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Thalassaemia Thalassaemia

Haemoglobin Definition
Disorder involving the Rate of Globin Synthesis ↓ or
Absent synthesis of 1≥ Globin type
β Thalassaemia - ↓ β chain synthesis
α Thalassaemia - ↓ α chain synthesis
Haemoglobinopathy
Globin structure is abnormal (Qualitative)
Amino Acid Substitution in Globin Chain
HbS
HbC
Heterogenous group of Genetic disorders
Divided into α, β, δβ, γδβ Thalassaemia
Hb A (α2β2) Hb A2 (α2δ2) Hb F (α2γ2)
Inherited in Mendelian Recessive fashion
96-98% 3.5% <1%
Classification/ Nomenclature
Synthesis
Clinical Genetic
Globin Hydrops Fetalis – Intrauterine death
Thalassaemia Major (Transfusion dependant)
Thalassaemia Intermedia (Splenomegaly)
Thalassaemia Minor (Symptomless)

Haemoglobin

Molecular Aspect
Chromosome 11 Chromosome 16
β globin gene cluster α globin gene cluster

Haemogobin Abnormalities
↓ Rate of Synthesis of Normal Globin chain
Synthesis of Abnormal Haemoglobin
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α Thalassaemia β Thalassaemia

Definition Definition
↓ Production of α chains Commonly with Point Mutations Terminology
Commonly due to Gene(s) Deletion (Uncommon with Deletions) β୭ - No Production at all
Terminology 3 Clinical Phenotypes βା - ↓ Amount of Produ ction of β Chain
α ା - 1 gene on 1 chromosome is inactivated Minor/ Carrier
α ୭ - Both genes on 1 chromosome are inactivated Intermedia
Severe/ Major
Classification of α Thalassaemia (No α Thalassaemia Major)
Normal Minor Hb H Disease Barts Hydrops Fetalis Classification & Terminology β Thalassaemia
αα/αα -α/αα --/-α --/-- Normal Minor Intermedia Major
-α/-α β/β β/β୭ βା /βା β୭ /β୭
--/αα β/β ା Clinically can be β୭ /βା
Minor/ Major

Normal Hb H Disease Hydrops Fetalis Pathophysiol ogy of β Thalassaemia

હା Trait

Hydrops Fetalis

હ‫ ܗ‬Trait

Pathophysiol ogy
Imbalance of Globin Genes
Normal α/β chain ratio = 1:1
Ratio is ↓ in α Thalassaemia
Excess of chain
(Lead to Precipitation)
β4 – HbH
γ4 – Hb Bart’s
HbH Inclusions can be
demonstrated in Red Cells
(↓ in Trait) Clinical Phenotypes of β Thalassaemia
(↑ in Intermedia/ HbH Disease) Thalassaemia Major Thalassaemia Thalassaemia Trait
(Cooley’s anaemia) Intermedia
Clinical Features Profound Anaemia Moderate → Severe Clinically Asymptomatic
Thalassaemia Trait Hb H Disease Hydrops Foetalis Anaemia
In 1 & 2 Genes Deletion Thalassemia Intermedia 4 Genes Deletion Total Transfusion Occasional Transfusion Very Mild → No
Asymptomatic with 3 genes Deletion Incompatible for Life Dependence Required Anaemia
Only Mild/ No Anaemia Hb range – 7-11 g/dL Hb Bart Hypochromic
Hypochromic, Intermittent Haemolytic (Hb Bart disease) Microcytic
Microcytic Red Cells episodes after Red Blood Cells
TRBC cou nt ↑ Infection, Pregnancy
(5.5x10ଵଶ /L) Splenomegaly Investigation Management
Normal Hb Hb H on Electrophoresis Screening Blood Transfusi on
Electrophoresis H Inclusions detected FBC/ FBP • Evidence of Impaired Growth & Development
on Blood Film Osmotic Fragility Test during growth Spruts
Hb Electrophoresis • Intercurrent Infection
Investigations Treatment HPLC • Pregnancy
Screening No Treatment – since they are Asymptomatic Confirmatory • Alleviation of complications
FBC/ FBP Hb H is treated only when patient is Symptomatic DNA Analysis (Leg ulcers, Extramedullar haemopoiesis)
Osmotic Fragility Test (Haemolytic Episodes) by Iron Chelation
HbH Inclusion Body Transfusion, Avoiding Drugs • Blood Transfusion regime starts
Hb Electrophoresis Hydrops Foetalis is Incompatible for Life • Evidence of Iron Overload
HPLC Prevention by Parental, Prenatal screening of Therapeutic augmentation of Hb F Production
ζ Chain Analysis Foetus, Genetic Counselling
Confirmatory
DNA Analaysia

