.3
Bernard Soulier syndrome (BSS): BSS is a manifestation
of a defect in platelet adhesion and is inherited as an
autosomal recessive trait. Heterozygotes are often
asymptomatic. The platelets in this syndrome lack
membrane glycoproteins Ib, V and IX. It mimics vWD
in that the clinical manifestations are similar.
Clinical manifestations: Patient can present with,
epistaxis, menorrhagia, petechiae and purpura.
Easy bruising, which is sometimes spontaneous
can be the presenting feature.
Laboratory manifestations:
- Thrombocytopenia (mild/moderate) with
macrothrombocytes
- Abnormal template BT but clot retraction is
normal
- Abnormal petechiometer test (in children)
- Reduced aggregation response to ristocetin.
The response may be abnormally increased in
type 2B vWD.
The template BT is not standardized in children; hence
a petechiometer is more useful in children for assessing
platelet function defects or vascular type bleeding.
Peripheral blood smear examination shows macroplatelets along with mild thrombocytopenia in most
patients of BSS but not in vWD. Tests for diagnosing
vWD are the factor VIII coagulant activity (factor VIII:C),
factor VIII related antigen (factor VIII:RAg) and ristocetin
cofactor activity.
Treatment: Platelet concentrates are given only if bleeding
is life threatening.
GLANZMANNS THROMBASTHENIA
Glanzmanns thrombasthenia (GT) and essential
athrombia are very rare primary aggregation disorders.
Patients of GT lack the membrane glycoprotein Gp IIb/
IIIa complex.
Clinical Findings
Patients present with history of easy and sometimes
spontaneous bruising and petechiae, menorrhagia and
very occasionally hemarthroses. The symptoms of bleeding
usually disappear as the patient grows older. This feature is
common to most of the hereditary hemostasis defects.
Laboratory Findings
The BT is prolonged. Platelet function defects such
as reduced or absent primary aggregation with ADP,

epinephrine, thrombin and collagen and reduced platelet
factor 3 availability are seen.
Clot retraction is impaired in GT but is normal in
essential athrombia.
Therapy
Treatment for both the disorders is platelet transfusion
only if the bleeding is severe and life threatening. Some
workers prefer to infuse platelets till the bleeding stops
rather than relying on empirical monitoring of aggregation
patterns or the template bleeding time. The vast majority
of patients with hereditary platelet function defect of any
type will stop bleeding immediately with the appropriate
use of platelets.
HEREDITARY STORAGE POOL DEFECT (SPD)
Fig. 5 Aggregation pattern in patients on acetylsalicylic acid

(ASA)5
Abbreviations: ADP: shows a disaggregation in the curve; Collagen
(COL) normal aggregation; Arachidonic acid (ARA), aggregation
shows reduced response.
Clinical Features
These patients have a variable pattern of inheritance and
commonly present with mucocutaneous hemorrhage,
hematuria and epistaxis. Petechiae are not so common
in these disorders as in other platelet function disorders.
These patients usually present with spontaneous bleeds.
Laboratory Findings
Prolonged BT and abnormal collagen-induced aggrega
tion is noted (absent or markedly reduced). Absent
secondary aggregation wave to ADP and epinephrine
is seen although the primary waves are present. Normal
ristocetin aggregation and usually normal response to AA
is observed.
Therapy
In case of heavy bleeding, patients can be given platelet
transfusion.
ASPIRIN-LIKE DEFECTS
This is an inherited condition which mimics the aspirininduced acquired platelet function defect. It is very rare
and is inherited as an autosomal dominant trait.
Clinical Features
Like other platelet function defects these patients present
with easy, spontaneous bruising and bleeding from
mucocutaneous areas, epistaxis, menorrhagia, petechiae
and purpura. This defect may be due to a hereditary
deficiency of the enzyme cydo-oxygenase or the enzyme
thromboxane synthetase.
Laboratory Findings
These patients have a prolonged BT and show abnormal
collagen adhesion. Secondary aggregation response to
ADP (Fig. 5) and epinephrine is absent. Aggregation to
collagen is normal or absent. Aggregation response to AA is
absent (Fig. 5) along with absence of cyclo-oxygenase and/
or thromboxane synthetase enzymes. The same findings
are seen in patients taking aspirin or COX-2 inhibitors.
Therapy
When clinically significant bleeding occurs, treatment
consists of infusing platelet concentrates. Steroids have
been used in some patients with beneficial effects.
ACQUIRED PLATELET FUNCTION DEFECTS

Patients with acquired platelet function defects present
with profuse bleeding during surgery or trauma. This is
a common cause of bleeding in adults. Acquired platelet
function defects can be seen in a variety of conditions but
the platelet aggregation abnormalities are not specific to
any condition, unlike the hereditary disorders.
Causes of acquired platelet function defects:
Myeloproliferative syndromes7
Essential thrombocythemia (ET)
Agnogenic myeloid metaplasia
Paroxysmal nocturnal hemoglobinuria (PNH)
Polycythemia vera (PV)
Chronic myeloid leukemia (CML)
MDS, RAEB
Sideroblastic anemia
Uremia

Malignant paraproteinemias
Waldenstrms macroglobulinemia
Multiple myeloma
Leukemic reticuloendotheliosis
Collagen vascular disease
Antiplatelet antibodies
Presence of FDPs
Primary fibrinolysis
Anemia
Severe iron deficiency
Severe folate or B12 deficiency
Drug induced
MYELOPROLIFERATIVE SYNDROMES
Acquired platelet function defects are often seen in these
disorders. However, the platelet aggregation pattern is not
characteristic of any one disorder.
UREMIA7
Almost all patients of uremia have a platelet function
defect. It is thought that the circulating guanidinosuccinic
acid and/or hydroxyphenolic acid in these patients cause
a platelet function defect by reducing platelet factor 3
activity. The aggregation pattern is not diagnostic of the
condition.
Dialysis can reverse this effect and normalize platelet
function.
Other mechanisms such as altered prostaglandin
metabolism have also been proposed in uremic patients.
Treatment
Fibrinogen degradation products: Fragments D and E

appear to bind to the platelet membrane causing a very
severe bleeding and abnormalities of platelet aggregation.
Nutritional anemia: Iron deficiency or vitamin B12 and
folic acid deficiency also demonstrate a platelet function
defect, with or without clinical bleeding.
DRUG-INDUCED PLATELET FUNCTION

DEFECTS7
Numerous drugs cause defective platelet aggregation;
though not all of them cause significant clinical bleeding.
Drugs act through the following pathways:
Interaction with platelet membrane or receptors.
The drugs acting through this mechanism are
propranolol, ampicillin, penicillin, diphenhydramine,
phenylephrine plus promethazine and alcohol.
Other drugs included in this class are reserpine,
nitrofurantoin, dextran and hydroxyethyl starch
Inhibition of prostaglandin pathways. The most
common drugs in this category are aspirin, indomethacin, phenylbutazone, ibuprofen, sulfinpyrazone and
furosemide. Other, not commonly used drugs in this
category are quinacrine, mefenamic acid, tocopherol,
hydrocortisone, methylprednisolone and cyclosporine
Inhibition of phosphodiesterase activity. The most
common drugs are caffeine, dipyridamole, aminophylline, theophylline and papaverine
Drugs with unknown mechanism. Acetazolamine, chlortetracycline, hydroxychloroquine and nitroprusside.
COMMONLY USED DRUGS WHICH INHIBIT

PLATELET FUNCTION7
Platelet concentrates are recommended for life threatening

bleeding. Cryoprecipitate, desmopressin and estrogen
compounds can also be used to correct bleeding time and
control the hemorrhage.
Anti-inflammatory drugs
Psychiatric drugs
Cardiovascular drugs
Antibiotics
General and local anesthetics
Antihistamines
PARAPROTEIN DISORDERS
HYPERACTIVE PLATELETS7
A majority of patients with malignant paraproteinemias

have platelet function defects. Paraproteins coat the
platelet membrane in malignant and benign states, thereby
impairing their function, which manifests as significant
bleeding and abnormal platelet aggregation curves.
Macrothrombocytes are commonly seen in hypercoagulable states and in patients with thromboses. Large
platelets are immature platelets with more RNA content
and this makes them prothrombotic.
MISCELLANEOUS CAUSES
Microvesicles and Platelet Procoagulant

Activity
Autoimmune disorders: Systemic lupus erythematosus,

rheumatoid arthritis and scleroderma.
A major advance in the last several years has been the

discovery of small, membrane-bound microparticles

which are shed from plasma membrane of activated
platelets. These microparticles are rich in binding
sites for factor Va and Xa, thus conferring on them a
procoagulant property. This shedding is accompanied
by local collapse of the normal asymmetrical distribution
of plasma membrane phospholipids and the exposure of
phosphatidylserine and phosphatidylethanolamine on
the outer surface.
PLATELET FUNCTION DEFECTS IN INFANTS

AND SMALL CHILDREN1
Hereditary platelet disorders such as GT and BSS are
usually seen in infants and young children. They pose a
diagnostic dilemma in very young children mainly due to
preanalytical errors occurring at this age. Blood collection
for platelet function tests should be done on a free-flowing
venous sample and not form heel or finger prick. At least
20 mL of blood is required for these assays; this may be
8-10% of the total blood volume of a neonate and could
result in hypovolemic shock. Generally, 19-21G needles
are used in adults but these are too big for use in infants as
they are likely to cause significant trauma to subcutaneous
tissues if a severe platelet disorder is present. For blood
collection in infants and smaller children, a 23G needle is
used. The control sample should also be collected with a
23G needle.1
There is a paucity of data regarding aggregation
patterns in normal neonates due to difficulty in collecting
large volume of blood form healthy children. Few
studies conducted in this group of patients suggest that
the platelets of infants are hyporeactive to all agonists
except ristocetin and sometimes collagen. Later, platelet
aggregation patterns and nucleotide release reactions
reach adult levels. Therefore, platelet function should be
assessed in children above 1 year of age. Family studies are
recommended to assess inheritance pattern. Severe platelet
function defects such as in GT or BSS show characteristic
patterns, which are easy to diagnose. Methods using less
blood volume like PFA-100/200 and flow cytometry can be
used in children prior to performing platelet aggregation
assay for confirmation of the disorder. In BSS, PFA reveals
a severe defect of primary hemostasis and this along with
macrothrombocytopenia and demonstration of absence
or very low levels of the defective receptor, is sufficient
to start appropriate treatment for bleeding. Both GT and
BSS show prolonged closure times on the PFA. In severe
unexplained bleeding (intracranial) when an inflicted
injury has to be differentiated from spontaneous bleeding
in a patient with a severe bleeding diathesis, this approach
is very helpful.1
LABORATORY TESTS FOR PLATELET

DISORDERS
Diagnosing these disorders in the laboratory is a
challenging task, more so in children because large volumes
of blood are required for testing. Newer testing modalities
are not universally available and need proper validation
especially in the pediatric age group. Standardization of
platelet function assays has recently been undertaken
and this effort is bound to improve the quality of testing
and diagnosis of these disorders. Specialized tests should
be made available to those requiring a diagnosis of rare
platelet function defects. 3
Basic clotting tests such as PT and APTT are mandatory
to exclude coagulation defects.
Measuring platelet number and size: A peripheral
blood smear examination is necessary to assess
platelet size, and granularity. Platelet morphology is
helpful in diagnosis of gray platelet syndrome (GPS) in
which platelets are large and appear gray in color due
to lack of granules, or a borderline thrombocytopenia
with large platelets suggests BSS. The diagnosis of
platelet function defects can be excluded in acute
leukemias which present with petechiae or purpura
by examination of the peripheral smear. Accurate
platelet counts are now possible with introduction of
fluorescence flow cytometry in hematology analyzers,
by improving the ability to distinguish large platelets
from RBCs. The international reference method (IRM)
for platelet counting is by flow cytometry. If the platelet
count is normal, but signs of platelet dysfunction
are present, the differential diagnosis lies between
a platelet function defect and a vascular defect, both
of which may cause a prolonged bleeding time by the
standardized template method
Global screening tests of platelet function: They are
normally performed as first line tests for assessing
platelet function. Screening tests should be done to
exclude the diagnosis of platelet function disorder so
that further specialized testing can be avoided. Thus,
global platelet function tests can be performed along
with routine coagulation assays such as PT, APTT, and
some specialized coagulation tests such as vWF assay.
The vWF panel of tests include vWF:Ag, vWF:RCo
and F:VIII:C assays and an accurate platelet count.
The template bleeding time is the simplest screening
test for platelet function and is easy to perform in all
laboratories. A prolonged BT can be followed up by
testing on the PFA-100.1
Apart from the PFA analyzers, other instruments
are available to test platelet function. These include
those that can assess the effect of antiplatelet
drugs. Thromboelastography (TEG) and Rotational
Thromboelastometry (ROTEM) are tests of coagulation
and platelet function which have found favor with
surgeons. Though used extensively in a surgical
setting, there is no proper validation of these systems,
and their routine use for diagnosing platelet function
defects is therefore not recommended currently.1
Template Bleeding Time

The oldest test of platelet function is the BT, which was
described by Duke in 1910. It was previously recommended
for diagnosis of platelet function by the BCSH hemostasis
and thrombosis Task Force and is widely used in the
UK. However, there is lack of standardization of this test
between laboratories.1 It is technologist dependent and
highly subjective. It varies according to certain patient
characteristics such as age, gender, hematocrit, vascular
pattern, skin thickness and skin temperature. Therefore, it
is not reproducible and has a low sensitivity and specificity.
Also, it is invasive and for these reasons it is not routinely
recommended and performed.
The template BT is standardized; therefore it possible
to compare this parameter from different labs. It is
performed by tying a sphygmomanometer cuff on the
upper arm of the patient, which is inflated to 40 mm Hg.
Using a spring-loaded template, an incision 5 mm long
and 1 mm deep is made on the extensor surface of the
forearm. Avoids going into scar tissue and blood vessels,
and make the incision within 60 seconds of inflating the
sphygmomanometer. The edges of the wound are blotted
by filter paper at 30 second intervals until the bleeding
stops. Normal template BT is 29 minutes.1
Platelet Function Analyzer PFA-1001

Assay Principle
The PFA-100 analyzer is made up of disposable cartridges
containing apertures coated with either collagenepinephrine (CEPI), or collagen-ADP (CADP). Blood
collected in citrate (0.8 mL per cartridge) is aspirated at
high shear rates (5000-6000s-1) into the PFA analyzer.
These agonists on the aperture initiate platelet adhesion,
activation and aggregation leading to rapid closure of the
aperture. The end-point for each agonist is time taken to
obstruct the blood flow. Nonclosure of the aperture is seen
if the closure time (CT) exceeds 300 seconds. Since small
quantities of blood are required, it is useful for pediatric
patients too.
It has been observed that a low platelet count (<100
109/L) and anemia (<20% hematocrit) often cause a
prolonged CT. The CT also correlates inversely with plasma
vWF activity and may therefore be longer in patients with

blood group O. The CEPI-CT is usually prolonged in
patients taking COX-1 inhibitors such as aspirin. This is
not the case with the CADP-CT,
PFA-100 in vWD 1
Abnormal CT on both CEPI and CADP cartridges is seen
in of vWD types 2A, 2B, 2M and 3 with a sensitivity of
>98%. The overall sensitivity of CT to vWD is lower (8590%) if type 1 vWD is also considered. There seems to be a
significant correlation between vWF level and CT. Type 2N
vWD shows normal results. The PFA-100 can also be used
for monitoring desmopressin therapy in vWD.
PFA-100 in Diagnosis of Hereditary Platelet

Function Defects
Nonclosure is typically seen in both cartridges in patients
with severe platelet function defects such as GT, BSS and
platelet type or pseudo-vWD. The PFA-100 CT is not very
sensitive for mild platelet dysfunction. A recent study
showed that the overall sensitivity was 83% and specificity
89% of the CEPI cartridge for primary hemostatic disorders.
CADP sensitivity was lower. The PFA-100 has shown a
sensitivity of >90% in screening patients with menorrhagia
for vWD and platelet function disorders.
However, if the platelet defect is strongly suspected,
a normal PFA result should be overlooked and specific
platelet function assays should be performed.
PLATELET FUNCTION ASSAYS

Platelet Light Transmission Aggregometry
(LTA)1
Platelet aggregometry is considered the gold standard for
platelet function testing. It was invented in the early 1960s.
However, this test varies widely in laboratory practice due
to lack of standardization of the assays for many years.
Recently, new guidelines for platelet aggregometry have
been published.
Principle
Platelet aggregometry works on the principle of optical
density in which upon addition of agonists the platelets
undergo a change in shape from discs to round structures
with extended filopodia. This results in a transient
decrease in light transmission, followed by an increase as
the platelets aggregate. The increase in light transmission
(% aggregation) is measured at 370C by a photometer.
A secondary aggregation response curve is seen with a
higher concentration of ADP and epinephrine. This is due

to TXA2 formation and release of the contents of platelet
granules. Platelet agglutination by ristocetin, which
changes the conformation of plasma vWF thereby making
it suitable to bind to the Gp IbIXV complex, can also be
assessed by platelet aggregometry.
Platelet aggregometry is carried out with a complete
panel of agonist and require at least 15 mL of blood, which
is a major disadvantage in children. A recently introduced
method for testing platelet function is whole blood
aggregometry, which requires a smaller blood volume and
measures platelet aggregation as the change in electrical
impedance between electrodes. It is not widely used
because it is more costly than platelet aggregation with
PRP. A more recently developed multiplate analyzer is
also available that operates on the principle of electrical
impedance. It requires only 175 mL of blood and is
therefore very useful in pediatric practice.
Preparation of Patient1
The patient and control subjects should be off drugs,
beverages and foods which may affect aggregation for
at least 7 days prior to performing the test
Both the patient and the control subject should fast
overnight as chylomicrons may interfere with the
aggregation pattern
20 mL of venous blood is collected in citrate tubes
keeping in mind the anticoagulant to blood ratio of 1:9
The blood should not be chilled as cold activates
platelets
PRP is obtained by centrifugation at room temperature
(1822 C) for 1015 minutes at 1000 rpm
The PRP is pipetted out slowly, avoiding mixing of
cells form the buffy coat or RBCs. The PRP is taken
in a stoppered plastic tube filled nearly to the top to
avoid changes in pH, which affect platelet aggregation

and tests of nucleotide release. It is kept at room
temperature till tested. It is stable for about 3 hours
After removing the PRP, platelet poor plasma (PPP)
for test and control is obtained by centrifugation of the
remaining blood sample at 2000 rpm for 20 minutes
Standardization of PRP: The platelet count of the PRP
is adjusted to 200 400 109/L. If it is high, the PRP is
diluted with the patients PPP. A platelet count lower
than 200 109/L gives rise to a diminished aggregation
response. In the case of a low platelet count, further
centrifugation of PRP is not recommended because it
induces platelet activation. The control PRP should be
diluted to the same count and tested as a comparison.
Aggregating Agents1
Five useful aggregating agents (agonists), which are
sufficient for the diagnosis of most functional platelet
disorders are ADP, collagen, ristocetin, epinephrine/
adrenaline and arachidonic acid (AA). An extended panel
of agonists can be used to characterize other defects
not defined by the primary panel. This includes gamma
thrombin, thrombin receptor activating peptides (TRAP),
collagen-related peptide, endoperoxide analog U46619
and calcium ionophore A23187.
A number of pre-analytical factors can influence the
results and interpretation of platelet aggregation (Table 2).
Interpretation (Fig. 6)
ADP: This is tested in two dilutions, 2.5 and 5.0 mol/L
(Figs 6 and 7). A primary or reversible aggregation
curve is seen (Fig. 7) with ADP in low concentrations
(<0.52.5 mol/L). ADP acts by binding to a membrane
Table 2 Technical factors which may influence platelet aggregation tests6

Centrifugation: At room temperature, not at 4C. Speed should be adjusted so that red cells and white cells are removed but not the
larger platelets. Residual red cells in the PRP may hamper proper aggregation.
Time: Platelets are refractory to the effect of agonists for up to 30 minutes after centrifugation. Progressive increase in reactiveness
occurs thereafter.
Platelet count: Slow and weak aggregation observed with platelet counts below 150 or over 400 x 109/L.
A pH of less than 7.7 slows down aggregation while more than 8.0 increases aggregation.
Mixing speed: <800 rpm or> 1200 rpm slows aggregation.
Hematocrit: >0.55 is associated with less aggregation, especially in the secondary phase owing to the increased concentration of
citrate in PRP. It may also be difficult to obtain enough PPP. Centrifuging twice may help.
Temperature: <35C causes decreased aggregation except to low dose ADP which may be enhanced.
Dirty cuvette may cause spontaneous platelet aggregation or interfere with the optics of the system.
Air bubbles in the cuvette cause large irregular oscillations even before the addition of agonists.
No stir bar: No response to any agonist obtained.
Note: These are illustrations and not actual tracings.

Fig. 6 Aggregometry patterns in rare platelet function disorders1
receptor resulting in release of Ca2+ ions. A complex with

extracellular fibrinogen forms and the platelets change
shape from discs to rounded structures. This causes a
slight increase in light absorbance. After this, reversible
aggregation occurs when bound fibrinogen participates in
the cell-to-cell interaction. When very low concentrations
of ADP are used, the platelets disaggregate after the first
phase and do not show a secondary aggregation response.
In the presence of higher concentrations of ADP, an
irreversible secondary wave of aggregation occurs owing
to activation of the AA pathway (Fig. 6) resulting in release
of dense and -granules. Therefore both concentrations of
ADP should be used as If only the high dose is used primary
wave defects (which measure the second pathway) will be
missed.
Collagen: This is available as a 1 mg/mL stock solution. A
short lag phase lasting between 10 and 60 seconds (Fig. 6)
precedes aggregation with collagen. The duration of the

lag phase depends on the concentration of collagen used
and to the responsiveness of the platelets being tested. The
lag phase is shorter with high concentrations of collagen
and vice-versa. A single wave of aggregation follows the lag
phase and is caused by activation of the AA pathway and
release of the granules. A higher concentration of collagen
(>2 g/mL) causes a spurt in calcium concentration within
the platelet and this results in a direct release reaction
without causing activation of the prostaglandin pathway.
Collagen responses should therefore always be measured
using 1 and 4 g/mL concentrations.
Ristocetin: It is used in a concentration of 1.4 mg/mL. If
used in higher concentrations, protein precipitation might
occur in plasma and give rise to false results. Ristocetin
induces clumping of platelets (agglutination) by reacting
with vWF and the membrane receptors. It does not act
Fig. 7 Pattern of platelet aggregation with different doses of ADP5

A - no agonist added or thrombasthenia platelets; B fIrst wave reverse aggregation seen with low dose ADP or high dose ADP if platelets
inhibited by aspirin; C - normal biphasic aggregation seen with moderate doses of ADP; D prompt irreversible aggregation stimulated
by high dose ADP and all potent agonists; E - platelets unresponsive to ristocetin as in vWD and BSS; F - normal response to ristocetin
through any of the usual aggregation pathways and

does not initially cause granule release. The response is
assessed on the basis of the angle of the initial slope (Fig. 6).
Aggregation to ristocetin is tested in high and low doses. In
Type 2B and platelet type vWD the aggregation response
to high dose ristocetin is normal but response to low dose
(0.5-0.7 mg/mL) ristocetin is hyper-reactive. If with high
dose ristocetin the aggregation response is absent, then
an external source of vWF, (e.g. cryoprecipitate, or a vWF
concentrate) is added to the patient PRP and repeat testing
is done to distinguish between a vWF or Gp Ib defect (BSS).
Arachidonic acid: TXA2 generation and secretion of
granule occur with AA even if there is a defect of receptors
for binding AA on the membrane or of endogenous release
of arachidonate induced by phospholipase (Fig. 6). In case
of absence and/or inhibition of cyclo-oxygenase (e.g.
aspirin effect), the AA induced aggregation is abnormal
(Figs 5 and 6). Abnormal AA aggregation requires further
testing with 1.0 M U46619 to look for any thromboxane
receptor abnormalities.
Epinephrine/Adrenaline: It is used in a concentration of
2.6 mol/L. Unlike ADP there is no shape change before
aggregation but the response later is the same as in ADP
(Fig. 6). A severely reduced response to epinephrine is
noticed in normal people due to natural variations of the
adrenoreceptor numbers. These patients are clinically
normal.
If abnormalities in the thrombin receptors, Gp VI,
calcium mobilization and protein kinase C are suspected,
an extended panel of agonists can be used for categorizing
the abnormality; such as gamma thrombin (which does
not cause clotting), PAR-1 (SFLLRN) and PAR-4 (AYPGKF)

TRAP peptides (if gamma thrombin is abnormal),
collagen-related peptide (CRP), calcium ionophore and
PMA (Phorbol 12-myristate 13 acetate). These tests are
available in highly specialized labs only.
Aggregation Patterns in Normal Subjects

Normal platelet aggregation response to ADP varies with
the concentration used. It is usually a single reversible
primary wave with 1 mol/mL of ADP or less, a biphasic
response with 2.5 mol/mL and a single irreversible wave
with 5 or 10 mol/mL. With 1 and 4 g/mL of collagen
a single wave is seen with a lag phase of not more than
1 minute. Ristocetin shows a single phase or biphasic
aggregation with 1.2 mg/mL. An abnormal response
to low dose ristocetin (0.5 mg/mL) is characteristic of
type 2 vWD (Figs 6 and 7). A single or biphasic response
is seen with 50100 mol/L of AA. Both primary and
secondary aggregation curves are seen with 210 mol/L
of epinephrine.
Every laboratory performing the test should establish
its own reference intervals.
The platelet aggregation pattern for some of the most
common inherited platelet function defects are shown in
Table 3.
SUBSTANCES COMMONLY AFFECTING

PLATELET FUNCTION1
Cyclo-oxygenase inhibitors (irreversible)
Aspirin and all drugs containing acetylsalicylic acid.
Table 3 Diagnostic criteria and LTA patterns in heritable platelet defects1
Plt function
defect
Plt number and

morphology
PFA result
Aggregation
pattern
vWD Type 1,
2A and 3
Within normal limits
Equally
prolonged
CADP/CEPi.
Markedly
prolonged in
2A and 3
Abnormal response Within normal limits

to high dose
ristocetin corrected
by vWF addition
Within normal
limits
Confirm with vWF

panel tests for this
subtype
Type 2N VWD
or platelet type
Both closure
times
prolonged
Ristocetin
aggregation
normal by adding
plasma or cryo.
Increased response
with low dose
Increased vWF
binding to
platelets can be
measured
Abnormal vWF panel

in Type 2B vWD/Loss
of high MW vWF in
platelet type vWD
GT
CADP/CEPI
both very
prolonged
closure times
Markedly low
response to all
agonists except
high dose ristocetin
Reduced copy
number of IIb/
IIIa
BSS
Mild to moderate
thrombocytopenia with
large platelets
CADPI/CEPI
both very
prolonged
closure times
Low response to
Normal to high levels
high dose ristocetin
not corrected by
adding vWF
Reduced copy
number of Gp Ib
(heterozygotes
can also be
measured)
Defect of
dense granule
Reduced or normal count

Electron dense granules
reduced as measured by
whole mount EM
CADP normal
CT
CEPI
sometimes
prolonged
Secondary
aggregation
response to ADP
and epinephrine is
decreased
Reduced
mepacrine
uptake and
release
Defect of
secretion
Within normal limit
Normal
CADP CT
CEPI
sometimes
prolonged
Reduced secondary Normal but with

aggregation
defective release.
response to ADP
Reduced ATP release
and epinephrine
Aspirin-like
defect
CADP normal
CT
CEPI
normally
prolonged
(NB can be
normal with
high vWF
levels)
Absent AA
response but
normal to U46619.
Decreased
secondary
aggregation to ADP
and epinephrine
Thromboxane Within normal limits

receptor defect
CADP normal Absent AA and

CT
U46619 response
CEPI
sometimes
prolonged
Giant platelet
syndrome
Sometimes
normal
Macrothrombocytopenia
Nucleotides assay
Reduced ADP
Increased ATP:ADP
ratio reduced ATP
release
Flow cytometry Remarks

results
Reduced serotonin
release seen in
Hermansky Pudlak
and Chediak-Higashi
syndromes which are
autosomal recessive
Normal
mepacrine
uptake but
defective release
Retest or defer for 10
days if patient is on
aspirin or NSAIDs
Normal response to Normal/high

ristocetin
Normal/
High receptor
numbers per
platelet
Contd...

Contd...
Plt function
defect
Plt number and

morphology
PFA result
Aggregation
pattern
Nucleotides assay
Flow cytometry Remarks

results
Collagen
receptor
defects
Both
prolonged
Decreased collagen Within normal limits

aggregation
Reduced Gp Ia/
IIa or Gp VI levels
P2Y12 defect
Both normal
ADP-decreased
aggregation.
Reversible response
at high doses
Reduced secondary
wave
Low P2Y12
number using
Retest or defer
if patient taking
clopidogrel or other
anti-P2Y12 agents
P2Y1 defect
Decreased
response to
ADP-curves not
reversible
Scott
syndrome
Within
Within normal
normal limits limits
Reduced
expression
of phosphatidyl serine
on activated
platelets using
Annexin-V
Reduced PCI and ETP
Abbreviations: GT: Glanzmann thrombasthenia; BSS: Bernard Soulier syndrome; PCI: Prothrombin consumption index; ETP: Endogenous
thrombin potential. The result for P2Y1 defect are hypothetical as these are rare disorders and have not been completely studied.
COX-1 and COX-2 inhibitors (reversible)

(Nonsteroidal anti-inflammatory drugs-NSAIDs) such
as ibuprofen, indomethacin, mefenamic acid
Platelet receptor inhibitors such as abciximab,
tirofiban,
eptifibatide
(IIbb3),
ticlopidine,
clopidogrel, prasugrel (irreversible), cangrelor
(revesible), ticagrelor (reversible) (P2Y12)
Phosphodiesterase inhibitors such as dipyridamole
and cilostazole
Anticoagulants vitamin K antagonists, heparinoids
and direct thrombin inhibitors.
Cardiovascular agents which include -adrenergic
blockers (propanolol), vasodilators (nitroprusside,
nitroglycerine), diuretics (furosemide) and calcium
channel blockers
Antimicrobials: Antibacterials such as -lactams
(penicillins,
cephalosporins),
antifungals
(amphotericin), antimalarial (hydroxychloroquine)
and nitrofurantoin
Chemotherapeutic drugs: L-aspraraginase, vincristine,
plicamycin
Psychotropics drugs: Antidepressants (imipramine),
phenothiazines (chloropromazine) and local and
general anesthetic agents (halothane)
Thrombolytic drugs: Streptokinase, urokinase, tissue
plasminogen activator (TPA)
Miscellaneous drugs such as clofibrate, dextrans,
guaifenesin (expectorant) and radiographic contrast
media
Foods and drinks commonly consumed affecting

platelet function are caffeine, alcohol, cumin,
fenugreek, garlic, onion, ginger, ginseng, fish oil,
tamarind, turmeric, vitamins C and E and, Chinese
mushroom.
Many other substances apart from the ones mentioned
above can affect platelet function. It is mandatory to take
a drug and relevant dietary history from the patient. Retesting is recommended to confirm if the defect is transient.
(Reprinted and modified with permission from KottkeMarchant and Corcoran G. The laboratory diagnosis of
platelet disorders. Arch Pathol Lab Med 2002:126:13346 with permission from Archives of Pathology &
Laboratory Medicine. Copyright 2002. College of American
Pathologists.)
FLOW CYTOMETRY1
Flow cytometry is used to quantify glycoproteins in GT
and BSS. Flow cytometric tests are also available for
measurement of dense granules using mepacrine uptake
and release, and for measurement of microparticle
procoagulant activity. These are used in the diagnosis of
SPDs. Flow cytometry can be employed to confirm certain
aggregometry findings such as (Gp Ia/IIa and Gp VI) and
PAR-1 receptor densities in collagen defects. Platelet
activation can be measured in response to routinely used
agonists, dense granule content, and exposure of anionic
phospholipids. Citrated whole blood is used for analysis.
Delay in performing the test can cause platelet activation
and give false results. The test is performed by adding
fluorescent-labeled antibodies to the blood, incubating
the tubes at room temperature in the dark, then diluting
the samples to a final volume of between 1 mL and 2 mL.
The tubes should be mixed gently, by tapping to avoid
platelet aggregation. Commercial antibodies/reagents
are available that can quantify the various receptors.
Receptor numbers may be lower in neonates. A limitation
of this method is that receptors with a density of less
than 500 receptors/platelet cannot be measured, so the
test cannot always be used reliably to detect reduced
number of receptors. It is possible to measure platelet
procoagulant activity, apoptosis and microparticles by
incubating samples with high affinity probes against
phosphatidylserine (e.g. Annexin-V) and activating the
cells with calcium ionophore, collagen-related peptide or
combinations of thrombin and collagen. The diagnosis of
Scott syndrome and related disorders though very rare can
be made with these assays.
MEASUREMENT OF NUCLEOTIDES1
Measuring the adenine nucleotides is an important
additional diagnostic method used along with
aggregometry for detecting deficiency in dense granule
numbers or content such as seen in SPDs or degranulation
or release defects in granules. These defects are easily
missed on platelet aggregometry alone. In spite of
nucleotide measurement being an easy to perform test,
in which ATP is measured by simple bioluminescent
assays (using firefly luciferin/luciferase assays), it is rarely
performed in a routine laboratory. Therefore, many
disorders of platelet storage and secretion defects are
being missed.
The lumiaggregometer is capable of performing
simple assays of released platelet nucleotides in real
time with whole blood or PRP. Assessment of ATP levels
during platelet aggregation and release of ATP during the
secondary aggregation phase can be measured by a lumiaggregometer. However, it is not possible to distinguish
between SPD and defects in release of secretory granules
using this approach. Therefore, many laboratories measure
the total content of ADP and ATP of the platelet by making
a lysate of platelets. These assays can be performed on
frozen samples which can be transported.
The platelet contains 2 nucleotide pools: the metabolic
pool and the dense granule or storage pool, which makes
up 60% of the total content. The ATP:ADP ratio is therefore
important as there is a marked difference between the
relative concentrations in the two pools. Storage defects
have a decreased amount of stored and released ADP
resulting in an increased ATP:ADP ratio. On the other

hand, a release defect shows normal ADP levels and
ATP:ADP ratio but decreased ADP release.
Serotonin (5-HT) is stored in the platelet dense granules
and the uptake and release of radiolabelled serotonin into
and from the platelets can be measured by ELISA tests.
WHOLE BLOOD AGGREGOMETRY1

A lumiaggregometer measures platelet function using
electrical impedance in whole blood or optical density
in plasma (LTA) while simultaneously measuring dense
granule secretion (ATP release) by the luminescence
method. It allows study of platelet function in whole blood
in presence of other cells before decay of labile modulators.
The quantity of blood required is less compared to LTA.
The turbidometric features permit the performance of
ristocetin cofactor assay and sticky platelet syndrome tests.
It can also be used to a) monitor aspirin therapy by looking
for lack of aggregation response to collagen in whole blood
b) monitor plavix therapy by ADP response in whole blood
c) to monitor DDAVP administration by ristocetin induced
aggregation in whole blood and d) to monitor Gp IIb/IIIa
receptor blockers and other anti-platelet drugs.
A study carried out by UK NEQAS surveyed 169
hemostasis centers. They found that out of 88 centers
doing platelet studies, only 4 performed whole blood
aggregometry. Very few studies are available which have
validated this new modality clinically and in the lab with
the conventional LTA.
OTHER TESTS USED FOR MEASURING

PLATELET AGGREGATION
Rapid Platelet Function Assay by Ultegra
RPFA1
This is a turbidometric test which works on the principle
of optical detection that correlates platelet aggregation
with an increase in light transmittance. This test correlates
well with platelet aggregometry and was originally used to
monitor antiplatelet drugs by measuring the anti Gp IIb/
IIIa complex.
Hemostasis Analysis System

The platelet contractile force (PCF), clot elastic modulus
(CEM) and thrombin generation time (TGT) are measured
in 700 L of whole blood by this instrument. It is capable
of diagnosing both thrombophilia and bleeding disorders
and is also used to monitor treatment in these conditions.
It is popularly used as a POC instrument in surgical
settings, cardiology clinics and ICUs.
ELISA, RIA and Western Blot

Platelet granule proteins comprising of platelet factor
4 (PF4) and -thromboglobulin can be measured by
various techniques such as ELISA, RIA or western
blot. They are contributory to the diagnosis of quebec
platelet disorder. However, there are problems with
reproducibility and interpretation of results. Adenine
nucleotide and serotonin release from the dense granules
are best measured by a specialist laboratory. The release
from -granules indicates activation of platelets and
thrombotic tendency. Platelet vWF is measured to
diagnose some variants of vWD. If the study suggests
a defect in the prostaglandin pathway, TXA2 can be
estimated quantitatively by radioimmuno assay. Highly
specific assays of various steps in AA metabolism are
available in specialized laboratories.1
Electron microscopy has made it possible to detect
ultra-structural abnormalities in platelets of patients with
platelet function defects. Dense granule defects can now be
diagnosed by whole mount electron microscopy. Substances
released from the granules can also be measured.1
Molecular diagnosis of inherited platelet function
defects is confirmatory in affected individuals and their
family members and for antenatal diagnosis. It is easily
done in GT and BSS because the number of candidate
genes is small. Diagnosis for clinically suspected cases of
GT and BSS can be confirmed by direct sequencing of PCRamplified genomic DNA. Individual affected genes can
occasionally be identified in patients with mild defects e.g.
MYH9 related disorder, CAMT, TAR, WAS, thromboxane
and P2Y12 ADP receptor defects and GPVI defects.
Molecular analysis of these disorders is mostly done in
research laboratories. In regions having a prevalence of
a specific mutation, e.g. 16bp deletion in HPS1 in Puerto
Ricans with Hermansky-Pudlak syndrome, allele specific
mutation detection strategies help in quick detection of
the molecular defect.1
CONCLUSION
Nonavailability of laboratories to perform platelet function
assays makes diagnosing inherited platelet disorders in
children very difficult. Screening tests can be done in most
routine laboratories. These include platelet count, MPV,
and examination of the peripheral blood smear to exclude
thrombocytopenia as a cause of bleeding in the patient.
Platelet function testing was a much-neglected area as

the previous guidelines were published in the late 1980s.
A variety of new tests and techniques have been added
to the armamentarium of platelet function testing. These
include platelet size distribution profiling and molecular
markers of platelet reactivity. Lumiaggregation has added
a significant new dimension to assessment of platelet
function. Flow cytomertry provides a variety of specific
tests that are very useful in diagnosing various defects.
Reliable but simple to use whole blood tests that attempt to
simulate in vivo hemostasis can be used to screen samples
rapidly before applying the existing battery of tests. The
general consensus is that the bleeding time should be
replaced. Many of the simpler platelet function tests
could be potentially utilized as point of care instruments
for assessing bleeding risk and monitoring antiplatelet
treatment. It is possible that in the near future important
developments in the platelet genome will be made leading
to exciting advances in this field such as platelet specific
microarrays which may have a significant impact on
the diagnosis and management of patients with either
thrombotic or hemostatic defects.
REFERENCES
1. Guidelines for the laboratory investigation of heritable
disorders of platelet function Paul Harrison,1 Ian
Mackie,2 Andrew Mumford,3 Carol Briggs,4 Ri Liesner,5
Mark Winter,6 Sam Machin2 and British Committee for
Standards in Haematology British Journal of Haematology
2011;155(1):30-44.
2. Harrison P. Platelet function analysis. Blood reviews
2005;19:III123.
3. Israels SJ, Kahr WHA, Blanchette VS, Luban NLC, Rivard
GE, Rand ML. Platelet disorders in children : A diagnostic
approach. Pediatr. Blood Cancer. 2011;56:975-83.
4. Rao AK, Gabbeta J, Congenital Disorders of Platelet Signal
Transduction Arterioscler. Thromb Vasc Biol. 2000;20:2859.
5. Mani H, Luxembourg B, Klaffling C, Erbe M, LindhoffLast E. Use of native or platelet count adjusted platelet
rich plasma for platelet aggregation measurements. J Clin
Pathol. 2005;58:74750. doi: 10.1136/jcp.2004.022129.
6. Laffan MA, Manning RA. Investigation of haemostasis. In:
Lewis SM, Bain BJ, Bates I, Eds. Dacie and Lewis Practical
Haematology. 9th ed. London: Churchill Livingstone,
Harcourt Publishers. 2001.pp.339-90.
7. Bick RL. Disorders of Thrombosis and Hemostasis: Clinical
and Laboratory Practice.
33
Pediatric Thrombosis
Rashmi Dalvi
Thromboembolic disease represents an infrequent event in childhood, however, one associated with considerable mortality and
morbidity. The incidence of venous thromboembolism (VTE) has been reported at about 0.07/10,000 children, 5.3 percent of pediatric
admissions and 2.4 percent of newborns in intensive care units. Neonates are at highest risk, possibly because of physiologically
lower anticoagulant levels and markedly reduced fibrinolytic activity. The incidence of vascular accidents decreases significantly
after infancy, with a second peak during puberty and adolescence, again associated with reduced fibrinolytic activity. Although in the
past, this was more an issue in the adult domain, thrombotic disorders are now an increasingly recognized clinical challenge. This is
due partly to enhanced clinician awareness, advances in pediatric therapeutics and tertiary care, as also to specific identification and
molecular characterization of a number of heritable prothrombotic defects.
PHYSIOLOGIC CONSIDERATIONS
The fluid state of blood is maintained by a delicate and
dynamic balance between the coagulant, anticoagulant
and fibrinolytic systems, all regulated through a series of
feedback mechanisms. Despite all progress in the field,
Virchows triad of three basic risk factors for thrombosis
viz:
1. Stasis, hypercoagulability and endothelial damage are
still central to clinical considerations in thrombosis. In
most cases, whether or not an underlying risk factor
is identified, clinical thrombosis always results from
a combination of two or more factors. The natural
anticoagulant system includes three pathways for
inhibition of procoagulant activation:
i. Cleavage of factors V and VIII by the protein C and
protein S system.
ii. Direct inhibition of thrombin by antithrombin
III (AT III), heparin cofactor II and alfa-2 macro
globulin
iii. Inhibition of factor VIIa by the tissue factor pathway
inhibitor/factor Xa complex.
2. In addition, the von Willebrand factor (vWF) cleavage
protease ADAMTS13 regulates the size of vWF
multimers thereby reducing its functional activity
in primary hemostasis. When thrombin binds to

thrombomodulin on endothelial surfaces, it no longer
cleaves fibrinogen but activates protein C, which
in turn complexes with protein S to proteolytically
inactivate factors V and VIII.
3. Clot dissolution in vivo is mediated by the enzyme
plasmin which is generated from its precursor plas
minogen by two known activators, tissue plasminogen
activator (tPA) and urokinase plasminogen activator.
Inherited or acquired deficiency in these pathways
may foster a hypercoagulable state.
The evolving hemostatic system in neonates and
children is distinctly different from the mature adult.
Neonates have a hypocoagulable state with decreased
capacity to generate thrombin, which, however, is
balanced by the protective effects of deficient circulating
anticoagulants. The physiological immaturity may extend
to variable extents through childhood, which perhaps
explains the strikingly low incidence of clinical throm
bosis. An elegant longitudinal study of normal children
from birth to adolescence has shown that during the
newborn period and infancy, although levels of AT
III, protein C and S are low, thrombin generation is
reduced and alfa-2 macroglobulin is increased. Likewise,
Chapter-33 Pediatric Thrombosis 349

throughout childhood, protein C and heparin cofactor
II are low, but alfa-2 macroglobulin is raised and
prothrombin and factor VII are reduced compared to
adult values. These physiologic differences bear effect on
the incidence and natural history of thrombosis, as well
as on pharmacokinetics and response to anti-thrombotic
drugs, making clinical management a greater challenge.
Among newer concepts, is the role of the endothelium
and endothelial heterogeneity in thrombosis and hemo
stasis. The endothelium is now not considered as
merely lining vascular channels, but a highly metabolic,
functional and dynamic tissue which uniquely adapts
to local tissue environment. Thrombotic complications
in various disorders or hypercoagulable states show a
predilection to specific locations, likewise with bleeding
too. Research supporting this changing paradigm has
shown heterogeneous distribution of coagulation and
fibrinolytic factors across organs and tissues. They also
show a variable response to stimuli, e.g. cytokines (TNFalfa), blood flow, drugs , toxins. In particular, inflammatory
cytokines upregulate endothelial prothrombotic factors
with a switch of homeostatic balance in favor of hemostasis,
but this too varies with location.
ETIOLOGY AND RISK FACTORS

IN CLINICAL THROMBOSIS
In the context of childhood thrombosis, more of venous
thromboembolism than arterial is encountered in clinical
practice. Arterial clotting is seen in the presence of
abnormal platelet activation or endothelial dysfunction,
whereas VTE is predisposed to by venous stasis, venous
endothelial damage, deficiency of anticoagulant or anti
fibrinolytic factors or an excess of anticoagulant protein.
As an extension of the traditional Virchows triad, another
researcher, Eberhard Mammen, postulated reduced
mobility as another important factor, which albeit may
be more applicable in adults. He proposed that decreased
muscle contraction reduced blood flow, with stasis and
accumulation of blood within intramuscular sinuses, thus
triggering hypercoagulabilty due to local accumulation of
activated clotting factors and simultaneous consumption
of anticoagulants.
Microparticles, which are circulating small fragments
of cell membranes are found to carry procoagulant and
anticoagulant proteins and plasminogen system compo
nents, are mainly derived from platelets and lesser degree
from leukocytes and endothelial cells. These microparticles are believed to have a thrombogenic role, as
increased circulating microparticles have been associated
with thromoboembolic complications in cancer, antiphospholipid syndrome, sickle cell disease, diabetes and
systemic inflammatory disorders.
In the clinical situation there may be an overlapping

presence of both inherited and acquired factors. Some
of the milder forms of inherited thrombophilia, develop
thrombosis only in the presence of other comorbid states
or therapeutic interventions, as is increasingly becoming
evident, many of the so-called acquired thromboses may
have an underlying thrombophilic defect.
ACQUIRED RISK FACTORS

Neonatal Thrombosis
Thrombotic complications occur five times more frequ
ently in the newborn compared to older children. Though
they may occur spontaneously, most often are associated
with a known event.
Risk Factors
Indwelling vascular catheters especially umbilical
artery cannulation
Malposition venous catheters or
Use of hyperosmolar solutions, dehydration
Polycythemia
Hypoxia
Maternal diabetes
Intrauterine growth retardation, or
Shock syndromes, as in asphyxia or sepsis
Severe congenital protein C or S deficiency may pre
sent in the newborn period. Abnormal chorionic
vessels occurring in a range of maternal disorders may
produce chorionic thrombi which embolize to fetal
pulmonary arteries or portal vein.
Maternal antiphospholipid antibody syndrome has
also been associated with neonatal arterial thrombosis.
Neonates have a propensity to large vessel thrombosis
and present with limb or organ dysfunction depending
on the vessel involved. Presentation may be in the form
of edema, lower limb cyanosis (Inferior vena cava), scalp
and facial edema (Superior vena cava, SVC), renal lump
with hematuria (renal vein), or seizures. Aortic thrombosis
may present with congestive heart failure, feeble femoral
pulses, necrotizing enterocolitis or renal failure, peripheral
artery block may have absent pulses with cold discolored
skin, and cerebral artery thrombosis may have apnea
and seizures. Neonates with homozygous protein C or S
deficiency invariably present with purpura fulminans.
VASCULAR ACCESS DEVICES

Central venous catheters are increasingly being used in
critical care settings and for prolonged vascular access
in children requiring parenteral nutrition, chemo
therapy, blood transfusions antibiotics. These are today
an important risk factor for pediatric thrombosis. Clinical
pointers to such an event include recurrent blockage,
frequent sepsis, local pain or swelling, chylothorax, SVC
obstruction or appearance of chest wall collaterals. Cardiac
catheterization may also be complicated by thrombosis at
the site of cannulation.
DEHYDRATION AND SEPSIS

These two factors alone or in combination may promote
thrombosis by causing a hyperviscosity of blood and
cytokine induced endothelial damage in the course of
sepsis. Thus, acute gastroenteritis with dehydration is a
common clinical setting where such an event is predis
posed often affecting cerebral venous sinuses. Suppurative
thrombophlebitis of the internal jugular vein or Lemierres
syndrome triggered by fusobacterial sepsis, though a rare
cause in children, carries a potential risk of CNS morbidity
and mortality.
NEPHROTIC SYNDROME
Thromboembolic complications can occur in about 25
percent of patients with nephrotic syndrome presenting
with not only renal vein thrombosis but also arterio venous
thrombosis at various other sites including CNS and abdo
minal vessels. Factors predisposing a hypercoagulable state
include AT III protein loss in urine, hyperfibrinogenemia,
increased platelet activation, hyperlipidemia, increased
platelet activation, hyperlipidemia, along with a propensity
to intravascular volume depletion, hyperviscosity, use of
diuretics, and relative immobilization.
ANTIPHOSPHOLIPID ANTIBODY
SYNDROME
This condition may occur as a primary antiphospholipid
antibody syndrome (APLA) or secondarily with systemic
lupus erythematosus or other connective tissue disorders.
APLA has most often been associated with CNS stroke in
children, although arterial thrombosis elsewhere may also
occur. APLA is also described in conjunction with viral
diseases such as hepatitis and human immunodeficiency
virus disease. APLA promotes thrombosis by platelet acti
vation, release of endothelial platelet factor and inhibition
of protein C and AT III.
THALASSEMIA
A higher than normal incidence of thromboembolic events
has been observed in patients with beta thalassemia
major (TM). Red blood cells in TM have been shown to
facilitate thrombin formation due to altered symmetry
of membrane phospholipids with enhanced exposure
of phosphatidyl serine. Studies have shown elevated

plasma levels of thrombin-antithrombin complexes and
significantly decreased levels of protein C and S in all TM
patients without other thrombophilic mutations. Thus, a
chronic hypercoagulable state exists in TM, with children
and adolescents presenting with CNS thrombosis, DVT,
cardiac thrombosis, pulmonary embolism or recurrent
thrombophlebitis. Identified risk factors for thrombosis in
TM include: platelet count > 6 lacs</cumm, protein C < 50
percent, plasminogen< 50 percent, protein S < 50 percent.
MALIGNANCY
Tumor microparticles, cytokine induced endothelial
changes, sepsis in neutropenic patients, vascular acce
sses and drugs such as L-asparaginase may promote
thrombosis in cancer.
Other risk factors include trauma, surgery, immo
bilization, infusion of prothrombin complex concentrates,
use of oral contraceptives in adolescent girls. Acquired
protein C deficiency may also occur in liver disease,
sepsis, disseminated intravascular coagulation (DIC)
and especially in purpura fulminans and DIC with acute
meningococcal infection.
Arterial thrombosis may be associated with sickle
cell disease, vascular malformations/Moyamoya disease,
APLA, hyperlipidemias, vasculitis.
FAMILIAL THROMBOPHILIA
Inherited prothrombotic states are usually suspected
in children with an unexplained cause for thrombosis,
a positive family history, recurrent thromboembolism,
or thrombosis at an unusual site. Most of them present
beyond adolescence unless compounded by additional
risk factors. However, severe deficiencies may have
spontaneous thrombosis as early as newborn period.
Coinheritance of these susceptibility genes is known and
the risk of thrombosis increases with multiple coinherited
defects. Some of the better understood anticoagulant
defects are discussed briefly here.
Protein C deficiency in its milder phenotype is
inherited as an autosomal dominant trait with a
population prevalence of 0.2 percent and having two
subtypes identified by quantitative and qualitative
defects respectively, the latter being less common.
Milder homozygotes and heterozygotes present with
recurrent thromboembolism usually beyond the
second decade and in association with additional risk
factors. Severe homozygous protein C deficiency is
usually inherited in an autosomal recessive form.
Protein S deficiency has a very similar inheritance
pattern, subtypes and clinical profile as protein C
deficiency.

Factor V Leiden is a form of inherited prothrombotic
defect characterized by a mutation in factor V (factor
V Arg506Gln) at exactly the site where it is spliced by
activated protein C, making it resistant to the action
of the latter. It is thus also called activated protein C
resistance. This mutation is present in about 8 percent
of Caucasians, but < 1 percent Asians and Africans.
Deficient individuals have a milder phenotype, and
both homozygotes and heterozygotes may have
recurrent thromboembolism during childhood or later,
usually with an associated risk factor. It may rarely
cause arterial thrombosis and has also been implicated
in porencephaly, cerebral palsy and Perthes disease.
Prothrombin gene mutation at the nucleotide 20210A
position estimated to occur with a frequency of 3 to
4 percent in the population. The mutation results in
abnormally high prothrombin levels, which probably
contributes to increased thrombotic risk by increased
thrombin generation. Clinical manifestations are mild
even in homozygotes.
Antithrombin III deficiency displays two types of
mutations, with quantitative and qualitative defects
respectively. The homozygous state is incompatible
with life. Heterozygotes present in early adulthood
with recurrent and/or thromboembolism. Thrombosis
in adulthood is rare, and its occurrence is usually
associated with secondary risk factors.
Hyperhomocysteinemia is classically due to deficiency
of cystathionine biosynthase. However, another more
common polymorphism in the methyltetrahydrofolate
reductase (MTHFR) gene appears to reduce conversion
of homocysteine into methionine. The MTHFR is not
an uncommon polymorphism and its homozygosity,
well documented in adults, may increase risk of
thrombosis especially stroke in children.
Among other heritable prothrombotic states, yet to be
clearly defined, are:
Elevated factor VIII levels
Raised lipoprotein associated with lipoprotein coagu
lation factor Lp(a)
Dysfibrinogenemia
Thrombomodulin mutations
Factor XII deficiency
Defects in plasminogen and plasminogen activator
inhibitor.
Mutations causing a deficiency in the ADAMTS13
protease present as congenital thrombotic thrombocyto
penic purpura, with predominantly a microangiopathic
hemolytic anemia that worsens with infection, showing
marked elevation in D-dimers.
Approach to Diagnosis
A high index of clinical suspicion is necessary for an
early diagnosis, which is crucial so as to prevent fatal
complications such as pulmonary embolism, organ
dysfunction and prevent long-term morbidity. Once VTE is
suspected, there are various laboratory tests and imaging
modalities that help confirm the diagnosis and delineate
the extent of thrombosis.
Radiologic Imaging
Although venography is the gold standard to demons
trate thrombosis, it is used infrequently as it is invasive,
needs specialized radiology, needs multiple peripheral
access and is not useful for internal jugular vein as the
dye cannot flow in a retrograde fashion.
Doppler ultrasound is the most frequently used
imaging, being noninvasive, easily available and
lower in cost. It has a high sensitivity for lower limb
and abdominal vein thrombosis. However, it may be
ineffective for upper limb thrombosis due to the chest
wall lung tissue and the clavicles.
Magnetic resonance (MR) venography clearly images
all large veins and is useful in cerebral sinus throm
bosis, though it is expensive and needs sedation. CT
angiography is also useful, but needs greater contrast,
has exposure to radiation.
Likewise for arterial thromboses, though angiography
is the gold standard, it is invasive, needs an interventional
radiologist, and may itself cause thrombosis. Doppler
ultrasound is a good screening and diagnostic modality
except for the chest region.
Laboratory Evaluation
Diagnostic evaluation for pediatric acute venous thromboembolism (VTE) includes a complete hemogram,
coagulation tests, comprehensive thrombophilia evaluation. Additional laboratory evaluation would depend on
associated medical conditions and VTE in specific organ
systems.
D-dimer assay may be useful as a screening test for
massive or diffuse thrombosis, however, low levels do
not exclude VTE. Other abnormal tests in VTE include
circulating prothrombin fragment 1.2 and the TAT
complex, however, these are not clearly adapted to the
clinical setting. Prolonged activated partial thromboplastin
time (APTT) with a normal prothrombin time (PT)
may indicate presence of lupus anticoagulant/APLA
or factor XII deficiency. Shortened APTT with normal
PT may be associated with elevated factor VIII levels.
Prolongation of both PT and PTT may be seen with DIC or
dysfibrinogenemia.
Hemogram may help identify sickling of red cells,
thrombocytosis or thrombocytopenia in massive throm
bosis or DIC. Sickling test and hemoglobin electrophoresis
is recommended in arterial thrombosis.
Recommended panel for identifying thrombophilic
states as per the Scientific and Standardization Sub
committee on Perinatal and Pediatric Hemostasis of the
International Society on Thrombosis and Hemostasis,
for laboratory evaluation of VTE in children include the
following.
Acquired or Genetic

AT III assay
Protein C assay
Protein S assay
Elevated plasma factor VIII assay
Blood homocysteine levels
APLA (including anticardiolipin antibodies, Russell
viper venom time, antibody to beta-2 glycoprotein 2,
APTTbased lupus anticoagulant test).
DIC (including platelet count, fibrinogen levels,
D-dimer)
Activated protein C resistance (APTT-based assay).
Genetic
Factor V Leiden polymorphism
Prothrombin G20210A polymorphism
Elevated plasma lipoprotein(a).
Therapeutic Approach
There are few clinical trials available to guide decision
making in the treatment of thrombosis. Most published
guidelines are based on adult trials, uncontrolled pediatric
studies, case series and reports and it is unclear how these
guidelines are being used. Nevertheless patients today are
being diagnosed with thrombosis and must be treated.
Therapy is based on methods that are best for restoring
circulation rapidly balanced by the risk of bleeding, with
an aim to re-establish flow through the occluded vessel,
prevent embolization, and arrest the thrombotic process.
ANTITHROMBOTIC AGENTS
The interaction of antithrombotic agents with the hemo
static system of the young differs from the adult with
respect to a multitude of variables. Pharmacokinetics of
these agents vary in an age-dependent manner as well
as with intercurrent illnesses and medications. Limited
vascular access poses problems with drug delivery and

with monitoring of anticoagulant effect. With most agents,
pediatric-specific formulations are not available making
reproducible dosing difficult, especially so in the case of
low molecular weight heparins (LMWH) and vitamin K
antagonists (VKA) warfarin. Dietary differences especially
in milk fed patients make VKA dosing difficult. Thus, actual
clinical experience becomes important and VTE should, if
possible be treated in a pediatric hematology setting, or if
not by a neonatologist/pediatrician in close consultation
with a pediatric hematologist.
Unfractionated Heparin
Standard heparin still remains the most common form
used in pediatric patients overall and acts by enhancing
AT III mediated inactivation of factor Xa and thrombin,
hence needs normal ATIII levels to be effective. Its efficacy
is monitored by aPTT or antifactor Xa activity. Newborns
have a faster clearance of unfractionated heparin (UFH)
due to a larger volume of distribution and hence need a
higher dose to achieve anticoagulant effect. Its major
disadvantage is the need for vascular access and repeated
monitoring. Risk of bleeding with UFH for deep vein
thrombosis (DVT) is low but may be as high as 24 percent in
the ICU setting. Osteoporosis with UFH is rare in children.
Heparin induced thrombocytopenia in various cohorts is
reported in 0 to 2.3 percent, at varying ages and in UFH
exposures ranging from vascular access device flushes to
massive doses in cardiopulmonary bypass surgery.
Low Molecular Weight Heparin

Despite unproven efficacy, low molecular weight heparin
(LMWH) have rapidly become a treatment of choice
on pediatric patients, both for primary prophylaxis and
treatment of VTE. Potential advantages of LMWH in
children include subcutaneous route of administration, no
significant need for monitoring, minimal risk of bleeding
HIT or osteoporosis and no interference with diet or drug
metabolism. Most available data in children is with the
use of enoxaparin, although dalteparin and reviparin have
been used as well. Bleeding with LMWH can be treated
with protamine sulfate, although multiple doses may be
required. LMWH should be withheld for 24 hours prior to
any procedure, as also it needs dose adjustment in renal
failure.
Thrombotic Agents
For large vessel and massive or extensive thrombosis, or
pulmonary embolism, thrombolytic therapy should be
considered, after weighing the potential benefits versus

risk of bleeding. It is recommended to ensure that serum
fibrinogen is > 50 mg/dL and platelet count > 50,000/
cumm and that efficacy be monitored by documenting
increasing D-dimer levels. Thrombolysis carries significant
risk in patients who have had surgery in the past 7 days,
premature neonates or with cerebral sinus thrombosis
when intracranial bleed may occur. Minor bleeding with
thrombolysis may be treated with local pressure, but major
bleeds will require stopping therapy and administration of
cryoprecipitate and/or antifibrinolytics. In children there
is no data showing any advantage of local over systemic
administration. In fact, except for catheter related TE,
catheter-directed local administration may cause more
harm in view of small vessel lumen size. The thrombolytic
agent of choice in pediatric patients is recombinant
tPA, however, it is expensive. Streptokinase is a cheaper
alternative, but may cause severe allergic reactions be less
effective in the presence of plasminogen deficiency as in a
newborn. Such situations will need supplementation with
fresh frozen plasma to make thrombolytic agents effective.
A recent study by Leary et al. has shown low-dose systemic
r-tPA an effective thrombolytic agent in DVT in children,
which may represent a transition between high dose r-tPA
and anticoagulation.
VITAMIN K ANTAGONIST
Warfarin is the commonly used vitamin K antagonist (VKA)
when long-term treatment is warranted and effects its
anticoagulant action by inhibiting gamma carboxylation
of vitamin K dependent proteins. Though an oral and
low-cost agent, it has unpredictable pharmacokinetics,
numerous drug and food interactions as well as a narrow
therapeutic index. It is extremely challenging thus, to
manage children under 4 years on warfarin. However,
currently point of care portable devices to monitor PT and
INR using capillary samples are available.
Alternative Thrombin Inhibitors

Patients with HIT may be treated with alternative agents
such as danaparoid, argatroban or hirudin, though
limited data is available on these children. Antifactor Xa
agents such as fondaparinux act by indirect inhibition of
thrombin.
ANTIPLATELET DRUGS
Aspirin is the most common antiplatelet drug used in
children at an empiric dose of 1 to 5 mg/kg/day, and
second commonest being dipyridamole (25 mg/kg/
day). However, clopidogrel (1 mg/kg/day) is found to
be effective and safe in children. Bleeding is uncommon
except in situations with added hemostatic abnormalities
or newborns also on indomethacin. Newer agents include

ticlopidine and glycoprotein IIb-IIIa antagonists such
as abciximab, the latter being found to induce faster
regression of coronary aneurysms in Kawasakis disease.
Venacaval Interruption
Inferior venacaval filters have been implanted in some
cases to prevent pulmonary TE.
Surgical Thrombectomy
Rarely used in children, it may be required in IVC throm
bosis in Wilms tumor, blocked Blalock-Taussig shunt,
massive intracardiac thrombosis following surgery, local
thrombosis after vascular access.
Treatment of Venous Thromboembolism

Initial management: This largely depends on the
location extent and symptoms. For severe massive
throm
bosis, thrombolytic therapy should be con
sidered, followed by anticoagulation. Less severe
DVT, non-occlusive or small thrombi of extremities,
simple catheter related thrombi can be treated with
anticoagulation alone, where currently the choice
is UFH or LWMH as a first line. LWMH is preferred
because of its safety and convenience in children. UFH
which has a shorter half life is preferred when there is a
greater comorbid risk of bleeding, labile acute clinical
status, impaired renal function or with cost constraints.
Recommended duration of heparinization is 5 to 10
days.
Further treatment: Once some flow is restored, further
anticoagulation is needed to treat residual thrombi,
prevent embolization and recurrence. Extended anti
coagulation in a subacute phase would prefer
LMWH, though warfarin is also used. For chronic
anticoagulation in an older child warfarin is used.
DETAILS OF ANTITHROMBOTIC AGENT

ADMINISTRATION (TABLES 1 TO 4)
Recommended Durations of Therapy
(Anti-thrombotic therapy in neonates and children:
Evidence-based guidelines, P Monagle et al.)
For idiopathic VTE as a first episode 6 months anti
coagulation with LMWH or warfarin (INR 2.5).
For secondary risk factors which have resolved, 3
months of VKA or LMWH.
For ongoing secondary risk factors (e.g. nephrotic
syndrome or L-asparaginase) continue anticoagulation
till risk factor resolution.
Table 1 Administration of unfractionated heparin
Loading dose
75 u/kg over 10 minutes for all
Maintenance dose
2530 u/kg for infants;

20 u/kg > 1 year of age
APTT monitoring
Table 4 Administration of systemic thrombolytic agents

r-tPA
First at 4 hours, then daily and 4 hours

after every change
0.10.6 mg/kg/hr over 6 hourssystemic

high dose
0.5 mg in normal saline volume required to
fill the linelocal
Streptokinase
Desired APTT
6085 sec
(antifactor Xa level 0.30.7 u/mL)
2000 u/kg bolus, then 2000 u/kg/hr for 612

hours
Urokinase
Dose modification
A PTT < 50 secincrease 20%

5059 secincrease 10%
8095 secdecrease 10%
96120 secwithhold heparin for
30 minutes and decrease 10%
>120 secwithold heparin
60 minutes and decrease 15%
Daily CBC
4400 u/kg bolus, then 4400 u/kg/hr for 612

hours
Monitor
PT, PTT, platelet count, fibrinogen for all
Table 2 Administration of LMWH (enoxaparin)

Initial treatment dose
2 mg/kg 12 hourly in neonates

1.5 mg/kg 12 hourly > 2 months age
Maintenance dose
1.5 mg/kg for neonates

1 mg/kg > 2 months age
Antifactor Xa
monitoring
First at 4 hours, 24 hours, 1 week,

monthly
Desired antifactor Xa
0.51 u/mL
Table 3 Administration of warfarin

Loading dose
0.2 mg/kg for 24 days
PT-INR monitoring
Daily till INR in therapeutic range,

then weekly
Desired PT-INR
2.03.0
Dose modification
a.Loading
INR 1.1-1.3100% of loading dose
INR 1.43 50%
INR 3.13.5 25%
INR >3.5 withhold till <3.5, restart
at 50%
b.Maintenance
INR 1.11.4; 120% of previous dose
INR 1.51.9; 110%
INR 2.03.0; 100%
INR 3.14.0; 90%
The above guidelines may be referred to for further

details in management of thrombosis in a wide spectrum
of clinical situations including neonates, venous access
devices, arterial ischemic stroke, cardiac devices and pros
thesis, cardiac procedures, cardiomyopathy, Kawasakis
disease, cancer, cerebral sinus thrombosis, APLA and
purpura fulminans.
Neonatal Purpura Fulminans

This is seen with homozygous or doubly heterozygous
protein C deficiency, wherein presentation is very early
in the newborn period large areas of skin necrosis due to
diffuse thrombosis within the skin vasculature. Clinical
effects may occur even earlier, in the fetus with CNS
thrombosis giving rise to neonatal seizures. Management
of these babies is complicated as, neither heparin nor
antiplatelet drugs are effective. Replacement therapy is
necessary with a source of protein C, usually FFP 10 to
20 mL/kg, or if possible protein C concentrates, 20 to
60 u/kg, on a 12 hourly basis. However, protein C has
a half life of 6 to 16 hours, and frequent administration
is limited by development of hyperproteinemia, hyper
volemia, hypertension, loss of venous access, potential
exposure to viral agents, infections. These babies are also
prone to warfarin induced skin necrosis although warfarin
is required for long-term control of thrombotic diathesis.
Liver transplantation may offer a cure with normalization
of protein C levels.
OUTCOMES
Complications of VTE may occur acutely or over a longterm. Early adverse outcomes include bleeding associated
with anti-thrombotic therapy, thrombotic hemorrhage,
For recurrent VTE with reversible risk factor, 6 to 12 and organ dysfunction depending on the site/severity
months and resolution of risk.
of thrombosis. Long-term adverse outcomes include
For idiopathic recurrent VTE, 12 months to lifelong.
recurrent VTE, renal dysfunction/hypertension, variceal
For chronic risk factor associated VTE, lifelong anti- bleeding, chronic SVC syndrome and post-thrombotic
coagulation is recommended.
syndrome.

