ANAEMIAS DUE TO EXCESSIVE RED CELL DESTRUCTION

A. Disorders of Haemoglobin
THALASSAEMIAS
• They are a heterogeneous group of inherited disorders of haemoglobin
characterized by reduced or absent production of one of the globin
chains (alpha or beta).
• Are an inherited autosomal recessive blood disease. The genetic defect
results in reduced rate of synthesis of one of the globin chains that make
up haemoglobin.
• Reduced synthesis of one of the globin chains can cause the formation of
abnormal hemoglobin molecules, thus causing anaemia, the
characteristic presenting symptom of the thalassemias.
THALASSAEMIAS CONT…

Inherited disorders of haemoglobin

• Thalassaemias: Deficient of synthesis of one or more of the globin
polypeptide chains.
• Haemoglobinopathies: Structural alteration of the globin polpeptide
resulting in the formation of a variant haemoglobin i.e. Sickle cell anaemia
Classification of thalassaemias
• Thalassaemia major
• Thalassaemia minor
• Thalassaemia intermedia alpha thalassaemia
• Hb Barts hydrops foetalis syndrome
• HbN disease
• Thalassaemia trait
• Silent carrier
THALASSAEMIAS CONT.....

There are three clinical forms of beta thalassaemias;

 Beta thalassaemia major
 Beta thalassaemia minor
 Beta thalassaemia intermidia
 Beta0 thalassaemia is characterised by complete absence of beta chain
synthesis while in beta+ thalassaemia, beta chain synthesis is reduced but
not completely lacking.
Beta thalassaemia major is produced by the following genotypes:
• Beta0/beta0 (Homozygous beta0thalassaemia)
• Beta0/beta+ (Heterozygous beta thalassaemia)
• Beta+/beta+ (Homozygous beta+ thalassaemia)
THALASSAEMIAS CONT.....

Beta thalassaemia minor results from the following genotypes:

• Beta0/beta (Heteozygous beta0 thalassaemia)
• Beta+/beta (Heterozygous beta+ thalassaemia)
Beta thalassaemia intermedia is produced by the following genotypes:
• Beta+/beta+
• HbE/beta
Thalassemia has an autosomal recessive pattern of inheritance
What is seen
In Beta Thalassemia Major (Homozygous beta thalassemia):
• Severe haemolytic anaemia (Hb 2-6g/dl) develops around 6 months of age
when switch occurs from HbF to HbA.
• Failure to thrive, skeletal changes, hepatosplenomegaly, infections and iron
overload are the usual features.
• Regular blood transfusions along with iron chelation therapy are required to
sustain life; without treatment death is usual during childhood.
• On blood smear: marked variation in size and shape of red cells,
hypochromia, microcytosis, basophilic stippling, target cells and nucleated
red cells.
• Slight reticulocytosis due to ineffective erythropoiesis.
• MCV, MCH and MCHC are reduced.
• Bone marrow iron and serum ferritin are increased
• Hb electrophoresis; in beta0/beta0 ,HbF is 98% with HbA2 while in
beta0/beta+ and beta+/beta+, amount of HbA is present.
What is seen CONT….

In Beta thalassaemia Minor (Hetrozygous Carrier State):

