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Dr.

Anca Colita
ANEMIA APLASTICA
 Anemia aplastică este o afectiune severa, potential
fatala, în care producția de eritrocite, leucocite și
trombocite este foarte scazuta.

 Anemia aplastică poate să apară la toate grupele de


vârstă și la ambele sexe.

 Boala este caracterizata prin pancitopenie periferică


însoțita de maduva osoasa hipocelulara.
MO hipocelulara
Anemia aplastica (AA)
 Anemie hiporegenerativa caracterizata prin:
 Pancitopenie
 Neutropenie < 1,5 x 10^9/L
 Tr < 50 x 10 ^9/L
 Hg < 10 g/dl
 Maduva osoasa (MO) hipocelulara pentru varsta
 Absenta infiltratiei neoplazice sau al fibrozei
medulare
Criterii de severitate
Fm severa (SAA) Fm foarte severa (VSAA)
 MO hipocelulara (< 25% )  Crt de SAA
 + cel putin 2 din  + neutrofile < o,2 x10^9/L
urmatoarele:
 1. neutrofile < 0,5 x 10^/L
 2. tr < 20 x 10^9/L
 Rt < 40 x 10^9/L

Fm moderata: cand nu sunt indeplinite criteriile de SAA


Epidemiologie
 Boala foarte rara: 1-3/1.000.000 copii
 >70% din fm dobandite au la prezentare criterii de
SAA
 Usoara predominenta a sexului masculin
Etiologie AA constitutionale
AA dobandite
 Idioaptica (70-80%)
 Postinfectioasa :  Anemia Fanconi
 Virala: hepatitice, herpes virusuri  Diskeratosis congenita
(CMV, EBV, HHV6, VZV), HIV,  AA ca urmare a altor
parvovirus B19, rubeola,
 Non-virala: rara (ex TBC)
sindroame de insuficienta
 Medicamente : medulara:
 Antibiotice: cloramfenicol,  Trombocitopenia
 Antimalarice: cloroquina amegakariocitara congenitala
 Anticonvulsivante: fenitoin, (CAMT)
carbamazepina  Schwachmann-Diamond
 Antiinflamatorii: fenilbutazona, sindrom (SDS)
indometacin, saruri de aur  anemia Diamond Blackfan
 Antitiroidiene: carbimazol, (DBA)
propiltiouracil
 Hipoglicemiante orale: sulfoniluree
 Expunere la s. chimice sau toxice
(benzen, vopsele, adezivi, insecticide)
 Altele : HPN, LES, AIJ, sarcina,
malnutritie
AA dobandita- patogenie
 1. Defect primitiv al celulelor stem hematopoietice
 2. Cauza extrinseca:
 A)Fenomene de autoimunitate mediata celular
impotriva celulelor stem hematopoietice sau
progenitorilor
 B) Anomalii ale stromei medulare sau a micromediului
medular
 C) Deficit al factorilor de crestere
Fiziopatologia AA
Young NEJM 1997
AA dobandita: manifestari clinice
 Debut de sapt – luni
 Durata prelungita a simptomelor – suspiciune de
anemie aplastica constitutionala
 Sindrom de insuficienta medulara:
 Anemie: paloare, astenie, cefalee
 Sindrom hemoragipar: petesii, epistaxis, gingivoragii etc
 Sindrom infectios
AA dobandita: investigatii
 Hemograma, formula leucocitara, reticulocite, frotiu sanguin
 HbF (inainte de transfuzii, semn de hematopoieza de stress)
 Coagulare
 Feritina, vit B12, folat
 BM aspirat + biopsie (+ examen citogenetic)
 Biochimie
 Virusologie
 Imunologie
 Flow-citometrie: pt HPN
 Imagistica: ECHO pt anomalii sugestive pt an constitutionala
 Teste de exludere a an constitutionale: fragilitate constitutionala,
genetica moleculara
 Teste HLA
AA - Evaluare
*CBC w/ diff & retic
*Bone marrow
* DEB (Fanconi’s test)
*Hep A, B, C, D titers HIV
*Test pt. PNH (CD55, CD59)
*HLA typing
*Fetal hemoglobin
*teste hepatice si renale
*Quantitative immunoglobulins, C3, C4, and
complement.
* Autoimmune disease evaluation: Antinuclear
antibody (ANA), total hemolytic complement
(CH50), Coombs’ test.
* HLA typing: Patient and family done at the time of
diagnosis of severe aplastic anemia to ensure a
timely transplant.
Diagnostic
Sange periferic Biopsie MO
*Pancitopenia *incarcare grasa
*anemie normocitara *numar redus de
normocroma celule
*reticulocite scazute hematopoietice
*limfocite si
plasmocite in
cantitate crescuta
BM : < 25% celularitate
AA: diagnostic diferential
 AA dobandita vs AA constitutionala
 LA fm aplastica (preleucemie)
 Mielodis plazie cu hipoplazie
Tratament

