APLASTIC ANAEMIA Most cases of “known” etiology follow exposure to

chemicals and drugs. Certain drugs and agents

DEFINITION :Aplastic anemia is pancytopenia with bone (including many cancer chemotherapy drugs and the
marrow hypocellularity  in the absence of abnormal organic solvent benzene) cause marrow suppression
infiltrate and with no increase in reticulin. that is dose related and reversible. In other instances,
aplastic anemia arises in an unpredictable, idiosyncratic
Epidemiology: fashion following exposure to drugs that normally cause
 Incidence- 0.6-6/million population little or no marrow suppression. The implicated drugs
 No race/age/ sex predilection  include chloramphenicol and gold salts. Persistent
 High incidence in Asia marrow aplasia can also appear after a variety of viral
 50% of cases occur before 3rd decade infections, most commonly viral hepatitis of the non-A,
 Biphasic age peak- 1-25years and more than 60 non-B, non-C, non-G type, which is associated with 5%
years to 10% of cases. Why aplastic anemia develops in
 In India 6000-8000 patients/ year certain individuals is not understood. Whole-body
irradiation can destroy hematopoietic stem cells in a
ETIOLOGY dose-dependent fashion. Persons who receive
Classification of Aplastic Anemia and Single therapeutic irradiation or are exposed to radiation in
Cytopenias nuclear accidents (e.g., Chernobyl) are at risk for
marrow aplasia.

Drugs and chemicals causing aplastic anaemia

Dose related-
Alkylating agents(carboplain)
Antimetabolites(methotrexate)
Benzene
anibioitics (Chloramphenicol,sulfonamide)
Inorganic arsenicals

Idiosyncratic-
aniepileptics (cbz,phenytoin)
Antithyroid (methimazole,PTU)
Chloramphenicol
NSAIDS(indomethacin,Phenylbutazone)
Organic arsenicals
Penicillamine
Gold salts

Specific abnormalities underlie some cases of aplastic

aplasia.
• Fanconi anemia is a rare autosomal recessive disorder
caused by defects in a multiprotein complex that is
required for DNA repair. Marrow hypofunction
becomes evident early in life and is often accompanied
by multiple congenital anomalies, such as short stature,
cafe au lait spots, and anomalies involving the thumb,
radius, and genitourinary tract.
• Inherited defects in telomerase are found in 5% to
10% of adult-onset aplastic anemia.
 Dyskeratosis congenita is characterized by the triad
of mucous membrane leukoplasia, dystrophic nails,
Reference Harrison reticular hyperpigmentation, and with the
development of aplastic anemia in childhood.
Dyskeratosis is due to mutations in genes of the
 telomere repair complex, which acts to maintain  Mutations in PIGA, BCOR and BCORL1 genes
telomere length in replicating cells: the X-linked (these cases are associated with good
variety is due to mutations in the DKC1 (dyskerin) prognosis)
gene; the more unusual autosomal dominant type is  Tests for specific mutation causing telomere
due to mutation in TERC, which encodes an RNA shortening. Done only if there is short telomere.
template, and TERT, which encodes the catalytic  Mutations typical of myeloid malignancies help
reverse transcriptase, telomerase to differentiate aplastic anemia from
 In Shwachman-Diamond syndrome, presentation is hypocellular MDS. 
early in life with neutropenia with pancreatic
insufficiency and malabsorption; most patients have
compound heterozygous mutations in SBDS that
may affect both ribosomal biogenesis and marrow
stroma function.

In most instances, however, no initiating factor can

be identified; about 65% of cases fall into this idiopathic
category.

