HAEMOGLOBINOPATHIES

Haemoglobinopathies are inherited disorders of Globin production of the haemoglobin

 Hb is tetramer with 2 pairs of Globin chains (held by non-covalent interactions), each
with a haem group
 HbA (α2β2), HbA2 (α2δ2), HbF (α2γ2)
 Hb & globin are produced in RBCs at 2 sites:
o Haem in mitochondria
o Globin in polyribosomes

Globin Synthesis
Genes for globin chains occur in 2 clusters:

 chrom 11: ε, γ, δ, β
 chrom 16: ζ, α1, α2

In the embryo and fetus, Gower 1, Portland, Gower 2and fetal Hb dominate at different
stages
 Hb Gower 1: ζ2 ε2
 Hb Portland: ζ2γ2
 Hb Gower 2: α2ε2

Embryonic globin chains expressed in yolk sac erythroblasts

 β gene expressed at a low level in early fetal life
 main switch to HbA occurs 3-6 mons after birth, replacing γ chain with β chain

Haemoglobinopathies

2 disorders:

1. Thalassaemia
2. Sickle cell Disease

Thalassaemia

Inherited autosomal, recessive blood disorder

Caused by variant or missing genes that affect erythropoiesis  mild or severe anaemia

A condition in which there is reduced rate of synthesis of one or more of the globin chains
 This leads to:
o imbalanced globin‐chain synthesis
o defective Hb production
o damage to red cells or precursors from effects of globin subunits that are
produced in relative excess
 ALPHA (α) THALASSAEMIA

 Caused by gene changes (i.e. deletions or mutations) of α-globin component in

haemoglobin  reduced rate of synthesis of α chains
 Severity depends on number of missing or inactive genes of the 4 copies of α-globin
gene
 Syndromes: Normal→ α‐trait→ Hb H (β4) → hydrops fetalis (4 α‐gene deletion- Bart
Haemoglobin, γ 4)

 Related to areas with Malaria exposure

Pathophysiology
 Abnormal production of α chains  excess production of γ-globin chains in foetus and newborn
or β-globin chains in children and adults

 β-globin chains can form soluble, unstable tetramers which precipitate within the
cell, forming insoluble inclusions called Heinz bodies
 These Heinz bodies damage the red blood cells  damage to erythrocyte precursors
and ineffective erythropoiesis in the bone marrow, hypochromia and microcytosis of
circulating red blood cells

α‐thalassaemia Trait

 1 to 2 α‐genes deleted or inactive

Lab findings
• FBC:
 RCC (red cell count) ↑ > 5.5 X 1012/L
 MCV & MCH low
 Iron deficiency anaemia should be ruled out
 MCV/RCC ≤ 12 (Crude way)

Hb H Disease (β4)
 3 gene deletion
 Moderately severe anaemia (Hb 7‐11g/dL)
 Microcytic, hypochromic anaemia
 Splenomegaly
 β‐chains form a tetramer, Hb H (β4)

α-Thal Clinical Presentation

 Anaemia, pallor, weakness, jaundice
 Hepatosplenomegaly
 Heart defects
 Abnormalities of the urinary system or genitalia
 Hb Bart Hydrops fetalis syndrome
 Premature delivery
 Treatment
 Regular blood transfusions and folate supplements
 Bone marrow transplant may help, especially children
 Splenectomy

BETA (β) THALASSAEMIA

 Caused by genetic deficiency in the synthesis of β- globin chains

 Unlike α‐thal, β-thal results from point mutations rather than gene deletions
 Syndromes: β-Thalassaemia trait (minor) or β - Thalassaemia intermedia or β-
Thalassemia major

β-thal trait (minor)

 Symptomless
 ↓MCV & ↓MCH: hypochromic &microcytic [like α‐thalassaemia trait]
 ↑ RCC with mild anaemia
 Because of reduced β‐chains, α‐chains pair with δ‐chains  ↑Hb A2 (>3.5%)
 Raised Hb A2 confirms diagnosis

β-thal intermedia
 Moderate anaemia
 No regular blood transfusions

β-thalassaemia major
 Either no βchain (β0) or small amounts (β+) are synthesised
 Severe anaemia 3-6 mons after birth, when switch from γ‐to β‐chain production should
take place
 Excess α‐chains precipitate in erythroblasts and mature red cells → severe ineffective
erythropoiesis and haemolysis
 Transfusion dependent

Clinical Features
 Severe anaemia
 Pallor, jaundice
 Skull and other bones may be deformed secondary to erythroid hyperplasia with
intramedullary expansion and cortical bone thinning
 Cardiac failure and arrhythmia, related to either severe anaemia or iron overload
 Splenomegaly, due extramedullary haematopoiesis or extravascular haemolysis

Laboratory Diagnosis
 FBC
o Hypochromic, microcytic anaemia.
o ↑ reticulocyte % with normoblasts & target cells in blood film
 Hb Electrophoresis
o Completely absent Hb A (α2β2)
o All circulating Hb being HbF (α2γ2)
o Hb A2 %: normal, low or slightly raised

Treatment
 Transfusions
 Surgical Treatment e.g. splenectomy
 Iron chelation in case of Iron overload
 CURATIVE- Bone Marrow Transplant

SICKLE CELL ANAEMIA AND RELATED ABNORNAMALITIES

 Autosomal, recessive genetic disorder

 SCD pts have RBC lifespan of 10-20 days

Types

 SCD-Hb SS: sickle cell anaemia

 SCD‐Hb SC
 SCD‐Hb S β0thal
 SCD‐Hb S β+thal

Sickle Hb (Hb S)