Factori de crestere
Transplant medular

Imunosupresie Suportiv
TRATAMENT
1. identificare agent etiologic
2. tratament suportiv
 Transfuzii izogrup izogrup , cu produse iradiate,
leucodepletate
 Antibiotice, antifungice
3. allotransplant de celule stem hematopoietice
-donator inrudit
-Curative in 60-90% cazuri
-aplicabil la 30% DIN CAZURI
4. Imunosupresie
Cyclosporin + ATG
Corticosteroids
High dose cyclophosphamide
5. Factori de crestere
G-CSF/ GM-CSF/ EPO
AA - prognostic
Varst: Younger is better
BMT
< 20 ani cu donator familial… 75%
20 - 40 ani cu donator familial …60%
< 20 ani cu donator nonfamilial … 40%
20 - 40 cu donator nonfamilial T…35%
Immunosuppression - 60 - 80%
- Pentru cat timp si cu ce consecinte…
Sdr de insuficienta medulara
congenitala
 Boli rare
 Hematopoieza afectata
 Predispozitie pentru cancer
 +/- anomalii congenitale
 Varsta la diagnostic
 copil
 Adult
 Dg dif cu AA dobandite este critica pentru tratament
Sdr de insuficienta medulara
congenitala
 Multilineala  Unilineala
 FANCONI ANEMIA  DIAMOND BLACKFAN
(FA) ANEMIA (DBA)
 DYSKERATOSIS  SHWACHMAN
CONGENITA (DSC) DIAMOND (SDS)
 AMEGAKARIOCYTIC
THROMBOCYTOPENIA
VERY RARE DISEASES:
Kostman sdr, CDA, Dubowitz sdr, Seckel sdr,
Pearson sdr, Cartilage Hair hypoplasia (CHH),
Reticular digenesis, TAR
Ribosomopathies: DC, CHH, DBA, SDS

RIBOSOM
-A large complex molecule
responsible for catalyzing
the formation of proteins
from individual aminoacids
using mRNA as a template.
-1974: Palade GE, Claude A.,
De Duve C. – Nobel Prize in
Physiology and Medicine for
the discovery of the
ribosome
-2009: Rasmakrishanan V,
Stritz TA, Yonath AE – Nobel
Prize in chemistry for
discovery the detailed
structure and mechanism of
the ribosome
Potential mechanisms for the cellular consequences of ribosomal haploinsufficiency.
Top panel: Normal cell in unstressed conditions, with unperturbed ribosome biogenesis and steady levels of p53.
Bottom panel: Ribosomal haploinsufficiency leads to up-regulation of rpL11, which binds to MDM2 causing p53 activation,
which results in apoptosis and cell-cycle arrest.
Kumar S, Bandyopadhyay U. Free heme toxicity and its detoxification systems in human. Toxicol Lett. 2005;157(3):175-188.
Telomeropathies: a newly described group of human diseases based
on the genetics and molecular biology of the telomeres
• Telomeres, the ends of chromosomes, are repeated
hexanucleotides and their associated proteins;
• They protect chromosomes from recognition as damaged DNA
• When telomeres become critically short in a cell, senescence,
apoptosis, or, rarely malignant transformation results.
 In individuals with mutations in genes involved in telomere
repair, severe deficiencies result in dyskeratosis congenita, a
congenital aplastic anemia with associated mucocutaneous
abnormalities.
 Mutations in TERT (the catalytic component) and TERC (the
RNA template) = risk factors for the development of bone
marrow failure, pulmonary fibrosis, and hepatic cirrhosis.
 Chromosome instability is a result of critical shortening of
telomeres
Dokal I, Hematology 2011
Sdr de insuficienta medulara
congenitala
► anamneza
► statura mica / nanism
► hiperpigmentatie
► Rash
► displazie ungheala
► Leukoplakia
► insuficienta de pancreas exocrin
► anomalii de schelet (radius, degete)
► alte anomalii congenitale
Hematologie
Citopenii periferice
severe/moderate sau
absente
FA Pancytopenia Macrocytosis HbF ↑
DC Pancytopenia Macrocytosis HbF ↑
Macrocitoza
SDS Neutropenia HbF ↑
inexplicabila
DBA Anemia Macrocytosis HbF ↑