Pathogenesis. The pathogenesis of aplastic anemia is not

fully understood. Indeed, it is unlikely that a single
mechanism underlies all cases. However, two major
etiologies have been invoked: an extrinsic, immune-
mediated suppression of marrow progenitors, and an
intrinsic abnormality of stem cells.
Robbins pathophysiology of aplastic anaemia
it seems that autoreactive T cells play an important
role. This is supported by a variety of experimental data MORPHOLOGY
and clinical experience showing that aplastic anemia The markedly hypocellular bone marrow is largely
responds to immunosuppressive therapy aimed at T devoid of hematopoietic cells; often only fat cells,
cells in 70% to 80% of cases. Much less clear are the fibrous stroma, and scattered lymphocytes and plasma
events that trigger the T cell attack on marrow stem cells remain. Marrow aspirates often yield little material
cells; viral antigens, drug-derived haptens, and/or (a “dry tap”); hence, aplasia is best appreciated in
genetic damage may create neoantigens within stem marrow biopsies). Other nonspecific pathologic changes
cells that serve as targets for the immune system. are related to granulocytopenia and thrombocytopenia,
Damaged stem cells can produce progeny expressing such as mucocutaneous bacterial infections and
neoantigens that evoke an autoimmune reaction, or abnormal bleeding, respectively. If the anemia
give rise to a clonal population with reduced necessitates multiple transfusions, systemic
proliferative capacity. Either pathway could lead to hemosiderosis can appear.
marrow aplasia.

Cytogenetics- By FISH karyotyping/ by Single nucleotide

polymorphism array (SNP-A) 19% patients show
chromosomal abnormalities Monosomy 7 (Most
common) and Others: Trisomy 8, 5q deletion, deletion
20q, deletion 13q, trisomy 1.Trisomy 8 and del 13q
herald good prognosis.Presence of cytogenetic
abnormality does not rule out the diagnosis of aplastic
anemia.

Next Generation Sequencing: 

