HAEMOLYTIC ANAEMIA

Dr. Mustafijur Rahman (Rizvi) Registrar Medicine unit III

What is hemolytic anemia?

Hemolytic anemia is a

disorder in which the red blood cells are destroyed prematurely.

RBCs are destroyed faster

than the bone marrow can produce them.

Features of Haemolysis
Red cell destruction overloads
pathways for Hb breakdown , causing a modest rise in unconjugated bilirubin in the blood and mild jaundice.

There is an increase in urinary

urobilinogen.

Features of Haemolysis(cont)
LDH Nucleated red cell precursors appear

in the blood as well as reticulocytosis.

Leuco-erythroblastic blood film.

Features of Haemolysis(cont)
Activation of the bone marrow
can result in a neutrophilia and immature granulocytes appearing in the blood to cause a leuco-erythroblastic blood film.

Features of Haemolysis(cont)
The appearances of the red cells
may give an indication of the likely cause of the haemolysis Spherocytes are small, dark red cells which suggest autoimmune haemolysis or hereditary spherocytosis.

Features of Haemolysis(cont)

Sickle cells suggest

haemoglobinopathy.

Red cell fragments indicate

microangiopathic haemolysis.

Features of Haemolysis(cont)
The compensatory erythroid
hyperplasia may give rise to folate deficiency, when the blood findings will be complicated by the presence of megaloblastosis. Measurement of red cell folate is unreliable in the presence of haemolysis and serum folate will be elevated.

Intravascular haemolysis
Free haemoglobin is released into

the plasma. Decreased amount of haptoglobin. Methaemoglobin is produced. Methaemoglobin plus albumin>>>methaemalbumin.

Intravascular haemolysis(cont)
Methaemoglobin is degraded and any
free haem is bound to a second binding protein termed haemopexin. Free haemoglobin may appear in the urine. When fulminant, this gives rise to black urine, as in severe falciparum malaria infection. Haemosiderinuria, which is always indicative of intravascular haemolysis.

Extravascular haemolysis
Physiological red cell destruction in

the liver or spleen. No free haemoglobin in the plasma.

Increased bilirubin, reticulocytosis.

Compensated haemolytic disease

Shortening of the red cell life span does
not necessarily result in anaemia as compensatory bone marrow hyperplasia may increase red cell production six to eight fold and maintain a normal haemoglobin level. So anaemia is not invariable in haemolytic disorders. But they show reticulocytosis or erythroid hyperplasia of bone marrow.

Morphology
Most haemolytic anaemias
are either normocytic and normochromic or macrocytic and normochromic.

Types of Hemolytic Anemia

Intrinsic(intra-corpuscular) - the destruction
of the red blood cells due to a defect within the red blood cells themselves. These are mainly congenital.

Extrinsic(extra-corpuscular) - red blood cells

are produced healthy but are later destroyed by becoming trapped in the spleen, destroyed by infection, or destroyed from drugs that can affect red blood cells.These disorders are acquired . These are immune or non-immune mechanism.

Aetiological classification of haemolytic anaemia

(A)Due to intra-corpuscular
mechanisms: 1. Congenital 2. Acquired

Classification(cont.)
1. Congenital
>Membrane defects (Hereditary >Haemoglobin defects
spherocytosis, Hereditary elliptocytosis). (Haemoglobinopathies, Thalassemia)

>Enzyme defects (G6PD deficiency)

2. Acquired
(Paroxysmal nocturnal haemoglobinuria)

Classification(cont.)
(B) Due to extra-corpuscular mechanism:
1. Congenital (None) 2. Acquired

Classification(cont.)
1. Congenital (None)
2. Acquired >Immune mechanisms

(Auto-immune acquired haemolytic anaemia/warm and cold antibody, Haemolytic disease of the newborn, Incompatibe blood transfusion, Drug induced haemolytic anaemia)

>Non-immune mechanisms
(Cardiac haemolytic anaemia, micro-angiopathic haemolytic anaemia, March haemoglobinuria)

>Miscellaneous
(Haemolytic anaemia due to direct action of drugs and chemicals, infection, burn, lead poisoning)

Basic principle of diagnosis of haemolytic anaemia

Following three questions must
be answered-

1. Is the anaemia haemolytic ?

>Evidence of increased haemoglobin breakdown ( jaundice, hyperbilirubnaemia,reticulocytosis, plasma haptoglobin, LDH). > Bone marrow regeneration.

