Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
Hemoglobin	metabolism	and	
its	clinical	applications
Dr.	Rohini C	Sane
Functions	of	Hemoglobin	molecule	in	oxygen	transport
Functions	of	Hemoglobin	molecule	in	carbon	dioxide		transport
Degradation	of	Heme	to	bile	pigments
Macrophages	of	reticuloendothelial (RE		)
in	spleen	/liver	/bone	marrow-Hb
RBC	à 12Od...
Fate	globin	(reutilization	)
• Formation	of	Hb	(	re	synthesis	)
• Degraded	to	amino	acids	–metabolism	including	formation	...
Sources	of	Heme
Heme
20%	immature	RBC	/Myoglobin	/globin	/cytochrome	/peroxidase	
/catalase	Trp		pyrrolase
80%	RBC	Hb
(	GREEN	–excreted	by	birds	&	amphibians	)→	
Transferrin	
←αGlobin	chains
←βGlobin	chains		
RBC	(	Aged	erythrocytes	)with	H...
Heme	oxygenase	
1. Microsomal	enzymes	
2. NADPH	,O₂	,	Methylene	bridges	between	two	pyrrole	ringsà
biliverdin	
3. Fe	²⁺	à ...
Degradation	of	Heme	to	bile	pigments
Biliverdin	reductase	
Biliverdin	(green	)	 Bilirubin(non	functional	therefore	excrete...
Transport	of	Bilirubin	to	Liver	
• Bilirubin- (	lipophilic	–insoluble	in	water)	
• Bilirubin	+	Albumin à Transported	in	pl...
Drugs :	sulphonomides /salicylates	/	Penicillin	displace	
Bilirubin	from	Albumin	binding	sites			
Bilirubin	enters	CNS
Dam...
Conjugation	0f	Bilirubin																																															Liver
Albumin	–Bilirubin	complex	
I		Uptake carrier...
Factors	affecting	conjugation	of	Bilirubin	in	liver
1. Drugs	like	Primaquine/Novobiocin/Chloramphenicol,/Androgen/Pregnane...
Production	&	excretion	of	Bilirubin
Retiiculoendothelial	system	(	RES	)
Hb	
↓
Biliverdin		(38	H	)
↓
Bilirubin		(	36		H	)
L...
Excretion	of	Bilirubin	into	bile	
Conjugated	Bilirubin
Active	transport*																							(	against	concentration	gra...
Production	&	excretion	of	Bilirubin
• Excretion	of	Biliverdin	à green	color	stool(	children	&	prolonged	
antibiotics	thera...
Fouchet’s Diagnostic	test	for	Bilirubin		in	urine
Bilirubin	–yellow	,Biliverdin	–green ,Bilinofuschin –Red	, Bilicyanin	-violet
←URINE→
Gmelin’s Test
←CONC	HNO₃→
Bilirubin	–yellow	,Biliverdin	–green ,Bilifuschin	–Red	, Bilicyanin	-violet
Fate	of	Bilirubin
Bilirubin	Glucuronides
Hydrolysis						↓		bacterial	enzyme	(β Glucuronidase )
Bilirubin
↓															...
Conjugated	and	unconjugated	bilirubin	(	Direct	and	indirect	bilirubin	)
Stercobilin and	Urobilin
Formation	of	conjugated	bilirubin	in	Hepatocytes
Types	of	Bilirubin	
Free	bilirubin	 Conjugated		bilirubin
1 In	H₂	O insoluble soluble	
2 In	alcohol soluble soluble
3 Norm...
Bilirubin	&	its	reduction	products	
number	of		H	atoms	 color
Bilirubin	(BR	) 36 Red	yellow
Meso bilirubin	(MB) 40 yellow
...
Jaundice- Hyperbilirubinemia
Physiological	– Total	Bilirubin	concentration	in	serum	=	(	0.2- 0.8mg/dl	)	
0.2	-0.6	mg/dl	(	...
*Diagnostic	laboratory	to	set	up	own	quality	controls	for	reference	ranges
Pre	hepatic	,Hepatic	and	post	hepatic	jaundice	– a	classification	based	on	site	(cause	of	of	Hyperbilirubinemia)
Classification	of	Jaundice	based	on	type	of	Bilirubin
Intra	hepatic	jaundice	(Genetic		/inherited	causes	)
Cause
• Hemolytic	Jaundice
• Causes	– Hemolysis		
Malaria										blood	
transfusion				sickle	cell	
anemia
• Liver	fails...
Differential		diagnosis		Jaundice	/Icterus
Hemolytic	Disease	of	Adults	à unconjugated		Hyperbilirubinemia
1. increase	in	unconjugated	bilirubin	in	blood	
2. Absence	...
Hemolytic	Disease	of	Adults	à unconjugated		Hyperbilirubinemia
Incompatibility	between	maternal	&	fetal	blood	groups
Anti	...
Erythroblastosis Fetalis
• Serum	Bilirubin	à >	20	mg/dl	à no	more	bound	to	Albumin	
• Bilirubin																Brain	(Kern...
Hepatocellular	Jaundice	
1. Viral	Hepatitis	(viruses	A	,B,C,D	or	G	)à pure	hepatocellular	
diseases	
2. ↓	conjugated	bilir...
Obstructive	Jaundice	à conjugated	Hyperbilirubinemia
1. ↑	conjugated	bilirubin	
2. Bilirubin	in	urine
3. ↓	urobilinogen (	...
Obstructive	Jaundice	à conjugated	Hyperbilirubinemia
• Causes	II	Extra	hepatic	Cholestasis
1. Stones	in	biliary	tract	
2. ...
Acquired	hyperbilinogen(	unconjugated	hyper	bilinogen)
vPhysiological	Jaundice	of	newborn	(	neonates	)
1. After	second	day...
Bile	pigment Diagnostic	Test
Bilirubin Van	Der	Bergh	(serum	)	,Fouchet’s Test	&	Gmelin ‘s	test	
in	Urine	
Urobilinogen (	U...
DIRECT	BILIRUBIIN	- Azo pigment	(p	H	5	)	àPURPLE	COLOR-
↓
INDIRECT	REACTION	–FREE	BILIRUBIN	(	H2O	insoluble	,	alcohol	solu...
*Diagnostic	laboratory	to	set	up	own	quality	controls	for	reference	ranges		
Enzyme	estimations	help	in	differential	diagn...
Enzyme	estimations	help	in	differential	diagnosis	of	Jaundice		
*Diagnostic	laboratory	to	set	up	own	quality	controls	for	...
