Anemia with intrinsic hemolysis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Differentiating Anemia with intrinsic hemolysis from Other Diseases

To review the differential diagnosis of anemia, click here.

Disease	Genetics	Clinical manifestation					Lab findings
		History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Iron studies					Specific finding on blood smear
		History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Serum iron	Serum Tfr level	Transferrin or TIBC	Ferritin	Transferrin saturation	Specific finding on blood smear
G6pd deficiency^[1]	Defect in G6PD enzyme X-Linked recessive	History of using Sulfa drugs Antimalarials Fava Beans Infections	Back pain Hemoglobinuria	Back pain	+	Intrinsic	Normochromic	Normocytic	↑	↑ but usually causes resolution within 4-7 days	↓	↓	Nl to ↑	Nl	↑	↑	↑	RBC with Heinz bodies Bite cells Blister cells
Pyruvate kinase deficiency^[2]	Mutation in the PKLR and PKM gene Autosomal recessive	Gallstones	Hydrops fetalis Neonatal hyperbilirubinemia Iron overload Perinatal complications	Skin ulcers Splenomegaly	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↑	Nl	Nl	↑	−	Prickle cells Polychromatophilic erythrocytes
Sickle cell anemia^[3]	Hbs point mutation causes a single amino acid replacement in β chain	High altitude Low Oxygen Acidosis African-American race Parvovirus B19 infection	Painful crisis Dactylitis Priapism Acute chest syndrome Avascular Necrosis Stroke Autosplenectomy Salmonella osteomyelitis	Dactylitis Priapism	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl or moderately ↑	Nl	Nl	Nl or moderately ↑	↓	Nl	Increased erythropoiesis Howell-Jolly bodies Anisocytosis
Disease	Genetics	History	Symptoms	Signs	Hemolysis	Intrinsic/Extrinsic	Hb concentration	MCV	RDW	Reticulocytosis	Haptoglobin levels	Hepcidin	Serum iron	Serum Tfr level	IBC	Ferritin	Transferrin saturation	Specific finding on blood smear
HbC disease^[4]	Glutamic acid–to-lysine mutation in β-globin	Gallstone	Joint pains Increased risk of infections	Splenomegaly Cholelithiasis Avascular necrosis of the femoral head	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	Nl	Nl	Nl	↓	−	Hemoglobin crystals inside RBCs Target cells
Paroxysmal nocturnal hemoglobinuria^[5]^[6]	PIGA gene mutations Impaired synthesis of GPI anchor for decay-accelerating factor	Associated with aplastic anemia Thrombosis	Fatigue Chest pain Dyspnea on exertion Headache	Chronic hemolysis Hepatomegaly Ascites Papilledema Skin nodules	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↓	Nl	↑	↓	−	NA
Hereditary spherocytosis^[7]	Mutations in Ankyrin, Band 3, Protein 4.2, and spectrin	Associated with parvovirus B19 Cholelithiasis Megaloblastic crisis	Aplastic crisis	Splenomegaly	+	Intrinsic	Normochromic	Normocytic	↑	↑	↓	Nl	↓	Nl	↑	Nl	−	Small, round RBCs with less surface area and no central pallor

References

↑ Luzzatto L, Seneca E (February 2014). “G6PD deficiency: a classic example of pharmacogenetics with on-going clinical implications”. Br. J. Haematol. 164 (4): 469–80. doi:10.1111/bjh.12665. PMC 4153881. PMID 24372186.
↑ Grace RF, Zanella A, Neufeld EJ, Morton DH, Eber S, Yaish H, Glader B (September 2015). “Erythrocyte pyruvate kinase deficiency: 2015 status report”. Am. J. Hematol. 90 (9): 825–30. doi:10.1002/ajh.24088. PMC 5053227. PMID 26087744.
↑ Singh PC, Ballas SK (March 2015). “Emerging drugs for sickle cell anemia”. Expert Opin Emerg Drugs. 20 (1): 47–61. doi:10.1517/14728214.2015.985587. PMID 25431087.
↑ Lemonne N, Billaud M, Waltz X, Romana M, Hierso R, Etienne-Julan M, Connes P (2016). “Rheology of red blood cells in patients with HbC disease”. Clin. Hemorheol. Microcirc. 61 (4): 571–7. doi:10.3233/CH-141906. PMID 25335812.
↑ Bunyaratvej A, Butthep P (January 1992). “Cytometric analysis of paroxysmal nocturnal hemoglobinuria erythrocytes”. J Med Assoc Thai. 75 Suppl 1: 237–42. PMID 1402472.
↑ Kahng J, Kim Y, Kim JO, Koh K, Lee JW, Han K (January 2015). “A novel marker for screening paroxysmal nocturnal hemoglobinuria using routine complete blood count and cell population data”. Ann Lab Med. 35 (1): 35–40. doi:10.3343/alm.2015.35.1.35. PMC 4272963. PMID 25553278.
↑ Da Costa L, Galimand J, Fenneteau O, Mohandas N (July 2013). “Hereditary spherocytosis, elliptocytosis, and other red cell membrane disorders”. Blood Rev. 27 (4): 167–78. doi:10.1016/j.blre.2013.04.003. PMID 23664421.

[pmid24372186-1] Luzzatto L, Seneca E (February 2014). “G6PD deficiency: a classic example of pharmacogenetics with on-going clinical implications”. Br. J. Haematol. 164 (4): 469–80. doi:10.1111/bjh.12665. PMC 4153881. PMID 24372186.

[pmid26087744-2] Grace RF, Zanella A, Neufeld EJ, Morton DH, Eber S, Yaish H, Glader B (September 2015). “Erythrocyte pyruvate kinase deficiency: 2015 status report”. Am. J. Hematol. 90 (9): 825–30. doi:10.1002/ajh.24088. PMC 5053227. PMID 26087744.

[pmid25431087-3] Singh PC, Ballas SK (March 2015). “Emerging drugs for sickle cell anemia”. Expert Opin Emerg Drugs. 20 (1): 47–61. doi:10.1517/14728214.2015.985587. PMID 25431087.

[pmid25335812-4] Lemonne N, Billaud M, Waltz X, Romana M, Hierso R, Etienne-Julan M, Connes P (2016). “Rheology of red blood cells in patients with HbC disease”. Clin. Hemorheol. Microcirc. 61 (4): 571–7. doi:10.3233/CH-141906. PMID 25335812.

[pmid1402472-5] Bunyaratvej A, Butthep P (January 1992). “Cytometric analysis of paroxysmal nocturnal hemoglobinuria erythrocytes”. J Med Assoc Thai. 75 Suppl 1: 237–42. PMID 1402472.

[pmid25553278-6] Kahng J, Kim Y, Kim JO, Koh K, Lee JW, Han K (January 2015). “A novel marker for screening paroxysmal nocturnal hemoglobinuria using routine complete blood count and cell population data”. Ann Lab Med. 35 (1): 35–40. doi:10.3343/alm.2015.35.1.35. PMC 4272963. PMID 25553278.

[pmid23664421-7] Da Costa L, Galimand J, Fenneteau O, Mohandas N (July 2013). “Hereditary spherocytosis, elliptocytosis, and other red cell membrane disorders”. Blood Rev. 27 (4): 167–78. doi:10.1016/j.blre.2013.04.003. PMID 23664421.

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