2. If so, is the red cell destruction intra-vascular or extra-vascular?

> Presence or absence of free haemoglobin and haemoglobin breakdown products in the plasma and urine. (Haemoglobinaemia , Haemoglobinuria, Methaemalbuminaemia, Haemosiderinuria)

3. What is the aetiology? By the clinical features and the results of the special investigations.

Auto-immune haemolytic anaemia

Due to red cell autoantibodies(IgG or

IgM, or more rarely IgE or IgA )

If an antibody avidly fixes

complement, it will cause intravascular haemolysis, but if complement activation is weak, the haemolysis will be extravascular.

Types of auto-antibody
Warm antibodies bind best at 37 C and
account for 80% of cases. The majority are IgG .

Cold antibodies bind best at 4 C but

can bind up to 37 C in some cases. They are usually IgM and bind complement. They account for the other 20% of cases.

Warm autoimmune HA

Approximately 1/100 000 population per annum; it occurs at all ages but is more common in middle age and in females.

Causes of W AIHA
Idiopathic: 50% cases. Lymphoid neoplasms: lymphoma, chronic
lymphocytic leukaemia, myeloma. Solid tumours: lung, colon, kidney, ovary, thymoma. Connective tissue disease: SLE, rheumatoid arthritis. Drugs: methyldopa, mefenamic acid, penicillin, quinidine. Miscellaneous: ulcerative colitis, HIV.

W AHIA (Cont)

Investigations
1.Evidence of haemolysis 2.Spherocytes on the blood film. 3.The diagnosis is confirmed by the direct Coombs or antiglobulin test.

W AIHA (cont)
A positive test requires about 200 antibody
molecules to attach to each red cell; with a very avid complement-fixing antibody, haemolysis may occur at lower levels of antibody-binding. So the direct Coombs test can be negative in the presence of brisk haemolysis.

The standard Coombs reagent will miss IgA or

IgE antibodies.

Management
Treatment of underlying cause. Removal of offending drugs. Prednisolone 1 mg/kg orally. A response is seen

in 70-80% of cases but may take up to 3 weeks. Once the haemoglobin has normalised and the reticulocytosis resolved, the corticosteroid dose can be reduced slowly over about 10 weeks. Transfusion support may be required for lifethreatening problems, such as the development of heart failure or rapid unabated falls in Hb.

Management(cont)
If the haemolysis fails to respond to
corticosteroids or can only be stabilised by large doses, then splenectomy should be considered. Good response in 50-60% of cases. or cyclophosphamide may be considered. This is least suitable for young patients, in whom long-term immunosuppression carries a risk of secondary neoplasms. The anti-CD20 (B cell) monoclonal antibody, rituximab, has shown some success in difficult cases.

If splenectomy is not appropriate, azathioprine

Cold auto-immune HA
Usually IgM, which bind to the red cells at 4 C. It may cause
intravascular haemolysis if complement fixation occurs. acute or transient when the antibody is polyclonal.

This can be chronic when the antibody is monoclonal, or Causes:

1. Low grade B cell lymphoma 2. Mycoplasma pneumoniae infection 3. IMN 4. Paroxysmal cold haemoglobinuria is a very rare cause seen in children in association with congenital syphilis.

C AHIA(cont)
Chronic cold agglutinin disease This affects elderly patients and may be associated with an underlying low-grade B cell lymphoma. It causes a low-grade intravascular haemolysis with cold, painful and often blue fingers, toes, ears or nose (so-called acrocyanosis). The blood film shows red cell agglutination and the MCV may be spuriously raised because the automated analysers count aggregates as single cells.

