HAEMOGLOBINOPATHIES

Introduction to Haemoglobinopathies

HAEMOGLOBIN VARIANTS

1. Sickle syndromes:

i. Sickle-cell trait

ii. Sickle-cell disease

2. Unstable hemoglobins:

Congenital Heinz body anemia; Hb Zurich 

3. Hemoglobins with abnormal oxygen affinity:

i. High affinity- Polycythemia (familial): Hb Chesapeake

ii. Low affinity- Cyanosis (familial): HbM

4. Structural variations leading to thalassemia:

i. Alpha thalassemia- Hb Constant spring

ii. Beta thalassemia- Hb Quong sze

5. Non-symptomatic hemoglobin variants: 

HbP, Q, N, J, etc.

PROPERTIES OF THE
HUMAN HEMOGLOBINS

  • Haemoglobin critical‐ oxygen delivery
  • Can alter red cell shape, deformability, and viscosity
  • Tetramer- Bind upto 4 O2
  • 2α chains (141 amino acids) & 2β chains (146 amino  acids)

PROPERTIES OF THE
HUMAN HEMOGLOBINS

  • HbA1 (α2 β2)‐ Major Adult
  • HbA2 (α2δ2)‐ Minor
  • HbF (α2γ2)
  • Haemoglobin Tetramer‐ Highly soluble but individual globin  chains are insoluble
  • Unpaired globin precipitates, forming inclusions that damage the cell

FUNCTION OF HAEMOGLOBIN

  • Oxygen transport
  • Bind O2 efficiently & retain at high O2 tension  (alveolus)
  • Release at low O2 tension (tissue)
  • Cooperativity or heme‐heme interaction
  • Bohr effect (ability of haemoglobin to deliver more oxygen to tissues at  low pH)

HEMOGLOBIN‐OXYGEN DISSOCIATION  CURVE

CLASSIFICATION OF HEMOGLOBINOPATHIES

  1. Structural Hemoglobinopathies: Hemoglobins with altered amino acid  sequences e.g., HbS
  2. Thalassemias: Defective biosynthesis of globin chains
  3. Thalassemic Hemoglobin Variants: Structurally abnormal Hb associated  with co‐inherited thalassemic phenotype HbE, Hb Constant Spring, Hb  Lepore
  4. Hereditary Persistence of Fetal Hemoglobin
  5. Acquired Hemoglobinopathies:

i. Methemoglobin

ii. Sulfhemoglobin

iii. Carboxyhemoglobin

iv. HbH in erythroleukemia

SICKLE CELL SYNDROME (Haemoglobinopathies)

  • Mutation in β globin gene that changes sixth amino acid from  glutamic acid to valine
  • HbS polymerises reversibly when deoxygenated, to form a  gelatinous network of fibrous polymer that stiffens the  erythrocyte membrane, ↑viscosity 

These changes produce  characteristic sickle shape‐ prone to hemolysis

  • Classification:

Homozygous SS Sickle Cell Anaemia

Heterozygous AS Sickle Cell Trait (generally asymptomatic –  protects against falciparum malaria)

FACTORS INCREASING SICKLING

  • Hypoxia
  • Low pH
  • Fever
  • Infection
  • Excess exercise
  • Anxiety, dehydration
  • Abrupt temperature changes

PATHOPHYSIOLOGY
OF SICKLE CELL CRISIS

CLINICAL FEATURES

  • Anaemia
  • Jaundice
  • Splenomegaly
  • Painful swelling in hands & feet
  • Chronic lower leg ulcers probably arise from ischemia and  super infection in the distal circulation
  • Constitutional symptoms: 

i. Impaired growth

ii. ↑ Susceptibility to infection

CLINICAL FEATURES

  • Vasooclusive phenomenon
  • Microinfarct- abdomen, chest pain, back pain, joints (recurrent  painful crisis)
  • These recurrent episodes, called painful crisis, are the most  common clinical manifestation
  • Macroinfarct- splenic sequestration crisis
  • Bone marrow infarct
    • Bone aseptic necrosis, osteomyelitis
    • Renal cortical necrosis 
    • Retinal damage 
    • Skin ulcers
    • Acute chest syndrome

INVESTIGATION

  • Diagnosis is usually established in childhood
  • Childhood history
  • Hemolytic anemia
  • Granulocytosis
  • RBC morphology‐ Sickle cell, Target cell, Howell‐jolly body
  • Intermittent episodes of ischemic pain
  • Diagnostic test- Sickling test +ve with reducing substance such as  sodium metabisulfite
  • Hb electrophoresis (HbS)

TREATMENT

  • Patient require ongoing continuity of care
  • Education and familiarity with pattern of symptoms provide  the best safeguard
  • Treatment of precipitating factors
  • Preventive measures‐ regular slit‐lamp examinations
  • Antibiotic prophylaxis appropriate for splenectomized  patients during dental or other invasive procedures
  • Vigorous oral hydration during or in anticipation of periods of  extreme exercise, exposure to heat or cold, emotional stress,  or infection
  • Pneumococcal and Haemophilus influenzae vaccines.
  • Hydroxyurea:
    • 10–30 mg/kg per day 
    • Increases fetal hemoglobin  and may also exert beneficial affects on RBC hydration, vascular wall  adherence, and suppression of the granulocyte and reticulocyte counts;  dosage is titrated to maintain a white cell count between 5000 and 8000  per L
  • BMT:
    • Definitive cures known to be effective and safe only in  children. Prognostic features justifying bone marrow transplant are the  presence of repeated crises early in life, a high neutrophil count, or the  development of hand‐foot syndrome
  • Gene therapy

