Approach to the Diagnosis

of Aplastic Anemia
Amy E. DeZem and Jane E. Churpek

Presented by:
Delviana Devi
2101410100043
Study period: 27 September - 5 December 2021

Supervisor:
dr. Cecilia Hendratta, Sp.PD-KHOM
 Introduction

Aplastic Anemia (AA) is a disease causes by bone marrow fail to produce blood cells,
marked by cytopenia. Mortality of severe aplastic anemia reach 70% within 2 years.
To achieve appropriate management, it is necessary to know the accurate etiology of
aplastic anemia, especially to differentiate between acquired and inherited form of
disease.
Patient 1

Female, 48 years-old, European ancestry with obesity, called her internist because
increased bruising, she also said that she has history of decreased exercise
tolerance, dyspnea on exertion and fatigue over the past 2 months.
Patient 1
She also has a history of:
• Obstructive sleep apnea Initial Laboratory:
• Hashimoto's hypothyroidism • Platelet Count: 5 x 109/L
• Family history of autoimmunity: • Hemoglobin: 6g/dL
1. Rheumatoid arthritis - paternal • Total WBC count: 2,9 x 109/L
grandmother and sister • Absolute neutrophil count: 1,1 x 109/L
2. Psoriatic arthritis - father

The patient started on prednisone 100mg/day for 3 days, but no changes on her counts.
Evaluation of a patient with a suspected new diagnosis
of Aplastic Anemia

Manifestation of aplastic anemia could be related to:

• Anemia
• Severe thrombocytopenia
• Low white blood cell counts and neutropenia
Clinical presentation and classification of aplastic
anemia

• Acquired anemia aplastic is a hematopoietic stem cell failure and reduce of bone marrow cellularity. The
failure of hematopoietic may affect 1 or 2 lineages of early stage of disease, but totally affect with
trilineage hypoplasia.

• Aplastic anemia may have 2 incidence peaks: first, among young adults, second, on elderly. Patient
with aplastic anemia is 25% of pediatric patients and ~5% - 15% of adults age 40 or younger present
have an inherited etiology. It is common to track family history of autoimmune disease, even if not the
identical disease.
Clinical presentation and classification of aplastic
anemia

It is challenging to diagnose this disease because commonly overlap with the other such as immune
cytopenias, myelodysplastic syndrome (MDS) or paroxysmal nocturnal hemoglobinuria (PNH), and
inherited bone marrow failure disease (IBMFD). Therefore, checking the family history could be
suggestive for autoimmune phenotype.
Patient 1 (Continue)
Aspirate of bone marrow biopsy on this patient found hypocellular (<5%) marrow contain
predominantly of fat with a few scattered areas of erythroid precursors but no sign maturing
of myeloid elements. The CD34 count was <1%, PNH red blood cell clone size of 0,09%
found in peripheral blood (0,06% type III cells, and 0,03% type II cells), PNH white blood cell
clone was detected in 13,1% of granulocytes and in 12,6% of monocytes.
Patient 1 (Continue)

Patients absolute neutrophil count was fell to 0,47 x 109/L. Patient receive 7 platelet
transfusions and 5 unit of packed red blood cell during 5 weeks assessment period.
Basic laboratory studies

The aim is to confirm the diagnosis and exclude the cause of other pancytopenia. At a
minimum, the laboratory test should be using peripheral blood.

The presence of paroxysmal nocturnal hemoglobinuria clones can be considered as a marker

of acquired disease, but different with classical PNH. The classical PNH requires hemolytic
anemia or thrombotic event, and hypercellular marrow.
Basic laboratory studies

• Severe aplastic anemia:

o Decrease ≥ 2 hematopoietic lineage of blood count
a. Absolute reticulocyte count <60 × 109 /L
b. Absolute neutrophil count <0,5 × 109 /L
c. Platelet count <20 × 109 /L
o Bone marrow hypocellularity <25% of the normal cellularity
• Very severe aplastic anemia: absolute neutrophil count <0,2 × 109 /L
• Moderate aplastic anemia: depression of blood count but no fulfilling the definition of severe aplastic
anemia.
Bone marrow studies