 Somatic mutations commonly seen- TP53, ASXL-
1, DNMT3, RUNX1 (these cases are associated
with poor prognosis)
History o Can be dry tap and fragments are
 Petechiae and ecchymoses due to usually easily obtained and they are
thrombocytopenia (most common) hypocellular.
 Frequent infections due to granulocytopenia- o Erythropoiesis is suppressed. Marked
Pneumonia and septicemia are frequent cause dyserythropoiesis is common. So this
of death alone does make the diagnosis of MDS.
 Anemia- Fatigue, lassitude, shortness of breath, o Granulocytes and megakaryocytes are
etc decreased or absent. Presence of
A striking feature of aplastic anemia is the restriction of dysplasia in them indicates diagnosis of
symptoms to the hematologic system, and patients hypocellular MDS.
often feel and look remarkably well despite drastically o Residual lymphocytes, plasma cells,
reduced blood counts. Systemic complaints and weight mast cells and macrophages are seen.
loss should point to other etiologies of pancytopenia. o Marrow lymphocytes >75% correlates
Prior drug use, chemical exposure, and preceding viral with poor prognosis
illnesses must often be elicited with repeated  Trephine biopsy
questioning. o Should be minimum 2cm long and avoid
A family history of hematologic diseases or blood tangential biopsies, as subcortical
abnormalities, of pulmonary or liver fibrosis should be marrow is normally hypocellular.
asked. o Hypocellular marrow
 <30% in age <60 years
Physical Examination  <20% in age >60years
 Petechiae and ecchymoses are typical, and o Empty marrow spaces populated by fat
retinal hemorrhages may be present. cells, fibrous stroma and scattered
 Pallor of the skin and mucous membranes is lymphocytes and plasma cells.
common except in the most acute cases or o Very few precursor cells are seen
those already transfused. (<25%)
 Infection on presentation is unusual but may o Megakaryocytes are usually absent
occur if the patient has been symptomatic for a o Hot spots: Focal hyperplasia of
few weeks. erythroid or granulocytic cells in
 Lymphadenopathy and splenomegaly are highly different stages of maturation may be
atypical of aplastic anemia. seen
o Sometimes lymphoid aggregates are
Cafe au lait spots and short stature suggest Fanconi seen, especially if aplastic anemia is
anemia; peculiar nails and leukoplakia suggest associated with systemic autoimmune
dyskeratosis congenita; early graying of hair disorder such as SLE or rheumatoid
suggests a telomerase defect. arthritis
o In a bone marrow of aplastic anemia,
Investigations: always look for hypocellular MDS,
hypocellular AML, hairy cell leukemia,
Specific invesigations lymphoma, myelofibrosis and
 Hemogram mycobacterial infection
o Pancytopenia  
o Normocytic normochromic RBCs. Mild Non specific findings
macrocytosis is usually observed  ESR – Elevated
o Leucopenia especially neutropenia  Serum erythropoietin level –Elevated
o No abnormal cells are seen  Hemoglobin electrophoresis: Hb F content is
o Platelets – Reduced counts, usually increased up to 1.5g/dL
small in size  Serum iron content – Increased
o Absolute reiculocyte count= <25*10 9 /l,
Corrected count - <1% TO RULE OUT OTHER DISEASES
 Bone marrow aspiration  Cytogenetics
  Flow cytometry for CD34 cells- Decreased o Reticulocyte count <20,000/cmm or
,CD 55 & CD 59- To rule out PNH. CD57 cells, if <1%
many large granular lymphocytes are seen  Very severe aplastic anemia: Same as severe
aplastic anemia but absolute neutrophil count is
NEXT GENERATION SEQUENCING:  <200/cmm
 Non severe aplastic anemia: Aplastic anemia
 Vitamin B12 levels and folate levels: As some not fulfilling criteria of severe/ very severe
megaloblastic anemia can present with aplastic anemia
hypocellular bone marrow  
 Abdominal USG- Enlarged lymph nodes and Prognosis:
splenomegaly indicate possibility of malignant  Untreated patients: 70% die within 5 years of
hematological disorder diagnosis
 20% patients spontaneously recover with
FOR ETIOLOGY supportive therapy
 Chromosome breakage study using  With immunosuppressive therapy- 5 year
diepoxybutane, or mitomycin C (stress survival rate is 75%
cytogenetics)  With bone marrow transplant from matched
o Positive in Fanconi’s anemia donor- 5 year survival is>90%
o It should be done in all patients of less  Those due to exposure to toxin, have better
than 35 years presenting with aplastic prognosis than idiopathic ones.
anemia  Major causes of death:
 Serological tests for HIV, EBV, CMV, hepatitis o Infections
(A/B/C), parvovirus B19 o Bleeding
 Measurement of peripheral blood leucocyte o In BMT patients: GVHD, toxicity from
telomere length- By PCR or flow FISH methods conditioning regimen
 LFT: To detect antecedent hepatitis o In immunosuppressant responders:
 ANA and anti-DsDNA PNH, MDS, Leukemia
 DCT and ICT
 Chest X ray: To exclude infections and for
comparison with subsequent films TREATMENT
 X ray radii- In young patients, to exclude NON SEVERE APLASTIC ANAEMIA
Fanconi anemia  IF Non transfusion dependant on prc/platelets-
observe
 HLA typing- To identify potential donor,  If transfusion dependent-ATG+CSA
especially in case of young patient IF responds taper cyclosporine A and maintain
Criteria for Diagnosis: If doesnt responds repeat 2 nd dose at 6
 Bone marrow - <25% cellularity without months, again if no response –
presence of abnormal cells or fibrosis and any BMT ,OXYMETHALONE
two of following findings
o Granulocytes - <1.5x109/L or absolute SEVERE APLASTIC ANAEMIA
neutrophil count  <0.5x109/L
o Platelet - <50x109/L Preferred treatment if donor available,good
o Corrected retic count - <1% performance scores,age <50-60 yrs-BMT
o Hb<10g/dL
  IF BMT not possible - AZT+CSA+Eltrombopag
Grading of severity: (Camitta criteria)
 Severe aplastic anemia: Bone marrow Poor patients who cannot afford ATG
cellularity<25% with at least two of following 3  Cyclosporine A + Danazol +/- Eltrombopag
criteria
o Absolute neutrophil count Response Criteria:
<500cells/cmm  Complete response:
o Platelet count <20,000/cmm o Hemoglobin concentration normal for
age and gender
 o Neutrophil count- >1500/cmm  Each daily dose should be preceded by IV
o Platelet count- >1,50,000/cmm Methylprednisolone (1-2mg/Kg),
 Partial response: chlorpheniramine maleate and paracetamol-
o Transfusion independence Minimum 30min before starting Horse ATG.
o No longer meet the criteria of severe  Highly immunosuppressive therapy, hence
aplastic anemia isolation of patient with reverse barrier nursing
is necessary. All principles of febrile
about Each Modality of Treatment: neutropenia need to be followed.
 BMT from HLA identical sibling/ Syngeneic  High risk of serum sickness- Hence prophylactic
donor steroids have to be administered (Prednisolone
o Best to do it within 180 days of 1mg/kg for 2 weeks, then taper slowly)
diagnosis  Should be given through central line
o Conditioning:  If there is fever/ rigor/ rash/ hypotension-
 High dose cyclophosphamide- Slowdown the rate of infusion, give
50mg/kg/day for 4 days (Days - corticosteroids, antihistaminics and pethidine
5 to -2) o Frequent platelet transfusions are
 12 hours after the first, second, necessary to maintain platelet count
and third dose of >30,000/cmm
Cyclophosphamide, horse ATG  Irradiated blood products must be given to
(Atgam) at 30 mg/kg i.v. per patients receiving ATG and it should be
dose infused over a period of continued indefinitely or at least till absolute
10 to 12 hours.i.e. 3 days (Days lymphocyte count is >1000/cmm
-5 to -3)..  Generally, 3-4 months are required for
 Methyl prednisolone- 2mg/kg improvement of marrow function. Till that time
for 3 days (Days -5 to -3) supportive transfusions have to be given.
 Unmanipulated bone marrow is
administered 36 hours after the last dose of
cyclophosphamide (Day 0).  CYCLOSPORINE 
 Avoid use of peripheral blood stem cells as they  2.5mg/kg BD Given from day 5 of ATG
produce unacceptably high risk of GVHD.  To be taken on empty stomach with fruit juice.
 Dose of stem cells- 3x108 mononuclear cells/kg And Plenty of fluids should be advised to
or 3x106 CD34+ cells/kg maintain adequate urine output.
 After achieving maximal hematological
GVHD prophylaxis response/ minimum of 1 year, taper the dose
 Cyclosporine- 2.5mg/kg- BD. Start from day -1 very slowly (25mg every 3 monthly)
and continue for 12 months. Tapering to be  Monitor BP, RFT, LFT, and cyclosporine levels
started from at 9 months to help prevent late  Target trough levels- Adults-
graft failure. 150-200microgm/L, Children- 100-150
 Short course of methotrexate- 15mg/m 2 on day microgm/L
+1 and 10mg/m2 on days +3, +6 and +11  65% patients respond to this therapy. 1/3rd of
 Survival is better if donor is of same sex. them have relapse.
 Overall survival is 75-90%  Factors indicating goods response:
 Post-transplant monitoring should be done as Young age,Less severe disease,Trisomy8/ del
any other HSCT (13q),Presence of PNH clone and Long
 . Avoid vaccinations as they may trigger relapse telomeres
of aplastic anemia.  Overall 5-year survival- 75%

