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Hemoglobinopathies
Hemoglobinopathy
Quantitative
o thalassemia: reduced rate of hemoglobin
synthesis but do not affect the amino acid
sequence of globin chains
produces anemia and stimulates the production of other
hemoglobins not affected by the mutation in an attempt
to compensate for the anemia
Structure of Globin Genes
o embryonic life
activated/ synthesis of production of
six months after birth replaced by chain Hb A or adult hgb
chains decreases (2 2 )
around birth chains at low levels Hb A2 or 2nd adult hgb
(2 2 )
Point Mutation
o substitution of one amino acid in the globin chain
product at position to the location of the original
point mutation
o 1109 of 1181 know hgb variants: point
mutation=amino acid substitution
o 35: two point mutations in same globin gene= two
amino acid substitution
Genetic Mutations
Chain extensions
o when stop codon is mutated so that translation
continues beyond the typical last codon
o amino acids continue to be added until stop codon
is reached by chance
o globin chains: longer than normal
o globin chain extensions= degradation of globin
chain and quantitative defect
Genetic Mutations
Chain extensions
o if extension of globin chain is insufficient to
produce significant degradation: defect is
qualitative and classified as hemoglobinopathy
o hgb molecules with extended globin chains: fold
inappropriately which affects hgb structure and
function
Genetic Mutations
Gene fusions
o when two normal genes break between
nucleotides, switch positions, and anneal to the
opposite gene
o example: if -globin gene and -globin gene
break in similar locations, switch positions, and
reanneal
resultant genes: and fusion genes= head of the
fusion gene is from one original gene and the tail is from
the other
Genetic Mutations
Gene fusions
o reading frames not disrupted
o similar globin chain lengths
o genes are transcribed and translated into hybrid
globin chains
o fusion chains fold differently
o affect the corresponding hemoglobin function
o 9 identified
Zygosity
o heterozygous -hemoglobinopathies
one gene mutated and the other is normal
50/50 distribution
variant hgb usually present in lesser amounts than
Hb A: due to an attempt to minimize the impact of
abnormal hgb
in some cases: present in equal amounts
examples: Hb S trait (Hb AS) and Hb C trait (Hb
AC)
Pathophysiology
History
o origin not identified
o symptoms of disease have been traced in one
Ghanaian family (1670)
o 1910: first report by Chicago cardiologist,
Herrick= West Indian student with severe anemia
o 1917: Emmel recorded that sickling occurred in
nonanemic patients and in patients who were
severely anemic
Hemoglobin S: History
Inheritance Pattern
o hemoglobin variants: autosomal codominants,
with one gene inherited from each parent
o patients with SCD (Hb SS), Hb SC, or Hb S--
thalassemia: inherited a sickle (S) gene from one
parent and an S,C, or -thalassemia gene from the
other
o homozygotes (Hb SS): more severe
o heterozygotes (Hb AS): generally asymptomatic
Hemoglobin S: Sickle Cell Anemia
Prevalence
o highest frequency: Sub-Saharan Africa: 230,000 babies
born each year with SCD (0.74%)
o in five geographic areas
Clinical Features
o from no symptoms to potentially lethal state
o symptoms vary between ethnic groups with Indian
patients expressing a much milder disease than their
African counterparts
o thousand hemoglobin variants known
o only 8 genotypes cause severe disease: Hb SS,
Hb S--thal, severe Hb S-+-thal, Hb SD-Punjab, Hb
SO-Arab, Hb SC-Harlem, Hb CS-Antilles, and Hb S-
Quebec-CHORI
BOX 27-3
Hemoglobin S: Clinical Features
o during inflammation:
increased WBCs interacting with endothelium
platelet activation= elevation of thrombospondin
clinical dehydration= increase VWF
trigger RBC adherence to endothelium
precipitate vascular obstruction
Hemoglobin S: Clinical Features
o Bacterial infections
major problem for SCD patients
increased susceptibility to life-threatening infection
from S. aureus, S.pneumoniae, and H.influenzae
acute infections: common causes of
hospitalization and most frequent cause of death
Hemoglobin S: Clinical Features
o Bacterial infections
Septicemia: bacterial infection of blood
exacerbated by autosplenectomy effect as spleen
gradually loses its ability to function as a
secondary lymphoid tissue to effectively clear
organisms from the blood
Hemoglobin S: Clinical Features
o Megaloblastic episodes
result from sudden arrest of erythropoiesis due to
folate depletion
folic acid def: cause of exaggerated anemia in