Recurrent TE rates are lower than adults, seen in 6 to
10 percent.
Post-thrombotic syndrome (PTS) seen in nearly
1/3rd of DVTs is characterized by edema, visibly dilated
superficial collateral veins, venous stasis dermatitis and
ulceration. Some patients, both neonatal VTE survivors
and older children, may have persistent residual
thrombosis which in the long-term may cause venous
valvar insufficiency and hence PTS. Factors predicting
poor long-term outcome in terms of recurrent VTE,
persistent thrombosis and PTS include, complete venoocclusion at diagnosis, and more importantly, elevated
factor VIII levels >150 u/dL and D-dimer> 500 ng/
mL at diagnosis and after 3 to 6 months of standard
anticoagulation.
CONCLUSION
Thrombotic disorders have emerged as a serious pediatric
concern and clinical challenge resulting in acute and
chronic sequel. Though we have come a long way over
the past decade, many questions remain regarding
pathogenesis, natural history, optimal therapy. Advances
in ability to predict outcomes may help risk-stratifying
therapy and achieve meaningful improvements in longterm outcomes.
BIBLIOGRAPHY
1. Aschka I, et al. Prevalence of factor V. Leiden in children
with thromboembolism. J Pediatr. 1996;155:1009.
2. Bick RL. Prothrombin G20210A mutation, antithrombin,
heparin cofactor II, protein C and protein S defects
Hematol Oncol Clin North Am. 2003;17:9.
3. Cantor A. Developmental Hemostasis. Nathan and
Oskis Hematology of Infancy and Childhood. Elsevier.
2009.p.147.
4. Edstrom CS, et al. Evaluation and treatment of thrombosis
in the neonatal intensive care unit. Clin Perinatol. 2000;
27:623.
5. Goldenberg N, et al. Venous thromboembolism in
chlidren. Pediatr Clin North Am. 2008;55:305.
6. Goldenberg NA. Long-term outcomes of venous
thrombosis in children. Curr Opin Hematol. 2005;12:370.
7. Harenberg J, et al. New anticoagulants. Semin Thromb
Hemost. 2007;33:449.
8. Hoyer PF, et al. Thromboembolic complications in

children with nephrotic syndrome: risk and incidence.
Acta Paediatr Scand. 1986;75:804.
9. Kenet Gili, et al. Bleeding and thrombosis issues in
pediatric patients: current approach to diagnosis and
treatment. Acta Haematol. 2006;115:137.
10. Kwaan HC, et al. The significance of endothelial hetero
geneity in thrombosis and hemostasis. Semin Thromb
Hemost. 2010;36:286.
11. Leary SE, et al. Low dose systemic thrombolytic therapy
for deep vein thrombosis in pediatric patients. J Pediatr
Hematol Oncol. 2010;32:97.
12. Lippi G, et al. Pathogenesis of venous thromboembolism:
when the cup runneth over. Semin Thromb Hemost.
2008;34:747.
13. Male C, et al. Central venous line related thrombosis in
children: association with central venous line location and
insertion technique. Blood. 2003;101:4273.
14. Manco Johnson MJ, et al. Laboratory testing for throm
bophilia in pediatric patients. On behalf of the Sub
committee for Perinatal and Pediatric Thrombosis of the
Scientific and Standardization Committee (ISTH), Thromb
Hemost. 2000;88:155.
15. Manco-Johnson MJ, et al. Diagnosis and management
of thrombosis in the perinatal period. Semin Perinatol.
1990;14:393.
16. Manco-Johnson MJ. How I treat venous thrombosis in
children. Blood. 2006;107:21-9.
17. Middledorp S, et al. Thrombophilia: an update. Semin
Thromb Hemost. 2007;33:563.
18. Monagle P, et al. Antithrombotic therapy in neonates
and children: ACCP evidence based clinical practice
guidelines, 8th edn. Chest. 2008;133:887.
19. Parasuraman S. Venous thromboembolism in children
Circulation. 2006;113:e12.
20. Rand JH, et al. Antiphospholipid antibody syndrome.
Annu Rev Med. 2003;54:409.
21. Schneippenheim R. Thrombosis in infants and children.
American Society of Hematology. 2006.pp.86-96.
22. Stein PD, et al. Incidence of venous thromboembolism
in infants and children: Data from National Hospital
Discharge Survey. J Pediatr. 2004;145:563.
23. van Ommen Ch, et al. Venous thromboembolism in
childhood: a prospective 2 year registry in the Netherlands.
J Pediatr. 2001;139:676.
24. Wiernikowski JT, et al. Thromboembolic complications in
children with cancer. Thromb Res. 2006;18:137.
25. Young G. Diagnosis and treatment of thrombosis in children:
General principles. Pediatr Blood Cancer. 2006;46:540.
34
Disseminated Intravascular
Coagulation in Neonates
VP Choudhary
Disseminated intravascular coagulation (DIC) is a

syndrome which develops following large number of
disorders (Flow chart 1). It occurs whenever there is
systemic activation of coagulation system leading to
generalized uncontrolled formation of fibrin with in the
blood vessels leading to micro-vascular thrombosis in
multiple organs along with consumption of platelets and
coagulation proteins which results in variable bleeding
symptoms. Therefore patients of DIC can have symptoms
related to bleeding and thrombosis simultaneously. The
subcommittee on DIC of the Scientific and Standardization
Committee of the International Society of Thrombosis
and Hemostasis (ISTH) has recently proposed the
following definition of DIC. It is an acquired syndrome
which presents with variable symptoms secondary to
intravascular coagulation and it may spread to involve
multiple organs leading to their dysfunction.1,2
First description of DIC appeared in the literature in
1950s.3 Over the years the pathogenesis of DIC have been
Flow chart 1 Disseminated intravascular coagulation
studied and with the better understanding of underlying

mechanism has helped to evolve multiple diagnostic
and monitoring tests and appropriate strategies for
its management which have improved the survival
significantly. The mortality in the neonatal period is
very high. Early diagnosis and prompt management is
essential. However, it is desirable that the development of
DIC should be prevented by appropriate measures.
Systemic activation of coagulation system may occur
in a large numbers of diseases. The activation of the
coagulation results in clinical symptoms which may vary
from decrease in platelet count, subclinical prolongation of
global clotting time, mild bleeding symptoms to fulminant
disease complex termed as disseminated intravascular
coagulation.
PATHOGENESIS OF DIC
Many pathogenetic mechanism either singly or
together play a major role in pathogenesis of DIC.4,5
Fibrin depositions plays the key role in its pathogenesis
which occurs following tissue factor mediated
thrombin generation which exceeds the physiological
anticoagulation mechanism (mainly antithrombin III
and protein C system). In addition fibrin removal is less,
as fibrinolytic activity does not increase proportional to
thrombotic activity. Fibrinolytic activity infact is inhibited
in DIC because of high level of PAI-1 which is a fibrinolytic
inhibitor. Thus there is impairment of endogenous
thrombolysis. All these processes are complex and occur
simultaneously. It is for the better understanding, these
factors have been described separately (Fig. 1 and Flow
chart 2). There is an interaction of these factors at multiple
levels.
Chapter-34 Disseminated Intravascular Coagulation in Neonates 357

on endothelial cells through various cytokines, such
as TNF- and interleukin (IL).8 These observations
are further supported by improved survival following
administration of activated protein C to patients with DIC.
Tissue factor pathway inhibitor (TFPI) is another major
inhibitor of coagulation system. There are experimental
and clinical evidences which have demonstrated that
administration of recombinant TFPI have blocked the
inflammatory process induced by thrombin generation. In
clinical studies the use of TFPI in pharmacological doses is
capable of reducing the mortality significantly in systemic
infection.9
Fig. 1 Disseminated intravascular coagulationpathogenesis
Flow chart 2 DICpathogenesis
Impaired Fibrinolysis
Presence of bacteremia and endotoxemia increase the
fibrinolytic activity because of the release of plasminogen
activators from the endothelial cells.10 However, increase
in plasma levels of PAI-1 results in reversal of fibrinolytic
activity.11 Rise in PAI-1 levels occurs as a result of release of
cytokines and endothelial injury (Flow chart 2).
Dysfunctional Physiologic Anticoagulant

Pathways
Activation of coagulation system occurs through various
regulatory pathways which are impaired thereby leading
to amplification of thrombin generation which leads to
increased thrombin formation.6 The antithrombin III(ATIII) is an important inhibitor of thrombin whose levels are
reduced in patients with severe sepsis. Multiple factors
in combination, such as (a) consumption due to ongoing
thrombin generation, (b) degradation by elastase, released
from activated neutrophils and (c) impaired synthesis. Low
levels of AT-III results in DIC with increased mortality.7
This impaired function of the protein C pathway occurs as
a result of down regulation of thrombomodulin expression
Based upon the onset and severity of symptoms, DIC has

been subdivided into acute and chronic DIC.
Acute DIC is of sudden onset and carries very high
morbidity and mortality. It is most common in neonate
period and therefore has been described in detail.
Neonates with severe acute DIC may manifest with
bleeding from multiple sites such as development
of purpuric and ecchymotic spots, mucosal oozing,
gastrointestinal blood loss and bleeding from venous
access.
Neonates may progress to hypotension, shock and
often develop fluid and electrolyte disturbances.
The deposition of thrombin is dependent upon the
organ involvement. Neonates may become lethargic
and neonatal reflexes are depressed or absent,
comatose, or develop seizures, become unconscious
as a result of CNS involvement, may develop stroke as
a result of thrombosis in cerebral vessels, which may
progress to hemorrhagic infarcts.
Micro thrombi in the renal system may progress
to oliguria, renal failure as a result of acute tubular
necrosis. Micro thrombi may cause acute abdominal
pain simulating clinical picture of acute abdomen or
bleeding in the gut as a result of gangrene.
DIAGNOSIS OF ACUTE DIC

High index of suspicion is essential. Any neonate, who
starts bleeding in pressure of underlying condition should
be considered to have DIC and should be investigated
periodically for diagnosis of DIC. Thrombocytopenia is
an early manifestation of DIC. Patients with acute DIC are
critically ill, and therefore early diagnosis is essential for
improved survival. Several of sensitive and sophisticated
tests are not readily available in clinical practice even in
the advanced centers. Therefore the diagnosis of DIC is
based upon the platelet count, examination of peripheral
smear, measurement of PT and APTT , high level of fibrin
degradation products (FDP) and D-dimers.
Thrombocytopenia is often attributed to consumptive
processes but underproduction also plays a role in
presence of severe sepsis which is often the cause of DIC
in neonates. Coagulation on studies when minimally
damaged, there may be difficulty in distinguishing it as
abnormal as low levels in preterm are expected. Similarly
there is no reliable range of D-dimers.
Fibrinogen concentration normally may increase
during the first few days of life. Therefore, at time diagnosis
of DIC in neonates becomes very difficult.
It has been observed that serial coagulation tests
and platelet counts are usually more helpful than single
laboratory results to establish the diagnosis of DIC.12 Low
fibrinogen level is detected only in severe DIC but it is not
a specific marker.3
High levels of FDP and D-dimers help the clinicians to
differentiate other disorders like chronic liver disease with
low platelet count and prolonged PT and APTT.13
The subcommittee on DIC of the International Society
of Thrombin and Hemostasis has recently published a
scoring system1 to facilitate the clinicians to establish the
diagnosis of DIC. In presence of any condition known to
cause DIC, algorithm suggested by the subcommittee
should be used to determine the score. A score of 5 or
more suggests the diagnosis of DIC. However this scoring
system needs to be validated by prospective studies in
neonatal DIC (Table 1).
MANAGEMENT OF DIC
The heterogeneity of the underlying disorder and clinical
severity is so variable therefore, it is difficult to have a
common therapeutic approach for management of DIC.
Thus, the treatment of DIC should be individualized,
based upon the clinical presentation, i.e. bleeding,
thrombosis or both and patients conditions such as
hemodynamic situation, presence of hypothermia or
not, electrolyte imbalance and gas exchange along with
renal, cardiac and neurological status.14 Early diagnosis
of underlying condition and their prompt appropriate
management plays a major role in the outcome of DIC.
The management of the underlying condition will not be
discussed as the underlying conditions are many and have
different specific treatment.
Replacement therapy: Platelets and coagulation factors
(FFP) are administered to correct thrombocytopenia and
coagulation factor to control the bleeding at multiple sites.
Currently it forms the major form of therapy for treatment
of DIC.15
Transfusion of Platelet Concentrates

One to two units of platelet concentrates per 10 kg of
body weight are administered if platelet count is below
30 x 109/L in absence of any bleeding. Platelet therapy
is essential in presence of bleeding manifestation even
if the platelet count is >30 109/L. The main objective is
to control the bleeding and there is no need to transfuse
platelets to maintain platelet count of >50 109/L which is
considered as a safe level.
Fresh Frozen Plasma

Fresh frozen plasma (FFP) should be administered
at a dose of 15 to 20 mL/kg in an attempt to correct the
Table 1 Diagnostic algorithm for diagnosis of DIC

Risk assessment: Does the patient have an underlying disorder known to be associated with overt DIC?
If yes proceed
If no, then do not use this algorithm
Order for screening coagulation tests (platelet count, PT, APTT, fibrinogen, soluble fibrin monomers or fibrin degradation
products)
Score screening coagulation tests results
Platelet count (>100,000=0, <100,000=1, <50000=2)
Prolonged PT (<3 sec = 0, >3 sec but <6 sec = 1, >6 sec = 2)
Fibrinogen level (1 g/L = 0, <1 g/L = 1)
Elevated fibrin related marker e.g. soluble fibrin monomers/FDP (no increase=0, moderate increase=2, strong increase=3).
Calculate score
If the total score is 5, then patient is compatible with overt DIC, repeat scoring daily.
If the score is <5, it is suggestive (not affirmative) of nonovert DIC, repeat the tests at 12 days interval till the patient
recovers or whenever the score exceeds 5, diagnosis of DIC can be made.
Chapter-34 Disseminated Intravascular Coagulation in Neonates 359

multiple factor deficiency and to control bleeding.
Alternatively fibrinogen concentrates (total dose
23 g) or cryoprecipitate (1 bag/10 kg body wt) may be
administered. Cryoprecipitate (510 mL/kg) is a better
source of fibrinogen, which should be kept above 1 g/L.
Dose and duration of therapy needs to be monitored
with platelet counts, PT and APTT levels daily. Treatment
should be directed to correct the PT and APTT levels and
to prevent the further deterioration.
Anticoagulants
The role of heparin in the treatment of DIC remains still
controversial.16 However, the present data indicates that
heparin is effective in treatment of neonate with acute DIC
having predominant thrombotic symptoms, e.g. purpura
fulminous. Presently role of heparin in chronic DIC is well
established. It has been used effectively in patients with
recurrent thrombosis such as hemangioma or dead fetus
syndrome.17
Heparin is usually given at relatively low doses (510
U/kg of body weight per hour) by continuous infusion
and may be switched to subcutaneous injection for longterm therapy. Its dose needs to be adjusted with APTT or
heparin level. Alternatively low molecular weight heparin
may be used. It is preferred these days as it is not essential
to monitor heparin level or APTT. Secondly the incidence
of heparin induced thrombocytopenia is less when
compared with standard heparin.
Recombinant hirudin which is newer anticoagulant
has AT III independent inhibitory activity of thrombin
has been used successfully to treat DIC in experimental
studies.18
Concentrates of Coagulation Inhibitors

In the pathogenesis of DIC it has been observed that there
is deficiency of coagulation inhibitors. Therefore the
normalization of anticoagulation pathway should form a
part of treatment for DIC.19 AT-III is a primary inhibitor of
circulating thrombin, its use in DIC certainly is rational.20
It has been shown to have beneficial effects in terms
of correction of coagulation parameters and organ
dysfunction.21
Use of activated protein C and recombinant throm
bomodulin has also been shown to reduce the mortality
significantly in patients with severe sepsis.22 The activation
of coagulation cascade in DIC occurs exclusively through
the extrinsic pathway. Thus inhibition of tissue factor
should block endotoxin associated thrombin generation.
De Jongeet al.23 was first to use the tissue factor pathway
inhibitor (TFPI) for treatment of DIC following sepsis.
Newer Agents
Some authors have demonstrated that the administration
of recombinant interleukin (IL-10), which is a potent
anti-inflammatory cytokine, has been demonstrated to
moderate the activation of coagulation system in humans
but not in neonates. Its use completely abrogated the
effects of endotoxins on coagulation pathway. Pajkrt
and his colleagues24 observed significant improvement
of DIC in patients with sepsis following administration
of monoclonal antibodies against TNF. While Branger et
al25observed that p38 nitrogen activated protein kinase
inhibitor modified the activation of coagulation, fibrinolysis
and endothelial cells injury following administration of
endotoxins in experimental studies. However, all these
modalities are still experimental. There is hope that with
better understanding of the pathophysiology, newer
diagnostic tests and development of newer agents, the
treatment of DIC will improve significantly in near future.
CONCLUSION
DIC is a syndrome characterized by systemic intravascular
activation of coagulation in the circulation. It is associated
with variable clinical manifestations from mild bleeding
to organ failure. Better understanding of pathogenesis
has lead to better clinical management strategies. Using a
scoring system based on the clinical as well as laboratory
tests, an early and accurate diagnosis of DIC can be made.
The cornerstone of the management of DIC is the vigorous
treatment of the underlying disorder. In addition, the
strategies that interfere with the coagulation system, such
as replacement, use of antithrombin III and activated
protein C, have improved the survival greatly. However,
larger studies are essential to determine their efficacy
and safety of products such as antithrombin III, activated
protein C, etc. Current research is likely to evolve newer
novel strategies for management of DIC in near future.
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Recombinant human activated protein C (rhAPC)
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Transfusion Medicine
CHAPTERS OUTLINE
35. Blood Components in Pediatric Practice

36. Nucleic Acid Amplification Testing

37. Transfusion Transmitted Infections

38. Noninfectious Hazards of Blood Transfusion

35
Blood Components in Pediatric Practice

Availability of blood components has improved the outcome of various childhood hematological disorders, especially the pediatric
malignancies. Every unit of whole blood collected must be subjected to components as one can satisfy the needs of more than one
patient from the same unit of blood. Whole blood has a limited application in clinical practice like during massive blood loss and for
exchange transfusion; and there too one can use reconstituted whole blood instead. The notable components prepared from one
unit of whole blood include packed red blood cells (PRBC), platelets and fresh plasma; which can be further frozen and used as fresh
frozen plasma (FFP). The PRBC can be used to improve the oxygen carrying capacity as well as volume expander in acute blood loss.
Platelets are very useful to treat bleeding due to thrombocytopenia caused by decreased platelet production and also in platelet
dysfunction. Single donor platelet is much more efficacious than random donor platelet but is expensive and not easily available.
Platelets must be kept on a constant agitator and stored at 22C. Platelets are often misused in clinical practice. Platelets have no role
in immune causes of thrombocytopenia or as prophylaxis in chronic stable thrombocytopenia. FFP has role to play in treating patients
with multiple factor deficiency classically seen in disseminated intravascular coagulation (DIC) or liver disorders. It should not be used
as volume expander or as source of proteins. Leukodepleted blood products are preferred as donor lymphocytes present in the blood
product can lead to severe toxicities like febrile reactions, allosensitization, increased chances of graft rejection in potential transplant
recipients and transfusion associated graft versus host disease. Use of blood filters can prevent these to a large extent; however
tagvhd can be only prevented by using irradiated blood products. The most important is to prevent unnecessary prescriptions of
blood products and that is possible if the center has written policies which are strictly followed by the clinicians and by in-built audit.
Keywords
Blood components, pediatric, guidelines, packed red blood cells, platelets, fresh frozen plasma, leukodepletion, IAP guidelines.
INTRODUCTION
Availability of blood components has improved the
outcome of children with malignancies and those in
intensive care set up. It has changed the main focus in
cancer therapy complications from bleeding to infections.
Blood components now allow administration of high dose
chemotherapy which has changed the outcome in some
pediatric cancers.
Child is not a miniature adult and so also a newborn is
not a miniature child. There are major differences between
an adult and a child in the etiology of cytopenias, the
effect of cytopenia on the homeostasis, the physiological
responses by the body to the cytopenia, the need of
various blood components, the choice and the dose of
the blood component used. This is even more true for a
newborn. Accordingly the guidelines for the use of blood

components differ in a child than that for an adult and
in a newborn as compared to a child. Various recent
publications are available which define the guidelines
for the use of blood components specific for children and
newborns.
Why not Whole Blood and why Components?

Each unit of whole blood has at least four basic components
which include red blood cells, white blood cells, platelets
and plasma. Each of these components has specialized
function. All these functions are not deranged in all the
patients and hence all the components are not required
all the time. Blood is always in short supply and making
components from one unit of whole blood will satisfy the
364Section-5Transfusion Medicine
needs of more than one patient from the same unit of blood.
Besides, giving whole blood can lead to harmful effects
like plasma overload; lymphocytes mediated toxicities
or allosensitization, etc. Some components can only be
given effectively as component, e.g. platelets, which are
otherwise, destroyed in refrigerated stored whole blood.
Some components are better given as component e.g.
clotting factors as one can not achieve effective levels by
using FFP alone. It is a social crime to use whole blood and
waste this rare commodity!
Which Components?
From one unit of unrefrigerated whole blood one can
make packed red blood cells, platelet pack (random
donor platelet), granulocytes pack and fresh plasma.
Fresh plasma can be further frozen at 30C and be
used as FFP in future. Pooled plasma can be converted
into further components like cryoprecipitate, albumin,
gamma globulins, anti-D globulins, plasma proteins,
etc. One can modify and manipulate these components
and obtain neocyte red cells, frozen red cells, washed red
cells or platelets, filtered red cells or platelets, UV light or
gamma irradiated red cells or platelets. One can select a
specific donor and get CMV negative blood components,
HLA matched blood components or blood products from
specific minor blood group compatible donor. Lastly
one can get stem cells from the umbilical cord blood
of a newborn or peripheral blood of an older child for
autologous or allogenic bone marrow transplant or rescue
as the case may be.
Storage and Shelf Life

Whole blood is stored at 1 to 4C. Shelf life will depend
upon the type of anticoagulant and additive used. ACD
is no more used. CPD or CP-2D blood can be kept for 21
days. CPDA1-A2 blood can be kept for 35 days. If one uses
additives like Nutrisol or Adsol, one can keep the blood for
42 days. Packed red blood cell is stored at 1 to 40C and
should be used within 24 hrs if packed using open system.
Platelets are stored at 20 to 22C and that too on a constant
agitator as resting platelets tend to aggregate. The shelf life
is 3 to 7 days. Granulocytes are kept at room temperature
and should be used within 24 hours of collection. FFP and
cryoprecipitate have shelf life of one year and are stored
at 30C. Frozen red blood cells can be kept at 70C and
have shelf life of 5 to 7 years.
ABO and Rh Compatibility

Tables 1 and 2 describe the choice of the ABO and Rh type
of the donor blood component in various recipient ABO
and Rh settings.
Table 1 Choice of ABO blood group of donor components in

children
Patients ABO
Donor ABO group
group
Red cells
Platelets
FFP
O
First choice
O
O
O
Second choice A
A or B or AB
A
First choice
A
A
A or AB
Second choice O*
O*
B
First choice
B
B#
B or AB
Second choice O*
A or O*
AB
First choice
AB
AB#
AB
Second choice A or B
A
A
Third choice
O*
* Group O component without high anti-A or anti-B titers
should be selected.
#
Platelet concentrates of B or AB group may not be easily
available.
Group O FFP should be given only to O group patients and no

one else. AB group FFP may not be easily available.
Table 2 Choice of Rh blood group of donor components in

children
Patients Rh
Donor Rh group
group
Red cells
Platelets
FFP
Rh positive
First choice
Rh +ve
Rh +ve
Rh +ve
Second choice Rh ve
Rh ve
Rh ve
Rh negative
First choice
Rh ve
Rh ve
Rh ve
Second choice Rh +ve*
Rh +ve
* If Rh +ve platelets are given to an Rh negative recipient, anti-D
globulin in the dose of 250 mcg should be given to the recipient,
which will cover up to 5 platelet transfusion for up to next 6
weeks.
FFP usually are not labeled as Rh positive or negative.
Whole Blood
Whole blood has all the components, but that is only in the
first 6 to 8 hours that too when stored at room temperature.
The platelets are the first to disappear in the first 4 to 48
hours, the labile clotting factors V and VII are the next to
disappear and the other clotting factors go down thereafter.
On prolonged storage the potassium levels go up whereas
Chapter-35 Blood Components in Pediatric Practice 365

the pH, the 2-3-DGP levels and the ATP levels fall. Hence
for the exchange transfusion one prefers to use less than 7
days old blood. Whole blood is stored at 1 to 4C and has a
shelf life of 21 to 42 days as discussed before.
Indications
Whole blood is used only when massive transfusions are
required like in exchange transfusion, massive blood
loss with at least one volume blood transfused or during
extracorporeal membrane oxygenation (ECMO). One can
use reconstituted whole blood and one should remember
that there is nothing like fresh blood! 10 cc/Kg body
weight of whole blood will raise HCT by 5 percent and Hb
by 1 to 1.5 gm percent.
Packed Red Blood Cells

Packed red blood cells (PRBC) contains packed red cells
in 22 to 50 percent of original plasma. Ideal HCT for PRBC
is 70 to 75 percent and it should not be too tightly packed.
For newborns, while doing exchange transfusion, HCT
can be adjusted to 50 to 55 percent using additional FFP
or albumin. PRBC is used for improving oxygen carrying
capacity as well as volume expander. Advantage of PRBC is
that it is low volume as compared to whole blood and hence
does not lead to circulatory overload. It has less plasma
and hence has less citrate related toxicity. It is mainly used
in patients with hemorrhage or chronic anemia needing
recurrent transfusions. However it contains significant
amount of plasma and leukocytes to lead to toxicities
related to them like allergic reactions, Nonhemolytic
febrile transfusion reactions (NHFTR), allosensitization,
Graft-versus-host disease (GVHD), etc. Full cross-match
for ABO and Rh and screening for abnormal antibody
should be done before each transfusion. 10 cc/Kg. Body
weight of PRBC will raise the HCT by 10 percent and Hb by
3 to 4 gm percent.
Indications
The cut offs used in various indications are shown in
Table 3. It is used for replacement of volume as well as
oxygen carrying capacity. It is used in acute hemorrhage
where more than 15 to 20 percent blood volume is lost,
monitoring vitals, blood pressure and CVP. The most
common indication of PRBC is chronic transfusion
dependent anemia as seen in thalassemia, sickle cell
disease, congenital dyserythropoietic anemia, Diamond
Blackfan syndrome, Fanconis anemia, aplastic anemia,
chronic renal failure, cancer patients, sideroblastic
anemia, etc. It is also useful in episodic transfusions
for acute hemolysis like in G6PD deficiency, malaria,
autoimmune hemolytic anemia, etc. It is rarely, if at
Table 3 Indications of using PRBC in a > 4-month-old child

Acute blood loss of >1520% blood volume with
hypovolemia
Hb <8 gm% with
Symptomatic perioperative anemia
Chronic congenital/acquired transfusion dependent
anemia
Emergency surgery with anticipated blood loss
Uncorrectable preoperative anemia
Severe infections
Associated severe pulmonary disease
Chronic transfusion dependent states, e.g.
Thalassemia
Other hemoglobinopathies
Bone marrow failure syndrome including Fanconis
anemia
Pediatric oncology
Hb <8 gm% with chemotherapy/radiotherapy
Hb <10 gm% if
i. Intensive chemotherapy planned
ii. Presence of febrile neutropenia
iii. Severe lower respiratory tract infection
iv. Thrombocytopenic bleeding
Hyperleukocytosis (partial exchange preferred)
all, used in nutritional anemia, if patient has severe

anemia with impending cardiac failure or has associated
cardiorespiratory disease. Lastly it can be used before
surgery, where patient is anemic with Hb less than 7 gm%
and where moderate blood loss is expected during surgery.
It is most often misused as top-up in patients with
nutritional anemia, or during surgery to keep Hb above
10 gm%. In such cases, it is counterproductive as it can
lead to immune suppression of the recipient and delay
healing.
Chronic Anemia
Special precautions are required while transfusing patients
with transfusion dependant states like thalassemia. Ideally
detailed blood grouping of the recipient should be done
before the first transfusion so that in future one can use
a specific donor if the patient develops intolerance to
some minor blood group antigen. Always use Coombs
cross matched, triple saline washed PRBC in the dose of
15 cc/Kg which will raise the Hb by 3 to 4 gm%. Maintain
the pre-transfusion Hb above 9.5 to 10 gm% and raise
the post Hb to around 12 to 14 gm%. Keep the record of
the pre- and post-transfusion Hb levels and the volume
transfused every time so that one can calculate and keep
a watch on the yearly requirements. If affordable, use a
WBC filter which will help reduce the nonhemolytic febrile
transfusion reactions, allosensitization, etc.
Platelet Transfusions
One can use same donor again after 2 to 3 weeks. One can
select specific donor like CMV negative or HLA matched
donor. But SDP is extremely costly and needs sophisticated
cell separator. Also it is not a product available on the blood
bank shelf and has to be preplanned.
Types of Platelets
ABO/Rh Compatibility
There are two types of platelets, random donor platelet

(RDP) obtained by centrifugation of a unit of whole blood,
and single donor platelet (SDP) obtained by apheresis. One
can use a HLA matched or CMV negative donor in specific
situation. Use of WBC filters helps reduce leukocytes and
hence allosensitization and febrile reactions.
Whenever possible use ABO and Rh identical platelets. If

not available, use ABO and Rh compatible donor. This is
shown in Tables 1 and 2. Platelets though are red cells free
can contain some RBCs or RBC stroma enough to lead to
Rh sensitization. Hence Rh positive platelets are given to
Rh negative patient only in emergency and in such cases
one has to give 250 g of anti-D globulin to recipient to
prevent Rh sensitization, especially in female recipient.
Random donor platelet

Random donor platelet (RDP) is obtained by centrifugation
of a unit of whole blood within 6 to 8 hours of collection.
Collected unit of whole blood must be stored at room
temperature till centrifugation as otherwise platelets will
lose their function if stored in refrigerator. The blood bag
is centrifuged first at 200 RPM for 2 to 3 minutes which will
separate the whole blood in to PRBC at the top, WBCs in
the buffy coat and platelet rich plasma at the bottom. The
PRBC is siphoned out in another satellite bag and platelet
rich plasma is then spun at 5000 RPM for another 2 to 5
minutes which will leave platelet poor plasma at the top
and platelets button at the bottom. Platelet poor plasma
is then siphoned out in another satellite bag and what
remains is one unit of RDP.
One unit RDP of contains 5 to 6 1010 platelets in 50 to
60 mL of plasma, trace to 05 mL of RBCs or RBS stroma, and
up to 108 leukocytes. One unit of RDP per 10 kg body weight
will raise the platelet count by 20,000 to 30,000/cumm.
RDP is less costly and easily available from the blood bank
shelf however it is less efficacious than SDP as it contains 6
to 7 times less number of platelets. Hence patients needing
repeated platelet transfusions may benefit by using SDP
which will reduce the exposure to a fewer donors. This will
also reduce chances of allosensitization which will reduce
future platelet refractoriness as well as reduce chances of
rejection in case of future stem cell transplant.
Single donor platelet
Single donor platelet (SDP) is obtained from a designate single
donor using cell separator or apheresis machine. Compatible
donor is screened for fitness and serology and once found to
be fit is subjected to continuous or discontinuous apheresis
and platelets are collected over 4 to 6 hours. SDP contains 2
to 3 1011 platelets in 250 to 300 mL of plasma, up to 5 mL
of RBCs and 106 to 109 leukocytes. Thus it has 6 to 7 times
more platelets than RDP (and also that much more volume).
The donor should be healthy, off medicines like aspirin and
should have platelet count of more than 1.5 lakhs/cumm.
Storage
Platelets are thermosensitive and become dysfunctional
if stored at temperature below 20 to 22C. Hence unlike
all other blood component, platelets are not stored in
refrigerator but are stored at 22C. Shelf life of platelets is
up to 5 days. Platelets have a natural tendency to aggregate
when left standing still making them lose their function.
Hence they need to be stored on a constant agitator.
Transport the platelet quickly and infuse the same in
20-30 minutes. Again do not leave platelets in a tray
lying still while awaiting transfusion. Caretaker should
be told to shake gently the platelet bags periodically to
prevent aggregation. Use plastic tubes and never use
glassware as platelet will stick to the glass surface and get
activated. Remember, platelets should never be stored in
a refrigerator! In case they are put in a refrigerator, they
should be discarded.
Criteria to Transfuse
Platelet transfusions are usually given to those with
thrombocytopenia due to decreased production than to
those with increased destruction. Platelet transfusions
are given when they have significant mucosal bleeds.
Only skin bleeds do not warrant platelet transfusion, but
such patients should be closely monitored for any further
mucosal bleeds.
It is controversial as to when to give prophylactic
platelet transfusion. Child with thrombocytopenia usually
does not bleed spontaneously unless the platelet count
falls less than 50,000/cumm. The chances of spontaneous
bleeds increase when the count drops to less than 5000
to 10,000/cumm. Hence the decision when to transfuse
platelets prophylactically is based on basic disease, type
of thrombocytopenia, platelet count, and presence of
associated coagulation abnormalities. A well child may

be given prophylactic transfusion when the platelet count
is less than 5,000-10,000/cumm. In patients with massive
hemorrhage it should be given when the count is less
than 50,000/cumm as most of the circulating platelets are
likely to be non-functional platelets of the infused stored
blood. The cut off used in various indication is shown in
Tables 4 and 5.
Indications
Platelet transfusions are given for thrombocytopenia or for
platelet dysfunction.
1. Decreased platelet production: This is seen when
bone marrow failure occurs like in aplastic anemia,
Fanconis anemia, thrombocytopenia with absent
radius (TAR) syndrome, and other constitutional hypo
plastic anemia. It is also seen when the bone marrow
is infiltrated, e.g. in leukemia and other metastatic
cancers or in presence of bone marrow suppression
due to chemoradiotherapy or fulminant infections.
Platelet transfusions have revolutionized the treatment
and the outcome of pediatric cancers. The cause of
mortality has shifted from bleeding to infections with
better platelet support available now.
2. Increased consumption of platelets: It is indicated
in disseminated intravascular coagulation (DIC),
Table 4 Indications of using platelets in a >4-month-old child
with thrombocytopenia
Prophylactic platelets (without bleeding)

<510,000/cumm in a nonsick child
<20,000/cumm in a sick child with
i. Severe mucositis
ii. Disseminated intravascular coagulation (DIC)
iii. Platelet likely to fall <10,000/cumm before next
evaluation
iv. Thrombocytopenic bleeding
Hyperleukocytosis (Partial exchange preferred)
i. Bone marrow aspiration/biopsy can be without
platelet support
ii. Lumbar puncture <30,000/cumm
iii. Other surgeries <50,000/cumm
iv. Surgery at critical sites like CNS, eyes <100,000/
cumm
<50,000/cumm with acute bleeding, massive
hemorrhage, head trauma, multiple trauma
Chronic stable thrombocytopenia only in presence of
significant mucosal bleeding

Platelet dysfunction only in presence of significant
mucosal bleeding
Chronic stable DIC only in presence of significant mucosal
bleeding
Table 5 Platelet transfusion guidelines for neonates

Prophylactic platelet transfusion (nonbleeding) in the
A
neonate:
a. Stable preterm neonate with platelet count <20,000
b. Stable term neonate with platelet count <10,000
c. Sick* preterm neonate with platelet count <30,000
d. Sick* term neonate with platelet count <20,000
e. Preparation for invasive procedurelumbar puncture
or minor surgery (central line insertion) with platelet
count <50,000
f. Major surgery with platelet count <100,000
Platelet transfusion in neonate with clinically significant
B
bleeding:
a. Neonate with platelet count <50,000
b. Neonate with condition that increases bleeding, e.g.
DIC and platelet count <100,000
c. Neonate with documented platelet function disorder
irrespective of circulating platelet count
d. Bleeding neonate meeting the clinical or laboratory
criteria for DIC, at discretion of treating physician
*Definition of a sick neonate:
a. Cardiovascular instability, HR >180/min or dopamine or
ionotropic infusion at >3 micrograms/kg/min
b. Respiratory instability, FiO2 requirements >0.4 or
significant mechanical ventilation MAP>7
c. Central nervous system instabilitywithin 72 hrs of
seizure
A specific threshold for transfusion may not be appropriate for
patients with chronic stable thrombocytopenia who are best
managed on an individual basis depending on the degree of
hemorrhage
necrotizing enterocolitis (NEC), and KasabachMerritt syndrome. In these cases, there is good platelet
recovery at one hour after transfusion, but not at 24
hours suggesting consumption. In cases with DIC,
frequent estimation of the platelet count and coagu
lation screening tests should be carried out. There
is no consensus on a target platelet count, but aim is
to maintain the platelet count > 50,000 as in massive
blood loss, would seem to be reasonable practice. In
chronic DIC, or in the absence of bleeding, platelet
transfusions should not be given merely to correct a
low platelet count. Platelets are contraindicated in
thrombotic thrombocytopenic purpura (TTP) and
hemolytic uremic syndrome (HUS).
3. Massive transfusions: There is consensus that the
platelet count should not be allowed to fall below
50,000 in patients with acute bleeding. A higher target
level of 1,00,000 has been recommended for those with
multiple trauma or CNS injury.
4. Increased platelet destruction: It can occur due to
immune or nonimmune mechanisms. Non-immune
destruction can occur following drugs or infections.
Immune destruction can occur in post-trans
fusion
purpura, autoimmune diseases, idiopathic throm
bocytopenic purpura (ITP), and alloimmune disease
of newborn. The ITP is the most common scenario
in this category. Platelet transfusions are generally
not effective in this group of diseases, as they will be
immediately destroyed by the antibody present in
recipient after transfusion. Platelet transfusions should
be reserved for patients with life-threatening bleeding
from the gastrointestinal or genitourinary tracts, into
the central nervous system or other sites associated with
severe thrombocytopenia. A large number of platelet
concentrates may be required to achieve hemostasis as
a result of reduced survival of the transfused platelets.
Therapies such as intravenous methylprednisolone
and immunoglobulin should be given at the same time
to maximize the chances of stopping the hemorrhage
and raising the platelet count.
5. Hypersplenism: Normally 1/3rd of platelets are pooled
in the spleen. This proportion will increase in patients
with hypersplenism due to any reason. Again platelet
transfusions may not be effective in such cases, as they
will be immediately removed from the circulation into
the enlarged spleen.
6. Dilutional: Dilutional thrombocytopenia can occur
following massive transfusions in patients with massive
hemorrhage or following exchange trans
fusions.
Supplemental platelet transfusions may be required in
such cases to keep platelet counts of > 50,000/cumm.
7. Platelet dysfunction: Various congenital and acquired
platelet functional disorders may present with signi
ficant bleeding. If local measures fail to control
bleeding, platelet transfusions will be required. One
should use platelets sparingly in such cases as allosensitization may prevent good recovery in future
after a number of transfusions are given. One can use
HLA matched platelets in such cases. Table 6 shows
the measures to be undertaken in a case of platelet
dysfunction with clinical bleeding.
Platelet transfusion efficacy: One unit of RDP per 10 kg
body weight increases platelet count by 20,000 to 30,000/
cumm. SDP is 5 to 7 times more effective than RDP. The
efficacy of platelet transfusion depends upon various
factors. Platelet factors like source of platelets, type of
platelets, storage, collection and administration will affect
the efficacy. Similarly, factors in recipient that affect the
efficacy include pretransfusion count, fever, sepsis, size of
liver and spleen, presence of antibodies or consumption
coagulopathy and drugs taken by the recipient.
Table 6 Measures to be undertaken in a patient with platelet

dysfunction with clinical bleeding
Avoid/withdraw drugs known to have antiplatelet
activities
Correct baseline condition known to lead to platelet
dysfunction
Correct HCT to >33% (with transfusion/EPO)
Use of DDAVP in a case of storage pool disorder
Use of alternate therapy like factor VIIa
Use of platelets when above measures are ineffective or
inappropriate
Consider platelet refractoriness after repeated use of
platelets
Clinically one can judge the efficacy by seeing the

cessation of bleeding. One can look for the expected
increments by calculating corrected count increment
(CCI) (109/L) as follows by doing platelet count at one
hour and 24 hr after transfusion.

Post-transfusion platelet count
platelet count BSA m2
_____________________________
CCI = Pretransfusion

Platelets infused 1011
Normal CCI is > 7.5 109/L at one hour, and > 4.5 109/L
at 20 to 24 hrs. If CCI is normal at one hour, but less at 24
hrs, it suggests consumption coagulopathy. If CCI is less at
1 hour itself, it suggests immune destruction.
Side effects: Both RDP and SDP contain platelets, small
volume of plasma, WBCs and some RBCs or RBC stroma.
Hence, platelets can lead to similar reactions like other
blood components including febrile reactions, urticaria,
allosensitization, transfusion associated infections and
rarely anaphylaxis. In a newborn, antibodies present
in the small volume of plasma contained in platelets
may be enough to lead to significant hemolysis if
there is a mismatch of blood groups between donor
and recipient. Hence it may be better to use a donor
with low titer anti-A or anti-B antibodies in case of a
mismatch. If not possible one can use washed platelets
as saline washing will remove the antibodies to a large
extent. In case of allosensitization patient will become
refractory to further platelet trans
fusions with poor
recovery of platelet counts in spite of adequate dose.
Allosensitization can also increase the chances of graft
rejection in case of future stem cell transplant. Such
patients may benefit by using immune suppression like
low dose steroids, plasmapheresis or using WBC filters
while transfusing platelets. Of course one can avoid
many of these complications by using WBC filters with
every platelet transfusion right from 1st transfusion

in patients who are likely to need repeated platelet
transfusions.
Granulocytes
Though its use in infections may sound logical, granulocytes
are rarely used in current clinical practice. People have
tried giving granulocyte transfusion in patients with
severe uncontrollable infection in presence of congenital
or acquired neutropenia or neutrophil dysfunction. It is
usually reserved for neutropenic patients with fulminant
sepsis not controlled by antibiotics and antifungal
with ANC < 300 in newborn, ANC < 100 in infants and
ANC < 500 in immune compromised host. It should always
be used along with antibiotics and antifungals. As colony
stimulating factors are now easily available and affordable,
use of granulocytes has fallen in to disrepute.
Buffy coat preparations are not very satisfactory as the
cells tend to become nonfunctional. Packs obtained by
apheresis are the best. They should be used within 24 hr of
collection and stored at room temperature. Each pack has
1011 granulocytes in 200 cc of plasma. Dose recommended
is 109 granulocytes/kg each time. It can be repeated every
12-24 hr for 4 to 6 days. It should be given obviously without
using the WBC filter. It leads to all the side-effected related
to plasma and lymphocytes. One should use ABO/Rh
compatible donor.
Leukodepleted Blood Components

Why Leukodepletion?
Various side effects and toxicities are associated with the
presence of significant number of donor lymphocytes in the
unit of blood component transfused. These include nonhemolytic febrile transfusion reactions; allosensitization;
increased chances of rejection of graft in candidates for
future transplant; lymphocyte mediated lung toxicity like
acute respiratory distress syndrome (ARDS); transmission
of viral infections like HIV, human T-lymphocyte virus
(HTVL), Epstein-Barr virus (EBV), cytomegalovirus
(CMV), etc. which are intracellular pathogens; transfusion
associated graft vs host disease (TAGVHD) in immune
compromised patients and in transfusion from first
degree relatives; and immune suppression of the recipient
especially in surgical patients. These donor lymphocytes
ordinarily do not serve any beneficial effects and hence
should be removed or depleted from the unit transfused to
eliminate or reduce the chances of these side effects and
toxicities.
Non-hemolytic febrile transfusion reactions (NHFTR)
occur when > 5 106 lymphocytes are present in the unit,
whereas for TAGVHD it is > 107 cells/kg body weight.
One pack of packed red blood cells (PRBC) has 109 WBC,
RDP has 4 to 6 107 WBC, SDP has 2 to 4 108 WBC and

granulocyte pack has 1011 WBC. Ideally all the transfusion
should be leukodepleted especially in patients needing
recurrent transfusions and in immunno compromised
hosts.
Methods of leukodepletion: There are various ways of
leukodepletion. Each method has its own merits and
demerits and efficacy.
1. WBC filter: Third generation WBC filters are 99.5
percent efficient in removing the donor lymphocytes.
Activated lymphocytes can release cytokines like IL2,
TNF- during storage and hence it is best to remove
the lymphocytes while collecting blood from the donor
using in-line WBC filter, rather than using the WBC filter
at bedside while giving the transfusion to the recipient.
The advantage of WBC filter is its high efficacy and
simplicity to use. The disadvantages include its high
cost and inability to prevent TAGVHD. Each filter costs
` 400-500/- and is not reusable. Ideally all transfusions
should be given using filters especially if patient needs
recurrent transfusions and develops NHFTR.
2. Washed cells: 90 percent of lymphocytes and 99
percent of plasma are removed by washing the PRBC
with saline or blood processor. This will help reduce
NHFTR, allosensitization and other toxicities related to
WBC as well as allergic reactions to plasma proteins.
It is a simple technique and needs cold centrifuge but
is not as effective as the WBC filter for leukodepletion.
One can combine washing and use of WBC filter
where the patient is prone to severe allergic reactions.
Washing does not prevent TAGVHD. Lastly, washed
platelets from mother are given in a baby suffering
from alloimmune thrombocytopenia.
3. Gamma irradiation: TAGVHD can be only prevented
by gamma irradiating the blood. Dosage of 25003500 cGy are used to irradiate the components. The
only disadvantage is need for the sophisticated and
expensive irradiator. There are chances of membrane
leak from the irradiated cells which can result in to
increased potassium levels. Hence blood should be
irradiated just before infusion or else supernatant
plasma should be removed before transfusion.
Ideally all blood should be irradiated where there is
risk of TAGVHD. This includes transfusion given to newborn especially preterms < 1200 g, intrauterine transfusions, patient with primary or secondary immunodeficiency, cancer patients, organ transplant recipients and
transfusion given to normal person from a first degree
relative donor.
4. Frozen cells: This is routinely available in the west but is
rarely available in India. RBC frozen at 70C has shelf
life of 5 to 7 years. While freezing, deglycerolization is
done to prevent intracellular ice formation. It should
be thawed gradually and once thawed should be used
within 24 hours. The efficacy for leukodepletion is 90
percent and plasma depletion is 99 percent. Hence
it reduces toxicities related to both lymphocytes and
plasma. Advantage of frozen cells is its availability
in emergency where one can use Ove frozen cells
in AB negative plasma. One can collect blood from
CMV negative donors; HLA matched donor or rare
blood group donor and freeze it for future use. Lastly
autologous blood collected for surgery can be frozen
and used in future if surgery gets postponed for some
reasons. Disadvantage of frozen cell is that it needs
sophisticated instruments to prepare and store it and
is extremely costly. It cannot prevent TAGVHD.
Fresh Frozen Plasma

Fresh frozen plasma (FFP) is made by freezing the plasma
obtained at the end of centrifugation of the whole blood
unit and is stored at <30 C. The shelf life of FFP is one
year when properly stored. It should be thawed at 37C
over 30 minutes in the water bath. Thawed FFP should
be used within 4 hours if used for hemophilia A or used
within 24 hours if used for other conditions provided it is
stored properly. The FFP contains all the plasma proteins
including albumin, gamma globulins and most important
clotting factors. As labile factor V and VIII tend to decrease
on storage, freezing of the plasma should be done within 4
to 6 hours of collection to prevent loss of these factors. One
unit of FFP has 200 to 250 mL of plasma and 1 mL of plasma
contains approximately 1 unit of each clotting factor. The
hemostatic content of a unit of FFP is shown in Table 7. As
the maximum tolerated dose of FFP is 10 to 15 cc/kg every
12 hr, one can not achieve very high plasma level of the
missing clotting factors without volume overloading the
patient.
The FFP is often misused as volume expander. As FFP
can lead to allergic reactions, anaphylaxis in Ig A deficient
patient and can transmit all the plasma borne infections,

albumin should be used as a volume expander which
is much safer. Similarly albumin and not FFP should be
used to replace proteins or albumin. If patient needs both
volume expansion as well as clotting factors like in DIC,
sepsis, NEC, etc. one can use FFP. However FFP should
not be used in a case of DIC without clinical bleeding.
FFP should also not be used prophylactically to prevent
intracranial bleeding in neonate.
Table 8 summarizes the indications of using FFP in
clinical practice. FFP is mainly used to replace clotting
factors. It can be given when the patient presents
with bleeding for the first time where the diagnosis is
uncertain as to which factor is deficient. In known cases
of hemophilia, it is better to use factor concentrates,
as they are more efficient and safe. FFP is used for
deficiencies of other factors like factor V, VII, etc. where
factor concentrates are not available. It is also used
where multiple factors need to be replaced as in case of
hemorrhagic disease of newborn, liver disease, preterm
with liver dysfunction, DIC, etc. FFP also contains AT
III, protein C and protein S and hence is useful in the
deficiency of these factors too like in the treatment of
purpura fulminans; however in the west activated protein
C concentrates are easily available. FFP is used for plasma
exchange in patients with TTP or HUS. It can be used to
reconstitute whole blood along with PRBC or to adjust
HCT of PRBC for exchange transfusion in newborn.
Lastly, FFP is useful to prevent and treat coagulopathy
due to L-asperginase in cancer p atients.
FFP leads to all the side effects related to plasma like
allergic reactions like urticaria, anaphylaxis, especially
in IgA deficient patient and transmission of plasma
borne infections to the recipient. In small babies, it can
lead to hemolysis if it contains high levels of antibodies
Table 7 Hemostatic content of a unit of FFP

Fibrinogen
2.67 mg/mL
Factor II
80 IU/mL
Factor V
80 IU/mL
Factor VII
90 IU/mL
Factor VIII
92 IU/mL
Factor IX
100 IU/mL
Factor X
85 IU/mL
Factor XI
100 IU/mL
Factor XII
83 IU/mL
Factor XIII
100 IU/mL
AT III
100 IU/mL
VWF
80 IU/mL
Table 8 Indications of using FFP considered as appropriate

Inherited factor deficiency
a. P
atient with unknown clotting factor deficiency
presenting for the first time
b. Single clotting factor where factor concentrate is not
available like factor V or XI
c. Multiple clotting factor deficiency
DIC with clinical bleeding
Hemorrhagic disease of newborn
Liver disease with coagulopathy for prevention and
control of bleeding
Dilutional coagulopathy as seen after massive transfusion
(surgical patients) to maintain PT, aPTT to <1.5 time the
control
Plasma exchange for TTP/HUS
Sick newborn with coagulopathy and bleeding

against recipients blood group antigens. FFP has also
been associated with rare but significant toxicities like
transfusion related acute lung injury (TRALI).
13. WBC filters are an excellent method of leukodepletion

and should be used more liberally.
14. One should avoid relatives as donors.
Take Home Messages
BIBLIOGRAPHY
1. It is a criminal waste to use whole blood in general as

one unit of whole blood can satisfy the needs of more
than one patient.
2. Whole blood is indicated only for massive blood loss
and for exchange transfusion. There too one can use
reconstituted whole blood.
3. Packed red blood cells can serve both the purposes,
increasing the oxygen carrying capacity and volume
expansion in acute blood loss.
4. Transfusions are rarely required if at all for patients
with nutritional anemia.
5. Transfusions are inappropriate to raise Hb in patient
with nonemergency surgery, as a top-up after surgery
and as a panacea in a sick malnourished pale child.
6. Iatrogenic blood loses are the most common cause of
anemia in a newborn. Minimize the investigations.
7. Thalassemics should ideally receive triple saline
washed, Coombs cross matched PRBC using a WBC
filter.
8. Platelets are to be stored at 22C on a constant agitator,
to be used in 20 to 30 minutes and not to be kept in
fridge at all. Do not use glassware while giving platelets.
9. Platelets are not indicated in immune causes of thrombocytopenia (like in ITP); and as also for prophylaxis
in a case of chronic stable thrombocytopenia (like in
aplastic anemia).
10. FFP is often misused as volume expander (in patient
with shock), as a source of proteins (in preterms), as
a source of known clotting factor 9 in a known case of
Factor VIII deficiency where cryoprecipitate or factor
concentrates are a better option.
11. FFP is indicated in multiple factor deficiency as seen
in liver disease and DIC or as factor replacement in a
patient with unknown factor deficiency coming for the
first time, and for plasma exchange for TTP/HUS.
12. Leukodepleted blood products are better as the donor
lymphocytes present in unit of blood product can lead
to unnecessary and avoidable side effects.
1. American Association of Blood Banks (2003). Pediatric

Transfusion: A Physicians Handbook; 1st edition. Edited
by Roseff SD.
2. Beulter E. Platelet transfusion: the 20000/L trigger. Blood.
1993;81:1411-3.
3. Consensus Conference on Platelet Transfusion. Br J
Cancer. 1998;78:290-1.
4. Ennio CR. Red cell Transfusion Therapy in Chronic
anemia. Hemat Oncol Clin North Am. 1994;8:1045-52.
5. Guidelines for the use of fresh-frozen plasma, cryopre
cipitate and cryosupernatant. Brit J Hematol. 2004;126:
11-28.
6. Guidelines for the use of platelet transfusions. Brit J
Hematol. 2003;122:10-23.
7. Indian Academy of Pediatrics transfusion guidelines for
neonates and older children (under publication).
8. Miller JP, Mintz PD. The use of Leucocyte-Reduced blood
components. Hemat Oncol Clin North Am. 1995;9:69-90.
9. Rentels PB, Kenney RM, Crowley JP. Therapeutic support
of the patient with thrombocytopenia. Hemat Oncol Clin
North Am. 1994;8:1131-51.
10. Roseff SD, Luban NL, Manno CS. Guidelines for
assessing appropriateness of pediatric transfusion. Trans.
2002;42:1398-413.
11. Rosen NR, Weidner JG, Boltd HD, et al. Prevention of
transfusion associated graft-versus-host disease: selection
of sufficient dose of gamma irradiation. Transfusion. 1993;
33:125.
12. Shah N, Lokeshwar MR. Blood components in pediatric
practice. Proceedings of South. Pedicon. 2000.pp.55-68.
13. Strauss RG, Levy GJ, Sotelo-Avila C, et al. National survey
of neonatal transfusion practices: II. Blood Component
therapy. Pediatrics. 1993;91:530-6.
14. Transfusion guidelines for neonates and older children.
Brit J Hematol. 2004;124:433-53.
15. Voak D, Cann R, Finney RD, et al. Guidelines for
administration of blood product transfusion of infants and
neonates. British Committee for Standards in Hematology
Blood Transfusion Task Force. Transfusion Medicine.
1994;4:1411-3.
36
Nucleic Acid Amplification Testing
In todays modern healthcare, blood and blood component transfusions have a very large range of indications and are life-saving for
the patients. However, with the increase in transfusions the risk of transfusion transmitted infections (TTIs ) has also increased. A major
challenge is to use screening assays with maximum sensitivity and specificity to make blood as safe as possible.
In India, the five tests mandatory by Food & Drugs

Administration (FDA) for the donated blood units are
HBsAg, HIV-Ab, HCV-Ab, VDRL and malarial parasites.
Currently, testing methods carried out in India are based
on serological assay detecting either antibodies or antigen.
Naturally, they have a long window period as they basically
detect the host immune response. The window period
is defined as the time period between the start of an
infection to the earliest diagnostic detection. Shortening
this window period has been the focus of attention in
transfusion medicine for the last three to four decades.
Size of the Problem

Over two billion people worldwide are infected with
HBV, which is the leading cause of liver disease. Of these,
more than 350 million are chronically infected, with a
higher risk for liver cancer and liver cirrhosis. Currently,
available screening technologies are designed to detect
core antibodies or surface antigens. However, these
infection indicators do not appear until eight weeks after
an infection. Thus HBV presents a higher residual risk of
transmission by transfusion than HCV or HIV and the HBV
infection window period is the real issue in the transfusion
setting. Countries like India with a high prevalence of HBV
have the highest risk of transfusion transmitted HBV and

probably would be the most to gain from HBV NAT. In
addition, worldwide 170 million people are infected with
HCV and 40 million with HIV. These are a serious global
concern.
Window Period and its Clinical Significance

Blood is processed into blood components to enable
more than one patient to benefit from a single donation.
Thus, a single unit of blood collected from a donor in the
window period of infection may be transfused to up to four
recipients or may be added to pools of more than 1000
units to manufacture blood derived products.
The greatest threat to the safety of blood supply is
donation by seronegative donors during window period
of initial infection and detectable seroconversion. Window
period samples have a very low viral load. Detection of very
low viral load samples requires highly sensitive assays.
Hence the Nucleic Acid Amplification Testing
(NAT).
With currently used ID-NAT assay the window period
is shortened considerably, as it is a highly sensitive and
specific test that detects very low levels of viral RNA or
DNA that may be present in donated blood.
Chapter-36 Nucleic Acid Amplification Testing 373
Window Period and Testing Technology: A Schematic Representation

Key for Interpretation
ID-NAT Ultrio Plus
MP-16 NAT Ultrio Plus
Ab or Ag
HIV-1 Detection
4.7
8.1
15.0P24 Antigen
(Window period in days)
HCV Detection
2.2
4.1
58.3-HCV Antibody
HBV Detection
14.9
24.9
38.3 HBsAg
Testing Options Available and their Principles

Genomic screening for infectious agents using NAT is
performed with several in vitro nucleic acid amplification
techniques, e.g. transcriptionmediated amplification
(TMA), polymerase chain reaction (PCR), ligase chain
reaction and nucleic acid sequence-based amplification.
All these techniques detect the presence of infectious
microorganisms in donor blood by amplifying the nucleic
acid sequences specific to the microorganism, giving it a
much higher level of sensitivity and specificity than routine
EIA test. Thus the power of NAT lies in its ability to detect
viral genomic nucleic acids rather than the presence of
antibodies. NAT screening is characterized by three critical
processes: sample extraction, amplification and detection.
NAT is used in addition to the antibody/antigen test since in
some individuals theoretically the amount of virus may have
fallen below detectable limits and antibodies could still be
detectable as in case of HCV. In some cases with HBV again,
the viral copies may be undetectable but the surface antigen
is present. NAT screening can be carried out as a minipool

testing or individual (ID-NAT) testing. Japan started in
1999 with a minipool of 500. All the countries currently use
minipool (6/24/48/96 samples) or ID-NAT testing.
Key to interpretation
NAT-yield: EIA negative, NAT positive
Sero-yield: EIA positive, NAT negative
Impact of NAT: Evidence from Published

Literature
A pilot project in India at Apollo Indraprastha Hospital,
showed that out of 12,224 study samples 133 (1.09 %) were
reactive by Ultrio assay. The 84 samples were seroreactive
but NAT nonreactive. There were 8 NAT yield cases1 HIV,
1 HIV-HCV coinfection and 6 HBV. Observed NAT yield
for all three viral TTIs was 1 in 1528 (0.065 %).
However, NAT yield reported from various centers
in India varies from 1 : 300 to approximately 1 : 8000 as
reported at our center.
Implementation of NAT has led to a residual risk of
transfusion transmitted infections of less than 1 : 1 million
in case of HIV and HCV in developed countries.
Blood donor screening by NAT for at least HIV-1
and HCV has been implemented in different countries
(e.g. USA, Canada, parts of Brazil, Spain, France, the UK,
Denmark, Germany, the Netherlands, Belgium, Greece,
Slovenia, the Czech Republic, South Africa, Ghana,
Luxembourg, Switzerland, Italy, Japan, parts of China,
Australia, Poland, Norway, Finland and New Zealand).
One exception in Europe is Sweden. Based on the very low
incidence of HIV-1 and HCV in their donor population,
they decided to stop blood donor screening by NAT in
2008. In India, NAT testing is carried out for HIV, HCV and
HBV also due to high prevalence of hepatitis B virus in the
population.
Pathogens for which NAT Testing is Available

a. HIV: 1st case of HIV was reported in 1982. The virus
doubling time is approximately 17 hours and the dia
gnostic window period is reduced to less than 5 days
using ID-NAT.
b. HCV: The virus was first described in 1989 but it was
known since 1970s that a virus other than HAV and
HBV existed, it was called non-A, non-B hepatitis
virus. The virus doubling time is very short (1012
hours), and therefore the diagnostic window period
has been brought down to approximately 4 days using
ID NAT. In Germany, the residual TTI risk for HCV was
estimated to be 1 : 200 and is currently calculated at
1 : 10.8 million.
c. HBV: Compared to HIV and HCV, the virus doubling
time is very low (approx 2.56 days). Hence, with the
current ID NAT assay the diagnostic window period
has been brought down to 15 days compared to 55 days
using EIA. Anti-HBc is used for blood donor screening
in low endemic countries such as USA and Germany.
This is not feasible in high endemic countries such
as India because the percentage of anti-HBc reactive
donors might cause an unacceptable loss of life-saving
blood units.
d. The other viruses which can be detected using NAT
are West Nile virus (WNV) infection (as in USA),
hepatitis A virus infection, hepatitis E virus infection,
parvovirus B19 virus infection, chikungunya virus
infection.
HIV-2 has been found predominantly in West Africa,
and cases have also been reported from India. Since EIA is
always used in conjunction with NAT testing risk of finding
HIV-2 yield is minimum and some NAT systems have
already incorporated HIV-2 in the multiplex screening
procedure.
Bacterial screening poses a special challenge in

transfusion medicine. With the introduction of NAT the
risk of transmission of clinically relevant viral infection is
far below the risk of bacterial infections. Many countries
have implemented culture methods to detect very low
levels of bacterial concentrations. NAT offers a good
method to detect bacteria.
Practical Considerations
It should kept in mind that a very small number of blood
donors may be infected with viral concentrations below
the level of analytical sensitivity and therefore NAT can
offer close to 100 percent but not 100 percent safety.
For proper interpretation of NAT results, in view of very
low number of viral copies, based on Poisson distribution
an algorithm was proposed in NAT users meet in India
which is followed by many centers.
Proposed algorithm:
Chapter-36 Nucleic Acid Amplification Testing 375
FURTHER READING
1. Kuhns MC, Busch MP. New strategies for blood

donor screening for hepatitis B virus. Mol Diag Ther.
2006;10(2):77-91.
2. Makroo RN, Choudhary N, Jagannathan L, PariharMalhotra M, Raina V, Choudhary RK, et al. Multicenter
evaluation of individual donor nucleic acid testing (NAT)
for simultaneous detection of human immunodeficiency
virus1 and hepatitis B and C viruses in Indian blood
donors. Indian J Med Res. 2008;127:140-7.
3. Schmidt M, Seifried E. Improving blood donor screening
by nucleic acid technology (NAT), ISBT Science Series.
2010;5:219-29.
4. Zanetti AR, Romano L, Zappa A, Velati C. Changing
patterns of hepatitis B infection in Italy and NAT
testing for improving the safety of blood supply.
Journal
of
Clinical
Virology.
2006;36(Suppl):
S51-5.
5. Zou S, Dorsey KA, Notari EP, Foster GA, Krysztof DE,
Musavi F, et al. Prevalence, incidence and residual risk
of human immunodeficiency virus and hepatitis C virus
infections among United States blood donors since
the introduction of nucleic acid testing, Transfusion.
2010;50:1495-504.
37
Transfusion Transmitted Infections
Most deaths caused by blood transfusion worldwide are due to transfusion transmitted infections. The various agents (viruses,
bacteria or protozoa) responsible share the following features: persistence in the donors bloodstream giving rise to carrier states; a
susceptible receptor population; the ability to cause asymptomatic infection; stability in stored blood and in many cases in plasma
fractions. Infectious agents that are only present in blood cells, e.g. malarial parasite can be transmitted by all blood components
except cell-free plasma. On the other hand, those viruses that are present in plasma, e.g. Hepatitis B, can be transmitted by cell-free
plasma and its fractions as well as by cellular components. Screening tests are effective preventive measures but they cannot detect
emerging agents such as HIV in the 1980s or West Nile fever at the beginning of this century. Presently in India, it is mandatory to test
donated blood for hepatitis B and C, HIV 1 and 2, malarial parasites and syphilis.
The following sections review the various transfusion

transmitted infections including their epidemiology,
clinical features, management and preventive measures.
Yersinia enterocolitica
Other enterobacteriaceae
Psychrophilic pseudomonas.
KNOWN TRANSFUSION TRANSMITTED

VIRAL INFECTIONS
Viral Hepatitis
Viral hepatitis
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis A
Hepatitis G
Transfusion transmitted virus (TTV) and SEN-V
Retroviral infection
Human T-cell leukemia virus (HTLV) types 1 and 2
Human immunodeficiency virus (HIV) types 1
and 2
Human herpes virus infection
Cytomegalovirus (CMV)
Transfusion transmitted cytomegalovirus (TT-CMV)
Epstein-Barr virus (EBV)
Human herpes virus (HHV) 6 through 8.
Parvovirus B19
Bacterial infections
Despite the dramatic reduction in the risk of viral

transmission during the past three decades, viral hepatitis
remains a serious complication of transfusions worldwide.
Hepatitis B
Hepatitis B virus (HBV) is a major human pathogen
that causes acute and chronic hepatitis, cirrhosis and
hepatocellular carcinoma.1 The overall prevalence of
HBV infection in the United States is about 5.6 percent
as indicated by HBsAg and anti-HBc positivity rates.2 The
estimated prevalence of HBV in India is between 3 and 7
percent.3 However, the risk of HBV infection in transfusion
recipients is progressively decreasing with the use of
sensitive screening tests, with an estimated risk of 1 per
205000 units in the USA.4
HBV is a double shelled DNA virus of the hepadnaviridae
family. The virus contains various antigens that may help
in distinguishing the duration of infection and infectivity
of the host.
Chapter-37 Transfusion Transmitted Infections 377

HBV antigens and antibodies in the blood
Fig. 1 Serological markers of HBV and their time of appearance during the course of infection
Hepatitis B virus is spread by transfusing infected

blood, plasma or coagulation factor concentrates. The
mean incubation period is 63 days (range 30150 days)
in post-transfusion hepatitis cases. Most cases of HBV
infection are asymptomatic as evidenced by high carriage
rate of serum markers in the absence of history of acute
hepatitis. The prodrome is characterized by lethargy,
malaise and anorexia and rise in liver transaminases 6
to 7 weeks after exposure. Some patients have a serum
sickness-like illness during the prodrome phase. Jaundice
is present in about 25 percent of the patients with onset
about 8 weeks after exposure and lasts for 4 weeks.
Acute fulminant hepatitis with coagulopathy,
encephalopathy and cerebral edema may occur with a
mortality of 0.5 to 1 percent of all HBV infections.
Five percent develop chronic hepatitis,5 which can
lead to cirrhosis and primary hepatocellular carcinoma.
The carrier state develops most commonly after
asymptomatic infection, especially if the infection is
acquired during infancy.
Evaluation of an individual for HBV infection usually
includes testing for serum HBsAg, antibody to HBsAg
and IgM anti-HBc (antibody to hepatitis B core antigen)
by enzyme immunoassays (EIA). Detection of IgM antiHBc in serum is helpful in the diagnosis of HBV infection
during window period prior to the appearance of HbsAg
(Fig. 1). Moreover, it can detect recent HBV infection in
rare HBV mutants with altered HBsAg epitopes. Although
most blood centers perform screening for HBsAg, there
is a convincing argument to augment it with anti-HBc
testing.6
Hepatitis B vaccine and hepatitis B immunoglobulin

(HBIG) are available for prevention of HBV infection.
Universal immunization of all children with hepatitis B
vaccine is recommended in both pre- and postexposure
situations and provides long-term immunity. The HBIG is
recommended in neonates born to HbsAg positive mothers
and children with intimate contact with acute HBV infection.
Interferon--2b (IFN--2b) and lamivudine are the
current two therapies available for chronic HBV infection.
Long-term eradication rates of 25 percent have been
reported in children. Patients most likely to respond are
those with low serum HBV DNA titers, HbeAg, active
inflammation and recently acquired disease. Liver
transplantation also has been used to treat patients with
end-stage HBV infection.
Hepatitis C
Hepatitis C virus (HCV) has now been recognized as the
cause of almost all parenterally transmitted cases of what
was previously called non-A non-B hepatitis. The HCV is
globally distributed with a remarkably uniform prevalence
rate of 1 to 2 percent.7 The epidemiology of HCV in India is
not well described, more so in children. The prevalence of
HCV in blood donors in India (11.5%) is higher than that
in developed countries (0.30.7%).8-10 A high prevalence
of HCV is found in many high-risk groups exposed to
blood or blood-products like hemophilics (2490% antiHCV positive), IV drug users (7092% anti-HCV positive),
patients with pediatric hematological malignancies (55%
HCV-RNA positive) and those with thalassemia (60% antiHCV positive).8,11,12
Hepatitis C virus (HCV) is a single-stranded RNA virus
from the Flaviviridae family. The HCV is transmitted by
blood components and blood products including IVIG,
anti-D Ig for IV use and factor VIII concentrate. The HCV
has never been transmitted by albumin concentrates or by
anti-D Ig for IM use.
Incubation period varies from 7 to 9 weeks.
Acute infection tends to be mild and insidious in both
adults and children.
Only 25 percent cases are icteric.
Fulminant liver failure rarely occurs.
About 85 percent cases develop chronic hepatitis.
After about 20 to 30 years 25 percent ultimately
progress to cirrhosis, liver failure and occasionally
primary hepatocellular carcinoma.
Detection of HCV infection is based on EIA for antiHCV antibodies or testing directly for viral RNA or DNA.
The recent risk estimate of HCV is 1:103,000 per donor
exposure in the US.13 This was calculated using second
generation HCV test with window period of 82 days.
Screening by third generation EIA reduces the window
period to 66 days and hence further decreases the risk of
transmitting HCV through transfusion to 1:127,000 units
transfused.14 With the implementation of nucleic acid
technology-based HCV screening (HCV-NAT) there has
been a major decline in the risk of HCV transmission to
1:3,68,000 units transfused in the US. The NAT testing for
HCV has shown reduction in window period for HCV from
66 to 1030 days.14,15 A recent study in US has shown risk of
HCV infection with mini pool-NAT screening to be as low
as 1 in 2 million.16 Though NAT can significantly improve
the safety of blood supply; its widespread use in developing
countries like India is unlikely in the near future due to the
expenditure involved.
No vaccine is available against HCV infection.
Immunoglobulin has not been found to be effective in
postexposure prophylaxis.
Combination therapy with IFN--2b and ribavirin has
resulted in sustained response (defined as normal ALT
levels and negative PCR results 6 months after completion
of therapy) in one-third patients and is now considered
first-line therapy. Monotherapy with IFN--2b resulted in
sustained response in 10 to 15 percent of patients.
Hepatitis D
Hepatitis D virus (HDV) is a small satellite RNA virus,
originally termed the delta virus that can infect only in the
presence of concurrent HBV infection:
Its genome codes a single peptide termed the delta
antigen. The infectious form of HDV is coated byHbsAg.
The incubation period in HDV superinfection is 2 to 8
weeks; with coinfection it is the same as HBV infection.
The clinical outcome of HDV infection depends on the

mode of infection.
In coinfection, acute hepatitis, which is much more
severe than that caused by HBV alone, is common
but risk of developing chronic hepatitis is low. In
superinfection, acute illness is rare and chronic
hepatitis is common. However, the risk of fulminant
hepatitis is highest in superinfection.
The diagnosis is made by detecting IgM anti-HDV,
which develop 2 to 4 weeks after coinfection and 10
weeks after superinfection.
PCR assays for viral RNA are available only as research
tools.
There is no vaccine against HDV. However, HDV has
little current relevance to transfusion safety, because
measures used to detect and prevent HBV infection are
also effective against HDV.
Hepatitis A
Hepatitis A virus (HAV) is a RNA virus belonging to the
picornaviridae family. The incidence of HAV varies
significantly with age. Highest incidence rates are seen
in children in the age group of 5 to 15 years accounting
for 30 percent of all cases. The HAV is rarely acquired by
blood transfusion with a transfusion-associated risk of less
than 1 per 1,000,000 units of blood transfused.17 Rarity of
parenteral transmission of HAV has been attributed to
short duration of viremia, exclusion of infectious potential
blood donors on the basis of history and absence of a
chronic carrier state. However, rare transmission via blood
products18 and clotting factors19 has been reported.
Currently, no specific laboratory screening of blood
donations for HAV is performed, as there is no chronic
carrier state. Two inactivated safe and effective vaccines
are available with 100 percent immunity after a second
dose. IVIG is recommended as pre-exposure prophylaxis
in susceptible travelers visiting endemic regions and in
selected situations for postexposure prophylaxis within 1
week of exposure.
Hepatitis G
Hepatitis G virus (HGV) is a recently discovered RNA virus
distantly related to HCV (flavivirus). Clinical data derived
from studies of HGV have established its transmission
by blood through donor recipient linkages and by the
recovery of virus in the recipient that was not present prior
to transfusion.
The HGV is present in 1 to 2 percent of donor
population.
Detection depends on PCR technology. As yet a
causal relationship has not been established between

HGV infection and hepatitis or any other disease
manifestation.20
Currently no method is available to prevent HGV
infection.
TTV and SEN-V