• Mild microcytic hypochromic anaemia (Hb 9-11g/dl).
• Clinical features absent; incidental diagnosis when low MCV is detected
on haematology cell analyzer or when family studies are performed in
case of thalassaemia major.
• Blood smear; micricytosis, hypochromasia, target cells and basophilic
strippling.
• Red cell indices: Low MCV (microcytosis).
• Hb electrophoresis: Raised Hb A2 (3.5-7%).
Note
• Accurate identification is essential for genetic couselling and to distinguish
it from iron deficiency anaemia.
SICKLE CELL DISORDERS
• These are conditions in which red cells becomes sickle shaped when they
are subjected to low oxygen tension.
Sickle cell disease (SCD)
• Sickle cell anaemia: Is the name of a specific form of sickle-cell disease in
which there is homozygosity for the mutation that causes HbS. It is also
referred to as "HbSS", "SS disease”-a person inherits a haemoglobin S (HbS)
gene from both parents. It is common in Africa, parts of India, the Middle
East and the Caribbean.
• Sickle beta-zero-thalassaemia (HbS/β 0): This is a double heterozygous state
in which the sickle cell gene is inherited from one parent and beta
thalassaemia gene from the other parent (HbS/β +) found in North Africa.
• Sickle cell haemoglobin C (HbSC) disease in which the person inherits HbS
gene from one parent and HbC gene from the other,found in West Africa.
• Sickle cell haemoglobin D punjub (HbSDpunjub) disease in which HbS is inherited
with HbDpunjub. It is found in amongst Sikh people.
Causes of Sickle Cell Anemia
• Sickle cell anemia is an inherited disease. People who have the disease
inherit two copies of the sickle cell gene—one from each parent.
• The sickle cell gene causes the body to make abnormal hemoglobin.
Hemoglobin is the iron-rich protein that gives blood its red color and
carries oxygen from the lungs to the rest of the body.
• In sickle cell anemia, the hemoglobin sticks together when it delivers
oxygen to the body’s tissues. These clumps of hemoglobin are like liquid
fibers. They cause the red blood cells to become stiff and shaped like a
sickle, or “C.” The sickled red blood cells tend to stick together and get
caught in the blood vessels.
• Two copies of the sickle cell gene are needed for the body to make the
abnormal hemoglobin found in sickle cell anemia.
Sickle Cell Disorders Cnt….

Sickle cell trait

• This is the heterozygous carrier state for HbS (HbAS) in which sickle cell
gene is inherited from one parent and gene for HbA from the other.
• If you inherit only one copy of the sickle cell gene (from one parent), you
will not have sickle cell anemia. Instead, you will have sickle cell trait.
• There is a change of a single base A to T (A→T) in the 6th codon of beta
gene found on short arm of chromosome 11 so that there is substitution
of thymine for adenine.
• This in turn results in substitution of valine for glutamic acid at position 6
of beta polypeptide chain.
• People who have sickle cell trait usually have no symptoms and lead
normal lives. However, they can pass the sickle cell gene to their children.
Example of an Inheritance Pattern for Sickle Cell Trait
Complications of Sickle Cell Anaemia
• Infections: e.g. Strep pneumonia, Haemophilus influenzae. This is because
sickle cell anemia can damage the spleen, an organ that helps fight
infections. Pneumonia is the most common cause of death in young
children while meningitis, influenza, and hepatitis are other infections that
are common in people who have sickle cell anemia.
• Vascular occlusive crises (obstruction of microcirculation by sickled cells
causing ischaemia and infarction).
• Haematologic crises: aplastic, megaloblastic, splenic sequestration,
haemolytic (acute aggravation of anaemia).
• Hand-Foot Syndrome: Sickle cells can block the small blood vessels in the
hands or feet leading to pain, swelling, and fever.
• Strokes: Two forms occur ; One form occurs when a blood vessel in the
brain is blocked and the other form occurs when a blood vessel in the
brain bursts causing learning disabilities and/or lasting brain damage,
long-term disability, paralysis (an inability to move), or death.
• Chest syndrome (fever, cough, chest pain and lung infiltrates).
Laboratory Diagnosis
Sickle Cell Anaemia:
• FBC: Reveals Hb levels in the range of 6-8 g/dl
• Reticulocytes is high as the bone marrow compensates for the destruction of
sickle cells by producing more red blood ceels.
• Blood film shows: sickled cells, target cells, nucleated red cells and may also
shows features of hyposplenism (target cells and Howell-Jolly bodies).
• Sickling test and solubility test: Positive
• Hb electrophoresis and high performance liquid chromatography (HPLC) will
show HbS as the major haemoglobin i.e. > 80% remaining being HbF.
Laboratory Test Principles
Hb Electrophoresis
 Is used to separate and identify the different haemoglobins by their migration
within an electric field.
 Haemoglobin variants separate at different rates due to differences in surface
electrical charge as determined by their amin acid structure.
Laboratory Test Principles Continued