SCD (extremely rare in US)
prophylactic folic acid: prescribed for SCD
patients
Hemoglobin S: Clinical Features
o Cardiac defects
enlarged heart and heart murmurs
severe anemia: cardiomegaly develop as heart
works harder to maintain adequate blood flow and
tissue oxygenation
increased cardiac workload with increased BM
erythropoiesis
increases calorie burning= reduced growth rate
at childbearing age: pregnancy becomes risky
Hemoglobin S: Clinical Features
o Microstrokes
lead to headaches, poor school performance, reduced
intelligence quotient (IQ), and overt CNS dysfunction
neurologic examination followed by magnetic
resonance imaging (MRI) and transcranial Doppler
ultrasonography or magnetic resonance angiography
recommended to detect microstrokes
Hb S: Incidence with Malaria
and G-6PD Deficiency
9
o moderate leukocytosis: 40-50 x10 WBC/ L
o neutrophilia and mild shift toward immature WBCs
o LAP: not elevated when neutrophilia is caused by
sickle cell crisis alone (no underlying infection)
o thrombocytosis
o BM: erythroid hyperplasia= attempt to
compensate for the anemia
Hb S: Laboratory Diagnosis
o HPLC
separated hemoglobin types in a cation
exchange column
requires only one sample injection
identify and quantitate low levels of Hb A2 and Hb F
comigration of Hb A2 and Hb E occurs
Hb S: Laboratory Diagnosis
o HPLC
best used in diagnosis of thalassemias rather
than hemoglobinopathies
quantitation of low levels of normal and abnormal
hemoglobin levels: to distinguish thalassemia
also used to quantitate Hb A1c levels to monitor
diabetic patients
Hb S: Laboratory Diagnosis
o Capillary Electrophoresis
separates hemoglobin types based on charge in an
alkaline buffer
use smaller volumes and produces better
separation than traditional agarose electrophoresis
semiautomated systems: Capillary system: allow
for the testing of up to eight samples in parallel
with computerized analysis of results
economical: each capillary can accommodate at
least 3000 runs
Hb S: Laboratory Diagnosis
o Neonatal Screening
requires more sophisticated approach
use three techniques: adapted IEF, HPLC, and
reversed-phase HPLC
mutisystem approach that needs to distinguish not
only the multitude of hgb variants but also the
numerous thalassemias
Hb S: Laboratory Diagnosis
o BM or HSC transplantation
patients for transplantation: children younger than
age 17 with severe complications (stroke, ACS, and
refractory pain)
morbidity and mortality after transplantation:
increase with age (another restriction)
restores some splenic function
Hb S: Treatment
o BM or HSC transplantation
cord blood stem cells transplantation from HLA-
identical related and unrelated donors: disease-free
survival rate of 90%
primary benefit: banking of cord blood increases
number of units available to achieve an HLA match
utero stem cell transplantation: to produce
engraftment while immune system of the fetus is
prone to HLA tolerance
Hb S: Treatment
o splenic infarcts
in severe respiratory infection, unpressurized flight
at high altitudes, and anesthesia in which pH and
oxygen levels are sufficiently lowered to cause
sickling
o failure to concentrate urine: only consistent
abnormality found in SCT patients
by diminished perfusion of vasa recta of the kidney
impairs concentration of urine by the renal tubules
renal papillary necrosis with hematuria in some px
Hb S: Sickle Cell Trait
Electrophoresis
o Hb S: 40% or less
also seen in patients with -thalassemia or iron or
folate deficiency
o Hb A: 60% or more
o Hb A2: normal or slightly increased
o Hb F: within reference interval
no treatment required
life span: not affected
Hemoglobin C
o lysine: +1 charge
o glutamic acid: -1 charge
o result of substitution: net charge of +2
o different structural effect on the hgb molecule
than the Hb S substitution
o inherited in the same manner as Hb S but
manifests milder disease
Hb C: Prevalence, Etiology,
and Pathophysiology
o Hb AC trait:
Hb A: 60%
Hb C: 30%
o cellulose acetate electrophoresis at alkaline pH
Hb C migrates in same position as Hb A2, Hb E,
and Hb O-Arab
o citrate agar electrophoresis at acid pH
Hb C separated from other hemoglobins
Hb C: Laboratory Diagnosis
o no specific treatment
o disorder becomes problematic only if infection
occurs or if mild chronic hemolysis leads to
gallbladder disease
Hb C-Harlem (Georgetown)
o heterozygotes: asymptomatic
o compound heterozygotes for Hb S and Hb C-
Harlem: crises similar to those in Hb SS disease
o solubility test: positive
o confirmatory: hgb electrophoresis and HPLC
o cellulose acetate at pH 8.4: migrates in C position
