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Thalassaemia

DR. AFSHAN SUMERA

Session Outcomes
At the end of session you should have learnt to
1. Discuss the pathogenesis of thalassemia 2. Explain the genetic basis of different types of thalassemia 3. Describe the clinical features of thalassemia 4. Differentiate thalassemia from other types of hypochromic microcytic anaemia

Background/Introduction
Thalassemia is a diverse group of genetic blood diseases Most common single gene disorder Worldwide prevalence 3% Progressive global public health problem Estimated 900,000 births expected worldwide in next 20 years
3

Worldwide Thalassemia Situation


Malaria resistant Thalassemia minor Along the mediterranian sea belt. Changing scenario population migration
-thalassemias
South East Asia, Malaysia, Southern China

-thalassemias
Mediterranean Sea area, Africa and Southeast Asia

North America
Increasing prevalence

Thalassemia in Malaysia- Perspective


Estimated frequency of beta thalassemia carrier
4.5% -6%

Incidence of thalassemia in new born babies


150 and 350 every year

Transfusion dependent patients of beta- thalassemia


5600

Organization Of The Gene Clusters Encoding Human Haemoglobin

MESOBLASTIC

HEPATIC BONE MARROW

spleen

22 FETAL

22 ADULT

22 - A2

Thalassemia Syndromes
Heterogeneous group of disorders
Inherited mutations
Decreased synthesis of adult hemoglobin, HbA (22)

Most common inherited disorders of humans chromosome 16 identical pair of -globin genes two chains chromosome 11 single -globin gene two chains

-Thalassemias-Pathogenesis
Causative mutations
0 mutations, associated with absent -globin synthesis + mutations, characterized by reduced (but detectable) -globin synthesis

Types of mutations
Splicing Promoter region (75-80%) Chain terminator mutations (0)

Anaemia in -Thalassemia
Deficit in HbA synthesis produces
under-hemoglobinized hypochromic, microcytic red cells subnormal oxygen transport capacity

Diminished survival of red cells and their precursors, which results from the imbalance in - and -globin synthesis

Unpaired chains
Unpaired chains precipitate within red cell precursors
insoluble inclusions
membrane damage

Pathogenesis of -thalassemia major

-Thalassemia- uncompensated Anaemia


Severe uncompensated anaemia
Erythropoietic drive
massive erythroid hyperplasia in the marrow

extensive extramedullary hematopoiesis (liver, spleen, and lymph nodes)

Excessive absorption of dietary iron leads to injury to parenchymal organs

Expanding mass of red cell precursors erodes the bony cortex,


impairs bone growth, and produces skeletal abnormalities

Crew-cut appearance

Bones of the face and skull the growing marrow erodes existing cortical bone and induces new bone formation, giving rise to a crew-cut appearance on x-ray

Clinical Syndromes
Clinical Syndromes
-THALASSEMIAS -Thalassemia major

Genotype

Clinical Features

Molecular Genetics

Homozygous -thalassemia Severe; requires blood (0/0, +/+, 0/+) transfusions Variable (0/+, +/+, 0/, +/)

-Thalassemia intermedia

Mainly point mutations that lead to defects in the transcription, splicing, or Severe but does not require translation of -globin mRNA regular blood transfusions

-Thalassemia minor

Heterozygous -thalassemia Asymptomatic with mild or (0/, +/) absent anaemia; red cell abnormalities seen

-THALASSEMIAS Silent carrier

-/ /

Asymptomatic; no red cell abnormality

Mainly gene deletions

-Thalassemia trait

-/- / (Asian) Asymptomatic, like -/ -/ (black African, Asian) thalassemia minor


-/- -/ Severe; resembles thalassemia intermedia Lethal in utero without transfusions

HbH disease

Hydrops fetalis

-/- -/-

-Thalassemia Major
Anaemia manifests 6 to 9 months after birth as hemoglobin synthesis switches from HbF to HbA

Untransfused patients, hemoglobin levels are 3 to 6 gm/dL. HbA2 levels are sometimes high but more often are normal or low (silent carriers)

Morphology
Blood smears show anisocytosis and poikilocytosis, microcytosis, and hypochromia. Target cells, basophilic stippling & fragmented red cells Reticulocyte count is elevated, but it is lower than expected for the severity of anaemia because of the ineffective erythropoiesis

Morphology- Beta Thalassemia


Lymphocyte Basophilic stippling

Target cell

Nucleated RBC

Clinical Course
Phagocyte hyperplasia and extramedullary hematopoiesis
Splenomegaly (1500 gms) liver and the lymph nodes can also be enlarged

Untreated children suffer from growth retardation and die at an early age from the effects of anaemia Blood transfusions
improve anaemia and suppress complications related to excessive erythropoiesis, lead to complications of their own

Clinical Course
Progressive iron overload (secondary hemochromatosis due to blood transfusion)) With transfusions and iron chelation, survival into the third decade is possible, but the overall outlook remains guarded Bone marrow transplantation is the only therapy offering a cure and is being used increasingly

Thalassemia Trait (Minor)


-Thalassemia minor is much more common than thalassemia major Subjects are usually asymptomatic with mild anaemia Peripheral blood smear shows hypochromia, microcytosis, basophilic stippling, and target cells

Hemoglobin electrophoresis usually reveals an increase in HbA2 (22)

Thalassemia Trait (Minor)

-thalassemia trait- Why differentiation needed?