Enzymes	indicating	Hepatocellular	damage
v↑	ALT	↑AST
Viral	Hepatitis	
v↑	IHD
Hepatocellular	necrosis	
v ALT	/ALT	>	1
Alcoh...
Parameter Hemolytic	Jaundice	 Hepatic		
Jaundice	
Obstructive		
Jaundice	
1 Blood	free	bilirubin	 ↑ ↑ normal
2 Conjugated	...
Fate	of	Bilirubin
Congenital	Hyperbilirubinemia
vAbnormal	uptake	,conjugation	or	excretion	of	bilirubin	due	to	inherited	
defects	
• 1.Gilbe...
Congenital	Hyperbilirubinemia
v(1) Gilbert’s	Disease	
a) Autosomal	dominant	trait
b) Defect	uptake	of	Bilirubin
c) Asympto...
Congenital	Hyperbilirubinemia
(2)	Crigler	Najjar syndrome	:Defect	in	conjugation
Type	I
a) Congenital	non	hemolytic	Jaundi...
Congenital	Hyperbilirubinemia
(2)	Crigler	Najjar syndrome	:Defect	in	conjugation
Type	II
a) Congenital	non	hemolytic	Jaund...
Management	of	Crigler Najjar Syndrome
Congenital	Hyperbilirubinemia
vDubin Johnson’s	syndrome	
a) Autosomal	recessive	trait
b) ↑	conjugated	bilirubin	in	blood	
...
Congenital	Hyperbilirubinemia
vDubin Johnson’s	syndrome	
Diagnostic	Test	:	Bromosulphthalein	Test
250	mg	Bromosulphthalein...
Congenital	Hyperbilirubinemia
vRotor	syndrome	
a) Cause	not	known		(	autosomal	recessive	)
b) Bilirubin	excretion	defectiv...
Comparison	of	Dubin Johnson	’s	and	Rotor	‘s	syndrome
Comparison	of	Gilbert	‘s	and	Crigler- Najjar syndrome
Biosynthesis	of	Heme	(	Porphyrin	ring	)
• Site	à Liver	/RBC	producing	cells	of	bone	marrow	(	erythroid cells)	
/other	tiss...
Biosynthesis	of	Heme	(	Porphyrin	ring	)
II	Synthesis	of	Porphobilinogen
2. δ amino	Levulinate (ALA	)
ALA	Dehydratase *
Por...
Biosynthesis	of	Heme	(	Porphyrin	ring	)
1. Succinyl	CoA	+	Glycine	→	ALA	
2. ALA	+	ALA	à Porphobilinogen	(	PBG	)	+	2H₂O
3. ...
Biosynthesis	of	Heme	(	Porphyrin	ring	)
Succinyl	CoA	+	Glycine	→	ALA	
ALA	+	ALA	à Porphobilinogen	(	PBG	)	+	2H₂O
4
4		X	(	...
ACETYL	à METHYL	,4CO₂	
PROPINYL	à VINYL+	2CO₂
Biosynthesis	of	Heme
Metallo- porphyrin
1. Uroporphyrin	I	&	III
2. Coporphyrin I	&	III
3. PROTOPORPHYRIN	IX	&	HEME	
vHeme	containing	proteins- ...
Heme	synthesis	
• Site :	mitochondria	of	all	mammalian	tissue		except	RBC	predominantly	
in	Liver	&	bone	marrow	
vStep	I :...
Heme	synthesis	
vStep	II :	Site	–MITOCHONDRIA		
*	ALA		DEHYDRATASE		PLP 2H	₂O
2	Molecules	of	ALA																										...
Heme	synthesis	
vStep	III : Site	–MITOCHONDRIA
*PBG	DEAMINASE																	4NH₃
4	Molecules	of	PBG																					...
Heme	synthesis	
vStep	IV :	Site	–MITOCHONDRIA	
*Uroporphyrinogen	decarboxylase								4CO₂
• Uroporphyrinogen(UBG)Type III...
Heme	synthesis	
vStep	V : Site	-CYTOSOLIC
*Coproporphyrinogen	oxidase									2CO₂
CoproporphyrinogenIII																		...
Heme	synthesis	
vStep	VI :	Site	-CYTOSOLIC
*Protoporphyrinogenoxidase									4H	
ProtoporphyrinogenIII																			...
Heme	synthesis	
vStep	VII :	Site	-CYTOSOLIC
*Heme	synthtase
Protoporphyrin	III (	IX	)																																					...
1.Succinyl	CoA	
+	Glycineà
ALA
ALA	
2	.ALA	à PBG
3.PBG	à UBG	III 4.UBG	à CPGIII	
CPG	III
CPG	III
5.	CPGIII	àPPG	III 6.	PPG...
Regulation	of	Heme	synthesis	
1.	↑	Glucoseà↑catabolism	of	CRP(repressor	protein	)à decrease	ALA	
(	induction	prevented	,Gl...
Regulation	of	Heme	synthesis	
Three	mechanisms	controlling	activity	of	ALA	synthase	by	Heme	
/Hematin	Fe³⁺		
a.	Feedback	i...
Effect	of	drugs	on	ALA	synthase	activity
1. *Phenobarbital	
2. *	Insecticides							 ↑	activity	of	ALA	synthase	
3. *	Carc...
Regulation	in	the	Erythroid	cells
vALA	synthase	dose	not	regulate	Heme	synthesis	in	Erythroid	cells	
vUroporphyrinogen	syn...
Regulation	of	Heme	synthesis
Porphyrin	&	Bilirubin	Metabolism
• Porphyrin :	Group	of	compounds	of	4	substituted	pyrrole	rings	
linked	by	Methane	bridge...
Porphyrin	&	Bilirubin	Metabolism
vIron	Porphyrins :
1. Hemoglobin
2. Myooglobin
3. Cytochrome
4. Catalase	&	peroxidase	
5....
Porphyrin		Metabolism
• Porphyria's:	Group	of	inborn	errors	of	metabolism	associated	with	
the	biosynthesis	of	Heme	
• Cha...
Porphyria's:
• Types	Porphyria's:	
1.	inherited	
a) Erythropoietin :	enzymes	deficiency	occurs	in	erythrocytes	
b) Hepatic...
Autosomal	recessive
Autosomal	dominant
Erythrodontia
RBC	-FLUORESCENCE
Liver	,skin	fluorescence
Acute	intermittent	Porphyrias
• Deficiency	of	enzymes	Uroporphyrinogen	synthase	I	
Succinyl	CoA	+	Glycine	
δ aminolevilina...