ANTITHYMOCYTE GLOBULIN (HORSE ATG) WITH

CICLOSPORINE A OTHER IMMUNOSUPPRESSIVES THAT HAVE BEEN
 Horse ATG: 40mg/kg/day in 500ml NS over 12- USED
18 hours for 4 days. On first day- Add only 1 vial  Alemtuzumab-
to 500ml NS and give slowly over 30min. If no  Mycophenolate mofetil
reaction, add remaining vials.  High dose Cyclophosphamide.
 ELTROMBOPAG
 Useful in high doses- start at dose of 50mg/day
and increase dose by 50mg every 2 weeks until
platelet count is >50,000/cmm. Maximun dose
of 150mg/day
 Overall response rate-30%
 Often added to standard immunosuppressive
therapy (In such case overall response rate
increases to >80%)
 In patients with trilineage response/ transfusion
independence for more than 8 weeks dose can
be reduced by 50%. Stop once at lowest dose
they fulfill above criteria for 8 weeks. If
ANC<500/cmm, platelet count <30,000/cmm,
Hemoglobin <9gm/dL, restart at the last lowest
dose.
ANDROGENS: 
 Options: Danazol and Oxymetholone-
2.5mg/kg/day
 Increase telomerase activity via aromatization
of estradiol to steroids
 If no response after 6 months, it should be
stopped
 Has 10-20% chance of response