Recognition of -thalassemia trait is important for two reasons


(1) differentiation from the hypochromic microcytic anaemia of iron deficiency and (2) genetic counseling

-Thalassemias- Inheritance
Inherited deletions
reduced or absent synthesis of -globin chains

In newborns with thalassemia,


excess unpaired -globin chains form 4 tetramers known as hemoglobin Barts

Older children and adults


excess -globin chains form 4 tetramers known as HbH

-Thalassemias- Pathogenesis
Free and chains are more soluble than free chains
form fairly stable homotetramers hemolysis and ineffective erythropoiesis are less severe than in -thalassemias

Gene deletion is the most common cause of reduced -chain synthesis

-Thalassemias- Pathogenesis
Clinical syndromes are determined and classified by the number of -globin genes that are deleted Each of the four -globin genes normally contributes 25% of the total -globin chains -Thalassemia syndromes stem from combinations of deletions that remove one to four -globin genes.

Severity of the clinical syndrome is proportional to the number of -globin genes that are deleted

Silent carrier state


Deletion of a single -globin gene
barely detectable reduction in -globin chain synthesis asymptomatic slight microcytosis

-Thalassemia Trait
Deletion of two -globin genes from a single chromosome (/, -/-), or the deletion of one -globin gene from each of the two chromosomes (/, /) Symptomatic -thalassemia is relatively common in Asian populations and rare in black African populations Clinical picture in -thalassemia trait is identical to thalassemia minor, that is, small red cells (microcytosis), minimal or no anaemia, and no abnormal physical signs HbA2 levels are normal or low.

Hemoglobin H Disease
Deletion of three -globin genes HbH disease is most common in Asian populations
Only one normal -globin gene HbH has high affinity for oxygen
tissue hypoxia

HbH is prone to oxidation


precipitate out intracellular inclusions red cell sequestration phagocytosis in the spleen

Moderately severe anaemia

Hydrops Fetalis
Severe form of -thalassemia
deletion of all four -globin genes

In fetus, excess -globin chains form tetramers (hemoglobin Barts)


high affinity for oxygen deliver little to tissues

Survival in early development is due to the expression of chains,


embryonic globin that pairs with chains to form a functional 22 Hb tetramer

fetal distress usually become evident by the third trimester of pregnancy

Laboratory Tests
Classical - thalassaemia carriers have

typically reduced red cell indices


MCV <80 fl MCH <27 pg MCHC normal high RBC counts

-thalassaemia HbA2 > 3.5% -thalassaemia HbA2 3.5 % -thalassaemia usually suggested by exclusion of -thalassaemia & Iron deficiency anaemia

Quantification of HbA2, HbF, HbS & HbC

Mutational analysis to detect alpha thalassaemia

Diagnosis- Flow chart

References
Madan N et al, Red cells Indices in anaemia. Indian J Pathol Microbiol 1999, Shahid et al, Prenatal diagnosis of -Thalassemia in Southern Punjab, Pakistan. Prenat Diagn2006, Urrechaga, Discriminant value of % microcytic/% hypochromic ratio in the differential diagnosis of microcytic anaemia. Clin Chem Lab Med 2008 Ghani R, hemoglobinopathies among five major ethnic groups in Karachi, Pakistan. Southeast Asian J Trop Med Public Health 2002 Tan JAMA, George E, Tan KL, Chow T, Tan PC, Hassan J, Chia P, Subramanium, R, Chandran R, Yap SF. Molecular defects in the -globin gene identified in different ethnic groups/populations during prenatal diagnosis for -thalassaemia: A Malaysian experience. Clin Exp Med 2004; 4: 142-147. George E. Beta thalassaemia major in Malaysia, an on-going public health problem. Med J Malaysia 2001; 56,4:397-400.

References
Tam S: RM 40 mil to treat 600,000 victims of thalassaemia. In The Star Online Kuala Lumpur; 2005. George E, Jamal A, Khalid F, Osman K: High performance liquid chromatography (HPLC) as a screening tool for classical beta-thalassaemia trait in Malaysia. Malaysian Journal of Medical Sciences 2001, 8(2):40-46. A trial of recombinant human interleukin-1 in patients with severe refractory aplastic anaemia Ann Rev Med. 1992 Robins & Cotran Pathologic Basis of Diseases, 8th Edition Essential Haematology, A.V. Hoffbrand, 6th Edition