1.	Acute	intermittent	Porphyria
• Age :	after	puberty		(Artist	–Vincet ,	King	George	III	–MAD	)
• Deficient enzyme :	Uropo...
2.	Congenital erythropoietin Porphyria
vCongenital
vDeficient enzyme :	↓	Uroporphyrinogen	co	synthtase	III
• Excretion	in	...
Congenital erythropoietin Porphyria	
Photosensitivity
Erythrodontia(	teeth)
Congenital erythropoietin Porphyria
Dermatitis	,scarring	burning	&	itching	of	skin- ear	&	nose	(	Leprosy	like	,
(as		ROS	↑...
Dermatitis	,scarring	burning	&	itching	of	skin- ear	&	nose	(	Leprosy	like	)
(as		ROS	↑	à accumulation	of	Porphyrins
Congen...
3.Porphyria Cutanea Tarda
• Cutaneous	hepatic	porphyria
• Deficient enzyme :	↓	Uroporphyrinogen	decarboxylase	
• Excretion...
4.Hereditary Coporphyria
• Deficient enzyme :	↓	Coporphyrinogen oxidase
• Excretion	in	urine	:	Uroporphyrinogen	I	&	Coporp...
5.Variegate porphyria
• Deficient enzyme :Protoporphyrinogen oxidase	
• Accumulation	in	plasma		&	excretion	in	urine	of:	P...
6.Herediatory Protophyria (	Erythropoietic protoporphyria )
• Deficient enzyme:		Ferrochelatase
• Accumulation	in	plasma	(...
7.	Acquired (toxic )	Porphyrias
• Exposure	of	body	to	toxic	compounds	(	toys	/	Xerox	ink	)
Examples	:	Heavy	metals	(	Lead	...
Reactions	of	Heme synthesis
Pre	natal	diagnosis	of	Porphyrias		
Enzyme	estimations	/PCR
Anemia	
• 75	%	Indian	population	suffer	from	anemia
• Hb	concentration	decreases	in	anemia		<10gm%	
(	normal	concentration...
Anemia	
II	-Impaired	production	of	RBC	
Defect	in	Heme	
synthesis	
• Nutritional	
• Deficiency	of	iron	
,Copper,	Vitamin	
...
Hemin crystals	
• Fe²⁺		↔	Fe³⁺	à Fe³⁺	+	Cl⁻	à Hematin	chloride	or	HEMIN	
vMedical	legal	cases
• Blood	+	Blood	stains	+	Nip...
Hemin crystals
Hemoglobin	estimation
vDrabkin’s Test	for	Hemoglobin	estimation	:	Cyanmeth Hemoglobin		Method	
• Blood	(	Hb	)	+	Drabkin’s ...
Sulph Hemoglobinemia
• Oxy	–Hb	+	H₂	S	à Sulph –Hb	(	absorption	peak	at	620nm)
vFormation	of	Sulph –Hb	by	sulphonamide ,Phe...
Abnormal	Hb	or	Hb	variants	
1.Sickle	syndrome	
a) 1. sickle	cell	trait	(	AS	)
b) 2.	sickle	cell	disease	with	SS	,SC,SD	,SO...
SICKLE CELL DISEASE
vCharacteristics of Sickle cell disease
a) Glutamic	acid	à Valine (6th position	on	beta	chain)
b) Hydr...
SICKLE CELL DISEASE
Signs	and	symptoms	of	Thalassemia	major
Inheritance	of	Thalassemia
Abnormal	Hb	or	Hb	variants	
III	Hemolytic	anaemias due	to	intra	-corpuscular	defect
a) Hemoglobinopathies :	HbS ,Hbc ,	HbM...
Abnormal	Hb	or	Hb	variants	
V	hemorrhages	
a) Hematuria	
b) Hematomesis
c) Hemoptysis	
d) Peptic	ulcers	
e) Hemorrhoides
f...
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Haemoglobin metabolism and.its clinical applications pptx
Prochain SlideShare
Chargement dans…5
×

Haemoglobin metabolism and.its clinical applications pptx

9 230 vues

Publié le

A comprehensive presentation on haemoglobin metabolism and its clinical application for MBBS,BDS, B.Tech,B.Pharma students for self study.

Publié dans : Santé & Médecine
  • Identifiez-vous pour voir les commentaires

Haemoglobin metabolism and.its clinical applications pptx

  1. 1. Hemoglobin metabolism and its clinical applications Dr. Rohini C Sane
  2. 2. Functions of Hemoglobin molecule in oxygen transport
  3. 3. Functions of Hemoglobin molecule in carbon dioxide transport
  4. 4. Degradation of Heme to bile pigments Macrophages of reticuloendothelial (RE ) in spleen /liver /bone marrow-Hb RBC à 12Odays Non protein ‘Heme ’Globin 6 gm /day heme broken down /resynthesisà Bilirubin ( 300 mg /day ) = 250 mg/day Hb + 50 mg/day myoglobin
  5. 5. Fate globin (reutilization ) • Formation of Hb ( re synthesis ) • Degraded to amino acids –metabolism including formation of Hb
  6. 6. Sources of Heme Heme 20% immature RBC /Myoglobin /globin /cytochrome /peroxidase /catalase Trp pyrrolase 80% RBC Hb
  7. 7. ( GREEN –excreted by birds & amphibians )→ Transferrin ←αGlobin chains ←βGlobin chains RBC ( Aged erythrocytes )with Hb phagocytosis by macrophages → specificity for α methylene bridge ← Presence in mammals ← Yellow with 36H← →Bilirubin- Albumin complex in Blood +
  8. 8. Heme oxygenase 1. Microsomal enzymes 2. NADPH ,O₂ , Methylene bridges between two pyrrole ringsà biliverdin 3. Fe ²⁺ à Fe³⁺ Heme oxygenase Heme Biliverdin+ Fe³⁺+ CO • Biliverdin à excreted by birds ,amphibians & mammals
  9. 9. Degradation of Heme to bile pigments Biliverdin reductase Biliverdin (green ) Bilirubin(non functional therefore excreted) 1gm hemoglobin *à 35 mg Bilirubin Biliverdin + Bilirubin à Heme derivatives • (* sources- 80% RBC + 10% ineffective erythropoiesis + 10% Myoglobin ) • 6 gm /day heme broken down /resynthesisà Bilirubin ( 300 mg /day ) = 250 mg/day Hb + 50 mg/day myoglobin
  10. 10. Transport of Bilirubin to Liver • Bilirubin- ( lipophilic –insoluble in water) • Bilirubin + Albumin à Transported in plasma • Per 100ml plasma à 25 mg Bilirubin bound tight to Albumin • Bilirubin has low affinity for Albumin à easily detached & enter tissue
  11. 11. Drugs : sulphonomides /salicylates / Penicillin displace Bilirubin from Albumin binding sites Bilirubin enters CNS Damage to neurons à Kernicterus Degradation of Heme to bile pigments
  12. 12. Conjugation 0f Bilirubin Liver Albumin –Bilirubin complex I Uptake carrier mediated active transport Sinusoidal surface of hepatocytes Bilirubin + protein ( Ligandin ) 2 UDP Glucoronate II Conjugation UDP Endoplasmic-reticulum (hepatic microosomes ) Bilirubin Glucuronyltransferase (chromosome 2 ) Bilirubin + 2 molecules of Glucuronate 80% Bilirubin Diglucuronide+ 20% Bilirubin monoglucuronide (MOAT –multiple specific organic ion transport )- present in canalculi III secretion Bilirubin Oligonucleotide Bile salts Fate of Bilirubin in human body