These viruses were separately identified among individuals
with hepatitis and were also shown to be poorly, if at all,
associated with hepatitis. They were readily transmitted
by transfusion. At this stage, there is little evidence that
this virus pair has any pathogenic potential.
Retroviral Infection
Prior to the outbreak of the acquired immunodeficiency
syndrome (AIDS) epidemic in the early 1980s, retroviruses
had been identified as a cause of rare malignancies but not
a threat to transfusion recipients. Presently, the clinically
significant transfusion transmitted retroviruses are the
human immunodeficiency virus (HIV) types 1 and 2 and
the human T-cell leukemia virus (HTLV) types 1 and 2.
HIV 1 and 2
Since AIDS was first described in the USA in 1981 in
young, previously healthy, homosexual men, the disease
has spread worldwide. At the end of 2003, an estimated
37.8 million people, 35.7 million adults and 2.1 million
children younger than 15 years, were living with HIV/AIDS
(UNAIDS 2004). Approximately two-thirds of these people
(25.0 million) live in sub-Saharan Africa and 20 percent (7.4
million) in Asia and the Pacific. Between 2002 and 2004, an
estimated 10 million people were infected with HIV and
nearly 6 million died from AIDS.21 The HIV seroprevalence
in Indian scenario has been reported between 0.2 and 1
percent.22 As per the 2006 NACO surveillance report, 3.8
percent of the total HIV cases are less than 15 years of age.
The HIV is a member of the family Retroviridae and
belongs to the genus Lentiviridae. The genome is a singlestranded RNA. Because HIV is both cell-associated and
present in the plasma, all blood components are potentially
infectious. Albumin preparations, immunoglobulins,
antithrombin III and hepatitis B vaccine have not been
associated with HIV infection.
For the first few days after infection, no markers of HIV
can be detected in blood, an interval known as the eclipse
phase. Viremia follows for a period of several weeks. This
stage is followed by a ramp up phase at about day 10
when HIV viral copy number rises rapidly.23
At about day 17, p24 antigen becomes detectable
in serum and at about day 22, anti-HIV seroconversion
occurs. During this phase more than 40 percent patients
develop a flu-like illness.24 After 1 to 2 months of
transfusion transmitted infection, more than 95 percent

of HIV infected patients exhibit a wide range of antibodies
to structural env, gag and pol viral proteins.25 As soon as
anti-p24 develops, p24 antigenemia disappears. A long
asymptomatic period follows primary infection, which may
last up to 10 years; however, disease progression continues
relentlessly. Levels of all anti-HIV antibodies are very
high during the asymptomatic period. Disease develops
when CD4 cells are severely depleted leading to severe
immunosuppression and spread of disease to multiple
organs and emergence of opportunistic infections. In the
absence of treatment, disease progression is relentless and
almost invariably fatal.
In most countries including India, screening tests for
antiHIV by EIA are now compulsory for blood donation. If
reactive, additional tests are used to confirm the diagnosis
of HIV infection.
Treatment of HIV infection consists of initiation of
antiretroviral medications guided by patients CD4 count
and WHO clinical stage and treatment of opportunistic
infections.
Risk of transfusion transmitted HIV infection can be
reduced by measures introduced at the blood collection
centers such as, improved donor screening, education and
exclusion techniques; enlightened transfusion practice
such as, judicious use of allogenic blood components,
appropriate use of autologous blood, and alternative to
transfusion and measures that depend on the development
of new technologies, such as viral inactivation of cellular
components and safe substitutes for blood. Measures
such as public education, self-deferral of donors engaged
in high-risk activities and confidential unit exclusion also
serve a similar purpose.
Human T-cell Leukemia Virus HTLV

Types 1 and 2
Human T-cell leukemia virus type I (HTLV-I) was the
first human retrovirus isolated and the first to be causally
associated with a malignant disease of humans, the adult
T-cell leukemia.26 It is also associated with myelopathy
and tropical spastic paralysis. HTLV-II, which was
described later, is known to show 60 percent homology
of genetic sequences to those of HTLV-I.26 The current
incidence of HTLV infection in the United States is 1 in
6250 individuals being seropositive per year half of these
being infected with HTLV-I and the rest half with HTLVII.27 HTLV-I infection shows geographic clustering with
high endemicity in Japan, sub-Saharan Africa and Central
and South America. HTLV-II shows clustering in Native
American population donors. In these areas, the donors
are screened using EIA screening tests.28 The transmission
rate of HTLV-I or HTLV-II in a recipient of an infective
blood unit is between 20 and 60 percent. The risk of
transmission of HTLV from a screened blood unit is low
(1 in 6,40,000).13 Contact with infected viable lymphocytes
can cause infection, as both the viruses are cell-associated.
Transmission is by cellular components and not by cellfree plasma or its derivatives. As refrigeration of blood
product over 10 days results in degradation of lymphocytes
and in decrease in load of infectious viruses, plasma and
plasma derivatives do not transmit the virus.20,27,29,30 The
association of infectivity with fresh cellular components
raises the possibility that transmission of HTLV by
transfusion requires viable T-lymphocytes and that their
removal from blood donations may clear the potentially
infectious cells.
With the use of combination of viral lysates from
HTLV-I and II viruses, there is sensitive detection of
both anti-HTLV-I and anti-HTLV-II. Such combination
HTLV-I/II EIA test is being used in United States for HTLV
screening as the originally licensed anti-HTLV-I EIA can
miss up to 50 percent of HTLV-II infections.30 HTLV-I
and II infections have not been reported in the Indian
subcontinent.
Human Herpes Virus Infection

Of the herpes viruses eight are known to infect humans.
Cytomegalovirus (CMV) has the greatest clinical relevance
in transfusion medicine. Other herpes viruses that may
contaminate blood products are Epstein-Barr virus (EBV)
and human herpes virus (HHV) 6 through 8.
Cytomegalovirus
Cytomegalovirus (CMV) is widely distributed with
a seroprevalence of 30 to 80 percent in developed
countries and that approaching 100 percent in developing
nations.31,32 The CMV is transmitted in a latent, particulate
state only by cellular blood components (such as red cells,
platelets, granulocytes), and the virus reactivates from
donor leukocytes after transfusion. Fresh frozen plasma
and cryoprecipitate have not been implicated.
Transfusion can lead to active CMV infection in the
recipient by three mechanisms:
1. The term transfusion transmitted CMV infection (TTCMV) is used to describe a primary CMV infection
occurring in a seronegative recipient transfused with
an infected blood component.
2. Reactivated CMV infection occurs when a seropositive
transfusion recipient experiences reactivation of
latent CMV infection after a blood transfusion from
a seronegative donor. The underlying mechanism
involves immunomodulatory interactions between
MHC mismatched leukocytes of the donor and

recipients.
3. Finally, CMV superinfection occurs when a seropositive
recipient is transfused a new strain of virus.
The clinical significance of TT-CMV is significantly
more than CMV reactivation and superinfection, because
in TT-CMV, the recipient has no immunological memory,
while the two former conditions are unlikely to cause
morbidity. Around 1.2 percent of immunocompetent
recipients experience TT-CMV.33
In contrast, TT-CMV causes significant morbidity and
mortality in immunocompromised recipients with 13 to 37
percent acquiring infection from infected and unfiltered
blood.34
The at-risk groups include premature newborns
born to seronegative mothers, seronegative recipients
of seronegative bone marrow transplant and solid
organ transplant and seronegative patients with AIDS.35
These patients first have a flu-like illness followed by
disseminated disease including hepatitis, retinitis, ence
phalitis, pneumonitis and gastroenteritis.
CMV Infection can be Detected by Serologic

Assays for AntiCMV Antibodies
The TT-CMV can be prevented by using seronegative
blood and filtered blood components. In comparison
to unscreened blood, the use of seronegative units can
reduce the incidence of TT-CMV from 13 to 37 percent to
2.5 percent in at-risk individuals.36 No effective vaccine is
available at present. Ganciclovir and IVIG are used in the
treatment of severe CMV infection immunocompromised
patients.
Epstein-Barr Virus
Epstein-Barr virus (EBV) has been implicated in endemic
Burkitts lymphoma, AIDS-related lymphoma, post-transfusion lymphoproliferative disease and nasopharyngeal
carcinoma.
Transmission of EBV by blood transfusion can manifest
in a similar manner to classic infectious mononucleosis.
Although EBV-seronegative blood components reduce the
incidence of TT-EBV, they are difficult to obtain given the
high seroprevalence of EBV.
Human Herpes Viruses 6 and 8

With ubiquity of (HHV-6) antibodies and absence of disease associations after transfusion, no recommendations
have been made for protection of seronegative blood
recipients from transmission by blood components.37
HHV-8 (Kaposis sarcoma associated herpes virus)
has been found in apparently healthy blood donors

but transfusion transmission of HHV-8 has not been
demonstrated.38
Parvovirus B19
Parvovirus B19 was discovered incidentally during the
screening of blood samples for hepatitis B surface antigen.
About 30 to 60 percent of blood donors have antibodies
to parvovirus B19. This is indicative of immunity rather
than chronic persistent infection.39 The virus has been
found regularly in clotting factor concentrates and has
been transmitted to persons with hemophilia. It is also
transmitted by cellular blood components and plasma,
but not intravenous immunoglobulin and albumin.40
Parvovirus B19 can infect and lyse red cell progenitors
in the bone marrow41 resulting in sudden and severe
anemia in patients with underlying chronic hemolytic
disorders. Patients with cellular immunodeficiency,
including those infected with HIV, are at risk for chronic
viremia and associated hypoplastic anemia.
However, parvovirus B19 screening of whole blood
donations has not been a high priority because of the
benign and/or transient nature of most parvovirus
diseases, the availability of effective treatment for chronic
hematologic sequelae and the extreme rarity of reports of
parvovirus B19 transmission by individual components.
Bacterial Infections
Septic shock was one of the earliest recognized
complications of blood transfusion. Prospective studies
have indicated that the clinical presentation is wide and
milder reactions are often misdiagnosed as febrile nonhemolytic transfusion reactions.
Transfusion reactions associated with contaminated
red cell concentrates are extremely severe with mortality
of 70 percent.42 Fever, rigors, hypotension, nausea,
vomiting and diarrhea are the usual presenting features.
Septic shock, oliguria and disseminated intravascular
coagulation are frequent complications. Majority of the
reactions are caused by infusion of endotoxins of gramnegative organisms such as Yersinia enterocolitica, other
Enterobacteriaceae and psychrophilic pseudomonas.
Because platelet concentrates are stored at room
temperature, they offer the most favorable media
for bacterial growth thus limiting their permissible
duration of storage to more than 3 days. Coagulase
negative staphylococci are the most frequent pathogens.
Pseudomonas species have been isolated from plasma and
cryoprecipitate thawed in contaminated water baths.
Possible mechanisms of blood component contami
nation include donor bacteremia, inadequate skin
disinfection and use of contaminated equipment during
blood collection storage and processing.
Possible measures to prevent transfusion associated

bacterial sepsis include extension of donor screening,
improved donor skin disinfection, removal of first aliquot
of donor blood, limiting storage time, pretransfusion
detection, altered blood processing and chemical and
photochemical decontamination.
Syphilis
Transfusion transmitted syphilis is not a major hazard of
modern blood transfusion therapy. Treponema pallidum,
the infectious agent causing syphilis survives at the most
for 5 days in blood stored at 4C.43 Only rare cases of
transfusion transmitted syphilis have been documented
and the causes of this decline are universal donor screening
and the overall decline in the incidence of syphilis with the
advent of penicillin. The rapid plasma reagin (RPR) test
is commonly used for screening the blood products for
syphilis. Blood donations from individuals who have had
or been treated for syphilis should be deferred for at least
12 months after successful completion of treatment. As
per the AABB standards, blood donations from any person
with a positive serological test result for syphilis should
be deferred for 12 months.44 It is not the transmission of
syphilis that is worrisome. Being a sexually transmitted
disease, its presence points towards donors indulgence
in high risk behavior and consequent higher risk of
exposure to infections like HIV and hepatitis. However,
the RPR test used for screening is not specific and a large
portion of positive tests in healthy donor population may
represent a biological false positive reaction.
Malaria
Malaria can be transmitted by the transfusion of any blood
component likely to contain even small number of red blood
cells; platelet and granulocyte concentrates, fresh plasma
and cryoprecipitate have all been implicated. Plasma that
has been frozen or fractionated does not transmit malaria.
Malaria parasite of all species can remain viable in stored
blood for at least a week and longer in adenine containing
solutions. The incubation period of transfusion malaria
depends on the number and strain of plasmodia transfused,
on the host and on the use of antimalarial prophylaxis.
With P. falciparum and P. vivax it is between 1 week and
1 month, but with P. malariae it may be many months.45
When blood smear are examined by simple microscopy,
a density of less than 100 parasites per microliter of blood
cannot be detected. Since most apparently healthy donors
have very low parasitemia, serological tests are useful in
detecting latent malarial infection. In endemic areas, it is
recommended that chemoprophylaxis should be given
to all recipients. In nonendemic areas, screening donors
by travel history can exclude the asymptomatic carriers.
Transfusion transmitted malaria responds to conventional
anti-malarials.
Babesiosis
As with malaria, asymptomatic individuals infected with
Babesiosis may present as prospective blood donors.
Babesiosis has been transmitted following the transfusion
of infected packed red cells, frozen-thawed-deglycerolized
red blood cells and platelet concentrates. The parasite
can survive at 4C in a unit of RBCs for up to 35 days. No
test is currently available for mass screening to detect
asymptomatic carriers of Babesia species.
Trypanosomal Infection
Only a few cases of transfusion-transmitted T. cruzi
infection have been diagnosed. The parasite is viable for
at least 21 days in the whole blood and RBC units that have
been stored at 4C.
Leishmaniasis
Transfusion transmission of Leishmania species is a rare
risk in countries where such organisms are endemic.
use of sophisticated, sensitive but expensive technologies

for screening of blood products. The last two decades
have also witnessed surfacing of new and re-emerging
infections. Hence, despite stringent donor eligibility
criteria, improved donor screening and introduction
of sophisticated technology, transfusion-transmitted
infection continues as a challenge for transfusion experts.
REFERENCES

Toxoplasmosis
Toxoplasma gondii is a WBC-associated parasite that
can survive for several weeks in stored whole blood.
Toxoplasmosis is caused by the ubiquitous parasite
Toxoplasma gondii and infection has been reported as a
rare transfusion complication in immunocompromised
patients. Given the high risk of symptomatic transfusiontransmitted toxoplasmosis, the option of using leukocytereduced blood may be considered while providing packed
cell or platelet transfusions to the immunocompromised
individuals.
Microfilariasis
Filarial infections are usually transmitted by vectors but
if blood from a microfilaremic individual is transfused,
the transfused microfilaria may persist in the recipients
circulation for more than 2 years. Transfusion-acquired
microfilaremia is self-limited because transfused
microfilariae do not develop into adult filarial worms.
Routine testing of donor blood is, therefore, not warranted.
In conclusion, there has been a substantial decline
in the incidence of transfusion-transmitted infections
due to improvement in donor screening, testing and viral
inactivation of blood products, particularly in developed
nations. However, in developing nations, blood safety
continues to be a major problem due to the high prevalence
of infections markers among blood donors compounded
with the problem of limited resources that preclude the
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38
Noninfectious Hazards of Blood Transfusion

The risks of blood transfusion should always be borne in mind whilst considering benefits of transfusing red cells, platelets, and
plasma. With the advances in infectious disease testing, noninfectious complications are now many-fold more likely to cause serious
morbidity or death following transfusion. Some of the more common noninfectious hazards of transfusion include transfusion reactions
(hemolytic, febrile, allergic/urticarial/anaphylactic). Other noninfectious hazards include transfusion related acute lung injury, posttransfusion purpura, transfusion-associated graft versus host disease, transfusion related immunomodulation, alloimmunization,
metabolic derangements, transfusion-associated circulatory overload and iron overload. Individuals who administer blood
transfusions should recognize these complications in order to be able to quickly provide appropriate treatment.
Though transfusion has many benefits it also involves

risks to the recipient. Any unfavorable event occurring in
a recipient due to blood transfusion, either during or after
transfusion, is considered an adverse effect of transfusion.
Transfusion can lead to serious adverse effects
including infectious and noninfectious complications.
With the more stringent donor selection criteria and
use of sensitive screening methods for transfusion
transmissible infectious marker testing, the risk of
infectious complications has decreased. The term NISHOT
(Noninfectious serious hazards of transfusion) was first
described in a 2000 AABB bulletin to broadly encompass
all noninfectious transfusion complications. Currently,
a patient is up to 1000-fold more likely to experience a
NISHOT than an infectious complication of transfusion.1
The noninfectious complications can be acute (within 24
hours) or delayed.
Children are a unique patient group and many
have special transfusion requirements. Neonates in
particular are often intensively transfused and are
especially vulnerable to the potential infective and toxic
effects of transfusion. They have immature immune
system and metabolism, and are still undergoing rapid
neurodevelopment. The chances for acute side effects
of transfusion may be greater for small children than for
adults, as a single unit of transfused blood forms a greater

proportion of their blood volume than that in an adult.
Problems may occur due to lack of knowledge of special
requirements in the neonatal age group or human error
such as overtransfusion. It is estimated that the incidence
of adverse outcome is 18:100,000 red blood cells issued for
children aged less than 18 years and 37:100,000 for infants.
The comparable adult incidence is 13:100,000.2 The health
care personnel involved in the transfusion process should
therefore be aware of correct recognition, prevention
and appropriate management of the adverse effects of
transfusion.
In most instances of transfusion reactions, the
pathophysiology, clinical diagnosis and management are
similar as the transfusion reactions in adults.
CATEGORIES OF NONINFECTIOUS HAZARDS

OF BLOOD TRANSFUSION
Acute

Allergic
Acute intravascular hemolysis
Febrile nonhemolytic transfusion reaction (FNHTR)
Transfusion related acute lung injury (TRALI)
Metabolic complications.
Chapter-38 Noninfectious Hazards of Blood Transfusion 385
Delayed

Delayed hemolytic transfusion reaction

Alloimmunization
Immunomodulation
Post-transfusion purpura (PTP)
Graft versus host disease (GvHD)
Circulatory overload
Iron overload.
ACUTE HAZARDS OF TRANSFUSION

Transfusion reactions can occur rapidly after transfusion
e.g. hemolytic reaction, or many days or weeks after
transfusion, e.g. graft versus host disease (GvHD). By
definition, acute transfusion reactions (ATRs) occur
within 24 hours of transfusion administration3 although
most occur during or within four hours after the end of
a transfusion. There are only few studies which have
reported the incidence and type of acute reactions in
pediatric patients. In one prospective study of acute
transfusion reactions in pediatric intensive care units, the
incidence of acute transfusion reactions was 1.6 percent.4
In that study, however, the only blood product
transfused was red blood cells (RBCs) and the only
ATR reported was febrile nonhemolytic transfusion
reaction (FNHTR). Another prospective study of platelet
transfusions in children by Couban et al5 reported seven
ATRs associated with sixty six leucoreduced platelet
transfusions (11%). ATRs consisted of two FNHTRs, four
allergic reactions, and one mixed reaction. According to
the Quebec Hemovigilance System (QHS) 2001 report,
the most frequent immediate transfusion reaction for all
components transfused was FNHTR (12:10,000 transfused
units), followed by minor allergic reactions (10:10,000).6
Allergic Reaction
Allergic reactions associated with transfusion may vary
from mild uncomplicated allergic reaction to anaphy
lactoid and severe anaphylactic reactions. Allergic
reactions are the most common cause of adverse
transfusion reactions. Uncomplicated mild allergic
reactions consists of localized or diffuse urticaria characte
rized by erythematous circumscribe raised lesions present
over the upper trunk and neck often associated with
itching. Mild urticarial reactions constitute 1 to 3 percent
of adverse transfusion reactions.3 Anaphylaxis is the severe
form of this type of reaction characterized by hypotension,
and is often associated with bronchospasm, dyspnea, and
in rare cases death. These severe reactions may occur after
infusion of few mL of blood.
The anaphylactoid reaction is placed in between
mild urticaria and anaphylaxis and is characterized by
one or more of the symptoms like urticaria, flushing,

respiratory tract obstruction, cough, chest pain, dyspnea,
nausea, vomiting, diarrhea, tachycardia and arrhythmias.
Absence of fever helps in differentiating these reactions
from hypotension due to hemolytic reaction or bacterial
contamination.3
Allergic reactions occur due to exposure to soluble
substances present in donor plasma which binds with
IgE antibodies resulting in release of histamine. This
assumption is based on the facts that these reactions recur
in an affected recipient and can be prevented by removal
of plasma. Anaphylactic and anaphylactoid reactions
are sometimes associated with anti-IgA, particularly in
IgA deficient recipient. First description of anaphylactic
reaction associated with anti-IgA was reported in 1968 and
approximately 30 additional cases have been reported by
1995.7
Treatment and Prevention

Anaphylaxis or anaphylactoid reactions should be
recognized promptly when the recipient shows symp
toms and the transfusion should be immediately
stopped. Treatment of transfusion related anaphylaxis
or anaphylactoid reaction is same as that of anaphylaxis
due to other reasons. Hypotension needs to be managed
by administering fluids and if required administration of
epinephrine along with supportive care.
If the recipient is known to be IgA deficient or there
is a previous history of life-threatening anaphylactic
reaction blood components which lacks IgA, either by
washing or obtained from IgA deficient donor, should
be administered. Availability of washed red cells is not
so difficult but washed platelets are not generally easily
available as washing of platelets may result in low platelet
recovery.
Treatment of uncomplicated urticaria requires dis
continuation of transfusion and administration of anti
histaminics. If symptoms are resolved the transfusion may
be restarted.
Immune Mediated Hemolysis

Immune mediated lysis of donor red cells can result
in hemolytic transfusion reaction. It is the most severe
hemolytic transfusion reaction and occurs due to
destruction of transfused donor red cells by recipients
antibodies, e.g. in case of ABO incompatible red blood cell
transfusion. Depending on the nature of the antibody the
hemolytic transfusion reaction may be acute or delayed
and may result in intravascular or extravascular hemolysis.
Incidence of hemolytic reaction varies from 1:38,000 to
1:70,000.3
Transfusion of an ABO incompatible unit causes rapid
destruction of red cells with the release of free hemoglobin
and RBC stroma in the circulation. ABO incompatible
transfusion may be life-threatening as it can lead to acute
renal failure, shock, and disseminated intravascular
coagulation.
In intravascular hemolysis the interaction of red cell
antigen-antibody causes complement activation and
release of cytokines resulting in clinical manifestations.
Complement activation depends on the specificity and
class of antibody, and number of antigen sites. The
complement activation results in formation of membrane
attack complex causing intravascular red cell lysis which
leads to hemoglobinemia and, if it exceeds renal threshold,
to hemoglobinuria. The free hemoglobin impairs renal
functions. The factors responsible for renal failure in
severe cases are hypotension, renal vasoconstriction,
antigen-antibody complex deposition, and formation of
thrombi in renal vasculature, all of which affect the renal
cortical blood supply.
If the antibody involved in immune reaction does
not fix the complement, there will be acute extravascular
hemolysis. Usually extravascular hemolytic reactions
are not associated with severe clinical symptoms. They
may present with fever. On investigation the direct antiglobulin test (DAT) may be positive due to binding of
antibodies to incompatible donor red cells.
Infants less than four months of age generally do not
have developed anti-A and anti-B antibodies, and therefore
are not usually susceptible to these reactions. However,
maternal IgG antibodies can cross the placenta and may
cause hemolysis of transfused red cells. Considering
this possibility it is recommended that the compatibility
testing should be performed using mothers serum up to
four months of age. RBCs units lacking corresponding
antigens should be selected for transfusion.
The symptoms of ABO incompatible transfusion are
chills, rigors, fever, abdominal or back pain, pain at the
infusion site, nausea, vomiting, hemoglobinuria, oliguria.
These clinical manifestations may be observed after
transfusion of even a few mL of blood. Therefore, the
initial period of transfusion is very important, and the rate
of transfusion during the initial 15 to 20 minutes should
be slow and can be increased later. Similarly, the recipient
should be under continuous medical monitoring during
transfusion so that any adverse reaction can be identified
and managed immediately. Information to the recipient
or attendants of recipient about the symptoms of adverse
reaction is necessary.
The severity of hemolytic reaction due to an ABO
incompatible transfusion varies and depends on the rate
and the volume of red cells transfused. In a 10 years study
of analysis of transfusion errors it was found that nearly
half (47%) of the recipients of ABO incompatible red cells

suffered no ill effects even after receiving a full unit. Half
(50%) exhibited an acute hemolytic transfusion reaction
and about 4 percent died as a result.8

Treatment of acute hemolytic reaction depends on its
severity. The aim is to maintain adequate renal perfusion
in order to prevent renal failure. Adequate renal perfusion
can be monitored by measurement of urine output
for at least 24 hours. The usual initial step is infusion of
intravenous normal saline but clinical monitoring is
necessary to avoid fluid overload. Furosemide is considered
a better diuretic as it improves renal cortical blood flow.
If the intravascular hemolysis is also complicated with
coagulopathy, administration of platelets, fresh frozen
plasma, and cryoprecipitated antihemophilic factor (AHF)
may be necessary.
The most common cause of transfusion of incompatible
units is clerical error such as incorrect labeling of blood
sample, blood bag or request form. Failure to follow the
identification procedure during sample collection and just
prior to transfusion may result in wrong blood transfusion
and hemolytic episode following transfusion. For bed
side transfusions each institute should develop policies
and procedures to ensure proper patient identification,
sample collection and labeling and unit identification.
In addition to this continuous monitoring and training of
the staff responsible for collection and administration of
blood is also required.
Hemolysis can also occur with the transfusion of
ABO incompatible platelet and plasma products. There
have been several reports of severe hemolytic reactions
after transfusion of minor ABO mismatched platelet
transfusion.9
Nonimmune Mediated Hemolysis

There are chances of in vitro hemolysis due to improper
handling during transportation or at the time of
administration. Malfunctioning of blood warmer or
accidental freezing can cause temperature related damage
to red cells. Addition of drugs or hypotonic solutions may
result in osmotic lysis of red cells. Transfusion of such
units can cause nonimmune mediated hemolysis in the
recipient. Treatment of such cases depends on the severity
of the reaction. If the patient develops shock, renal failure
intensive medical management is needed.
Such cases are preventable. All the staff involved in
processing, issuing and administration of blood should
be trained for storage and correct handling of blood and
blood components. The equipment used for warming and

for administration of blood should be properly maintained
and staff should be adequately trained for use of such
equipment.
Febrile Nonhemolytic Transfusion Reaction

A febrile nonhemolytic transfusion reaction (FNHTR) is
defined as temperature rise of more than 1C associated
with transfusion without any other demonstrable cause.
FNHTRs are caused by antibodies present in recipients
plasma that interact with white cells in the transfused
product and are most frequently HLA antibodies or
sometimes granulocyte antibodies. This mechanism
appears to be the primary cause of FNHTR after transfusion
of red cells but for FNHTRs consequent to platelet
transfusions the leukocyte derived cytokines, generated
during the warmer room temperature storage of platelets,
have been implicated.
FNHTRs present with fever with or without chills. Most
FNHTRs are mild and benign but they cause discomfort
to the recipient. Severe reactions may be accompanied by
hypotension, cyanosis, tachycardia, tachypnoea, dyspnea,
cough, transient leukopenia. Febrile reactions should be
differentiated from hemolytic transfusion reaction and
reactions due to a bacterial contaminated product. If the
patient has received multiple units it becomes difficult
to find out which unit has caused the febrile reaction. In
such instances all units transfused within four hours prior
to transfusion should be included for transfusion reaction
workup.

FNHTRs need prompt management and exclusion of
other causes of fever. Like any other adverse reactions the
transfusion should be stopped immediately and evaluation
done to rule out other causes of fever. Generally, fever
responds to antipyretic agents such as acetaminophen.
At some centers pretransfusion medication is given
specially in recurrent FNHTRs. But this practice is not
recommended as it may mask the fever associated with
other types of reactions like hemolytic transfusion and
bacterial contamination.
Febrile reactions to red cells can be prevented in most
of the cases by removal of leukocytes by either prestorage
or poststorage leukoreduction or administering saline
washed red cells because leukocyte antibodies are the
primary reason. Cytokines related febrile reactions may be
most effectively prevented by prestorage leukoreduction.
Transfusion Related Acute Lung Injury

Transfusion related acute lung injury (TRALI) is an
important cause for transfusion related morbidity and
mortality. The incidence of TRALI is estimated to be

between 0.08 percent and 15 percent of patients receiving
a blood transfusion.10 TRALI can occur after transfusion
of whole blood, red blood cells, fresh frozen plasma,
platelet concentrate (random donor and apheresis),
cryoprecipitated antihemophilic factor VIII.
Transfusion related acute lung injury is characterized
by acute noncardiogenic edema and respiratory com
promise associated with transfusion. The National Heart,
Lung and Blood Institute (NHLBI) working group has
defined TRALI as new acute lung injury occurring during
or within six hours of transfusion, with a clear temporal
relationship to transfusion in the patient without alternate
risk factor for lung injury.11 Clinically, TRALI should be
considered whenever the recipient experiences acute
respiratory insufficiency and or chest X-ray shows bilateral
pulmonary edema. It is accompanied by other symptoms
like fever, chills, and hypotension. The severity of TRALI is
not related to the volume of blood transfused.
The exact mechanism of TRALI is not known but it
may result from multiple factors. Antibodies against HLA
class I and II or neutrophils antigens present in donor
units are thought to cause increased permeability of
pulmonary microcirculation resulting in collection of fluid
in interstitial and alveolar spaces.

The transfusion should be stopped when there is
respiratory distress and the same unit should not be
started even if the symptoms have subsided. Management
of TRALI is mainly supportive with oxygen therapy and
ventilation. Most of the patients recover within 48 to 72
hours.
No specific precautions are needed if the reaction
has occurred due to antibodies in donor plasma, and
components from other donors are available. In many
centers in the UK the current practice is not to transfuse
plasma sourced from female donors.
Metabolic Complications
Hypothermia
Hypothermia may be caused by rapid infusion of large
quantities of cold blood (210oC) or RBC units. Due to
their large body surface area-to-weight ratio infants and
children are predisposed to hypothermia. Hypothermia
during massive transfusion can induce cardiac arrhythmia
and arrest.12 Transfusion of cold blood in neonates has
been associated with apnea and hypoglycemia.13 Blood
does not have to be warmed for transfusions administered
at a standard rate. For rapid infusion, generally considered
to be more than 50 mL/kg/hour for an adult and more
than 15 mL/kg/hour for a child, blood should be warmed
using a monitored blood warming device.
Hyperkalemia
During storage of red cell products potassium leaks from
the cells, increasing the potassium concentration. Risk
of hyperkalemia from a blood transfusion depends on
the patients size, clinical condition, type and amount of
component transfused, concentration of potassium in the
plasma. Hyperkalemia resulting from massive transfusion
of older RBC units containing elevated amount of
extracellular potassium can cause significant cardiac
complications or possibly death in some patients.14 In one
case of neonatal mortality following transfusion of red
cells with high plasma potassium levels reported by Hall
et al15 it was observed that the patients cardiac arrest was
probably related to rapid transfusion of RBCs with high
plasma potassium levels.
In neonatal transfusions, hyperkalemia can be avoided
by use of RBC units less than seven days old or older units
that have been saline washed.16
Citrate Toxicity
Blood collected for transfusion is anticoagulated with
citrate, which chelates calcium ions. Plasma and whole
blood are the blood components most likely to cause
hypocalcemia because they contain the most citrate
per unit volume. Rapid blood transfusion can cause a
transient decrease in ionized calcium and a hypocalcemic
state.17 Symptoms of hypocalcemia include peripheral and
perioral paraesthesia, muscle spasm, cardiac arrhythmia
and hypotension. Symptomatic hypocalcemia is rare
and calcium supplementation is usually not required.
Mild citrate toxicity is managed by slowing the rate of
transfusion. If severe, parenteral calcium may be required.
DELAYED HAZARDS OF TRANSFUSION

Delayed Hemolytic Transfusion Reaction
Delayed hemolytic transfusion reaction (DHTR) occurs
when the antigen on donor red cells elicit immune response
in the recipient. Secondary immune response occurs
usually four to seven days after transfusion. Most of the
antibodies associated in DHTR are IgG and the resulting
hemolysis is of extravascular type. Secondary immune
response may not result in hemolysis always. In some
patients clinically significant delayed hemolytic reaction
occurs. Clinically, it is detected by falling hemoglobin,
fever, mild jaundice and positive antibody screen. If DHTR
is suspected, tests for detection of red cell antibodies
should be done along with other investigations like direct

antiglobulin test (DAT) and serum bilirubin. Detection of
red cell alloantibody with the history of recent transfusion
indicates DHTR in such cases. Delayed intravascular
hemolysis is uncommon and is often associated with
antibodies to Duffy or Kidd blood group system.18

In most of the cases no specific treatment is required.
The patient should be monitored for renal function and
coagulation.
For future transfusion requirements the donor unit
should lack the corresponding antigen for the alloantibody.
Alloimmunization
Alloimmunization is one of the clinically significant
adverse effects of blood transfusion. Development of
antibodies against donor antigen present in the blood
component may pose difficulties in finding compatible
red cell units or result in platelet refractoriness or adverse
transfusion reaction. The immune system of the recipient
reacts to donor antigens as they are foreign to recipient.
The first exposure generally sensitizes the immune system
of recipient. With subsequent exposure the secondary
immune response results in rapid production of large
amount of IgG type of antibodies. These antibodies attach
to the surface of the antigen carrying cells and causes
destruction of cells by complement system or reticuloendothelial system. Primary alloimmunization to red cell
or platelet antigens with transfusion is rare in the first
few months of life.19 Beyond newborn period, pediatric
patients with clinical conditions like sickle cell disease or
thalassemia requiring repeated transfusions may develop
alloimmunization to red cell antigens.
Alloimmunization to platelet antigens and refracto
riness to platelet transfusions may be a problem in
oncology patients or other clinical conditions dependent
on platelets. HLA alloimmunization is the most common
immune cause of platelet refractoriness and can be
confirmed by demonstration of HLA class I antibodies.20
Clinically the severity varies from mild symptom of
fever and falling hematocrit to severe effects like platelet
refractoriness and bleeding.
Laboratory work up to detect clinically significant
red cell antibodies needs to be done. For HLA antibodies
lymphocytic panels and lymphocytotoxic antibody can be
done using patients serum.

Treatment depends on the severity of reaction. Mild
reaction in case of a single time need of transfusion may

not need any active treatment. Patients requiring multiple
transfusions need to undergo antibody identification and
should be transfused preferably with antigen negative
blood to prevent further alloimmunization. However, it
is very difficult to prevent alloimmunization completely.
Selection of phenotype matched blood is recommended
specially in patients requiring multiple transfusions to
prevent alloimmunization. Use of leukoreduced products
for transfusion also prevents alloimmunization up to
certain extent. Several strategies have been evaluated
to prevent alloimmunization to platelets. They include
reduction in numbers of leukocytes in the platelets and
use of ultraviolet B irradiation.20 The report of Trial to
Reduce Alloimmunization to Platelets (TRAP) study
group indicated that use of either leukocyte filtered or
UVB irradiated blood components reduced the incidence
of HLA antibody generation from 45 percent to 17 and
21 percent respectively.21
Post-transfusion Purpura
Transfusion Related Immunomodulation
Blood transfusion can modulate the immune response of

the recipient. This phenomenon was reported by Opelz
and coworkers in 1973, who observed the improved
renal allograft survival in transfused patients.22 However,
there may be other adverse effects of transfusion in
different clinical situations, such as increased risk of
bacterial infection, activation of latent infections and
tumor recurrence. In one controlled study on patients
with hematologic malignancies, a history of allogeneic
blood transfusion was associated with an increased risk
for lymphoplasmacytic and marginal zone lymphomas.23
The exact mechanism is not clear but the soluble
mediators released from WBCs are postulated as a
potential cause for the immunomodulatory effect. Several
studies have been conducted to understand the effect of
blood transfusion on immune response and to develop
preventive strategies. Leukoreduction as a preventive
strategy remains controversial as the only clinical situation
where the findings of randomized clinical trials of adverse
transfusion related immunomodulation (TRIM) effects
have been consistent is in cardiac surgery patients. In
that setting, the use of leukoreduced allogeneic RBCs has
been shown to reduce the short-term (up to three months
post-transfusion) mortality from all causes. Based on the
results of the cardiac surgery RCTs, leukoreduction of all
cellular blood components transfused in cardiac surgery
patients should be recommended. In clinical settings
other than cardiac surgery, the available evidence does
not yet justify implementation of universal leukoreduction
for the specific prevention of adverse TRIM effects, but
universal leukoreduction may be justified on the basis of
other WBC-related adverse effects.24
The thrombocytopenia is usually self limiting. This

condition can be treated by corticosteroids, plasma
pheresis and exchange transfusions. Intravenous
immunoglobulin can also be given. Platelet transfusions
should be avoided during the treatment of PTP. There are
no preventive measures for PTP. History of transfusion
and any adverse reaction should be asked before blood
transfusion. Patients with positive history should be tested
for presence of antibodies.
Post-transfusion purpura (PTP) manifests as sudden and

severe thrombocytopenia occurring one to two weeks
after red cells, plasma or platelet transfusions. The platelet
count may fall up to below 10 109/L. The recipient may
have hematuria, melena and vaginal bleeding.
Post-transfusion purpura is generally thought to be
due to the anamnestic development of antibodies against
donor platelets. These antibodies also start destroying
autologous platelets leading to severe thrombocytopenia
and purpura. Most frequently found antibody is anti-HPA1a. Platelet antibodies attach to platelet surface resulting
in extravascular destruction of platelets. The exact
mechanism of platelet destruction is not fully known.
Multiparous female patients are more likely to develop
PTP after transfusion because of sensitization during
previous pregnancies.
Transfusion Associated Graft versus Host

Disease
Transfusion associated graft versus host disease (TAGvHD) is a severe immunological reaction in a susceptible
host resulting from engraftment and proliferation of
donor lymphocytes present in the transfused product.
The engrafted lymphocytes elicit immunogenic response
against recipient tissues leading to the clinical presentation
of pancytopenia, bleeding, diarrhea and skin rash.
Transfusion associated graft versus host disease occurs
in an immunocompromised host or in immucompetent
recipient when the donor cells are homozygous for an
HLA type for which the recipient is heterozygous. The
pathophysiology is complex. The donor lymphocytes are
not recognized by recipient as foreign and are not cleared
by the host immune system resulting in engraftment and
proliferation in the host. Later these donor cells start
attacking host tissue. Clinically, GvHD presents as skin
rash, blanching and maculopapular erythema of upper
trunk, neck, palms and soles that may develop into
blistering lesions. Skin biopsy shows infiltration of upper
dermis by mononuclear cells and damage to the basal
layer. Involvement of liver is manifested as hepatitis,
raised bilirubin and enzyme levels. Enterocolitis causes
anorexia, nausea and severe diarrhea.

The clinical effects of TA-GvHD are difficult to treat even
with immunosuppressive drugs. Irradiation of cellular
blood components is accepted as method for prevention of
TA-GvHD. The recommended dose is 25 Gy to the center
of the blood container and at least 15 Gy to the periphery of
the blood container. This dose renders the T-lymphocyte
inactive without affecting functional status of red cells,
platelets and granulocytes. These blood components,
given to recipients from donors homozygous for an HLA
haplotype shared with the recipient, pose a specific risk
for TA-GvHD. This circumstance can occur when first and
second degree relatives serve as directed donors and when
HLA matched platelet components donated by related or
unrelated individuals are being transfused. Irradiation
of blood components has been recommended in these
situations. Other recipients who should receive irradiated
cellular blood component are recipients of hematopoietic
progenitor cells transplant and intrauterine transfusions,
and patients with congenital immunodeficiency.
Blood transfusion of irradiated blood product in
pediatric patients requires more attention. Irradiated red
cells undergo an enhanced efflux of potassium during
storage at 2 to 6C.25 When irradiated red cells are used for
neonatal exchange transfusion or the equivalent of a whole
blood exchange is anticipated, red cell washing should be
considered to prevent the possible adverse effects caused
by hyperkalemia associated with irradiation and storage.26
Circulatory Overload
Transfusion therapy sometime may result in circulatory
overload especially in young children and the elderly.
Rapid increase in blood volume due to transfusion is not
tolerated by some patients with compromised cardiac
and pulmonary functions. Circulatory overload presents
as dyspnea, cyanosis, severe headache and hypertension.
Congestive cardiac failure may occur during or after
transfusion.
Treatment
The condition can revert if the transfusion is stopped with
the onset of symptoms. Diuretics and oxygen support may
be needed in some patients, even if the symptoms are not
resolved phlebotomy may be required.
Iron Overload
This complication is particularly common in multiple
transfusion recipients especially those with hemo
globinopathies since every red blood unit contains
approximately 200 mg of iron. These patients are
multiply transfused at regular intervals to maintain
hemoglobin levels, resulting in accumulation of
excess iron. During the initial phase iron is stored in
reticuloendothelial sites and later in parenchymal cells.
Iron deposition hampers the function of heart, liver,
endocrinal glands. Cardiac involvement causes most of
the morbidity and mortality.
Treatment
Treatment is to remove excess iron without affecting
hemoglobin levels. Use of iron chelating agents like
desferrioxamine can reduce iron stores.
CONCLUSION
Though the list of noninfectious hazards of transfusion is
long and diverse and although blood transfusion will never
be absolutely safe, tremendous progress has been made
in the understanding of the complications of transfusion
and their prevention and management. To prevent
hemolytic reactions, advanced identification systems
that link donor and recipient with greater precision
minimize human error. Febrile non hemolytic transfusion
reactions (FNHTR) and platelet refractoriness due to HLA
alloimmunization can be prevented by transfusion of
leukoreduced blood. Though TA-GVHD can be prevented
by selective irradiation concerns about transfusion
related immunomodulation (TRIM) still need to be
resolved. Blood centers and transfusion services should
provide education for creating clinical awareness of the
complications of transfusion so that potential transfusion
risks are identified and managed while they continue to
occur, until, ultimately they are reduced to a negligible
concern for transfusing physicians and their patients.
REFERENCES

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2. Lavoie J. Blood transfusion risks and alternative strategies
in pediatric patients. Paediatric Anaesthesia. 2011;21(1):
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3. Technical manual. Noninfectious complications of blood
transfusion. In: Brecher ME, Leger RM, Linden JV, Roseff
SD, (eds) Technical Manual. 15th edn. Bethesda MD:

4. Gauvin G, Lacroix J, Robillard P, et al. Acute transfusion
reactions in the pediatric intensive care unit. Transfusion.
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5. Couban S, Carruthers J, Andreou P, et al. Platelet
prospective crossover trial of plasma removal and
a prospective audit of WBC reduction. Transfusion.
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6. Robillard P, Nawej KI, Jochem K. The Quebec
hemovigilance system: description and results from the
first two years. Transfus Apher Sci. 2004;31(2):111-22.
7. Sandler SG, Mallory D, Malamut D, et al. IgA anaphylactic
transfusion reactions. Transfus Med Rev. 1995;9(1):1-8.
8. Linden JV, Wagner K, Voytovich AE, et al. Transfusion
errors in New York State: an analysis of 10 years experience.
Transfusion. 2000;40(10):1207-13.
9. Lozano M, Cid J. The clinical implications of platelet
transfusions associated with ABO and Rh incompatibility.
Transfus Med Rev. 2003;17(1):57-68.
10. Vlaar APJ, Juffermans NP. Transfusion related acute lung
injury: a clinical review. Lancet. 2013;382:984-94.
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Update. Hematology. 2006.pp.497-501.
12. Boyan CP, Howland WS. Blood temperature: A critical factor
in massive transfusion. Anesthesiology. 1961;22:559-63.
13. Barcelona SL, Cote CJ. Paediatric resuscitation in the
operating room. Anesthesiol Clin North Am. 2001;19:339-65.
14. Perkins RM, Aboudara MC, Abbott KC, Holcomb JB.
Resuscitative hyperkalaemia in noncrush trauma: A
prospective, observational study. Clin J Am Soc Nephrol.
2007;2:313-9.
15. Hall TL, Barnes A, Miller JR, et al. Neonatal mortality
following transfusion of red cells with high potassium
levels. Transfusion. 1993;33:606-9.
16. Bansal I, Calhoun BW, Joseph C, et al. A comparative study
of reducing the extracellular potassium concentration in
red blood cells by washing and by reduction of additive

solution. Transfusion. 2007;47:248-50.
17. Dzik WH, Kirkely SA. Citrate toxicity during massive blood
transfusion. Transfus Med Rev. 1988;2:76-94.
18. Adverse effects of blood transfusion. In: Roseff SD,
Gottschall JL (eds). Pediatric Blood Transfusion: A
physicians handbook. 3rd edn. Bethesda: American
Association of Blood Banks. 2009.pp.155-200.
19. Strauss RG, Johnson K, Cress G, Cordle DG.
Alloimmunization in preterm infants after repeated
transfusions of WBC reduced RBCs from the same donors.
Transfusion. 2000;40:1463-8.
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antibodies. In: Roback JD, Grossman BJ, Harris T, Hillyer
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Hemato-Oncology
CHAPTERS OUTLINE
39. Pediatric Acute Lymphoblastic Leukemia

40. Pediatric Acute Myeloid Leukemia

41. Chronic Myeloid Leukemia

42. Juvenile Myelomonocytic Leukemia

43. Pediatric Hodgkin Lymphoma

44. Non-Hodgkin Lymphoma in Children and Adolescents

45. Langerhans Cell Histiocytosis

46. Hemophagocytic Lymphohistiocytosis: Revisited

47. Bone Marrow Transplantation

39
Pediatric Acute
Lymphoblastic Leukemia
Acute lymphoblastic leukemia (ALL) is a neoplasm of precursor hematopoietic cells (B- and T-lymphoblasts) involving bone marrow
(BM) or other tissues like lymph node, thymus with or without peripheral blood involvement. ALL is clinically, morphologically,
immunophenotypically, and genetically a heterogeneous disease. It is the most common childhood malignancy and accounts
for nearly 30 percent of all childhood cancers and approximately 75 percent of all cases of childhood leukemia. The treatment of
childhood ALL is one of the true success stories of modern clinical oncology. Before the advent of effective chemotherapy in the
1960s, ALL usually was a fatal disease. In the developed countries, with modern intensive protocols approximately 83 to 93 percent
of children with ALL are now long-term survivors.1 However, this is not the case in developing countries where 80 percent of the
children with ALL reside.
INTRODUCTION
Though as per the cancer registry data, it has been noted
that incidence of ALL is less in India as compared to the
developed countries, it is estimated that approximately
8000 new cases of childhood ALL diagnosed each year
in India.2 Unfortunately of these only 25 percent receive
appropriate treatment. Studies from India have shown that
40 to 60 percent of patients treated in a pediatric oncology
center on an affordable protocol, with manageable toxicity
can be cured.2,3 There are several reasons for these poor
results including poverty, lack of awareness, lack of access
to adequate medical care, lack of adequately trained
personnel and competent oncology units. These factors
lead to delayed and sometimes improper diagnosis, delayed
referrals, poor compliance, inadequate or inappropriate
therapy and poor outcome.
Suspected case of acute leukemia should be examined
meticulously. Evaluation starts with a detailed history and
clinical examination.
Patients commonly present with symptoms including
weakness, fatigue, fever, bleeding, bone pains, either
gradually or abruptly. Children with ALL often present
with signs and symptoms that reflect bone marrow

infiltration and/or extramedullary disease (Table 1).
Bone marrow failure due to infiltration by leukemic
blast manifests as anemia, thrombocytopenia, and
neutropenia.
History of prior treatment in the form of transfusion or
drugs prescribed especially steroids should be taken as
these factors may interfere in diagnosis.
Respiratory distress and orthopnea secondary to
a mediastinal mass may be a presenting symptom
in patients with T-lineage ALL; B-lineage ALL may
present with mass in abdomen, head and neck or in
central nervous system.
Very frequently patients present with life threatening
complications like congestive cardiac failure, acute
bleeding, tumor lysis syndrome (TLS) (hyperuricemia,
hyperphosphatemia, hyperkalemia hypocalcemia
and/or azotemia)4 and superior vena cava syndrome.
Clinical examination and investigations (pathological,
biochemical and imaging) helps to find out need for urgent
intervention and management of these life threatening
consequences of leukemia.
Differential diagnosis (Table 2): ALL should be differ
entiated from benign conditions like juvenile rheu
matoid arthritis, infectious mononucleosis, idiopathic
396Section-6Hemato-Oncology
Table 1 Symptomatology of acute lymphoblastic leukemia
Table 3 Usual cytological features of AML and ALL
Fever
Parameters
AML
ALL
Bleeding (e.g. petechiae or purpura)
Blast size
Large and uniform
Small to medium:
variable
Lymphadenopathy
Chromatin
Finely dispersed
Coarse
Splenomegaly
Nucleoli
1-4 often
prominent
Absent or 12,
indistinct
Cytoplasm
Granules often
present
Granules lacking
Aur rods
60-70% cases;
diagnostic
Absent
Myelodysplasia
Often present
Absent
Bone pain
Hepatosplenomegaly
Testicular swelling
C
entral nervous system symptoms (cranial nerve palsies,
intracranial bleed, seizures)
Table 2 Differential diagnosis of acute lymphoblastic leukemia

in children
Nonmalignant conditions:
Juvenile rheumatoid arthritis
Table 4 Commonly used immunophenotypic markers

Myeloid or
Monocytic
CD13, CD33, CD117, CD15, CD16,

MPO
At least 2 of the following:
NSE, CD14, CD64, CD11c, lysozyme
B-lymphoid
CD19, CD20, CD22, Cyto CD79a

Cyto CD22
T-lymphoid
CD1a, CD2, CD3, CD4, CD5, CD7,

CD8, Cyto CD3
Other markers
CD34, Tdt, HLADR, CD41, CD61
Infectious mononucleosis
Idiopathic thrombocytopenic purpura
Pertussis; parapertussis
Aplastic anemia
Acute infectious lymphocytosis
Malignancies:
Hematolymphoid malignanciesAcute myeloid leukemia,
Hodgkin lymphoma, non-Hodgkin lymphoma (NHL)
Neuroblastoma
Retinoblastoma
Rhabdomyosarcoma
thrombocytopenic purpura, pertussis, parapertussis,

aplastic anemia, and acute infectious lymphocytosis.
These diseases have overlapping symptomatology.
Hematolymphoid malignancies especially nonHodgkin lymphomas with marrow involvement have a
common spectrum of signs and symptoms and should
be differentiated with ALL. Clinical symptomatology
like abdominal mass in Burkitts lymphoma, bony
involvement in anaplastic large cell lymphoma
helps in making working diagnosis. Clinical features,
morphology and immunohistochemistry are helpful
tool to distinguish ALL from acute myeloid leukemia
(AML). Some features are given in Tables 3 and 4.
Solid tumors with advanced stage (i.e. bone marrow
infiltration) may mimic ALL. Neuroblastoma with bone
marrow involvement may have features of anemia, body
pain, abdominal distension, though the early age of
presentation, ecchymosis, primarily abdominal mass
may help it to distinguish it from ALL. Other solid tumors
like retinoblastoma, rhabdomyosarcoma, also having

morphology of small round cell tumor, should be kept
as differential diagnosis though the site of origin and
immunohistochemistry is helpful to diagnose these solid
tumors.
Laboratory confirmation is mandatory for the diagnosis
and management of ALL.
LABORATORY DIAGNOSIS OF ACUTE

LYMPHOBLASTIC LEUKEMIA
Laboratory investigations should be directed for con
firming the diagnosis, assessment of organ function, and
to rule out need for urgent intervention like tumor lysis
syndrome.
Confirmation of Diagnosis
Laboratory work up starts with complete blood counts
(CBC), peripheral blood and bone marrow evaluation.
CBC generally shows anemia and thrombocytopenia.
However patients may have leukopenia, normal leukocyte
count or leukocytosis. Peripheral blood examination is
usually followed by bone marrow (BM) examination. BM
aspiration is preferably done from the posterior superior
Chapter-39 Pediatric Acute Lymphoblastic Leukemia 397

Table 5 Immunological markers in B-ALL and T-ALL5
Lineage
Immunological subgroup
Frequency
Immunophenotypic profile
B-ALL
Early pre-B cell
6070%
CD10, CD19, CyCD22, CD34, Good except CD10-ve ALL, especially in <1 year
and Tdt positive. CD24
age group, infantile leukemia associated with
strongly positive, CD45
translocation of 11q23 and have poor prognosis
dim/-ve
Pre-B cell
20%
Cyu heavy chain, CD10,

CD19, cyCD79a, and CD22
+ve
Poor compared to early pre-B. Expression of

t(1:19) is the primary determinant of adverse
prognosis in pre B-ALL
Mature B-Cell
25%
Surface immunoglobulin
(bright), CD19, CD20, CD22,
CD24 +ve CD34. Tdt ve.
Poor with standard ALL therapeutic regimen,

but dose intensive chemotherapy leads to cure
rate of 75%.
Pro-T-cell
CyCD3 and/or CD7 +ve
With more intensive chemotherapeutic

approach outcome reaching to the level of nonT-cell ALL.
Pre-T-cell
CyCD3, CD7, CD2 and/or

CD5 +ve
Cortical T-cell
CyCD3, CD7, CD2 and/

or CD5 and CD1a +ve, coexpression of CD4/CD8
Mature T-cell
CyCD3, CD7, CD2 and/or

CD5 and CD3 positive,
segregated CD4 or CD8 +ve
T-ALL
iliac bone and sample is aliquoted for morphology,

flow cytometry, molecular studies (EDTA vacutainer),
cytogenetics (Heparin vacutainer) and trephine biopsy
(formalin fixed). The diagnosis of ALL should be
established by cytomorphological examination of MayGrunwald Giemsa (MGG) or Wright-stained smears of
peripheral blood and/or a BM aspirate.
FAB criteria and scoring system have become
generally accepted for morphological classification. The
myeloperoxidase (MPO) or Sudan-Black (SB) reaction and
the non-specific esterase (NSE) reactions are recommended
for differentiation from AML. In ALL, the MPO reaction is
negative. A positive PAS and/or acid phosphatase reaction
may support the diagnosis of ALL; these reactions, however,
are not positive in all cases of ALL.
Remarks
Cytogenetics of Acute Lymphoblastic

Leukemia
Blasts in ALL contain somatically acquired genetic abnor
malities that help in understanding pathogenesis and
strongly influence prognosis. This includes changes in
chromosome number (hyperdiploid/hypodiploid) and
chromosomal translocations.
Numerical Abnormalities
High hyperdiploidy: It is defined as 51 to 65 chromo
somes per cell or a DNA index larger than 1.16.
Hypodiploidy: Patients with fewer than 45 chromo
somes defined as hypodiploidy.
Structural Abnormalities (Chromosomal

Leukemic cells demonstrate particular subsets of surface Translocations)
Flow Cytometry
and intracellular molecules dened as cluster of differen

tiation (CD) antigens (Table 5). Identication of which
by flow cytometry (FCM) helps in lineage identication
and sub-categorization. Diagnosis of acute leukemia by
immunophenotyping is based on the fact that leukemic
cells frequently disclose aberrant phenotypes compared
to normal hematopoietic cells, known as the leukemiaassociated phenotypes (LAP).
TEL-AML1, (t [12; 21]): It is seen in 20 to 25 percent

of cases of B-precursor ALL at least in the developed
countries. The t (12; 21) occurs most commonly in
children aged 2 to 9 years.
Philadelphia chromosome, (t [9; 22] translocation): It is
present in three percent of children with ALL, and is
more common in older patients with precursor B-cell
ALL and high WBC count.
MLL gene rearrangements: It is seen in five percent of
childhood ALL cases. The t(4; 11) is the most common
translocation involving the MLL gene in children with
ALL. Patients with t (4; 11) are usually infants with high
WBC counts; usually have CNS disease.
E2A-PBX1, (t[1; 19] translocation): It occurs in
five percent of childhood ALL cases. The t(1;19)
translocation has higher risk of CNS relapses.
Role of Trephine Biopsy

It is especially required in cases wherein the BM
aspirate smears are acellular or dry tap, diluted with
peripheral blood, in partially treated cases where blood
transfusion/treatment by steroids and other drugs alter
the morphological picture or in cases where the sample
is degenerated during transport to a referral laboratory
for ancillary investigations. It is recommended to obtain a
trephine biopsy upfront in all new cases of hematolymphoid
malignancies as the paraffin block is an invaluable
diagnostic archival material for immunophenotyping.
Organ Function Assessment

Renal function test, liver function test, serum electrolyte,
serum lactate dehydrogenase (LDH) with serology
especially of hepatitis (B&C), HIV should be done routinely.
Total leukocyte count, serum LDH, and extramedullary
involvement (hepatosplenomegaly) are the indicators for
tumor burden and helps to find patients who need urgent
intervention.
Other Tests
Lumbar puncture with cytospin morphologic analysis is
performed before systemic chemotherapy is administered
to assess for central nervous system (CNS) involvement

and to administer intrathecal chemotherapy. In males,
USG of testis is done to rule out testicular involvement, if
clinically indicated.
PROGNOSTIC FACTORS (TABLE 6)

Outcome of patients with ALL has improved over time
though the prognosis depends on multiple factors, still
type of treatment and its response is the strongest point
for predicting the outcome.
Prognosis depends on various factors:
The host genotype (host biology)
The leukemic cell genotype (tumor biology)
Response to therapy.
A. Host Biology
Age
Gender.
Age
The age at diagnosis correlates with clinical outcome.
In childhood ALL, infants and adolescents have a worse
prognosis than patients aged 1 to 10 years6. The improved
outcome in patients between 1 to 10 years is due to more
frequent occurrence of favorable cytogenetic features in
the leukemic blasts including hyperdiploidy, or trans
location t(12;21).7 Infants with ALL have high-risk of
treatment failure as they have high presenting leukocyte
counts, increased frequency of central nervous system
leukemia at presentation and a very high incidence (~80%)
of rearrangement of the MLL gene on chromosome 11q23.
Amongst infants with MLL gene rearrangements, those
Table 6 Prognostic factors in childhood ALL

Adverse
Favorable
Age
<1, >10
19.99
WBC
>50,000
<50,000
Sex
Boy
Girl
DNA index
<1 (Hypodiploidy) >1.16 (Hyperdiploidy)
Immunophenotype
T-ALL, EPB
CALLA+
Cytogenetics
t (4;11)
TEL-AML
t (9;22)
Trisomy 4,10,17
Treatment
Inappropriate
treatment
Appropriate treatment
In vivo response
Poor ESR*
Good ESR*
(Most important)
MRD** +
MRD**
Clinical
Laboratory
*ESR: Early steroid response; **MRD: Minimal residual disease.

presenting at a young age (< 6 months) or with extremely
high leukocyte counts (> 300,000/L) have the worst
prognosis.8
Adolescents (ages 16-21 years) with ALL have a less
favorable outcome than children aged 1 to 10 years, as
they frequently present with T-cell immunophenotype,
high leukocyte counts, and a higher incidence of the
Philadelphia chromosome [t(9;22)].9 Adolescents are also
at higher risk for certain treatment-related complications,
such as hyperglycemia, osteonecrosis, pancreatitis and
deep vein thromboses, which may also impact prognosis.10
Gender
The prognosis for boys with ALL is slightly worse than
girls.11 Potential reason for the better prognosis for girls
is the occurrence of testicular relapses among boys. Also,
boys appear to be at increased risk of bone marrow and
CNS relapse for reasons that are not well understood.
With current treatment regimens, there is no difference in
outcome between males and females.12
B. Tumor Biology

White blood cell (WBC)

CNS status at diagnosis
Testicular involvement at diagnosis
Immunophenotype
Cytogenetics
Numerical abnormalities
Structural abnormalities (Chromosomal transloca
tions)
Early response to therapy.
White Blood Cell Count at Diagnosis

White blood cell count reflects tumor burden. Although the
relationship between WBC count and prognosis is a con
tinuous rather than a step function, the National Cancer
Institute (NCI) stratifies patients into two subsets based on
WBC counts; standard risk (WBC count < 50,000) or highrisk (WBC count > 50,000). High WBC count is usually as
sociated with unfavourable chromosomal translocations
such as t(4; 11), t(9; 22) and T cell immunophenotype.13
Central Nervous System Status at Diagnosis

The presence of CNS disease at diagnosis is an adverse
prognostic factor in spite of intensification of therapy.
Patients are divided into three categories based on the
number of WBC/L and the presence/absence of blasts
on cytospin (Table 7).
The adverse prognostic significance associated
with CNS2 status can be overcome by the application of
Table 7 Definition for central nervous system

involvement by leukemia
CNS-1 No lymphoblasts
C
NS-2 <5 WBCs/mL with definable blasts on cytocentrifuge
examination
CNS-3 5 WBCs/mL with blasts or cranial palsy
more intensive intrathecal therapy, especially during

the induction phase.12 Furthermore, a traumatic lumbar
puncture (more than 10 erythrocytes/L) that includes
blasts at diagnosis appears to be associated with increased
risk of CNS relapse and requires intensification of therapy.
Testicular Involvement at Diagnosis

Overt testicular involvement at the time of diagnosis
occurs in approximately two percent of males. Historically,
testicular involvement at diagnosis was identified as an
adverse prognostic factor, but with aggressive therapy
it has lost its prognostic significance.14 Overt testicular
involvement is not an independent prognostic factor,
despite association with high-risk features.15
Immunophenotype
The World Health Organization (WHO) classifies ALL as
either B-lymphoblastic leukemia(B-ALL) or T-lineage
lymphoblastic leukemia (T-ALL), based on its cell of origin
detected by surface or cytoplasmic expression of B or T-cell
antigens. Precursor B-cell ALL is defined by the expression
of cytoplasmic CD79a, CD19, HLA-DR, and other B cellassociated antigens. It accounts for 80 to 85 percent of
childhood ALL and has a better prognosis compared to
T-ALL. Precursor B-cell ALL patients are further divided
into immunologic subtypes, of which Pro-B ALL (CD10
negative and no surface or cytoplasmic Ig) is commonly
seen in young infants with a t (4; 11) translocation and has
a poor outcome. T-cell ALL is defined by expression of the
cytoplasmic CD3, with CD7 plus CD2 or CD5 on leukemic
blasts. High-risk features at presentation were significantly
more frequent in T-ALL as compared to B-lineage ALL.16
T-ALL is further divided into immunologic subtypes,
of which early T-progenitor (ETP)-ALL (CD1a and CD8
negative, CD5 weak, at least one stem-cell-associated or
myeloid-associated antigen) has stem-cell-like features
with high-risk of induction failure or relapse.17
Myeloid antigen expression: Myeloid-associated antigen
expression is associated with specific ALL subgroups
(MLL gene and TEL-AML1 gene rearrangement). No
independent adverse prognostic significance exists for
myeloid-surface antigen expression.18
Cytogenetics
Blasts in ALL contain somatically acquired genetic
abnormalities that help in understanding pathogenesis
and strongly influence prognosis. This includes changes
in chromosome number (hyperdiploid/hypodiploid) and
chromosomal translocations
E2A-PBX1, t(1;19): It is associated with pre-B ALL

immuno
phenotype. It was associated with poor
prognosis in the context of less intensive anti
metabolite-based therapy in the past, but with most
current treatment protocols, the t(1;19) translocation
has no adverse prognostic significance except higher
risk of CNS relapses.25
Numerical Abnormalities
C. Early Response to Therapy
High hyperdiploidy: High hyperdiploidy generally occurs

with clinically favorable prognostic factors (patients aged
19 years with a low WBC count) and is itself an independent
favorable prognostic factor. Hyperdiploid leukemia cells
are particularly susceptible to undergoing apoptosis and
accumulate higher levels of methotrexate and its active
polyglutamate metabolites which may explain the favorable
outcome commonly observed for these cases19. Among
specific trisomies, patients with triple/trisomies (4, 10, and
17) have been shown to have an improved outcome.19
The kinetics of the reduction in tumor burden in response

to treatment has been shown to be highly prognostic
of event free survival. Response to therapy is the most
reliable prognostic factor, as it reflects leukemic cell drug
sensitivity, intensity of therapy, and pharmacogenomic as
well as pharmacodynamic features of the host.
Hypodiploidy: Patients with fewer than 44 chromosomes

have a worse outcome than patients with 44 or more
chromosomes in their leukemic cells. Cases with 24 to 28
chromosomes (near haploidy) have the worst outcome.20
Patients with a reduction in peripheral blast count to

less than 1,000/L after a 7-day induction prophase with
prednisone and one dose of intrathecal methotrexate
(good prednisone response) have a more favourable
prognosis than patients whose peripheral blast counts
remain above 1,000/L (a poor prednisone response).26
German Berlin-Frankfurt-Munster (BFM) clinical trials
group stratifies its treatment based on early response to
the 7-day prednisone prophase.
Structural Abnormalities
(Chromosomal Translocations)
TEL-AML1, (t[12; 21]): The t(12; 21) occurs most
commonly in children aged 2 to 9 years.21 It has good
prognosis. However, its impact may be modified by
factors such as early response to treatment, NCI risk
category, and treatment regimen. There is a higher
frequency of late relapses in patients with TEL-AML1
fusion compared with other B-precursor ALL.22
Philadelphia chromosome, (t[9; 22] translocation): It is
associated with poor prognosis especially in those who
present with a high WBC count or have a slow early
response to initial therapy. However, its prognosis
seems to have improved by incorporation of tyrosine
kinase inhibitors, such as imatinib, in the treatment.
A COG study, using intensive chemotherapy and
concurrent imatinib given daily, demonstrated a
3-year EFS rate of 80.5 percent.23
MLL gene rearrangements: The t(4; 11) is the most
common translocation involving the MLL gene in
children with ALL. Patients with t(4; 11) are usually
infants with high WBC counts; usually have CNS disease
and respond poorly to initial therapy. Children with MLL
rearrangement have a better prognosis than infants.24
The t(11; 19) occurs in one percent of cases and
occurs in both early B-lineage and T-cell ALL. Outcome
for infants with t(11; 19) is poor, but outcome appears
favorable in older children with T-cell ALL.
Peripheral Blood Response to Steroid

Prophase
Day 7 and Day 14 Bone Marrow Responses

Patients who have a rapid reduction in leukemia cells to
less than 5% (M1 marrow) in their bone marrow within 7
or 14 days following initiation of multiagent chemotherapy
have a more favorable prognosis than do patients who
have slower clearance of leukemia cells from the bone
marrow.27
Peripheral Blood Response to Multiagent

Induction Therapy
Patients with persistent circulating leukemic cells at 7 to
10 days after the initiation of multiagent chemotherapy
are at increased risk of relapse compared with patients
who have clearance of peripheral blasts within 1 week of
therapy initiation.28
Induction Failure
Five percent of patients do not achieve complete mor
phologic remission by the end of induction therapy. A
cut-off of five percent blasts in the bone marrow is used
to determine the remission status. Patients at highest risk
of induction failure include T-cell phenotype and patients

with B-precursor ALL with very high presenting leukocyte
counts or the Philadelphia chromosome. Induction failure
portends a very poor outcome.29
Minimal Residual Disease

Bone marrow morphology cannot discriminate well
between patients at high-risk of relapse and patients with
excellent prognosis. Therefore, more sensitive techniques
have been developed for detection of submicroscopic
levels (<5%) of malignant cells during and after treatment,
i.e. MRD. Minimal residual disease (MRD) is defined
as the detection of the clones of cells resistant to the
chemotherapy given.
Three types of techniques allow detection of MRD
of 10-3 to 10-6 (1 leukemic cell in 1000 to 1 million cells):
Multiparametric flow cytometry (MPFC) for surface
phenotype of leukemia cell (sensitivity of 10-310-4) can be
used in up to 80 to 90 percent patients with ALL; PCR for
T-cell receptor or immunoglobulin gene rearrangement or
fusion transcripts (sensitivity 10-3 10-5) can be performed
in 90 to 95 percent patients with ALL; PCR Analysis of
breakpoint fusion regions of chromosomal aberrations can
be performed in 30 to 45 percent patients MRD is the most
robust and strongest independent predictor of outcome in
children and adolescents with ALL, which is independent
of age, sex, immunophenotype, WBC count and treatment
group.
MRD discriminates outcome even in subsets of patients
defined by cytogenetic abnormalities and other prognostic
factors. Patients with higher levels of end-induction MRD
(>0.01%) have a poorer prognosis than those with lower
or undetectable levels. Therefore, post-induction MRD
is utilized as a factor determining the intensity of postinduction treatment. MRD levels at earlier (e.g. day 8 and
day 15 of induction) and later time points (e.g. week 12 of
therapy) also predict outcome.30
Newer Factors
Molecular Genetic Abnormalities
IKAROS/IKZF1 deletions, JAK mutations and kinase
expression signatures have been associated with poor
prognosis in B cell acute lymphoblastic leukemia.31-33
Based on combination of gene expression profile and flow
cytometric measures of minimal residual disease (MRD),
children with high-risk B-precursor ALL can be classified
as low, intermediate, and high-risk and thus allow
prospective identification of children who respond or fail
current treatment regimens. Furthermore, integrated use
of both MRD and IKZF1 status allows prediction of 79% of
all the relapses with 93% specificity in MRD-medium risk
group as compared to 46 and 54 percent of the relapses
respectively predicted by use of MRD or IKZF1 alone. The

above findings signify that the use of combined parameters
enhances the risk stratification, particularly for patients
originally classified as nonhigh-risk.34
Pharmacogenetics
It is the study of genetic variations in drug-processing
genes and individual responses to drugs which enables
improved identification of patients at higher risk for
either disease relapse or chemotherapy-associated side
effects. Patients with ALL who are homozygous for TMPT
mutant alleles experience severe or fatal myelotoxicity and
increased relapse because of long delays in therapy.35
Studies from St Jude Childrens Research Hospital
(SJCRH) have shown that when patients are treated
pharmacologically according to phenotype or genotype,
carriers of variant TMPT alleles experience outcomes as
good as, or better than, those with wild-type TPMT.36
The reduced folate carrier (RFC) is the primary
transporter of MTX into cells. RFC expression in leukemic
blasts is linked to MTX sensitivity, while defective
transport associated with reduced RFC expression is a
common mechanism of acquired methotrexate resistance.
Increased copies of RFC are present in hyperdiploid
blasts and MTX-polyglutamate accumulation in blasts
correlates with better outcome in hyperdiploid ALL. The
null genotype of glutathione S-transferases, enzymes that
catalyze the inactivation of many antileukemic agents, has
been associated with a reduced risk of relapse.
RISK STRATIFICATION OF CHILDHOOD ALL

NCI Risk-grouping
Age and WBC count at diagnosis strongly correlates with
outcome in B-Precursor ALL. The high predictive value
of age and WBC among all studies, and the fact that
these variables can be easily and reliably measured by
all investigators worldwide, make them one of the most
important prognostic factors based on which the patients
with ALL are divided into two risk groups:
1. Standard risk
Age 19.99 years

WBC <50000/cumm
2. High-risk
Age >10 years

WBC >50000/cumm
Childrens Oncology Group Risk Stratification

In the current childrens oncology group (COG)
classification system and treatment algorithm, patients
with precursor B-cell ALL are initially assigned to a
standard-risk or high-risk group based on NCI grouping.
All children with T-cell phenotype are considered
high-risk regardless of age and initial WBC count. Early
treatment response, assessed by day 7 or day 14 marrow
morphology along with end-induction MRD assessment
and cytogenetics is subsequently used to determine the
intensity of post-induction therapy. Patients are classified
as very high-risk if they have very high-risk cytogenetics
with poor response or induction failure as detailed here.
In developing countries outcome of disease is also
affected adversely by inadequate supportive care, delay in
diagnosis, and poor access to acute care.2
MANAGEMENT OF ACUTE LYMPHOBLASTIC

