Case report :

A 63 year old male who is a car driver by profession came to the General Medicine Out-Patient
Department with the complaints of back pain, neck pain, restricted left shoulder movements,
numbness over right leg and blurring of vision. There was no history of trauma. He is a known
Diabetic since 10 years taking oral hypoglycemic agents. He is a known case of anemia with previous
multiple blood transfusions. There were previous hospital admissions for generalised weakness,
anemia and diabetic ulcer. He was non-alcoholic and non-smoker. The history and presenting
complaints were likely in favour of multiple myeloma.

On examination, he was a moderately built man with a body mass index of 24.8kg/m2. The general
examination showed pallor. His pulse rate was 86 beats/min which was regular in rate, rhythm, and
character with no delays. The blood pressure was 120/70mm Hg. The straight leg raising test was
more than 80 degrees in both the legs. There were no spinal deficits. Abdominal examination
showed splenomegaly. Sensory examination showed evidence of posterior column involvement with
impaired fine touch and vibration sense upto the mid leg. Motor system and reflexes were normal.
There were no cerebellar signs. These findings were likely in favour of diabetic neuropathy.

Basic laboratory investigations showed hemoglobin of 7.9gm/dl. MCV was 58fl. Reticulocyte count
was 5.4% , indicating a hyperproliferative marrow. Total counts and platelet counts were within
normal limits. Peripheral blood smear showed microcytic hypochromic anemia with reticulocytosis.

Serum Iron , Vitamin B12 and Folic acid levels were normal. Thyroid profile was normal. Multiple
myeloma was suspected and urinary Bence Jones proteins test was sent which was negative. Xray
skull didn’t show any lytic lesions. Protein electrophoresis showed hypoalbuminemia with increase in
gamma globulins and no M band was seen. To rule out hemolytic anemia , LDH levels were sent
which were normal. Direct and indirect Coomb’s tests were negative. USG abdomen and pelvis
showed splenomegaly, fatty liver , cholelithiasis and malrotated left kidney.

Hb electrophoresis with reflex PCR was done which showed Hb A2 of 0.9% and abnormal band in
HbH region suggestive of HbH disease. Supravital stain showed golf ball inclusions. Alpha thallasemia
mutation detection PCR showed homozygous for 3.7kb deletion in alpha globin gene.

Discussion:

A category of diseases known as thalassemias are brought on by an abnormal growth of globin

chains. The Indian subcontinent, South-East Asia, Africa, the Middle East, and Mediterranean nations
are among those that are most likely to experience this monogenic gene condition. Because of
demographic changes over the past few decades, alpha thalassaemia has become more common in
Northern European and American countries (1). One or more of the globin chains' production may
be reduced or cease entirely. The generation of normal haemoglobin is hampered by this mismatch
in globin chain formation. This deficiency results in intramedullary hemolysis and inefficient
erythropoiesis. The term "alpha thalassemia" primarily refers to the aberrant or non-existent
production of alpha-globin chains. These have more than 15 separate genetic mutations connected
to them. Based on the type of mutation, the clinical condition's severity is determined (2).

The main abnormality is the decreased or missing generation of the alpha globin chains, which are
the components of numerous forms of haemoglobin (Hb), including adult HbA (alpha2 beta2), foetal
HbF (alpha2 gamma2), and the minor component HbA2 (alpha2 delta2). Silent carriers and the -
alpha/- alpha thalassemia trait are the two categories of carrier states at the phenotypic level. The
silent carrier state is characterised in newborns by a very slight increase (1-2%) of Hb Bart, a
tetramer of globin chains (gamma4) that is present when there is an excess of gamma chains relative
to alpha chains. The silent carrier state is most frequently caused by the presence of a single alpha
globin gene deletion (-alpha/alpha alpha). With normal HbA2 and F, the one gene deletion genotype
in adults may be totally silent or linked to a moderate microcytosis and hypochromia. Alpha-
thalassemia trait (alpha trait) is clearly visible in individuals who have two residual functional alpha
genes, either in cis (- -/alpha alpha) or in trans(- alpha/- alpha). This trait is characterised by an
alpha-thalassemia-like red blood cell index with normal HbA2 and F in adults and a reduced
alpha/beta globin chain synthesis ratio in the range of 0.7-0.8 (3,4).

Inconsistency in the formation of globin chains is the main pathophysiological alteration associated
with thalassemia. In the bone marrow or peripheral blood, Red Blood Cell (RBC) progenitors are
consequently eliminated. Due to the growth of the bone marrow, this results in persistent anaemia,
splenomegaly, and typical skeletal abnormalities (5).

A comprehensive blood count with red cell indices, HPLC or Hb electrophoresis, and eventually a
measurement of the ratio of globin chain synthesis should be part of the initial laboratory
evaluation. However, DNA analysis is occasionally used as an alternative to the latter process in
order to diagnose -thalassaemia because it is less time-consuming. The most straightforward
method (at the protein level) to identify beta-thalassaemia is to measure the ratio of beta- and beta-
globin chain production. Using a number of molecular genetic techniques, it has gotten easier over
the past 30 years to reliably diagnose thalassaemia and characterise the precise abnormalities
underlying these illnesses. Ultimately, Southern blotting and DNA sequence analysis have been used
to characterise the majority of globin rearrangements. For the seven most prevalent deletions in -
thalassaemia, gap-PCR has been established (1,6).

There is hemolytic anaemia, so folic acid supplements should be administered. Patients with HbH are
susceptible to oxidative damage's clinical symptoms. During times of oxidative stress, such as
infections or the use of oxidative drugs, blood counts should be monitored and transfusional
intervention may be necessary. Patients must be closely watched for chronic transfusion-related
problems and provided iron chelation assistance as necessary, particularly in the second and third
decades of life. Careful genetic counselling is necessary for patients (2).

In our case, in view of the clinical symptoms, multiple myeloma was suspected initially. There was
reduced haemoglobin and MCV. Alpha thallasemia mutation detection PCR showed homozygous for
3.7kb deletion in alpha globin gene, confirming the diagnosis.

References:

1. Harteveld CL, Higgs DR. α-thalassaemia. Orphanet J Rare Dis. 2010 May 28;5(1):13.
2. Harewood J, Azevedo AM. Alpha Thalassemia. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 [cited 2023 May 21]. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK441826/

3. Galanello R, Cao A. Alpha-thalassemia. Genet Med. 2011 Feb 1;13(2):83–8.

4. Tamary H, Dgany O. Alpha-Thalassemia. In: Adam MP, Mirzaa GM, Pagon RA, Wallace SE, Bean LJ,
Gripp KW, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington,
Seattle; 1993 [cited 2023 May 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1435/

5. Motiani A, Sonagra AD. Laboratory Evaluation Of Alpha Thalassemia. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 May 21]. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK587402/

6. Brancaleoni V, Di Pierro E, Motta I, Cappellini MD. Laboratory diagnosis of thalassemia. Int J Lab
Hematol. 2016 May;38 Suppl 1:32–40.