 A mutant β‐globin chain in which adenine is replaced by thymine in the 6th position in
the β chain
 In the DNA (gene) that codes for β‐globin chain, there is a single base change: adenine is
replaced by thymine

o caused by substitution of valine for glutamic acid in position 6 in the β chain

 This Hb becomes polymerised and poorly soluble when O2 tension is lowered

 cells become distorted and rigid

Epidemiology
 Greatest prevalence in tropical Africa
 Pts resistant to malaria

Sickle cell trait (Hb AS): Heterozygote

 One β‐gene point mutation
 It’s a benign condition and does not produce any abnormalities of the blood count
o i.e. no anaemia and normal appearance of red cells in a blood film
 Prevalence 20% but, in some areas, 40%
 40% of total Hb

Sickle cell anaemia (Hb SS): Homozygous

 Homozygous sickle cell anaemia

 Characterized by inheritance of 2 mutant β‐genes from father and mother
 The disease is characterised by:
- Haemolytic anaemia
- Painful vaso-occlusive crises
- Visceral sequestration crises
- Aplastic crises
Pathogenesis
 HbS molecules undergo polymerization when deoxygenated
 Initially, the red cell cytosol converts from a freely flowing liquid to a viscous gel as HbS
aggregates form
 With continued deoxygenation, aggregated HbS molecules assemble into long needle-
like fibres within red cells, producing a distorted sickle or holly-leaf shape.

Morphology

 PBC: [slide 48]

o Irreversibly, sickled cells
o Reticulocytosis
o Target cells (due to red cell dehydration)
o Howell-Jolly bodies (small nuclear remnants) (due to asplenia)
 Bone marrow hyperplasia (due to erythroid hyperplasia)
 BM expansion  bone resorption + formation
o produces prominent cheekbones
o changes in skull that look like a crew-cut in x-rays
 Extramedullary haematopoiesis
 Pigment gallstones and hyperbilirubinemia due to increased breakdown of Hb

Variables Affecting Sickling

 In heterozygous sickle cell trait:

o 40% HbS, rest is HbA
o HbA (1) interferes with HbS polymerization
o so, red cells sickle only in intense hypoxic conditions
o HbF (2) inhibits HbS polymerization more than HbA, hence, infants become
symptomatic only after 5/6 mons when HbF levels fall
 o MCHC (3). The higher the HbS conc., the higher the aggregation and
polymerization during deoxygenation
- IC dehydration increases MCHC so increases sickling
- HbS homozygous decreases MCHC
o Intracellular pH (4). Decrease in pH reduces O2 affinity for Hb, hence, increasing
the fraction of deoxygenated HbS and increasing sickling

Pathophysiology

Microvascular Occlusions
 Depends on red cell membrane damage, inflammation
- slow or arrest RBC movement in microvascular beds
 Sickle red cells express higher than normal levels of adhesion molecules and are sticky
 Granulocytes release mediators during inflammation  enhance the expression of
adhesion molecules on endothelial cells  enhance the tendency of sickle red cells to
get arrested during transit through the microvasculature
 Stagnation of red cells in vascular beds results in low O2 tension, sickling & vascular
obstruction
 Depletion of NO also occurs
- sickle red cells release free HB
- Free Hb can bind & inactivate NO
o a potent vasodilator
o inhibitor of platelet aggregation
- So, low NO:
o increases narrowing of vessels (vascular tone)
o enhances platelet aggregation
- Causing cell stasis, sickling and thrombosis
 Consequences:
- auto splenectomy: spleen enlarged by red pulp congestion caused by trapping of
sickle red cells in cords & sinuses. This chronic erythrostasis leads to splenic
infarction, fibrosis & progressive shrinkage by adolescence or early childhood
- Other infarctions can take place in subcutaneous tissue, bones, brain, liver,
kidney, retina, pulmonary bv’s ex: ulcers of lower legs

Pathophysiological Complications of SCD

 Vaso-occlusive crises
- or pain crises, are episodes of hypoxic injury and infarction that cause severe
pain in the affected region
- can be spontaneous or triggered by infection, dehydration & acidosis
- occurs mostly in bones, lungs, brain, liver, spleen, penis (priapism)
- cause hand-foot syndrome or dactylitis
- cause acute chest syndrome  stroke
o a vaso-occlusive crisis in lungs
o causes pulmonary inflammation  sluggish, spleen-like blood flow 
sickling and vaso-occlusion
o compromises pulmonary function
 o causes stroke due to adhesion of sickle red cells to arterial vascular
endothelium and vasoconstriction caused by the depletion of NO by free
Hb
o presents with fever, cough, chest pain, pulmonary infiltrates

 Sequestration crisis
o occurs in children with intact spleen
o entrapment of sickle red cells  enlarged spleen, hypovolemia, shock

 Aplastic crisis
o result of infection of red cell progenitors by parvovirus B19
o PV B19 ceases erythropoiesis and worsens anaemia

 Chronic hypoxia
o impairs generalized growth, development & organ damage (spleen, lungs,
kidneys, heart, lungs)
o hypertonicity in renal medulla provokes sickling  hyposthenuria 
dehydration

 Increased susceptibility to infection with encapsulated organisms

o splenic macrophages tend to attack encapsulated organisms
- (e.g. Pneumococcus pneumoniae, Haemophilus influenzae septicemia and
meningitis)
o splenic infarction due to congestion and poor blood flow alters the spleens
function above

Diagnosis
 by various tests & clinical findings
 presence of irreversibly sickled cells

Laboratory Investigations
 Solubility test
 Sickling test
 Electrophoresis
 High-performance liquid chromatography (HPLC)
 Molecular diagnosis

Treatment

{NB: NEVER GIVE IRON SUPPLIMENTS IN SICKLE CELL ANAEMIA}

 Transfusion
 Haematinics- folic acid