LEUKEMIA IN CHILDREN
Induction chemotherapy for ALL
Consolidation/Intensification therapy
Maintenance therapy
Central nervous system (CNS) therapy
The treatment of childhood acute lymphoblastic leukemia
(ALL) has advanced significantly over the past 3 decades,
with overall survival rates progressing from 20 to 95
percent.1,37,38 The standard backbone of treatment for ALL
has remained unchanged for over 25 years and includes
remission induction, consolidation, treatment to prevent
overt leukemic infiltration of the central nervous system
(CNS directed therapy), and continuing (maintenance)
therapy. The steady improvement in survival of children
with ALL is a result of a number of modifications of this
treatment, the value of which have been confirmed by
randomized clinical trials (Tables 8 and 9).
In an effort to appropriately balance the risks and
benefits of therapy, risk-adapted therapy has been
Table 8 Principles of childhood ALL therapy
T reat patients on cooperative group based clinical trials, if
possible
A
dopt effective treatment components of successful clinical
trials:
Reinduction therapy: BFM, CCG
Intensive asparaginase: DFCI
Augmented therapy: BFM
Intensive intrathecal therapy: SJCRH
Individualized therapy:
Risk assessment based mainly on MRD studies
Targeted HD-MTX dose
Mercaptopurine dose based on TPMT, 6TGN and ANC
Risk-adapted therapy to decrease late complications:

Omit cranial irradiation in all patients
Decrease dose of anthracyclines to bare minimum
Avoid use of etoposide
Table 9 Key components of treatment in ALL

Protocol based therapy
Risk-directed therapy
Empiric multiagent induction therapy
Presymptomatic CNS therapy
Early intensification of chemotherapy
Systemic and IT
Consolidation/intensification
Early reinduction
Augmented therapy only in high-risk patients
Late intensification where indicated:
Delayed intensification
Double delayed intensification
Extended continuation of treatment:
Dose intensity of antimetabolites
Dexa/VCR pulses
adopted. The NCI criteria risk stratified in to standard and

high-risk based on: age, initial white blood cell (WBC)
count, and the presence of extramedullary disease at
diagnosis.39
Currently most cooperative groups use additional risk
factors that have been shown to have an impact on patient
outcomes (e.g. ploidy, blast karyotype/cytogenetics, and
early morphologic response). The resulting classification
system thus incorporates the strongest prognostic
indicators predictive of outcome, and stratifies the treat
ment based on their risk of relapse.
Induction Chemotherapy for ALL

Three-drug induction therapy using vincristine,
corticosteroid (prednisone or dexamethasone), and
L-asparaginase in conjunction with intrathecal (IT)
therapy, results in complete remission (CR) rates of
greater than 95%. For patients who are at standard risk
or low risk of treatment failure, four-drug induction
therapy does not appear necessary for favorable outcome
provided that adequate post remission intensification
therapy is administered. Because of the likelihood of
increased toxicity with four-drug induction therapy, many
co-operative groups including the Childrens Oncology
Group (COG), National Cancer Institute (NCI), protocols
for standard-risk precursor B-cell acute lymphoblastic
leukemia (ALL) utilize a three-drug induction consisting
of dexamethasone, vincristine, and PEG-L-asparaginase.
For patients presenting with high-risk features, a
more intensive induction regimen (four or five agents)

may result in improved event-free survival (EFS), and
such patients generally receive induction therapy
that includes an anthracycline (e.g. daunorubicin) in
addition to vincristine, prednisone/dexamethasone, plus
L-asparaginase.
Consolidation/Intensification Therapy
Once remission has been achieved, systemic treatment in
conjunction with central nervous system (CNS) sanctuary
therapy follows. The intensity of the post induction
chemotherapy varies considerably depending on risk
group assignment, but all patients receive some form of
intensification following achievement of remission and
before beginning maintenance therapy. Intensification
may involve use of the following:
Intermediate-dose or high-dose methotrexate with
leucovorin rescue or escalating-dose methotrexate without
rescue;40 drugs similar to those used to achieve remission
(re-induction or delayed intensification);41 different drug
combinations with little known cross-resistance to the
induction therapy drug combination; L-asparaginase for
an extended period of time; or combinations of the above.42
In children with standard-risk acute lymphoblastic
leukemia (ALL), regimens utilizing a limited number of
courses of intermediate-dose or high-dose methotrexate as
consolidation followed by maintenance therapy (without
a re-induction phase) have been used with good results.
Similarly favorable results for standard-risk patients have
been achieved with regimens utilizing multiple doses of
L-asparaginase (2030 weeks) as consolidation, without
any post induction exposure to alkylation agents or
anthracyclines.43
Post induction consolidation for regimens using a
German Berlin-Frankfurt-Munster BFM-backbone, such
as those of the Childrens Oncology Group (COG), include
a delayed intensification phase, during which patients
receive a 4-week re-induction (including anthracycline) and
reconsolidation containing cyclophosphamide, cytarabine,
and 6-thioguanine given approximately 3 months after
remission is achieved. In a Childrens Cancer Group (CCG)
study, which included a three-drug induction and utilized
prednisone as the corticosteroid throughout all treatment
phases, two blocks of delayed intensification produced
a small event-free survival (EFS) benefit compared with
one block of delayed intensification in intermediate-risk
patients.44,45
In high-risk patients, a number of different approaches
have been used with comparable efficacy. Treatment
for high-risk patients generally is more intensive than
that for standard-risk patients, and typically includes
higher cumulative doses of multiple agents, including
anthracyclines and/or alkylating agents. The former
CCG developed an augmented BFM treatment regimen

featuring repeated courses of escalating-dose intravenous
methotrexate (without leucovorin rescue) given with
vincristine and asparaginase during interim maintenance
and additional vincristine/L-asparaginase pulses during
initial consolidation and delayed intensification. Augmen
ted therapy also included a second interim maintenance
and delayed intensification phase. Of note, there is a
significant incidence of osteonecrosis of bone in teenaged
patients who receive the augmented BFM regimen.
The augmented BFM regimen has also been evaluated
in children with high-risk ALL and a rapid early response
to induction therapy. For these children, augmented
intensity during consolidation, interim maintenance,
and delayed intensification resulted in a higher EFS rate
than that achieved with standard-intensity treatment.
Increased duration of intensive therapy was not beneficial,
and a single application of delayed intensification was as
effective as two applications.46
For children with Ph+ ALL, imatinib mesylate in
conjunction with chemotherapy during post induction
therapy has produced a 3-year EFS of 87.7 10.9 percent.
These patients fared better than historic controls treated
with chemotherapy alone (without imatinib), and at least
as well as the other patients on the trial who underwent
allogeneic transplantation. Longer follow-up is necessary
to determine if this novel treatment improves cure rate or
merely prolongs DFS.
Infant ALL is uncommon, representing approximately
2 to 4 percent of cases of childhood ALL. Despite the
inclusion of post induction intensification courses with
high doses of cytarabine and methotrexate. Long-term
EFS rates remain below 50 percent, and for those infants
with MLL gene rearrangement, the EFS rates continue to
be in the 17 to 40 percent range.47
Factors predicting poor outcome for MLL-rearranged
infants include a very young age (<6 months), extremely
high presenting leukocyte count (300,000/mL), and high
levels of MRD at the end of induction and consolidation
phases of treatment.48
The role of bone marrow transplantation in infants
with MLL-rearranged ALL remains controversial.
Maintenance Therapy
(Standard risk and high-risk ALL) The backbone of
maintenance therapy in most protocols includes daily
oral mercaptopurine and weekly oral methotrexate.
On many protocols, intrathecal chemotherapy for CNS
sanctuary therapy is continued during maintenance
therapy. The use of continuous 6-thioguanine (6TG) instead of 6-mercaptopurine (6-MP) during the
maintenance phase is associated with an increased risk of
hepatic complications, including veno occlusive disease
and portal hypertension. Because of the risk of hepatic
complications, 6-TG is no longer utilized in maintenance
therapy in current protocols.
Pulses of vincristine and corticosteroid are often
added to the standard maintenance backbone, A CCG
randomized trial demonstrated improved outcome
in patients receiving monthly vincristine/prednisone
pulses,49 and a meta-analysis combining data from six
clinical trials showed an EFS advantage for vincristine/
prednisone pulses. Maintenance chemotherapy generally
continues until 2 to 3 years of continuous complete
remission. On some studies, boys are treated longer than
girls; on others, there is no difference in the duration of
treatment based on gender. Extending the duration of
maintenance therapy beyond 3 years does not improve
outcome.50
Central Nervous System Therapy

Options for central nervous system (CNS)-directed
therapy include IT chemo
therapy, high dose systemic
chemotherapy, and cranial radiation. The type of CNStherapy, i.e. used, is based on a patients risk of CNSrelapse, with higher-risk patients receiving more intensive
treatments. The proportion of patients receiving cranial
radiation has decreased significantly over time, with those
receiving cranial radiation, the dose has been significantly
reduced. IT chemotherapy is usually started at the
beginning of induction, intensified during consolidation
and, in certain protocols, continued throughout the
maintenance phase. IT chemotherapy typically consists of
either methotrexate alone or methotrexate with cytarabine
and hydrocortisone. Unlike IT cytarabine, IT methotrexate
has a significant systemic effect, which may contribute to
prevention of marrow relapse.
Systemically administered drugs, such as dexame
thasone, L-asparaginase, high-dose methotrexate with
leucovorin rescue, and high-dose cytarabine, provide
some degree of CNS protection. For example, in a
randomized CCG study of standard-risk patients who all
received the same dose and schedule of IT methotrexate
without cranial irradiation, oral dexamethasone was
associated with a 50 percent decrease in the rate of CNS
relapse compared with oral prednisone.51
RELAPSE OF DISEASE AND

ITS MANAGEMENT
Diagnosing relapse of ALL
Risk stratification of relapsed ALL
Treatment of marrow relapse
Reinduction therapies after marrow relapse
Postremission therapy
Continuation chemotherapy
Hematopoietic stem cell transplantation (HSCT)
Treatment of central nervous system relapse
Isolated testicular relapse.
Diagnosing Relapse of ALL

Suspected patients should undergo bone marrow aspira
tion with morphology, surface marker studies and
cytogenetic studies. Examination of extramedullary sites
like CNS, testis, eyes, and skin should be done at the time
of diagnosis of relapse.
Risk Stratification of Relapsed ALL

It is important to have risk stratification of relapse for
counseling and tailoring the salvage treatment.
Length of 1st CR: Patients with very early (< 18 months
from start of therapy) BM relapse have < 10 percent
long-term survival (LTS) compared to approximately
50 percent LTS for patients who have late BM relapse.
Immunophenotype: Childhood ALL patients with
T-cell ALL fare more poorly than those with CALLA+
ALL.
Site of relapse: Historically, isolated marrow relapse
has had the worst prognosis; isolated CNS, testicular,
or other extramedullary relapse carried a significantly
better prognosis, and combined marrow and extramedullary relapse, an intermediate prognosis
The nature and intensity of previous therapy: Patients
previously treated with lower intensity primary therapy
have a higher reinduction rate.
Minimal residual disease (MRD) studies: MRD is an
important tool even for patients with ALL at time of
relapse. The level of minimal residual disease after
achieving second remission or before transplant may
predict outcomes.52
Treatment of Marrow Relapse

Reinduction Therapies after Marrow Relapse
Typical treatment of first relapse involves a combination
of vincristine, a glucocorticoid (prednisone, prednisolone,
or dexamethasone), and asparaginase, plus an anthra
cycline, methotrexate, or cytarabine in varying doses and
schedules. Only a few randomised trials have investigated
reinduction therapy.53
In the absence of randomized trials and consistent riskstratified reporting of patients outcomes, with possibly
exception of mitoxantrone, no reinduction combination is
significantly superior to the others.
Postremission Therapy
Therapeutic options after CR2 include further chemo
therapy and HSCT. Most pursue HSCT options for patients
with early relapses, although outcomes remain poor for
most patients with measurable MRD after reinduction.
Similar outcomes are reported for matched related donor
and matched unrelated donor transplants.
For late marrow relapse, outcomes are similar with
chemotherapy and HSCT options. Some recommend
HSCT options for patients with late marrow relapse and
an MRD-positive CR2. Chemotherapy options may be
pursued for isolated extramedullary relapse with success
in most patients.
relapse is around 2 to 5 percent with current protocols.

Effective treatment includes systemic chemotherapy and
administration of local radiotherapy. Doses of 2400 cGy to
both testes is optimal.
LATE EFFECTS OF THERAPY

Prolonged consequences of ALL therapy should be kept in
mind while following these patients and need special after
therapy clinic to diagnose and manage these effects.
Central nervous system:

Continuation Chemotherapy
All patients who achieve a second remission receive
additional chemotherapy, even if hematopoietic stem cell
transplantation is planned. To maintain control of disease,
higher dose intensity is used, and higher regimen-related
toxicity is tolerated than in first-line treatment.
Most reports describe single-arm studies with combi
nations of vincristine, glucocorticoids, metho
trexate,
cytarabine, etoposide, cyclophosphamide or ifosfamide,
and thiopurines, with or without maintenance therapy for
up to 2 years.
CNS prophylaxis includes high-dose methotrexate or
cytarabine, intrathecal chemotherapy, and in more recent
BFM group trials, 12001800 cGy cranial irradiation.54
Hematopoietic Stem Cell Transplantation

The only strategy that has shown to improve outcome of
patients with relapsed ALL with high-risk features is to
give intensified consolidation chemotherapy regimen,
followed by hematopoietic stem cell transplantation
(HSCT). Recent data has shown that outcome of HSCT
is better than chemotherapy alone even in patients with
intermediate risk relapsed ALL and HSCT is currently
being offered to these patients if they have an HLA
matched sibling donor.
Treatment of Central Nervous System Relapse

A common approach is first to induce a CSF remission
with IT chemotherapy, reinstitute systemic therapy, and
then later administer craniospinal irradiation, at doses of
2,400 to 3,000 cGy to the cranial vault and 1,200 to 1,800
cGy to the spinal axis.55
Isolated Testicular Relapse

Isolated testicular relapse, again, is very rare with
modern aggressive protocols. The incidence of testicular
Cortical atrophy
Necrotizing leukoencephalopathy
Subacute leukoencephalopathy
Mineralizing microangiopathy
Neuroendocrine abnormalities:
Growth hormone deficiency
Obesity
Cardiac abnormalities:
Cardiomyopathy
Late onset congestive heart failure
Others toxicities:

Avascular necrosis
Primary gonadal failure
Second malignancies (SMN)
Post-traumatic stress disorder (PTSD)
SUMMARY
Acute lymphoblastic leukemia is the most common
malignancy in pediatric age group. With current chemo
therapy agents high cure rate can be achieved. Detailed
work-up and sophisticated management is required
while dealing with child of acute lymphoblastic leukemia.
Type of treatment and minimal residual disease (MRD)
measurement are promising tool to predict the prognosis.
Treatment is based on risk stratification or response
evaluation. Though the treatment is prolonged with
significant toxicities, still outcome is quite satisfactory.
Unlike relapse of other malignant condition pediatric
acute lymphoblastic leukemia can be treated with
intensive chemotherapy and hematopoietic stem cell
transplant with reasonable outcome. Major worry after
completion of treatment is post treatment consequence
of chemotherapy and radiotherapy which needs special
attention.
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40
Pediatric Acute Myeloid
Leukemia
Acute myeloid leukemia (AML) is a heterogeneous disease. AML accounts for 15 to 20 percent of all acute leukemias in children.1
Five-year survival rates for children in the US younger than age 15 years with AML increased from < 20 percent in 1975 to 1978 to 58
percent in 1999-2002.2 Although there are no systematic statistics for pediatric AML from India, survival outcomes range from 23 to
53.8 percent.3 The understanding of disease biology has resulted in changes in classification and risk stratification. This, along with
improvements in supportive care which allow for more intensive treatment, risk-adapted treatment approaches, and the selective
use of hematopoietic stem cell transplant (HSCT) have all contributed to improvements in outcome. However, Pediatric AML has
unfortunately not replicated the success story of pediatric acute lymphoblastic leukemia (ALL), and still remains a challenging disease
to treat, especially so in resource-poor settings.
BIOLOGY AND PATHOGENESIS

A number of inherited and acquired disorders have
been associated with development of AML in children,
although the cause is unknown in the vast majority of
patients. Inherited conditions like Down syndrome,
Fanconi anemia, congenital neutropenia, inherited bone
marrow failure syndromes; acquired conditions like
aplastic anemia, paroxysmal nocturnal hemoglobinuria,
myelodysplastic syndrome as well as environmental
exposures to drugs (alkylating agents and topoisomerase
inhibitors) and ionizing radiation have been found to have
an increased association.
The cancer stem cell model is increasingly being
accepted in the pathogenesis of AMLit proposes that
AML cells, like normal hematopoietic progenitors,
are hierarchically organized into compartments that
contain leukemic stem cells (LSCs) that have unlimited
self-renewal capacity and are capable of propagating
leukemia.4,5 Multiple genetic mutations have also been
implicated in the pathogenesis of AML. These have been
broadly classified as type/class 1 and 2 mutations. Class
1 mutations include lesions that confer a proliferative
and/or survival advantage by aberrant activation of
protein kinases, such as FLT3, cKIT, and RAS, whereas
Class 2 mutations impair cell differentiation and confer

self-renewal properties and are gene fusions commonly
generated by chromosomal translocations, such as t(8;21)
(q22;q22)/RUNX1-RUNX1T1 and inv(16)(p13.1;q22)/
CBFB-MYH11.6 Data suggest that class 1 and 2 mutations
co-operate to induce leukemia. Currently, more than 90
percent of pediatric AML cases are identified to have at
least one known genomic alteration.7
CLASSIFICATION
Although, the French-American-British (FAB) classi
fication8 (based on morphological features) continues to be
widely used, the most comprehensive classification of AML
is the WHO 20089 classification, which includes clinical
features, morphological findings, immunophenotyping
and cytogenetics, to define specific disease entities.
(Table 1). Although, the present classification is for adult
population, it is being incorporated slowly in the practice
of pediatric oncology.
CLINICAL FEATURES AND DIAGNOSIS

Pediatric AML can have a varied presentation. As in
other acute leukemias, patients can present with fever,
pallor, bleeding, hepatosplenomegaly and infections.
Chapter-40 Pediatric Acute Myeloid Leukemia 409

Children presenting with high leukocyte counts may
have symptoms due to CNS or pulmonary leukostasis.
Approximately 10 to 20 percent of AML may present with
extramedullary myeloid tumors (EMMT, granulocytic
sarcoma/chloroma) due to infiltration of tissues with
leukemic blasts.5 Common sites include lymph nodes,
skin (leukemia cutis), gums and orbits. These are usually
associated with t (8; 21), inv (16) or 11q23 translocation.
Central nervous system (CNS) involvement in the
form of CSF involvement or CNS chloromas can occur in
approximately 11 percent10 of children with AML, and is
more common in subtypes M4/5, and hyperleukocytosis.
Children with AML have a lower number of functional
neutrophils and thus may present with infections
(including florid), even at diagnosis.
An initial step in diagnosis is examination of complete
blood count and peripheral smear, which typically show
pancytopenia with circulating blasts. Twenty percent
of children may have a WBC count > 100,000/mm3 at
diagnosis.5
Table 1 Current classification of myeloid neoplasms
(WHO 2008)9
1. AML with recurrent genetic abnormalities:
AML with t (8; 21) (q22; q22), RUNX1-RUNX1T1 (CBFA/ETO).
AML with inv (16) (p13; q22) or t (16; 16) (p13; q22), CBFBMYH11.
Acute promyelocytic leukemia with t (15; 17) (q22; q11-12),
PML-RARA.
AML with t (9; 11) (p22; q23), MLLT3-MLL.
AML with t (6; 9) (p23; q34); DEK-NUP214.
AML (megakaryoblastic) with t (1; 22) (p13; q13), RBM15MKL1.
AML with mutated NPM1.
AML with mutated CEBPA.
Other laboratory features may include electrolyte

abnormalities suggestive of tumor lysis (hyperuricemia,
hyperkalemia, hyperphosphatemia), although less
commonly than in acute lymphoblastic leukemia
(ALL). A small proportion of patients also may present
with coagulopathiesa DIC like picture may be seen
most commonly in acute promyelocytic leukemia
(APML) but also in AML M4/5 and in the presence of
infection.
The definitive diagnosis can be made by bone marrow
aspirate and trephine biopsy. The differential count is
to be done on at 500 bone marrow cells (or 200 cells
in peripheral blood). For the diagnosis of AML, there
should be 20 percent or more myeloblasts in the
peripheral blood or bone marrow. Certain types of
translocations, such as t (8;21),t(15;17) and inv 16, are
also diagnostic of AML irrespective of blast percentage.9
On morphology, myeloblasts are classically described
as being large and uniform with finely dispersed
chromatin, with 1 to 4 nucleoli, granular cytoplasm
and the presence of Auer Rods in 60 to 70 percent of
cases. Myelodysplastic changes may be seen in cases
of secondary AML.
A bone marrow trephine biopsy is especially required
in cases wherein the BM aspirate smears are acellular
or dry tap, diluted with peripheral blood, in partially
treated cases where blood transfusion/treatment
by steroids and other drugs alter the morphological
picture or in cases where the sample is degenerated.
The paraffin block is an invaluable diagnostic archival
material for immunophenotyping and other studies.
Myeloperoxidase (MPO) stain is specific for the
diagnosis of AML and positivity in > 3 percent of
blasts is considered diagnostic. Blasts of AML-M0,
2. AML with myelodysplasia-related features.

3. Therapy-related myeloid neoplasms.
4. AML, not otherwise specified:
AML with minimal differentiation.

AML without maturation.
AML with maturation.
Acute myelomonocytic leukemia.
Acute monoblastic and monocytic leukemia.
Acute erythroid leukemia.
Acute megakaryoblastic leukemia.
Acute basophilic leukemia.
Acute panmyelosis with myelofibrosis
Table 2 Initial evaluation of a patient with suspected acute

myeloid leukemia
Diagnostic tests/procedures
Complete blood count with differential count
Bone marrow aspirate and trephine biopsy
Lumbar puncture
Immunophenotyping
Cytogenetics
Molecular genetics/translocations/mutations
5. Myeloid sarcoma
Additional evaluation
6. Myeloid proliferations related to Down syndrome:
Physical examination
Transient abnormal myelopoiesis.

Myeloid leukemia associated with Down syndrome
Syndromes/constitutional anomalies
7. Blastic plasmacytoid dendritic cell neoplasm.
Chest X-ray, echocardiography
Biochemistry, coagulation
M6 (erythroblasts), M7 (megakaryoblasts) and M5
(monoblasts) are MPO negative. Nonspecific esterase
(NSE), alpha naphthyl butyrate (ANB) and alpha
naphthyl acetate (ANA), show diffuse cytoplasmic
activity in monoblasts and monocytes.
Immunophenotyping utilizes various lineage-specific
monoclonal antibodies that detect antigens on
AML cells, and should be used at the time of initial
diagnostic workup. The common myeloid markers
are CD13, CD33, CD117, CD15, CD16, and MPO. For
the diagnosis of monocytic lineage, at least 2 of the
following are required: NSE, CD14, CD64, CD11c, and
lysozyme Table 2.
The basic work-up of a patient with suspected
acute myeloid leukemia is given in Table 2.
RISK STRATIFICATION AND PROGNOSTIC

FACTORS
As with ALL, multiple variables have been associated
with outcomes in pediatric AML. Host factors such as
younger age11 and constitutional abnormalities (Down
syndrome)12,13 have been found to be favorable. Other
factors include disease related featuresFAB morphology
(M3-favorable; M0 and M7-unfavorable), cytogenetics
and molecular markers. The presence of CNS disease has
not been found to affect overall survival.10
The current focus is on genetic/molecular abnor
malities and Minimal residual disease.
Cytogenetic
abnormalities: Multiple recurrent
cytogenetic abnormalities are described in AML,
some of which have a consistent clinical and
immunophenotypic profile. These are summarized in
Table 3.
Favorable cytogenetic Abnormalities include t(8; 21),
inv(16), and t(16;16). This group is classically described
as core binding factor (CBF) leukemias, and found to
have a favorable prognosis in many studies13-18 with
overall survival > 90 percent.
Intermediate risk cytogenetic abnormalities have
classically included those with normal cytogenetics,
trisomy 8 and a few abnormalities associated with
11q23 translocations t (1; 11) and t (10; 11).
Poor risk cytogenetics include monosomy 5 and
7, deletion 5q and 7q, and other less common
abnormalities like inv(3), t(3;3), t(6;9) and t(9;22).
t(9;11) has been found to be favorable19 in some studies
and unfavorable16,18 in others.
Molecular genetics: The widespread use of molecular
markers has helped further refine the risk stratification
of AML. The commonly used mutations/abnormalities
include:
Table 3 Risk status based on validated cytogenetic and

molecular abnormalities
Risk status
Cytogenetics
Molecular abnormalities
Better risk
Inv (16) or t (16;16),

t (8;21)
t 915;17
Normal cytogenetics
with NPM1 mutation
or isolated CEBPA
mutation in the absence
of FLT3-ITD
Intermediate
risk
Normal cytogenetics t (8;21), inv (16),

+8
t (16;16); with c-KIT
t(9;11)
mutation
Other nondefined
Poor risk
Complex (>= 3
clonal chromosomal
abnormalities)
-5, del 5q, -7, del 7q
11q23-non t (9;11)
Inv(3), t (3;3),
t(6;9).t(9;22)
Normal cytogenetics:
with FLT3ITD mutation
Adapted from the National Comprehensive Clinical Network

(NCCN) Clinical Practice Guidelines in Oncology Acute Myeloid
Leukaemia v 2.201328
Nucleophosfomin (NPM1) mutations: These are

usually seen associated with normal karyotypes,
and carry a favourable prognosis,20-22 with OS > 80
percent.
FMS-like tyrosine kinase (FLT3)-ITD mutations:
There is strong evidence that these mutations
confer a higher risk of relapse in children with
AML.23,24 The ratio of FLT3-ITD to wild type allele >
0.4 is an independent predictor of adverse outcome
with a PFS of <10 percent.27 Outcomes might be
improved by HSCT.25
c-KIT mutations: Usually seen in CBF leukemias.
Although they confer inferior prognosis in adults,
their role in children is not clear.
CEBPA mutations: Like NPM mutations, they are
associated with a normal karyotype and favorable
outcome.26
Other molecular markers with adverse prognostic
significance include WT1 mutations and high expression
of BAALC.23
Minimal residual disease (MRD): A recent advance in
risk adapted approach to AML has been monitoring of
MRD, and is currently the most important predictor of
outcome. The presence of MRD (with varying cut-offs)
at the end of induction has been found to consistently
predict a higher rate of relapse, and have been found
to be a better predictor of outcome compared to a risk
stratification schema based on FAB, cytogenetics and

Day 15 blast percentage.14,27 MRD levels at later time
points do not appear to have any significance.
TREATMENT OF PEDIATRIC AML

Although treatment approaches to pediatric AML have
evolved over the past few decades, the outcomes have
not paralleled that of pediatric ALL. Improvements in
risk stratification (including monitoring of MRD) and
supportive care, as well as intensive treatment regimens
and the selective use of hematopoietic stem cell transplant
(HSCT), have brought up the 5-year event-free survival
(EFS) of children with AML to only 40 to 55 percent
(Table 4).29
Induction Therapy
The primary goal of induction therapy is to achieve a
significant reduction of leukemia burden, i.e. achievement
of remission defined as a normal peripheral blood cell
count (absolute neutrophil count >1,000/mm3 and
platelet count >100,000/mm3), normocellular marrow
with less than 5 percent blasts in the marrow and no signs
or symptoms of the disease.30
Most treatment regimens use an intensive combination
of anthracycline and cytarabine. The classic 3 + 7 regimen
(daunorubicin 45 mg/m2 per day for 3 d; and cytarabine
100 mg/m2 per day for as continuous infusion for 7 d) was
demonstrated to induce remission in 60 to 70 percent
of AML patients and became the standard of care for
induction therapy in the 1980s.1
There have been several attempts to improve on this
regimenthese include:
Higher doses: Intensification of cytarabine dose has
been most recently studied in the AML02 trial, where
the introduction of high-dose (18 g/m2) versus lowdose cytarabine (2 g/m2) did not significantly lower the
rate of MRD-positivity after induction 1.14 Similarly,
POG 9421 study which compared different doseshigh
dose cytarabine (1 g/m2) and standard dose cytarabine
in 3+7 regimen failed to show any improvement in
remission rates; however 3 y EFS was higher in those
who received two courses of high-dose cytarabine.31
Randomized trials in adults comparing high and
standard doses of daunorubicin, have had conflicting
results, and there is no clear data in pediatric
population. Also, dose intensification of anthracyclines
has an increased risk of cardiotoxicity, especially in
children.
Addition of other agents: Various groups have tried to
add other agents in an attempt to improve outcomes, but
there has been no convincing effect of benefit. Examples
include 6-thioguanine,32 etoposide,33 cladribine,34
fludarabine and gemtuzumab ozogamicin.35
Dose intensification: The classic example of dose

intensification by compression of timing was
demonstrated by the CCG-2891 study36 where 4-day
treatment courses were separated by only 6 days
rather than the standard timing of 2 weeks or longer;
EFS in the former group was better. Similarly, in the
MRC-10 trial,37 the duration of cytarabine infusion was
prolonged to 10 days in order to intensify dose with
improved outcomes.
The choice of anthracycline in the treatment of AML
has been a topic of debate.38-40 Certain anthracyclines
(idarubcin and mitoxantrone) are favored for their
perceived greater antileukemic effect and/or their lower
cardiotoxicity, but no anthracycline agent has been
demonstrated to be superior.
Postremission Therapy
Most protocols for pediatric AML (including CCG,33
BFM,41 POG42 and MRC37 groups) consolidate therapy
with a backbone of high-dose cytarabine ), although the
timing, dose and accompanying agents vary considerably.
Other strategies used in consolidation include continuous
delivery of multiagent low-dose chemotherapy (thioguan
ine, vincristine, cyclophosphamide, fludarabine), delivery
of repeated cycles of myelosuppressive therapy with
or without stem cell rescue and allogeneic stem cell
transplantation.1 The optimum number of cycles for postremission chemotherapy has yet to be determined and
probably depends on the therapy used for induction. In
the MRC AML 12 trial,39 children randomly assigned to
receive four cycles vs. five had the same EFS and OS rates.
Maintenance Therapy
In the background of more intensive induction and postremission therapies, most studies33,43 have shown no
additional benefit of additional maintenance therapy in
non-M3 AML. However, some groups44,45 continue to use
either oral or parenteral maintenance chemotherapy to
improve outcome.
Current Status of Stem Cell Transplantation in

Pediatric AML
Although allogeneic SCT has improved outcomes in some
subsets of pediatric AML, the role in other subsets as well
as the timing, remain a controversial issue. Studies have
varied in recommending HSCT in first complete remission
(CR1), 2nd complete remission (CR2) or at relapse.
Studies from the North American CCG trials (251, 213
and 2891)46,47 demonstrated the superiority of allogeneic
SCT over autologous SCT, and also that there was no
benefit of HSCT in favorable risk cytogenetics. However,
European studies32,40 have not demonstrated the survival
advantage of allogeneic HSCT on outcomes as compared
to intensive chemotherapy. This variation in outcomes at
different centers has led to varying recommendations. In
general, study groups in the United States recommend
HSCT for a larger proportion of patients than do the
European groups. A meta analysis of co-operative trial
groups48 (POG, CCG and MRC) indicated that HLA
matched related donor HSCT is an effective treatment of
intermediate risk AML in first CR, but that patients with
high risk AML fare poorly even with HSCT.
There is emerging data to suggest that among children
with high risk AML, the 5-year OS does not differ according
to donor source.49
In summary, most pediatric co-operative groups agree
that there is no role for HSCT in patients with favorable
risk cytogenetics. There is some evidence of benefit for

those with intermediate risk disease. However, outcomes
remain dismal in high risk disease, and HSCT is of unknown
benefit in these patients.5 The potential benefits of SCT
need to be weighed against the risk of transplant related
mortality and morbidity. Autologous transplantation is
not recommended in the management of pediatric AML.
SUPPORTIVE CARE
Infectious complications remain a major cause of morbid
ity and mortality in children with AML, both at presentation,
as well as following intensive chemotherapy/SCT.50,51 Both
bacterial and fungal infections can be life-threatening.
Randomized, controlled trials which demonstrate the
role of prophylactic antibiotics in reducing the rates of
Table 4 Result from recent pediatric AML trials (Source: Reference 2)

Study
Years of
enrollment
Eligible age
(years)
Number of
patients
CR rate*
(%)
Outcome
Reference
MRC AML 10
19881995
14
341
92
7-year EFS: 48%

7-year OS: 56%
Stevens et al (1998)
LAME 89/91
19881996
<20
268
90
6-year EFS: 48%

6-year OS: 56%
Perel et al (2002)
Perel et al (2005)
TCCSG M91-13, M96-14
19911998
NA
192
89
5-year EFS: 54%

5-year OS: 60%
Tomizawa et al (2007)
AML-BFM93
19331998
<18
471
82
5-year EFS: 50%

5-year OS: 58%
Creutzig et al (2001a)
Creutzig et al (2001b)
NOPHO-AML93
19932000
<18
219
91
7-year EFS: 49%

7-year OS: 64%
Lie et al (2003)
POG9421
19951999
21
565
89
3-year EFS: 36%

3-year OS: 54%
Gale et al (2005)
MRC AML12
19952002
<16
529
92
10-year EFS: 54%

10-year OS: 64%
Gibson et al (2011)
CCG2961
19962002
21
901
88
5-year EFS: 42%

5-year OS: 52%
Lange et al (2008)
AML-BFM 98
19982003
<18
473
88
5-year EFS: 49%

5-year OS: 62%
Creutzig et al (2006)
Lehrnbecher et al (2007)
AML99
20002002
18
240
95
5-year EFS: 62%

5-year OS: 76%
Tsukimoto et al (2009)
SJCRH AML02
20022008
21
216
94
3-year EFS: 63%

3-year OS: 71%
Rubnitz et al (2010a)
COG AAML0391
20032005
21
350
87
3-year EFS: 53%

3-year OS: 66%
Cooper et al (2012)
NOPHO-AML 2004
20042009
18
151
92
3-year EFS: 57%

3-year OS: 69%
Abrahamsson et al (2011)
Abbreviations: BFM: Berlin-Frankfurt-Mnster study group; CCG: Childrens cancer group; LAME: Leucamie aique myeloide enfant (The
French Cooperative AML Group); MRC: Medical research council; NOPHO: Nordic society of paediatric haematology and oncology;
POG: Pediatric oncology group; SJCRH: St Jude childrens research hospital; TCCSG: Tokyo children cancer study group; CR: Complete
remission; EFS: Even-free survival; OS: Overall survival.
*CR rate after two courses of induction therapy.

bacterial infection in children are lacking.50 Prophylaxis
with intravenous cefepime or a vancomycin regimen, and
voriconazole, reduced morbidity in children with AML,
and resulted in dramatic decreases in the incidence of
septicemia and hospitalization days in a retrospective
single center analysis.52 A current COG open-label,
randomized, controlled trial (ACCL0934) is designed to
evaluate whether prophylactic therapy with levooxacin
will decrease the incidence of bacteremia in children
undergoing intensive chemotherapy/HSCT. On the basis
of randomized, controlled trials of prophylactic antifungal
therapy in adults with cancer studies, many pediatric
oncologists recommend antifungal prophylaxis with
voriconazole, posaconazole, micafungin, or caspofungin,
which have a broad-spectrum of activity and good
tolerability. A recent survey conducted by COG53 found that
Antibacterial and G-CSF prophylaxis reduced infection
rates while mandatory hospitalization did not reduce
infection or significantly affect nonrelapse mortality.
Novel Therapeutic Agents

With outcomes remaining poor in many subtypes of AML,
there is a constant search for newer therapeutic agents.
Many new agents (Table 5) with diverse mechanisms of
action are currently being studied in relapsed/refractory
disease, but only a few are being used in children.
Gemtuzumab ozagamicin (GO): GO is a humanized
anti-CD33 antibody conjugated to cytotoxin
calicheamicin. It has been evaluated both singly,54
as well as in combination with chemotherapy, (in
previously untreated as well as relapsed/refractory
patients) with encouraging results.14,35 Although, it
was approved for use in AML by the US Federal Drug
Administration in 2000, it was withdrawn in 2010
when an interim analysis of a randomized trial [SWOG
(South Western Oncology Group) 106] in adults
demonstrated an increased early death rate in the GO
arm of the trial. Judicious use of GO in combination
with chemotherapy may improve clinical outcome in
selected subgroups of newly diagnosed patients and
may also be a useful agent in the treatment of relapsed
AML.
FLT3 inhibitors: FLT3 is a trans-membrane enzyme
that promotes proliferation after activation by ligand
binding and plays an important role in the survival and
proliferation of AML blasts. The signaling inhibitors
lestaurtinib, midostaurin, quizartinib, and sorafenib
are being tested in adult and pediatric trials.
Farnesyltransferase inhibitors (FTI): Farnesylated
protein products of the Ras gene family are frequently
activated in MDS and AML. Two farnesyltransferase
inhibitors, tipifarnib and lonafarnib, are currently
under development for the treatment of AML.
Epigenetic agents: Histone deacetylase inhibitors

(HDAC) inhibitors
HDAC inhibitors are a class of agents that modulate
the expression of genes by causing an increase in
histone acetylation, thereby regulating chromatin
structure and transcription. There is increasing evide
nce to show that HDAC inhibitors and demethylating
agents may have a prominent role in the treatment of
AML.55 HDAC inhibitors evaluated in clinical trials in
adults with AML/MDS are depsipeptide, vorinostat
and valproic acid.56 A drug which holds promise in
resource poor settings is sodium valproate (VPA),
which has recently been identified as an antitumor
agent with HDAC inhibition. Pediatric phase I studies
of decitabine, valproic acid, and SAHA are underway.57
TREATMENT OF RELAPSED ACUTE

MYELOID LEUKEMIA
Acute myeloid leukemia recurs in 30 to 40 percent of
patients and is associated with a poor prognosis; less
than one-third of children with relapsed AML survive.
The length of first remission (CR1) is an important factor
affecting both remission rates, as well as survival; those
with CR1 < 1 year have substantially lower rates of both
than those with CR1 >1 year.58 Other prognostic factors
following relapse include not having undergone HSCT
in CR1, and favorable cytogenetics (t(8;21), t(15;17),
and inv(16).58 The standard approach is to use intensive
chemotherapy regimens to achieve remission, followed
by consolidation with allogeneic SCT. It is often necessary
to administer non-anthracycline based chemotherapy as
most patients are heavily pretreated. Various remission
induction regimens, including fludarabine plus cytarabine
and mitoxantrone plus etoposide,58,59 have been used
in children. The targeted immunotherapy agents such
as gemtuzumab ozogamicin and clofarabine along with
newer chemotherapeutics as mentioned earlier in this
chapter have shown some activity in clinical trials.
ACUTE MYELOID LEUKEMIA IN CHILDREN

WITH DOWN SYNDROME
Children with Down syndrome (DS) have a ten-fold
to twenty-fold increased risk of leukemia compared to
children without DS. The ratio of ALL to AML incidence is
similar to that in normal children, except in the first 3 years
of life, where AML, particularly the M7 (megakaryoblastic
subtype dominate. Typically, AML in DS exhibits a
distinctive biology characterized by GATA1 mutations.
Ten percent of neonates with Down syndrome may also
develop a transient myeloproliferative disorder (TMD),
which typically improves spontaneously within the first 3
months of life. Although, TMD is usually a self-resolving
Table 5 Novel therapeutic agents in the treatment of AML
Class
Agent(s)
Target
Deoxyadenosine analog
Clofarabine
Ribonucleotide reductase, DNA

polymerase, mitochondria
Tyrosine kinase inhibitor
Sorafenib, quizartinib, lestaurtinib,

midostaurin, sunitinib
Tyrosine kinase (e.g. FLT3-ITD)
Demethylating agent
Azacitidine, decitabine
DNA methyltransferase
Proteosome inhibitor
Bortezomib
Proteasome
Histone deacetylase inhibitor
Valproic acid, vorinostat, panobinostat,

depsipeptide
Histone deacetylase
Farnesyltransferase inhibitor
Tipifarnib, lonafarnib
Ras, lamin A
Janus kinase (JAK) inhibitor
Ruxolitinib, TG101348
JAK
Chemokine receptor (CXCR4) antagonist
Plerixafor
CXCL12/CXCR4 axis
Apoptosis inducer
Obatoclax, oblimersen
BCL2
Angiogenesis inhibitor
Bevacizumab
Vascular endothelial growth factor

(VEGF)
Multidrug resistance inhibitor
Cyclosporine
P-glycoprotein
Lineage-specific antibody
Anti-CD33 (mylotarg), -CD45, -CD66
Lineage-specific antigen
Immune therapy
NK cells, T cells
Leukemia cells
condition, it can be associated with significant morbidity

and may be fatal in 10 to 20 percent of affected infants.
DS children with leukemia frequently experience higher
levels of treatment-related toxicity, including cardiac and
infectious complications; with an increased sensitivity to
cytarabine and daunorubicin. The outcome is generally
favourable (EFS > 80%), especially in children aged 4 years
or younger at diagnosis. Appropriate therapy for these
children is less intensive than current AML therapy, and
hematopoietic stem cell transplant is not indicated in first
remission. Since, this is an exhaustive topic beyond the
scope of this chapter, interested readers may refer to these
publications.12,13,60-62
Treatment of AML in children with Down syndrome
is a large topic in itself, which is why we have given the
references of standard review articles on this topic.
Therapy-related Acute Myeloid Leukemia

The development of AML following treatment with
ionizing radiation or chemotherapy, particularly alky
lating agents and topoisomerase inhibitors, is termed
therapy-related AML (t-AML). The risk of t-AML/t-MDS
is related to the cumulative doses of chemotherapy
agents received, as well as the dose and field of radiation
administered. High cumulative doses of either epipodo
phyllotoxins (e.g. etoposide or teniposide) or alkylating
agents (e.g. mechlorethamine, melphalan, busulfan,
and cyclophosphamide) are implicated. T-AML (and
t-MDS) resulting from epipodophyllotoxins and other

topoisomerase II inhibitors (e.g. anthracyclines) usually
occur within 2 years of exposure and are commonly
associated with chromosome 11q23 abnormalities
whereas t-AML following exposure to alkylating agents
or ionizing radiation often occurs 5 to 7 years later and is
commonly associated with monosomies or deletions of
chromosomes 5 and 7.
Treatment of t-AML is challenging due to the
following due to previous treatment, and poor remission
rates resulting from adverse cytogenetics. HSCT is
the only curative option, although rates of transplant
related morbidity and mortality are high. Studies
describing treatment outcomes in t-AML have not been
encouraging.63,64
ACUTE PROMYELOCYTIC LEUKEMIA

Although acute promyelocytic leukemia (APML) was
conventionally classified as AML FAB M3, it is considered
to be a separate entity in view of its unique morphology,
cytogenetics and molecular characteristics. Cytogene
tically, it is characterized by a balanced translocation
between the PML gene on chromosome 15 and the RARA
gene on chromosome 17, i.e. t(15;17). This translocation
leads to the PML-RARA transcript which leads to matura
tion arrest at the promyelocyte stage. This translocation
is also a target for therapy, and the discovery of all
transretinoic acid (ATRA, which induces differentiation of

leukemic blasts into mature granulocytes) has dramatically
improved outcomes in APML.65
Acute promyelocytic leukemia in children behaves
similarly to that in adults, and commonly presents with
coagulopathy and bleeding manifestations. Notable
differences include a higher incidence of hyperleukocyto
sis (WBC count higher than 10 109/L) and microgranular
(M3v) variant. Coagulopathy and hemorrhage are more
common in M3v.6
The risk stratification of APML is based on WBC count
and platelet count at presentation.66 High-risk patients
have presenting WBC count >10 109/L, intermediate risk
WBC count <10 109 /L and platelet count <40 109/L; and
low-risk patients WBC count <10 109/L with a platelet
count of >40 109/L. FLT3 mutations are observed in 40
to 50 percent of APL cases, and are associated with both
hyperleukocytosis and M3v, and an increased risk of
induction death, and of treatment failure.67
The initial management in APML includes stabilization
and correction of coagulopathy with platelets and fresh
frozen plasma +/ cryoprecipitate The standard of care
for treatment of APML is induction with sequential
combination of ATRA followed by chemotherapy (usually
anthracycline), which has been found superior to either
agent used singly. This is followed by 2 to 3 cycles of
anthracycline based consolidation therapy.65-68 In contrast
to other subtypes of AML, patients with APML have been
found to benefit from (ATRA based) maintenance therapy.
Another drug which is being widely used in the
management of APML is arsenic trioxide, either singly or in
combination with ATRA in newly diagnosed and relapsed
patients.69-71 HSCT is an option in persistent MRD as well
as relapsed disease. Interestingly in APML; autologous
transplant also has satisfactory outcomes in the absence
of a suitable donor.
For detailed guidelines on the management, please
look up references.72,73
CONCLUSION AND FUTURE DIRECTIONS

In spite of remarkable advances in the field of diagnosis
and treatment of pediatric AML, the survival of these
patients is not more that 50 to 60 percent. Better
understanding of the biology of disease will allow more
personalized and risk-adapted treatment, thus improving
outcomes while minimizing toxicities. In resource poor
settings such as ours, early detection and appropriate
emergency management at primary/secondary care
level is woefully lacking. Very few centers are equipped
to manage AML. Late presentations, financial and other
logistical constraints, treatment abandonment and
refusal all contribute to poor outcomes. Improvements in
existing infrastructure, as well as scrupulous supportive
care measures, along with a risk-adapted approach, will

hopefully improve outcomes in children with AML.74
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2013.
41
Chronic Myeloid Leukemia
Chronic myeloid leukemia (CML) is clonal hematopoietic stem cell disorder involving the entire myeloid lineage and at least some
of the lymphoid lines. It is characterized by myeloid hyperplasia of the bone marrow, extramedullary hematopoiesis, leukocytosis
(presence of complete range of granulocyte precursors in peripheral blood) and a specific cytogenetic signature.
CML was a model disease from its discovery: the word leukemia (white blood) was coined to describe the neoplastic nature
of colorless corpuscles or leukocythemia seen in the blood of these patients by Virchow in 1845.1 CML usually progresses from a
chronic phase through an accelerated phase to a myeloid/lymphoid blast crisis (BC), which depicts the molecular multi-hit theory of
oncogenesis. CML was the first neoplasm associated with a chromosomal aberration, known as the Philadelphia chromosome (Ph).2
The elucidation of molecular pathogenesis of this disease led to development of specific therapy, making CML a model of targeted
therapy for human malignancies.
EPIDEMIOLOGY
CML is primarily a disease of middle age; peak incidence
being in the 4th and 5th decade of life with annual
incidence of 12 cases per 100,000 population/year. In
children, CML comprises 3 percent of newly diagnosed
leukemia. It is even rarer in children younger than 4 years
with 80 percent of cases of pediatric CML diagnosed after
4 years and 60 percent after 6 years of age.3 As per the
population-based registry of Mumbai, proportion of CML
is 5.1 percent of all newly diagnosed leukemias in females
and 2.5 percent in males.4
There is no ethnic or genetic predisposition. Ionizing
radiation is a risk factor for development of the disease with
an increased incidence in radiologists, survivors of atomic
explosions and in persons exposed to therapeutic radiation.
However, radiation and other environmental exposures
have not been demonstrated to be causal in children.
PATHOPHYSIOLOGY
CML is disease of hematopoietic stem cells, having
cytogenetic hallmark in form of Ph chromosome, which
results from t(9:22) (q34;q11) balanced reciprocal trans

location. This translocation leads to juxtaposition of
the ABL1 gene from chromosome 9 and BCR gene from
chromosome 22, resulting in formation of the BCR-ABL
fusion oncogene that encodes a chimeric protein with a
constitutive tyrosine kinase activity (Fig. 1).1
ABL1: The wild type of ABL1 gene encodes a 145-kd
protein that is predominantly located in the nucleus and
is universally active in hematopoietic cells at all stages of
differentiation. The ABL1 protein participates in signal
transduction and regulation of gene transcription, also
acting as a tyrosine kinase.
BCR: The BCR region is a part of a much larger gene
known as BCR, which encodes for a 160-kd protein.
BCR-ABL1: This fusion gene encodes tumor specific
210-kd hybrid protein that differs from normal ABL1
kinase in following aspects:
It has higher and constitutive TK activity
It has ability to autophosphorylate
It is translocated to cytoplasm, thereby exposing it to
new spectrum of substrates
It binds to F-actin.
Table 1 BCR-ABL1: Alternate splicing patterns
Fusion gene
Region
Clinical phenotype
p190 kd*
Minor BCR
Ph positive ALL
p210 kd
Major BCR
Positive CML
p230 kd
-BCR
Chronic neutrophilic leukemia
*Has 5-fold higher TK activity than p 210
Fig. 1 The Philadelphia chromosome
Formation of BCR-ABL1 fusion protein in CML

activates numerous downstream signaling pathways
including RAS pathway leading to increased transcription
of MYC and BCL-X genes, activation of BCL-2 by abroga
tion of inhibitory effect of interferon consensus sequencebinding protein and activation of RAC family kinases such
as CRKL, ERK as well as c-Jun N-terminal kinase, which
leads to increased proliferation and survival of myeloid
progenitors.
There are 3 main breakpoint cluster regions (m-bcr,
M-bcr, and -bcr) in BCR and ABL1 contains 2 alternative
first exons (1b and 1a) with different breakpoints. The
combination of breakpoints within BCR and ABL1 genes
generates at least 3 different fusion transcripts encoding
proteins with distinct molecular weights (p210, p190, p230)
that are associated with different neoplastic phenotypes
(Table 1). p190 is found to be associated with Ph+ acute
leukemia in almost 80 percent of pediatric patients and 50
percent of adults; and has got five times higher tyrosine
kinase activity as compared to p210 protein.
Biology of CML
CML is an acquired clonal disorder of unicellular
origin, where the target of neoplastic transformation is
multilineage stem cell with potential for generating all
hemic cell lines and in some instances lymphoid lineages.

An initial triggering event (possibly rearrangement of
C-ABL) may occur prior to the formation of BCR-ABL
fusion protein, which is acquired at some point in the
disease evolution. The cytogenetic changes in CML
precursor cells are expressed in its progeny as multiple
cytologic abnormalities that confer a distinct survival
advantage, in turn producing a neoplastic clone (Table 2).
Overtime approximately 80 percent of patients with CML
develop additional nonrandom cytogenetic abnormalities
in Ph cell, i.e. clonal evolution, which reflects the genetic
instability and transformation to advanced-phase CML.5
The most common of these are trisomy 8, isochromosome
17, and duplicate Ph chromosome. At the molecular level,
most common mutations associated with CML progression
are p53 (25%30% of patients with myeloid BC) and INK4A/
ARF exon 2 (50% of cases of lymphoid BC).6
Clinical Features
The natural history of CML is triphasic progressing through
3 phases, from a predominantly mature hyperproliferative
phase called chronic phase (CP) through an advanced
accelerated phase (AP) to a predominantly immature
blast crisis (BC), as defined in Table 3. Approximately,
95 percent of children with CML present in CP and only
5 percent in advanced phases.7 Chronic phase usually
lasts for 3 years. Sudden onset of blastic phase, i.e.
within 3 months of previously documented complete
hematological response can rarely occur at a rate of 0.4 to
2.6 percent in first 3 years with interferon8 and 0.7 percent
on imatinib.
Table 2 Cytologic abnormalities in CML

Abnormality
Consequence
Distorted adhesive kinetics
Reduced stromal/stem cell interaction and abrogation of normal cell surface signal
maturation
Discordant nucleocytoplasmic maturation
Extension of late progenitor proliferative phase
Resistance to apoptosis
Increased survival and accumulation
Abnormalities in feedback regulation

Production of inhibitory molecules
Insensitivity to feedback inhibition
Suppression of normal HSC

Selective growth advantage
Altered cell kinetics
Prolonged survival/increased accumulation
Chapter-41 Chronic Myeloid Leukemia 421

Table 3 WHO criteria for chronic, accelerated and blast phase9
CMLCP
CMLAP
CMLBC
Documentation of
Blasts 1019% of peripheral blood WBC or bone marrow Blasts >20% of WBC or BM cells
t( 9,22) or BCR-ABL fusion gene (BM)
Bone marrow
blast <10%
Peripheral blood basophils at least 20%
Extramedullary blast proliferation
Does not meet criteria for AP

or BC
Persistent thrombocytopenia unrelated to therapy
Large foci/clusters of blasts in BM biopsy
Increasing spleen, or WBC count or high platelets

unresponsive to therapy
Cytogenetic evidence of clonal evolution
Megakaryocytic in sheets/clusters, with marked fibrosis,
and/or severe granulocytic dysplasia
Symptoms and Signs
Complete blood counts and peripheral smear (Fig. 2):

Chronic phase CML is generally characterized by a
normocytic normochromic anemia, hyperleukocytosis

(mean WBC count of 2.5 lac/mm3 which is usually
higher than in adults) with predominant neutrophilia
with or without thrombocytosis (mean: 5,00,000/
cumm). Peripheral smear shows myeloid cells in all
stages of differentiation with predominant neutrophils,
increased absolute basophil and eosinophil count;
however, myeloblasts and promyelocytes account for
less than 15 percent of differential count. Accelerated
phase manifests as increasing leukocyte/platelet
counts with higher proportion of blasts between 10 to
19 percent and more than 20 percent basophils. Blast
crisis usually manifests as pancytopenia and more
than 20 percent blasts. The characteristic biochemical
abnormality of the granulocytes in CML is reduced
leukocyte alkaline phosphatase (LAP) score.
Bone marrow examination (Fig. 3): In CML-CP,
bone marrow is hypercellular with granulocytic and
megakaryocytic hyperplasia and less than 10 percent
blasts. Accelerated phase has 10 to 19 percent blasts
and blast crisis is characterized by >20 percent blasts.
Myelofibrosis may be seen in 30 to 40 percent of cases
during the course of disease.
Fig. 2 Peripheral blood picture of CML-CP
Fig. 3 Bone marrow picture of CML-CP
Patients in CML-CP usually present with complains

of fever, night sweats, fatigue, asthenia, and left upper
quadrant pain. Complications in form of priapism,
neurologic dysfunction or respiratory distress can be seen
with hyperleukocytosis.
On examination, patient would usually have pallor,
massive splenomegaly, and hepatomegaly. Papilledema,
retinal hemorrhages, visual loss, and tachypnea can be seen
in patients presenting with hyperleukocytosis. The onset
of accelerated phase is marked by progressive systemic
symptoms and increasing splenomegaly despite therapy.
Occasionally, the first manifestation of progression could
be extramedullary, i.e. meningeal leukemia or a chloroma.
In patients with extreme basophilia, histaminemic symp
toms would be present in form of cold urticaria, pruritis
and gastric ulceration. Blast crisis usually presents with
signs and symptoms of acute leukemia.
Investigations
DIFFERENTIAL DIAGNOSIS
Figs 4A and B Interphase FISH (A) 2 Red (BCR) and 2 green (ABL)
signals of normal nucleus; (B) Two yellow-white fusion signal
corresponds to Ph chromosome
Cytogenetics: The gold standard for the diagnosis of

CML is either the demonstration of the Philadelphia
chromosome by conventional cytogenetic techniques,
or the demonstration of the products of the underlying
t(9;22) translocation, namely the BCR-ABL fusion
mRNA or the BCR-ABL protein.
Conventional cytogenetics: Conventional bone marrow
cytogenetics should be done for initial workup, as it not
only confirms presence of Ph chromosome but also
detects other clonal abnormalities that may indicate
advanced phase CML.
Fluorescence in situ hybridization technique (FISH):
FISH employs large DNA probes linked to fluorophores;
it permits direct detection of the chromosomal position
of the BCR and ABL1 genes when employed with
metaphase chromosome preparations. Its advantage
is that it can also be utilized on interphase cells from
bone marrow or peripheral blood, in which physical colocalization of BCR and ABL probes is indicative of the
presence of the BCR-ABL fusion gene (Figs 4A and B).
Reverse transcription polymerase chain reaction
(RT-PCR): Reverse-transcription polymerase chain
reaction (RT-PCR) is a highly sensitive technique that
employs specific primers to amplify a DNA fragment
from BCR-ABL mRNA transcripts. Depending upon the
combination of primers used, the method can detect
the e1a2, e13a2 (b2a2), e14a2 (b3a2) and e19a2 fusion
genes. The use of nested primers and sequential PCR
reactions makes the technique extremely sensitive,
capable of routine detection of one Ph positive cell
in 105 to 106 normal cells. Quantitative RT-PCR is
recommended before starting therapy as well as for
monitoring response to therapy.
Leukemoid reaction, juvenile myelomonocytic leukemia

(JMML) and other myeloproliferative disorders may
mimic CML.
Leukemoid reaction usually has an obvious inflamma
tory focus, a high LAP score, a less marked splenomegaly
and absence of Ph chromosome. JMML is generally
characterized by greater involvement of skin, lymphoid
tissue and monocytic cell line as compared to CML, with
lesser leukocytosis and splenomegaly, and absence of
Ph chromosome, though the LAP score may be low.
CML may be differentiated from other myelopro
liferative disorders by more pronounced involvement
of the granulocytic cells and the presence of Ph
chromosome.
Blast crisis mostly follows chronic phase and does
not pose diagnostic dilemma. However, children who
initially present in BC need to be differentiated from
de novo acute leukemia and de novo acute Ph positive
leukemia. A combination of massive splenomegaly,
basophilia and Ph chromosome helps distinguish BC
of CML with de novo leukemias. However, BC of CML
and de novo Ph positive acute leukemias need to be
differentiated at molecular and cytogenetic level. Phpositive acute leukemia will produce a 190 kd protein,
while CML-BC produces a 210 kd protein and has
specific nonrandom cytogenetic aberrations.
Prognostic Factors
The major predictors of survival are phase of disease
and duration of chronic phase. Unlike adults; spleen
size, burden of white cells, platelets, basophils or blast
percentage in peripheral blood have not been found to
be prognostically useful in children and hence prognostic
score like Sokal, Hasford or EUTOS are not applicable in
children. Early response to imatinib has been found to be
prognostic in recent studies.
Treatment (Fig. 5)
The therapy for CML is has evolved significantly over
time from earlier (Phase-1) palliative approaches such
as arsenic, splenic RT, busulphan and hydroxyurea (late
1860s1970) to phase-II of aggressive nontargeted curative
approaches such as allogenic stem cell transplant,
interferon with or without cytarabine (1970s2000) finally
to the current phase of targeted molecular therapies such
as imatinib, dasatinib, and other tyrosine kinase inhibitors.

preferentially expanded in CML. In addition, it also has an
immunomodulatory action.10,11 In the scant pediatric data
available, nearly 58 percent pediatric patients treated with
interferon achieved complete hematological response,
50 percent achieved major cytogenetic response and 14
percent showed complete cytogenetic responses, with an
overall survival of 60 percent at 8 years.12,13 In one study
combination of IFN and AraC was found to be superior to
IFN alone.14
Tyrosine Kinase Inhibitors (TKI)
Fig. 5 Evolution of treatment for CML
Medical Management
The initial goal of therapy in CML is to reduce the
leukocytosis and organomegaly. Early agents like busu
lphan and hydroxyurea did achieve this goal but could
not achieve cytogenetic remission. Interferon was the first
drug to achieve a significant cytogenetic remission. Since
its introduction, tyrosine kinase inhibitors have become
the frontline therapy and helped achieve rapid and
durable complete cytogenetic and molecular remissions.
Hydroxyurea
It is an inhibitor of ribonucleoside diphosphate reductase,
preventing conversion of ribonucleotides to deoxyribo
nucleotides and interferes with DNA synthesis during
the S phase. Recommended starting dose is 25 to 50 mg/
kg, which is further adjusted according to hematological
response.
Interferon (IFN)
In 1980s, interferon with or without cytarabine (AraC)
constituted standard management of patient awaiting
transplant or not eligible for transplant. IFN exerts anti
proliferative effect on myeloid precursors, in parti
cular on those in the late progenitor phase which is
The unique disease biology of CML paved way for the

development of first molecular targeted therapy in human
cancers in the form of imatinib mesylate which has changed
the entire outlook towards management of CML, receiving
an accelerated FDA approval for pediatric use in 2003.
Imatinib, a small 2-aminopyridine molecule, competitively
inhibits the inactive configuration of the BCR-ABL protein
tyrosine kinase by blocking the ATP binding site and
thereby preventing a conformational change to the active
form. It inhibits cellular proliferation without inducing
apoptosis, producing a 92 to 98 percent decrease in CML
colony growth in vitro without inhibiting normal colony
growth. Imatinib also inhibits platelet-derived growth factor
(PDGFR) and c-kit, but not the SRC family kinases.15,16 The
second generation TKIs inhibit both BCR-ABL and other
signaling pathways. Dasatinib and bosutunib inhibit both
BCR-ABL and SRC kinases. Nilotinib, like imatinib, is an
inhibitor of BCR-ABL, c-kit, and PDGFR. Both nilotinib and
dasatinib are >100-fold more potent than imatinib in vitro.
Dose of TKI
The recommended standard dose of imatinib in children
is 260 to 340 mg/m2 (maximum absolute dose 400 mg/
day) which gives drug exposures similar to the 400 to
600 mg adult dosage levels. The recommended pediatric
dose for CML-AP is 400 mg/m2 daily (maximum absolute
dose, 600 mg) and for CML-BC is 500 mg/m2 daily (maximum
absolute dose, 800 mg). The anticipated decrease in the
white cell count may be observed not earlier than 2 weeks
after the start of treatment and complete hematological
response is usually achieved after a median of 4 weeks.
Pediatric experience with second generation TKI is
limited though dasatinib is being evaluated in pediatric
phase II trial (NCT00777036) with a dose of 60 mg/m2
daily for CML-CP and 80 mg/m2 daily for more advanced
phases. Dosage recommendations for children concerning
nilotinib cannot yet be made. The dose approved for
treating adults is 300 to 400 mg twice daily. Table 4 details
the starting dose and administration guidelines for TKI.
Response Rates and Response

Assessment to TKI
Effectiveness of therapy with TKI is assessed based on the
achievement of landmark responses, i.e. hematologic,
cytogenetic and molecular responses as defined in Table 5.