Management(C AHIA)
Treatment is directed at any underlying
lymphoma.

If the disease is idiopathic, then patients must

keep extremities warm, especially in winter.

Some patients respond to corticosteroid therapy

and blood transfusion may be considered, but the cross-match sample must be placed in a transport flask at a temperature of 37 C and blood administered via a blood-warmer.

Alloimmune haemolytic anaemia Alloimmune haemolytic anaemia is due

to an antibody against non-self red cells. It has two main causes:

An unmatched transfusion of red cells (a

haemolytic transfusion reaction) Maternal sensitisation to paternal antigens on fetal cells (haemolytic disease of the newborn).

 Physical trauma : characterised by the presence of

red cell fragments on the blood film and markers of intravascular haemolysis: A. Mechanical heart valves. B. March haemoglobinuria. C. Thermal injury. D. Microangiopathic haemolytic anaemia.
Fibrin deposition in capillaries can cause severe red cell disruption. It may occur in a wide variety of conditions:

Non-immune haemolytic anaemia

1. disseminated carcinomatosis, 2. malignant or pregnancy-induced hypertension, 3. haemolytic uraemic syndrome, 4. thrombotic thrombocytopenic purpura 5. disseminated intravascular coagulation

NIHA(cont)
Infection:
1. Plasmodium falciparum (blackwater fever). 2. Clostridium perfringens septicaemia usually in the context of ascending cholangitis, may cause severe intravascular haemolysis with marked spherocytosis due to bacterial production of a lecithinase which destroys the red cell membrane.

NIHA(cont)
Chemicals or drugs
Dapsone and sulfasalazine cause haemolysis by oxidative denaturation of haemoglobin. Denatured haemoglobin forms Heinz bodies in the red cells, visible on supravital staining with brilliant cresyl blue. Arsenic gas, copper, chlorates, nitrites and nitrobenzene derivatives may all cause haemolysis.

Paroxysmal nocturnal haemoglobinuria (PNH)

This rare acquired non-malignant clonal

expansion of haematopoietic stem cells deficient in GPI-anchor protein results in intravascular haemolysis and anaemia because of increased sensitivity of red cells to lysis by complement. Episodes of intravascular haemolysis result in haemoglobinuria, most noticeable in early morning urine which has a characteristic red-brown colour.

PNH (cont)
The disease is associated with an increased risk
of venous thrombosis in unusual sites such as the liver or abdomen. PNH is also associated with hypoplastic bone marrow failure, aplastic anaemia and myelodysplastic syndrome. Management is supportive with transfusion and treatment of thrombosis. Recently the anticomplement C5 monoclonal antibody ecluzimab was shown to be effective in reducing haemolysis.

 The red cell diameter is 8 m but the

Red cell membrane defects

narrowest capillaries 2 m ( In the spleen).

When there is deficiency of one or more

proteins in the cytoskeleton, cells lose their elasticity.

Increase in mean cell haemoglobin

concentration (MCHC), abnormal cell shape and reduced red cell survival due to extravascular haemolysis.

Hereditary spherocytosis
Usually autosomal dominant
inheritence. 25% of cases is new mutations. The incidence is approximately 1:5000 in developed countries. The most common abnormalities are deficiencies of beta spectrin or ankyrin.

Normal RBC structure

Hereditary spherocytosis(cont)
Most cases are asymptomatic compensated
chronic haemolytic state. Pigment gallstones are present in up to 50% of patients and may cause symptomatic cholecystitis. Occasional cases are associated with more severe haemolysis; these may be due to coincidental polymorphisms in alpha spectrin or co-inheritance of a second defect involving a different protein.

Hereditary spherocytosis(cont)
The clinical course may be complicated by crises: A haemolytic crisis ----this is rare, and usually associated with infection.

A megaloblastic crisis ----this may occur as a first

presentation of the disease in pregnancy.