THALASSEMIA SYNDROME (Haemoglobinopathies)

  • Hemoglobin consist of 2α & 2β peptide chains
  • HbA 95% – α2β2
  • HbA2 5% ‐ α2 δ2
  • Fetal HbF ‐ α2 γ2

(may persist in β thalassemia)

  • At birth, Hb F appx. 80 % and Hb A- 20 %.
  • By approximately six months of age, healthy infants will have transitioned to 
    • Mostly Hb A, 
    • A small amount of HbA2, and  
    • Negligible Hb F

BLOOD FILM
OF THALASSEMIA

EPIDEMIOLOGY

  • Affects men and women equally and occurs in approximately 4.4 of every10,000 live births
  • Alpha thalassemia occurs most often in persons of African and  Southeast Asian descent
  • Beta thalassemia is most common in persons of  Mediterranean, African, and Southeast Asian descent
  • Thalassemia trait affects 5 to 30 percent of persons in these  ethnic groups

ALPHA THALASSEMIA

  • Alpha thalassemia is the result of deficient or absent  synthesis of alpha globin chains, leading to excess beta  globin chains
  • Alpha globin chain production is controlled by  two genes on each chromosome 16

BETA THALASSEMIA

  • Beta thalassemia is the result of deficient or absent  synthesis of beta globin chains, leading to excess alpha  chains
  • Beta globin synthesis is controlled by one gene on  each chromosome 11

CLASSIFICATION OF THALASSEMIA

α‐ THALASSEMIAS

  • Hb Barts‐ Hydrops Foetalis
  • Deletion of all four α chain genes
  • Total suppression of α globin chain synthesis
  • Most severe form (Homozygous state)
  • Incompatible with life
  • Diagnosis‐ Lab picture of severe HA
  • Hb‐ Electrophoresis‐ Hb Barts‐ diagnostic

Hb‐H disease

  • Deletion of three α‐chain genes
  • Hb‐H β‐globin chain tetramer (β4)
  • Markedly impaired α‐chain synthesis
  • Clinical feature‐ s/o HA
  • Lab‐ Hemolytic Anemia, Heinz bodies (brilliant cresyl  blue stain)
  • Diagnostic‐ Hb‐ Electrophoresis

β‐ THALASSEMIAS

  • β‐ Thalassemia Major
  • Common form of congenital anemia
  • Homozygous form characterized by complete absence of β chain synthesis
  • Diagnosis‐ Lab picture of severe HA
  • Hb‐ Electrophoresis‐ HbF &
    HbA2‐ Diagnostic

SEVERITY OF
β-THALASSEMIA

CLINICAL FEATURES

  • Anemia
  • Marked hepatosplenomegaly
  • Marrow hyperplasia, frontal bossing & prominent malar eminence
  • Chipmunk facies, thalassemic facies
  • Iron overload
  • Growth retardation
  • Delayed puberty, DM
  • Cardiomegaly

CHIPMUNK FACIES, THALASSEMIC FACIES

TIME OF COMPLICATIONS OF  THALASSEMIA

DIAGNOSIS

  • Most persons with thalassemia trait are found  incidentally when their complete blood count shows a  mild microcytic anemia
  • Microcytic anemia can be caused by:
  1. Iron deficiency  
  2. Thalassemia
  3. Lead poisoning  
  4. Sideroblastic anemia  
  5. Anemia of chronic disease

SUPPLEMENTAL TESTS

  • Include:
  • Serum ferritin
  • The peripheral smear
  • Hemoglobin electrophoresis
  • Serum lead level
  • Rarely bone marrow aspirate

THE HEMOGLOBIN ELECTROPHORESIS

TREATMENT

  • Blood transfusion to maintain hematocrit
  • Folate supplementation
  • Avoid iron therapy
  • Desferrioxamine for iron chelation
  • Splenectomy
  • Allogenic bone marrow transplantation
  • Gene therapy
  • Antenatal diagnosis of thalassemia syndromes is now widely  available.
  • DNA diagnosis is based on PCR amplification of fetal DNA,  obtained by amniocentesis or chorionic villus biopsy

PREVENTION

  • Blood tests and family genetic studies can  show whether an individual has  thalassemia or is a carrier
  • A genetic counselor can detail the family  background, discuss risks

Other Biochemistry Notes

. Biochemistry of Proteins

Carbohydrate Metabolism

VITAMIN PYRIDOXINE AND BIOTIN

Vitamin A

Pyrimidine metabolism

Purine Metabolism

Cardiac Biomarkers

VITAMIN D

. Blood Metabolism (Heme synthesis and breakdown)

DNA Repair

Regulation of gene expression

DNA Replication

Transcription

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