The response achieved in relation to time, i.e. milestones
is used to grade response as optimal, suboptimal and
failure, providing basis for timely alteration of therapy as
detailed in Table 6.17,18
The pediatric TKI treatment results are comparable
to the results achieved in adults. Data from pediatric
trials have shown that with use of imatinib in CML-CP,
96 percent achieve CHR and 69 percent achieve CCyR after
Table 4 Starting doses and instruction for administration of TKI25

TKI
Dose (mg/m )
Instructions
Imatinib
340, OD
To be dispersed in water or apple juice, 50 mL for 100 mg tablet. Take with water or food to avoid
esophageal irritation
Dasatinib
6080, OD
Dissolve in 30 mL lemonade/preservative-free apple or orange juice
Nilotinib*
170230, BD
Capsules may be dispersed in 5 mL of apple juice/sauce and ingested immediately on an empty

stomach, abstain from eating for at least 1 hour
* Pediatric dosing has not been established but is based on 300 mg or 400 mg twice daily, if less than or greater than 40 kg,
respectively.
Table 5 Landmark responses to treatment17,18

Hematological response (CBC and Clinical)
Cytogenetic response (Ph+metaphases)
Molecular response (BCR-ABL transcripts)
Complete:
1. WBC <10 103/L
2. Platelets <450109/L
3. Differential with no immature
granulocyte and <5% basophils
4. Spleen not palpable
Complete: 0%
Partial: 135%
Minor 3665%
Minimal 6695%
Complete: Transcripts not detectable,

or >3-log reduction in transcript from
diagnosis
Major: <0.1%
Table 6 Milestones of response in CML-CP17,18 with therapeutic option

Time (Months)
Optimal
Suboptimal
Failure
Diagnosis
NA
NA
NA
CHR and minor CyR
CHR and no CyR
No CHR
Partial CyR
Minor/Minimal CyR
No CyR
12
Complete CyR
Partial CyR
Less than partial CyR
18
MMoIR
<MMoIR
<Complete CyR
Anytime
Stable or improving MMoIR
Loss of MMolR, BCR-ABL kinase

domain mutations still sensitive
to imatinib, >0.05% increase in
transcript levels
Loss of CHR, CCyR, new

chromosome abnormalities in
presence of Ph+, BCR-ABL kinase
domain mutations insensitive
to TKI
Management
Consideration13-15
Continue same with monitoring
Increase dose of imatinib

Introduce second generation TKI
Introduce second generation TKI

Consider HSCT

Table 7 Response rates to imatinib in pediatric CML trials
Study
Dose
CHR (%)
CCyR (%)
At months (m)
MMR (%)
At months (m)
OS
At months (m)
260570
100
83
NA
78.5% (24 m)
European phase II (N = 30)
260340
80^
75*
60^
29*
50
0*
95^ (12 m)
75* (12 m)
French national (N = 44)20+
260
98
62 (12 m)
31 (12 m)
98 (36 m)
AAML0123 (N = 50)
340
78
91 (9 m)
CML-PAED II ( N = 51)
300**
95
93 (12 m)
85 (18 m)
I-CML-Ped (N = 150)27+
63 (12 m)
awaited
97 (42 m)
COG-phase I (N = 20)19
26
23+
21+
98 (12 m)
^ : In CP, *: advanced phase, ** : 400 for AP, 500 for BC

+ : Patients treated upfront with imatinib
1 year 19-23 as depicted in Table 7. Imatinib is more effective

in CML-CP with overall survival of 95 percent at 1 year as
compared to 75 percent in advanced phases.26
Dasision and ENESTnd Trial in treatment nave CML
adults have demonstrated a significantly faster as well as
deeper responses and better transformation free survival
with dasatinib and nilotinib as compared to imatinib,
however, not showing a difference in the PFS and OS at 3
and 4 years respectively.28-31 There is very scant data and
little experience with second generation TKI in pediatric
population, with two phase 1 trials confirming effectiveness
of dasatinib in pediatric age group.24,33 In the COG phase
1 trial in the dose range of 60 to 110 mg/m2 once daily,
dasatinib could achieve CCyR in 3 and partial CyR in 3 of
8 evaluable patients with resistant CML-CP.24 In another
CA180-018 phase I study of 17 children with resistant CMLCP, 14 (82%) achieved complete cytogenetic response
(CCyR) and eight (47%) achieved major molecular res
ponse. Of 17 patients with advanced-phase CML or
Ph-positive ALL, six (35%) achieved CHR and 11 (65%)
achieved CCyR.33
Intolerance and Resistance to TKI

Up to one-fourth of patients either may not tolerate or may
show resistance to TKI.
Intolerance
A patient is considered to be intolerant to therapy
when a nonhematologic toxicity of at least grade three
recurs despite appropriate dose reductions and optimal
symptomatic management. In general <5 percent of
patients are intolerant to imatinib therapy.
Resistance
It is divided into two categories:
1. Primary resistance: It is defined as failure to achieve a
timely response (Table 6). It has been seen in 10 to 20
percent of CML-CP pediatric trials of imatinib. It could
be due to inadequate inhibition of tyrosine kinase or
BCR-ABL mutations.
2. Secondary resistance: Loss of a previously achieved
response constitutes secondary resistance. It occurs
in 80, 50, and 15 percent of patients in blast crisis,
accelerated phase, or chronic phase, respectively
after 2 years of imatinib therapy. It is due to reactiva
tion of BCR-ABL signaling (mutation of BCR-ABL,
imatinib excretion, overexpression of BCR-ABL)
or activation of other signaling pathways including
SRC kinases.
Managing Resistance
Once resistance is suspected, the disease status should
be re-evaluated. Compliance and tolerance to therapy
should be confirmed in patients suspected to have
resistance, as none of the patients with compliance 80
percent to imatinib could achieve a MMR in past studies.
The trough plasma imatinib levels should be obtained
since level <1000 ng/mL is associated with higher rate of
progression of disease. In addition, mutational analysis
of BCR-ABL should be performed. Primary resistance
due to inadequate inhibition of tyrosine kinase can be
overcome by increasing the dose of imatinib. Resistance
due to mutation can be overcome by changing the TKI
known to be active for the particular mutation keeping
the side effect profile and comorbidities in the child in
mind.
Toxicity of TKI
Allogenic Stem Cell Transplant (Allo-SCT)
Imatinib is generally well tolerated in children. Table 8

enlists the major acute side effects with TKI as well as their
management. Generally, the acute side effects of TKI tend
to be manageable and decrease over time.
However, the developing organs and potentially
prolonged use of TKI, known to act on off target kinases
involved in normal function of organs, in pediatric
patients makes them more particularly vulnerable to
long-term side effects of TKI, many of which may not
be apparent for years (Table 9). Among these, most
concerning long-term side effects are growth retardation,
impact on bone health, and cardiac dysfunction. Growth
delay has been demonstrated in many recent studies due
to disturbance in GH:IGF-1 axis. Similarly, altered bone
mineralization has been shown in few studies. The cardiac
dysfunction is still a topic of debate, however, definite invitro evidence definitely warrants more evaluation. Thus,
TKI administration in children requires close monitoring
of side effects.25 Hence, the risk and benefits of TKI
therapy should be weighed against the alternative options
available, including allogeneic SCT.
Prior to imatinib, allogenic stem cell transplant was the

treatment of choice for CML and was usually performed
during the early chronic phase since outcome of AlloSCT in BC is dismal with less than 20 percent long-term
survival.32 Allo-SCT is the only known curative treatment
available for children with CML. In most studies of
pediatric patients, the survival ranges between 60 to 80
percent with better results in matched sibling donors
compared to voluntary unrelated donors. However, owing
to the complications of high early mortality, growth failure,
infertility, graft versus host disease, metabolic syndrome,
and secondary malignancies associated witth Allo-SCT,
it has become a form of rescue treatment for patients in
advanced CML (AP/BC), treatment failure after receiving
second generation TKI, and patients with T315I tyrosine
kinase mutation (till proven role of ponatinib).
However, in developing countries, where one time
cost of transplant is significantly lesser as compared
to potentially lifelong therapy with TKI and good
contemporary outcome and potential cure with matched
sibling donor transplant, it remains an attractive option in
Table 8 Major acute side effects of TKI25

TKI side effects
Recommended intervention
Hematologic toxicity:
Neutropenia, anemia, or
thrombocytopenia
Hold TKI until count recovery for up to 2 weeks; G-CSF may be administered to treat neutropenia;
restart at full dose if cytopenia persists < 2 weeks; reduce dose by 20% if longer than 2 weeks
Rash
Observation; consider topical steroids
Elevated liver function tests
Observation, avoid ibuprofen
Muscle cramps
Check CK and electrolytes, consider electrolyte repletion
Nausea, vomiting
Supportive care, consider ondansetron
Headache
Supportive care
Table 9 Chronic side effects of TKI25
TKI side effects
Recommended intervention
Cardiac toxicity
Imatinib: Possible, not proven
Dasatinib: Possible, not proven
Nilotinib: QT prolongation
and sudden death have
been reported
Consider ECG, echocardiogram, troponin, electrolytes, if there is clinical concern

Do not use nilotinib with history of cardiac or electrolyte problems
Effusions
Dasatinib: Pleural effusions
Hold TKI; if multiple sites of edema, give diuretics; and if severe, thoracocentesis and brief
course of steroids
Decreased height/growth retardation Closely monitor height, GH stimulation tests and IGF-1 levels
Poor bone health
Closely monitor calcium and phosphorus; vitamin D repletion as necessary
Teratogen
Avoid TKIs during pregnancy

Table 10 Laboratory monitoring on TKI therapy
Test
Recommendation
Bone marrow cytogenetics/FISH
At diagnosis to establish disease phase and additional mutations, if any

Every 3 months till complete CyR
Rising levels of BCR-ABL(1 log) without MMR
Quantitative RT-PCR (peripheral blood)
At diagnosis to determine baseline transcript type and levels

Every 3 month after cytogenetic CR till MMR, then 612 monthly
Rising levels of BCR-ABL (1 log) with MMR then 13 monthly
TKD mutations
Failure to reach (suboptimal response) or maintain CHR, CCyR, or MMR; rise in quantitative
PCR after MMR; cytogenetic relapse or increase in Ph chromosomes, if CCyR not obtained
CML-CP in presence of a matched sibling donor. Recent

studies have shown promising early results with reduced
intensity conditioning transplants in children with CML
with significantly lower long-term morbidity. Also,
preliminary data using imatinib for cytoreduction pretransplant has demonstrated a significantly lower risk of
death attributable to the lower disease burden at the time
of transplant making it an attractive strategy. Also, imatinib
has shown to be effective in relapse post-transplant as well
as maintenance post-transplant, with most centers using
1 year of imatinib post-transplant to reduce the risk of
disease relapse.
Flow chart 1 Management of CML-CP in children
Guidelines for Management of

CML in Children
Chronic Phase CML (Flow chart 1)
Initiate treatment with hydration, hydroxyurea, allopu
rinol and start imatinib at 340 mg/m2 per day after
confirmation of diagnosis. Monitor disease status through
CBC, differential count and peripheral blood FISH every 3
months till achievement of cytogenetic remission followed
by quantitative RQ-PCR every 3 month till MMR, then 6
to 12 monthly (Table 10). If child fails to achieve optimal
response (Table 6), check for compliance, imatinib levels,
BCR-ABL mutations and switch to dasatinib 60 mg/m2 per
day if none or sensitive mutations are present and initiate
screening for related and unrelated allogeneic stem cell
donors. If second line-TKI is not affordable/available, or
child is noncompliant with low-serum levels consider
increasing the dose of imatinib and follow for response. In
children with resistant mutations (T315I), or progression
or relapse on dasatinib, allo-SCT should be done with the
best available donor as soon as possible.
Accelerated Phase CML (Flow chart 2)

Start imatinib 400 mg/m2 or dasatinib at 80 mg/m2 per
day in 2 divided doses (preferred). Initiate search for
HLA-matched sibling or unrelated donors and proceed to
myeloablative allogeneic SCT if sibling donor is available

after achievement of remission. If patient fails or has
a suboptimal response at any time (Table 6), proceed
immediately to myeloablative allogeneic SCT with best
available donor. These patients may benefit from posttransplant maintenance with TKI in view of high risk of
relapse.
Flow chart 2 Management of CML-AP in children
REFERENCES

Flow chart 3 Management of CML-BC in children

Blast Crisis CML (Flow chart 3)

Start imatinib at 500 mg/m2 or dasatinib at 80 mg/m2 per
day in 2 divided doses (preferred) along with appropriate
anti-leukemic regimen based on type of blast crisis and
screen for HLA-matched sibling or unrelated donors.
Once in remission or second chronic phase, move
to myeloablative allogeneic SCT with best available
donor. These patients may benefit from post-transplant
maintenance with TKI in view of high-risk of relapse.
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42
Juvenile Myelomonocytic Leukemia
Juvenile myelomonocytic leukemia (JMML) is a clonal panmyelopathy and a unique kind of chronic myeloproliferative disorder seen
almost exclusively in infants and young children. It is characterized by myeloid proliferation, especially in the monocytic lineage
and occurs due to well-characterized molecular defects at the genetic level which directly affect granulocyte macrophage-colony
stimulating factor (GM-CSF) invoked downstream signaling pathways involved in cellular proliferationespecially the RAS pathways.
This results in a progressive organ infiltration of the spleen, liver and finally lungs in a progressive, relentless march to fatality if
untreated. Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT) is the only known cure resulting in long-term remission.
The unique leukemogenesis model of JMML has provided in depth understanding of cancer cytogentics and offers a wide array of
potential targeted therapies that may have applications across several malignancies.
Juvenile myelomonocytic leukemia (JMML) is a clonal

panmyelopathy, which presents with leukocytosis, spleno
megaly and organ infiltration due to excessive proliferation
of cells of the monocytic and granulocytic lineages. It is one
of those enigmatic diseases of childhood that has evaded
categorization and generated considerable confusion over
its classification over the years until recently. It was first
broadly categorized under myeloproliferative disorders,
a term coined by Dameshek in 1951 when he observed that
different chronic proliferative disorders sharing similar
clinical and hematologic features often developed a more
aggressive form over the course of their illness,1 and has
jumped categories till its molecular basis has been better
understood in recent times.
HISTORY AND CLASSIFICATION

Earlier termed a chronic myeloproliferative disorder, it was
only after the discovery of the Philadelphia chromosome
by Nowell and Hungerford in 19602 which characterized
adult-type chronic myeloid leukemia (CML), that it was
shown that this unique anomaly was absent in children
and infants with a similar clinical picture.3 Hardisty in
1964 had coined the term juvenile CML (jCML), which
stayed in popular parlance for several decades since,4,5
leading to much confusion over its classification and its

persistent identification as the ph negative chronic
myeloid disorder. Subsequently, the finding of elevated
HbF levels,6 and the identification of monosomy 7 as a
unique chromosomal anomaly in many infants and young
children with recalcitrant myeloid proliferations and acute
leukemias7 led to further disorders being broadly clubbed
under this entity.
After the French-American-British (FAB) group had
successfully classified MDS in adults, there was a move
to extend the same for the pediatric entity and called
it chronic myelomonocytic leukemia (CMML) instead
of jCML. In 1997, Niemeyer reported one of the largest
series to date and described in painstaking of CMML in
childhood, jCML and the infant monosomy 7 syndrome
highlighting their common biological features.8 Later
leading an international group she proposed the term
JMML to include all these entities and established its
diagnostic criteria.9 The 2001 classification system of the
World Health Organization (WHO) grouped these into a
separate category of myelodysplastic/myeloproliferative
disorders as it reflects both elements, i.e. dysplastic and
proliferative features of the myeloid cells.10 With the recent
identication of certain genetic mutations in JMML,
a revised set of diagnostic criteria was proposed by the
Chapter-42 Juvenile Myelomonocytic Leukemia 431

International JMML Working Group in 2006.11 The existing
criteria and the proposed ones are given in Tables 1 and 2
respectively.
EPIDEMIOLOGY
From the few population-based studies, it can be derived
that JMML represents about 2 to 3 percent of leukemias
in children, and has an annual incidence of 1.2/million
children per year.12,13 JMML predominates in infants
and toddlers with a median age at diagnosis of 1.8 years,
and close to 85 percent of all cases are diagnosed from 4
months to 6 years of age. A male preponderance is seen
through all age groups at with a sex ratio of about 2:1.8 Few
reports exist of a familial occurrence in twins pairs and
other siblings.14,15
JMML is closely associated with neurofibromatosis
type 1 (NF1).16-19 These patients have a 200- to 350-fold
Table 1 Current JMML diagnostic criteria (2nd International
JMML Working Group11)
All of the following
At least 2 of the following
Absence of the t(9;22) BCR/

ABL fusion gene
Circulating myeloid precursors
Absolute monocyte count

>1000/micL
White blood cell

> 10,000/micL
<20% blasts in the bone

marrow
Elevated fetal hemoglobin

(HbF)
GM-CSF hypersensitivity
higher risk of developing JMML.8,19 While about 11 percent

of patients with a clinical diagnosis of NF1 develop JMML,
another 15 percent of JMML patients without a clinical
diagnosis of NF1 have mutations in the NF1 gene.14,20,21
A few cases of JMML have been associated with Noonan
syndrome (NS), which is diagnosed in about 2 percent of
JMML patients registered. In all such cases a heterozygous
PTPN11 mutation, a gene that encodes the nonreceptor
protein tyrosine phosphatase SHP-2 was observed.22
PATHOPHYSIOLOGY AND GENETICS

As previously noted, JMML came to be defined among the
group of disorders primarily identified by the absence of
the Philadelphia chromosome. In contrast monosomy
7 was identified in about 25 percent of patients, other
abnormalities in 10 percent and a normal karyotype
in 65 percent.8,14,23 When monosomy 7 is present, it is
generally the sole abnormality. Among the chromosomal
abnormalities other than monosomy 7, loss of material on
the long arm of chromosome 7 is the most frequent.8
While JMML involves the myeloid, erythroid and
megakaryocytic lineages and transforms into myeloid
leukemias, clonal involvement of the B-lymphoid lineage
is also seen, including lymphoid blast crisis.24,25 It may
be gathered that malignant transformation takes place
at a stage of a committed stem cell that has the ability
for myeloid, as well as early B-lymphoid differentiation.
Involvement of T-lymphoid precursors has only been
reported in one child with JMML and T-cell lymphoma.26
Molecular Aspects
Table 2 Proposed criteria of the 2nd International
JMML Working Group11
Category 1
Category 2
Category 3
All of the following
At least 1 of the
following
At least 2 of the
following
Splenomegaly
Somatic
mutations in RAS
or PTPN11
Circulating myeloid
precursors
Absolute monocyte Clinical diagnosis

count >1000/L
of NF1 or NF1
gene mutation
WBC >10,000/L
Blasts in PB/BM
<20%
Elevated fetal
hemoglobin (HbF)
for age
Absence of the
t(9;22) BCR/ABL
fusion gene
Age less than 13
years
Monosomy 7
Clonal cytogenetic
abnormalities
excluding
monosomy 7
Molecular pathways in JMML have been extensively

studied and still draw interest as they serve as models
for studying leukemogenesis. Several molecular events
that activate RAS dependent signaling pathways and
deregulate growth and survival of leukemic cells, have
been described in JMML27,28 (Fig. 1), primarily including
mutations in the genes encoding RAS, NF1 and SHP-2. In
addition Casitas B Lymphoma (CBL) is also increasingly
recognized as a causative gene.29 Figure 1 also highlights
the targets of JMML therapy covered later in this text.
ONCOGENIC RAS MUTATIONS

A hypersensitivity of JMML cells to GM-CSF has been
well-established and was used as a diagnostic test for
its confirmation long before the molecular pathways
responsible became apparent. A specific defect in the
GM-CSF signal transduction pathway was postulated
to drive the pathogenesis of this disease. However, no
abnormalities in the GM-CSF receptor (GM-CSFR)
could be found, but a host of abnormalities in the
Fig. 1 Molecular activation pathways in JMML and the potential therapeutic targets28
downstream pathways were soon identified in the RAS/

MAPK pathway.27 The RAS family of signaling proteins
regulate cellular proliferation by cycling between an active
guanosine triphosphate (GTP)-bound state (RAS-GTP)
and an inactive guanosine diphosphate (RAS-GDP)-bound
state. Mutant RAS alleles encode proteins that accumulate
in the GTP-bound conformation because of defective
GPT hydrolysis. Common sites of these mutations along
with other candidate genes are summarized in Table 3.27,30
Oncogenic point mutations of NRAS and KRAS are seen in
15 to 20 percent of children with JMML.27,30

Other genetic pathways include NF1 in neurofibro
matosis and PTPN11 in Noonan syndrome. A group
of GTPase- activating proteins (GAPs) facilitate the
conversion from active RAS-GTP to the inactive RAS GDP
state. Neurofibromin, the protein encoded by the gene for
NF1, functions as GAP and negatively regulates RAS.27,28,30
As described above, 25 to 30 percent of JMML cases carry
the clinical diagnosis of NF114 or are known to harbor
NF1 gene mutations.20,21 Extensive studies in the field
by Shannon and co-workers who demonstrated loss of
heterozygosity (LOH) by loss of the normal NF1 allele from
the bone marrow of children with type 1 neurofibromatosis
and malignant myeloid disorders,31 were instrumental in
proving that NF1 works as a myeloid tumor suppressor
Table 3 Summary of gene mutations in JMML28

Gene
Sites of mutation
Frequency
PTPN11
E76K, D61Y, D61V, E69K,

A72T, A72V, E76V/G/A
35%
RAS
NRAS
KRAS
HRAS
25%
Codons 12 and 13
Codon 13
No mutation in codons 12,
13, and 61 was found
NF1
Loss of wild-type NF1

allele
1115%
CBL
Codons 371, 380, 381, 384, 17%

396, 398, 404, and 408.
Splice sites 1227, 1228,
and 1096
gene (TSG) that functions by negatively regulating RAS

signaling.
Noonan syndrome (NS): It is a heterogeneous disorder
defined by short stature, facial dysmorphia, cardiac defects
(most commonly pulmonic stenosis and hypertrophic
cardiomyopathy), skeletal defects, mental retardation

and bleeding diathesis, in which JMML is an occasional
association, NS is caused by germline mutations in
PTPN11, the gene encoding the nonreceptor protein
tyrosine phosphatase (PTP) SHP-2, 130 a member of a small
subfamily of cytoplasmic src-homology 2 (SH-2) domain
containing PTPases.32 It is required for hematopoietic cell
development and participates in signal transduction of
a number of cytokines, including GM-CSF and IL-3.30,32
Binding of the SH2 domain to phosphorylated tyrosine
residues induces a conformational shift that relieves the
inhibitory interaction between the SH-2 domain and the
catalytic PTP domain. Heterozygous germline mutations
of PTPN11 are present in children with NS and JMML.22
PTPN11 mutations also represent a major molecular event
in nonsyndromic JMML. About 35 percent of patients with
JMML harbor somatic mutations in PTPN11.28,30
The Casitas B-cell lymphoma (CBL, c-CBL) protein, is
also now increasingly recognized to have a causative role
in JMML.29 First reported by Loh, et al. c-CBL mutations
have been detected in up to 17 percent of cases.29,30 The
germ line mutation represents the first hit, with somatic
loss of heterozygosity being the second hit positively
selected in JMML cells. Individuals with germ line CBL
mutations are at increased risk of developing JMML,
which might follow an aggressive clinical course or resolve
without treatment.33,34
CLINICAL FEATURES
The typical presentation is that of an infant with
progressive pallor, fever, infection, petechiae, cough and
progressive abdominal distention due to splenomegaly
and hepatomegaly.8 Occasionally, the spleen may be
normal at diagnosis, but will rapidly increase thereafter.
However, most patients presenting in the authors
experience have had large spleens with varying degree of
hypersplenism (personal experience, unpublished data).
Lymphadenopathy is fairly common too, a feature which
distinguishes it from CML.8,23 The tonsils may be markedly
enlarged due to infiltration. Dry cough, tachypnea
and interstitial infiltrates on chest X-ray are signs of
peribronchial and interstitial pulmonary infiltrates.
Patients with advanced disease frequently have cachexia.
Skin is usually involved by eczematous eruptions or
erythematous maculopapules on the face, trunk, and
hands.23,35 Indurated raised lesions with central clearing,35
and petechiae may also be seen.
In addition to these often nonspecific lesions, juvenile
xanthogranulomas composed of numerous foamy cells
may be seen in JMML. They are present by the end of
the second year of life and are often multiple.36 In some
but not all children, xanthogranulomas are associated
with multiple cafe au lait spots and the clinical diagnosis
of NF1.17 Abdominal distension and discomfort are

generally due to hepatosplenomegaly. Gut infiltrates may
predispose to diarrhea and gastrointestinal infections.
Unlike acute monoblastic leukemia, JMML rarely involves
the central nervous system (CNS). A small number of
patients with CNS chloroma8 and with ocular infiltrates37
have been described. Pituitary infiltration and diabetes
insipidus, responsive to antileukemic therapy, has also
been described.38 In addition, clinical features of NF1
with multiple cafe au lait spots, and the characteristic
dysmorphisms of NS may be seen in 11 percent and 7
percent of JMML cases respectively.8
HEMATOLOGICAL AND
LABORATORY FEATURES
The hematologic profile is characterized by leuko
cytosis, anemia and thrombocytopenia. Unlike CML,
the median white blood cell (WBC) count is 33 109/L
and rarely exceeds 100 109/L.12,25,47 Rarely the counts
may be less than 10 109/L, especially in children with
monosomy 7.8,14
Both mature and immature myeloid lineage cells are
seen along with a characteristic monocytosis, often
with dysplastic cell forms. An absolute monocyte
count of more than 1 109/L has been retained as a
diagnostic criteria (Table 2).9,11
Occasionally, eosinophilia and basophilia may be
seen.
The median blast cell percentage in PB smears is less
than 2 percent8 and rarely exceeds 20 percent.
In about 14 percent of children, the platelet count at
diagnosis is below 20 109/L.
Most patients have a hemoglobin level between 7
and 11 g/dL. The reticulocyte count and the number
of normoblasts vary over a wide range. Red cells are
generally normocytic, while macrocytosis is noted in
some patients with monosomy 7. Microcytosis may be
due to iron deficiency, but can often be noted even in
the absence of laboratory detected deficiency.8
Bone marrow (BM) aspirate shows increased
cellularity with predominance of granulocytic cells in
all stages of maturation. Monocytosis in BM is usually
less than in PB, with a median of 10 percent cells.8 The
BM blast count is moderately elevated, but is more than
10 percent in only 10 percent of patients.8,10 Dysplasia of
granulocytes is usually minimal, with hypogranulation
of neutrophil cytoplasm and pseudo-Pelger-Hut
forms.10 Besides macrocytic differentiation in a few
cases, erythroid cells mature normally. Megakaryocytes
are reduced or absent in about 75 percent of children.8
Cytochemical and immunophenotypic studies are
not specific, but might be helpful in identifying the
monocytic population.10 Because smears of PB and
BM provide sufficient information, BM biopsy may
be omitted in most cases. Reticulin fibrosis has been
noted in biopsies of some patients.8,39
HbF synthesis is increased especially in those with
a normal karyotype resulting from a high number
of circulating F cells. In addition, other fetal red cell
characteristics, such as increased expression of the I
antigen and decreased carbonic anhydrase levels, are
present.40 Despite these changes, maturation of red
cells does not seem to be compromised.
While clinical features of patients with monosomy
7 and those with a normal karyotype are similar,8
hematological differences are often seen. Monosomy 7
patients have a lower median WBC but similar absolute
monocyte count, red blood cells are often macrocytic,
and erythropoiesis in BM is more pronounced. In
addition, they have a normal or only moderately
elevated HbF, which is often elevated in patients with
normal karyotype.8
Immunological abnormalities are frequently seen
in JMML. Serum IgG, IgM and IgA levels are often
increased in a polyclonal fashion. Autoantibodies, such
as antinuclear antibodies, antibodies against red cells
causing a positive Coombs test and anti-thyroglobulin
antibodies may be present.8
These include fusing of diphtheria toxin to GM-CSF,45 the

use of GM-CSF receptor antagonist E21R,46 and inhibition
of production of GM-CSF, TNF- and IL-1 by IL-10.47
Spontaneous growth of JMML myeloid progenitors in
vitro can also be inhibited by 13-cis or all-trans retinoic
acid48-50 possibly due to their antagonistic effect of retinoic
acid on the transcription factor AP-1, which is activated by
Jun/Fos oncoproteins shown to be upregulated in JMML.51
Interferon- (IFN-)52 and farnesyltransferase inhibitors
(FTIs)53 have also been shown to inhibit colony formation.
MANAGEMENT OF JMML
Several viruses have been implicated in creating a clinical

and hematological picture resembling JMML. These
include cytomegalovirus (CMV), Epstein-Barr virus
(EBV), human herpesvirus 6 (HHV-6) and parvovirus
B19.41-43 Concomitant viral infections must therefore
always be carefully excluded, especially in those with a
normal karyotype or when a molecular analysis has not
been feasible. Other disorders like leukocyte adhesion
deficiency (LAD) variant and some metabolic disorders
can also mimic JMML. Strict adherence to the diagnostic
criteria can usually avoid misdiagnosis.
It has now long been recognized that Allo-HSCT offers the

only real chance of cure in JMML. However, historically
in the developed countries and in the current reality
of developing countries, few have reached the stage of
transplant. In the absence of this possibility, either from
lack of donor availability or socioeconomic constraints,
a host of alternative options have long been practiced. In
addition there is now a growing list of molecular directed
therapies as the JMML model of leukemogenesis has
become increasingly well-defined and newer targets
identified.27,28,30 Comparative evaluation of the efficacy of
these different approaches has been hampered to a large
extent by the lack of adequate response criteria. This was
addressed to an extent by the 2nd International JMML
Working Group which evolved the new response criteria
reflected in Table 4.11
Hematopoiesis in Cell Culture Studies

When JMML cells are cultured in semisolid media, an
increased number of monocyte-macrophage colonies
are formed even in the absence of added growth factors.44
This hypersensitivity of JMML cells to GM-CSF, since its
first identification, has become the hallmark of the disease
and an essential element of its diagnosis.9,11,44 The shift to
left in colony assays of JMML cells in absence of GM-CSF
stimulation, as compared to controls is characteristic.
GM-CSF appears to be obligatory for survival of JMML
cells. This has led to several novel approaches in blocking
colony formation of JMML cells by different strategies.
Natural Course and Prognostic Factors

The JMML is a relentlessly aggressive disorder and
uniformly fatal in untreated patients. Allogeneic hema
topoietic stem cell transplantation (HSCT) offers the
only hope of a permanent cure. Thrombocytopenia, age
above 2 years and high HbF at diagnosis predict a poor
outcome.8,14 A scoring system was devised in which HbF
of 10 percent or higher and a platelet count of 33 109/L
or less had an adverse impact on outcome.14 JMML rarely
transforms to a blastic stage and infiltration of the lungs
leading to respiratory failure is the usual cause of death in
progressive disease. Watchful observation may be of use in
cases of Noonans syndrome as some of them are known
to spontaneously remit.
Low-dose Conventional Chemotherapy

Historically 6-mercaptopurine (6-MP) has been used
either as a single agent54 or in combination with lowdose cytarabine or etoposide,54,55 and was shown to be of
benefit. In a later update in 2006 of the original 110 cases
reported by Neimeyer, sixty-three patients who did not
receive transplant were analyzed and all the above agents

Table 4 Response criteria of the 2nd International
JMML Working Group11
Complete clinical
response
Partial clinical
response
White blood cell

count
<20000/L
<50% of initial WBC

count but total
still greater than
20000/micL
Splenomegaly
Normalization of
spleen size
25% decrease from

initial size
used either singly or in combination in a maintenance

like therapy showed some efficacy in producing partial
response or stable disease three months from start of
therapy. However, the variability in response evaluation
made it unreliable and the setting up of uniform criteria
was the main thrust of this paper.56 This came to fruition
with the efforts of the 2nd International JMML Working
Group recommendations in 2009.11 At best, this therapy
may be used currently only in the palliative setting.
Intensive Chemotherapy
This has usually involved AML type protocols and has been
far more controversial. A few small series have reported
benefit,57,58 with one CCG study reported remission in seven
of 12 patients who received intensive chemotherapy.59 This
success has allowed some groups to use a combination of
intensive cytoreduction with cis-retinoic acid as a bridge to
Allo-HSCT. However, these results have not been widely
replicated and many other studies have reported prolonged
aplasia which is often fatal.60,61 In addition, there may be no
difference in outcome between those who receive intensive
therapy and those who do not, as in the absence of AlloHSCT, both groups do poorly with overall survival (OS) of 6
percent at 10 years.
Other Measures
In vitro sensitivity of JMML cells to IFN- led to its initial
use in JMML.52 However, apart from isolated case reports,
no benefit has ever been proven. A POG study using an
IFN- dose of 30,000 units/m2 was stopped for excessive
toxicity.62 None of the evaluable patients had either a
partial or complete response. A similar basis was found
to justify the use of 13-cis retinoic acid (isotretinoin).48,49
However, the earlier promise was not borne out a phase II
POG study 63 or by other investigators.54
The role of splenectomy has remained undecided. It is
often offered to reduce respiratory distress or abdominal
discomfort due to massive spleen size, and sometimes
also to reduce transfusion requirements in the presence
of hypersplenism. Its role is largely limited currently

to symptomatic relief or to tackle hypersplenism due
to massive spleens or prior to Allo-HSCT to accelerate
hematologic recovery and reduce the risk of hemorrhagic
complications post-transplant. 8,54,56
Experimental Therapeutic Approaches

The recent focus in JMML has been on designing targeted
drug therapy to the many recognized molecular defects.
Most of these therapies have been tested and developed
on mouse models, while some have undergone early phase
human trials. Since RAS hyperactivation remains a crucial
element in the pathogenesis, suppression of its activity has
been one of the prime targets, and various methods have
been used to achieve this end (Fig. 1).
One such method has been targeting RAF1a MAP
kinase which functions downstream of the RAS
subfamily of proteins and plays an important role in
the signal transduction. A DNA enzyme designed to
specifically cleave mRNA for RAF1, has been found
to be very specific for JMML cell lines while sparing
normal marrow cells, which indicates a high level of
safety.64 Another means of achieving the same purpose
is the use of a RAF1 inhibitor. BAY 43-9006a low
molecular-weight agent binds at the active site of the
RAF1 kinase65 and has undergone further trials.11
Another target has been stopping RAS activation at
the cell membrane level where addition of a farnesyl
group to the newly translated protein is one of the first
steps of RAS activation. Farnesyltransferase inhibitors
(FTIs) are able to prevent RAS translocation to the
plasma membrane, leading to downregulation of RASactivated cellular pathways.53 L-744,832 is one such
FTI, which can abolish the in vitro growth of myeloid
progenitor colonies in response to GM-CSF.66 Other
FTIs too, have reported some in vitro activity, however,
they have shown only modest to little activity in clinical
trials when used as a single agent.
SHP-2 phosphatase has presented a very tempting
target for inhibition due to the direct correlation
between the driving mutation of PTPN11 and JMML,
much like the tyrosine kinase inhibition of imatinib
in CML with a direct driving gene at the bcr-abl locus.
However in JMML, this has been plagued with issues
related to the highly selective SHP-2 inhibition required
due to a shared homology in catalytic pathways with
SHP-1 which has a negative role in cytokine signaling67,68
resulting in neutralized end results of SHP-2 inhibition.
The key role of GM-CSF stimulation and proliferation
of JMML cell lines has also led to interest in the role of
GM-CSF antagonists for its cure, which has already been
covered in this text elsewhere.
Other approaches have focused on the tumor micro
environment. Angiogenesis inhibition with Endostatin and
PI-88, have shown promise in mouse xenograft models
for JMML.69 Even newer approaches now are focusing
on inhibition of STAT5, which is activated downstream
of activated RAS. This has been found to be an effective
biomarker70 and also presents a potential therapeutic target.
Hematopoietic Stem Cell Transplantation

Allogeneic HSCT is the only known curative treatment
for JMML, resulting in long-term survival in about a third
of the patients.71-73 The malignant JMML clone is difficult
to eradicate even with HSCT,74 and post-transplant
relapse rate is high. For this reason, right from the first
successful HSCT in JMML from Seattle, a conditioning
regimen including total-body irradiation (TBI) has been
used.75 However, radiation-induced late effects such as
severe growth retardation, cataracts, hypothyroidism and
neuropsychologic sequelae, have been daunting, and inc
reasingly conditioning regimens without TBI have been
used and reported to be equally effective.72,73
Younger age at HSCT may predict improved sur
vival.71,73 Thus, transplant should be recommended soon
after diagnosis. This is imperative as long-term survival
in children with JMML without HSCT is less than 10
percent.8 Where feasible, a matched unrelated donor
(MUD) must be searched for if a matched sibling donor is
not available.72,74 Though relapse rates in both approaches
are comparable, graft rejection76 and transplant-related
mortality71 are expectedly higher in MUD grafts. Unrelated
umbilical cord transplants have also found to have similar
rates of success as other sources.77
The efficacy of HSCT depends on both the conditioning
regimen and the GvL or graft versus leukemia reaction.
Children who receive less immunosuppressive therapy for
GvHD prophylaxis have a lower relapse rate.71 Similarly,
acute or chronic GvHD is associated with a lower risk of
relapse.71-73 Reducing the intensity and duration of GvHD
prophylaxis may significantly contribute to successful
leukemia control; however, unlike BCR-ABL positive CML,
donor lymphocyte infusion in JMML relapse is largely
unsuccessful.72
Post-HSCT relapse rates continue to be as high as
50 percent72,77 and tend to occur within a few months.71,72
A strategy of pretransplant intensive chemotherapy does
not reduce relapse rates.54,71 The impact of pretransplant
splenectomy is also unclear.54,72 Risk factors for relapse
include older age at transplant, increased HbF and
abnormal karyotype.71-73 However, a second transplant
often works in children who have relapsed.54,78
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43
Pediatric Hodgkin Lymphoma
Hodgkin lymphoma (formerly called Hodgkins disease) is a malignant lymphoma, first described by Hodgkin, in 1832 as some morbid
appearances of the absorbent glands and spleen that accounts for approximately 5 to 7 percent of childhood cancers and 1 percent
of all deaths.1 Hodgkin lymphoma (HL) is characterized by a progressive painless enlargement of lymph nodes and defined by
specific histopathological features. Pediatric HL is one of the few pediatric malignancies that shares aspects of its biology and natural
history with its adult counterpart. The odyssey of treatment in HL, which began with radiotherapy and then got revolutionized with
multiagent chemotherapy, has continued to grow better in terms of cure rates. With the currently available treatment modalities
(multiagent chemotherapy either alone or in conjunction with low-dose involved-field radiation therapy) and the use of risk-adapted
therapy, over 90 percent of children diagnosed with HL are long-term survivors. Currently, management designed to achieve maximal
cure rates with the fewest late-effects of therapy continues to be the paradigm for pediatric oncologists across the world.
EPIDEMIOLOGY
Variation in the incidence, age, and gender distribution of
HL occurs in different populations according to geographic
location, socioeconomic status, and immunologic status.
In Industrialized countries, HL presents with a bimodal
distribution with regard to age, with a rise in incidence
in young adults (2034 years) and in the elderly (5574
years).2 In contrast, in low-income countries, there is a
trimodal distribution. There is an inverse relationship
between the incidence of the HL in children and young
adults within countries according to their economic
development.3 Such patterns of occurrence being similar
to Epstein-Barr virus (EBV), tuberculosis and poliomyelitis
infections; the role of an environmental exposure has been
suggested as a possible etiology of HL. As many as 20 to
30 percent of childhood HL cases in developing countries
occur before 5 years of age4,5 against some 5 percent in
industrialized countries. Overall, there are three distinct
forms of Hodgkin lymphoma:
1. Childhood form (Ages 14 years and younger): This
type increases in prevalence in association with larger
family size and lower socioeconomic status. Early
exposure to common infections in early childhood
appears to decrease the risk of Hodgkin lymphoma,

most likely by maturation of cellular immunity.2
2. Young adult form (Ages 1534 years): This is associated
with a higher socioeconomic status in industrialized
countries, increased number of siblings, and earlier
birth order. Delayed EBV infection, particularly when
associated with infectious mononucleosis, is a risk
factor for the young adult form. It has been proposed
that delayed exposure to a common infectious agent
may also play a role in EBV-negative young-adult
cases, although the identity of the agent has not been
established.6
3. Older adult form: Most commonly presents in indi
viduals aged 55 to 70 years.
In India, lymphomas are the second most common
malignancies in children ahead of CNS tumors especially in
males unlike west where brain tumors are more common.
Importantly, HL exceeds non-Hodgkin lymphoma in India
in contrast to west due to significantly higher incidence of
HL in males in India. The age standardized incidence of
HL in Indian children ranges from 8.2 to 19.6 per million
children per year compared to 5.7 in USA and 6.4 in
Britain. Furthermore, mixed cellularity is most common
phenotype in India (likely related to early childhood EBV
exposure) leading to much younger age peak (median
age 89 years) compared to 1630 years in west where
nodular sclerosis is most common.7 Pediatric HL shows a
significant male predominance in low-income countries
including India (male : female ratios being 2.5:1 to 8:1)
compared to ratio of about 1.5:1 in west.8,9
ETIOLOGY
The etiology of Hodgkin lymphoma is believed to be
multifactorial and may include the following;
Infectious agents: Several studies have documented
a link between Hodgkin lymphoma and EBV. EBV
DNA can be identified in tumor cells in approximately
50 percent of patients in the United States as well
as Western Europe and in more than 90 percent of
patients in developing countries.10 EBV positivity is
most commonly observed in tumors with mixedcellularity histology and is almost never seen in
patients with lymphocyte-predominant histology. EBV
positivity is more common in children younger than
10 years compared with adolescents and young adults.
Patients with a prior history of serologically confirmed
infectious mononucleosis have a four-fold increased
risk of developing EBV-positive HL but are not at
increased risk for EBV-negative HL.11
Genetic predisposition: Clustering in families suggests
a genetic predisposition, with an increased incidence
observed among same-gender siblings, monozygotic
twins, and parent-child pairs. Familial Hodgkin
lymphoma has been associated with specific human
leukocyte antigens. Familial cases account for 4.5
percent of all cases.
Immune dysregulation: The increased susceptibility to
HL in patients with T-cell immunodeficiency, human
immunodeficiency virus (HIV) infection, or congenital
immunodeficiency syndromes suggest a role for
immune dysregulation in its development.
Environment: Clustering of cases in families or racial
groups supports the idea of a common environmental
link. At present, no conclusive association is recognized
with common environmental factors other than EBV
infection.
BIOLOGY
HL is a B-lineage lymphoma. The malignant cells of HL are
clonal Hodgkin/Reed-Sternberg (HRS) cells or lymphocytic
and histiocytic (L&H) cells or their morphologic variants,
which usually constitute less than 1 percent of the cells
in involved lymph nodes. Characteristic RS cells are
binucleate or multinucleate giant cells with prominent
nucleoli and abundant cytoplasm. The rest of the lymph
node contains a variable cellular infiltrate consisting of

lymphocytes, eosinophils, macrophages, plasma cells,
and fibroblasts. These infiltrating cells secrete an array of
cytokines and chemokines, which are important for HRS
cell survival and maintenance of the characteristic cellular
infiltrate. These malignant cells have three distinct origins;
in nodular lymphocyte predominant HL, the tumors cells
(L&H) derive from germinal centre (GC) or postgerminal
centre B-cells and retain expression of all B-cell specific
antigens. In classical HL, HRS cells are GC B-cells but have
crippling mutations that destroy the coding capacity of
their functional IgV gene rearrangements. In a minority
(2%) of classical HL cases, HRS cells display a cytotoxic
T-lymphoid phenotype.
In EBV-positive Hodgkin lymphoma, EBV-encoding
genes play a role in preventing apoptosis. Latent membrane
protein-1 (LMP-1) expressed in EBV-positive HRS cells
mimics an activated CD40 receptor, activating the antiapoptotic nuclear factorkappa-B (NF-B) pathway. A
paracrine activation of NF-B in Hodgkin lymphoma is
observed; both HRS cells and the surrounding supporting
cells produce cytokines that upregulate several members
of the TNF receptor superfamily, including CD30, CD40, or
EBV latent membrane protein-1 (LMP-1). The production
of the ligand for these receptors is responsible for the
phosphorylation and translocation to the nucleus of
NF-B. The constitutive translocation of NF-B to
the nucleus of HRS cells is essential for the malignant
transformation of HRS cells. It leads to inhibition of
apoptosis, proliferation, and secretion of proinflammatory
cytokines.12
PATHOLOGIC CLASSIFICATION
The current World Health Organization classification
classifies HL in two broad types based on both morphologic
appearance as well as immunophenotypic characterization
including type of neoplastic cells, inflammatory mileu and
overall growth pattern as detailed here.13
Classical Hodgkin Lymphoma

The hallmark of classic HL is the Reed-Sternberg cells
(R-S) cells and their mononuclear (Hodgkin cells) and
multinucleate variants which lack the immunophenotypic
evidence of B-cell differentiation. R-S cells almost always
express CD30, and approximately 70 percent of patients
express CD15. CD20 is expressed in approximately 6 to
10 percent of cases, and generally RS cells do not express
B-cell antigens such as CD45, CD19, and CD79A.
The classical HL is subclassified into four subtypes
according to the number of R-S cells, characteristics of
the inflammatory milieu, and the presence or absence of
Chapter-43 Pediatric Hodgkin Lymphoma 441

Table 1 Histopathological classification of classical Hodgkin lymphoma
REAL subgroups
Distinctive features
Lymphocyte rich (LR)
Benign appearing lymphocytes with or without histiocytes. Few Reed- 1015

Sternberg (RS) cells. No fibrosis
Nodular sclerosis (NS)
Thickened capsule with proliferation of orderly collagenous bands that 2050

divide lymphoid tissue in nodules: Lacunar variant of RS cells
Mixed cellularity (MC)
515 RS cells per high power field. Fine fibrosis in interstitium. Focal 2040
necrosis may be present
Lymphocyte depletion (LD)
Abnormal cells with relative paucity of lymphocytes. Fibrosis and necro- 516
sis common but diffuse
fibrosis. The histologic features and clinical symptoms

of HL have been attributed to the numerous cytokines
secreted by the R-S cells, which include interleukin-1,
interleukin-6, and tumor necrosis factor. Classical HL
subtypes are detailed in the Table 1.
Nodular LymphocytePredominant Hodgkin

Lymphoma
This pathologic class of Hodgkin lymphoma is
characterized by large cells with multilobed nuclei,
referred to as popcorn cells. These cells express B-cell
antigens, such as CD19, CD20, CD22, and CD79A, and are
negative for CD15 and may or may not express CD30. The
OCT-2 and BOB.1 oncogenes are both expressed unlike
classical HL. Nodular lymphocyte-predominant Hodgkin
lymphoma (NLPHL) is most common in males younger
than 10 years and constitutes 5 to 10 percent of all HL
cases. Patients with NLPHL generally present with slow
growing, localized, non-bulky disease usually in axilla and
inguinal regions without any B symptoms.
PRESENTING SYMPTOMS AND SIGNS

Presenting symptoms and signs of HL in children include
lymphadenopathy, systemic symptoms, and mediastinal
mass. HL almost always presents at a site above the
diaphragm, with only 3 percent of cases presenting in a
purely subdiaphragmatic location.14
Lymphadenopathy
Most common presenting sign is painless lymphadenopathy. Approximately, 80 percent of young children present with cervical lymphadenopathy. The affected lymph
nodes typically feel rubbery and more firm than inflammatory adenopathy; they may be sensitive to palpation, if
they have grown rapidly.
Relative frequency (%)
Hepatosplenomegaly
Hepatic and/or splenic enlargement may be present in
patients with advanced stage HL. Overall, children are
more likely than adults to present with stage I/II disease
and less likely to present with stage IV disease.
Mediastinal Mass
Unlike adolescents and young adults, only few young
children with HL have mediastinal disease at presentation
(approximately 75 vs 33 percent, respectively), in part
reflecting the tendency of these patients to have mixed
cellularity histology. Mediastinal masses are almost always
present in association with low cervical or supraclavicular
adenopathy. Such bulky mediastinal disease may cause
dysphagia, dyspnea, cough, stridor and the superior vena
cava syndrome.
Systemic Symptoms
Patients with HL may present with nonspecific systemic
symptoms including fatigue, anorexia, and weight
loss. Fewer than 20 percent of children with HL have B
symptoms which include unexplained persistent fever
(above 38C or 100.4F), drenching night sweats and weight
loss (more than 10 percent of body weight) in the previous
six months. These symptoms have important implications
for staging and prognosis. As in adults, pruritus, which
typically resolves with treatment, has been described.
Rarely, patients present with autoimmune disorders such
as autoimmune hemolytic anemia, thrombocytopenia, or
neutropenia.1518
The presenting symptoms and signs of HL in children and
adolescents may be caused by a variety of diseases and the
differential diagnosis includes other malignant, infectious,
and inflammatory diseases. In India, mycobacterial
infections are the most common differential diagnosis.
Others include EBV infection, Non-Hodgkin lymphoma,
metastatic adenopathy from other primary tumors (e.g.
nasopharyngeal carcinoma, soft tissue sarcoma), toxo
plasmosis, systemic lupus erythematosus, and other
disorders causing reactive hyperplasia of lymph nodes.19
DIAGNOSTIC EVALUATION
A complete evaluation of patients with suspected HL is
mandatory before beginning treatment. The goal is to
confirm the diagnosis, stage the disease, document other
prognostic factors, and to evaluate organ function that
may influence the selection of therapy.
ESTABLISHING THE DIAGNOSIS

After a careful physiological and radiographical evaluation
of the patient, the least invasive procedure should be used
to establish the diagnosis of lymphoma by biopsy of one
or more peripheral lymph nodes. Fine-needle aspiration
cytology alone is not recommended because of the lack
of stromal tissue, the small number of cells present in
the specimen, and the difficulty of classifying Hodgkin
lymphoma into one of the subtypes. An image-guided
biopsy may be used to obtain diagnostic tissue from intrathoracic or intra-abdominal lymph nodes. Patients with
large mediastinal masses are at risk of cardiac or respiratory
arrest during general anesthesia or heavy sedation. In
these patients, peripheral lymph node biopsy or imageguided core-needle biopsy of mediastinal lymph nodes
may be feasible using light sedation and local anesthesia
before proceeding to more invasive procedures. Supine
position should be avoided and procedures should be
done with the patient on his or her side or prone. If airway
compromise precludes biopsy, immediate treatment
with steroids or localized radiation therapy should be
considered and biopsy performed as soon as feasible
preferably within 48 hours.
LABORATORY STUDIES
Hematological and chemical blood parameters show
nonspecific changes that may correlate with disease
extent. Abnormalities of peripheral blood counts may
include neutrophilic leukocytosis, lymphopenia, eosino
philia, and monocytosis. Acute-phase reactants such as
the erythrocyte sedimentation rate and C-reactive protein,
if abnormal at diagnosis, may be useful in follow-up
evaluation. Patients with history of recurrent infections,
autoimmune and inflammatory disorders, or a family
history of immune deficiency should undergo a detailed

immunologic evaluation.
IMAGING STUDIES
The goal of imaging is to define the accurate extent and
stage of the disease. The following studies should be
obtained:
Anatomical Imaging
CT of neck, thorax, abdomen, and pelvis (with and without
intravenous contrast) should be obtained. Establishment
of lymphomatous involvement on CT-scan is complicated
by great variability of normal nodal size with body region
and age as well as the frequent occurrence of reactive
hyperplasia. However, contiguous nodal clustering or
matting, focal mass lesion in a visceral organ, size on long
axis of 2 cm or greater or between 1 cm and 2 cm with
other suggestive clinical features should be considered
significant. Currently, definitions of bulky disease are not
uniform and often depend on the clinical protocol with
bulky peripheral (non-mediastinal) lymphadenopathy
varying from aggregate nodal masses exceeding 4 to 6 cm
and bulky mediastinal mass as a transverse mediastinal
diameter over one-third of the maximum intrathoracic
diameter on an upright posterior-anterior (PA) chest
radiograph. However, the Cotswolds modification of the
Ann-Arbor classification has defined lymph nodes more
than 10 cm in greatest dimension on CT imaging as bulky.
Combined Anatomical and Metabolic Imaging

PET-CT, which integrates functional and anatomic tumor
characteristics, is being increasingly used for staging and
monitoring of pediatric patients with HL. In PET scan,
uptake of the radioactive glucose analog, 18-fluoro-2deoxyglucose (FDG) correlates with proliferative activity
in tumors undergoing anaerobic glycolysis and adds to the
anatomical information from CT scan. In recent studies,
PET findings resulted in a change in staging in more than
50 percent of patients and subsequent adjustments in
involved-field radiation therapy treatment volumes in 70
percent of patients. Concordance between PET and CT is
generally high for nodal regions, but lower for extranodal
sites such as spleen, lung nodules, bone/bone marrow, and
pleural and pericardial effusions. Generally, a suspected
anatomic lesion which is PET-negative should not be
considered involved unless proven by biopsy and areas
of PET positivity that do not correspond to an anatomic
lesion should be disregarded in staging. PET scan is
more accurate in detecting viable HL in post-therapy
residual masses. Residual or persistent FDG avidity has

Table 2 Cotswolds revision of Ann Arbor staging classification
Stage
Definitions
Involvement of a single lymph node (LN) region (I) or of a single extranodal organ or site (IE)
II
Involvement of two or more LN regions, on the same side of the diaphragm (II) or localized involvement of an
extralymphatic organ or site and one or more LN region on the same side of the diaphragm (IIE)
III
Involvement of LN regions on both sides of the diaphragm (III), which may be accompanied by involvement of the
spleen (III S) or by localized involvement of an extralymphatic organ (III E) or both (IIISE)
IV
Noncontiguous involvement of one or more extralymphatic site with or without LN involvement
Annotations
Definitions
No B symptoms
At least one of the following within the last 6 months:

a. Weight loss >10%
b. Unexplained persistent or recurrent fever
c. Drenching night sweats
Bulky disease (>6 cm in diameter or mass >1/3 of mediastinal) diameter
Extension to a single extralymphatic organ adjacent to a known involved site
been correlated with prognosis. Rapid early response

documented by significant reduction in disease volume
and PET negativity at an early stage (after one or two cycles
of chemotherapy) is associated with a favorable outcome.
PET scanning should be performed at baseline and a not
earlier than 3 weeks postchemotherapy completion and 8
to 12 weeks post-radiation.2022
Staging and Prognostic Factors

Current Hodgkins lymphoma staging is based on
Cotswolds modification of Ann Arbor staging proposed
in 1998 (Table 2). The assessment to determine stage of
disease involves scrupulous history for B symptoms and
laboratory studies including a blood count, LDH, ESR, and
liver function tests apart from imaging studies detailed
here. Bone marrow biopsy is indicated in those with
advanced disease (stage III/IV), B symptoms, elevated
alkaline phosphatase or hematologic abnormalities.
Recently, with the advent of PET-CT scan, which is highly
sensitive for bone marrow involvement, bone marrow
biopsy is considered mandatory only in ambiguous cases.
Sites of bulk disease, disease infiltration into extranodal
tissues, presence of B-symptoms, ESR, hemoglobin, WBC
count, and gender should be documented.
These prognostic factors may be able to identify a
group of patients with an extremely low risk of relapse for
whom therapy may be minimized. Because the treatment
of HL has improved and fewer patients relapse after initial
therapy, many previously reported clinical factors have lost
their prognostic significance. Also, these factors may be
interrelated in the sense that disease stage, bulk, and biologic
aggressiveness are frequently codependent. Consequently,
no uniform system of prognostic strati
fication exists in
pediatric HL. Different clinical trial groups have established

various risk categorizations as outlined in Table 3. In
general, these incorporate stage of disease, disease bulk, and
systemic (B) symptoms.23-26
TREATMENT
The treatment of Hodgkin lymphoma (HL) in children
requires a careful balance between providing enough
therapy to eradicate the tumor and avoiding unnecessary
treatment that could result in excessive long-term
treatment-related side effects. Hence, focus is on
maximizing treatment efficacy and minimizing risks for
late toxicity associated with both RT and chemotherapy.
The treatment paradigm for childhood HL is risk,
gender and response adapted use of non-crossresistant
combination chemotherapy with or without low-dose
involved-field radiation therapy. This approach is
supported by information obtained from clinical trials
and meta-analyses of randomized trials evaluating the
influence of radiation field size, dose and the role of
chemotherapy in children with HL.
Combined Modality Therapy in Children

with Hodgkin Lymphoma
A number of randomized clinical trials have investigated
the benefit of adding chemotherapy to radiation therapy
in the treatment of HL. While the radiation therapy acts to
control known sites of tumor, the chemotherapy is aimed
at occult disease outside the radiation field. The judicious
combination of the two modalities allows for a decrease
in the dose and size of the radiation field used and a
reduction in the intensity or duration of chemotherapy
Table 3 Prognostic factors and risk stratification in pediatric Hodgkin lymphoma
Study group/Trial
Low risk
Intermediate risk
High risk
Childrens Oncology Group
IA/IIA no bulk or extranodal extension
IIIB, IVB
German studies/Euronet PHL
IA/B
IIA
IIB
IIEA
IIB
St Jude/Stanford/Dana Farber
IA/IIA no bulk
IA bulk
IB
IIA bulk
IIB
III
IV
Childrens Cancer Group 5942
IA/B patients no adverse features*

IIA patients no adverse features*
IA/B patients with adverse features*

IIA patients with adverse features*
IIB
IIIA/B
IA bulk or E extension
IB
IIA bulk or E extension
IIB
IIIA
IVA
IIEB
IIIEA/B
IIIB
IV
IV
*Adverse factors include hilar lymphadenopathy, >4 sites of nodal disease, or bulky disease.
Patients categorized as favorable or unfavorable risk.
below toxicity thresholds that would not be possible if

single modality chemotherapy or RT were used, thus
decreasing overall acute and late toxicities. The use of RT
in pediatric HL permits reduction in dose-related toxicity
of anthracyclines, alkylating agents, and bleomycin that
may preserve cardiopulmonary as well as gonadal function
and reduce the risk of secondary leukemia. The results of
prospective and controlled randomized trials indicate that
combined modality therapy, compared with chemotherapy
alone, produces a superior event-free survival (EFS). Thus,
combined modality treatment approach has become the
preferred initial therapy for children with HL.27
Chemotherapy Regimens in Children with

Hodgkin Lymphoma
Contemporary chemotherapy regimens in HL combine
non-crossresistant agents wherein each agent is indi
vidually active against tumor but targets different
cellular events to prevent drug-resistance and have nonoverlapping toxicities which allow delivery of each agent
at full dose which are detailed in Table 4. All of the agents
in original MOPP and ABVD regimens continue to be used
in contemporary pediatric treatment regimens. However,
COPP with less leukemogenic and gonadotoxic potential
(substituting cyclophosphamide for mechlorethamine)
has replaced MOPP as the preferred alkylator regimen. In
contrast to adult HL, pediatric chemotherapy approaches

have focused on 2 unique strategies.
Avoidance of Late Toxicity

Non-crossresistant regimen like ABVD has demonstrated
superior efficacy (i.e. freedom from progression) and less
toxicity when compared with MOPP in adults with Hodgkin
lymphoma.28 However, due to cardiac and pulmonary
toxicity of ABVD in children, many investigators have
evaluated regimens either devoid of anthracyclines,
alkylators and/or bleomycin such as VAMP (St Jude), VBVP
(French MDH-90 study) or hybrid regimens that utilize
lower total cumulative doses of alkylators, doxorubicin,
and bleomycin such as COPP/ABV (CCG) or ABVE-PC
(POG). VAMP like less-toxic regimens can be safely used in
favorable risk HL but not in intermediate or high-risk HL.29
Gender-Adapted Chemotherapy
In an effort to decrease risk for male infertility, etoposide
has been substituted for procarbazine in the initial
courses of therapy in studies of the German pediatric HL
group (OPEA) and Pediatric Oncology Group (DBVE and
DBVE-PC)30 and dacarbazine (COPDAC) has been used to
replace procarbazine (COPP) with preservation of efficacy
and minimization of infertility.31

Table 4 Contemporary chemotherapy regimens for children with Hodgkin lymphoma
Name
Drugs
COPP
Cyclophosphamide, vincristine (oncovin), procarbazine, prednisone
COPDAC
Dacarbazine substituted for procarbazine in COPP
OPPA
Vincristine (Oncovin), procarbazine, prednisone, doxorubicin (Adriamycin)
OEPA
Vincristine (Oncovin), etoposide, prednisone, doxorubicin (Adriamycin)
ABVD
Doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine
COPP/ABV
Cyclophosphamide, vincristine (Oncovin), procarbazine, prednisone, doxorubicin (Adriamycin), bleomycin, vinblastine
VAMP
Vinblastine, doxorubicin (Adriamycin), methotrexate, prednisone
DBVE
Doxorubicin, bleomycin, vincristine (Oncovin), etoposide
ABVE-PC
Doxorubicin (Adriamycin), bleomycin, vincristine (Oncovin), etoposide, prednisone

cyclophosphamide
BEACOPP
Bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine
Radiotherapy
Consolidative radiation therapy (RT) after risk-adapted
chemotherapy is an integral part of treatment of children
with HL.27 Radiation has been used as an adjunct to
multiagent chemotherapy in intermediate/high-risk pedi
atric HL with the goal of reducing risk of relapse in initially
involved sites and preventing toxicity associated with
second-line therapy. Compared with chemotherapy alone,
adjuvant radiation produces superior EFS for children
with intermediate/high-risk HL who achieve a complete
remission (CR) to multiagent chemotherapy, but it does
not affect overall survival (OS) because of the success of
second-line therapy.29,30 Since, adjuvant radiation therapy
may be associated with excess late effects or mortality;
there has been a movement to decrease the field of
radiation as well as dose of radiation therapy in order to
limit toxicities while maintaining survival rates.
Radiation Dose
The dose of radiation is variously defined and often
protocol specific. However, doses of 15 to 25 Gy are
typically used with modifications based on patient age, the
presence of bulky or residual (postchemotherapy) disease,
and normal tissue concerns.37 Some protocols prescribe
a boost of 5 Gy in regions with suboptimal response to
chemotherapy.
Radiation Therapy Volume

Involved field radiation therapy (IFRT) is the current
standard of care in children in place of total nodal RT.
The IFRT treats the clinically involved region(s), with
coverage of the whole nodal region but accounts for tumor
regression with chemotherapy and avoids extensive

inclusion of uninvolved regions. With contemporary
low-dose RT, treatment of contralateral uninvolved sites
is not necessary in most children. Currently, targeted
RT, which entails restricting RT to areas of initial bulky
disease (generally defined as 5 cm at the time of disease
presentation) or post-chemotherapy residual disease
(generally defined as 2.5 cm or residual PET-avidity),
and involved-nodal RT, which treats only the initially
involved nodes with a margin (typically 2 cm), are under
investigation.
Radiation Therapy Technique

While CT-based two-dimensional RT remains the standard
technique for radiation delivery, three-dimensional
conformal RT (3D CRT) or intensity-modulated radiation
therapy (IMRT) are often used in situations where
the more conformal techniques would reduce dose to
surrounding normal critical structures. Proton therapy is
currently being investigated and may further decrease the
mean dose to the surrounding normal tissue compared
with IMRT or 3D CRT.
Response-Adapted Therapy
Response to therapy is one of the most robust prognostic
factors in HL as in many other pediatric tumors. The concept
of tailoring the extent as well as dose of radiotherapy and
duration of chemotherapy based on response to therapy
in HL is the focus of many recent and future trials.
With regards to avoiding radiotherapy in patients with
early stage favorable risk HL, finding from three recent
studies32,33 (COG-9542, GPOH HD-95 and Euronet PHL
C-1) have shown that RT can be safely avoided in patients
who achieve CR after initial chemotherapy. However,
omission of RT was found to be detrimental in intermediate
and high-risk subgroups except in a recent North American
study (COG AHOD 0031) which showed that RT can be
avoided in rapid early responders in intermediate risk HL.34
In advanced HL, a recent POG study (P9425) has
shown that in rapid early responders to a dose dense
chemotherapy, further chemotherapy can be safely
curtailed. In this study, 216 children with intermediate or
high-risk HL received ABVE-PC every 21 days. Rapid early
responders (RER, 63% of patients) to 3 cycles received 21
Gy RT to involved regions. Slow early responders received
two additional cycles before 21 Gy radiation.35 Five-year
EFS was 86 percent for the RER and 83 percent for the
slow early responders (P = 0.85). Five-year OS was 95
percent. Cumulative doses of alkylators, anthracyclines,
and epipodophyllotoxins were below thresholds usually
associated with significant long-term toxicity.
Similarly, Childrens Cancer Group (CCG) (CCG59704) evaluated response-adapted therapy featuring four
cycles of the dose-intensive BEACOPP regimen followed
by a gender-tailored consolidation for pediatric patients
with high-risk HL. For rapid early responding girls, an
additional four courses of COPP/ABV (without IFRT) was
given in an effort to reduce breast cancer risk. Rapid early

responding boys received two cycles of ABVD followed
by IFRT. Slow early responders received four additional
courses of BEACOPP and IFRT. RER was achieved by 74
percent of patients after four BEACOPP cycles and 5-year
EFS among the cohort was 94 percent.36
RECOMMENDATIONS FOR TREATMENT OF

PEDIATRIC HODGKIN LYMPHOMA
Treatment of Low-risk Classical Hodgkin
Lymphoma
The preferred treatment option for early stage, favorable
prognosis HL (stages IIIA; no bulky disease; no B
symptoms, less than four sites of disease) is combined
modality treatment including hybrid chemotherapy with
less or no alkylators and anthracyclines (VAMP/VBVP/
OPPA/OPEA or equivalent) for two to four cycles with
or without low-dose IFRT of 15 to 25 Gy. IFRT can be
safely avoided in children who achieve CR after initial
chemotherapy in some regimens (Table 5). Ongoing
trials for patients with low-risk HL are evaluating the
effectiveness of treatment with fewer cycles of combination
chemotherapy alone that limit doses of anthracyclines
and alkylating agents.29-31
Table 5 Risk-adapted treatment of newly diagnosed Hodgkin lymphoma in children

Risk group
5 yr EFS
5 yr OS
92%
98%
85%
95%
83%
94%
Low risk disease

Four cycles of VAMP with LD-IFRT (if not in CR after 2 cycles) or without IFRT ( if in CR post 2 cycles)
Four cycles of COP/ABV plus LD-IFRT
ABVE, administered for two to four courses depending on response, followed by LD-IFRT
Two cycles of OEPA or OPPA with LD-IFRT (if not in CR after two cycles) or without IFRT (if in CR post two cycles)
Intermediate risk disease
Six cycles of COPP/ABV plus LD-IFRT
ABVE-PC, administered for three to five courses depending upon response, with or without LD-IFRT
Two cycles of OPPA (for males) or OEPA (for females), followed by two cycles of COPP (for females) or COPDAC
(for males) plus LD-IFRT
High-risk disease
ABVE-PC, administered for three to five courses depending upon response, followed by LD-IFRT
Two cycles of OPPA (for males) or OEPA (for females), followed by four cycles of COPP (for females)
or COPDAC (for males) plus LD-IFRT
Two cycles of cytarabine/etoposide, COPP/ABV, and CHOP plus LD-IFRT
Four cycles of BEACOPP with subsequent dependent upon response; rapid responders: four cycles of COPP/ABV
without IFRT (for females) or two cycles ABVD with IFRT (for males); slow responders: four additional cycles of
BEACOPP plus IFRT
Treatment of Intermediate Risk

Classical Hodgkin Lymphoma
Patients with intermediate risk HL (all stage I and stage II
patients not classified as early stage; stage IIIA) generally
qualify for combined modality treatment. However,
the ideal chemotherapy and radiation combinations
are not yet clearly defined, and there is an ongoing
desire to optimize treatment in this risk group. These
children require 3 to 6 cycles of dose-intense alkylator
based chemotherapy followed by low-dose IFRT. In
some studies, chemotherapy is given to maximal tumor
response, as judged by CT scan and PET, after which
two additional cycles of consolidation chemotherapy are
given followed by limited RT (Table 5). The patients with
rapid early response may be treated with less number of
chemotherapy cycles as shown in the recent studies (POG
9425)35 or may not require RT (COG AHOD 0031).34
Treatment of High-risk Classical

Hodgkin Lymphoma
Children with high-risk (Stages IIIB, IV) HL require 6 to
8 cycles of dose-intense alkylator based chemotherapy
regimens followed by low-dose IFRT (Table 5).37 Current
trials for patients with intermediate/high-risk HL are
testing, if chemotherapy and radiation therapy can be
limited in patients who achieve a rapid early response to
dose-intensive chemotherapy regimens.
Treatment of Nodular LymphocytePredominant Hodgkin Lymphoma

NLPHL, an uncommon subtype, represents a more indo
lent disease than classical HL, and is therefore managed
uniquely. Most information concerning its therapy
has come from reports of single institutions or pooled,
multi-institutional retrospective analyses in children and
adults. Generally, patients with stage I/II NLPHL without
B symptoms are treated with less intensive therapy than
patients with classical HL. In contrast, patients with stage
III/IV are treated in a similar fashion to patients with
classical HL. The current strategies for treating NLPHL in
children are modest intensity chemotherapy regimens,
some without anthracyclines, with or without IFRT.
Given the indolent nature of NLPHL and because
deaths observed among individuals with this histological
subtype are more frequently related to complications
from cytotoxic therapy, several pediatric study groups
have evaluated treatment de-escalation in an attempt to
avoid toxicities associated with treatment.38,41,42 Some have
evaluated the use of chemotherapy alone or observation
without treatment following excision in children with

stage I NLPHL. The overall survival (OS) in most series is
100 percent, with lower progression-free survival (PFS)
and EFS in series with surgery alone (67 to 82 percent)38,39
or with CVP (cyclophosphamide, vincristine, prednisone)
chemotherapy (74 percent).40
Relapsed or Refractory Disease

Most relapses in children with HL occur in first 3 years.
Treatment and prognosis after relapse depends upon
the timing of relapse, the initial stage of disease, and the
initial treatment given. Also, presence of B symptoms,
extranodal disease and inadequate response to secondline therapy portend poor prognosis. Relapsed patients
may be classified in 2 groups for prognostication and
treatment planning.
Low-risk (Favorable) Group

Children with localized late ( 12 months after completing
therapy) recurrences after limited risk-adapted therapy or
with chemotherapy alone and/or IFRT have a high likelihood of achieving long-term survival following treatment
with more intensive conventional chemotherapy alone.
Intensive non-crossresistant regimens using agents not
part of initial treatment such as cytarabine at moderate or high doses, carboplatin and cisplatin, ifosfamide,
etoposide, vinorelbine, gemcitabine, and vinblastine are
used. Approximately, two-third of these patients may be
salvaged with second-line chemotherapy.
High-risk Group
Children who develop refractory disease during therapy
or relapsed disease within 1 year after completing
therapy require aggressive salvage chemotherapy and
consolidation with high dose chemotherapy and sub
sequent autologous hematopoietic cell transplantation
(HCT).43,44 Autologous source of stem cells is preferable to
allogeneic because of the high transplant-related mortality
(TRM) associated with allogeneic transplantation.
Following autologous HCT, the projected overall survival
rate is 45 to 70 percent and progression-free survival (PFS)
is 30 to 89 percent. Patients who fail autologous HCT or
for patients with chemoresistant disease, allogeneic HCT
has been used with encouraging results. Salvage rates
for patients with primary refractory HL are poor even
with autologous HCT and range from 20 to 40 percent.
Brentuximab vedotin (Anti-CD30 monoclonal antibody)
has been evaluated in adults with relapsed/refractory
HL and has shown promising response rates of 50 to 70
percent in phase-I/II studies.
Table 6 Late effects in Hodgkin lymphoma survivors
Adverse effects
Predisposing therapy
Clinical features
Thyroid
Radiation to thyroid
Hypothyroidism, hyperthyroidism, thyroid nodules
Cardiovascular
Radiation to heart
Left ventricular dysfunction, cardiomyopathy pericarditis, heart valve

dysfunction, conduction disorders, vascular disease, myocardial
infarction, stroke
Anthracyclines
Left ventricular dysfunction, cardiomyopathy, congestive heart

failure
Radiation to lungs
Subclinical pulmonary dysfunction
Bleomycin
Pulmonary fibrosis
Radiation to musculoskeletal tissues
Growth impairment
Glucocorticosteroids
Bone mineral density deficit
Alkylating agents
Hypogonadism
Gonadal irradiation
Infertility
Alkylating agents
Myelodysplasia/acute myeloid leukemia
Epipodophyllotoxins
Myelodysplasia/acute myeloid leukemia
Radiation
Solid benign and malignant neoplasms
Pulmonary
Musculoskeletal
Reproductive
Subsequent neoplasm
or disease
FOLLOW-UP AND LATE EFFECTS
SUMMARY
Current 5-year relative survival for HL is approximately 90

percent with higher rates reported in younger populations.45
However, emergence of late toxicity among survivors can
limit long-term survival and affect quality of life. Mortality
in the first 15 years after diagnosis relates to the primary
disease and following that to second cancers (SMNs)
and cardiovascular disease (CVD).46 Hence, children
treated with HL should be closely followed for relapse
as well as late effects. Imaging is not recommended for
routine follow-up, as a recent Childrens Oncology Group
Study, which evaluated surveillance CT for detection of
relapse, found that most relapses were detected based on
symptoms, laboratory, or physical findings without any
incremental value of imaging. The method of detection
of late relapse, whether by imaging or clinical change, did
not affect overall survival.47
HL survivors continue to be at risk of treatment related
mortality for decades beyond their initial disease. In a
recent Childhood Cancer Survivor Study of morbidity
and mortality risks among 2742 survivors of HL in the
USA, substantial excess absolute risk of mortality per
10000 person-years was identified: overall 95.5; death
due to HL-38.3, SMNs-23.9, and CVD-13.1.48 Commonly,
adverse treatment effects may impact musculoskeletal
development, endocrine, reproductive, cardiovascular
and pulmonary function and risk of secondary carcino
genesis. Adverse effects have reduced overtime with use
of risk-adapted less toxic chemotherapy and low-dose
radiotherapy. Table 6 summarizes the common late effects
and their etiology in children with HL.
Pediatric Hodgkin lymphoma is currently one of the

most curable childhood malignancies with more than 90
percent cure rates in recent studies. Risk and responseadapted combined modality therapy is the current stan
dard of care and is stratified based on disease stage and
the presence of adverse prognostic factors. Long-term
follow-up of pediatric HL patients should take place in
a comprehensive pediatric-oncology center, where late
complications can be anticipated, monitored, and treated.
Recent trials are exploring to reduce toxicities of treatment
with the selective elimination of radiotherapy, devising
less toxic chemotherapy regimens and assessing the role
of functional imaging with PET in assessing response and
predicting outcome.
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44
Non-Hodgkin Lymphoma in Children

and Adolescents
Non-Hodgkin lymphoma (NHL) is diverse collection of neoplasms of lymphoid system derived from numerous cell types comprising
the immune system including B-cell progenitors, T-cell progenitors, mature B-cells, or mature T-cells. Lymphomas are systemic diseases
and have patterns of spread that mimic the migration patterns of their normal cellular counterparts. Progress in therapy of childhood
NHL is one of the greatest success stories of the pediatric oncology in past two decades. More than 75 percent of children with NHL
can now be cured with modern therapy. These extraordinary advances in treatment have resulted from enhanced understanding of
the biology, immunology, and molecular biology of the NHL; improvements in imaging and staging systems; advances in supportive
care; and more rational application of risk adapted chemotherapy by cooperative group trials. Consequent to such high cure rates, the
current focus is on optimization of therapy to reduce the acute and long-term consequences of treatment.
Childhood NHL is a heterogeneous collection of diseases

derived from both mature and immature cells of Band T-lineage. Early morphology based classification
systems have given way to a practical approach
utilizing available immunologic and molecular genetic
techniques in addition to the standard morphologic
criteria in the current World Health Organization
(WHO) classification of hematopoietic and lymphoid
tumors. Although nearly all pathologic subtypes of NHL

can be seen in children, majority of NHL that occur in
children appear in four major categories in the WHO
classification systems which are detailed in Table 1.
Unlike adults where more than 60 percent lymphomas
are indolent, childhood NHL are diffuse, intermediatehigh grade, clinically aggressive and are predominantly
multifocal and disseminated at diagnosis.1
Histology
Burkitt and Burkitt-like
Table 1 Major biologic subgroups in childhood NHL

Immunology
Clinical features
B-cell
Abdominal masses, GIT tumors,
Waldeyers ring
Diffuse large B-cell lymphoma

(DLBCL)
Primary mediastinal DLBCL
Anaplastic large cell
B-cells (germinal center or postgerminal center)

B-cells (medullary thymus)
T-cell, null cell or NK cell (CD30+)
Abdominal masses, GIT tumors,

Waldeyers ring
Mediastinum
Skin, nodes, bone, lung
Precursor T lymphoblastic
T-cell
Anterior mediastinal mass
Precursor B lymphoblastic
B-cell precursors
Skin, lymph node
Cytogenetics
t(8;14)(q24;q32)
t(2;8)(p11;q24)
t(8;22)(q24;q11)
t(8;14)(q24;q32)
t(2;17)(p23;q23)
t (2;5) (p23;q35)
t (1;2) (q21;p23)
t (2;3) (p23;q21)
t (1;14) (p32;q11)
t (11;14) (p13;q11)
t (10;14) (q24;q11)
t (7;19) (q35;p13)
EPIDEMIOLOGY AND ETIOLOGY OF