Crestere HbF in mod


obisnuit
BM biopsy/aspirate
 Nu este patognomonica
 This response to MMC or Chromosomal
DEB distinguishes
Fanconi anemia from breakage:FA
most of the other
chromosomal breakage
syndromes such as
ataxia telangiectasia
and Bloom’s syndrome.
• Telomere length is markedly Telomere length:
shorter (<1st percentile) in patients
with DC, even in comparison to other DC
patients with marrow failure.
•Telomere length is emerging as a
useful screen for DC , although
experience with this test is still limited
and interpretation must be made
within the clinical context.
•Granulocytes in particular commonly
exhibit shortened telomeres.
•A study measuring telomere lengths
in a panel of five lymphocyte subsets
plus granulocytes reported that
telomere lengths below the 1st
percentile for age in at least 3 different
lymphocyte subsets strongly correlated
with the diagnosis of DC
Exocrine pancreas insufficiency:
SDS
 SDS hallmark: exocrine pancreatic atresia with
steatohreea
 Serum trypsinogen
 Pancreatic isoamylase
 CT/MRI: fatty pancreas
Erythrocyte adenosine deaminase
(eADA): DBA
 Patients with DBA often have elevated eADA levels.
The reason for this finding is unknown, but this has
nonetheless proven a useful diagnostic marker.
 Elevated eADA and HbF, red cell macrocytosis,
congenital anomalies, familial anemia, and age less
than 1 year favors the diagnosis of DBA rather than
transient erythroblastopenia of childhood (TEC).
 Laboratory testing must be interpreted cautiously
during the recovery phase of TEC as some overlap with
features of DBA may transiently arise
Genetic testing
 Many of the genes responsible for these syndromes
have been elucidated.
 However, negative genetic testing is insufficient to
rule out these syndromes.
 Likely additional genes remain to be identified.
FANCONI ANEMIA
Disease
Transmision Gene Chromo. Fenotype
FANC A 16q 24-3 ٥ Hypostature, LBW
FA FANC B 13q 12-13 ٥ Microcephaly
▪ AR FANC C 9q 22-3
٥ Skin hyperpigmentation, “café au lait”
spots
٥Malformations(skeleton,heart,kidney)
▪ X-linked FANC D1 1q 12-13
٥ AA
FANC D2 3p 25-3 ٥ HbF, αFP

FANC E 6p 25-22 ٥ Chromosome breakage/fragility

FANC F 11p 15 ٥ Secondary neoplasia (AML with


clonal anomalies 7- ,5- ,8- chr1,chr11;
FANC G 9p 13
Solid tumours)
>15
genes E.Gluckman,2004
DISKERATOSIS CONGENITA
Disease
Gene Chromosome Fenotype
Transmision

DKC 1 ٥ Abnormal skin


DKC Xq28
(X-Linked) pigmentation
▪ X-linked
٥ Leukoplakia
TERC, 3q26
▪ AD ٥ Nail distrophy
TERT, 5p15
TIN2 14q11 ٥ Congenital anomalies

NOP10, 15q14 ٥ AA
TERT, 5p15
▪ AR ٥ Solid
NHP2, 5q35 tumours/MSD/Leukemia
TCAB1,
C16orf57 17p13.1
16q21
HEREDITARY BONE MARROW FAILURE
Disease Gene Chromosome Fenotype
Transmision
٥ Erythroblastopenia
DBA
٥ Erythrocytic ADA↑
▪ AD RPS 19
19q 13 ٥ Congenital anomalies (30%,
▪ (AR?) (25%) thumbs, upper limbs, cranio facial,
heart, uro-genital)
Shwachman ٥ AA
▪ AR SBDS 7q 11 ٥ Exocrine pancreas insufficiency