  13. 13. Factors affecting conjugation of Bilirubin in liver 1. Drugs like Primaquine/Novobiocin/Chloramphenicol,/Androgen/Pregnanediol interfere with conjugation process may cause jaundice. 2. Decrease concentration of UDP-Glucuronyl Transferase 3. Phenobarbital induces UDP-Glucuronyl Transferase
  14. 14. Production & excretion of Bilirubin Retiiculoendothelial system ( RES ) Hb ↓ Biliverdin (38 H ) ↓ Bilirubin ( 36 H ) Liver Bilirubin Diglucuronide BilirubinDiglucuronide ↓ Deconjugation Free Bilirubin (36 H) ↓ reduction Urobilinogen (44H ) by E coli (colorless ) Reduction of vinyl group of stercobilinogen (48H ) ↓ stercoblin(46H ) DARK BROWN /200 MG/DAY BLOOD UROBILINOGEN KIDNEY UROBILINOGEN UROBILLINOGEN (44H ) ↓ UROBILIN IN URINE (42H ) ( < 4 GM/DAY ) BILE DUCT→ ←PORTAL CIRCULATION EHC ↓ ←SMALL PORTION EHC –Entero hepatic circulation
  15. 15. Excretion of Bilirubin into bile Conjugated Bilirubin Active transport* ( against concentration gradient ) Rate limiting step Bile > 98% Bilirubin enters bile in conjugated form *Induced by Phenobarbitone
  16. 16. Production & excretion of Bilirubin • Excretion of Biliverdin à green color stool( children & prolonged antibiotics therapy ) • Black color stool during constipation • Schlesinger test : Stercobilin (SB ) & Urobilin (UB)+Zn ²⁺ à green fluroscent
  17. 17. Fouchet’s Diagnostic test for Bilirubin in urine
  18. 18. Bilirubin –yellow ,Biliverdin –green ,Bilinofuschin –Red , Bilicyanin -violet
  19. 19. ←URINE→ Gmelin’s Test ←CONC HNO₃→ Bilirubin –yellow ,Biliverdin –green ,Bilifuschin –Red , Bilicyanin -violet
  20. 20. Fate of Bilirubin Bilirubin Glucuronides Hydrolysis ↓ bacterial enzyme (β Glucuronidase ) Bilirubin ↓ small portion reabsorbed Urobilinogen(colorless )à SBG ( Erhlich +ve ) ↙ ↘ Stercobilin Urobilin (excreted in stool -) (excreted in urine by kidney ) ↓ ↓ Brown color of stool pale yellow color of urine Serum Bilirubin à Van Der Berg Test, Urine Bilirubin à Fouchet’s Test ,Gmelin Test
  21. 21. Conjugated and unconjugated bilirubin ( Direct and indirect bilirubin )
  22. 22. Stercobilin and Urobilin
  23. 23. Formation of conjugated bilirubin in Hepatocytes
  24. 24. Types of Bilirubin Free bilirubin Conjugated bilirubin 1 In H₂ O insoluble soluble 2 In alcohol soluble soluble 3 Normal plasma levels 0.2 mg /dl 0.2 -0.8 mg /dl 4 In bile Absent present 5 In urine Always absent Normally absent ( present in hemolytic & Obstructive jaundice ) 6 Absorption from GIT Absorbed Not Absorbed 7 Diffusion in tissue Diffuses to cause yellow Dose not diffuse 8 Van der Bergh Test Indirect positive direct positive
  25. 25. Bilirubin & its reduction products number of H atoms color Bilirubin (BR ) 36 Red yellow Meso bilirubin (MB) 40 yellow Urobillinogen (UBG ) 44 colorless Stercobilinogen ( SBG ) 48 colorless Urobilin(UB ) 42 Orange brown Stercobillin( SB ) 46 Dark brown
  26. 26. Jaundice- Hyperbilirubinemia Physiological – Total Bilirubin concentration in serum = ( 0.2- 0.8mg/dl ) 0.2 -0.6 mg/dl ( unconjugated ) 0- 0.2 mg/dl ( conjugated ) Yellow color sclera & skin ( deposition of bilirubin )-conc of serum bilirubin > 2mg/dl q Conjugated Hyper bilirubinemia q Unconjugated Hyper bilirubinemia vSymptoms 1. Nausea 2. Vomiting 3. Appetite Ø Latent Jaundice (1-2 mg/dl )
  27. 27. *Diagnostic laboratory to set up own quality controls for reference ranges
  28. 28. Pre hepatic ,Hepatic and post hepatic jaundice – a classification based on site (cause of of Hyperbilirubinemia)
  29. 29. Classification of Jaundice based on type of Bilirubin
  30. 30. Intra hepatic jaundice (Genetic /inherited causes )
  31. 31. Cause • Hemolytic Jaundice • Causes – Hemolysis Malaria blood transfusion sickle cell anemia • Liver fails to conjugate excess of Bilirubin • Therefore ↑unconjugated bilirubin ↑Urobilinogen ↑ stercobilinogen (brown color stool ) • SGPT / ALP -Normal • Hepatic Jaundice • Causes –dysfunction of Liver Hepatitis al infection poisons/toxins cirrhosis/CCF • ↑unconjugated bilirubin ↑conjugated bilirubin ↑Urobilinogen ↑ stercobilinogen (brown color stool ) ↑SGPT / ALP • Obstructive Jaundice • Gall stone stool contains fat unavailability of bile salts • ↑conjugated bilirubin ↑Urobilinogen ↓ stercobilinogen (pale color stool ) ↑SGPT / ALP Comparison of Hemolytic / hepatic and obstructive Jaundice
  32. 32. Differential diagnosis Jaundice /Icterus
  33. 33. Hemolytic Disease of Adults à unconjugated Hyperbilirubinemia 1. increase in unconjugated bilirubin in blood 2. Absence of bilirubin in urine 3. Excretion of urobilinogen à ( Ehrlich Test positive ) 4. Excretion of stercobilinogen in faeces vDiseases associated with a) congenital spherocytosis b) G6PD deficiency c) Autoimmune hemolytic anemia d) Toxin carbon tetrachloride
  34. 34. Hemolytic Disease of Adults à unconjugated Hyperbilirubinemia Incompatibility between maternal & fetal blood groups Anti antibodies ABO IgM type cannot be transferred to placenta vRh incompatibility Fetus mother Rh ( +ve ) Rh ( -ve ) RBC RBC elicit immune response Anti-D ( IgG ) Destruction Anti-D( IgG ) Of RBC ← Placenta Second pregnancy ( before birth –destruction of RBC ) à CHILD born with severe hemolytic disease à Erythroblastosis fetalis