o citrate agar at pH 6.2: migration in S position
Hb C-Harlem (Georgetown)
o net charge: +2
o no hemoglobin polymerization due to the position
of the substitution
o aa substitution at codon 26: inserts a cryptic
splice site
causes abnormal alternative splicing
decreased transcription of functional mRNA for Hb E
globin chain
Hb E: Prevalence, Etiology,
and Pathophysiology
o Hb E trait: aysmptomatic
o Hb E combined with -thalassemia: more severe
than Hb EE and more closely resembles -
thalassemia major
requires regular blood transfusions
Hb E: Laboratory Diagnosis
homozygotes heterozygotes
Hb E 90% 30-40%
MCV 55-65 fL (low) 65 fL
Target cells few to many present
others normal slight
reticulocyte count erythrocytosis
Hb E: Laboratory Diagnosis
o Hb G-Philadelphia
chain variant: substitution of asparagine by lysine at
68 Asn Lys
position 68 (2 2)
most common G variant in African Americans
seen with greater frequency than Hb D variants
also found in Ghana
o do not sickle
o hemoglobin solubility test: negative
Hemoglobin D and G
o alkaline electrophoresis
Hb D and G have same mobility as Hb S
o citrate agar at pH 6.0
Hb D and G separated from Hb S
o these variants should be suspected whenever :
a hgb is encountered that migrates in S position on
alkaline electrophoresis
and if the hgb solubilty test is negative
Hemoglobin D and G
o alkaline electrophoresis
Hb D-Punjab comigrates with Hb S
mutation look like SCD
o both are not clinically significant in either the
heterozygous or homozygous form
Hb S- Korle Bu
Hemoglobin C- Harlem
hemoglobin solubility test: positive
cellulose acetate at alkaline pH
migrates to the C position
citrate agar at acid pH
migrates to S position
Concomitant Cis Mutations
with Hb S
Hb S-Antilles
Hb S mutation with a second substitution of
isoleucine for valine at position 23
Hb S-Oman
Hb S mutation with a second substitution of lysine
for glutamic acid at position 121
Clinical Features
o detected in early childhood in patients with
hemolytic anemia with jaundice and splenomegaly
o fever or ingestion of an oxidant: worsen hemolysis
o severity of anemia depends on the degree of
instability of the hgb molecule
o unstable hgb: precipitates in vivo and in vitro
in response to factors that do not affect normal hgb (eg
drug ingestion and heat or cold exposure)
Unstable Hemoglobin Variants
Clinical Features
o Heinz bodies: precipitated hgb
attaches to the cell membrane, causing clustering of
band 3, attachment of autologous immunoglobulin, and
macrophage activation
trapped mechanically in the splenic sieve= shortens
RBC survival
abnormal oxygen affinity
Unstable Hemoglobin Variants
Clinical Features
o most prevalent: Hb Koln
o other: Hb Hammersmith, Hb Zurich, Hb Gun Hill
o large variability in the degree of instability
extent of hemolysis varies greatly
o Hb Zurich: presence of an oxidant is required for
any significant hemolysis to occur
Unstable Hemoglobin Variants
Laboratory Diagnosis
o RBC morphology varies
o normal or slight hypochromia
o prominent basophilic stippling
may be caused by excessive clumping of ribosomes
o before splenectomy: hgb= 7-12 g/dL
: retic count= 4-20%
o after splenectomy: anemia is corrected,
reticulocytosis persists
Unstable Hemoglobin Variants
Laboratory Diagnosis
o Heinz bodies in supravital stain
after splenectomy: larger and more numerous
o many patients excrete dark urine with dipyrrole
o many unstable hemoglobin: migrate in the normal
AA patterns
not detected on electrophoresis
Unstable Hemoglobin Variants
Laboratory Diagnosis
o other tests to detect these variants
isopropanol precipitation test
principle: isopropanol solution at 37C weakens
the bonding forces of the hgb molecule
if unstable hgb present: rapid precipitation
occurs in 5 mins, heavy flocculation after 20 mins
normal hgb: precipitate after approx 40 mins
Unstable Hemoglobin Variants
Laboratory Diagnosis
o other tests to detect these variants
Heat Denaturation Test
incubated at 50C for one hour
heat sensitive unstable hgb: flocculent precipitation
normal hgb: little or no precipitation
Unstable Hemoglobin Variants
Laboratory Diagnosis
o significant number of Heinz bodies appear after
splenectomy
o individuals with intact spleen:
with longer incubation and addition of oxidative
substance (eg acetylphenylhydrazine)
unstable hgb: form more Heinz bodies
Unstable Hemoglobin Variants
Laboratory Diagnosis
o isoelectric focusing: resolve many hgb variants
with only a slight alteration in their isoelectric point
o HPLC or DNA-based globin gene analysis
Unstable Hemoglobin Variants