To diagnose aplastic anemia, bone marrow and aspiration reveal hypocellular bone marrow
or “empty” bone marrow on histology. Measured from flow cytometry and
immunohistochemistry, revealed a very low CD34 count.
Patient 2

Male, 63 years-old, went to the emergency department suffered nosebleed on 3

continuous day. He only has history of hypercholesterolemia, type 2 diabetes, and
hypertension.
Patient 2

a. Laboratory:
• Platelet count: 9 × 109 /L
• Hemoglobin: 7,9 g/dL
• Total white blood cell: 1,6 × 109 /L
• Absolute neutrophil count: 0,9 × 109 /L
b. Bone marrow biopsy: hypocellular at 5% cellularity with scattered of fat cell with rare
myeloid cells.
c. Next-generation sequencing panel test: Pathogenic BCOR variant, at allele frequency of
5.3%, and DNMT3A mutation below limit standard (<2%)
Molecular diagnostic studies in AA diagnostic

Mutation of genes such as BCOR/BCORL1, DNMT3A, and ASXL1 did not give specific
difference for aplastic anemia and MDS, because these mutation are seen in both.

On some studies, suggest that detection of some somatic mutations by ASXL1, DNMT3A,
and BCOR, can stratification the risk of progression to myeloid neoplasm on patient with
aplastic anemia.
Molecular diagnostic studies in AA diagnostic

On some studies, suggest that detection of some somatic mutations by ASXL1, DNMT3A,
and BCOR, can stratification the risk of progression to myeloid neoplasm on patient with
aplastic anemia.
Patient 2

Patient 2 receive a related BMT for his treatment, has normal hemogram and full
donor chimerism without clonal hematopoiesis for 2 years.
Patient 3

Male, 16 year-old, no significant health history. He mentioned that he was weak

and less engaged for several weeks. On examination, founded that he was pale
and ecchymoses on his lower extremities.
Patient 3
His laboratory result:
• WBC: 0,4 x 109/L
• Neutrophils: 0%
• Hemoglobin: 7,7 g/dL
• Platelet count: 8 x 109/L

The pediatrician found “irregular bloodwork”. There was no significant

family history.
Patient 4

Male, 19 year-old, come to emergency room with intense migraines, fatigue,

has a gingival bleeding several weeks. He admit he had upper respiratory
infection 6 to 8 weeks ago. He also had wet purpura on mouth, thrush, and
ecchymoses through his lower extremities.
Patient 4
On his laboratory result:
- WBC: 1.2 x 109/L
- Neutrophils: 24%
- Hemoglobin: 5.7
- Platelet count: 2 x 109/L

On peripheral blood smear, showing paucity of cells and no circulating malignant

cells. His family history was unrevealed.
Clinical and family history
Approach to evaluation of patients with AA for an
IBMFD

Patients aged less than 40 years or those proceeding to BMT as initial therapy, would have
peripheral blood lymphocyte telomere length measurement by Flow-FISH, and chromosome
breakage with DEB to eliminate STS and FA.

The benefit is that it quickly identifies patients at risk for STS and FA who are at high risk for
increased toxicity, and harm from the conditioning for BMT if undiagnosed.
Patient 4 (Continue)
Patient 3 was diagnosed with Acquired SAA,
• Negative DEB testing
• Normal telomere lengths by Flow-FISH
• Skin biopsy negative for known genes associated with IBMFDs.

He got a matched sibling donor BMT and normal blood counts at 5 years post
procedure.
Patient 4 (Continue)
Patient 4 was found
• Negative DEB testing
• Normal telomere lengths by Flow-FISH
• Skin biopsy grown for fibroblast culture, revealed billelic mutation of the MPL
gene, as presumed etiology for his SAA.

He received an unrelated donor BMT, and normal blood counts at 3 years post
procedure.
 Conclusion

Accurately diagnosis aplastic anemia is necessary to treat this disease. The severity of the
disease also helps in choosing the right treatment. Germline predisposition to aplastic anemia,
even in adolescents and adult, more common than previously known and it is important for
diagnosis in real time prior to treatment, especially for BMT.
Thank You