  35. 35. Erythroblastosis Fetalis • Serum Bilirubin à > 20 mg/dl à no more bound to Albumin • Bilirubin Brain (Kernicterus-deposition of bilirubin in brain ) • Basal ganglia à mental retardation • ↓ ATPase mitochondria à fits ,spasticity ,toxic encephalitis • Treatment : (1) phototherapy before age < 1 year à isomerization ZZ à ZE (2 ) Blood transfusion
  36. 36. Hepatocellular Jaundice 1. Viral Hepatitis (viruses A ,B,C,D or G )à pure hepatocellular diseases 2. ↓ conjugated bilirubin therefore ↑free Bilirubin 3. Inflammatory odema of cells à intracellular canalculi compressed à obstruction ( at site of bile formation ) 4. Increase obstruction à ↑ obstructionà ↑conjugated Bilirubin therefore Biphasic 5. Bilirubinuria 6. UrobilinogenàNORMAL or decreased in hepatocellular Jaundice
  37. 37. Obstructive Jaundice à conjugated Hyperbilirubinemia 1. ↑ conjugated bilirubin 2. Bilirubin in urine 3. ↓ urobilinogen ( nil if obstructive is complete ) 4. Faeces clay color (↓ stercobilinogen ) 5. Absence of bile salts à Stetorrhoea may result 6. Causes I Intrahepatic Cholestasis a) Active hepatitis b) Biliary cirrhosis c) Lymphomas d) Hepatoma e) Viral hepatitis
  38. 38. Obstructive Jaundice à conjugated Hyperbilirubinemia • Causes II Extra hepatic Cholestasis 1. Stones in biliary tract 2. Stones in gall bladder 3. Biliary atresia 4. Carcinoma head of pancreasà lymph glands enlarged 5. Porta hepatitis
  39. 39. Acquired hyperbilinogen( unconjugated hyper bilinogen) vPhysiological Jaundice of newborn ( neonates ) 1. After second day of life ,transient hyper bilinogen –Jaundice 2. ↑ rate of destruction of RBC ( transient ) 3. à immature hepatic system of conjugation 4. à Bilirubin donot exceed 5mg/dl 5. à 2 weeks phototherapy + barbitone to induce conjugation( ZZ bilirubin à ZE + EE à excreted without conjugation in urine ) 6. Undue prolongation à crenism 7. Breast milk jaundice ( estrogen à ↓ enzyme Glucuronyl transferase)
  40. 40. Bile pigment Diagnostic Test Bilirubin Van Der Bergh (serum ) ,Fouchet’s Test & Gmelin ‘s test in Urine Urobilinogen ( UBG ) Ehrlich’s Test Urobilin Schlesinger’s test
  41. 41. DIRECT BILIRUBIIN - Azo pigment (p H 5 ) àPURPLE COLOR- ↓ INDIRECT REACTION –FREE BILIRUBIN ( H2O insoluble , alcohol soluble )
  42. 42. *Diagnostic laboratory to set up own quality controls for reference ranges Enzyme estimations help in differential diagnosis of Jaundice
  43. 43. Enzyme estimations help in differential diagnosis of Jaundice *Diagnostic laboratory to set up own quality controls for reference ranges
  44. 44. Enzymes indicating Hepatocellular damage v↑ ALT ↑AST Viral Hepatitis v↑ IHD Hepatocellular necrosis v ALT /ALT > 1 Alcohol liver disease Obstructive liver disease: cholestasis /hepatic carcinoma/parenchymal cell damage
  45. 45. Parameter Hemolytic Jaundice Hepatic Jaundice Obstructive Jaundice 1 Blood free bilirubin ↑ ↑ normal 2 Conjugated bilirubin normal ↑ ↑ 3 ALP normal ↑ ↑ ↑ 4 Bile salts Nil Nil PRESENT 5 Urine Bilirubin Nil Nil PRESENT 6 Urine urobilinogen ↑ Nil Nil 7 Stool Dark brown Clay color Differential Diagnosis of Jaundice
  46. 46. Fate of Bilirubin
  47. 47. Congenital Hyperbilirubinemia vAbnormal uptake ,conjugation or excretion of bilirubin due to inherited defects • 1.Gilbert Disease –defect in uptake • 2. Crigler Najjar syndrome – defect in conjugation
  48. 48. Congenital Hyperbilirubinemia v(1) Gilbert’s Disease a) Autosomal dominant trait b) Defect uptake of Bilirubin c) Asymptomatic d) Presence of jaundice( Bilirubin à 3mg/dl )
  49. 49. Congenital Hyperbilirubinemia (2) Crigler Najjar syndrome :Defect in conjugation Type I a) Congenital non hemolytic Jaundice b) Deficiency of UDP –Glucuronyl transferase c) Fatal ( death before two years of age ) d) Jaundice appears within 24hrs of life e) Unconjugated bilirubin ( >20 mg/dl ) f) Kernicterus g) Barbiturates no effect ( enzyme no defect )
  50. 50. Congenital Hyperbilirubinemia (2) Crigler Najjar syndrome :Defect in conjugation Type II a) Congenital non hemolytic Jaundice b) Deficiency of UDP –Glucuronyl transferase c) Disease runs more benign course d) Bilirubin –mononucleotide present e) Total bilirubin seldome rises :Unconjugated bilirubin ( >15 mg/dl ) f) No Kernicterus g) Barbiturates use in treatmentà Jaundice improves
  51. 51. Management of Crigler Najjar Syndrome
  52. 52. Congenital Hyperbilirubinemia vDubin Johnson’s syndrome a) Autosomal recessive trait b) ↑ conjugated bilirubin in blood c) Defect in excretion of conjugated Bilirubin( ATP ase dependent organic anion Transporter protein-MOAT mutation d) Defect ATP dependent organic anion transport in bile canalculi e) Bilirubin gets deposited in liver therefore Bilirubin gets deposited in liver ( Black Liver Jaundice ) f) Diagnostic Test : Bromosulphthalein Test
  53. 53. Congenital Hyperbilirubinemia vDubin Johnson’s syndrome Diagnostic Test : Bromosulphthalein Test 250 mg Bromosulphthalein ( intravenous ) Normal ( dye remaining plasma ) Dubin Johnson’s syndrome ( dye remaining plasma ) 45 min < 5 % > 2hrs levels (< 2 % ) 2 hrs < 2 % < 45 min levels ( > 5 % ) ( 2hr level more than 45min ) At 45 min BSP taken up by hepatocytes / therefore decrease in blood levels EXCRETORY DEFECT :BSP regurgatesin blood
  54. 54. Congenital Hyperbilirubinemia vRotor syndrome a) Cause not known ( autosomal recessive ) b) Bilirubin excretion defective c) No deposition of pigment in liver ?