Sickling test
 Blood is mixed on a slide with a chemical reducing agent such as Sodium
metabisulphate or Sodium dithionate covered with a cover glass and
incubated at room temperature for up to 1 hour or more.
 The reducing agent deoxygenates the haemoglobin in the red cells
providing the condition for cells containing HbS to sickle.
Hbs Solubility Filtration test
 Blood is mixed in a phosphate buffer- saponin solution containing Sodium
dithionate and filtered.
 In its deoxygenated form, HbS is insoluble. HbSS is indicated by a red
precipitate on a filter paper with a pale yellow filtrate.
 Other forms of haemoglobin are soluble when in a reduced state.
Appearance of Sickled cells on Blood film
Laboratory Diagnosis continued

Sickle Cell Trait:

• Usually assymptomatic; absence of anaemia.
• Occasionally inability to concentrate urine, haematuria (renal papillary
necrosis); painful crises at high altitudes.
• No sickle red cells on blood smear
• Haemoglobin electrophoresis and HPLC shows more HbA than Hb
NOTE
• In a carrier, the presence of the malaria parasite causes the red blood
cells with defective haemoglobin to rupture prematurely, making the
plasmodium unable to reproduce. Further, the polymerization of Hb
affects the ability of the parasite to digest Hb in the first place. Therefore,
in areas where malaria is a problem, people's chances of survival actually
increase if they carry sickle-cell trait (selection for the heterozygote).
Treatment
• Cyanate: Dietary cyanate, from foods containing cyanide derivatives. The
cyanate would have to be administered to the patient for a lifetime, as
each new red blood cell created must be prevented from sickling at the
time of creation.
• Folic acid and penicillin: Children born with sickle-cell disease will require
management by a hematologist to assure they remain healthy. These
Laboratory Diagnosispatients will take a 1 mg dose of folic acid daily for
life.
• Painful crises are treated symptomatically with analgesics; pain
management requires opioid administration at regular intervals until the
crisis has settled.
• Dialysis or kidney transplant for kidney disease.
• Drug rehabilitation and counseling for psychological complications .
• Gall bladder removal (if patient has gallstone disease).
ANAEMIAS DUE TO EXCESSIVE RED CELL DESTRUCTION
CONTINUED
B. Hereditary Spherocytosis (HS)
• This is a congenital haemolytic disorder characterized by an inherited
defect in red cell membrane cytoskeleton leading to the formation of
spherocytic red cells.
• Spherocytes have reduced surface compared to volume and are
osmotically fragil.e
• The most common defect is abnormality of ankyrin in the red cell
membrane leading to instability of spectrin, membrane loss and
formation of spherocytes.
• Spherocytes are less deformable than normal red cells and are destroyed
in spleen.
• The usual presentation is in the form of mild chonic haemolytic anaemia
with splenomegaly.
Diagnosis of Hereditory Spherocytosis

It is based on combination of the following features:

• Presentation in childhood with anaemia, jaundice and splenomegaly.
Gallstones is a common complication.
• Positive family history of jaundice or, gallstones or of splenectomy.
• Spherocytes on blood smear.
• Reticulocytosis.
• Negative direct antiglobulin (Coomb’s) test –to differentiate HS from
haemolytic anaemia that also causes spherocytosis.
• Osmotic fragility (OF) test showing increased fragility of red cells.
Note: (It is not necessary for diagnosis if all above features are present)
REFERENCES

• Shirish M Kawthalkar- Ashan Gold Standard Mini Atlas Series:

Haematology.
• Samuel I Rapaport- Introduction to Haematology 2nd Edition, pages 88-109
• Monica Cheesbrough, District Laboratory Practice in Tropical Countries 2nd
Edition pages 334-337