CHILDHOOD NHL
Lymphoma (Hodgkin and non-Hodgkin) is the third
most common childhood malignancy, and NHL accounts
for approximately 7 to 10 percent of cancers in children
younger than 20 years. NHL occurs most commonly in
the second decade of life, and occurs less frequently in
children younger than 3 years.
Immunodeficiency, both congenital and acquired (HIV
infection or post-transplant), increases the risk of NHL
more than 100-fold compared with general population.
Epstein-Barr virus (EBV) has been shown to transform
human B-cells and has been associated with lymphomas
in immunocompromised hosts. However, its role in
pathogenesis of NHL in immunocompetent individuals
is unproven. EBV DNA has been found in more than 95
percent of tumor cells in endemic Burkitt lymphoma (BL)
in Africa in contrast to only 15 to 20 percent in sporadic BL
in Europe and North America.1,2
The incidence and relative frequency of various subtypes
of lymphoma in children varies considerably in different
world regions. In India, the estimated incidence is between
6 to 10/million/year with an almost equal distribution of
B- and T-cell tumors.1,2 In India, there is no populationbased study with sufficient immunohistochemical backup
to allow assignment according to the WHO classification.
However, data from lymphoma registry at Tata Memorial
Hospital (TMH) suggests that B-cell lymphomas form 48.1
percent of NHLs whereas T-cell lymphomas form 44.3
percent of all the lymphomas. Of B-cell, diffuse large B-cell
lymphoma (DLBCL) is the most common (22.9%) followed
by BL (15.3%) and in T-cell, lymphoblastic lymphoma
(LL) is the most common (31.5%) followed by anaplastic
large cell lymphoma (ALCL) seen in 11.1 percent cases.
Overall, there seems to be a higher prevalence of DLBCL
and LL and lower frequency of BL compared to western
countries.3
CLINICAL FEATURES
Burkitt Lymphoma
Burkitt lymphoma (BL) is the most common subtype and
accounts for about 30 to 50 percent of childhood NHL.
It exhibits consistent, aggressive clinical behavior. The
malignant cells display a mature B-cell phenotype with
expression of surface immunoglobulin M with either
kappa or lambda light chains, CD20, CD22, CD10 and
are negative for the enzyme terminal deoxynucleotidyl
transferase (TdT). BL expresses a characteristic chromo
somal translocation, t(8;14) in 80 percent cases and t(8;22)
or t(2;8) in rest 20 percent of children; which is considered
the gold standard for diagnosis of BL. Each of these
translocations results in the inappropriate expression of

cMYC, the gene involved in cellular proliferation due to
juxtaposition of the cMYC oncogene on chromosome
8 and immunoglobulin locus regulatory elements
on chromosome 14, 2 or 22. Endemic BL possesses
breakpoints upstream of cMYC while sporadic BL have
breakpoints within cMYC. The two most common primary
sites of disease are the abdomen and head-neck region.
Other sites of involvement include testes, bone, peripheral
lymph nodes, skin, bone marrow (BM), and central
nervous system (CNS).1,4
Diffuse Large B-cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) represents 10 to 20
percent of pediatric NHL. DLBCL occurs more frequently
during the second decade of life. Pediatric DLBCL is
clinically similar to BL, though it is more often localized
and less often involves the BM or CNS. These cells have
a mature B-cell immunophenotype with expression of
CD19, CD20, CD22, CD79a, and PAX5. Most cells express
monoclonal surface immunoglobulin light chain. They
have a high mitotic rate but MIB-1 index is less than 90
percent. In contrast to adults, pediatric DLBCL have
high expression of cMYC and low expression of BCL-2.
Majority of pediatric DLBCL have a germinal center B-cell
phenotype with expression of normal germinal center
markers such as the BCL6 gene product and CD10. Unlike
adult DLBCL, pediatric diffuse DLBCL rarely demonstrates
the t(14;18) translocation but 30 percent of will have a gene
signature similar to BL.
About 20 percent of pediatric DLBCL present as
primary mediastinal disease (primary mediastinal B-cell
lymphoma [PMBCL]). This presentation is more common
in older children and adolescents. These tumors arise
from thymic B-cells and show diffuse large cell prolife
ration with classic compartmentalizing sclerosis. Cells
have surface markers similar to DLBCL but lack surface
immunoglobulins and commonly express CD30. It is
associated with distinctive chromosomal aberrations
(gains in chromosome 9p and 2p in regions that involve
JAK2 and c-REL, respectively) and has an inferior outcome
compared with other pediatric DLBCL.1,4
Lymphoblastic Lymphoma
Lymphoblastic lymphoma (LL) makes up approximately
20 percent of childhood NHL. More than 75 percent of
LL usually have a T-cell immunophenotype (T-LL) and
the remainders have a precursor B-cell phenotype (BLL). These are part of a spectrum of precursor blast cell
neoplasms seen in children. By definition, patients with
more than 25 percent marrow blasts are considered to have
leukemia, and those with fewer than 25 percent marrow
Chapter-44 Non-Hodgkin Lymphoma in Children and Adolescents 453

blasts are considered to have lymphoma. However, this is
arbitrary and current WHO classification labels them in the
category of lymphoblastic lymphoma/leukemia. Notably,
despite the clinicopathologic overlap between ALL and LL,
there is suggestion of different gene expression profile and
loss of heterozygosity at 6q indicating biologic differences
between them. Cytologically, cells have a high mitotic rate
and express TdT. T-LL display cortical thymocyte origin
and express CD1a, CD2, CD5 and CD7 along with coexpression of CD4 and/or CD8. B-LL displays early pre-B
or pre-B immunophenotype with expression of CD19,
CD10 and TdT. Majority of patients with T-LL present with
an anterior mediastinal mass and may have symptoms
of dyspnea, wheezing, stridor, dysphagia, or swelling of
the head and neck due to compression of mediastinal
structures which is called superior vena cava syndrome
(SVCS). Pleural effusions and supradiaphragmatic lymph
nodes may also be present. There may also be involvement
of bone, skin, bone marrow, CNS, abdominal organs
(but rarely bowel), and occasionally other sites such as
lymphoid tissue of Waldeyer ring and testes.1,4
Anaplastic Large Cell Lymphoma

Anaplastic large cell lymphoma (ALCL) is a peripheral
T-cell lymphoma (PTCL) as per WHO classification and
accounts for approximately 10 percent of childhood NHL.
Majority of ALCL are mature T-cell, but 20 percent may
have null-cell disease (i.e. no T-cell, B-cell, or NK-cell
surface antigen expression). However, ALK positive null
ALCL shows TCR gene rearrangements. Morphologically,
classic variant shows large anaplastic cells and horseshoe
like multinucleate hallmark cells. Ten percent would
have lymphohistiocytic variant with lots of benign
histiocytes and a small percentage would show the small
cell variant. The latter two variants have relatively poor
prognosis. Immunophenotypically, tumors cells variably
express CD30, CD45, epithelial membrane antigen and
ALK protein. More than 90 percent of ALCL cases have the
translocation t(2;5)(p23;q35) leading to the expression of
the fusion protein NPM/ALK. Clinically, ALCL has protein
presentations, including involvement of lymph nodes and
a variety of extranodal sites, particularly skin and bone and,
less often, gastrointestinal tract, lung, pleura, and muscle.
Involvement of the CNS and bone marrow is uncommon.
ALCL is often associated with systemic symptoms (e.g.
fever, weight loss) and a prolonged waxing and waning
course, making diagnosis difficult and often delayed.1,4
Rare Lymphomas in Children

Indolent mature B-cell lymphomas, are rare in children
but follicular lymphoma (FL) and nodal marginal zone
lymphoma (MALT) have been described and accepted by
WHO as unique entities. Pediatric follicular lymphoma

predominantly occurs as cervical adenopathy and tonsillar
enlargement generally in males, and is more likely to be
localized disease. It can rarely involve extranodal sites such
as the testis, kidney, gastrointestinal tract, and parotid.
The outcome of pediatric follicular lymphoma is excellent.
MALT lymphomas present as low-stage (stage I or II)
disease both in nodal and extranodal sites such as stomach
(associated with H. pylori infection) and conjunctiva
(associated with chlamydial psittaci infections).4-6
Diagnostic and Staging Evaluation

The diagnosis of NHL is based upon the pathologic
evaluation of involved tissue, usually an abdominal mass,
extranodal site, or lymph node, interpreted within the
clinical context. Subtypes of NHL are identified using
histology, immuno
phenotype, and genetic studies.
Most children present with advanced-stage disease
including BM invasion or/and malignant effusions. In
such cases, correct diagnosis can be made by cytology
and immunophenotyping by flow cytometry. If this is not
possible, diagnosis is based on biopsy, and most cases are
correctly classified by cytology of tumor touch imprints,
histomorphology, and immunohistochemistry. In most
cases, these enable correct classification and allocation
of patients to appropriate treatment subgroups. In certain
cases, cytogenetics is also required for diagnosis, such
as variant BL/BL-like lymphomas. Fluorescence in situ
hybridization (FISH), which can be performed on tumor
touch preparations, or paraffin sections, is a standard
method for confirming most of the chromosomal
translocations.1,4
Routine staging of pediatric NHL should include
contrast enhanced computerized tomographic (CT)
imaging of the neck, chest, abdomen, and pelvis.
Baseline CT serves to help determine disease stage at
diagnosis and to provide a baseline for comparison
to determine response to treatment. Examination
of cerebrospinal fluid and BM is crucial for staging
evaluation. Laboratory tests also may be abnormal
in patients with newly diagnosed pediatric NHL
such as unexplained anemia, thrombocytopenia, or
leukopenia due to extensive bone marrow infiltration,
hyperuricemia as well as other features of tumor
lysis syndrome and elevated level of serum lactate
dehydrogenase (LDH) due to high tumor burden.1,4
Emerging role of PET-scan: PET-CT scan of whole body
for staging and response evaluation in children is
currently investigational and being evaluated in many
current studies. Although PET-CT is recognized to be
advantageous in the primary staging of adult NHL,
this has not been demonstrated in childhood NHL.
This may be, because majority of children present
with advanced disease (stages III or IV) which is easily
detectable by CT-scan. However, PET-CT appears to
have a higher level of sensitivity than bone marrow
biopsy in the detection of bone marrow infiltration
and hence may be useful as a noninvasive modality
for detecting bone marrow involvement in pediatric
NHL.1,4,7
Similarly, early response assessment to chemo
therapy with an interim PET is now routine done in the
management of adults with NHL; this is not regarded
as standard practice in children due to limited data.
However, PET may be potentially useful for assessing
the speed of response and confirmation of posttherapy remission (CR).7
Staging and risk stratification (Tables 2 and 3): The
Ann Arbor staging classification used for HL does
not adequately reflect prognosis in childhood NHL
because of the unique biology, clinical behavior and
outcome of the four major subtypes of NHL seen in
children.
Currently used St. Jude children research hospital

(Murphys) staging classification takes into consi
deration increased extranodal involvement, metastatic
spread to the BM or CNS and noncontiguous spread
of disease in this group (Table 2).1,4 However, with the
evolution of more intensive therapy, it is becoming
redundant. For example, in BL, the cure rates for
stages 2, 3 and 4 (CNS-negative) have become
almost equal. Hence, the French Society of Pediatric
Oncology (SFOP) and BFM group have modified the
St. Judes system with incorporation of other clinical
and biological parameters for better risk-assignment
(Table 3). This classification is being applied in the
ongoing B-NHL international study (FAB-LMB).8-13
St. Judes system is also not ideal for LL and ALCL. In
LL, patients presenting with stage 1 or 2 disease are rare
and majority present in stage 3. Moreover, there is no
significant difference in outcome in those with stage 3 and
stage 4 disease.1,4 Similarly, ALCL frequently involves sites
atypical of childhood lymphoma (such as skin, bone and
lung). Le Deley evaluated prognostic factors for ALCL in
Table 2 St. Judes staging system for childhood NHL

Stage Definition
I
Single tumor (extranodal)
Single anatomic area (nodal) excluding mediastinum or abdomen
II
Single tumor (extranodal) with regional node involvement
Primary gastrointestinal tumor with or without involvement of mesenteric node only
On same side of diaphragm:
(a) Two or more nodal areas
(b) Two single extranodal tumors with or without regional node involvement
III
All primary intrathoracic tumors
All extensive primary intra-abdominal disease
Two or more nodal or extranodal areas on both sides of diaphragm
IV
Any of the above with CNS or bone marrow involvement
Table 3 Pediatric B-NHLcurrent risk grouping

Protocol
B-NHL
(LMB89)
B-NHL
(BFM)
Group
Definition
5 years EFS
Completely resected stage-1 and abdominal stage 2
98%
Unresected stage-1, nonabdominal stage 2

All stages 3 and 4
B-ALL <25% blasts, CNS ve
92%
B-ALL >25% blast or CNS +ve
84%
R1
R2
R3
Stage I, II initial complete resection

Stage I, II unresected, stage III with LDH <500 U/L
Stage III with LDH <500999 U/L
BM+ve and LDH <1000 U/L
LDH >1000 U/L and/or CNS +ve
94%
94%
85%
R4
81%

culled data from BFM, SFOP and UKCCSG studies and
found that, mediastinal involvement (p=0.004), lung,
spleen and/or hepatic disease (p=0.006) and skin lesions
(p=0.02) were associated with a significantly poorer
outcome. Based on this, two risk groups were delineated:
standard (EFS 87%), and high risk (skin, mediastinal and/
or visceral disease; EFS 61%).14
Furthermore, in B-NHL, adolescent age, primary
medi
astinal DLBCL subtype, involvement of CNS with
bone marrow, high LDH (more than 2.5 times upper limit
of normal), and poor response to COP prophase (<20%
reduction in tumor burden) are associated with poor prog
nosis.15 Also, secondary cytogenetic abnormalities, other
than cMYC rearrangement including gain of 7q or deletion
of 13q have been shown to be strong adverse factors in
two recent studies in BL. Similarly, deletion of 6q has been
demonstrated to be a poor prognostic factor in LL.16
Upcoming role of minimal residual disease (MRD)
evaluation: Monitoring residual clonal lymphoma
cells in the blood and/or BM by means of aberrant
immunophenotype or PCR-based identification of
specific fusion gene products is an emerging tool
for evaluating the kinetics of treatment response in
childhood NHL. The cumulative incidence of relapse
was 71 percent in children with ALCL having > 10
copies of NPM-ALK/10,000 copies ABL in BM or blood.
Quantitative PCR for NPM-ALK in BM or blood allowed
identification of 20 percent of patients experiencing 60
percent of all relapses with an event-free survival of
only 20 percent in one study. Similarly, in BL, a assay
that can detect the t(8;14) has been used at diagnosis
or during therapy and has been found superior to BM
aspirate and BM biopsy in the assessment of MRD.17,18
TREATMENT
Principles of Management
Childhood NHL are extremely chemosensitive tumors.
Surgery plays a very limited role, mainly for arriving at a
diagnosis. Radiation of primary sites is used very rarely in
emergency situations. Hence, multiagent chemotherapy
directed to the histologic subtype and stage of the disease
remains the cornerstone of therapy.
There are two potentially life-threatening clinical
situations that are often seen in children with NHL at
presentation:
Superior vena cava syndrome (or mediastinal tumor
with airway obstruction), most often seen in LL
Tumor lysis syndrome, most often seen in lympho
blastic and BL. These emergent situations should be
anticipated and addressed immediately.
Patients with large mediastinal masses are at risk of
cardiac or respiratory arrest during general anesthesia or
heavy sedation. If peripheral blood counts are normal, the
least invasive procedure should be used to establish the

diagnosis of lymphoma such as pleural tap, bone marrow
examination, a lymph node biopsy under local anesthesia
or a computed tomographyguided core needle biopsy
should be contemplated. These children should be closely
monitored in intensive care units in propped-up lateral
position and may be started on steroids if it is unsafe
to perform a diagnostic biopsy because of the risk of
anesthesia or sedation. Biopsy should be obtained as soon
as patient is able to undergo the procedure safely.1,4
Tumor lysis syndrome (TLS) results from rapid
breakdown of malignant cells resulting in a number of
metabolic abnormalities, most notably hyperuricemia,
hyperkalemia, and hyperphosphatemia. Hyperhydration
and allopurinol or rasburicase (urate oxidase) are essential
components of therapy. Rasburicase, a recombinant
urate oxidase rapidly lowers serum uric acid levels and
prevents the metabolic problems associated with TLS.
Use of rasburicase (0.05 to 0.1 mg/kg IV [max 1.5 mg])
preserves renal function and allows early administration of
planned therapy. The use of rasburicase has dramatically
reduced the requirement for dialysis in this population.
Gastrointestinal bleeding, obstruction, and (rarely)
perforation may also occur during the initial phase of
therapy in B-NHL with gut involvement.19
Principles of Chemotherapy in NHL

Many studies including the seminal Childrens Oncology
Group (COG) trial that randomized all children with NHL
to be treated with short duration pulse intensive COMP
regimen (cyclophosphamide, vincristine, methotrexate,
and prednisone) or to a long duration modified LSA2L2
regimen (used for acute lymphoblastic leukemia) have
shown that LL fare better when treated with long duration
LSA2L2 leukemia regimen and short duration COMP was
better for patients with B-cell NHL.20,21
DLBCL has a similar pattern of initial disease
distribution and the same rapid response to chemotherapy
as BL. Results from the large studies such as LMB and BFM
suggest that with similar therapy there is no difference in
outcome between BL and DLBCL and these should be
treated with the same approach. In B-NHL, in view of high
growth fraction and short doubling time; short, pulseintensive, multi-agent chemotherapy is given in courses of
3 to 5 days with a schedule characterized by fractionation or
continuous infusion of drugs. To prevent rapid re-growth,
courses are administrated at shortest intervals. Treatment
intensity is adapted to tumor burden (stage, LDH level,
BM involvement, CNS involvement) and response to COP
pre-phase. In addition, intensive CNS directed therapy
using high dose methotrexate or cytosine-arabinoside
and intrathecal therapy (single agent methotrexate +/ara-c or triple intrathecal) is usually necessary. Cranial
radiotherapy is not necessary.8-13
T-cell Lymphomas (Table 4)

Table 4 Treatment and outcome of T-NHL
ALCL ( T-cell type approach)
Protocol
LSA2L2
CCG-5941
POG 9315
AIEOP
(LNH-92)
Number
19
86
86
34
Stage
III/IV
III/IV
III/IV
II/III/IV
EFS (%)
56
78
72
65
Duration /number of cycles

1436 months
12 months
12 months
24 months
ALCL (B-Cell type approach)

BFM 90
8
20
55
6
I
II
III
IV
100
79
74
50
Stage I/II (completely resected): 3 cycles

Stage II (unresected)/stage III: 6 cycles
Stage IV/bone disease: 6 intensied cycles
SFOP-HM
89/91
82
I/II
III/IV
94
55
78 months
UKCCSG
72
III/IV
59
Stage III/IV (CNSneg): 5 cycles

CNS positive: Intensified 5 cycles
MCP-842
27
I/II
III/IV
67
40
68 (alternating A and B) cycles
Lymphoblastic lymphoma
LSA2L2/ADCOMP
with LSA2L2
281
I/II
III/IV
84
64
18 months
POG8704
218
III / IV
67
24 months
LMT 81
76
8
I / II
III / IV
76
73
12 months
UKCCSG
59
III / IV
65
24 months
BFM- 90
82
19
III
IV
90
95
24 months
BFM- 95
22
169
I / II
III / IV
95
78
24 months
Precursor T Lymphoblastic Lymphoma

Localized LL: For localized LL patients (stage I/II
disease), induction therapy with short, pulsed
chemotherapy (CHOP) results in a 95 percent CR rate.
However, only 60 percent can achieve long-term DFS
due to late relapses in bone marrow. Majority of these
patients can be salvaged, giving an overall survival
(OS) of >90 percent at 5 years. There is no survival
benefit of involved field irradiation. Using a leukemia
like approach with induction, consolidation, and
maintenance therapy for a total of 24 months, most
studies have shown more than 90 percent survival
for localized LL. No reinduction therapy and local or
cranial radiation is given for stage I and II patients.21,22
Advanced stage LL: Advanced LL have event free

survival (EFS) rates higher than 80 percent with
protocols designed for high-risk ALL consisting of
a four-drug induction, consolidation incorporating
high-dose methotrexate, cyclophosphamide, cytara
bine, CNS directed therapy including intrathecal
therapy and long maintenance with total 24 months
of therapy.21-26 Some recent studies have shown that
patients receiving high-dose asparaginase regimen
had a superior outcome.23 Several studies also suggest
that high dose methotrexate (MTX) results in survival
advantage. No benefit on outcome has been observed
with use of high dose cytarabine. The results of the
various chemotherapeutic regimens are shown in
Table 4.21-26

Until recently, CNS directed therapy included the
combined use of cranial irradiation and intrathecal
chemo
therapy. However, recent studies have demon
strated that cranial irradiation can be safely omitted if
systemic high-dose methotrexate combined with intra
thecal chemotherapy is administered. However, cranial
irradiation may be necessary for children who present
with CNS disease (fewer than 5% of children).26 Irradiation
of primary sites such as mediastinum has not been shown
to improve outcome when added to chemotherapy. Even
in patients with testicular disease at diagnosis, testicular
radiation is only indicated for residual disease after
systemic therapy incorporating high-dose MTX.21-26

In NHL-BFM-95, prophylactic cranial radiation was
omitted, and the intensity of induction therapy was
modified (reduction of asparaginase and/or doxorubicin).
There was no significant increase in CNS relapses,
suggesting cranial radiation may be reserved for patients
with CNS disease at diagnosis. However, survival was
worse in BFM-95 than in BFM-90 (90% vs. 82%), possibly
due to reduced intensity induction and increased number
of secondary malignancies in BFM-95.26 Currently,
ongoing BFM-based trials are trying to determine whether
dexamethasone instead of prednisone during induction
can further improve outcome of patients with LL, as was
observed in children with ALL.
B-Precursor LL
The correct treatment for B-lineage LL constituting around
20 percent of LL has not been clearly defined because
of rarity of this disease. The results of the largest review
of 98 patients (64% <18 years old) showed that majority
had skin (with or without adjacent nodal disease), lymph
node, bone, head and neck and retroperitoneal disease.
Mediastinal disease was uncommon. The disease free
survival was 74 percent at a median follow-up of 28 months.
In BFM-NHL trials, 27 children with precursor B-cell LL
were treated; 21 on ALL-type therapy (<10% relapses) and
6 on Burkitt type therapy (50% relapses). All relapses on
the latter regimen were salvaged with ALL-type therapy
leading to 73 percent EFS and 92 percent OS for the group
at 10 years. This suggests that patients with B-lineage LL
should be treated with ALL like therapy duration of 18 to
24 months.27
Anaplastic large cell lymphoma (Table 4): There
is no consensus on management of ALCL due to
small number of patients treated in various studies,
heterogeneity in inclusion criteria, different staging
systems and diverse treatment approaches used in
past trials. However, following broad principles can be
derived.
Localized ALCL: For localized ALCL (grossly resected,

i.e. >90% stage I/II disease), the best results have come
from using pulsed chemotherapy similar to B-NHL
therapy. BFM group has shown results similar to those
obtained with the BFM-90 regimen for B-NHL with use
of 3 cycles after cytoreduction. In POG studies, Stage I
and II disease was very effectively treated with CHOP
for three cycles without RT. The recent ALCL-99 trial
used three cycles of chemotherapy following prophase
for patients with stage I completely resected disease
with good results. Primary cutaneous ALCL may be
treated successfully with surgical resection and/or
local radiotherapy without systemic chemotherapy.
Thus, children with standard risk disease (Stage I/II
completely resected with no high risk features such
as involvement of skin, mediastinum, viscera, CNS or
BM) can be managed with 3 cycles (1012 weeks) of
B-cell type regimen and intrathecal therapy.28-32
Disseminated ALCL: Children with disseminated ALCL
have EFS of approximately 60 to 75 percent. Majority
of European studies (BFM, SFOP, UKCCSG, ALCL-99)
have used short duration (58 months) pulse intensive
B-cell type approach with good results while American
(CCG, POG) and Italian groups (AIEOP) have used
leukemia type long duration (1224 months) less
intensive approach with almost equivalent survival
but increased hematological toxicity. The recent
POG studies demonstrated no benefit of adding
methotrexate and high-dose cytarabine to 52 weeks
of cyclic chemotherapy. Cranial prophylaxis using
high or intermediate dose methotrexate with (BFM) or
without intrathecal (SFOP) or only intrathecal therapy
(COG, MCP-842) have shown equivalent results with
less than 1 percent incidence of CNS relapses. Cranial
radiotherapy (RT) is not recommended.28-32
Recently conducted international ALCL 99 study
has shown that HD MTX (3 g/m intravenously over 3
hours) is sufficient to protect the CNS in CNS-negative
patients in the absence of additional intrathecal
chemotherapy and addition of vinblastine during
induction and as maintenance for a total treatment
duration of 1 year did not reduce the risk of failure.31,32
Thus, disseminated ALCL may be managed with 6
cycles (6 months) of B-cell type regimen using short
infusion HD MTX.
B-Cell Lymphoma (Table 5)

Treatment of limited stage B-NHL: Children with
limited stage B-cell NHL (stage I or stage II, BFM R1 or
FAB group A) have a good prognosis with an estimated
five-year EFS of 90 to 95 percent with minimal
Table 5 Outcome of B-NHL in International Studies
Protocol
Number
Stage
EFS (%)
Duration/number of cycles
COMP
57
135
I/II
III/IV
84
53
6 months
LMB 89
52
386
123
Gp A
Gp B
Gp C
98
92
84
Group A: 2 cycles, No IT
Group B: 5 cycles
Group C: 8 cycles
FAB-LMB96
136
760
238
Gp A
Gp B
Gp C
98
90
79
Group A and C: As LMB 89

Group B: 4 cycles with reduced dose
cyclophosphamide
Group C: 8 cycles
BFM-95
98
233
82
142
R1
R2
R3
R4
94
94
85
81
R1: 2 cycles
R2: 4 cycles
R3: 5 intensified cycles
R4: 6 intensified cycles
CHOP
266
I/II
90
6 cycles
Orange (CCG)
34
III/IV
77
57 months
chemotherapy (range 6 weeks to 6 months). There are

several multiagent chemotherapy regimens that have
resulted in this excellent outcome, including 6 weeks of
COPAD (FAB), 3 to 6 months of COMP (CCG and POG),
or two cycles of multiagent chemotherapy (BFM). In
the most recent BFM study (BFM-95), it was shown that
reducing the dose or duration of methotrexate infusion
did not affect the results for localized disease.8-13,21
Treatment of advanced B-NHL: The prognosis of
advanced B-NHL has improved significantly over
the past decade with the use of short intensive
chemotherapy regimens such as FAB/LMB 96 (FAB),
Orange (CCG) or BFM NHL 95 with more than 90
percent 5-year disease-free survival except in patients
with CNS disease.4-9 Recent studies have demonstrated
that cranial irradiation can be eliminated in patients
with CNS-positive disease with the substitution of more
aggressive high-dose methotrexate and additional
intrathecal chemotherapy. 8-13,21
Recently conducted FAB/LMB 96 study showed
that intermediate-risk patients (group B) with and
good response to prophase COP can be treated with
reduced intensity therapy with 4 courses but highrisk patients should receive standard FAB/LMB
therapy (8 courses).12,13 Children with BM and/or CNS
involvement have an inferior outcome if they have a
poor response to reduction chemotherapy with COP
prophase or have combined BM and CNS disease.15
Rituximab, a mouse/human chimeric monoclonal
antibody targeting the CD20 antigen, has shown
good responses in relapsed B-NHL and a promising
response rate of 41.4 percent in a phase II window study

in newly diagnosed B-cell NHL and Burkitt leukemia.
Based on results of a COG pilot study (ANHL01P1)
that it is feasible and safe to include rituximab in the
current chemotherapy backbone, current studies are
evaluating rituximab in high-risk B-NHL patients.33
Primary mediastinal DLBCL (PMBL): The response to
chemotherapy is slow and outcome is poor in PMBL.
In one CCG series of 20 children with PMBCL, where
almost half received local irradiation, the 5-year EFS
was only 75 percent. In a BFM report of 30 children,
the 5-year EFS was 70 percent using chemotherapy
alone. In FAB/LMB-96 study of stage III primary
mediastinal large B-cell lymphoma, the 5-year eventfree survival (EFS) was 66 percent, versus 85 percent
for adolescents with nonmediastinal DLBCL. Recently,
a single-arm study in adults showed excellent eventfree survival utilizing the DA-EPOCH-R regimen (doseadjusted etoposide, doxorubicin, cyclophosphamide,
vincristine, prednisone, and rituximab; usually six
cycles) with filgrastim and no radiation therapy.
The 5-year EFS was 93 percent and overall survival
(OS) was 97 percent. This is currently being tested in
pediatric clinical trials. Early mediastinal irradiation in
incomplete initial responders may be considered.34
Outcome of pediatric NHL in India (Table 6): Before
1986, survival of pediatric NHL patients in India was
less than 30 percent. To improve survival rates and
to overcome the barriers of limited resources, suboptimal supportive care, high prevalence of infectious
diseases, impaired nutritional status and delayed

Table 6 Outcome with MCP-842 (19862006) at Tata Memorial Hospital
Histology
Number
Stage
Burkitt-lymphoma
107
I/II
III/IV
100%
78%
83%
DLBL
53
I/II
III/IV
96%
82%
82%
ALCL
27
All stages
75%
71%
diagnosis; a moderately intensive, short duration

protocol (MCP842) was designed in 1984. Protocol
consisted of 6 to 8 alternating cycles of two different
drug combinations designated as regimens A and B
with intrathecal therapy during the first four cycles.
The drugs used in regimen A were cyclophosphamide,
vincristine, doxorubicin and cytarabine, while regimen
B included ifosfamide, etoposide and MTX. Intrathecal
MTX and cytarabine were used for central nervous
system (CNS) prophylaxis. Neither cranial nor local
radiotherapy were included in the treatment protocol.
Over last 2 decades, MCP 842 has been found to be an
effective protocol for the management of patients with
B-cell NHL and may be an ideal protocol for patients in
centers with limited resources since it involves no high
dose chemotherapy, there is no need for methotrexate
level monitoring, no central line/hyperalimentation
requirement and there is minimum blood component
usage. This protocol has been recently modified with
addition of vinblastine as well as maintenance (612
months) for ALCL, addition of COP prephase (for
patients with bulky disease or poor GC), use of urate
oxidase in tumor lysis. The survival with modified
MCP-842 is significantly better compared to standard
MCP-842.The results of this protocol are summarized
in Table 5.35-37
Management of Relapse
Relapse is a significant obstacle to long-term survival for
children with advanced-stage NHL. In LL, most relapses
occur within 2 years of diagnosis, but occasional late
relapse is observed. In contrast to relapse for earlystage disease, the outcome after salvage chemotherapy
is poor for children with advanced-stage disease at
initial presentation. However, survival rates of 30 to 50
percent have been reported after allogenic stem cell
transplantation (SCT).38,39
The outcome of relapsed patients with BL is dismal
because most relapses tend to occur early during active
chemotherapy, and drug resistance is a major obstacle
to successful salvage. Rituximab have been reported to
Modified MCP-842
EFS (%) (10 years)
OS (%) (10 years)
be active in the relapse setting. Current investigational

protocols combine chemotherapy with rituximab followed
by allogeneic or autologous SCT. The outcome is more
favorable for patients who achieve a second remission
before proceeding to SCT.38
Children with relapsed DLBCL are often treated with
salvage chemoimmunotherapy regimens such as ICE,
GDP (Gemcitabine, dexamethasone and cisplatinum) and
DECAL (dexamethasone, etoposide, cisplatin, HD cytarabine, and L-Asp) with rituximab followed by autologous
SCT based on the adult experience. The outcome is quite
favorable for those children who have chemosensitive disease at the time of relapse.38
The outcome for survival after relapse of ALCL is
relatively favorable in contrast to the less optimistic
outcome for children with relapsed LL and BL. A French
study demonstrated excellent responses to single-agent
vinblastine followed by some very durable second remiss
ions. A survival rate of 69 percent at 3 years with courses of
CCNU, vinblastine, bleomycin or cytarabine followed by
autologous HSCT in some of the patients has been reported.40
Even in high-risk patients with on-therapy relapse or
relapse after autologous HSCT, long-term remissions
have been observed after allogeneic HSCT.41 The potential
benefit of vinblastine and anti-CD30 antibody combined
with either an APO or BFM-like regimen is currently under
investigation. Phase 1 study of ALK oncogenic tyrosine
kinase inhibitor (Crizotinib) in pediatric patients with
anaplastic large-cell lymphoma has shown response rate of
88 percent in ALK positive patients.42 Brentuximab vedotin
is a novel antibody-drug conjugate that targets CD30, a cell
surface antigen expressed by HL and ALCL. A phase II trial
in adults with relapsed anaplastic large cell lymphoma has
shown CR rates of approximately 55 to 60 percent and PR
rates of 29 percent.43
CONCLUSION
Refinements in systemic chemotherapy fuelled by better
understanding of NHL biology in children have led to
cure in approximately 80 to 85 percent of all patients. This
improved outlook for childhood NHL, however, has come
with a certain price. The use of intense chemotherapy has
resulted in long hospitalizations, severe hematopoietic as
well as non-hematopoietic toxicity and late effects, such
as sterility, cardiomyopathy, and secondary malignancies.
Consequently, the emphasis for the near future is to
decrease the therapy in good risk patients as well as
better identification and development of new therapeutic
approaches for high-risk cases. In future, as the molecular
pathogenesis of the malignant lymphomas is better
elucidated using molecular diagnostic tools, new targets
for therapy will emerge. Also, it is likely that targeted
therapy will substitute for some of the toxic chemotherapy
and thereby minimize the chemotherapy related morbi
dity. This novel molecular biologic information will also
be valuable for developing more sensitive diagnostic
tools, measurement of early response to therapy as well as
submicroscopic disease and for identifying new prognostic
subgroups. Superior risk-adapted therapy based on these
advances would maximize the chance for cure while
avoiding both acute and chronic toxicities of treatment.
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25. Patte C, Kalifa C, Flamant F, et al. Results of the LMT81
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28. Seidemann K, Tiemann M, Schrappe M, et al. Shortpulse B-non-Hodgkin lymphoma-type chemotherapy is
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32. Marie-Cecile Le Deley, Angelo Rosolen, Denise M
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J Clin Oncol. 2012;30:2190-6.
45
Langerhans Cell Histiocytosis
Langerhans cell histiocytosis (LCH) is an enigmatic disorder occurring due to a reactive clonal proliferation of dendritic cells, which are
immunophenotypically and functionally immature and comprises a group of idiopathic disorders characterized by the presence of
these cells in a background of hematopoietic cells, including T-cells, macrophages, eosinophils and occasional multinucleated giant
cells.1 Accumulation of these cells at various sites in the body are responsible for its clinical manifestations. More recent work has
shown that the pathologic LCH cells have a gene expression profile of a myeloid dendritic cells rather than the skin Langerhans cells
(LC) that are closer to the sites where the disease usually occurs. Controversy too exists whether the clonal proliferation of LCH cells
results from a malignant transformation or due to immune dysregulation of LCs.2
Earlier, LCH was subcategorized based upon clinical

presentation (i.e. Letterer-Siwe disease, Hand-SchllerChristian, eosinophilic granuloma, etc.). Lichtenstein
was the first to suggest integration of these disorders
under the common term histiocytosis X, the first
word recognizing their common origin, while the X
underlined his uncertainty as to what the origin was!3
However, over the past few decades since then, there
has been unprecedented progress in the understanding
of this enigmatic disease by means of collaborative trials
notably the LCH trials by the Histiocyte Study Groups, and
large single institutional studies.4-6 The common etiology
between Lichtensteins groups is now well understood.
Minimum diagnostic criteria have been evolved to ensure
clarity and uniformity allowing comparison between
various studiesa prerequisite all the more essential for
rare disorders like LCH. For treatment purposes too, the
disorders are now clubbed and categorized by the number
and nature of organs involved at diagnosis. Involvement of
the liver, spleen, lung, and bone marrow, and their degree
of dysfunction has been shown to be the key determinant
to outcome irrespective of the therapies offered. This was
even corroborated when the new risk classifications were
applied retrospectively to past cases, to see how they fared,
in a large single institution study from India, showing the
robustness of these risk stratifications.7
EPIDEMIOLOGY
The reported incidence of LCH from various studies
is two to ten cases per million children aged 15 years
or younger.8,9 The male/female (M/F) ratio is close to
one and the median age of presentation is 30 months.10
Solvent exposures in parents, family history of cancer,
and perinatal infections have been weakly associated with
LCH.11,12
CLINICAL FEATURES
LCH is a rare childhood malignancy. In a large Indian
cancer center, only 52 cases were registered over a 17-yearsperiod.7 In addition to its rarity is the fact that it has myriad
presentations and its clinical course can range from low
grade chronic and persistent to the rapidly progressive
and fatal, making its behavior unpredictable to most
individual clinicians. Collaborative trials and large single
institutional studies therefore, have been the major means
of shedding light on the understanding of this disease and
deciding its management. The most important concept
that has evolved has been that multiorgan involvement
has worse outcome than single-organ disease and needs
some form of cytotoxic therapy. Also, among those with
multiorgan disease, some patients are more at risk
Chapter-45 Langerhans Cell Histiocytosis 463

for disease progression, sequelae, and death. High-risk
organs include liver, spleen, and bone marrow. Low-risk
organs include skin, bone, lymph nodes, gastrointestinal
tract, pituitary gland, and central nervous system
(CNS).4-7,9,10,13,14
LCH in children usually presents with a skin rash or
painful bone lesions. Systemic symptoms of fever, weight
loss, diarrhea, edema, dyspnea, polydipsia, and polyuria
may relate to specific organ involvement by disease.7, 9, 10
Patients may present with a single organ involvement
(single-system LCH), which may be a single site (unifocal)
or involve multiple sites (multifocal). Involvement of more
than one organ is categorized as multisystem LCH. In this
group, involvement may be in a limited number of organs
or it may be disseminated. Patients may present with
LCH of the skin, bone, lymph nodes, and pituitary in any
combination and are still considered at low-risk of death.
Multisystem LCH patients have relatively high-risk for
long-term consequences of the disease.7, 9, 10, 13, 14
Single-System Disease
In single-system LCH, the patient presents with involve
ment of a single site or organ, including skin and nails, oral
cavity, bone, lymph nodes and thymus, pituitary gland,
and thyroid.
Skin and nails: Dermal involvement occurs in 35 to
50 perent cases in most series.10,15 However, in Indian
literature, the reported incidence was lower at 25
percent. This may have been due to under-reporting
of minor lesions such as seborrheic dermatitis, the
data being from a large referral center.7 In infants,
seborrheic involvement of the scalp may be mistaken
for prolonged cradle cap. Infants may also present
with brown to purplish papules over any part of
their body (Hashimoto-Pritzker disease). These
lesions in infants may be self-limited as the lesions
often disappear without treatment during the first
year of life; however, they need to be followed up
closely for systemic disease manifestations which
may present later on after the initial skin lesions.15-17
Children may present with a red papular rash in
the groin, abdomen, back, or chest that resembles a
diffuse candidal rash. Seborrheic involvement of the
scalp may be mistaken for a severe case of dandruff
in older children. Ulcerative lesions behind the ears,
involving the scalp, under the breasts, or genitalia or
perianal region may be misdiagnosed as bacterial or
fungal infections on presentation. Involvement of nails
is an unusual presentation. They may present as a
single site or in conjunction with other sites, and often
show longitudinal, discolored grooves with loss of nail
tissue.15-17
Oral cavity: The oral cavity lesions may precede

evidence of LCH in other organs. Presenting symptoms
may be gingival hypertrophy, and ulcers of the soft or
hard palate, buccal mucosa, or on the tongue and lips.
Hypermobile teeth (floating teeth) and tooth loss may
occur.18
Bone: Bones are the most common site of involvement
in LCH. Skeletal involvement with or without other
sites occurs in 80 to 100 percent of patients in most
large series.7,10,13 Hands and feet are often spared, but it
can involve almost any other bone, the most frequent
site being the skull. It presents as a lytic bony lesion
with associated soft tissue swelling, which may be
asymptomatic or painful. In the skull, the soft tissue
mass may impinge inwards on the dura.19 Other
frequent sites involved are the femur, ribs, humerus,
and vertebra.19,20 Amongst the vertebra, the cervical
are the most common to be involved. Vertebral lesions
may result in collapse of the vertebral body (vertebra
plana). Vertebral lesions with soft tissue extension may
present with pain and neurologic deficits.20 Disease of
the facial bones or anterior or middle cranial fossae
(e.g. temporal, sphenoid, ethmoid, zygomatic) with
intracranial tumor extension comprise part of a CNSrisk group. These children have a threefold increased
risk of developing diabetes insipidus and an increased
risk of other CNS disease.21, 22
Lymph nodes and thymus: Lymphadenopathy has
been reported more commonly in a large Indian
series than in western literature, where it is reported
to be less than 10 percent.7,22 Cervical nodes are
most frequently involved. Nodes may be soft- or
hard-matted with accompanying lymphedema. An
enlarged thymus or mediastinal node due to LCH
can mimic lymphoma or an infectious process, or
asthma.
Pituitary gland and thyroid: Posterior pituitary gland
involvement presents with central diabetes insipidus
(DI). Involvement of anterior pituitary results in
growth failure and delayed or precocious puberty.
DI more commonly manifests in multisystem LCH
where it can afflict nearly 1/3rd of all such patients
and can develop at any time during the course of the
illness.4,7,21,22
Multisystem Disease
In this presentation, multiple organs are involved at the
outset. The involvement of certain organs like the liver,
spleen and hematological system put the patients into a
higher risk category. Other organs that can be involved
are the same as in single system disease but in various
combinations.
Bone and other organ systems: LCH patients may
present with multiple bone lesions (single-system
multifocal bone) or bone lesions with other organ
involvement (multisystem including bone). As already
discussed above, the later group has a higher incidence
of diabetes insipidus, probably due to the higher
frequency of lesions in the facial bones (temporal
bone, mastoid/petrous bone, orbit, and zygomatic
bone).
Abdominal/gastrointestinal system: Liver and spleen
are considered high-risk organs. Enlargement of these
organs may be due to direct infiltration of LCH cells
or as a secondary phenomenon of excess cytokines
leading to macrophage activation or infiltration of
lymphocytes around bile ducts.
Hepatomegaly is often present in systemic disease
and pathological changes might be present in the liver
on histology, even in the absence of liver dysfunction.23
LCH in liver has a portal (bile duct) tropism and
can cause biliary damage and ductal sclerosis. He
patomegaly may be accompanied by hypoalbumine
mia with ascites, hyperbilirubinemia, clotting fac
tor deficiencies, elevated alkaline phosphatase, liver
transaminases, and gamma glutamyl transpeptidase
levels. Cholestasis and sclerosing cholangitis is one of
the most serious complications of liver involvement
in LCH.23, 24 Sonography, computed tomography (CT),
or MRI of the liver will show hypoechoic or low-signal
intensity along the portal veins or biliary tracts when
the liver is involved with LCH.25 This usually occurs
months after initial presentation, but occasionally
may present at diagnosis. Children with sclerosing
cholangitis will not respond to chemotherapy as the
disease is not active and the fibrosis and sclerosis
remain. Liver transplantation is the only treatment
when hepatic function worsens.24 Rare cases of LCH
infiltration of the pancreas and kidneys has been
reported.26
Splenic involvement has been noted to be much higher
(25%), at presentation in a large Indian center,7 while
the French in a series of nearly 350 patients found it
in only 5 percent at presentation.10 This may represent
natural evolution in a country like ours where many
patients tend to present late. Massive splenomegaly
may lead to cytopenias due to hypersplenism and
may cause respiratory compromise. Splenectomy may
provide transient relief of cytopenias, but should be
done only as a life-saving measure.
Other gastrointestinal manifestations in LCH are
diarrhea, hematochezia, perianal fistulas, or malab
sorption.27,28 Diagnosis of gastrointestinal involvement
in LCH is difficult because of patchy involvement.
Endoscopic examination with multiple biopsies is

usually needed.
Lung: Lung is less frequently involved in children than
in adults, in whom smoking is an etiologic factor.29
It was seen in 15 percent cases in an Indian series.
Criteria used to diagnose pulmonary lesions play a
major role in frequencies reported in various series
and these have been the most diverse criteria used
among all organ involvements ranging from plain
radiographs to more sophisticated anatomical and
functional imaging and even pulmonary function
tests. The incidence was as high as 50 percent
in a large series that also included patients with
isolated abnormal pulmonary function tests.30 The
lung is usually involved in a symmetrical manner
and predominantly involves the upper and middle
lung fields, while sparing the costophrenic angle.31
Confluence of cysts may cause bullous formation,
which can sometimes rupture spontaneously leading
to a pneumothorax. Occasionally this may be the first
sign of LCH involvement of the lung. As the disease
progresses, widespread fibrosis and destruction of
lung tissue leads to severe pulmonary insufficiency,
and patients can present with progressive tachypnea
or dyspnea. Eventually declining diffusion capacity
may lead to pulmonary hypertension.32, 33
Bone marrow: Patients with bone marrow involvement
are usually younger, with multisystem disease and often
have diffuse disease in the liver, spleen, lymph nodes,
and skin. They present with variable thrombocytopenia
and anemia with or without neutropenia.34 Patients with
LCH may sometimes present with hemophagocytosis
involving the bone marrow.35
Endocrine system: The most frequent endocrine
manifestation in LCH is diabetes insipidus. This
is caused by damage to the antidiuretic hormone
(ADH)secreting cells of the posterior pituitary.
MRI scans show nodularity and/or thickening of the
pituitary stalk with loss of the pituitary bright spot on
T2-weighted images. Pituitary biopsies are rarely done
for diagnosis, and are only indicated when the stalk is
greater than 6.5 mm or there is a hypothalamic mass.
Most often the diagnosis is established by biopsying
the other sites of involvement in patients who also have
pituitary abnormalities. LCH patients with diabetes
insipidus have a 50 to 80 percent chance of developing
other organ involvement diagnostic of the disease
within one year of onset of diabetes insipidus.7, 21, 23, 36-38
Ocular: Ocular involvement in LCH is very rare.
Sometimes it may lead to blindness. Patients may have
other organ systems involved, and this form of LCH
rarely responds well to conventional chemotherapy.39

Central nervous system: Apart from mass lesions
in the hypothalamic-pituitary region, LCH may also
involve the choroid plexus, the gray matter, or white
matter. CD1a-positive LCH cells and CD8-positive
lymphocytes are present in these lesions.
Chronic neurodegenerative syndrome manifested
by dysarthria, ataxia, dysmetria, and sometimes beha
vioral changes may develop in one to four percent of
LCH patients, and sometimes, these neuropsychologic
dysfunctions may be severe.37 MRI scan may show
hyperintensity of the dentate nucleus and white
matter of the cerebellum on T2-weighted images
or hyperintense lesions of the basal ganglia on T1weighted images and/or atrophy of the cerebellum.38
These radiologic findings may precede the onset
of symptoms by many years or found coincidently.
The neurodegenerative form of the disease has
been compared to a paraneoplastic inflammatory
response.37, 38
DIAGNOSTIC EVALUATION OF LANGERHANS

CELL HISTIOCYTOSIS
Diagnostic evaluation of LCH must proceed along logical
and established lines. This helps to correctly identify risk
groups as well established by the LCH trials. Incorrectly
assigning risk groups due to faulty or incorrect assessment
test or overdiagnosis due to a very sensitive test makes
comparisons difficult in what still remains a rare disorder.
The strength of the diagnostic criteria established by the
LCH trials has been validated even when applied in a
retrospective analysis, proving there robustness.7 The
current recommendations have been recently summarized
in an exhaustive review.14
Tests and Procedures

Blood tests: These include complete blood count
and biochemical evaluations that include liver
and renal function tests and serum electrolytes. A
coagulation work-up with prothrombin time/partial
thromboplastin time in patients with hepatomegaly
and jaundice should also be done.
Urine tests: Apart from routine urinalysis, a waterdeprivation test must be done if diabetes insipidus is
suspected.
Bone marrow aspirate and biopsy: This is indicated
in all patients with multisystem disease who have
unexplained anemia or thrombocytopenia. The bone
marrow biopsy sample should be stained with antiCD1a and/or anti-CD207 (langerin) and anti-CD163
immunostains for the detection of LCH cells.
Radiologic and imaging evaluation: This is the
most important aspect of work-up for a case of
LCH. Mandatory in all cases as a first screening, is
a complete skeletal survey with skull series, bone
scans, and a chest X-ray. Radionuclide scanning
has been shown to provide no additional benefit as
against its suggested complimentary role in earlier
studies.40- 42
Fludeoxyglucose F18 (18F-FDG)

The PET scans have proved to be the most sensitive
technique in detection of involvement and for assessing
response to treatment and in follow-up of patients with
LCH,43 but is as yet not recommended to replace the
standard tests14 as its exact role is still being evaluated.
Depending on the clinical scenario in a given case,
Table 1 Recommended additional diagnostic testing in a case of LCH40

Clinical scenario and recommended additional testing
History of polyuria or polydipsia
Early morning urine specific gravity and osmolality
Blood electrolytes
Water deprivation test if possible
MRI of the head
Bicytopenia, pancytopenia, or persistent unexplained single cytopenia
Other causes of anemia or thrombocytopenia has to be ruled out according to standard medical practice. If no other causes are
found, the cytopenia is considered LCH-related
Bone marrow aspirate and trephine biopsy to exclude causes other than LCH
Evaluation for features of macrophage activation and hemophagocytic syndrome (triglycerides and ferritin in addition to coagulation
studies)
Liver dysfunction
If frank liver dysfunction (liver enzymes >5-fold upper limit of normal/bilirubin >5-fold upper limit of normal): consult a hepatologist
and consider liver MRI which is preferable to retrograde cholangiography
Liver biopsy is only recommended if there is clinically significant liver involvement and the result will alter treatment (i.e. to
differentiate between active LCH and sclerosing cholangitis)
Contd...
Contd...
Lung involvement
Further testing is only needed in case of abnormal chest X-ray or symptoms/signs suggestive of lung involvement, or pulmonary
findings not characteristic of LCH or suspicion of an atypical infection
High resolution-computed tomography (HR-CT) is preferred mode
Only cysts and nodules are typical of LCH; all other lesions are not diagnostic
In children already diagnosed with MS-LCH, low dose CT is sufficient to assess extent of pulmonary involvement, and reduce radiation
exposure
Lung function tests (if age appropriate)
Bronchoalveolar lavage (BAL): >5% CD1a + cells in BAL fluid may be diagnostic in a nonsmoker
Lung biopsy (if BAL is not diagnostic)
Suspected craniofacial bone lesions including maxilla and mandible
MRI of head including the brain, hypothalamus-pituitary axis, and all craniofacial bones. If MRI not available, CT of the involved bone
and the skull base is recommended
Aural discharge or suspected hearing impairment/mastoid involvement
Formal hearing assessment
MRI of head or HR-CT of temporal bone
Vertebral lesions (even if only suspected)
MRI of spine to assess for soft tissue masses and to exclude spinal cord compression
Visual or neurological abnormalities
MRI of head
Neurological assessment
Neuropsychometric assessment
Suspected other endocrine abnormality (i.e. short stature, growth failure, hypothalamic syndromes, or delayed puberty)
Endocrine assessment (including dynamic tests of the anterior pituitary and thyroid)
MRI of head
Unexplained chronic diarrhea, failure to thrive, or evidence of malabsorption
Endoscopy
Biopsy
Adapted from Haupt, et al40
additional specific testing is required. These are

summarized in Table 1.
Biopsy: This remains the gold standard for establishing
LCH, and is indeed mandatory for a confirmed
diagnosis, except in the cases of isolated vertebra plana
without a soft tissue mass or isolated pituitary stalk
disease when the risk outweighs the benefits.14
Lytic bone lesions, skin, and lymph nodes are the most
frequent sites biopsied.7,14 Biopsies from other sites are
indicated only in specific situations already summarized
in Table 1.
The LCH cells are large cells with abundant pink
cytoplasm on hematoxylin and eosin staining with a beanshaped folded nucleus. LCH cells stain with anti-CD1a or
anti-langerin (CD207) and any one of these is essential to
confirm the diagnosis of LCH. Other types of histiocytes
and macrophages may stain with S-100, which is not
considered sufficient to establish the diagnosis of LCH.14
included surgery, radiation therapy, or oral and topical

medications. Later intravenous chemotherapy was also
used. The earliest chemotherapy trials were from the
German-Austrian-Dutch (Deutsche Arbeitsgemeinschaft
fr Leukmieforschung und-therapie im Kindesalter
[DAL]) Group trials.44 In updated results from these trials
guidelines for formulations for single-system and multisystem disease were made.4,22 However, since the mid
nineties, most of the European study groups merged under
the umbrella of the LCH trials, and were increasingly joined
by the North American groups. By the time of the launch
of the LCH IV trial in 201314, will become a truly global
study group, with representation from all continents. Most
of the current recommendations on treatment are based
on the LCH I, II and III trials.
TREATMENT OF LANGERHANS CELL

HISTIOCYTOSIS
Isolated skin involvement has been historically

treated with topical steroids, oral methotrexate, oral
thalidomide, topical application of nitrogen mustard,
and later with psoralen and UV light. However, if no other
site is involved, most lesions resolve spontaneously and
Treatment of langerhans cell histiocytosis (LCH) depends

on the site(s) and extent of disease. Treatment historically
Low-Risk Disease (Single-System or

Multisystem)

only observation would be required. Single-site, single
lesion disease similarly requires observation only.14, 22
Skull lesions in the mastoid, temporal, or orbital bones
form a risk group for later CNS involvement and DI
(CNS-risk lesions) and need to be treated with 6 to 12
months of vinblastine and prednisone to decrease the
risk of developing DI.5
For instability of the cervical vertebrae and in patients
with neurologic symptoms bracing or spinal fusion
may be needed. Chemotherapy is often successful in
patients with soft tissue extension from the vertebral
lesions.20, 22
Multiple bone lesions; or combinations of skin, lymph
node, or pituitary gland with or without bone lesions
should be treated with 12 months of vinblastine and
prednisone. A short ( 6 months) treatment course
with only a single agent (e.g. prednisone) results in a
higher number of relapses compared to combination
chemotherapy.22,45 Pamidronate is also effective in
LCH with bone lesions.46
High-Risk Multisystem Disease

The standard therapy length recommended for LCH
involving the spleen, liver, or bone marrow (high-risk
organs) is based upon LCH-I, LCH-II, and the DALHX-83 studies and varies from 6 months (LCH-I and
LCH-II) to 1 year (DAL-HX-83).4-6,44 The LCH-II and
LCH-III studies used a standard arm consisting of
vinblastine and prednisone but 6-mercaptopurine
was added to the continuation phase of the proto
col. These two studies also conclusively proved
that treatment intensification,47 and prolongation,6
works better for multisystem LCH. The LCH-II
study was a randomized trial which compared treat
ment of patients with vinblastine, prednisone, and
mercaptopurine or vinblastine, prednisone, mercap
topurine, and etoposide.47 There was no statistical
significance in outcomes (response at 6 weeks, 5-year
probability of survival, relapses, and permanent
consequences) between the two treatment groups.
Hence, etoposide has not been used in subsequent
Histiocyte Society trials. The LCH-III study rando
mized risk organ-affected patients to either velban/
prednisone/6-mercaptopurine or velban/ predni
sone/6-mercaptopurine plus methotrexate (intra
venous during the induction phase and oral in the
continuation phase).6 The response rates at 6 and 12
weeks and overall survival were not improved. Signifi
cantly increased grade 3 and grade 4 toxicities were
seen in patients who received methotrexate.
Treatment of CNS disease: CNS LCH arises initially
at areas where the blood brain barrier is deficient.
So drugs that cross the blood-brain barrier, such as

cladribine (2-CdA), or other nucleoside analogs, such
as cytarabine, seem to be the best option for active CNS
LCH lesions.48-50 For treatment of symptoms of LCH CNS
neurodegenerative syndrome, dexamethasone, retinoic
acid, intravenous immunoglobulin (IVIg), infliximab,
with or without vincristine have been used. 51, 52
Treatment of Recurrent, Refractory, or

Progressive Childhood Langerhans Cell
Histiocytosis
Various strategies have been evolved to manage LCH
patients with recurrent, refractory, or progressive
LCH. Optimal therapy for these patients has not been
determined. Low-risk recurrence occurring after comple
tion of planned treatment can be treated with a reinduction
of vinblastine and prednisone for 6 weeks. Cladribine (2CdA) has also been used effectively for recurrent low-risk
LCH (multifocal bone and low-risk multisystem LCH).53
For patients having refractory high-risk organ
involvement therapy needs to be changed early. Evaluation
points at 6 and 12 weeks post initiation of induction are
predictive of outcome. For example, those with progressive
disease after 6 weeks of standard treatment, or partial
response by 12 weeks require new treatment plan, as
they have only a 10 to 50 percent chance of surviving.5,6,47
Patients with refractory high-risk organ (liver, spleen, or
bone marrow) involvement and resistant multisystem
low-risk organ involvement have been treated with an
intensive acute myeloid leukemialike protocol. Prompt
change of therapy to cladribine (2-CdA) and/or cytosine
arabinoside may provide an improvement in overall
survival (OS).54, 55
Hematopoietic stem cell transplantation (HSCT)
has been used for multisystem high-risk organ disease
refractory to chemotherapy.56, 57
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46
Hemophagocytic
Lymphohistiocytosis: Revisited
INTRODUCTION
Hemophagocytosis lymphohistiocytosis (HLH) is a
disorder of immune dysregulation and is not an uncommon
disorder encountered at a tertiary care. It is a potentially
fatal hyperinflammatory syndrome with high-grade fever,
organomegaly and characteristic laboratory abnormalities
like pancytopenia, coagulopathy, hyperferritinemia,
hypertriglyceridemia and hemophagocytosis.1-4
It was first described in 1939 by Scott and Robb Smith
and was initially considered a malignant histiocytic disorder
called Malignant Histiocytic Reticulosis.5 Subsequently
Farquhar and Claireaux provided its correct description
in 1952.6 Risdall et al. in 1979 was the 1st to recognize
this as a reactive hemophagocytosis secondary to viral
infection in a cohort of 19 highly immunocompromised
postrenal transplant patients and he coined the term
virus-associated hemophagocytic syndrome (VAHS). He
observed that though it was a benign disorder the mortality
was extremely high and most had infections with herpes
group viruses like EBV and CMV.7,8
Acquired HLH is commonly seen with infections (IAHS
Infection associated Hemophagocytic Syndrome). The
most common infections, which trigger HLH are EBV, CMV,
HSV, HHV, Kochs, Salmonella, Malaria, Kala azar in the
Indian set up but virtually any infection can trigger HLH.9,10
PATHOGENESIS
The hallmark of HLH is defective NK cell and cytotoxic T
cell activity. NK cells and cytotoxic T cells can be recognized
morphologically as large lymphocytes with azurophilic
granules in wright preparation. These granules contain
apoptosis inducing machinery the Perforin protein and
Granzyme B.
To understand HLH we must understand the function

of NK cell and cytotoxic T cells. Both are designed to kill
virally infected cells.
Natural killer cells are our innate immune system
cell that comprise 10 to 15 percent of peripheral blood
lymphocytes and are like Rambos of the immune system
with ready to kill receptors but have to be inhibited by
receptors for MHC class I molecule, which override the
kill signal. Thus, MHC class I molecule protect us from NK
cell toxicity. Cytotoxic T cells are produced as an adaptive
response to any infection. They recognize cytosolic protein
antigen (e.g. viral proteins) which are presented on the
major histocompatibility complex (MHC) class I molecule.
Cytotoxic T cells are specific for that infection and are
produced later after 4 to 5 days of infection. They are the
atypical lymphocytes seen in infectious mononucleosis
and express Cd3+ and Cd8+ on their surface.11
Familial Hemophagocytic
Lymphohistiocytosis
Inheritance of familial HLH is autosomal recessive. Up
till now there are 5 genes discovered in familial HLH. Of
which most common is perforin gene (10q21) i.e. PRF 1
mutations seen in 2040 percent of cases.12 NK cell and
cytotoxic T cells eliminate a virally infected target cell via
the Perforin Granzyme pathway. Perforin is a protein like
Complement C5-9, it perforates the target cell membrane
forming a channel thus allowing Granzyme B to enter the
target cell and induce apoptosis by activating the apoptotic
mechanism.13-15 Recent studies suggest that granzyme B
can enter into target cells, independent of perforin,16-18
but granzyme alone is not sufficient to induce toxicity.
Once NK cell or Cytotoxic T cell binds the virally infected
Chapter-46 Hemophagocytic Lymphohistiocytosis: Revisited 471

cell they form an immunologic synapse at the contact
site. All the subsequent events occur at the immunologic
synapse. The azurophilic granule undergoes steps of
vesicle maturation (LYST protein), polarization to the
immunologic synapse (AP3B1 and SH2D1A), docking
(RAB 27), and priming (Unc13)19, vesicle fusion (Syntaxin
11), vesicle docking, priming and fusion (MUNC 18-2)
before it fuses with the surface membrane and releases
its content with in the immunological synapse (Fig. 1).
XLP (X-linked lymphoproliferative disorder) is of two
types XLP1 due to defect in SAP protein and XLP2 due
to defect in XIAP (X-linked Inhibitor of Apoptosis) gene.
60% of XLP1 patients develop EBV induced HLH while
90% of XLP2 develop HLH. Currently it XLP2 is being
reclassified as HLH causing disease rather than causing
lymphoproliferation.20-25
Genes Associated with Familial

Hemophagocytic Lymphohistiocytosis
(Table 1, Fig. 2)
Inability to kill target cells by NK cell and cytotoxic T cells
following events can occur. There is excessive stimulation
of the immune system, increase in antigen presentation
and increase in T cell proliferation with infiltration of
various organs like CNS, liver, spleen, and lymph nodes.
Ultimately this results in hyper cytokine storm producing
mainly TNF alpha, INFG (most important), IL1, Gm-CSF.
The Antigen Presenting Cell needs to be culled by NK cells
to achieve immune homeostasis. This does not happen
and results in further activation of immune system by

antigen presenting cell. The cytokine IFNG activate the
macrophages that result in hemophagocytosis, thus giving
the name to this syndrome30 (Fig. 2).
Not only NK cells and cytotoxic CD8+ve T cells but
also other cells with cytotoxic activity like CD4+ cytotoxic
T cells and iNKT cells participate in pathogenesis of HLH.
There is some correlation between hyper cytokinemia and
the diverse clinical manifestations in HLH.
Secondary Hemophagocytic
Lymphohistiocytosis
In most cases of secondary HLH cytotoxicity and cytotoxic
lymphocyte degranulation are not impaired31 (Figs 3 and 4).
There is increases APC activation that disrupt the balance
between APC activation and CTL-mediated control.
APC can directly activated by intracellular pathogens for
example via toll-like receptor (TLR) activation.
Based on in vitro analyses, four distinct pathways of
macrophage activation have been described. Classical
activation via interferon- or lipopolysaccharide induces
microbicidal activities and upregulation of expression of
class II MHC. Alternative activation by interleukin 4 or 13
induces the expression of genes that are involved in tissue
repair or suppression of inflammation. Innate activation
via toll-like receptor ligands also, not surprisingly, induces
microbicidal activities. Deactivation by stimulation of
interleukin-10 or transforming growth factor- reduces
class II expression and increases secretion of antiinflammatory cytokines.32-34
Fig. 1 Pathogenesis of hemophagocytic lymphohistiocytosis. Depicts the events occurring at the immunologic synapse and highlights
molecules important in process of granule exocytosis. Abbreviations: CHS: Chdiak-Higashi syndrome; FHL: Familial hemophagocytic
lymphohistiocytosis; GS: Griscelli syndrome; HP: HermanskyPudlak; NK: Natural killer cell; CTL: Cytotoxic T lymphocyte1, 29
Disease
FHLH 1
FHLH 2
FHLH 3
FHLH 4
Table 1 Genes associated with familial HLH

Locus
Gene
Gene symbol
9q22.1-23
Unknown
Unknown
10q22
Perforin
PRF 1
17q25
C. elegans Unc13
MUNC 13-4
6q24
Syntaxin 11
STX11
Function
Pore forming protein
Vesicle priming
Vesicle fusion
FHLH 5
c. 1697G > A
p. G566D
Griscelli syndrome type 2
5q21
HSP (Hermansky-Pudlak type II)
Chr. 10
CHS (Chdiak-Higashi syndrome) 1q42.142.2
MUNC 18-2 (STXBP2

MUNC 18-2
Vesicle Bocking, priming and
gene)
fusion
Ras ass protein
RAB27A
Vesicle docking
AP3B1
AP3B1
Granule polarization
Lysosomal trafficking
LYST
Vesicle maturation
regulator
XLP 1
Xq25
SLAM ass protein (SAP)
SHD2D1A
Granule polarization
XLP 2
Xq24-25
XIAP
BIRC4
Inhibition of apoptosis
Abbreviations: EBV: Epstein-Barr virus; FHLH: Familial hemophagocytic lymphohistiocytosis. Adopted from1,26-28
Fig. 2 Patients of HLH due to genetic defect; there is inability to kill virally infected cell as well as antigen presenting cells resulting in
massive clonal expansion of CTLs, secretion of their cytokines like interferon gamma (IFNg), tumor necrosis factor (TNF) alpha, IL6, IL18 and
granulocyte macrophage colony stimulating factor (GM-CSF). IFNg activate macrophages, which then phagocytose blood cells resulting
in hemophagocytosis. Since the cytokines are produced in a massive amount by macrophages, T cells and NK cells, hyperstimulation
continues and the patient has a cytokine storm with signs and symptoms of HLH. The normal contraction of the immune system also
does not take place resulting in persistent cytokine secretion, infiltration of various organs by T cells, massive tissue necrosis and organ
failure
Fig. 3 Natural killer cell and cytotoxic T lymphocyte (CTL) response to virally infected cells. In normal patients there is clonal expansion,
secretion of interferon gamma and killing of virally infected cell resulting in control of viral infection. Once infection is controlled the CTL
are culled and immune homeostasis achieved. Some of these cells become memory cells
Figs 4A and B Neutrophil phagocytosis and erythrophagocytosis respectively
Types and Causes of HLH35
Genetic causes of HLH
Familial HLH
Pigmentary dilution disorders
- Chdiak-Higashi syndrome
- Griscelli syndrome type 2
- Hermansky-Pudlak syndrome type II
X-linked lymphoproliferative (XLP) disease type 1
and 2
Infection associated HLH
Viruses-EBV, CMV, HHV-6, HHV-8, HIV, adeno,
hepatitis, parvo virus.
Bacteria numerous including Kochs, Salmonella.
Parasites-Malaria, Kala azar in the Indian set-up
Spirochetal, and fungal-associated infections.
Malignancy associated HLH: Leukemia lymphoma,
GCT.
Macrophage activation syndrome (MAS) associated
with autoimmune disease like rheumatoid arthritis,
SLE.
Clinical Features
Presentation of HLH in initial period is nonspecific and
easily confused with common infection, autoimmune
disorders and malignancy.1 HLH typically presents
with prolonged fever; unresponsive to antibiotics,
hepatosplenomegaly, rash (665%), lymphadenopathy,
cytopenias, liver dysfunction, hypofibrinogenemia,
hypertriglyceridemia, hypoalbuminemia, hyponatremia.
In initial course,CNS manifestations in form of irritability,
hypo- or hypertonia, cranial nerve palsies, meningismus,
signs of increased intracranial pressure and altered
sensorium seen in 30% of cases.36,37 In early course of the

disease, hemophagocytosis may not be obvious on bone
marrow examination study and may need repeat bone
marrow if clinical suspicion is strong38 (Figs 4A and B).
Incidence of FHLH is 1 in 5000 live births.39 Ratio of
male and female affection is equal. Almost 70% of FHLH
are diagnosed in first year of life, with peak age between
1 and 6 month. With availiblity of genetic testing, it is
possible to point out the first significant episode of FHLH
throughout life,40 including in utero.
In 1987, the Histiocyte Society adopted the unifying
term hemophagocytic lymphohistiocytosis (HLH) and
defined a set of diagnostic criteria to assist clinicians and
researchers (Table 2). The criteria have subsequently been
refined to account for advances in our understanding of
the syndrome, and to simplify it for practical usage. In 2009,
Filipovich et al has revised the HLH diagnostic criteria,
which are practical usage and very much applicable in our
set-up as shown in Table 3.
The HLH must be suspected in setting of rapidly
evolving cytopenias, LFT dysfunction, organomegaly,
coagulopathy. It is prudent to ask for serum ferritin and
triglycerides with D dimer. If ferritin is >500 ng/mL and
specially >3000 ng/mL a BMA done to rule out HLH.
Macrophage Activation Syndrome Associated

with Autoimmune Disease
Macrophage activation syndrome (MAS) is observed in
number of autoimmune disorders, infections and neoplasms. It is caused by an excessive proliferation and activation of macrophages. Incidence of MAS in systemic onset
juvenile inflammatory arthritis is 7-30% and usual triggers
Table 2 Diagnostic guidelines for hemophagocytic lymphohistiocytosis (2004)35,38

The diagnosis of HLH can be established if one of either 1 or 2 below is fulfilled
1. A molecular diagnosis consistent with HLH
2. Diagnostic criteria for HLH fulfilled (five out of the eight criteria below)
Clinical criteria
i. Fever
ii. Splenomegaly
Laboratory criteria
i. Cytopenias (affecting >2 of 3 lineages in the peripheral blood): HB<9 g/dL (in infants <4 weeks: HB<10.0 g/dL), platelets
<100,000/mm3, neutrophils <1,000/mm3.
ii. Hypertriglyceridemia and/or hypofibrinogenemia: Fasting triglycerides > 3 SD, fibrinogen < 3 SD
iii. Hemophagocytosis in bone marrow or spleen or lymph nodes. No evidence of malignancy.