  55. 55. Comparison of Dubin Johnson ’s and Rotor ‘s syndrome
  56. 56. Comparison of Gilbert ‘s and Crigler- Najjar syndrome
  57. 57. Biosynthesis of Heme ( Porphyrin ring ) • Site à Liver /RBC producing cells of bone marrow ( erythroid cells) /other tissue • Excretion to rule à mature RBC lacking mitochondria • I Formation of δ amino Levulinate (mitochondria ) Glycine + succinyl CoA * Pyridoxal phosphate dependent δ amino Levulinate synthtase δ amino Levulinate (ALA ) * rate controlling step
  58. 58. Biosynthesis of Heme ( Porphyrin ring ) II Synthesis of Porphobilinogen 2. δ amino Levulinate (ALA ) ALA Dehydratase * Porphobilinogen (PBG ) • Activity decreases by Pb /Hg & Zinc containing enzyme
  59. 59. Biosynthesis of Heme ( Porphyrin ring ) 1. Succinyl CoA + Glycine → ALA 2. ALA + ALA à Porphobilinogen ( PBG ) + 2H₂O 3. 4 X ( PBG ) 4. Uroporbilinogen III (UBG ) 5. Coporphyrinogen III ( CPG III )+ CO₂ 6. Protoporphyrinogen III ( PPGIII ) 7. HEME
  60. 60. Biosynthesis of Heme ( Porphyrin ring ) Succinyl CoA + Glycine → ALA ALA + ALA à Porphobilinogen ( PBG ) + 2H₂O 4 4 X ( PBG ) Uroporphyrinogen CoporphyrinogenIII ( CPG III )) ProtoporphyrinogenIII ( PPGIII ) HEME HEMGLOBIN 1. ALA SYNTHTASE 2. ALA DEHYDRATASE 3. PBG DEAMINASE & UPG III COSYNTHTASE 4 .UROPORPHYRIN DECARBOXYLASE 5 COPORPHYRINOGEN OXIDASE 6.Heme synthtase → 4CO₂ NADP+O₂ → → NADPH+H+ 2CO ₂ ACETYL à METHYL PROPINYL àVINYL
  61. 61. ACETYL à METHYL ,4CO₂ PROPINYL à VINYL+ 2CO₂ Biosynthesis of Heme
  62. 62. Metallo- porphyrin 1. Uroporphyrin I & III 2. Coporphyrin I & III 3. PROTOPORPHYRIN IX & HEME vHeme containing proteins- hemoglobin ,cytochromes ,catalase ,tryptophan pyrrolase
  63. 63. Heme synthesis • Site : mitochondria of all mammalian tissue except RBC predominantly in Liver & bone marrow vStep I : *ALA synthase PLP CO₂ CoASH Succinyl CoA + Glycine δ ALA • δ ALA :Delta amino Levullinic acid • * Regulatory enzyme = rate limiting step qINH treatment à PLP ↓ à ALA SYNTHESIS ↓
  64. 64. Heme synthesis vStep II : Site –MITOCHONDRIA * ALA DEHYDRATASE PLP 2H ₂O 2 Molecules of ALA Porphobilinogen( PBG ) * activity decreased by heavy metals
  65. 65. Heme synthesis vStep III : Site –MITOCHONDRIA *PBG DEAMINASE 4NH₃ 4 Molecules of PBG Uroporphyrinogen(UBG ) • *Uroporphyrinogen I synthtase & Uroporphyrinogen III synthtase • * deficiency of Uroporphyrinogen III synthtase leads to formation of Type I UBG à Porphyria
  66. 66. Heme synthesis vStep IV : Site –MITOCHONDRIA *Uroporphyrinogen decarboxylase 4CO₂ • Uroporphyrinogen(UBG)Type III Coproporphyrinogen III • *Acetyl à Methyl • * deficiency of à Porphyria
  67. 67. Heme synthesis vStep V : Site -CYTOSOLIC *Coproporphyrinogen oxidase 2CO₂ CoproporphyrinogenIII ProtoporphyrinogenIII O ₂ • * Methyl à Vinyl • * deficiency of Coproporphyrinogen oxidase à Porphyria
  68. 68. Heme synthesis vStep VI : Site -CYTOSOLIC *Protoporphyrinogenoxidase 4H ProtoporphyrinogenIII ProtoporphyrinIII ( IX ) Methylene ( CH2 )à Methenyl ( CH - ) • * deficiency of Protoporphyrinogen oxidase à Porphyria
  69. 69. Heme synthesis vStep VII : Site -CYTOSOLIC *Heme synthtase Protoporphyrin III ( IX ) Heme Fe²⁺ • Ferrochelatase • Heme + Protein= HEMOGLOBIN
  70. 70. 1.Succinyl CoA + Glycineà ALA ALA 2 .ALA à PBG 3.PBG à UBG III 4.UBG à CPGIII CPG III CPG III 5. CPGIII àPPG III 6. PPGà PP 7.PPà HEME CYTOSOLIC -2,3,4 MITOCHONDRIAL HEME SYNTHESIS
  71. 71. Regulation of Heme synthesis 1. ↑ Glucoseà↑catabolism of CRP(repressor protein )à decrease ALA ( induction prevented ,Glucose administered for treatment of porphyria 2.↓ ALA synthase by Hematin ,Excess of free Heme ( Fe²⁺ à Fe³⁺) 3. Compartmentization of enzymes à easier for regulation ,rate limiting steps in mitochondria 4. Heme synthesis controlled by a) globin synthesis b) Drug like barbiturates ( require cytochrome 450) 5 .lead /Mercury ↓ ALA Synthase ↓ Ferrochelatase
  72. 72. Regulation of Heme synthesis Three mechanisms controlling activity of ALA synthase by Heme /Hematin Fe³⁺ a. Feedback inhibition(Heme /Hematin Fe³⁺ ) b. Repression of ALA synthase C. Inhibition of ALA synthase transport from cytosol to mitochondria ( the site of action ) Heme synthesis site : liver ( ALA synthase à regulatory enzyme )
  73. 73. Effect of drugs on ALA synthase activity 1. *Phenobarbital 2. * Insecticides ↑ activity of ALA synthase 3. * Carcinogen * Metabolized by HEME containing protein cytochrome 450 ↓ Increased in corporation of Heme in cytochrome 450 ↓ ↓ cellular level of Heme ↓ ↑ ALA synthase ( de repression ) to meet cellular demands