Non-Deletional α Thalassaemia (હ‫)܂‬

Uncommon
Pathogenesis
Point Mutation
Mutation affecting Termination of Translation
Hb Constant spring (most common )

Blood Smear/ Hb H Preparation Hepato-splenomegaly Frontal Bone Enlarged

FBP Hair-on-End Appearance
Target Cells
Hypochromic, Microcytic
Thalassaemia

Peripheral Blood Film

HbH Inclusion Body
Golf Ball Appearance
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Haemoglobinopathy

Thalassemia Trait Hb S Disease/ Sickle Cell (SS) Disease

Mutation in β globin gene
Heterozygous (βୱ/β) – Asymptomatic/ Mild Anaemia / No Anaemia
(Normal Red Cells, Occ. Haemolytic Crisis/ Sickling during Anaesthesia)
Homozygous (βୱ/βୱ) – More Severe presentation
(Haemolysis & Punctuated by crisis)
Laboratory
Hb ↓
Sickle cells in Blood
Splenic Atrophy
Pathophysiol ogy

Hypochromic, Microcytic
Target Cells

Thalassemia Major

Clinical
Asymptomatic at Birth
Symptoms appear as % of Fetal Hb ↓during 1st year of Life
Untreated crises ↑ Morbidity & Early Death
Clinical Features Complications
Haemolysis Folate Deficiency
Occlusion of blood vessels Aplastic Crisis
• Bone (Painful Crisis) Renal Papillary Necrosis
• Lung (Acute Chest Syndrome) Infection (P neumococcal)
• Brain Leg ulcer
• Heart Priapism
• Spleen (Acute Splenic Sequestration)
• Hands (Dactylitis in Children)
Therapy
Symptomatic – Painful Crisis
Nucleated RBC Hydroxyurea – Painful Crisis
Fragment Transfusions – Severe Anaemia
Exchange Transfusion - CNS events, Chest Syndrome
β Thalassemia Major (Post Splenectomy) Folate Prophylaxis
Allogeneic Marrow Transplantation
Sickle Cell Trait
Heterozygous Stage for HbS (HbAS)
No serious clinical conseq uences
Sudden death during intensive training
Haematuria (Renal Papillary Necrosis)
Blood Film

Howell-Jolly Bodies
Hb E Disease
Polychromasia – Hemolytic Anemia
Mutation in β globin gene (common in SEA – inc. Malaysia)
Types
Hb E Trait (β୉/β) – Mild Anaemia/ Asymptomatic
Hb E Disease/ Homozygous Hb E (β୉/β୉) – Mild Anaemia/ Asymptomatic
Compound Heterozygous (βା /β୉ or β୭ /β୉) – Resemble Thalassemia Intermedia
or Homozygous β୭ Thalassemia, Become Transfusion Dependant

Polychromatic cells
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Hb Electrophoresis HPLC

Principle Principle
At Alkaline pH (8.4-8.6) – Hb is –ve charged protein Fully Automated Analyzer
When placed in electrical field, Hb migrates towards anode (+) Cation exchange High Performance liquid chromatography
Separation of Hb fraction of agarose gel (based on Electrophoretic mobility) Separate & Determine Area % for HbA2, HbF
Provide Qualitative determinations of Abnormal Hb
by identification of Peaks, Retention time
Analyte % RT
F 2.8 1.16
P2 4.1 1.34
P3 4.1 1.72
A0 78.1 2.49
A2 7.2 3.68

Hb A 96-98%
Hb A2 3.5% (Memorize - Hb A2 ↑ but not more than 8%) Analyte % RT
HbF <1% F 7.2 1.14
P2 1.5 1.34
Lane 1 P3 3.2 1.76
Hb A 90% A0 30.6 2.63
Hb A2/E 8% A2 57.6 3.69
Hb F 2%
β Thalassemia (Minor)

Lane 4
Hb A 77.2%
Hb A2/E 2.8%
Hb F 1.0%
HbH 12%
Hb Bart 7%
α Thalassemia

Lane 6
Hb A 70%
Hb A2/E 29%
Hb F 1%
Hb E Trait (β୉/β)

Lane 3
Hb A 0%
Hb A2/E 98%
Hb F 2%
Hb E Disease
Lane 3
Hb A 4.1%
Hb A2/E 58.2%
Hb F 37.7%
Compound Hb E
β Thalassemia
βା /β୉