An aplastic crisis ----occurs in association with

erythrovirus infection.Patients present with severe anaemia and a low reticulocyte count.

Hereditary spherocytosis(cont)
Investigations : Screening of the familly members.

Flow cytometric tests--detecting

binding of eosin-5-maleimide to red cells, are recommended in borderline cases.

Hereditary spherocytosis(cont)
Management : 1. Folic acid prophylaxis, 5 mg once weekly, should be given for life. 2. Splenectomy (indications include moderate to severe haemolysis with complications (anaemia and gallstones).

Red cell enzymopathies

Anaerobic glycolysis via the Embden-

Meyerhof pathway generates ATP, and the hexose monophosphate shunt produces NADPH and glutathione to protect against oxidative stress.

Red cell enzymopathies(cont)

Defects in the hexose
monophosphate shunt pathway result in periodic haemolysis induced by oxidative stress, whilst those in the Embden-Meyerhof pathway result in shortened red cell survival and chronic haemolysis

Glucose-6-phosphate dehydrogenase (G6PD) deficiency

This enzyme is pivotal in the hexose
monophosphate shunt pathway.

Most common human enzymopathy, affecting

10% of the world's population.The enzyme is encoded by a gene on the X chromosome.

What is G6PD?
It is an X-linked recessive inheritance. (males usually
affected and females are carriers)

Risk factors: being black, being male, or having a

family history of G6PD deficiency.

G6PD enzyme functions in the Pentose-Monophosphate

shunt and in the process, catalyzes the reduction of NADP+ to NADPH required in triggering a cascade of events that can detoxify the harmful oxidant H2O2.

Glycolytic Pathway
Know this diagram
Glucose
hexokinase

ATP ADP

Glucose-6-phosphate
isomerase

(2 Net ATP)

Drugs
ATP ADP

H2O2 Fe3+ + O2
MetHb reductase

Pyruvate

Fructose-6-phosphate
PFKinase

O2 + Fe2+

Fructose-1,6-bisphosphate
NAD+ NADH

NAD+

hydroxyetone hosphate

Glyceraldehyde3-phosphate
G-3-P Dehydrogenase

1,3-Bisphosphoglycerate

PMP Generation of NADPH

Glyceraldehyde-3-phosphate + Fructose-6-phosphate

Know this diagram

Ribose-5-phosphate
NADPH NADP+

GSH
GSH reductase

H2O2
H2 O

Catalase

O2

6-Phosphogluconate NADPH

GSSG

uh S es o ne P t

G6P Dehydrogenase

NADP+ Glucose6-phosphate Glucose

yceraldehydephosphate

ADP ATP

How Drugs Affect G6PD Deficient Individuals?

Drugs
Glyceraldehyde-3-phosphate + Fructose-6-phosphate Fe2+ (oxyHb) Fe3+ (metHb) (O2 ) GSH
GSH reductase Superoxide Desmutase (SOD)

NAD+

NADH

Ribose-5-phosphate
NADPH NADP+

H2O2
GSH Peroxidase

Catalase NADPH

O2

6-Phosphogluconate NADPH

(Fe2+)

GSSG

H2 O

uh S es o ne P t

G6P Dehydrogenase

2 OH NADP+

yceraldehydephosphate

Glucose6-phosphate

Glucose

Hemolysis

Clinical features
Acute drug-induced haemolysis to
(e.g.) Analgesics: aspirin, phenacetin Antimalarials: primaquine, quinine, chloroquine, pyrimethamine Antibiotics: sulphonamides, nitrofurantoin, ciprofloxacin Miscellaneous: quinidine, probenecid, vitamin K, dapsone

Clinical features (cont)

Chronic compensated haemolysis Infection or acute illness Neonatal jaundice: may be a

feature of the B- enzyme Favism, i.e. acute haemolysis after ingestion of the broad bean Vicia faba

Laboratory features
Non-spherocytic intravascular haemolysis
during an attack The blood film will show:

Bite cells (red cells with a 'bite' of membrane missing) Blister cells (red cells with surface blistering of the membrane) Irregularly shaped small cells Polychromasia reflecting the reticulocytosis Denatured haemoglobin visible as Heinz

bodies within the red cell cytoplasm, if stained with a supravital stain such as methyl violet

Treatments may include

Stopping use of offending drug. For more severe cases, treat with: corticosteroids (e.g. prednisone) intravenous immunoglobulin infusions immunosuppressive (e.g. azathioprine (Imuran) and

cyclophosphamide (Cytoxan) Vitamin and mineral supplements (e.g. folic acid). Change in diet. If Hb levels , treatment may include blood transfusion or splenectomy (surgical removal of the spleen). If physical damage to RBC, then treat w/ blood transfusions or simple iron supplements. Iron - Taken during pregnancy and when iron levels are low. Erythropoietin (Procrit) - To increase RBC production in people w/ kidney problems.

Management
To stop any precipitant drugs
and treat any underlying infection.

Transfusion support.

Haemoglobinopathies (abnormal HB)

.are characterized by the

production of structurally defective haemoglobin due to abnormalities in the formation of the globin moiety of the molecule.

Normal human haemoglobin

Adult- Hb-A ----- alpha2/beta2
Hb A2 ----- alpha2/delta2

Fetal- Hb-F -------alpha2/gama2

Hb-Barts---gama4

Embryonic- Hb gower 1, Hb gower 2,

Hb Portland

 Majority of the abnormal Hb differ from the

corresponding normal haemoglobin by the substitution of a single amino acid in one of their pairs of polypeptide chains.

Common abnormal haemoglobin:

Hb-S------alpha2/beta2 (6 glu---> val). Hb-C------alpha2/beta2 (6 glu---> lys). Hb-E-----alpha2/beta2 (26 glu--->lys). Hb-D punjab--alpha2/beta2(6 glu-> val).

Lab test Hb electrophoresis is the most

useful method for the demonstration of abnormal haemoglobin.

The thalassaemias (Inadequate HB)

The thalassaemias are a heterogenous group of disorders with a genetically determined reduction in the rate of synthesis of one or more types of normal haemoglobin polypeptide chain.

Classifications
(A) Alpha thalassaemia--- Levels of Hb-A , Hb-F and Hb-A2 are equally depressed since they all have alpha chains. Causes microcytic and hypochromic anaemia. (B)Beta thalassaemia--- decrease production of beta chain leads to a reduction in the amount of Hb-A in red cell. Causes microcytic hypochromic anaemia. But Total Hb is maintained in part by the product of gama and delta chain. Thus increase Hb-F or Hb-A2 is usually found.

Beta thalassaemia
Beta 0 thalassaemia --Complete absence of

beta chain. Beta + thalassaemia --- Incomplete absence of beta chain. Clinically --- 1. Beta thalassaemia major (homozygous form of disease). 2.Beta thalassemia minor.

Beta thalassaemia major

Onset of anaemia is insidious. Initial manifestation being pallor which is
usually obvious within the first year of life and in severe cases within few weeks of birth.

Growth retardation is common. Anorexia, nausea ,loss of fat and recurrent

Beta thalassaemia major(cont)

Splenomegally is obvious at the

age of 3 years. Moderate to marked hepatomegally is also present. Clinical jaundice is uncommon but is sometimes present.

Laboratory Investigation Thalassemia

Variable hemogram results proportional to the
severity of the thalassemia Severe cases present with
Microcytosis Hypochromia Poikilocytosis RBC counts higher than expected for the level of anemia

Laboratory Investigation Thalassemia (cont)

Findings in severe cases can mimic those seen in other
microcytic/hypochromic anemias Results of the reticulocyte count are variable NRBCs may be present (contrast with iron deficiency anemia) Hemoglobin electrophoresis
Major test for identifying thalassemia and hemoglobinopathy

Treatment of betathalassaemia major

Erythropoietic failure: Allogeneic bone
marrow transplantation from human leucocyte antigen (HLA)-compatible sibling Transfusion to maintain Hb > 100 g/L Folic acid 5 mg daily Iron overload: Iron therapy forbidden Iron chelation therapy Splenomegaly: causing mechanical problems, excessive transfusion needs Splenectomy.