  74. 74. Regulation in the Erythroid cells vALA synthase dose not regulate Heme synthesis in Erythroid cells vUroporphyrinogen synthase & Ferrochelatase regulate Heme synthesis vCellular uptake of iron regulate Heme synthesis vHeme stimulate globin synthesis
  75. 75. Regulation of Heme synthesis
  76. 76. Porphyrin & Bilirubin Metabolism • Porphyrin : Group of compounds of 4 substituted pyrrole rings linked by Methane bridges • à formation of complexes with metal ions bound to N₂ atom of pyrrole ring IRON Heme Hb MAGNASIUM Chlorophyll Photosynthetic pigment
  77. 77. Porphyrin & Bilirubin Metabolism vIron Porphyrins : 1. Hemoglobin 2. Myooglobin 3. Cytochrome 4. Catalase & peroxidase 5. Tryptophan pyrrolase
  78. 78. Porphyrin Metabolism • Porphyria's: Group of inborn errors of metabolism associated with the biosynthesis of Heme • Characteristics of Porphyrias :increase in production & excretion of porphyrin & their porphyrin precursors ALA & PBG • Autosomal dominant or Autosomal recessive • Diagnosis of Porphyria's: • 1. urine ( exoposure to UV à red fluorescence ) • 2. urine + CHCl₃ à extraction • Aqueous layer ( PBG ) + Ehrlich reagent à pink color
  79. 79. Porphyria's: • Types Porphyria's: 1. inherited a) Erythropoietin : enzymes deficiency occurs in erythrocytes b) Hepatic : enzymes deficiency lies in the liver 2. Acquired 💟
  80. 80. Autosomal recessive Autosomal dominant Erythrodontia RBC -FLUORESCENCE Liver ,skin fluorescence
  81. 81. Acute intermittent Porphyrias • Deficiency of enzymes Uroporphyrinogen synthase I Succinyl CoA + Glycine δ aminolevilinate (ALA ) ↑ Porphobilinogen ↑ UroporphyrinogenIII δ aminolevilinate synthase ALA Dehydratase Uroporphyrinogen synthase Uroporphyrinogen I ↑ ALA ↑PORPHYRINOGEN
  82. 82. 1. Acute intermittent Porphyria • Age : after puberty (Artist –Vincet , King George III –MAD ) • Deficient enzyme : Uroporphyrinogen synthase I ( ↑ ALA –no feed back mechanism ) • No porphyria ,no photosensitivity • Excretion in urine : δ aminolevilinate (ALA ) & porphobilinogen ( PBG ) • Exposure of porphobilinogen ( PBG ) to air darkens ( formation of Porphobilin ) • Diagnosis : urinary conc of PBG (darkens on exposure to air ) • Symptoms : Abdominal pain ,Vomiting ,cardiovascular abnormalities ,neuropsychiatric disturbances ( therefore ↓ Trp pyrrolase , ↑ Trp, 5 ʹOH Tyramine • Treatment : Hematin à↓ ALA , ↓ PBG • Adverse effects : Barbiturate ( ppt of attack )à ↑ ALA synthase (as cytochrome 450 )àPBG↑, increase with carbohydrate diet & menopause
  83. 83. 2. Congenital erythropoietin Porphyria vCongenital vDeficient enzyme : ↓ Uroporphyrinogen co synthtase III • Excretion in urine : Uroporphyrinogen I & Coporphyrinogen Ià ↓ oxidation ↓ Uroporphyrin I & CoporphyrinI Symptoms : 1.↑ Hemolysis 2. Erythrodontia ( teeth ) ,port wine color urine 3. Exposure OF SKIN à UV sensitization of porphyrin à absorbed & emit red fluorescent light 4. Dermatitis ,scarring burning & itching of skin- ear & nose ( Leprosy like ),(as ROS ↑ à accumulation of Porphyrin ) 5. port wine color urine (Uroporphyrin I & CoporphyrinI )
  84. 84. Congenital erythropoietin Porphyria Photosensitivity Erythrodontia( teeth)
  85. 85. Congenital erythropoietin Porphyria Dermatitis ,scarring burning & itching of skin- ear & nose ( Leprosy like , (as ROS ↑ à accumulation of Porphyrins)
  86. 86. Dermatitis ,scarring burning & itching of skin- ear & nose ( Leprosy like ) (as ROS ↑ à accumulation of Porphyrins Congenital erythropoietin Porphyria
  87. 87. 3.Porphyria Cutanea Tarda • Cutaneous hepatic porphyria • Deficient enzyme : ↓ Uroporphyrinogen decarboxylase • Excretion in urine : Porphobilinogen & Uroporphyrin ( I &III ) rarely • Symptoms : 1. Cutaneous 2. Photosensitivity 3. Liver exhibits fluorescence Treatment : Hematin( ↓ ALA synthase, ↓ accumulation various intermediate )
  88. 88. 4.Hereditary Coporphyria • Deficient enzyme : ↓ Coporphyrinogen oxidase • Excretion in urine : Uroporphyrinogen I & Coporphyrinogen Ià ↓ oxidation ↓ Uroporphyrin I & Coporphyrin I • Urine dark color : presence of Uroporphyrin I , Coporphyrin I,ALA, PBG • Treatment : Hematin( ↓ ALA synthase, ↓ accumulation various intermediate ) •
  89. 89. 5.Variegate porphyria • Deficient enzyme :Protoporphyrinogen oxidase • Accumulation in plasma & excretion in urine of: Porphobilinogen Uroporphyrinogen ,Uroporphyrin ,Coproporphyrinogen ,Coproporphyrin ,Protoporphyrin ( ↓Heme synthesis ) • Photosensitivity exhibited • Plasma exhibits red fluorescence ( due presence of Coproporphyrinogen • Neuropsychiatric manifestation