New diagnostic criteria

i. Low or absent NK-cell activity (according to local laboratory reference)
ii. Ferritin >500 g/L
iii. Soluble CD25 (i.e. soluble IL-2 receptor) >2,400 U/mL.
Adapted from Treatment Protocol of the 2nd International HLH Study, 200435,38

Table 3 Filipovich HLH diagnostic criteria 200941
Molecular diagnosis of HLH or XLP OR
At least 3 of 4
Fever
Splenomegaly
Hepatitis
Cytopenias
And at least 1 of 4
Hemophagocytosis
Hyperferritinemia
Increased soluble IL2R alpha
Absent or very decreased NK cell function
Supportive of HLH
Hypertriglyceridemia
Hypofibrinogenemia
Hyponatremia
Adapted from hematology ash education book. 2009;1:127-31.
are gold therapy, aspirin, viral infection and some reports

with anti TNF antibodies.41 Other diseases associated
with MAS are SLE, Kawasaki disease and other rheumatic
diseases.42,43 Specific parameters taken into consideration
are falling WBC and platelet counts, hyperferritinemia,
hypofibrinogenemia, hemophagocytosis in bone marrow,
elevated liver enzymes, elevated erythrocyte sedimentation rate, and hypertriglyceridemia.44,45 It can be presenting
manifestation of autoimmune disorder and features of such
diseases (such as arthritis or rash) should therefore be carefully looked in patient with HLH.
Work-up for Patient of Hemophagocytic

Lymphohistiocytosis38
Laboratory evaluation of HLH is directed with following
considerations:
Establish diagnosis of HLH
CBC platelet
ESR
PS (look for peripheral blood HLH)
LFT
Creatinine
LDH
Serum electrolytes
Serum ferritin
Serum triglycerides
Coagulation profile (PT, PTT, plasma fibrinogen
and D dimer)
CSF for pleocytosis and elevated proteins (50% of
cases).
Supportive evidence for HLH
PB or bone marrow aspiration
Liver biopsy
Lymph node biopsy

Sophisticated lab investigations
sCD25 >2400 IU/L
NK cell activity (may be normal in 30% of cases)
Serum Beta 2 microglobulin
Etiological work-up
Anti-EBV VCA IgM, PCR
Anti-CMV Abs, antigen, PCR
Appropriate microbiological cultures
Hair mount studies for pigmentary dilution
disorders.
Work-up for familial HLH (Flow chart 1)
Perforin by flow cytometry
Granule release assay (GRA)
Gene sequencing to identify mutations.
MANAGEMENT OF HEMOPHAGOCYTIC
LYMPHOHISTIOCYTOSIS31
Principle of Treatment
The immediate aim of treatment is to suppress the severe
hyperinflammation. The secondary aim is to eliminate
pathogen activated antigen presenting cells (APCs) so as
to remove the stimulus for ineffective activation of T cells.
The treatment recommended is HLH 2004 protocol that is
devised by Histiocytic Society. It essentially consists of 3
drugs:
Dexamethasone is lympholytic, inhibit expression of
cytokines, and suppresses maturation of APCs, better
CNS penetration hence preferred over prednisolone.
Cyclosporine A prevents T cell activation and
proliferation.
Flow chart 1 Algorithm for investigation of HLH
Etoposide (VP-16) has activity against monocytes
and macrophages, inhibits EBNA synthesis and EBV
infected cells.
IV gammaglobulins provide cytokine and pathogen
specific antibodies and immunomodulation.
HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS
2004 PROTOCOL
Initial Therapy (8 Weeks)
Dexamethasone, 10 mg/m2/day for 2 weeks followed
by a decrease every 2 weeks to 5 mg/m2, 2.5 mg/m2 and
1.25 mg/m2 for a total of 8 weeks.
Etoposide IV, etoposide 150 mg/m2 IV, twice weekly
for the first two weeks, then weekly during the initial
therapy. Paradoxically even if ANC <0.5 109/L and
the bone marrow is hypocellular, at least the first two
doses should be given.
Cyclosporine A, aiming at levels around 200 microg/L
(monoclonal, trough value). Start with 6 mg/kg daily
orally (divide in 2 daily doses), if normal kidney
function.
Intrathecal methotrexate (IT MTX), age-adjusted doses
of intrathecal methotrexate weekly for 3 to 6 weeks as
follows if there are progressive neurological symptoms
or if abnormal cells persist in the CSF.
Supportive therapy: Cotrimoxazole eq 5 mg/kg
of trimethoprim 2 to 3 times weekly (week 1 and
onwards), an oral antimycotic (from week 1 to 9), IV
immunoglobulin (0.5 g/kg) every 4 weeks.
Continuation Therapy (940 Weeks)

The continuation therapy is a continuation of the initial
therapy with the major aim to keep the disease nonactive
week 9 to 40. Increasing disease activity may make it
necessary to intensify the treatment in some children.
Patients with nonfamilial disease and no genetic evidence
of HLH, are suggested to start continuation therapy only
if the disease is active after the initial therapy. Etoposide
150 mg/m2 IV, every second week. Dexamethasone pulses
every second week, 10 mg/m2 for 3 days. Cyclosporin A
aims for blood levels around 200 microgram/L, as above.
Monitor GFR.
Indications for BMT

Familial hemophagocytic lymphohistiocytosis (FHLH)
Relapsing secondary HLH.
Results of BMT are:46
Matched related donor: 71 percent 16 percent
Matched unrelated donor 71 percent
HLA mismatched unrelated donor: 54 percent 27

percent
Haploidentical related donor: 50 percent 24 percent.
Disease Directed Therapy

Antileishmania therapy, antilymphoma therapy. Please
note in secondary HLH pathogen directed therapy is
not sufficient to control the hyperinflammation. Leishmaniasis treated with liposomal amphotericin B is the
only exception. In patients with EBV-induced HLH or XLP
with fulminant EBV induced HLH use injection rituximab
(monoclonal Ab to CD 20) at doses of 375 mg/m2 weekly for
4 weeks, to knock out the B cells harboring EBV in addition
to HLH directed therapy. This strategy works very well to
control EBV induced HLH and in fulminant infectious
mononucleosis. In desperate situations, anti-TNF alphareceptor blocking agents have been tried.47-50
Macrophage activation syndrome: In addition to
corticosteroids, CSA has been found effective in patients
with corticosteroid-resistant MAS.51
The French group does not use etoposide and they use
anti-thymocyte globulin (ATG) to control HLH.52
Once inflammation is controlled a search for a potential
bone marrow donor is done and if a match is available the
child should be transplanted to achieve a cure. In HLH,
1994 protocol median survival was 64 percent with overall
survival (OS) of 55 percent.46
If there is poor or no response to 4 weeks of HLH
2004 protocol treatment, HLH is probably refractory
and continuing HLH 2004 protocol will be of no further
benefit. Salvage treatment options that can be tried in
such a situation are ATG, fludarabine, alemtuzumab,53,54
Daclizumab, anti TNF-alpha receptor blocking agents,
anti-interferon gamma antibodies, chemotherapeutic
agents. There is no established salvage regime. ATG is
rarely effective, if etoposide-based regimen has been
ineffective. Search for BM donor should be done and one
should attempt to transplant these patients.
In secondary HLH treatment is given for 8 weeks. HLH
re-evaluation is done and if normal treatment is stopped
and close follow-up including signs of reactivation
are warranted (such as fever, hepatosplenomegaly,
neurological abnormalities; hemoglobin, platelets, WBC,
ANC, ferritin, transaminases). Once hyperinflammation
is controlled there can be reactivation of HLH or
development of CNS events. Intrathecal MTX would
benefit for CNS activation. The HLH therapy is reinforced
in case of systemic reactivation. If the patient develops
a reactivation, it is recommended to intensify therapy,
such as to restart from week 2, but the initial therapy may
be less than 8 weeks, and then continue with modified
continuation therapy. Add intrathecal therapy in case of

CNS reactivation. Consider dexamethasone daily, also
between the dexa-pulses, in continuation therapy, but be
aware that it may lead to severe side-effects, so an early
SCT is then suggested.
Poor prognostic factors: Degree CSF pleocytosis,
severity of thrombocytopenia, hyperbilirubinemia and
hyperferritinemia are important risk factors for outcome
in HLH. HLH associated with EBV infection with high
viral load is associated with poor outcome.56 Persistent
fever and thrombocytopenia also associated with poor
outcome.55
Increasing awareness among pediatricians regarding
HLH; with early diagnosis and initiation of early treatment
decreases morbidity and mortality. Bone marrow
transplantation cures disease with good success rate.
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47
Hematopoietic Stem Cells

Hematopoietic stem cells reside primarily in the bone marrow but do circulate in the peripheral blood. These cells may replenish
damaged or missing components of the hematopoietic and immunologic system.1
Hematopoietic stem cell transplantation was originally conceived more than 50 years ago. Initial studies done in animals showed
that transplantation of genetically identical material or the animals own marrow averted death. Studies in animals later translated to
work in humans and a team led by Dr E Donnall Thomas pioneered this. In 1959, he reported that a patient with end stage leukemia
sustained a remission for more than 3 months following total body irradiation and infusion of bone marrow from her identical twin.
Later in 1970s the same group performed identical sibling transplant in leukemic patients. This work laid the foundation for further
advances in hematopoietic stem cell transplantation and this was recognized by the 1990 Nobel Prize awarded to Dr E Donnall
Thomas.2
GRAFT TYPES IN HEMOTOPOIETIC

STEM CELLS
There are three different graft types that can be used for
bone marrow transplant.3
1. Autologous
2. Allogeneic
3. Syngeneic
Autologous Transplants
Autologous transplants use stem cells derived from the
patients own marrow or peripheral blood. Initially, this
was developed in order to rescue the bone marrow of
patients undergoing chemotherapy.1
Autologous transplants are being increasingly incorpo
rated in protocols for solid tumors like neuroblastoma.
This now is the most important form of stem cell
transplantation performed worldwide. Stem cells can be
stored without loss of viability and mortality is low with
this procedure. In addition, there is no risk graft versus
host disease.
Allogeneic transplants are hemopoietic stem cells

from the bone marrow, peripheral blood, or umbilical
cord blood of a healthy donor matched for HLA type,
who may be a family member or an unrelated volunteer.
Initially, allogeneic was developed for treatment of
hematological malignancies. Now it is being utilized
for a variety of hematological disorders and for nonhematological disorders like inborn errors of metabolism
and autoimmune diseases.1
Syngeneic transplant: Syngeneic transplant involves
transplantation from a person sharing identical genetic
material, i.e. an identical twin.
SOURCES OF STEM CELLS

Bone marrow: Bone marrow obtained by repeated
aspiration of posterior iliac crests while donor is under
general or local anesthesia is the traditional source of stem
cells (Fig. 1). This does not cause any side effects to the
donor except for slight discomfort at the site of aspiration
and the requirement of packed cell transfusion in some
cases of pediatric donors.
Fig. 2 Peripheral blood stem cell apheresis
Fig. 1 Bone marrow harvesting
Peripheral blood stem cells (PBSC): It was noted in early

1980s that marrow stem cells circulated in the peripheral
blood. Stem cell yield from peripheral blood can be
increased by giving bone marrow growth factors like
granulocyte colony stimulating factor. Stem cells are then
harvested by leukapheresis (Fig. 2). CD 34 cell surface
molecule is used as a surrogate marker of stem cells.4
G-CSF increases the proliferation of neutrophils and
causes release of proteases. PBSC causes the most rapid
hematopoietic reconstitution. But, it contains more T
cells than bone marrow. Peripheral blood stem cells are
associated with increased risk of chronic GVHD.
Peripheral Blood Stem Cell Apheresis

Umbilical cord blood stem cells (Fig. 3): Cord blood of
neonates contains substantial number of hematopoietic
stem cells that can be harvested at delivery, frozen and
then transplanted into a patient (Fig. 3). They can be
matched with potential donors without much delay. Cord
blood requires less stringent HLA matching than marrow/
peripheral blood stem cells. The first umbilical cord
transplantation was done in 1988 for a child with Fanconi
anemia from cryopreserved cord stem cells from an HLA
matched sibling.5 With the emergence of cord blood
banks with public cord blood banking facilities, they form
an important source of stem cells especially for ethnic
Fig. 3 Umbilical cord blood stem cells
minorities and countries where marrow donor registries

do not exist.
Cord blood is also associated with:
Minimal GVHD due to nave T cells in it.
The disadvantage with cord blood is delayed
engraftment due to the small number of stem cells
Hence infections are more common during the
prolonged neutropenic period.
The cell dose in one cord blood unit may not be
sufficient for an older child or an adult.
The use of double cords has overcome this problem.6
A comparative analysis of the various sources of stem
cells is given in Table 1.
Table 1 Comparison of various sources of stem cells

Bone marrow
Peripheral blood
Umbilical cord
Stem cell content
Usually adequate
Good can be increased, if needed
Fixed source
T cell content
Low
High
Low, nave
HLA matching
Close matching required
Close matching required
Close matching not very important
Engraftment
Fast
Fastest
Slowest
Chapter-47 Bone Marrow Transplantation 481
HUMAN LEUKOCYTE ANTIGEN MATCHING

Allogeneic transplantations became feasible with the
identification and typing of human leukocyte antigen (HLA)
located on major histocompatibility locus on chromosome
6. There are two sets of genes on both alleles and hence they
are inherited as haplotypes. Thus two siblings have one
chance in four of being HLA identical. The HLA loci that are
important in the transplant setting include Class I antigens
(HLA A, B and C) and Class II antigens (HLA DR). For a
successful transplant, it is necessary to have matching at all
these loci.1 The immune reaction against HLA molecules
can cause problems. Mismatching at Class I antigenic loci,
increase the chance of rejection of the donor, where as that
at Class II locus increases graft vs host disease.
DONOR REGISTRIES
Only 20 to 25 percent of patients eligible for allogeneic
transplantation will have suitable sibling donors. To
make transplants available to a greater number of eligible
patients, bone marrow donor registries have been esta
blished in several countries. This will identify unrelated
but matched donors for prospective patients. With the
establishment of international marrow donor registries
there are good chances of finding a matched unrelated
donor depending on the ethnic group. For patients from
Asia and Indian subcontinent, the probability of finding a
donor of Asian origin is low due to the poor representation
in these registries and due to the absence of local
registries. The strongest transplant reactions occur when
the major histocompatibility antigens of the donor and of
the recipient are incompatible.
The HSCT has resulted in sustained remission in
patients with autoimmune diseases. SCT results in
re-education of the immune system and hence is now
used for refractory rheumatoid arthritis and other
autoimmune diseases. HSCT cures many genetic diseases
like thalassemia and sickle cell disease in developing
countries such one shot treatments are highly desirable
because chronic treatments often are difficult to sustain.
Among the above mentioned indications, immuno
deficiencies, certain genetic disorders and severe aplastic
anemia deserves urgent referral to a transplant center for
consideration for an early transplant (Table 2).
COLLECTION OF HEMATOPOIETIC
STEM CELLS
Bone marrow is harvested from posterior iliac crest and is
generally well tolerated. The donor needs to be admitted
and the procedure is done under general anesthesia. The
harvested marrow is collected in a special harvest bag
with adequate anticoagulation. The harvest bag should be
Table 2 Common indications for hematopoietic

stem cell transplantation
Diseases commonly treated with hematopoietic
stem cell transplantation
Malignant conditions
Nonmalignant conditions
Autologous
Acute myeloid leukemia
Hodgkins disease
Neuroblastoma, Ewings
sarcoma
Autoimmune diseases
Allogenic
Acute myeloid leukemia
Chronic myeloid leukemia
Myelodysplastic syndromes
Myeloproliferative syndromes
Aplastic anemia
Fanconis anemia
Paroxysmal nocturnal
Hemoglobinuria
Diamond blackfan anemia
Dyskeratosis congenita
Thalassemia
Sickle cell disease
Glanzmann thrombasthenia
Severe combined
immunodeficiency
Wiskott-Aldrich syndrome
Chronic granulomatous disease
Congenital neutropenia
Congenital megakaryocytosis
Inborn errors of metabolism
gently shaken during the procedure to avoid the formation

of clots. The puncture site is changed after 10 to 15 mL is
aspirated from the site. After collection of the desired
volume, bony spicules and clumps are filtered out and the
final product is made ready for infusion.7
Peripheral blood stem cells can be collected after
being mobilized from the bone marrow by G-CSF given at
a dose of 10 g/kg/day for 4 to 5 days. PB stem cells are
then collected by leukapheresis. Neither anesthesia nor
hospitalization is required for the donor.
Children may experience minor side effects related
to G-CSF use like body aches and influenza like illness.
Adequate vascular access and extracorporeal volume in
the circuit of leukapheresis are the main limiting factors
for peripheral blood stem cell collection in small children.
Central venous catheter is usually inserted in subclavian
or femoral veins and should be sufficiently stiff to avoid
collapse under the negative pressure while drawing
blood into the apheresis machine. In children adequate
priming of the extracorporeal circuit may be required
in order to avoid hypotension.8 As the anticoagulation
most commonly used during is citrate dextrose (ACD A),
hypocalcemia should be anticipated and managed with
calcium boluses given under proper monitoring. Heparin
may also be used for anticoagulation, but has been
observed to have higher frequency of bleeding during
catheter removal.
Umbilical cord blood is collected at the time of delivery
by clamping the cord and cutting the umbilical cord. The
median volume collected is around 60 mL. Once collected,
it is then processed and stored in liquid nitrogen till further
use.
Umbilical cord blood is collected after clamping
the cord. The collected blood is tested, processed and
cryopreserved. At the time of use, the cord blood cassette
is transported in liquid nitrogen.
After collection of the marrow/peripheral blood
stem cells, the product can be infused immediately, or
may be cryopreserved and stored till need arises. Graft
manipulation like T cell depletion may be done when
required. In case of major or minor ABO incompatibility, it
is necessary to either deplete the red cells or plasma in the
product as required.
PREPARATIVE REGIMENS/CONDITIONING
REGIMENS
The chemotherapy or irradiation given prior to stem cell
infusion is called conditioning regimen. The regimen
is intended to be myeloablative as well as immuno
suppressive. The objective of myeloablation of the reci
pient prior to transplant is to eradicate the recipients
own bone marrow stem cells. In case of malignancies,
such high doses of chemotherapy help in eradicating the
cancer cells.1 The preparative regimen also augments the
antitumor immune response by causing a breakdown of
tumor cells, which results in flood of tumor antigens into
the antigen presenting cells. This results in proliferation of
T cells that attack the surviving malignant cells.
ing to the plasma levels or by using intravenous instead of

oral busulfan.
Non-myeloablative regimens are those that usechemo
therapy agents/radiation in lower doses than men
tioned above. These regimens are immunosuppressive,
but do not destroy the entire recipients marrow. The
advantage of this regimen is that the toxicity associated
with the conditioning regimen is significantly less. It is
immunosuppressive as well and can be used in patients
with comorbidities. So also in case of malignancies the
residual cells of the recipient can exert a graft versus tumor
effect. However, the risk of rejection of the graft increased
with non-myeloablative regimens.1
STEM CELL INFUSION

After the preparative regimen, the processed stem cells
are infused intravenously. The patients are kept in HEPA
filtered rooms and are on prophylactic antifungals,
antibiotics and antiviral agents (Fig. 4).
Engraftment is defined as absolute neutrophil count
more than 500/cumm for more that 3 days consecutively.
COMPLICATIONS (FIG. 6)
Early Effects
Mucositis: It is the most common complication of myelo
ablative preparative regimes especially with the use of
total body irradiation and melphalan. Other factors that
contribute to mucositis include GVHD, use of methotrexate
for GVHD prophylaxis and co-existent infections. Oropha
ryngeal mucositis results in painful ulcers in the mouth
and throat. It can also lead to mucoid diarrhea and pain
abdomen. In addition to the considerable pain and need
Total body irradiation: It is both myeloablative and

immunosuppressive. The effects are independent of blood
supply, and the effects reach sites that are not accessible
by chemotherapy. It is also not associated with crossresistance to chemotherapy. Local shielding of organs
and fractionation of the total dose can reduce toxicity.
The toxicity and scarcity of facilities for TBI have led to
development of radiation free regimens.
Busulfan-Cyclophosphamide (Bu-Cy): In 1983, a regimen
of Bu with high doses of Cy proved effective in treatment
of acute myeloid leukemia. Acute adverse effects are
associated with high plasma levels of busulfan and me
tabolites of cyclophosphamide. The dose of cyclophos
phamide was later lowered to reduce toxicity. Toxicity can
also be reduced by adjusting the dose of busulfan accord
Fig. 4 Bone marrow transplantation room (HEPA filtered)

for narcotics, mucositis leads to compromised enteral
nutrition and predisposition to infections due to breach in
mucous membranes. Management includes prophylaxis
against herpes infections with acyclovir as well as against
candidal infections. There are several ongoing studies
with agents like glutamine, palifermin, medicated pastes,
topical lidocaine which have not yet been of proven
benefit.9
Sinusoidal obstruction syndrome/veno-occlusive disease
(SOS/VOD): Hepatic veno-occlusive disease is an organ
injury syndrome that occurs after high dose chemotherapy
employed in HSCT. After myeloablative conditioning
in allogeneic transplantation VOD is seen in up to 10
percent of patients. It is potentially fatal syndrome of
painful hepatomegaly, jaundice and fluid retention. Total
body irradiation, busulfan, cyclophosphamide and many
other preparative regimens cause SOS. The metabolites
of these drugs and irradiation result in sloughing of the
sinusoidal endothelium, which results in obstruction
of hepatic circulation and injury to the centrilobular
hepatocytes.9 Recognized risk factors for VOD includes
older transplant age, HLA disparity between donor and
recipient, preexisting liver disease, etc. The type and
intensity of transplant conditioning regimen are probably
the greatest determining factor for development of severe
VOD. High plasma levels of Busulfan or metabolites of
cyclophosphamide are associated with increased risk of
VOD.
Because there is no effective treatment of this
complication, prevention is critical. Use of reduced
intensity conditioning regimens and the substitution of
fludarabine for cyclophosphamide appears to reduce
the risk. Defibrotide is a mixture of single-stranded
oligonucleotides that have local antithrombotic, antiischemic and anti-inflammatory properties. It protects
the sinusoidal endothelium without compromising the
cytotoxic therapy. Defibrotide modulates endothelial
cell injury and protects the sinusoidal endothelium. It
also modulates platelet activity and enhances fibrinolytic
activity. Hence, it is used now for prophylaxis as well as
treatment of SOS. Other agents used with variable results
include tissue plasminogen activator, antithrombin III
and prostaglandin E1, low molecular weight heparin,
Ursodeoxycholic acid, etc. Despite emerging therapies,
VOD remains a much feared transplant complication and
severe cases are associated with dismal prognosis.10
ACUTE GRAFT VERSUS HOST DISEASE

The graft versus host disease (GVHD) is the most im
portant complication of allogeneic transplantation. The
development of GVHD is a complex process that is
dependent on many factors including the condition

ing regimen used. The pathogenesis of acute GVHD is
described as a three-step process that includes
Conditioning induced tissue damage phase:
Donor lymphocyte activation phase
Cellular and inflammatory effector phase.
The first phase consists of tissue damage induced by
conditioning regimen and infection. As a result of the
inflammatory cytokines released, there is maturation/
activation of host dendritic cells with subsequent recog
nition of host major and minor histocompatibility antigens
by mature donor T cells. Despite matching of major HLA
antigens, there may be minor HLA mismatches that may
be recognized as foreign. This results in activation of
the donor T cells against the recipient antigens. The IL
2 and IFN gamma produced by T helper 1 cells result in
activation of NK cells and cytotoxic T lymphocytes. Thus
various cytokines and T cell subtypes are involved in the
pathogenesis of aGVHD and they are potential targets for
intervention.11
Acute GVHD is characterized by manifestations in the
skin, liver, and GI tract. Grading of the severity of aGVHD
is based on evaluation of the degree of involvement in
each of these organs (Table 3).
Skin involvement in GVHD starts as redness and
maculopapular rash, initially of face, ears and palms
and soles. Later the rash may progress to other parts
of the trunk and may progress to bullae formation and
desquamation (Figs 5A to C).
Hyperbilirubinemia is the primary hepatic manifesta
tion of liver involvement in GVHD. The other causes of
jaundice in transplant patients include veno-occlusive
disease, drug toxicity and infections.
The GIT involvement is characterized by diarrhea,
nausea and food intolerance.
Other organs may also be involved in GVHD, e.g.
ocular GVHD is manifested by hemorrhagic conjunc
tivitis and pseudomembrane formation.12
MANAGEMENT OF GVHD
Over the years, there have been several strategies deve
loped for management of GVHD. Prophylactic measures
include methotrexate, steroids and cyclosporine. Cyclo
sporine is a calcineurin inhibitor that interferes with T
lymphocyte functions. Agents used for treatment include
steroids, agents like tacrolimus, mycophenolate mofetil,
monoclonal antibodies like Infliximab (TNF alpha
inhibitor) and photopheresis. The principal risk factor
for aGVHD is HLA mismatch, but it can occur despite
a full HLA match. The incidence of GVHD can also be
reduced by in vitro T cell depletion of the graft before
transplantation.12
Table 3 Grading of graft versus host disease
Clinical staging
Stage I
Stage II
Stage III
Stage IV
Skin
Rash <25% BSA
Rash 2550% BSA
Rash 50100% BSA
Desquamation and bulla

formation
GIT
Persistent nausea or
Diarrhea 510 mL/kg/day
Diarrhea 1015 mL/kg/

day
Diarrhea > 15 mL/kg/day
Pain +/ ileus
Liver
Bilirubin 23 mg/dL
Bilirubin 36 mg/dL
Bilirubin 615 mg/dL
Bilirubin >15 mg/dL
Clinical grading
Skin
GIT
Liver
Functional impairment
III
II
IIII
III
IIIIII
IIIII
IIIII
II
IV
IIIV
IIIV
IIIV
III
Figs 5A to C Skin rash in GVHD
Interstitial Pneumonitis
DELAYED EFFECTS
Transplantation associated lung injury usually occurs

within four months of the procedure, and the mortality
exceeds 60 percent. Risk factors include TBI, allogeneic
transplantation and acute GVHD suggesting that donor
lymphocytes target the lung. Treatment with etanercept
that blocks tumor necrosis factor, combined with corti
costeroids may reduce the injury promptly.9
Chronic GVHD: The risk of chronic GVHD increases

with recipient and donor age. Chronic GVHD is asso
ciated with loss of self-tolerance and often resembles
Sjgrens syndrome or scleroderma. Chronic GVHD
can cause bronchiolitis, keratoconjunctivitis sicca,
esophageal stricture, malabsorption, cholestasis,
hematocytopenia, and generalized immunosuppres
sion. Treatment with corticosteroids may be needed for
two years or longer.1
Growth and development are impaired in children
who undergo transplantation as a result of myeloablative
preparative regimens. Growth hormone therapy increases
height in these children.
Fertility in adulthood may be impaired in children
undergoing transplantation. Young men may recover
their fertility later in life. If sperms are present before
transplantation, semen can be cryopreserved and used
later. Women can also go in for cryopreserved oocytes.
Infections
Transplant related infections result from damage to the
mouth, gut and skin from preparative regimens as well
as from catheters, neutropenia and immunodeficiency.
Prolonged neutropenia, GVHD and the administration of
corticosteroids predispose patients to fungal infections.13
Cytomegalovirus is an important cause of morbidity
during this period. The various infections which occur in
the course of transplantation are given in Figure 1.
Fig. 6 Timeline of infections in a patient undergoing transplantation
Secondary cancers increase after transplantation: Myelo

dysplasia and acute leukemia are complications of auto
logous transplantation for Hodgkins and non-Hodgkins
lymphoma. Survivors of transplantation should be followed
indefinitely to detect early cancer or precursor lesions.
Beta Thalassemia
The median survival of patients with beta thalassemia
major who are on regular transfusion and chelation
program is around 35 years. By the fourth decade of life
most of the patients succumb to complications of the
disease. At present, the only curative approach in this
illness is allogeneic stem cell transplant. The first transplant
was performed in 1982 and ever since, the transplant
group from Pesaro, Italy headed by Dr Guido Lucarelli
has led the subsequent way. The Pesaro group with their
experience, has divided patients with thalassemia into 3

major risk classes based on the presence of hepatomegaly,
inadequate chelation and portal fibrosis.14
Pesaro Thalassemia Risk Classification

Risk Factors
Hepatomegaly: Determined by physical examination
Hepatic fibrosis: Liver biopsy
Inadequate chelation: History, ferritin value, liver iron
quantitation.
Risk Classification
Class 1 risk: No risk factors present
Class 2 risk: 1 or 2 risk factors present
Class 3 risk: All 3 risk factors present.
The conditioning regimen used was Bu 14 to 16 mg/kg
and Cy 200 mg/kg.
On analysis of their data of 1003 patients, the overall
thalassemia free survival observed was 68 percent (Class
1: 87%, Class 2: 84%, Class 3: 58%). The major problem
observed was with Class 3 patients, as many could
not tolerate the toxicity of the regimen. In 1997, a new
preparative regimen was developed that used myelo
suppression and immunosuppression with azathioprine,
hydroxyurea and fludarabine followed by conditioning
with Bu 14 mg/kg and Cy 160 mg/kg. This strategy
named Protocol 26 has shown good results. In 33 class 3
thalassemics <17 years of age, the thalassemia free survival
has increased to 85 percent and the rate of rejection has
dropped from 30 to 8 percent.
Thus allogeneic transplantation is increasingly beco
ming a feasible option across the globe. The availability
of HLA matched sibling donor is the limiting factor as it is
seen only in 25 to 30 percent of cases. Recently, there have
been reports of use of alternative donors like umbilical
cord blood, HLA mismatched related donors, etc. such
techniques need to be perfected before they can be
accepted as a standard of care.15
APLASTIC ANEMIA
Severe aplastic anemia is defined as ANC <500/mL,
Absolute reticulocyte count <20,000/mL and platelet count
<20,000/mL. Currently, the frontline therapy consists of
either immunosuppressive therapy or matched sibling
transplantation. Stem cell transplantation provides
curative therapy in SAA. Initial reports of success have
been with the use of syngeneic donors. The first successful
allogeneic transplantation was done in 1972. The
combination of cyclophosphamide with ATG was shown
to be a successful conditioning in these patients. Survival
for HLA matched sibling transplants has increased from
48 percent in the 1970s to 66 percent in the late 1980s and
to 70 to 90 percent in recent data. The rate of graft rejection
has fallen since cyclophosphamide with ATG has become
the standard conditioning regimen.16
The comparison of hematological response rates, as
well as long-term responses strongly supports SCT as the
treatment of choice in SAA, in cases where an HLA matched
related donor is available. However, transplantation
is also associated with risk of early mortality. Data indicates
that in patients younger than 40 years of age, SCT is always
superior to immunosuppressive therapy. In older subjects
immunosuppression may be a more feasible option consi
dering the comorbidities. In patients >40 years of age,
the decision should be made on an individual basis. The
response to immunosuppressive therapy may take as
long as 6 to 12 months and also carries a 10 percent risk of
evolution of clonal hematopoietic disorders like PNH and

myelodysplasia.17
LEUKEMIA
Allogeneic stem cell transplantation is used for pediatric
patients with acute lymphoblastic leukemia (ALL), acute
myeloid leukemia (AML) as well as for chronic myeloid
and juvenile myelomonocytic leukemia. In addition to the
stem cells, the donor graft also has T cells and NK cells.
They populate in the recipients hematopoietic system
and give rise to a new immune system. This can help in
eliminating the remaining leukemia cells that escape
the conditioning regimen. This is called the Graft versus
Leukemia effect. The GVL effect is exerted through T cell
mediated allo reactivity.18
Acute lymphoblastic leukemia is the most common
indication for stem cell transplantation in pediatric age
group. In ALL transplantation is done in first remission
for patients at very high-risk of a relapse. This includes
high risk cytogenetic features like t(9; 22) and t(4; 11). In
other patients who relapse while on or after completion
of primary treatment, transplantation is indicated in
second remission. Conditioning regimens that utilize total
body irradiation are associated with better survival than
with busulfan/cyclophosphamide alone. The estimated
probability for event free survival for patients transplanted
in first and second remission is around 65 percent and 50
percent respectively.1
Less intensive GVHD prophylaxis is employed to reap
the benefits of GVL effect.
Acute myeloid leukemia is another indication for
allogeneic stem cell transplantation from an HLA identical
donor. Subtypes of AML including acute promyelocytic
leukemia and good cytogenetic features like t(8; 21) and
inv(16) are no longer considered for transplantation
in first remission due to good results with conventional
therapy.
In chronic myeloid leukemia, the earlier treatment of
choice was allogeneic SCT. With the advent of targeted
therapy directed against t(9; 22), i.e. imatinib mesylate,
the treatment has been revolutionized. Transplant is
indicated only for those patients who fail this treatment or
progress to blast crisis.
IMMUNODEFICIENCIES
Bone marrow transplantation for lethal congenital
immunodeficiencies has been established as a treatment
modality ever since transplants done for severe combined
Immunodeficiency and Wiskott Aldrich syndrome were
successful in 1968. In contrast to other indications, the goal
of transplantation in these patients, is complete recovery of

immune function. Hence 100 percent donor engraftment
may not be needed inorder to cure the immunodeficiency.
In certain diseases like chronic granulomatous disease,
stable donor chimerism of around 10 to 15 percent cells
is enough to establish normal host defense mechanisms.
Before taking up for transplantation, a detailed evaluation
for infections must be undertaken and cure of underlying
infections must be attempted whenever possible. Myelo
ablative chemotherapy conditioning regimens are utilized
for patients with non-SCID primary immune deciency
diseases undergoing SCT. Non-myeloablative or reducedintensity conditioning regimens also have the potential for
engraftment without the risk of morbidity and late sequelae
associated with standard myeloablative regimens.20
INDIAN SCENARIO
The first Bone Marrow transplantation done in India was
in 1983 at Tata Memorial Hospital, Mumbai in 1983 for a
patient with Acute Myeloid Leukemia. At present more
than 15 centers in India have facility for BMT. India caters
not only to patients within our country but also to patients
from neighboring countries. Since, its humble beginnings,
HSCT has progressed to a successful modality of treatment.
The BMT Unit at Christian Medical College, Vellore has
been designated as center of excellence by ICMR.19
As far as our experience of HSCT program at Sir Ganga
Ram Hospital is concerned, over a period from January
2006 to August 2009, 39 transplants (16 allogeneic and
23 autologous) were done. The median age of transplant
patients was 34 years (11 months-68 years). Children
comprised 41.2 percent of the patients. The indications
for 16 allogeneic transplants were thalassemia major-6,
acute
myeloid
leukemia
(AML)/myelodysplastic
syndrome-6, severe aplastic anemia-3 and high-risk acute
lymphoblastic leukemia-1. Donors were HLA-matched
sibling in 13 cases, HLA-matched relative in 1 and
unrelated umbilical cord blood in 2. The source of HSCT
was peripheral blood in 8 patients, bone marrow in 6 and
umbilical cord blood in 2. Fourteen patients underwent
myeloablative transplants and two were given reduced
intensity conditioning. Three Donor Lymphocyte infusions
were given to two patients. Seven patients (44.8%) are alive
and disease free at a median follow-up of 453 days (65591
days). Thirteen patients showed neutrophil engraftment
at a median duration of 14 days (range 11 to 44).
Acute graft versus host disease (GVHD) was seen
in 6 patients, grade I-II was seen in 5 patients, which
responded to steroids. Steroid-refractory grade IV GVHD
was seen in one child; it did not respond to mycophenolate
and infliximab. Three patients developed sinusoidal
obstruction syndrome. All were given defibrotide and two
responded. A total of 7 allogeneic HSCT recipients have
died, out of which 2 AML patients died of relapse at 56 and

90 days post-transplant. The main causes of death in 5 other
patients were sepsis (3 bacterial and 2 fungal), sinusoidal
obstruction syndrome (1 case), acute GVHD (1 case) and
chronic GVHD (1 case). Two thalassemic children rejected
graft but are alive and transfusion dependent.
The main indications for 19 autologous HSCT were
multiple myeloma-9, Non-Hodgkins lymphoma-4, meta
static neuroblastoma-2, relapsed Hodgkins lymphoma-1,
relapsed rhabdomyosarcoma-1, relapsed primitive neuro
ectodermal tumor (PNET) of the kidney-1 and rejection
post cord blood transplant in thalassemia-1. The source
of HSCT was peripheral blood in 16 patients and bone
marrow in 3. Ten patients (55.6%) are alive and diseasefree at a median follow up of 114 days (range 21-617 days).
Seventeen patients engrafted neutrophils at a median
duration of 12 days (range 9 to 30).
At a median follow-up of 200 days (range 21 to 1200 days),
the estimated overall survival and event free survival for all
the transplant population are 67.3 percent 8.6 percent and
63.5 8.9 percent respectively. Overall transplant related
mortality is 23.5%, with a decrease from 28.6 percent to
22.2 percent after a dedicated HSCT unit with HEPA filtered
rooms became functional by mid 2007.20
It is remarkable that, through bone marrow and HScell transplants, stem-cell therapies have brought about
permanent cures for many patients suffering from blood
disorders. There are efforts underway to develop therapies
using alternative sources of stem cells, such as embryonic
stem cells. However, because HS cells are relatively
abundant and accessible, alternative sources might be
less crucial for treating common blood disorders than
for diseases of other organs and tissues. Advances in HS
cell based therapies would probably be the answer for the
many incurable diseases of today.21
REFERENCES
1. Velardi A, Locatelli F. Hematopoietic stem cell trans
plantation. In: Kleigman RM, Behrman RE, Jenson HB,
Stanton BF (eds): Nelson Textbook of Pediatrics, 18th edn.
Elsevier. 2007.pp.924-33.
2. Allogeneic bone marrow/stem cell transplantation. A
medical and educational handbook. (Online) 2001. Avail
able at URL http://www.bonemarrow.org/downloads/
AllogeneicBook.pdf
3. Fairview-University Blood and Marrow Transplant
Services. Blood and Marrow Transplantation: a Patients
Guide to Hematopoietic Stem Cell Transplantation.
Minneapolis, MN: Fairview Press. 2004.
4. Guidelines for the clinical use of blood cell separators.
Prepared by a joint working party of the transfusion and
clinical hematology task forces of the British Committee for
Standards in Hematology. Clin Lab Haem. 1998;20:265-78.
5. Grewal SS, Wagner JE. Umbilical Cord Blood Trans
plantation. In: Kline RM (ed): Pediatric Hematopoietic
stem cell transplantation. Informa Healthcare USA. 2006.
pp.161-87.
6. Gluckman EG, Rocha V, Chastang C. The use of cord blood
cells for banking and transplant. Oncologist. 1997;2:340-3.
7. Blood and Marrow Stem Cell Transplantation (Online).
The Leukemia and Lymphoma Society. 2001.
8. Takaue Y, Kawano Y, Abe T, Okamoto Y, Suzue T, Shimizu
T, et al. Collection and transplantation of peripheral blood
stem cells in very small children weighing 20 kg or less.
Blood. 1995;86(1):372-80.
9. Aquino VM, Sandler ES. Supportive Care of the Pediatric
Hematopoietic Stem-Cell Transplant Patient. In: Kline RM
(ed): Pediatric hematopoietic stem cell transplantation.
Informa Healthcare USA. 2006.pp.1-26.
10. Ho VT, Revta C, Richardson PG. Hepatic veno-occlusive
disease after hematopoietic stem cell transplantation:
update on debrotide and other current investigational
therapies. Bone Marrow Transplant. 2008;41:229-37.
11. Moore TB, Feig SA. Acute graft versus host disease.
In: Kline RM (ed). Pediatric hematopoietic stem cell
transplantation. Informa Healthcare USA. 2006.pp.65-84.
12. Socie G, Blazar BR. Acute graft versus host disease: from
bench to bedside. Blood. 2009;114:4327-36.
13. Bradfield SM, Neudorf M, Reubin E, Sandler ES. Prevention
and treatment of infectious disease. In: Kline RM (ed):
Pediatric hematopoietic stem cell transplantation. Informa
Healthcare USA. 2006.pp.27-63.
14. Boulad F. Hematopoietic Stem-Cell Transplantation

for the Treatment of Beta Thalassemia. In: Kline RM
(ed). Pediatric hematopoietic stem cell transplantation.
15. Lucarelli G, Gaziev J. Advances in the allogeneic trans
plantation for thalassemia. Blood Rev. 2008;22:53-63.
16. Paley C, Vlachos A, Lipton JM. Hematopoietic Stem-Cell
Transplantation for acquired aplastic anemia. In: Kline RM
(ed). Pediatric hematopoietic stem cell transplantation.
17. Marsh JCW, Ball ES, Cavenagh J, Darbyshire P, Dokal I,
Gordon-Smith EC, et al. Guidelines for diagnosis and
management of aplastic anemia. Br J Haematol. 2009;147:
43-70.
18. Haining WN, Duncan C, Lehmann LE. Principles of bone
marrow and stem cell transplantation. In: Orkin SH,
Nathan DG, Ginsburg D, Look AT, Fisher DE, Lux SE (eds).
Nathan and Oskis hematology of infancy and childhood,
7th edn. Elsevier. 2009.pp.395-452.
19. Loechelt BJ, Kamani NR. Primary immunodeficienies. In:
Kline RM (ed): Pediatric hematopoietic stem cell trans
plantation. Informa Healthcare USA. 2006.pp.321-36.
20. Kalra M, Yadav SP, Dinand V, Parashar N, Kohli S,
Choudhary D, et al. The experience of hematopoietic stem
cell transplantation from an emerging centre in North
India. Poster Presentation at PHOCON 2009/PP36/CS19.
21. Radhakrishnan N, Yadav SP, Sachdeva A. Stem cell
transplantation. Indian Journal of Practical Pediatrics.
2009;11(2):127-35.
7
General
CHAPTERS OUTLINE
48. Gene Therapy

49. Monoclonal Antibodies in Pediatric Hematology and Oncology

50. Biological Response Modifiers

48
Gene Therapy
INTRODUCTION
Normal as well as some defective genes are present in
all individuals. The genes usually remain dormant until
a disease associated with the gene manifests in a case.
Genetic defects can lead to more than four thousand
diseases. Apart from the genotype of an individual, the
environment in which the individual lives also affect the
manifestation of the disease.
Gene therapy is the introduction of a target gene into a
cell. Gene therapy can be somatic or germ-line. In somatic
gene therapy the genetic make-up of the individual is not
altered and it is not transmissible to the off-spring. Somatic
gene therapy aims at the introduction of the target gene to
correct a defective organ or tissue. Germ-line gene therapy
is the introduction of the target gene into the zygote, a

change that is transmissible to the offspring. Before the
initiation of gene therapy the candidate gene needs to be
identified. Diseases that are amenable to probable gene
therapy are enumerated in Table 1. The complexity of gene
therapy lies in the mechanisms to deliver the therapeutic
gene into the target organ in an accurate, controlled and
effective way.
In 1990 in NIH, Maryand a four-year-old-boy with
severe combined immunodeficiency (SCID) received an
infusion of genetically modified stem cells. This was the
first instance of gene therapy and the recipient was later
known as the bubble boy. Since then the field of gene
therapy has targeted many diseases and has expanded its
coverage.
Table 1 Diseases for which gene therapy is being explored

Disease
Underlying defect
Target cell for genetic manipulation
SCID
ADA deficiency
T-lymphocytes
Hemophilia
Factor VIII or IX deficiency
Hepatocytes, muscle fibroblasts or

hematopoietic cells
Cystic fibrosis
CFTR gene mutation
Airway epithelial cell in lungs
Hemoglobinopathies
Globin chain defects
Hematopoietic cells
Gauchers disease
Defect in enzyme glucocerebrosidase
Macrophages or hematopoietic cells
-1 antitrypsin deficiency
Lack of -1 antitrypsin
Lung and liver cells
Familial hypercholosterolemia
Lack of LDL receptors
Liver cells
Cancer
Multiple causes
Different cancer cell types
Neurological diseases
Parkinsons/Alzheimers, etc.
Neuronal cells
Cardiovascular diseases
Arteriosclerosis
Endothelial cells of vessels
Infections
HIV, Hepatitis B
T-cells, liver, macrophages
492Section-7General
PROCEDURE OF GENE THERAPEUTICS

Target Tissue
Nature of the disease determines the somatic candidate
organ for gene therapy. The target cell needs to be clearly
defined. For example in cystic fibrosis the target tissue is
the lung where delivery of the therapeutic gene is being
tried by the aerosolized route. In a clotting disorders
like hemophilia the deficient factor can be provided by
introduction of the candidate gene into the myocytes or
the hepatocytes. The choice of the target tissue depends
upon factors such as protein modification, gene delivery
efficacy of the vector and immunological factors.
Vectors
The method of delivery of the target gene into the tissue is
of vital importance. Naked genes can be delivered into the
cells but the method has low efficiency. Vectors which are
usually plasmids or viruses, can move recombinant DNA
from one cell to the other. Special synthetic vectors have
also been designed for gene transfer.
Retroviruses are RNA viruses that can integrate its

nucleic acid into the host cells, using reverse transcriptase
enzyme that transcribes RNA into DNA . Other vectors used
in gene therapy can be adenoviruses, retrotransposons
and liposomes (Fig. 1). Engineered vectors are used for
gene therapy where the detrimental gene is removed and
the corrective gene is added. The properties of an ideal
vector are enumerated in Table 2.
Type of Vectors

Retrovirus
Lentivirus
Adenovirus
Herpes viruses
Plasmids, retrotransposons and liposomes.
Low host immunogenicity and allowance for large
scale production are advantages of non viral methods over
the viral methods. Non viral methods however have the
disadvantage of low levels of transfection and subsequent
gene expression, but these have been now overcome with
modern vector technologies that yield molecules and
Fig. 1 Gene therapy (a simplified representation)
Chapter-48 Gene Therapy 493

Table 2 Properties of a good vector for gene therapy
All vectors used in gene therapyviral or nonviral have certain limitations. The disease type often dictates the type of vector to be
employed. Adenoviral vectors are useful in situations where a short term expression of the gene product is needed (e.g. products that
may be toxic to malignant cells). In case of sustained gene expression the integrating vector that leads to minimal immunological
response is desirable. An ideal vector should have

A good concentration in minimal amount of injection so that a maximum number of target cells are infected
Easily reproducibility
Ability of a stable and site specific integration into the host genome
Specificity for the target cell
Minimal immunogenic potential
Ability of its transcriptional unit to respond to external manipulation.
Presently such a desirable vector that possesses the advantages of both the synthetic and viral vectors is not available. Availability of
an ideal vector will make gene therapeutics grow by leaps and bounds.
techniques with transfection efficiencies similar to the

viral vectors. Injection of naked DNA, electroporation,
the gene gun, sonoporation and magnetofection and
the use of dendrimers, lipoplexes, oligo-nucleotides and
inorganic nanoparticles are some non viral methods of
gene delivery.
GENE THERAPY AND ITS USE IN PEDIATRIC

HEMATOLOGY AND ONCOLOGY
antibodies. In vivo certain promoters undergo inactivation

hampering long term factor VIII or factor IX expression.
Several phase I clinical trials are underway presently
for hemophilia and some subjects have reported lower
bleeding episodes and detectable clotting factor activity.
Gene Therapy for Hemoglobinopathies
As hematopoietic cells can be easily collected and are

amenable to in vitro manipulation they are ideal targets for
gene therapy. Genetic manipulation of the hematopoietic
stem cells can be utilized for the cure of many acquired
and inherited hematological and oncological diseases.
The target cells can be the red cells, leukocytes or any other
mature blood element. The desired type of blood cell can
be continuously produced for the lifetime of an individual
by integrating the desired transgene into the chromatid
of the concerned pleuripotent stem cell. For example the
sources of deficient clotting factors could be cells such as
the hepatocytes and the myocytes.
A lentiviral vector has been used for inserting the gene for
a normal hemoglobin expression in hemoglobinopathies
into stem cells from the bone marrow, in mice cells cultured
in vitro. These cells have then been re-introduced into the
mice. The mice that have received this genetic treatment
are no different from the normal counterparts. As the stem
cells used here were autologous, their rejection has been
avoided. Although this therapy is still untested in humans
it is possible that the mutations in the -globin gene be
corrected by gene targeting in induced pluripotent stem
cells (IPS) derived from somatic cells. Skin fibroblasts have
been differentiated into IPS cells. The IPS cells in future
could be utilized to create hematopoietic stem cells that
synthesize hemoglobin.
Gene Therapy for Hemophilia
Gene Therapy for Immunodeficiencies
In mice, expression of factor VIII in blood cells and

platelets has been achieved by the use of ex vivo transduced
hematopoietic stem cells. In vivo, transposons expressing
factor VIII can be transferred into the endothelial
cells or hepatocytes. In canine models the neonatal
administration of reteroviral vectors expressing the canine
factor VIII completely corrected hemophilia in dogs.
Similarly in dogs with hemophilia B factor IX levels that
were 28 times more were achieved using double stranded
adenoviruses in comparison to the single stranded ones.
The factor IX expression however was short lived due to
probable immune destruction of the modified cells. Stable
phenotypic correction is often hampered by neutralizing
In mice models the restoration of lymphocyte function

in SCID mice secondary to JAK deficiency has been
reported as early as 1998. The same has however proved
challenging in larger animals. The transduction efficiency
of human hematopoietic stem cells is being optimized
by use of alternative envelope proteins to pseudotype
vector particles including hat derived from Gibbon ape
leukemia virus (GAVL). Cytokine combinations and use of
fragments of fibronectin, retronectin to co-localize vector
particles and target cells also help the cause.
In chronic granulomatous disease success has been
achieved in two patients where genetically modified
hematopoietic cells have been successfully engrafted after
494Section-7General
partial myeloablation. In these two patients the vector
used was the spleen focus forming virus (SFFV) as its
enhancer-promoter region is active in myeloid cells.
Gene Therapy for Hematological Malignancies

Inhibitory signals to the host immune response by tumor
cells helps in their survival. This can be blocked by the
use of gene products or cytokines released from the site
of vaccination (i.e. the therapeutic tumor vaccine). The
methods used could rely either on the use of genetically
modified autologous tumor cells or allogenic tumor cells
which may provide a paracrine stimulus. Skin fibroblasts
expressing IL-2 and CD-40 ligand have been mixed
with irradiated tumor cells and injected into patients of
refractory leukemias thereby inducing T cells reactive
against the blast cells.
Chimeric antigen receptors (CAR) are single chain
antibodies with specificity for the antigen expressed on the
human tumor cell is linked to an internal kinase domain
which mediates cell activation when the antibody is
engaged by the target antigen. In mice CARs targeting CD19 have been used to cure B cell leukemias. LMP-2 protein
of the EBV which is expressed in some human lymphomas
can be generated by gene transfer on population of
lymphoid cells. These can then be used to yield a
population of T cells with potent antitumor property.
Suicide Gene Therapy for Graft Versus Host

Disease (GVHD)
A suicide gene can be inserted into a target cell making
it susceptible to drug induced cell death. The target cell
can be the donor lymphocytes and this can be used to
control alloreactivity as seen in allogenic hematopoietic
transplants. As shown in Figure 2 , a suicide gene is
introduced into the allogenic donor lymphocytes and
this in turn has the potential to convert a prodrug into
an active drug. Following HSCT the donor receives
these genetically modified lymphocytes for immune
reconstitution. In event of a GVHD occurring the prodrug
can be administered resulting in the ablation of these
alloreactive lymphocytes.
CHALLENGES WITH GENE THERAPY

Short-lived natureAs many cells are rapidly
multiplying ones, long term benefits after gene therapy
is difficult. Many rounds of gene therapy are needed to
achieve a substantial amount of benefit.
Immune response to the inserted DNA material or the
virus per se could lead to fatal complications.
Viruses are the vectors of choice in most gene therapy
studies. They however have a variety of potential
problems to the patient including toxicity, immune
Fig. 2 Gene therapy and its use in HSCT
Chapter-48 Gene Therapy 495

and inflammatory response. With these viral vectors
gene control and targeting issues are also a problem.
The possibility of the viral vector regaining its virulence
once inside the host cell is always a danger.
Multigene disorders are poor candidates for gene
therapy.
The novel DNA may inadvertently impact the germline
by breach of the somatic-germline barrier against the
intentions of the therapy.
Insertional mutagenesis can occur whereby a tumor
can be induced if the DNA is integrated in a wrong
place (e.g. in a tumor suppressor gene). Gene therapy
in SCID has resulted in T cell leukemias in 3 out of 20
patients due to insertional mutagenesis.
BIBLIOGRAPHY
1. Borem A, Santos FR, Bowen DE. Gene therapy.

Understanding biotechnology. 2003.pp.87-98. Prentice
Hall.
2. Cross D, Burmester JK. Gene therapy for cancer treatment:

past, present and future. Clinical Medicine and Research.
2006;4(3):218-27.
3. Dubnar CE. Gene therapy for hematologic disease: dont
throw the baby out with the bathwater!. Seminars in
Hematology. 2004;41(4):255-6.
4. Dunbar CE, Wu T. Gene therapy for hematological
disorders. An introduction to molecular medicine and
gene therapy. 2001;6:133-52. Wiley-Liss, Inc.
5. Edelstein ML, Abedi MR, Wixon J. Gene therapy clinical
trials worldwide to 2007an update. J Gene Med. 2007;9:
833-42.
6. Mulherkar R. Gene and cell therapy in India. Current
Science. 2010;99(11):1542-7.
7. Nienhuis AW. Development of gene therapy for blood
disorders. Blood. 2008;111:4431-44.
8. Scollay R. Gene therapy a brief overview of the past,
present, and future. Annals New York Academy of
Sciences. 2006;953a:26-30.
9. Verma IM, Somia N. Gene therapy-promises, problems
and prospects. Nature. 1997;18(389):239-42.
49
Monoclonal Antibodies in
Pediatric Hematology and Oncology
Despite the tremendous progress in the treatment of pediatric cancers in the past decade, current therapies are associated with wide
range of toxicities, which leads to treatment associated mortality and substantial morbidity in long-term survivors. Novel approaches
are needed to overcome resistance and to decrease adverse effects of standard treatment. Targeted therapies, which include
monoclonal antibodies (MoAbs) have signicantly changed the treatment of adult cancers.1 During the last few years, progress has
been made in the therapeutic use of MoAbs in specic groups of pediatric cancers and hematologcal disorders.
In 1975, Kohler and Milstein demonstrated for the rst

time that monoclonal antibodies (MoAb) could be
generated from hybridomas.2 Because MoAbs can bind
to antigens expressed on the surface of malignant cells,
it was proclaimed that these agents could be used as
chemoimmunotherapy to specifically target and destroy
these cells. Moreover, by offering cytotoxic mechanisms
different from conventional chemotherapy, MoAb therapy
could potentially reduce the risk of tumor cell resistance to
the common chemotherapeutic agents. By 1979, the first
patient was treated using MoAb therapy and in the ensuing
decade over 100 patients with hematologic malignancies
have been similarly treated.3 Although progress in this field
has proceeded much slower than was initially anticipated,
recent clinical trials have also demonstrated antitumor
activity in a variety of pediatric malignancies.
MONOCLONAL ANTIBODY THERAPY

Effective MoAb therapy for cancer requires the
identification of appropriate tumorspecific targets
expressed on the surface of the cancer cells.
Ideally, the antibody should have minimal crossreactivity with normal tissues and specifically target the
tumor cell. Nonspecific binding will reduce effective
drug delivery. Moreover, any cross-reactive tissues
that are damaged may compromise patients function
and survival.
The target of the MoAb should not be shed from the

tumor following MoAb binding; rather, the antigenMoAb complex should be internalized by the tumor
cell.
The ideal antigen should not undergo modulation (in
which the antigen is no longer expressed on the cell surface
after antibody binding). Its disappearance from the cell
membrane can limit the effectiveness of treatment.
Despite the fact that many of the patients are inherently
immunosuppressed secondary to their malignancies and
extensive prior chemotherapy, development of neutra
lizing antibodies have been seen in few patients. Its
development can preclude the efficacious administration
of MoAbs because of enhanced clearance of the antibody
from the circulation, the formation of antigen-antibody
complexes with subsequent end organ damage. Hence,
they must be rendered sufficiently nonimmunogenic to
prevent development of neutralizing antibodies.
Recent advances in genetic engineering have allowed
the development of chimeric antibodies and fully humani
zed MoAbs which limit the likelihood of neutra
lizing
antibody development.
Mechanism
The overall success of MoAb therapy in cancer is
determined by the ability of antibody binding to result in
Chapter-49 Monoclonal Antibodies in Pediatric Hematology and Oncology 497

tumor cell death. A variety of mechanisms are thought to
play important roles in mediating the observed anti-tumor
effects.4
Antibody-dependent cellular cytotoxicity (ADCC) and
complement-mediated cytolysis. Binding the antibody
to the tumor cell recruits cells with Fc receptors like NK
cells and macrophages to the site of the tumor, which
then kill the tumor cell, or complement is fixed and the
tumor cell is killed.
Direct killing: Key process include interruption of a
critical cell signaling cascade by inhibition of ligand
binding; downregulation of a receptor tyrosine kinase,
which transmits a necessary life signal; and induction
of an apoptotic signal following ligation of the target by
the MoAb.
Targeting via a conjugated antibody of antibody
receptor (e.g. radionuclide, immunotoxin, cell-based
genetic fusion). This targets a lethal hit to the tumor
cell.
The following gives an overview of the various MoAb
which are now in clinical use or in various phases of
clinical trials.
Rituximab: It is a chimeric unconjugated MoAb
directed to CD20, which is expressed on the surface of
malignant and normal B-cells, but not hematopoietic
stem cells. It has been shown to signicantly increase
the response rate and survival of adult patients with
CD20-positive B-cell lymphomas. It appears that
rituximab has efcacy in children with high-grade
B-lymphoma/B-cell acute lymphocytic leukemia.
The mechanisms of action include inhibition of
B-cell proliferation, antibody-dependent cellular
cytotoxicity, complement-dependent cytotoxicity
and possible induction of apoptosis.5 The Childrens
Oncology Group is currently researching the efcacy of
rituximab in recurrent and refractory CD20 lymphomas
in children (NCT01230788). With rituximab, a 96
percent overall response rate was reported in one
phase II trial for lymphocyte-predominant Hodgkin
lymphoma, with 75 percent remaining in remission
after one year.6 Another phase II trial by Ekstrand
et al, 2003 showed 100 percent overall response rate
(n = 22) with complete response (CR) in 41 percent,
unconfirmed complete response in 5 percent, and
partial response in 54 percent.7 A phase II pilot study
is underway through the Childrens Oncology Group
to assess the toxicity of adding rituximab to upfront
chemotherapy for B-cell leukemia and lymphoma
(NCT00324779). Children with refractory chronic
immune thrombocytopenic purpura (ITP) have been
treated with rituximab in various series with response
rates of 30 to 70 percent. Most of the responses were
obtained within 4 weeks and were maintained for
a year.8,9 International consensus report on the

investigation and management of primary immune
thrombocytopenia recommends a dose of 100 mg
or 375 mg/m2/week administered for four times as
standard treatment strategies for children with chronic
ITP.10
Rituximb has also been proved to be effective in
treatment of various benign hematologic conditions like
autoimmune hemolytic anemia (refractory to steroids
immune-suppressants and splenectomy),11 AIHA in
setting of Evans syndrome, SLE and autoimmune lymphoproliferative syndrome12 and in patients with hemophilia
who develop inhibitory antibodies to factor VIII and IX.13
Gemtuzumab ozogamicin (GO): It is a recombinant
humanized MoAb (IgG4) directed against the CD33
antigen that is conjugated to the derivative of the
cytotoxic antibiotic calicheamicin.14 In pediatric acute
myeloid leukemia (AML), the differentiation antigen
CD33 is expressed in almost all patients. Following
binding of GO to the CD33 antigen, the antibodyantigen complex gets internalized into the AML cells.
The calicheamicin conjugate is released inside the
cell through hydrolysis and subsequently binds to the
minor groove of DNA, inducing double strand breaks
and leukemia cell apoptosis.
Currently, the agent is being tested both as a single
agent and in combination with chemotherapy in children
with AML. Results of phase I and II clinical trials indicate
promise, with an overall remission response rate of 45
percent and a 1-year event-free survival and overall survival
estimates of 38 percent and 53 percent, respectively.15,16
Several earlier case reports found responses to anti-CD33
in pediatric ALL and in a few cases of relapsed adult ALL.17
Patients responding to gemtuzumab had very high (>90%)
CD33 expression.17.
The US Food and Drug Administration (FDA) approved
anti-CD33 conjugated with calicheamicin (gemtuzumab
[Mylotarg]) for treatment of adult AML in 2000, but the
agent was withdrawn from the US market on June 21,
2010. Apart from some infusional allergic reactions, the
primary toxicity has been bone marrow suppression
caused by binding the MoAb-toxin conjugate to normal
hematopoietic precursors that express CD33. Another
still unexplained toxicity of anti-CD33calicheamicin
conjugates is hepatic damage, which is characterized by
transient increases in liver enzymes in approximately
25 percent of patients and, occasionally, a more severe
complication consistent with veno-occlusive disease.
Epratuzumab: It is a humanized anti-CD22 MoAb that
binds to the extracellular domain of CD22. Epratu
zumab appears to modulate B-cell activation and
signaling. Proposed mechanisms of action include
antibody-dependent cell-mediated cytotoxicity, comp
498Section-7General
lement dependent cytotoxicity and direct induc
tion of apoptosis. CD22 is widely expressed in B-cell
lymphomas and B-precursor ALL. It is rapidly
internalized after antibody binding and re-expression
on the cell surface is slow, occurring over the period of
several days. Internalization of CD22 has been shown
to directly induce apoptosis in malignant cells.
Epratuzumab has recently been studied by Childrens
Oncology Group in pediatric patients with rst relapse
of pre-B ALL (n = 15). The addition of epratuzumab to
re-induction chemotherapy was well tolerated, with no
apparent signicant increase in toxicity.18 Although, it did
not improve the second remission rates, among patients
who attained CR, postinduction MRD-negative rates were
higher in comparison with those of historical controls
treated with chemotherapy alone (42% versus 25%).11
Bevacizumab: It is a humanized murine MoAb
that binds to vascular endothelial growth factor-A
(VEGF-A) with high afnity and neutralizes its activity.
VEGF is one protein that plays a big role in the process
of angiogenesis. By cutting off the blood supply to the
tumor, it is predicted that the tumor cells should die.
Bevacizumab is an antiangiogenesis agent approved
for the treatment of colon cancer in adults and has
shown activity in carcinoma of the kidney, adeno
carcinoma of the rectum and nonsmall-cell lung
cancer. VEGF is overexpressed in a number of solid
tumors seen in children (NCT01218867), including
Ewing sarcoma and glioblastomas, and is currently
being investigated in these and other pediatric solid
tumors.19
Alemtuzumab: It is a humanized MoAb active against
CD52; a cell surface co protein expressed by most T and
B lymphoblasts. CD52 is neither shed nor internalized,
making it ideal for antibody directed immunotherapy.
Most malignancies of B-cell origin and almost all T-cell
malignancies strongly express the antigen. Binding of
alemtuzumab induces the lysis of lymhocytes, while
monocytes and their precursors are less sensitive.
Alemtuzumab has shown antitumor activity in chronic
lymphocytic leukemia, T-prolymphocytic leukemia, T-cell
non-Hodgkins lymphoma.17 In a few cases, clinical effects
were observed in patients with single-drug treatment in
relapsed adult ALL.20 It is being studied by COG in children
with ALL in second or greater relapse or primary induction
failure after two different regimens (PMC3120889).
Other antibodies that have demonstrated activity in
T-cell leukemias, either in vitro or in vivo, include antiCD7-ricin, CD25 antigen (IL-2 receptor), anti-CD7-PAP,
anti-CD2, OKT3, and a humanized anti-CD3 MoAb.
Overall experience with MoAbs in T-cell ALLwith the
exception of anti-CD52 alemtuzumab is scarce.
Neuroblastoma cells have been characterized for the

expression of tumor associated antigens recognized by
antibodies. The identication of GD2 as a major target
for MoAb therapy has led to the production of both
murine and chimeric anti-GD2 MoAbs in combination
with granulocyte-macrophage colony-stimulating factor
(GM-CSF) and interleukin-2 (IL-2). The mechanisms
whereby anti-GD2 MoAbs kill tumor cells are likely related
to complement activation and antibody-dependent
cell-mediated cytotoxicity (NCT00026312). The COG
is currently investigating the efcacy of a humanized
MoAb in combination with a human recombinant
interleukin-2 (Hu14.18-IL2) for the treatment of refractory
neuroblastoma.
Alice et al. 2010 compared between two treatment
groups in patients with high-risk neuroblastoma, the
first group received the standard therapy of six cycles of
isotretinoin. The second group received the new immuno
therapy treatment: six cycles of isotretinoin plus five cycles
of the monoclonal antibody ch14.18, in combination with
alternating GM-CSF and interleukin-2. Study results after
two years showed, the rate of survival without relapse or
disease progression was 20 percent greater in the children
who received immunotherapy (66% versus 46%).21
In a recent phase II trial, Memorial Sloan-Kettering
Cancer Center has shown promising result by the use of
anti-GD2 monoclonal antibody 3F8 and granulocytemacrophage colony-stimulating factor in neuroblastoma
resistant to intensive induction therapy.22
Trastuzumab: In a retrospective review of 53 osteo
sarcoma patients treated on the Memorial SloanKettering Cancer Center T12 protocol, higher freque
ncies of HER2/erbB-2 expression were correlated with
metastatic disease at presentation, poor histologic
response to chemotherapy and significantly decreased
event-free survival (47% versus 79% at 5 years, P = .05).23
Trastuzumab, a MoAb directed against the human
epidermal growth factor receptor 2 (HER2), is being
attempted as a therapy for osteosarcoma.24,25 Although,
it suggested that trastuzumab can be safely delivered in
combination with anthracycline-based chemotherapy
and dexrazoxane, the actual therapeutic benefit still
remains uncertain.
Adverse Effects of MoAbs

Most reports of adverse events are from adult phase I and
II trials, since data for children are limited.
Acute infusion reactions are frequent, which can often
be managed with antipyretics, antihistamines, and/or
corticosteroid. Immunosuppression and increased risk
of infection is not uncommon due to depletion of healthy
Chapter-49 Monoclonal Antibodies in Pediatric Hematology and Oncology 499

hematopoietic cell (rituximab, alemtuzumab). Rapid
malignant cell kill can cause tumor lysis syndrome. Hepa
titis B virus reactivation with fulminant hepatic failure has
also been reported with rituximab. Other adverse effects of
monoclonal antibodies documented are hemolytic uremic
syndrome, vascular leak syndrome, hypo
albuminemia
and transaminitis, veno-occlusive disease, pulmonary
inltrates and acute respiratory distress syndrome
(ARDS).26
Late effects include congestive heart failure, cardio
myopathy, pericardial effusion, pericarditis, pulmonary
brosis and nephrotic syndrome.
Monoclonal antibodies that contain high amounts of
mouse protein result in various immunogenic responses,
including infusion-related reactions. More advanced
humanized antibodies contain only 5 to 10 percent of
mouse protein sequences in an attempt to overcome
the potential for dose-limiting or fatal hypersensitivity
reactions. Recently, B-cell epitope mapping has been
conducted to identify immunogenic amino acids, with
the goal to modify immunotoxin sequence to generate a
less immunogenic protein. Other techniques like coating
immunotoxin with high molecular weight polyethylene
glycol (so called PEGylation) is also under investigation.27
Future
Modern recombinant techniques have made it possible to
rapidly produce both chimeric and humanized antibodies.
Identification of surface receptors that are integral to
proliferation and apoptosis has also provided more targets
for monoclonal antibodies. At present, there are more
than 100 monoclonal antibody based biologic drugs under
clinical trials and the optimal agents, dose, schedule, and
combination regimens have yet to be defined.
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1. Bassan R, Hoelzer D. Modern therapy of acute
lymphoblastic leukemia. J Clin Oncol. 2011;29(5):532-43.
2. Kohler G, Milstein C. Continuous cultures of fused cells
secreting antibody of predefined specificity. Nature. 1975;
256:495.
3. Nadler LM, Stashenko P, Hardy R, et al. Serotherapy of a
patient with a monoclonal antibody directed against a
human lymphoma-associated antigen. Cancer Res. 1980;
40:3147-54.
4. Weiner GJ. Monoclonal antibody mechanisms of action in
cancer, Immunol Res. 2007;39(1-3):271-8.
5. Maloney DG, Smith B, Rose A. Rituximab: mechanism of
action and resistance. Semin Oncol. 2002;29:2-9.
6. Rehwald U, Schulz H, Reiser M, et al. Treatment of relapsed
CD20+ Hodgkin lymphoma with the monoclonal antibody
rituximab is effective and well tolerated: results of a phase
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2 trial of the German Hodgkin Lymphoma Study Group.