SCKL1 3q22.1-24 ٥ “Bird headed” nanism


Seckel SCKL2 18q11.31-11.2
٥ Congenital anomalies
٥ AA
▪ AR
SCKL3 14q23
HEREDITARY BONE MARROW FAILURE
Disease
Gene Chromosome Fenotype
Transmision
ELA 2 ٥ Leukopenia / chronic neutropenia
Kostmann 19p13.3 ٥ Early onset of severe infection
(Neutrophil
elastase) ٥ MSD / AML (10%)

Amegakariocytic ٥ Early onset (neonatal)


congenital MPL 1p 34 thrombocytopenia
Thrombocytopenia
٥ Amegakariocytic bone marrow
٥ Skeletal anomalies (TAR)
٥ AA

E.Gluckman,2004
Guido Fanconi

Fanconi Anemia – 1927


descrie 3 frati cu
pancitopenie si anomalii
fizice
Fanconi Anemia (FA)
 Rara (< 1/ 100,000 nasteri)
 Autosomal recesiva/X -linkata
 Multiple anomalii descrise,
Dar 20-25% nu asociaza nicio anomalie
 Varsta mediana la diagnostic 7.8 ani
 > 15 gene anornmale descrise pana in prezent
 Anomaliile genice – afectarea mecanismelor de
reparare a ADN
Autosomal Recessive Inheritance
FA- aspecte clinice
Anomalia % FA Pat
Hipepigmetare cutanata 60%
Nanism 57%
anomalii membre 48%
Microcefalie 27%
Renal 23%
retard mental 13%
Fara anomalii 20%
Doar Statura mica 1%
Doar Anomalii cutanate 3%
Aspecte clinice
 Statura mica
 Anomalii membre: absenta sau hipoplazia policelui +/- radius,
clinodactilie, hipoplazia eminentei tenare, luxatie congenitala de
sold, picior plat, anomalii degete picioare
 Alte anomalii scheletice: microcefalie etc
 Retard
 Ochi: anomalii morfologice si vizuale
 Urechi: anomalii morfologie si tulburari de auz
 Cardiac: PCA, DSA, DSV
 Urogenital: rinichi ectopic, displazic sau absent
 Gonade: anomalii morfologice, azoospermie
 Gastrointestinal: atrezie de esofag, duoden, jejun, anomalii anale
 Piele : pete café au lait, hiperpigmetare
Caracteristici clinice
Insuficienta medulara progresiva

Risc crescut de SMD sau LAM (15,000x)

Risc crescut de aparitie de tumori solide


(hepatice, esofageale, orofaringeale,
vulvare)
varsta medie la dg 23 ani
incidenta cumulativa la 45 ani: 30%
Diagnostic- teste de
fragilitate cromozomiala
 Mitomycin C (MMC)
 diepoxybutane (DEB)
FA cells were treated with mitomycin C and harvested in metaphase. Typical
abnormalities include radial formation (green circle) and chromosome breaks (red
arrows).
Tratament
Sfat genetic – analiza familiala
Echo renal, audiograma, exam oftalmologic
Evaluare endocrina
Consult chirurgie ortopedica
Biopsie MO
TRATAMENT
 Insuficienta medulara
 Transfuzii
 Androgeni (e.g. oral oxymethalone)
 Factori de crestere ???(G-CSF, CM-CSF) – atentie la cei cu anomalii
genetice
 Transplant medular
 Terapie genica ?
2. Alte sindroame de insuficienta
medulara congenitala
Dystkeratosis Congenita
- leucoplachie
- displazie ungheala
- hiperpigmetare cutanata
- insuficienta medulara
Schwachman-Diamond
- insuficienta de pancreas exocrin
Cartilage-Hair Hypoplasia
Diskeratosis congenita
Sdr de insuficienta medulara
congenitala
Pearson’s syndrome
Seckel’s syndrome
Amegakaryocytic Thrombocytopenia
Noonan’s syndrome
Sdr de insuficienta medulara
congenitala
Unilineale:
 Pure Red Cell Aplasia (Diamond-Backfan)
 Congenital Neutropenia (Kostmann’s)
 Thrombocytopenia with Absent Radii