  90. 90. 6.Herediatory Protophyria ( Erythropoietic protoporphyria ) • Deficient enzyme: Ferrochelatase • Accumulation in plasma ( increase in concentration ) , excretion in urine ( increase in concentration )& faeces (increase in concentration ) of: PROTOPORPHYRIN IX • RBC ,skin exhibit red fluorescence •
  91. 91. 7. Acquired (toxic ) Porphyrias • Exposure of body to toxic compounds ( toys / Xerox ink ) Examples : Heavy metals ( Lead ) ↓ALA Dehydratase Hexchlorobenzene ↓Uroporphyrin synthase I Drugs ( Griseoflavin ) ↓ Ferrochelatase Therefore ↓Heme ↑ALA synthase Aquried porphyrias associated with anamia
  92. 92. Reactions of Heme synthesis
  93. 93. Pre natal diagnosis of Porphyrias Enzyme estimations /PCR
  94. 94. Anemia • 75 % Indian population suffer from anemia • Hb concentration decreases in anemia <10gm% ( normal concentration of blood Hb – 14-16 mg% -male ,13-15 mg% -female ) vI Iron Deficiency anemia –most common a) Nutritional b) Lack of absorption of Iron ( Gastrectomy & Achlorhydria) c) Hookworm infection ( 0.3ml/ day / hookworm ) d) Repeated pregnancy ( ↓hemoglobin -1gm per delivery ) e) Nephrosisà Glomerular filtration →proteinuria f) Loss of Haptoglobin /Hemopexin / Transferrin g) Heavy metal poisoning h) Loss of blood ( menustrual cycle , piles , peptic ulcers, Uterine hemorrhages )
  95. 95. Anemia II -Impaired production of RBC Defect in Heme synthesis • Nutritional • Deficiency of iron ,Copper, Vitamin B12 ,Vitamin C • Lead poisoning Deficiency of ERYTHROPOITIN • Physiological –kidney cells synthesize ERYTHROPOIETIN ↓ • ↑RBC synthesis • Chronic renal failure à no ERYTHROPOIETIN Decrease in stem cells • APLASTIC ANEMIA • MALIGNANT INFITRATION • INFLECTION
  96. 96. Hemin crystals • Fe²⁺ ↔ Fe³⁺ à Fe³⁺ + Cl⁻ à Hematin chloride or HEMIN vMedical legal cases • Blood + Blood stains + Nippe ’s fluid ( 1% KCL + KBr + KI + Glacial acetic acid à dark brown RHOMBIC crystal à microscopic inspection Heme part of Blood à Test positive
  97. 97. Hemin crystals
  98. 98. Hemoglobin estimation vDrabkin’s Test for Hemoglobin estimation : Cyanmeth Hemoglobin Method • Blood ( Hb ) + Drabkin’s reagent àCyanmeth Hemoglobin ( Absorbance - 540nm )à colorimetric estimation • Hb + potassium ferricyanide à Meth- Hb
  99. 99. Sulph Hemoglobinemia • Oxy –Hb + H₂ S à Sulph –Hb ( absorption peak at 620nm) vFormation of Sulph –Hb by sulphonamide ,Phenacetin , Dapsone ,Acetone vBasophilic striping of RBC ←Irreversible
  100. 100. Abnormal Hb or Hb variants 1.Sickle syndrome a) 1. sickle cell trait ( AS ) b) 2. sickle cell disease with SS ,SC,SD ,SO ,Sβ Thalassemia 2.Unstable Haemoglobins Congenital Heinz body anemia –Hb Zurich 3. Hb with abnormal oxygen affinity A. High affinity à Polycythemia (familial ) à Hb Chesapeake ,Olympia B.Low affinity à Cyanosis (familial ) à Hb M, Hb –Kansas, Hb- Hoppe 4. Structural variation leading to Thalassemia's phenotype A. Alpha Thalassemia à Hb Constant spring ,Delta beta Thalassemia, Hb – Lepore B. Beta Thalassemia: Hb Quong C. 5.Hemoglobin that donot produce any clinical symptoms: HbP HbQ ,HbJ
  101. 101. SICKLE CELL DISEASE vCharacteristics of Sickle cell disease a) Glutamic acid à Valine (6th position on beta chain) b) Hydrophilic à Hydrophobic ( stickiness on surface of molecule ) c) Polymerization of Hb in RBC àdistortion of RBC into sickle shaped d) Deoxy HbS has protrusion on one side & cavity on other sideà many molecules adhere together
  102. 102. SICKLE CELL DISEASE
  103. 103. Signs and symptoms of Thalassemia major
  104. 104. Inheritance of Thalassemia
  105. 105. Abnormal Hb or Hb variants III Hemolytic anaemias due to intra -corpuscular defect a) Hemoglobinopathies : HbS ,Hbc , HbM b) Thalessemias : major & minor c) Abnormal shape spherocytosis & elliptocytosis d) Enzyme deficiency à Glucose 6 Phospho dehydrogenase IV Hemolytic anemia due extra corpuscular cause /defects a) Infection –malarial parasites ,streptococcus b) Autoimmune Hemolysis –RBC membrane component ,Syphilis, Lympholenticular neoplasia c) Isoimmune hemolysis à Rh incompatibility in Newborn d) Hemolysis due to drug sensitization –Dopa quinone ( fixed on RBC )à Abnormal antibodies against altered membrane
  106. 106. Abnormal Hb or Hb variants V hemorrhages a) Hematuria b) Hematomesis c) Hemoptysis d) Peptic ulcers e) Hemorrhoides f) Thrombocytopenia g) Menorrhagia h) Bleeding tendencies

×