Course and Treatment Thalassemia

Untreated thalassemia Major: Death in first or second decade of life Intermedia: Usually normal life span Minor/Minima: Normal life span

Course and Treatment Thalassemia

Time of presentation
Related to degree of severity Usually in first few years of life Untreated severe thalassemia --/--: Prenatal or perinatal death --/- & --/ cs : Normal life span with chronic hemolytic anemia

X-ray skull of congenital haemolytic anaemia

Broadening of the diploic space with
seperation of the tables and thickening of the vault of the skull , especially of the frontal and parietal bones. The medulla is less dense, giving a ground glass appearance and the tables, especially outer, are thickened. Bony trabeculae may develop at right angles to the tables giving rise to hair-onend or brush appearance which is common in thalassemia major.

Sickle haemoglobinopathy are hereditary disorders in which the red

cells contain Hb-S. The sickling of the red blood cells in the circulating blood has two major pathological effects1. The distorted and rigid cells block small vessels , impairing flow and causing ischaemia and infarction. 2. Repeated sickle/unsickle cycles lead to loss of fragments of the cells and the cells become spherocytic and fragile.

What is Sickle Cell?

People who have
Sickle Cell have sickle shaped red blood cells, which causes complications because the blood cells are not able to reach certain parts of the body.

Red blood cells Going through Vessels

Abdominal and bone/joint pain Breathlessness Delayed growth and puberty Fatigue and fever Jaundice (yellowed skin) Paleness Rapid heart rate Greater risk for infection Adolescents and adults can develop ulcers on their legs Chest pain Excessive thirst Poor eyesight, blindness when blood cant get to the back of eyes, they dont have a constant nourishment, causing people to not be able to see

* About 30% of Jamaican patients with Sickle Cell develop ulcers in comparison to 1% of Americans

Diseases and Conditions people with Sickle Cell are likely to develop:
Acute chest syndrome Aplastic crisis Dactylitis swelling of the hands and feet Painful crises: really painful episodes when blood cells are blocked from going to certain parts of the body pain can occur anywhere, but it is usually in the chest, arms, and legs An x-ray of a hand swollen from dactylitis Enlarged spleen sickle cells pool in the spleen, and in some cases there is no spleen in the body.

Who would you think has Sickle Cell?

Indian girl
Hispanic boy

Black boy

White girl

Who can get Sickle Cell?

ANYONE can get Sickle Cell Disease. It is most common in the following ancestries:
o o o o o o o African Central or South American Cuban Indian Saudi Arabian Mediterranean Hispanics

 People can live a relatively normal life with Sickle Cell if they have the proper treatment. The average life expectancy for males is 42. The average life expectancy for females is

48.

In 2003 the oldest patient to have Sickle cell was an 85 year old Jamaican woman.

Genetics of Sickle Cell

Sickle cell is an autosomal recessive disease. Therefore, the child can only get Sickle cell if both parents are carriers, not if only one is and the other is normal. They have a 25% chance of getting it if both are Carriers

How is sickle cell disease diagnosed?

Many states now use hemoglobinopathy testing (looking at the blood for abnormalities of testing) as part of the newborn screening blood tests between 2 and 7 days of age. Careful examination of family history. Physical examination some symptoms are visible, such as jaundice. A hemoglobin electrophoresis can determine if a person is a carrier.

Main Treatment Methods

There is no known cure for sickle cell anemia. The four main treatment options are: Blood Transfusions Drug Treatment Blood and Marrow Stem Cell Transplantation Gene Therapy These main treatment options for the painful crisis involves heavy reliance on painkilling drugs and oral and intravenous fluids whose main functions are to reduce pain and prevent complications.