Blood. 2003;101(2):420-4.
Ekstrand BC, Lucas JB, Horwitz SM, et al. Rituximab in
LP Hodgkin disease: results of a phase 2 trial. Blood.
2003;101(11):4285-9.
Franchini M, Zaffenello M, Veneri D, Lippi G. Rituximab
for the treatment of childhood chronic idiopathic
thrombocytopenic purpura and hemophilia with
inhibitors. Pediatr Blood Cancer. 2007;49:6-10.
Mueller BU, Bennett CM, Feldman HA, Bussel JB, Abshire
TC, Moore TB, et al. One year follow-up of children and
adolescents with chronic immune thrombocytopenia
treated with rituximab. Pediatr Blood Cancer. 2009;52:
59-62.
Provan D, Stasi R, Newland AC, et al. International
consensus report on the investigation and management
of primary immune thrombocytopenia. Blood. 2010;115:
168-86.
Zecca M, Nobili B, Ramenghi U, et al. Rituximab for the
treatment of refractory autoimmune hemolytic anemia in
children. Blood. 2003;101:3857-61.
Bader-Meunier B, Aladjidi N, et al. Rituximab therapy
for childhood Evans syndrome. Haematologica.
2007;92:1691-4.
Collins PW, Mathias M, Hanley J, et al. Rituximab and
immune tolerance in severe hemophilia A: a consecutive
national cohort. J Thromb Haemost. 2009;7:787-94.
Hamann PR, Hinman LM, Hollander I, et al. Gemtuzumab
ozogamicin, a potent and selective anti-CD33 antibodycalicheamicin conjugate for treatment of acute myeloid
leukemia. Bioconjugate Chemistry. 2002;13:47-58.
Aplenc R, Alonzo TA, Gerbing RB, et al. Safety and
efficacy of gemtuzumab ozogamicin in combination with
chemotherapy for pediatric acute myeloid leukemia: a
report from the Childrens Oncology Group. J Clin Oncol.
2008;26(14):2390-3295.
Arceci RJ, Sande J, Lange B, et al. Safety and efficacy
of gemtuzumab ozogamicin in pediatric patients with
advanced CD33+ acute myeloid leukemia. Blood.
2005;106(4):1183-8.
Pui CH, Evans WE. Treatment of acute lymphoblastic
leukemia. N Engl J Med. 2006;354(2):166-78.
Raetz EA, Cairo MS, Borowitz M. Reinduction chemo
immunotherapy with epratuzumab in relapsed ALL in
children, adolescents and young adults: results from
childrens oncology group (COG) study ADVL04P2. Blood.
2011;573.
Bender JL, Adamson PC, Reid JM, et al. Phase I trial and
pharmacokinetic study of bevacizumab in pediatric
patients with refractory solid tumors: a Childrens
Oncology Group Study. J Clin Oncol. 2008;26(3):399-405.
Cheung KC, Wong LG, Yeung YM. Treatment of CD33
positive refractory acute lymphoblastic leukemia with
Mylotarg. Leuk Lymphoma. 2008;49(3):596-7.
Yu AL, Gilman AL, Ozkaynak MF, et al. Anti-GD2
antibody with GM-CSF, interleukin-2, and isotretinoin for
neuroblastoma. N Engl J Med. 2010;363(14):1324-34.
500Section-7General
22. Kushner BH, Kramer K, Cheung NK. Phase II trial of the
anti-G(D2) monoclonal antibody 3F8 and granulocytemacrophage colony-stimulating factor for neuroblastoma.
J Clin Oncol. 2001;19(22):4189-94.
23. Gorlick R, Huvos AG, Heller G, et al. Expression of HER2/
erbB-2 correlates with survival in osteosarcoma. J Clin
Oncol. 1999;17(9):2781-8.
24. Scotlandi K, Manara MC, Hattinger CM, et al. Prognostic
and therapeutic relevance of HER 2 expression in
osteosarcoma and Ewings sarcoma. European Journal of
Cancer. 2005;41(9):1349-61.
25. Ebb D, Meyers P, Grier H, et al. Phase II trial of trastuzumab

in combination with cytotoxic chemotherapy for treatment
of metastatic osteosarcoma with human epidermal growth
factor receptor 2 overexpression: a report from the childrens
oncology group. J Clin Oncol. 2012;30(20):2545-51.
26. Pastan I, Hassan R, FitzGerald DJ, et al. Immunotoxin
therapy of cancer. Nature Rev. 2006;6:559-65.
27. Tsutsumi Y, Onda M, Nagata S, et al. Site-specific chemical
modification with polyethylene glycol of recombinant
immunotoxin anti-Tac(Fv)-PE38 (LMB-2) improves
antitumor activity and reduces animal toxicity and
immunogenicity. Proc Natl Acad Sci USA. 2000;97:8548-53.
50
Biological Response Modifiers
Rapid advances in standard management approaches (surgery, chemotherapy and radiotherapy) for cancer, have led to remarkable
cure rates in children with cancer. Certain limitations include unresectability of the tumor, resistance to chemotherapeutic agents,
intolerability of vital structures to radiotherapy, and critical effect of radiotherapy on growth of pediatric patients. Consequently, new
therapeutic approaches are being explored, including the use of biologic response modifiers.
Cancer cells express a wide range of different proteins that

act as antigens. Some of these may be a result of oncogenic
transformation and are relatively specific to cancer cells.
These tumor-associated antigens are delivered to the
immune system by antigen-presenting cells (APCs)
through major histocompatibility complex (MHC)
class I or class II pathways. In the class I pathway, the
phagocytosed tumor cells are processed by proteosomes
and converted to short peptide fragments, which are then
presented on class I MHC molecules. These are recognized
by CD8+ cytotoxic lymphocytes, which have direct
cytotoxic effects leading to tumor cell lysis. In the class II
pathway, the secreted products from tumor cells enter the
APCs, which are then processed and presented to MHC
class II molecules. These processed antigens are recognized
by CD4+ helper lymphocytes, which enhance the CD8+
cytotoxic responses as well as the humoral response
to surface antigens present on tumor cells. Lowered
expression or lack of MHC antigens on the tumor cells may
allow tumor cells to escape the host immune surveillance.1
The goal of biologic response modifiers is to stimulate
the bodys own immune system to help eradicate tumor
cells. In 1884, Cooley2 observed absence of postsurgical
recurrence of round cell sarcoma in one patient who had
erysipelas infection at surgical site. He directly inoculated
an infectious agent to a tumor site in hopes of stimulating
an immune response against tumor. Immunotherapy has
evolved considerably since these early days.
DEFINITION
Biological response modifiers (BRMs) are natural or
synthetic substances used to boost or restore the ability of
the immune system to fight cancer, infections, and other
diseases or used to lessen certain side effects that may
be caused by some cancer therapies. These substances
are also called as biological therapy, biotherapy or
immunotherapy.
CLASSIFICATION OF BIOLOGICAL
RESPONSE MODIFIERS
Newer molecularly targeted drugs and biotherapeutic
agents have made the classification of anticancer drugs
more complicated. Xiong-Zhi Wu3 tried a simpler
classification based on mechanism of action of the drugs.
For descriptive purpose, BRMs can be classified as below:
Monoclonal antibodies
Nucleic acid based agents
Small molecule agents
Cytokines
Tumor vaccines.
The two sections that follow address monoclonal
antibody and nucleic acid-based therapeutic approaches
with relevance to pediatric oncology. Examples of small
molecule inhibitors directed at specific targets are
discussed in later sections. Cytokines and tumor vaccines
are discussed briefly thereafter.
502Section-7General
Monoclonal Antibodies
Monoclonal antibodies directed against unique tumor
antigens have efficacy against neoplastic cells. After
binding to their target antigen, monoclonal antibodies
have multiple mechanisms of anticancer effect, including:
Antibody-dependent cellmediated cytotoxicity (ADCC).
Complement-dependent cytotoxicity (CDC).
Interfering with ligand-receptor interactions, including
down-regulation of receptor expression on the cell
surface.
Modification of signaling pathways to produce
apoptosis.
Delivery of toxic substances to cancer cells. The
antitumor activity of monoclonal antibodies can be
increased by:
Enhancement of ADCC by priming of effector cells
with cytokines like GM-CSF, interleukin (IL)-2 and
IL-12;
Enhancement of CDC mediated by binding of
-glucan to complement receptor-3 on neutrophils;
Conjugation with cytotoxic entities such as radio
nuclides, toxins, chemotherapy agents, and
enzymes. Significant progress has been made in the
past few years in the area of antibody drug conju
gates (ADCs) for the selective delivery of cytotoxic
drugs to tumors. These include SGN-35, an ADC
directed against the CD30-positive malignancies
such as Hodgkins disease and anaplastic large
cell lymphoma, and trastuzumab-DM1 which has
shown activity in metastatic breast carcinoma.4
The toxicities associated with monoclonal antibodies
can generally be attributed to the action of the antibody
on normal cells expressing its target antigen. For example,
skin rash with epidermal growth factor receptor (EGFR)
targeted antibodies, severe pain with GD2 ganglioside
targeted antibodies and first dose reaction with CD52 targeted alemtuzumab.5
Clinical Significance of Monoclonal Antibodies5

Rituximab is an anti-CD20 chimeric IgG1 antibody
having cytotoxic effect, both through complement
activation and ADCC. Rituximab may also induce
apoptosis through down-modulation of Lyn kinase.
The later may contribute to the chemosensitizing
activity of rituximab. Rituximab is the first US food
and drug administration (FDA) approved monoclonal
antibody for cancer therapy. Clinical trials evaluating
the addition of rituximab to standard chemotherapy
have documented improved outcome for both indolent
lymphomas and aggressive lymphomas. It is being
studied in children with CD 20 expressing tumors
like Burkitts lymphoma, DLBCL, and post-transplant
lymphoproliferative disease.
Anti-GD2 antibodies tried in neuroblastoma patients

had shown limed success. These include murine
monoclonal 3F8, ch14.18 with GM-CSF and IL-2
and ch14.18-IL-2 fusion protein. Radiolabeled 3F8murine antibodies have been used to deliver up to 40
Gy radiation to tumor. The molecule ch14.18 is being
evaluated in the setting of minimal residual disease
and in adjuvant setting.
Epratuzumab is an anti-CD22 antibody under clinical
trial for CD22 expressing B-cell ALL and NHL.
Alemtuzumab is an anti-CD52 antibody, being evaluated
in children with recurrent ALL expressing CD52.
Trastuzumab is an anti-HER2 antibody, being evaluated
in children with osteosarcoma.
Anti-CD30 antibodies have entered phase I/II evalu
ation in adults with Hodgkins lymphoma and ALCL
expressing CD30, with some evidence of antitumor
activity observed.
IGF-1R blocking antibodies are of potential pediatric
interest in rhabdomyosa coma and Ewings sarcoma.
Nucleic Acid Based Agents/Antisense Agents

The antisense agents are single-stranded DNA-like
molecules that modify expression of specific genes by
targeting based on complimentary base pairing. Antisense
molecules can inhibit production of functional protein by
their target mRNAs through several distinctive processes:
RNA cleavage by RNase H, an ubiquitous endonuclease
Inhibition of translation machinery
Alteration in RNA splicing
Degradation of homologous RNA by small interfering
RNA (RNA interference)
Fomivirsen was approved by the FDA in 1998 for CMV
retinitis in AIDS.6 Bcl-2 antisense agent, oblimersen, is
a phosphorothioates, that can induce RNase H cleave
of BCL-2 mRNA leading to activation of apoptotic
pathways. It is being studied in pediatric population in
neuroblastoma (phase1 trial), as higher BCL-2 expression
is associated with unfavorable histology and N-Myc gene
amplification. Prolonged aPTT and thrombocytopenia are
major side effects due to polyanionic backbone structure.
Therapies Targeted to Apoptotic Pathways

The ability of cancer cells to evade apoptosis, provide
a survival advantage during tumorigenesis and can
also provide cancer cells with increased resistance
to treatment. An obvious approach to enhance the
effectiveness of cancer therapy is by manipulating the
dysregulated cancer cell apoptosis pathways to favor cell
death. The two primary apoptotic pathways, the extrinsic
(death receptor) pathway and intrinsic (mitochondrial)
pathway, are described in Flow chart 1.
Chapter-50 Biological Response Modifiers 503

Flow chart 1 Extrinsic and intrinsic apoptotic pathways5
Molecules Targeting IAPs

Inhibitors of apoptotic pathways (IAPs) are cytoplasmic
proteins that can inhibit caspases. Survivin, X-IAP, c-IAP1,
and c-IAP2 have been most studied for their association
with cancer. XIAP overexpression appear to be associated
with poor prognosis in children with AML.7 XIAP antisense
molecules have entered clinical evaluation in AML. Survivin
is of particular pediatric interest because of association
between survivin over expression and poor prognosis
in neuroblastoma. Survivin maps to chromosome band
17q25, a region that is often represented by chromosome
gain and poor prognosis in neuroblastoma.8
Survivin antisense molecule (LY2181308) has entered
clinical evaluation. The molecule inhibited tumor growth
in xenograft models and sensitized cancer cells to radiation
therapy and chemotherapy.9
TNF-related Apoptosis Inducing Ligand (TRAIL)

Receptor Agonism
Extrinsic pathway is initiated by ligation and clustering

of members of death receptor superfamily (e.g. tumor
necrosis factor receptor-I, Fas, and the TNF-related
apoptosis inducing ligand receptors TRAIL-R1 and
TRAIL-R2) followed by recruitment of adaptor proteins
and caspase-8, which can then activate downstream
effector caspases leading to apoptosis. The intrinsic
(mitochondrial) pathway is responsive to internal toxic
stimuli (e.g. DNA damage, disruption of microtubules, etc.).
Inhibition of Bcl-2 and Bcl-xL function or direct activation
of Bax and Bak in mitochondrial membranes results
in the release of cytochrome C and other proapoptotic
factors into the cytoplasm. Subsequent formation of
apoptosome in cytoplasm results in production of active
caspase-9 and which then activates downstream
effector caspases. Inhibitors of apoptotic pathways are
evolutionarily conserved cytoplasmic proteins that can
inhibit caspases.
These pathways can be targeted at Bcl-2 family
proteins, inhibitors of apoptotic pathways (IAPs), and the
death receptor pathway.
Inhibition of Bcl-2 Family Proteins

Oblimersen is a Bcl-2 antisense agent. Gossypol, a natural
product derived from cottonseed extract, is a small molecule
inhibitor of Bcl-2 and Bcl-xL. Preclinical studies demon
strated in vitro and in vivo anticancer activity for this agent.
By death receptor pathway, TRAIL induces apoptosis in

many cancer cell lines but does not do so for most normal
cells. TRAIL-induced apoptosis does not require p53
function, which could allow TRAIL to remain effective
against cancer cells that are resistant to chemotherapy
and radiation therapy due to loss of p53 function. A
recom
binant soluble version of human TRAIL, and
agonistic antibodies directed towards TRAIL receptors
(e.g. mapatumumab) have entered clinical evaluation.
Of note, TRAIL induced apoptosis in pediatric-relevent
cancer cell lines including those of Ewings sarcoma,
rhabdomyosarcoma, and high grade glioma.
Therapies Targeted to Extracellular Survival

Signaling Pathways
Growth factor receptor activation can initiate signaling
along multiple intracellular pathways that promote pro
liferation and survival (Flow chart 2). These pathways
include:
Mitogen activated protein (MAP) kinase pathway or
extracellular signal regulated kinases (ERKs) cascade
is initiated when Ras activation leads to Raf membrane
recruitment and activation, followed by activation
of MEK and ERK. Activated ERK can translocate to
the nucleus and phosphorylate specific transcription
factors.
Growth factor receptor signaling also leads to PI3K and
AKT activation. PTEN can reduce the extent of AKT
activation, whereas mutations of PTEN resulting in
absence of PTEN can lead to constitutive AKT activation.
504Section-7General
Flow chart 2 Extracellular survival signaling pathways5
AKT plays a central role in promoting survival by

phosphorylating multiple proteins involved in survival/
apoptosis pathways. AKT activates mTOR, which leads
to phosphorylation of eukaryotic initiation factor 4E
(eIF4E)-binding protein 1 (4E-BP1) and ribosomal
protein S6 kinase 1 (S6K1). Phosphorylation of 4EBP1 by mTOR frees eIF4E and promotes translation
of mRNAs with complex secondary structures in their
5-untranslated region (e.g. cyclin D1 and c-Myc).
Activation of S6K1 leads to increased mRNA translation.
Growth factor receptor signaling can also lead to
NF-B pathway activation, in part through AKT
phosphorylation and activation of IkB kinase (IKK),
which leads to IkB phosphorylation and freeing of NFB to translocate to the nucleus.
STAT pathway can also promote proliferation and
survival of following growth factor receptor activation.
The importance of these signaling pathways in cancer
cells is indicated by the variety of activating mutations
reported for members of the receptor tyrosine kinase
family, including EGFR mutations, translocations resulting
in platelet-derived growth factor receptor (PDGFR)
activation, KIT mutations in gastrointestinal stromal
tumors, and FMS like tyrosine kinase-3 (FLT3) mutations
in AML. Activating mutations in cancer cells also occur
in downstream signaling pathways, as exemplified by
mutations of PTEN (which results in AKT activation) in
many cancer types and mutations of B-Raf in melanoma.
EGFR Inhibitors
EGFR family includes four members: EGFR/human
epidermal growth factor receptor 1(HER1), HER2 (ErbB2),
HER3 (ErbB3), and HER4 (ErbB4). Binding of either EGF

or transforming growth factor alpha (TGF-) to EGFR
activates kinases and initiate signaling cascades.
Small molecule inhibitors (gefitinib and erlotinib) and
monoclonal antibodies (cetuximab) are the EGFR blocking
agents most evaluated clinically. Gefitinib is a welltolerated oral EGFR-tyrosine kinase inhibitor, improved
disease-related symptoms and induced radiographic
tumor regressions in patients with NSCLC persisting after
chemotherapy.10 Use of erlotinib in advanced nonsmall
cell lung cancer demonstrated survival advantage.11 A
phase 1 study of gefitinib by COG12 demonstrated that the
drug is well tolerated in pediatric patients at oral doses 150
to 500 mg/m2. Skin rash, anemia, diarrhea, nausea, and
vomiting were common side effects. Preliminary evidence
of activity was noted in Ewings sarcoma, CNS tumors and
Wilms tumor. Gefitinib was shown to have synergistic
action with topotecan or irinotecan and additive action
with cyclophosphamide in neuroblastoma cell lines.13
Cetuximab was approved by FDA for use in com
bination with irinotecan (or as a single agent if patients
cannot tolerate irinotecan) for patients with advanced
EGFR-expressing colorectal cancer that is refractory
to irinotecan-based chemotherapy.14 A case report by
Grisanti S et al15 showed anticancer activity of cetuximab
against recurrent and metastatic mucoepidermoid car
cinoma of salivary gland. The report also revealed inability
of cetuximab to cross the blood-brain barrier and the
consequent development of CNS metastases during
treatment.
Lapatinib is a small molecule reversible tyrosine kinase
inhibitor of both EGFR and HER-2. Objective responses
have been observed in patients with HER-2 overexpressing
breast cancer.16
Trastuzumab is a humanized antibody that targets
the extracellular domain of HER-2 over expressing breast
cancer and newly diagnosed metastatic osteosarcoma.
Trastuzumab is approved by FDA for use as monotherapy
in patients with HER-2-overexpressing metastatic breast
cancer. A concern with the use of trastuzumab is increased
incidence of cardiac dysfunction.
KIT and PDGFR Inhibitors

KIT (CD117) and PDGF receptors, along with FLT3, are
members of PDGF receptor subfamily of receptor tyrosine
kinase. Binding to their ligand activate tyrosine kinase and
subsequent signaling pathways.
Imatinib, sunitinib and masitinib are small molecule
inhibitors of KIT and PDGFR, with imatinib having more
widely accepted additional activity as bcr/abl kinase
inhibitor. Imatinib has a well established role in CML
and Ph+ ALL with bcr/abl kinase activation. Tyrosine

kinase activating mutations are important as predictors
of single agent response to imatinib. Gastrointestinal
stromal tumors typically express KIT with gain of function
mutation and imatinib is effective in blocking signaling
from these mutant receptors. Sunitinib may be active in
imatinib resistant GISTs. Masitinib (AB1010), is a novel,
potent and selective tyrosine kinase inhibitor targeting
KIT that is active, orally bioavailable in vivo, and has
low toxicity.17 PDGFR and KIT signaling may play roles
in the growth and survival of some pediatric cancers.18
Approximately 60 percent of pediatric AMLs express KIT.
High grade gliomas, sarcomas and neuroblastoma also
express PDGF subfamily receptors, but the concentrations
required for growth inhibition exceeded those required
for KIT and PDGFR inhibition by 20-fold, suggesting that
targets other than KIT and PDGFR may be responsible for
imatinibs effect against these cell lines.
FLT3 Inhibitors
FLT3 is expressed primarily on hematopoietic and neural
tissues. Activating mutations in FLT3 have been observed
in adult and childhood AML, in children with hyperdiploid
ALL and in infants with ALL with MLL rearrangements.19
CEP-701, PKC-412, sunitinib and sorafenib are small
molecule tyrosine kinase inhibitors which already entered
clinical evaluation. Although the clinical responses to
FLT3 inhibitors are somewhat encouraging, true clinical
benefit will require additional measures to enhance the
magnitude of these responses, including evaluation of
regimens that combine an FLT3 inhibitor either with
standard chemotherapy agents or with other cell signaling
inhibitors.20
Src Family Kinase Inhibitors

Src family kinases (SFKs) have a critical role in cell adhesion,
invasion, proliferation, survival, and angiogenesis during
tumor development. Dasatinib is an orally available smallmolecule multikinase inhibitor. It potently inhibits BCRABL and SFKs, but also inhibits c-KIT, PDGFR, and ephrin
receptor kinase. Dasatinib is about 300 times more potent
than imatinib in cells expressing unmutated BCR-ABL
in vitro, and have good CNS penetration. It effectively inhibits
the growth of leukemic clones harboring all known imatinibresistant BCR-ABL kinase domain point mutations, with the
exception of V299L, T315I, and F317L mutations. Dasatinib
is approved for the treatment of patients with BCR-ABLpositive CML and ALL, resistant or intolerant to imatinib. It
has been used at doses of 100 mg/m2/day in chronic phase
of CML, 140 mg/m2/day in ALL and accelerated/crisis phase
of CML in adults, and 60 to 160 mg/m2/day in children.
Porkka et al21 demonstrated promising therapeutic potential
of dasatinib in managing intracranial leukemic disease and

substantial clinical activity in patients who experience CNS
relapse while on imatinib therapy.
Mammalian Target of Rapamycin

(mTOR) Inhibitors
Mammalian target of rapamycin (mTOR), a serine/
threonine kinase that is ubiquitously expressed in
mammalian cells, is an important regulator of cell growth
and proliferation in response to external factors (e.g.
growth factors) and nutritional conditions, through its
downstream effectors, 4EBP1 and S6K. Inappropriate
mTOR activation has been implicated in the pathogenesis
of numerous tumor types. The largest body of clinical
experience with mTOR inhibitors is in the solid organ
transplant setting. Rapamycin (sirolimus), temsirolimus,
ridaforolimus, and everolimus are the mTOR inhibitors,
which are being studied in cancer patients. Temsirolimus is
a pro-drug, and its primary active metabolite is rapamycin
(sirolimus). Temsirolimus is approved by the FDA for the
treatment of advanced renal cell carcinoma (RCC). It is
administered intravenously on a once-weekly schedule.
Ridaforolimus is also administered intravenously on
an intermittent schedule, although an oral formulation
is currently being evaluated in sarcoma. Everolimus
is an orally available mTOR inhibitor that is typically
administered on a continuous daily schedule or on a
weekly schedule in combination regimens. Everolimus
has recently obtained FDA approval for the treatment of
advanced RCC after failure of treatment with sunitinib or
sorafenib.22 Reversible leukopenia, thrombocytopenia,
and dose-dependent hyperlipidemia have been the
principal toxicities associated with rapamycin and evero
limus in the transplant setting. Preclinical studies in
pediatric setting have shown activity of rapamycin against
a number of pediatric malignancies, including ALL, rhab
domyosarcoma, osteosarcoma, medulloblastoma, and
Ewings sarcoma. Preclinical observations that the combi
nation of rapamycin and tyrosine kinase inhibitors (e.g.
FLT3 or Bcr-Abl inhibitors) showed enhanced activity
in vivo against leukemias provide rationale for exploring
such combinations in the pediatric setting.23
Histone Deacetylase Inhibitors

Histones are a family of nuclear proteins that interact with
DNA, resulting in DNA being wrapped around a core of
histone octamer within the nucleosome. Acetylation of
selected lysine residues plays a key role in controlling the
function of many proteins, including histones. The level of
protein acetylation is maintained by the counterbalancing
actions of histone acetyltransferases (HATs) and histone
506Section-7General
deacetylases (HDACs). Histone acetylation alters chromatin structure and induces a local chromatin environment
conducive with gene transcription, whereas histone de
acetylation is commonly associated with repression of
transcription.
Through histone hyperacetylation-mediated changes
in chromatin conformation and gene expression, histone
deacetylase (HDAC) inhibitors induce differentiation, cell
cycle arrest, apoptosis, growth inhibition and cell death,
which are more pronounced in transformed cell-lines
than in normal cells. Additional anti-cancer effects of
HDAC inhibitors include inhibition of migration, invasion
and angiogenesis in vivo.
Preclinical data have demonstrated the efficacy of
various HDAC inhibitors as anticancer agents, either as
monotherapies or in conjunction with other treatments
such as chemotherapy, biologic therapy, or radiation
therapy. Vorinostat and depsipeptide, two actively
studied HDAC inhibitors, were recently approved by
the FDA for the treatment of refractory cutaneous T-cell
lymphoma. Other inhibitors, for example, belinostat
(PXD101), PCI-24781, ITF2357, MGCD0103, MS-275,
valproic acid and panobinostat (LBH589) have also
demonstrated therapeutic potential. It is noteworthy that
ITF2357 showed significant anti-Hodgkins lymphoma
activity. Panobinostat showed consistent antileukemic
effects. Belinostat appears to be promising for treating low
malignant potential ovarian tumor. The combination of
demethylating agents, valproic acid, and all transretinoic
acid (ATRA) has significant clinical activity in leukemia
and MDS. Epigenetic agents in combination regimens for
cancer therapy are being actively studied.24
Role of valproic acid in infant spinal glioblastoma needs
further evaluation as a case report showed decrease in the
size of the tumor and improvement of symptoms with the
use of sorafenib plus valproic acid.25 Preclinical studies have
shown activity of HDAC inhibitors in some pediatric tumors
including neuroblastoma (with ATRA), medulloblastoma,
Ewings sarcoma and Burkitts lymphoma.
Protein Farnesyl Transferase Inhibitors

Ras is an important anticancer target, but intracellular ras
signaling requires its association with the cell membrane,
which in turn requires a post-translational addition of
farnesyl or geranyl group at carboxy terminal cysteine
residue, a process known as prenylation. There are two
forms of prenylation-farnesylation by farnesyltransferase,
and geranylation by geranylgeranyl transferase. Farnesy
lation is the dominant class of post-translational modi
fication required for proper intracellular localization
of RAS to the inner surface of the cell membrane.
Farnesyl transferase inhibitors (FTIs) were developed to
inhibit this process and thus interfere with the function of

RAS. One such FTI is tipifarnib (R115777), which is currently
being evaluated in acute leukemias, juvenile myelomonocytic
leukemia, pediatric brain tumors, and neuroblastoma.
Goemans et al identified T-cell ALL and AML-M5 as the most
sensitive subset of pediatric acute leukemia.26 Oral tipifarnib
is well tolerated in children receiving the drug twice daily for
21 days and a continuous dosing schedule at 200 mg/m2/
dose, which is equivalent to the maximum tolerated dose
(MTD) in adults. The pharmacokinetic profile of tipifarnib in
children is similar to that in adults.27
Proteosome Inhibitors
The 26S proteosome regulates the degradation of many
proteins involved in cell cycle control, apoptosis, and
tumor growth. The inhibition of the proteosome by
specific inhibitors, which results in stabilization of tumor
suppressor proteins IkB, p21 and p53, is a viable target for
antitumor therapy. Most prominently, the proteosome
inhibitor bortezomib was approved by the FDA for the
treatment of relapsed or refractory multiple myeloma
in adults, and is presently considered for pediatric
malignancies such as leukemias, lymphomas, neuro
blastoma, rhabdomyosarcoma, and Ewings sarcoma.
The first clinical trials by the Childrens Oncology Group
(COG) were conducted with bortezomib for the treatment
of refractory solid tumors and refractory leukemia.
Bortezomib is well tolerated in children with recurrent or
refractory solid tumors and leukemia. The recommended
phase II dose of bortezomib for children was 1.2 mg/m2/
dose, administered as an intravenous bolus twice weekly
for 2 weeks followed by a 1-week break. Thrombocytopenia
was dose limiting toxicity.28
Angiogenesis Inhibitors
Although angiogenesis is a complex process involving
many factors, VEGF appears to be rate limiting in
normal and pathologic blood vessel growth. Therapeutic
approaches to targeting this angiogenic pathway include
antibodies directed against VEGF, antibodies directed
against VEGF-R2, small molecule inhibitors of VEGF-R2,
and interference of integrin-matrix interactions. Trials are
currently underway to evaluate several antiangiogenesis
agents, including SU5416, bevacizumab, TNP-470,
thali
domide, SU6668, ZD4190, ZD6474, and PTK787.
Bevacizumab is a monoclonal antibody that inhibits a
single isoform of the VEGF ligand, VEGF-A. It has FDA
approval for administration as second line treatment of
metastatic carcinoma of the colon or rectum. It is also
approved in the USA and Europe for the first-line treatment
(in combination with interferon) of advanced RCC.29

Thalidomide has antiangiogenesis and other biologic
activities. It was approved by FDA for erythema nodosum
leprosum and multiple myeloma. Lenalidomide is active
against multiple myeloma and is being tried in childhood
refractory solid tumors/brain tumors. Sunitinib and
sorafenib are VEGFR small molecule inhibitor which signi
ficantly prolonged progression free survival in patients
with advanced RCC.
Cytokines
Active immunotherapy with cytokines such as interferons
(IFNs) and interleukins (ILs) is a form of nonspecific active
immune stimulation. The cytokines have been tested as
therapies for many hematologic and solid neoplasms
and have demonstrated therapeutic benefits in various
cancers. To date, only two cytokines have achieved
approval for cancer. IL-2 for the treatment of metastatic
melanoma and renal cell carcinoma, and IFN-alpha for
the adjuvant therapy of stage III melanoma.30
Interferons
Interferons (IFNs) are a group of glycoproteins that are
produced by a variety of cells stimulated by viral antigens
and mitogens. There are three types of interferons
produced by a variety of cells. IFN-alpha is produced by
macrophages and lymphocytes, IFN-beta is produced
by fibroblasts and epithelial cells, whereas IFN-gamma
is produced by CD4+, CD8+, natural killer (NK) cells, and
lymphokine-activated killer (LAK) cells. IFNs have anti
proliferative, immunomodulatory, apoptotic inducing,
and antiangiogenesis activities.31
In a cooperative group multi-institutional clinical
trial, stage III melanoma patients were treated with 1
year of IFN-alpha-2b. An overall improvement in median
relapse-free survival from 1 to 1.7 years and in median
overall survival from 2.8 to 3.8 years was reported.32
Based on initial clinical trials data, IFN-alpha was
approved by the FDA for the treatment of hairy cell leukemia
(HCL). Despite, the initial enthusiasm, a large number
of patients developed relapse after discontinuation of
therapy. The introduction of nucleoside analogues, with a
complete response rate close to 90 percent, has relegated
IFN therapy to second-line treatment in patients who have
refractory disease or in those with contraindications to
nucleoside analogs.
Interferon-alpha has also been tested in patients who
have CML, and preliminary trials suggested that complete
hematologic responses were possible in more than half of
patients who had CML, with complete cytogenic responses in
nearly 25 percent. Prospective randomized trials documented
the superiority of IFN-alpha over chemotherapy.33 Patients
with Kaposis sarcoma with mucocutaneous or asympto

matic visceral involvement and patients with follicular
lymphoma have also been shown to benefit from IFN-alpha.
Constitutional symptoms are quite common in
patients receiving IFN therapy, and are likely to occur in
80 percent or more of patients. These typically consist of
fever, fatigue, headaches, and myalgias. More serious
are the neuropsychiatric issues, which include depres
sion (45%), confusion (10%), and mania (1%). Close
monitoring of patient mental status or prophylactic
use of antidepressants can reduce the risk for these side
effects. Gastrointestinal side effects, myelosuppression,
autoimmune thyroid dysfunction are among the other
significant toxic effects.34
Interferon-gamma has been shown to enhance DNA
fragmentation and cytotoxicity caused by tumor necrosis
factor.35 Daily subcutaneous recombinant gamma-IFN
can be easily administered on an outpatient basis with
minimal local skin toxicity, results in prolonged serum
levels, and is associated with immunological changes of
potential antitumor significance.36
Interleukins
IL-2 is a glycoprotein produced by mature T-lymphocytes
during an immune response after receiving a signal from
an antigen-presenting cell (APC). IL-2 increases HLArestricted cytolytic activity of cytotoxic T-lymphocytes
and NK cells. Furthermore, the activation and expansion
of lymphocyte-activated killer (LAK) cells, which are a
mixture of NK cells and CD4/CD8 T cells, is responsible
for HLA-unrestricted killing of all tumor cell lines. The IL-2
also have regulatory effect on immune response through
activation of regulatory T cells. The balance between
effector T cells and regulatory T cells may be critical for
influencing the rejection or acceptance of tumors.
IL-2 is a promising immunotherapeutic agent for the
treatment of metastatic melanoma, acute myelogenous
leukemia, and metastatic renal cell carcinoma. While
high-dose IL-2 regimens have shown clinical benefit in
the treatment of melanoma and renal cell carcinoma,
serious dose-limiting toxicities have limited their clinical
use in a broader group of patients. The toxicity profile of
IL-2 is largely associated with a capillary leak syndrome.
In addition, IL-2 can cause constitutional symptoms
(e.g. fever, chill, fatigue) and gastrointestinal side effects,
pulmonary edema, cardiac arrhythmias, myocarditis,
reversible renal and hepatic dysfunction, pruritus,
electrolyte abnormalities, thrombocytopenia, anemia,
and coagulopathy. Although early studies with IL-2
reported a 2 percent mortality rate that was generally
508Section-7General
related to gram-positive sepsis, current IL-2 centers that
routinely use prophylactic antibiotics report no mortality.
Low dose and combination regimens have been tried
to reduce the toxicity, but these attempts were mostly
disappointing. The addition of IL-2 to chemotherapeutic
regimens (biochemotherapy) has been associated with
overall response rates of up to 60 percent in patients with
metastatic melanoma, but this has yet to be translated
into a confirmed improvement in survival. It remains to
be determined whether further modifications of IL-2based regimens or the addition of newer agents to IL-2 will
produce better tumor response and survival.37
IL-12, IL-15, IL-18, IL-21, IL-23 and GM-CSF are among
the other cytokines under investigation for their antitumor
activity.
their expression in cancer cells and normal testis), have

widespread expression in pediatric cancers including
gliomas, medulloblastoma, neuroblastoma and Ewings
sarcoma. The forth group of tumor antigens include
mutated forms of normal self molecules. For example,
breakpoint region of translocation in leukemias represent
noval epitope that do not exist in normal tissues and hence,
may be susceptible to immune targeting. Finally, viral
antigens also provide potential tumor targets particularly
relevant to EBV associated tumors in children.39
In summary, although cancer vaccines have shown
limited success so far, the barriers to inducing effective
tumor immunity are rapidly being defined. Future
challenges include investigating whether immunotherapy
is most effective as a combinatorial therapy with surgery,
chemotherapy and/or radiation therapy.30
Tumor Vaccines
SUMMARY
Current cancer vaccines aim to improve tumor-antigen

presentation and host T-lymphocyte activation. This is
done by enhancing antigenic peptide-MHC molecule
stability, by restoring costimulatory signals, and by
amplifying recruitment of the hosts immune effector cells.
Some clinical trials used autologous or allogeneic tumor
cells genetically modified to express immunostimulatory
molecules, and some of the trials used tumor cells
admixed with nonspecific adjuvant or soluble cytokines
(adjuvant-specific immunotherapy) like BCG, IFN, or
GM-CSF. Other approaches have used vectors encoding
immunomodulatory gene products or tumor antigens
directly administered in situ in the tumor, with limited
efficacy. Overall, the toxicity of these approaches is
minimal. Some studies report a rise in the frequency
of precursors to cytotoxic T cells specific to the tumor
cells, but the relevance of this finding is not established.
Cytotoxic T cells capable of lysing tumor cells ex vivo have
been isolated from fresh peripheral blood in some patients
after vaccination, but the correlation of these findings to
the clinical response is not obvious.38
The major advance in T-cell based immunotherapy
in last few years has been the molecular definition of
a number of tumor antigens that can be targeted by T
cells. One family of tumor antigens can be described
as differentiation antigens, with most defined being
melanoma associated differentiation antigens. Several
new differentiation antigens have been called universal
tumor antigens because they are expressed in vast
majority of tumors, including childhood cancers. For
example, telomerase expression in Ewings sarcoma, and
survivin expression in Ewings sarcoma, osteosarcoma
and neuroblastoma. Another family of tumor antigens
called as cancer-testis antigens (so called because of
Although current treatment approaches in children with

cancer are highly successful, we need new treatment
approaches for a significant number of unresponsive and
relapsed cases. On the other hand, it is very difficult, rather
unethical, to introduce experimental therapy in an already
successful standard regimen. Furthermore, effect of a
new modality is difficult to quantify in a patient receiving
established treatment regimen or in a heavily pretreated
patient. Because of these problems, most of the studies
have been done in adult cancer patients. Till date, the
success of biological therapy is limited but significant. With
more and more understanding of molecular pathology,
biological response modifiers may have more defined role
in pediatric cancer treatment.
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Index
Page numbers followed by f refer to figure, t refer to table and fc refer to flowchart.
A
ABO incompatibility 50, 364, 366, 367
Absolute neutrophil count 248
Acanthocytes 97f
Acetylsalicylic acid 337f
Acidified serum lysis test 243
Acquired disorders 276
Activated protein C 10, 12
Acute graft versus host disease 483
cytogenetics of 397
management of 402
pediatric 395
Acute myeloid leukemia,
pediatric 408, 412
Adenosine diphosphate 10, 42
Adenosylcobalamin 130
Adrenal insufficiency 159
Adrenaline 343
Age-specific blood cell indexes 88t
Alder anomaly 268
Alder granulation 268t
Alemtuzumab 498
Allele-specific oligonucleotide 208
Allergic reaction 385
Allogenic stem cell transplant 426
Alloimmune neutropenia 265, 265t
Alloimmune thrombocytopenia,
neonatal 79
Alloimmunization 388
Alpha interferon 327
Alpha naphthyl acetate 410
Alpha naphthyl butyrate 410
Alpha thalassemias 204
Alports syndrome 269
Alternative thrombin inhibitors 353
Amegakaryocytic thrombocytopenia,
congenital 82, 256
American Academy of Pediatrics 66
American Academy Recommendation 66
Amplification refractory mutation
system 207, 208
Amylophagia 106
Anaplastic large cell

lymphoma 452, 453, 457
Androgen 244
deficiency 159
Anemia 24, 29, 45, 49, 53, 54, 90t, 91fc,
117, 149, 156, 158, 194, 233, 244, 322
aplastic 241, 247, 248, 250, 252,
321f, 486
associated with endocrine
disorders 158
chronic 365
classification of 87, 91f
hemolytic 49, 97, 97f, 227
hypochromic microcytic 108fc
in newborn 45, 46, 49
incidence of 102t
macrocytic 93fc, 94
mediterranean 163
megaloblastic 126, 127, 138, 140
microcytic hypochromic 92f, 93fc, 109,
109f, 110f
mild 106
neonatal 54fc
nonphysiologic 46
normocytic normochromic 94fc
nutritional 100
of chronic disease 149, 150
causes of 149t
of chronic renal insufficiency 154
of infancy 29
of liver disease 157f
of prematurity 29-31, 31t, 33, 34, 34t, 45
management of 31
pernicious 131, 132f
physiologic classification of 88t
prevention of 55
severe aplastic 248
sickle cell 191-192, 195f
sideroblastic 97f, 269
Angiogenesis 43
inhibitors 506
Anorexia nervosa 160
Antibody dependent cellular
cytotoxicity 497
Antibody drug conjugates 502

Antidiuretic hormone 464
Antigen presenting cells 475, 501, 507
Antilymphocyte globulin 156
Antimicrobials 345
Antiphospholipid antibody
syndrome 350
Antiplasmin 43
Antiplatelet antibody 322
Antiplatelet drugs 353
Antithrombin 42, 70, 348
Antithrombotic agents 352
Anti-thymocyte globulin 250, 476
Aplastic anemia
acquired 247
classification of 248t
Appendicitis, hematology of 260t
Apt test 72
Arachidonic acid 341, 343
Arterial blood gases 61
Arthroscopic synovectomy 292
Arthrotomy, conventional 292
Asphyxia, intrapartum 59
Aspirin-like defects 337
Autoimmune disease 266
Autoimmune disorder 338
Autoimmune hemolytic anemia,
classification of 228
Autoimmune thrombocytopenia,
neonatal 79
Autologous transplants 479
Automated hematology analyzer 60
Autosomal recessive disorders 7, 277
Autosplenectomy 197
Avascular necrosis 197
Azathioprine 315
B
Bacterial infections 261t, 381
babesiosis 382
leishmaniasis 382
malaria 381
microfilariasis 382
512 Textbook of Pediatric Hematology and Hemato-Oncology

syphilis 381
toxoplasmosis 382
trypanosomal infection 382
Basic fibroblast growth factor 43
Basophilic stippling 95f
Battered baby syndrome 284f
B-cell lymphoma 457
Bernard-Soulier syndrome 81, 333, 336
Bevacizumab 498
Biological response modifiers 501
Blast crisis 420, 428
Bleeding
disorder 70, 73, 277f, 278
management of 314
neonate 68, 70, 74, 75
time 43, 281, 300
Blood circulation, onset of 4
Blood coagulation
cell based model of 11
inhibitors 12
physiology of 10
theories of 11
Blood loss,obstetric causes of 46
Blood transfusion 32, 234, 240
issues in 32
noninfectious hazards of 384, 385
role of 31
Blood urea 60
Blood volume 24
Bone disease 172, 182
Bone marrow 395, 396, 421t, 433, 452,
464, 479
aspiration 157, 248, 321f, 322
evaluation 111
examination 112, 154, 233, 242, 322
failure syndromes, inherited 255
harvesting 480f
transplantation 201, 479, 482, 482f
trephine biopsy 248
Bone mineral density 172
Brain neurotransmitters 38
Breastfeeding, protection and
promotion of 116
British Committee for Standards in
Hematology 332
Burkitt lymphoma 452
Burns 95f
Burr cells 157
Busulfan-cyclophosphamide 482
C
Cancer 158
Cardiopulmonary system 60
Cardiovascular disease 448
Carnitine deficiency 268
Casitas B lymphoma 431

Cell
death 260
megaloblastic 96f
membrane 333f
Cellulose acetate electrophoresis 171f
Central nervous system 60, 398, 399, 402 404, 433, 452, 459, 463, 465
Central venous pressure 53
Cephalhematoma 74, 74f, 277f
Cerebral folate transport across
choroid plexus 135
Cerebral venous thrombosis 241
Chediak-Higashi syndrome 270
Chelation therapy 175, 201
Chemotherapeutic drugs 345
Chemotherapy 456
intensive 435
low dose conventional 434
regimens 444
Chest syndrome, acute 197
Childrens Cancer Group 403, 446
Childrens Oncology Group 401-403,
455, 506
Chimeric antigen receptors 494
Cholecystitis 199
Cholestatic disorders 66
Chorionic villus sampling 207
Chromium chloride 144
Chromosomal anomalies 81
Chromosomal disorders 58
Chromosomal translocations 397, 400
Circumferential microtubular system and
microfilaments 332
Cirrhosis 156
Citrate toxicity 388
Clot retraction 281
Clotting tests 339
CNS disease, treatment of 467
Coagulation
acquired inhibitors of 311-314
cascade 11fc, 312
further aggregation and
activation of 17
inhibitors, concentrates of 359
intravascular 278f
proteins 41
system 41
Cobalamin 128, 135, 142, 142t
absorption and transport of 129f
deficiency 141
development of 130
intracellular metabolism of 130f
prophylaxis with 145
Cold agglutinin disease 231
Cold centrifuge 174f
Collagen ADP 340
Combination therapy 179

Combined modality therapy 443
Common hereditary coagulation
disorders 296
Complement dependent cytotoxicity 502
Complete blood count 48, 89, 155, 168,
247, 396, 421
Complete cytogenetic response 425
Complete remission 402, 441, 445
Compound heterozygotes 192
Computed tomography 464
Concurrent inflammation 239
Confirmatory tests 73, 109, 109t
Continuation chemotherapy 405
Conventional therapy 145
Cord blood, hemoglobin
concentration of 23t
Cord clamping 59
Corn-soya-milk preparation 120
Corticosteroid therapy 323
Cotswolds revision of Ann Arbor staging
classification 443t
Cryohydrocytosis 218
Cryoprecipitate 294, 302, 315
Cubulin 132
Customized traction system 290f
Cyclic neutropenia 262
Cyclophosphamide 315
Cyclosporine 250, 251, 315
Cystic fibrosis, atypical 269
Cytogenetics 400, 422
Cytokines 507
Cytomegalovirus 32, 80, 249, 369, 376,
380, 434
Cytoplasmic anomalies 268
Cytotoxic drug therapy 315
D
Dactylitis 196, 196f
Daycare transfusion center 175
Deep vein thrombosis 352
Deferiprone, side effects of 177
Dehydration 350
Dense granules 333
Dense tubular system 332
Dermal and epididymal veins,
thrombosis of 241
Desferal infusion pumps 176f
Desferrioxamine 176
toxicity of 177
Desferrithiocin 178
Desmopressin acetate 300
Diabetes insipidus 463
Diamond-Blackfan anemia 256
Dichlorophenol indophenol 222
Diet containing low iron 104
Index 513
Dilute Russel vipor venom test 283
Diphyllobothrium latum 132
Direct anti-globulin test 386, 388
Disease directed therapy 476
Disseminated intravascular
coagulation 61, 70, 78t, 80, 98, 350,
356, 356fc, 357f, 363, 367, 367t
Divalent metal transporter 151
Dohle bodies 95, 96f, 269
Down syndrome 413
Drug immune neutropenia 266
Drug induced immune hemolytic
anemia 229, 232
Drug induced platelet function
defects 338
Dyskeratosis congenita 256
Dysprothrombinemia 304
E
Eculizumab 244
Ehler-Danlos syndrome 72, 73
Elastic modulus 346
Electrocardiogram 178
Electronic methods, advantages of 48
Elliptocytes 95f, 217f
Elliptocytosis, hereditary 216, 217
Endocrine dysfunction 172
Endocrine system 464
Endothelial protein C receptor 12
Enzyme linked immunosorbent 306
Epidermal growth factor receptor 502
Epinephrine 343
Epithelial cells 106
Epratuzumab 497
Epstein-Barr virus 369, 376, 380, 434,
439, 452
Erythroblasts 259
Erythrocytapheresis 201
Erythrocyte 259
sedimentation rate 149
Erythropoiesis
hepatic 4
ontogeny of 3
Erythropoietin 29, 30, 33, 182
current status of 33
early versus late 33
recombinant 33, 55, 155
resistance 156
Ethinyl estradiol and levonorgestrel 302
Ethylene diamine tetra-acetic acid 281
Euglobulin clot lysis time 283
Evans syndrome 266
Extracellular signal regulated kinases 503
Extracellular survival signaling
pathways 503, 504fc
Extracorporeal membrane
oxygenation 365
Extrinsic and intrinsic apoptotic

pathways 503fc
F
Familial hemophagocytic
lymphohistiocytosis 470-472, 476
Familial neutrophilia 258
Familial thrombophilia 350
Fanconi anemia 82, 255
Farnesyltransferase inhibitors 413, 434,
435, 506
Febrile neutrophilic dermatosis,
acute 258
Febrile nonhemolytic transfusion
reactions 384, 385, 387, 390
Fechtners syndrome 269
Feltys syndrome 266
Femoral head, avascular necrosis of 197
Fetal erythropoiesis 58
Fetal hemostatic system 41
Fetal latent iron deficiency 38
Fetomaternal hemorrhage, chronic
causes of 47
Fetoplacental hemorrhage, causes of 47
Fibrin degradation products 358
Fibrin sealant 294
Fibrin stabilizing factor
deficiency 307, 308
Fibrinogen deficiencies 303
Fibrinogen degradation products 338
Fibrinogen split products 80
Fibrinolytic activity 69
Fibrinolytic pathway 13
Fibrinolytic system 43
Fibrosis, hepatic 485
Flow cytometry 345, 397
Fludeoxyglucose f18 465
Fluorescence in situ hybridization
technique 422, 453
Folate
and intrinsic hematologic disease 138
deficiency 141t
development of 137
homeostasis, regulation of 135
receptors 135
recommended daily allowance of 134t
renal retention of 135
structure 133f
Folic acid, prophylaxis with 145
Follicular lymphoma 453
Food and Drug Administration 200, 372,
497, 502
Food stability 134
Free erythrocyte protoporphyrin 109, 111
Fresh frozen plasma 294, 304, 358,
363, 370
Frozen cells 369
G
Gall stones 180
Gamma carboxylase 12
Gamma glutamyl carboxylase 64, 74
Gamma thalassemia syndrome 53
Gastrointestinal bleeds 291
Gastrointestinal surgery 105
Gastrointestinal system 60, 464
Gemtuzumab ozogamicin 413, 497
Gender-adapted chemotherapy 444
Gene inheritance of 166
Gene therapeutics, procedure of 492
Gene therapy 182, 491, 492f, 493
Genetic syndromes 263t, 264t
Germinal centre 440
Giant granulation 270
Gibbon ape leukemia virus 493
Glanzmanns thrombasthenia 19f, 278,
279f, 333, 336, 337
Glucocorticoids 235
Glucose 6 phosphate dehydrogenase
deficiency 52, 98, 219
Glutathione 219, 221
Glycogen granules 95f
Glycolytic pathway, enzymes of 223t
Glycoprotein 296, 298
specific acute antibody assay 322
Glycosyl phosphatidyl inositol 238
Graft versus host disease 252, 365, 385,
483, 487, 494
grading of 484t
Granule 333f
exocytosis 471f
release assay 475
Granulocyte 268, 270, 271, 369
colony stimulating factor 263
cytoplasm, anomalies of 268t
macrophage colony-stimulating
factor 498
nuclei, abnormalities of 271t
Gray platelet syndrome 81, 339
Gray staining bodies 270
Growth retardation 107
Guanosine triphosphate 432
H
Haemophilus influenzae 197, 233, 236
Hairy cell leukemia 507
Ham test 243
Hand-foot syndrome 196, 196f
HBV detection 373
HCV detection 373
Heinz bodies 52f
Hematinics, deficiency of 267
Hematological malignancies, gene
therapy for 494

Hematoma 319
scrotal 291f
Hematopoiesis 241, 434
development of 3
Hematopoietic cell transplantation 447
Hematopoietic cytokines 5
Hematopoietic stem cell
collection of 481
transplantation 250, 252, 404, 405,
408, 411, 434, 436, 467, 481t
Heme iron 103
Hemochromatosis, neonatal 269
Hemoglobin 23, 87, 121, 154, 165, 431f
A 194
electrophoresis 193
ontogeny of 6
production, physiology of 87
solubility test 193
Hemoglobinopathies 53, 204
gene therapy for 493
inheritance of 205
Hemoglobinuria 240
Hemolysis 192, 244
chronic 54
immune mediated 385, 386
intravascular 239, 240
Hemolytic anemia
acute 220
autoimmune 51, 227, 228, 234, 235
Hemolytic disease 50
causes of 50
Hemolytic transfusion reaction 388
Hemolytic uremic syndrome 98, 367
Hemophagocytic lymphohistiocytosis 82,
470, 471, 474, 474t, 475, 476
management of 475
secondary 471
Hemophilia 278f, 285-287
A 286
acquired 311
B 287
C 307
severe 288f, 289f
surgery in 293
treatment of 286
Hemophilic arthropathy 287, 288, 292
Hemorrhage 46, 48, 49
adrenal 49
causes of 46
chronic 54
fetofetal 47
fetomaternal 46, 47, 105
incidence of 46
intracranial 323
splenic 49
subconjunctival 277f
Hemorrhagic telangiectasia 73
Hemostasis
analysis system 346
developmental aspects of 41
mechanism of 68, 70, 71
neonatal 73
primary 68, 296
secondary 297
types of 296
Hemostatic defects, primary and
secondary 334t
Hemostatic disorders 280t
Hemostatic system, development of 64
Hemotopoietic stem cells,
graft types in 479
Henoch-Schnlein purpura 279f
Heparin
low molecular weight 352
unfractionated 352
Hepatitis
A virus 378
B 376
immunoglobulin 377
virus 376
C 179, 377
virus 377, 378
D 378
virus 378
G 378
virus 378
viral 376-379
Hereditary elliptocytosis, types of 217
Hereditary platelet function defects,
Heritable platelet defects 344t
Heterogeneous nuclear
ribonucleoprotein-e1 135
Heterozygosity, loss of 432
Histocompatibility complex,
major 470, 501
Histone acetyltransferases 505
Histone deacetylase inhibitors 201, 413,
505, 506
Hodgkin lymphoma 439, 440, 441, 441t,
443, 444, 445t, 446, 446t, 447, 448t
pediatric 439-443, 444t
Home therapy programs 288
Howell-Jolly bodies 96f
Human
epidermal growth factor
receptor 498, 504
erythrocyte membrane proteins,
major 213t
erythropoietin, recombinant 155
globin chains, chromosome map of 6f
herpes virus 376, 380
infection 380
immunodeficiency virus 180, 376,

379, 440
leukocyte antigen 481
T-cell leukemia virus 369, 376, 379
thrombopoietin, recombinant 328
Humeral head, avascular necrosis of 197
Hydroxybenzyl-ethylenediamine-diacetic
acid 178
Hydroxyurea 181, 423
therapy 200
Hyperkalemia 388
Hyperparathyroidism 160
Hyperphosphatidylcholine hemolytic
anemia, hereditary 217
Hypersplenism 180, 368
Hypertension, pulmonary 199
Hyperthyroidism 159
Hypertransfusion 59
Hyperviscosity syndrome 57, 59
Hypodiploidy 397, 400
Hypopituitarism 159
Hypoprothrombinemia 304
Hypothermia 387
Hypothyroidism 158
Hypoxia 79
I
Ichthyosis 268
Idiopathic thrombocytopenic
purpura 229t, 368
Imerslund-Grsbeck syndrome 132
Immune suppressive therapy 250
Immune thrombocytopenic
purpura 276, 279f, 318, 497
Immunization 240, 253
Immunoadsorption 315
Immunodeficiencies,
Immunoglobulins 315
Immunoradiometric assay 306
Immunosuppressive therapy 236, 250
Inactivated poliovirus vaccine 250
Inadequate erythropoiesis 158
Indian Council of Medical Research 36
Induced pluripotent stem cells 493
Infantile genetic agranulocytosis 263
Inferior vena cava thrombosis 241
Inherited bone marrow failure syndrome,
classification of 255t
Inherited disorders 275
International PNH Interest Group 242t
International Reference Method 339
International Society of Thrombosis and
Hemostasis 356
Intrathecal methotrexate 476
Intrauterine growth restriction 58, 78
Index 515
Intravenous immunoglobulin 325
Intravenous iron 115
Intravenous pulse methylprednisolone
pulse therapy 324
Iron 156
across placenta, transport of 104
chelation therapy 176
content of food articles 117t
deficiency
anemia 36, 100, 101, 105, 108, 110,
112, 150
causes of 104
development of 36
molecular genetics of 110
placenta in 37
stage 105
stages of 105
dextran complex 115
folic acid 113
fortification 118
malabsorption of 104
metabolism, abnormal 151
overload 175, 390
replacement therapy 244
sources of 102
status in pregnancy 37
studies 170
supplementation 33, 120
therapy 113, 153
oral 113
parenteral 115
transfer, regulation of 107
transport 37, 104
Isolated neutropenia, chronic 263t, 264t
J
Jaundice, neonatal 220, 221
JMML, management of 434
Jordans anomaly 268
Judes staging system for childhood
NHL 454t
Juvenile myelomonocytic
leukemia 422, 430, 431, 433,
K
Kallekrein-Kinin system 12
Kasabach-Merritt syndrome 80, 280f
Kelfer capsules 177f
Kidney function tests 60
Kleihauer-Betkes test47f
Knee joint
bleeding in 277f
chronic synovitis of 288f
Koilonychia 106f
Kostmann syndrome 256, 263
L
Lactate dehydrogenase 248, 398, 453
Langerhans cell histiocytosis 462,
465-467
treatment of 466
Large for gestational age 58, 60
Late onset sepsis 80
Latent deficiency 36
Latent membrane protein 440
Lazy leukocyte syndrome 263
Leg ulcer 180
Leukemia 321f, 399t, 486
associated phenotypes 397
Leukemic stem cells 408
Leukocyte 259, 260, 260t
adhesion deficiency 434
alkaline phosphatase 421
count 154, 322
abnormal 322
Leukodepleted blood components 369
Leukodepletion, method of 369
Lipopolysaccharides 239
Liver function test 154, 172
Liver iron concentration 170
LMWH, administration of 354t
Lupus anticoagulant 283, 313
Lymph node 443t, 463
Lymphadenopathy 441
Lymphoblastic leukemia 395, 396, 396t,
398, 402, 403, 408, 409, 486
Lymphocyte depletion 441t
Lymphoma
lymphoblastic 452
marginal zone 453
Lymphoproliferative disease 228
M
Macrocytosis 140t
Macrophage activation
syndrome 474, 476
Maintenance therapy 403, 411
Malaria 191
hypothesis 220
Malignancy 350
Marrow hypoplasia 269
Marrow neutrophils,
multinuclearity of 264
Marrow transplantation 266
Massive transfusions 367
Maternofetal transfusion 59
Maximum tolerated dose 506
May-Hegglin anomaly 81, 269
Mean cell hemoglobin concentration 169
Mean corpuscular volume 25, 89, 138,
138t, 248
Mean platelet volume 81, 320, 321

Mediastinal mass 441
Medicinal iron, supplementation of 119
Megakaryocytes 321
Megaloblastic anemia
causes of 127t
syndrome 145
Megaloblastosis 140t
treatment of 144
Methotrexate 456
Methylcobalamin 130
Methylfolate trap 137
Methylmalonic acid 143
Methyltetrahydrofolate reductase 351
Minimal residual disease 401, 404,
405, 410
Minkowski-Chauffard syndrome 214
Mitogen activated protein 503
Monitoring therapy 153
Monoclonal antibody therapy 496,
499, 502
Monocytes 270
Mosquito bite 72f
Mucocutaneous bleeds 319f
Mucosa, normal 132f
Mucositis 482
Mucous membrane bleeds 292
Multiagent induction therapy 400
Multidrug resistance-associated
protein 134
Multiparametric flow cytometry 401
Multisystem disease 463
Muscle
bleeds 290
hematoma 291f
Mutations, diversity of 166
Mycoplasma pneumoniae 233
Myelodysplastic syndrome 242t, 248
Myeloid antigen expression 399
Myeloid leukemia
acute 239t, 396, 408, 409t, 413, 414,
486, 487, 497
chronic 337, 419-423, 430
Myeloid neoplasms,
current classification of 409t
Myelokathexis 264
Myelomonocytic leukemia, chronic 430
Myeloperoxidase 397, 409
Myeloproliferative disorders 95f
Myeloproliferative syndromes 338
N
Naked-eye single tube red cell osmotic
fragility test 169
National Family Health Survey 37
National Nutritional Anemia Control
Program 113, 119

Natural killer cell 473
Necrotizing enterocolitis 60, 78, 367
Neonatal
anemia, management of 53
hemostasis, normal 68
infections 80
intensive care unit 30
polycythemia, incidence of 57
thrombocytopenia
causes of 78, 78t, 79
patterns of 78
Nephrotic syndrome 350
Neutral lipid
storage disease 268
vacuoles of 268
Neutropenia 262-264, 266
antibody induced 265
autoimmune 265, 265t
chronic 263t
Neutrophil 259
benign disorders of 258
nuclei, hypersegmentation of 271, 271t
specific granule deficiency 269
Newborn sickle cell disease screening 193
Nicotinamide adenine dinucleotide
phosphate 219
Nitric oxide 43, 201
Nocturnal hemolysis 239
Nodular lymphocyte 441
Nodular sclerosis 441t
Nonbioavailable dietary iron 104
Nonhemolytic anemia, treatment of 245
Nonhemolytic febrile transfusion
reactions 365, 369
Non-Hodgkin lymphoma 396t, 451,
452, 455
Nonimmune mediated hemolysis 386
Noninvasive prenatal diagnosis 211
Nonreplacement therapy 302
Non-specific esterase 397, 410
Nonspherocytic hemolytic anemia,
chronic 220, 222
Nonsteroidal anti-inflammatory
drugs 286, 289
Noonan syndrome 431, 432
Normal hematological values 23
Normal platelet rich plasma sample 18f
Normoblast 169f
Normocytic normochromic RBC 25f
Novel erythropoiesis-stimulating
protein 156
Nucleic acid amplification testing 372
Nucleophosfomin mutations 410
Nucleotides, measurement of 346
Nutrition 128
education and dietary
modification 117
Nutritional deficiency 130
O
Ontogeny and hematopoiesis, cytokine
regulation of 5
Oral cavity 463
Oral chelator 177
Oral iron therapy, side effects of 114
Osteopenia 172, 179, 182
management of 179t
prevention of 179
Osteoporosis 172, 179, 182
management of 179t
prevention of 179
Overhydrated hereditary
stomatocytosis 217
P
Packed red blood cell 249, 363, 365, 369
Pain
abdominal 196, 260t
relief of 289
Paper electrophoresis 171f
Pappenheimer bodies 97f
Parahemophilia 305
Paraprotein disorders 338
Paroxymal nocturnal hemoglobinuria,
molecular genetics of 238
Paroxysmal cold hemoglobinuria 231, 232
Paroxysmal nocturnal
hemoglobinuria 238, 248t, 337
Partial exchange transfusion 61
Partial thromboplastin time,
activated 12, 69, 282, 313, 351
Parvovirus B19 381
Pearsons syndrome 256
Pediatric AML, treatment of 411
Pediatric Hodgkin lymphoma,
treatment of 446
Pelger-Huet anomaly 271
Pentameric IgM antibodies 231
Pentose phosphate pathway 219f
Perinatal sepsis 80
Peripheral blood
film 154
stem cells 480
Peripheral T-cell lymphoma 453
Peroxidase deficiency and
monocytes 270
Persistent recurrent bleeding 276f
Pesaro Thalassemia Risk Classification 485
PET scan, emerging role of 453
Petechiae 319
Philadelphia chromosome 397, 400, 419,
420f
Phlebotomy 62
Phosphodiesterase activity,
inhibition of 338
Pituitary gland 463

Placenta, accidental incision of 47
Placental growth factor 59
Placental transport 135
Plasma 294
glycocalicin 322
Plasmapheresis 315
Plasminogen activator inhibitor 43
Plasmodium falciparum 220
Platelets 42, 249
activating factor 10
aggregation response 282t
aggregation studies 283
clumping 15f
concentrates, transfusion of 358
consumption of 80
contractile force 346
count 61, 154, 157, 281, 320f, 321f
defects 334
derived growth factor 333, 423, 504
disorders 73, 339
distribution width 321
dysfunction 334, 368
flow cytometry 18f
function
analyzer 281, 340
assays 340
defects 334, 337, 339, 340
disorders 332, 335fc, 342f
global screening tests of 339
granules 16t, 332
increased consumption of 367
light transmission aggregometry 340
morphology of 333f
neutralization procedure 283
poor plasma 341
rich plasma 19f
structure 332
transfusions 366, 368
types of 366
Pneumococcus polysaccharide 263
Pneumocystis carinii pneumonia 250
Pneumonitis, interstitial 484
PNH cells, types of 239t
Polycythemia 57, 59, 59t, 62
primary 58
secondary 59
vera 337
Polymerase chain reaction 222, 373
Polymorphonuclear neutrophils 138t
Pomalidomide 201
Portal system, veins of 240
Postremission therapy 405, 411
Post-thrombotic syndrome 355
Post-transfusion purpura 385, 389
Post-traumatic stress disorder 405
Precursor T-lymphoblastic
lymphoma 456
Index 517
Primitive neuroectodermal tumor 487
Promyelocytic leukemia, acute 409, 414
Prophylactic therapy 289, 290
Prophylaxis
intermittent 290
primary 290
secondary 290
Prostaglandin pathways,
inhibition of 338
Protein farnesyl transferase
inhibitors 506
Protein tyrosine phosphatase 433
Proteosome inhibitors 506
Prothrombin complex concentrates,
activated 314
Prothrombin deficiency 304
Prothrombin time 66, 281, 300, 313, 351
Proton-coupled folate transporter 134
Proximal renal tubular acidosis 240
Pseudo-Chediak-Higashi
granulation 270
Pseudotumors 292, 293f
Purpura fulminans, neonatal 354
Pyridoxal isonicotinoyl hydrazone 178
Pyrophosphorolysis-activated
polymerization 211
Pyruvate kinase 224
deficiency 52, 224, 224t
Q
Qualitative platelet
defects 279f
disorders 73, 281
Quantitative defect 303
R
Radiation therapy 445
intensity modulated 445
technique 445
volume 445
Radioimmunoassay 112
Radiotherapy 445, 457
Radioulnar synostosis 82
Random donor platelet 366
Rapamycin inhibitors,
mammalian target of 505
Rapid plasma reagin 381
Rare coagulation disorders 303
Red blood cell 25, 30, 87, 150, 213, 219,
232, 385
agglutination of 504
deformity 96f
dehydration, prevention of 201
distribution width 142, 168, 215, 248
enzymopathy 219
membrane disorders 213
Reduced folate carrier 401

Reed-Sternberg cells 440
Refractory disease 447
Refractory episodes 198
Renal cell carcinoma 505
Renal damage, chronic 240
Renal disease 199
Renal dysfunction 240
Renal failure 157f
acute 240
chronic 240
Renal replacement therapy 156
Renal system 60
Renal transplantation 156
Respiratory distress syndrome,
acute 369, 499
Restriction fragment length
polymorphism 210
Reticular dysgenesis 256
Reticulocyte 96f, 169f, 193f
count 25, 26f, 154, 157, 169
Retinal vein thrombosis 241
Retinopathy 199
Retroviral infection 379
Reverse dot blot analysis 208
Reverse transcription polymerase chain
reaction 422
Revolutions per minute 60
Rh-compatibility 364, 366, 367
Rh-isoimmunization 50
Rheumatoid arthritis 266
Ristocetin induced platelet
aggregation 300
Rituximab 236, 327, 497
Romanowsky-stained blood films,
bacteria in 262t
Russell viper venom 307
S
S-adenosyl-methionine 137
Schilling test 143
Screening tests 72, 73t, 108, 111
Sebastian platelet syndrome 269
Sepsis 350
hematologic scoring system for 261t
Serum ferritin 111, 112
Serum iron 112, 155, 243
Shock 53
Shortened erythrocyte survival 150, 158
Shwachman syndrome 269
Sickle cell 95f
anemia
genetics of 192
management of 194, 197
disease 190, 191, 194, 195f, 200,
205, 211
homozygous 192
gene mutations, types of 190

syndromes 192
trait 192
Sickling test 193
method of 193
Single donor platelet 366
Single nucleotide polymorphisms 211
Single system disease 463
Sinusoidal obstruction syndrome 483
Skin ulcers 198
Small for gestational age 58, 60
Soluble plasma transferrin
receptor 110, 112
Spherocytes 52f, 94f, 215f
Spherocytosis, hereditary 51, 52f, 213,
214, 214t, 215, 216
Splanchnic vein thrombosis 241, 494
Splenectomy 180f, 216, 236, 245, 326
ITP, indication of 326
Splenic vein thrombosis 241
Standard deviation 109, 141
Staphylococcus aureus 249
Stem cell
infusion 482
transplantation 181, 459
current status of 411
sources of 479, 480t
Steroids 315, 323
dose of 324
Stomatocytes 95f, 217f
Stomatocytosis
dehydrated 217
hereditary 217, 218
Storage iron depletion 105
Storage pool defects 336, 337
Streptococcus pneumoniae 197
Stuttering episodes 198
Sucrose lysis test 243
Suicide gene therapy 494
Superconducting quantum interference
device 171
Superior vena cava syndrome 453
Supportive therapy 201, 476
Sweets syndrome 258
Synovectomy 292
types of 292
Synovitis
chronic 288, 289f
subacute 288
Systemic lupus erythematosus 228, 229,
319
Systemic thrombolytic agents,
administration of 354t
T
Target cell 97f, 169f
T-cell immunophenotype 452

T-cell lymphomas 456
Template bleeding time 340
Terminal deoxynucleotidyl
transferase 452
Thalassemia 163, 350
belt 164
inheritance of 167f
intermedia 168, 170f
leg ulcer in 180f
major 168, 170f, 350
management of 168, 173
minor 169
outdoor center 174
prenatal diagnosis protocol 207fc
syndrome 163-165, 204
trait 167
Therapeutic test 111
Therapy, recommended durations of 353
Thrombin
activable fibrinolytic inhibitor 10, 13
clotting time 283
generation time 346
receptor activating peptides 341
regulation of 42
time 300, 303
Thrombocytopenia 79-81, 256, 335, 367
congenital 82
inherited 80-82
neonatal 77, 78
Thromboelastography 340
Thromboembolic disease,
management of 245
Thrombolytic drugs 345
Thrombopoietin 77, 328
Thrombosis 240, 241
acute onset of 240
neonatal 349
pathophysiology of 240
pediatric 348, 354
Thrombotic thrombocytopenic purpura
367
congenital 78t
Thromboxane 333
Tissue factor pathway inhibitor 10, 12,
70, 357, 359
Tissue plasminogen activator 13, 43,
345, 348
TKI, toxicity of 426
Toll-like receptor 471
Topical thrombin, use of 302
Total body irradiation 436, 482
Total iron binding capacity 105, 111, 112,
149, 170
Total leukocyte count 157
Total tissue factor pathway inhibitor 42
Toxic granulation 95f
Tranexamic acid 294
Transcobalamin 129
Transcranial Doppler 197
Transcription mediated amplification 373

Transferrin receptors 110, 112
Transferrin saturation 111, 112
Transforming growth factor alpha 504
Transfusion 153, 200
acute hazards of 385
adequacy of 175
advances in therapy 175
associated graft versus host
disease 369, 389, 390
delayed hazards of 388
rate of 175
reactions, acute 385
related acute lung injury 371, 387
related immunomodulation 389, 390
support 249
therapy 173, 200
chronic 244
complications of 175
initiation of 174
transmitted cytomegalovirus 376
transmitted infections 179, 372, 376
transmitted virus 376
types of 174
Transient deficiency of coagulation
factors, exaggeration of 70
Transient myeloproliferative disorder 413
Transient neutropenia 260
Transplant related mortality 447
Trephine biopsy, role of 398
Tumor biology 399
Tumor lysis syndrome 395, 455
Tumor suppressor gene 432
Tumor vaccines 508
Twin-to-twin transfusion syndrome 47, 59
Tyrosine kinase inhibitors 423
U
Ulcers, unhealed 198, 198f
Umbilical cord 47
blood stem cells 480
stem transplantation 181
Umbilical vessels, treatment of 26
Unfractionated heparin,
administration of 354t
Uremia 338
Uridine diphosphoglucoronate
glucoronosyltransferase-1 gene
promoter 222
Urinary tract
bleeding 291
infections 100
Urine hemosiderin 242
V
Vaccinations 240
Valproate 413
Vascular access devices 349

Vascular cell adhesion molecule 201
Vascular endothelial growth
factor 43, 59, 498
Vaso-occlusive crisis 195
Veins, hepatic 240
Venacaval interruption 353
Veno-occlusive disease 483
Venous thromboembolism 348, 351
treatment of 353
Vessel wall 43, 68
Viral infection 261t, 266
Virus associated hemophagocytic
syndrome 470
Vitamin
B12 128
absorption and transport of 128
recommended daily
allowance of 128t
D receptor 173
K 66, 73
antagonist 352, 353
cycle 65
deficiency 48, 64, 65, 73, 74f
epoxide reductase 12, 65
biology of 64, 73
chemical structure of 65
Volkmanns ischemic contracture 290f
von Willebrand disease 276, 279f,
296-300, 301t, 302, 303, 332, 336
von Willebrand factor 10, 41, 69, 296, 297,
302, 315, 348
von Willebrand syndrome 302
W
Warfarin, administration of 354t
Washed cells 369
WBC filter 369
Wells-Brookfield cone-plate
microviscometer 57
West nile virus 374
White blood cell 249, 399, 402, 433
Whole blood 346, 364, 365
Whole genome sequencing 211
Wiskott-Aldrich syndrome 71f, 81, 280f
Wolmans disease 269
World Health Organization 100, 101, 399,
430, 451
X
Xerocytosis, hereditary 217
X-linked inheritance 71
X-linked recessive pattern 277
Y
Yersinia enterocolitica 381

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Textbook of

Pediatric Hematology and

Pediatric Hematology and

Consultant Pediatrician and Pediatric Hematologist Oncologist

President, Indian Academy of Pediatrics, 2006

Mamta Vijay Manglani

Professor and Head

Director, Pediatric Hematology-Oncology and

The Health Sciences Publisher

Jaypee Brothers Medical Publishers (P) Ltd.

Jaypee-Highlights Medical Publishers Inc.

Jaypee Brothers Medical Publishers (P) Ltd.

Jaypee Medical Inc.

Jaypee Brothers Medical Publishers (P) Ltd.

Aditya Kumar Gupta

viii Textbook of Pediatric Hematology and Hemato-Oncology

Dilraj Kaur Kahlon

Mamta Vijay Manglani

x Textbook of Pediatric Hematology and Hemato-Oncology

Rajesh B Sawant MD Path

Rajiv Kumar Bansal

Raj Warrier MD FAAP FIAP

(Late) Ram Kumar Marwaha

xii Textbook of Pediatric Hematology and Hemato-Oncology

Shilpa Sanjay Borse MD

Former Professor and Head

2. Physiology of Blood Coagulation

3. Structure, Function and Physiology of Platelets

Section 2 NEONATAL HEMATOLOGY

6. Effect of Maternal Iron Status on Placenta, Fetus and Newborn

7. Developmental Aspects of Hemostasis in the Fetus and Newborn

8. Anemia in the Newborn

9. Polycythemia and Hyperviscosity Syndrome

10. Vitamin K Deficiency: Bleeding in Newborns

11. Bleeding Neonate: Approach and Management

12. Approach to Neonatal Thrombocytopenia

Section 3 RBC AND WBC DISORDERS

xxiv Textbook of Pediatric Hematology and Hemato-Oncology

16. Anemia of Chronic Disease

17. Thalassemia Syndromes

18. Sickle Cell Anemia in Children

19. Antenatal Diagnosis of Hemoglobinopathies

20. Red Cell Membrane Disorders (Spherocytosis, Elliptocytosis, Stomatocytosis)

21. Red Cell Enzymopathy

22. Autoimmune Hemolytic Anemia

23. Paroxysmal Nocturnal Hemoglobinuria

24. Diagnosis and Management of Acquired Aplastic Anemia in Children

25. Inherited Bone Marrow Failure Syndromes

26. Benign Disorders of Neutrophils

Section 4 BLEEDING DISORDERS

28. Diagnosis and Management of Hemophilia Patients

29. von Willebrand Disease and Other Rare Coagulation Disorders

30. Acquired Inhibitors of Coagulation

31. Immune Thrombocytopenic PurpuraDiagnosis and Management

32. Platelet Function Disorders

33. Pediatric Thrombosis