Role of G6PD
Responsible for maintaining adequate levels of
NADPH inside cell.

The oxidation of NADPH back to NADP+ is

coupled with the reduction of oxidized glutathione (GSSG) to glutathione (GSH).

Thus, NADPH keeps glutathione, a tri-peptide, in

its reduced form.

Role of G6PD Contd...

Reduced glutathione (GSH) acts as a scavenger for
dangerous oxidative metabolites in the cell.

GSH converts harmful hydrogen peroxide to water

catalyzed by the enzyme, glutathione peroxidase (catalase enzyme also detoxifies H2O2).

If H2O2 cannot be detoxified by GSH or catalase, hydroxyl

radical formed from H2O2 can be scavenged by Vit C/E.

G6PD Deficiency
Red cells deficient in G6PD are unable to

neutralize hydrogen peroxide - H2O2 converts to hydroxyl radicals and this can lead to oxidative damage/toxic injury.

Impaired response to oxidizing drugs can

also induce hemolytic anemia (Individuals with G6PD deficiency are particularly susceptible)

Drugs that affect it

Drugs that can precipitate this reaction
include: anti-malarial agents sulfonamides (antibiotic) aspirin non-steroidal anti-inflammatory drugs (NSAIDs) nitrofurantoin quinidine quinine others Also: exposure to certain chemicals such as those in mothballs and flava beans.

 The most common symptoms include:

abnormal paleness or lack of color of the skin jaundice, or yellowing of the skin, eyes, and mouth dark color to urine fever weakness dizziness confusion intolerance to physical activity

What are the symptoms?

Signs of anemia include:

pale skin and fingernails rapid pulse heart murmur Enlarged spleen and liver

Required Tests
Blood tests are taken to measure levels of:
red cells, assess size and shape of red cells measure the Hb level determine the number of reticulocytes.

Other blood tests may include:

Coombs' test (direct and indirect) checks for hemolytic anemia caused by an abnormal immune reaction. Heinz body presentation looks for a deficiency in amount of G6PD enzyme, which results in hemolysis if certain medications or foods are ingested.

References

Ezra E. W. Cohen, M.D., Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL. 11 Jan 2004 <http://www.nlm.nih.gov/medlineplus/ency/article/000571.htm > <http://www.nlm.nih.gov/medlineplus/ency/article/000571.htm Updated by: Corey Culter, M.D. M.P.H., F.R.C.P.C., Department of Medical Oncology, Dana Farber Cancer INsitiute; Instructor of Medicine, Harvard University, Boston, MA. Review provided by VeriMed Healthcare Network. Source: MEDLINEplus Medical Information. 11 Jan 2004 http://www.hlm.nil.gov/medlineplus/ency/article/000528.htm Ramez A. Ethnasios. An Introduction to G6PD Deficiency. 7 Jan 2004 <http://www.rialto.com/g6pd/physiolo.htm> Ethnasios. <http://www.rialto.com/g6pd/physiolo.htm> Peggy Gulley, MD. Hemolytic Anemia Lecture. 9 Jan 2004 <http//:pathology.uthscsa.edu/MSII/Hemo.html> <http//:pathology.uthscsa.edu/MSII/Hemo.html> Rebecca Elstrom, M.D., Division of Hematology-Oncology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network. . 11 Jan 2004 <http://www.umm.edu/blood/anehemol.htm> <http://www.umm.edu/blood/anehemol.htm> Patrick Yorba, MD, Staff Physician, Department of Emergency Medicine, University of Virginia Health Sciences Center. 11 Jan 2004 http://www.emedicinehealth.com/articles/4893-6.asp?pd=1/11/2004%2010:25:15%20PM Faculty of Harvard Medical School 1996-2003 Aetna InteliHealth Inc. 11 Jan 2004 < http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/21246.html> http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/21246.html> Images taken from http://health.allrefer.com/health/hemolytic-anemia-pictures-images.html> . 11 Jan 2004 http://health.allrefer.com/health/hemolytic-anemia-pictures-images.html>