EDITORIALS & PERSPECTIVES

Ring sideroblasts and sideroblastic anemias

Mario Cazzola1 and Rosangela Invernizzi2
1
Department of Hematology Oncology and 2Department of Internal Medicine, University of Pavia Medical School & Fondazione IRCCS
Policlinico San Matteo, Pavia, Italy; E-mail: [email protected] doi:10.3324/haematol.2011.044628
(Related Original Article on page 808)

T
he sideroblastic anemias are a heterogeneous group of Classification of sideroblastic anemias
inherited and acquired disorders characterized by ane- The sideroblastic anemias include both hereditary and
mia of varying severity and the presence of ring sidero- acquired conditions, and the main disorders are reported in
blasts in the bone marrow.1 Table 1. Representative peripheral blood and bone marrow
smears from a patient with X-linked sideroblastic anemia
Ring sideroblasts (XLSA) and a patient with refractory anemia with ring sidero-
Ring sideroblasts are erythroblasts with iron-loaded mito- blasts (RARS) are shown in Figures 1 and 2, respectively.
chondria visualized by Prussian blue staining (Perls’ reaction)
as a perinuclear ring of blue granules (Figures 1D and 2C). X-linked versus autosomal recessive congenital sideroblastic
The International Working Group on Morphology of anemias
Myelodysplastic Syndrome (IWGM-MDS) recommended XLSA is caused by germline mutations in the erythroid-spe-
that ring sideroblasts be defined as erythroblasts in which cific ALA synthase gene (ALAS2). Males with XLSA may pres-
there are a minimum of five siderotic granules covering at ent in the first two decades of life with symptoms of anemia
least one third of the circumference of the nucleus.2 Ring or later with manifestations of anemia and/or those of
sideroblasts are found exclusively in pathological conditions, parenchymal iron overload.4 However, the phenotypic expres-
and should not be confused with ferritin sideroblasts, which sion of XLSA is highly variable,5 and occasional patients, both
are present in normal bone marrow. These latter are normal males and females, may present late in life.6,7 Distinctive labo-
erythroblasts that, after Prussian blue staining, show a few ratory features are microcytic anemia with hypochromic red
blue granules scattered in the cytoplasm, representing endo- cells, increased red cell distribution width and evidence of
somes filled with excess iron not utilized for heme synthesis parenchymal iron overload: for a conclusive diagnosis of
(siderosomes). While the iron of ferritin sideroblasts is stored XLSA, however, identification of the ALAS2 mutation is
in cytosolic ferritin, whose subunits are encoded by the required. The management of XLSA involves not only treat-
FTH1 and FTL genes, the iron of ring sideroblasts is stored in ment of anemia, but also prevention and treatment of iron
mitochondrial ferritin, encoded by the FTMT gene.3 Indeed, overload, family studies to identify additional at-risk individu-
mitochondrial ferritin is specifically detected in ring sidero- als, and genetic counseling.1 Most patients with XLSA are
blasts, as illustrated in Figure 2D. responsive, to some extent, to pyridoxine, and subjects with

A B

Figure 1. Representative
peripheral blood and bone
marrow smears from a patient
with X-linked sideroblastic
anemia. (A) Peripheral blood
smear showing many hypo-
chromic and microcytic cells.
May-Grünwald-Giemsa (MGG),
x1,000. (B) Bone marrow
smear showing erythroid
hyperplasia: erythroblasts are
small with abnormal conden-
C D sation of nuclear chromatin
and ragged cytoplasm with ill-
defined edges. MGG, x1,000.
(C) Bone marrow smear show-
ing erythroblasts with defec-
tive hemoglobinization (left)
and erythroblasts containing
multiple Pappenheimer bodies
(right). MGG, x1,250. (D) Bone
marrow smear. Perls’ stain
shows that most erythroid pre-
cursors are ring sideroblasts
with at least five positive gran-
ules disposed in a ring sur-
rounding a third or more of the
circumference of the nucleus.
x1,250.

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 Editorials and Perspectives

iron overload can safely undergo mild phlebotomy pro- depleting cytosolic iron in human erythroblasts.10
grams under pyridoxine supplementation. Two years ago, Guernsey et al.11 studied three Canadian
Patients affected with other inherited forms of siderob- families, each with one child affected by congenital sider-
lastic anemia are not responsive to pyridoxine, and the oblastic anemia. The data available were inconsistent with
molecular basis of these autosomal recessive disorders has an X-linked recessive inheritance, while the families
been clarified only recently. Camaschella et al.8 studied a derived from a local subpopulation isolate, consistent with
middle-aged anemic patient with ring sideroblasts and iron a possible genetic founder effect. A single nucleotide poly-
overload whose anemia was partially reversed by iron morphism-based genome-wide scan performed in individ-
chelation therapy. The phenotype of this patient resembled uals belonging to these families led to the identification of
that of the shiraz zebrafish, a mutant resulting from a large SLC25A38 as the mutant gene responsible for this type of
deletion encompassing the GLRX5 gene.9 In fact, sequenc- autosomal recessive pyridoxine-refractory sideroblastic
ing of GLRX5 showed that the patient had a homozygous anemia.11 Studies on additional subjects with familial or
mutation of this gene. GLRX5 deficiency causes sideroblas- sporadic congenital sideroblastic anemia without ALAS2
tic anemia by specifically impairing heme biosynthesis and mutations showed multiple additional biallelic SLC25A38

Table 1. Classification of congenital and acquired sideroblastic anemias.

Condition Molecular basis Clinical features
Non-syndromic congenital sideroblastic anemias
X-linked sideroblastic anemia Germline mutation in the erythroid-specific Hemizygous males have hypochromic microcytic anemia due to
(XLSA) (MIM ID # 300751) ALA synthase gene (ALAS2, chromosome ineffective erythropoiesis and secondary iron overload
Xp11.21) (iron-loading anemia). Heterozygous females may have minor red
cell abnormalities (in particular, increased red cell distribution
width). Most patients are responsive to pyridoxine.
Autosomal recessive Germline mutations in the SLC25A38 gene Homozygous males and females have severe microcytic anemia
pyridoxine-refractory (chromosome 3p22.1) that almost inevitably becomes transfusion-dependent.
sideroblastic anemia Heterozygous individuals have no hematologic phenotype.
(MIM ID #205950) Conservative therapy includes regular red cell transfusion and iron
chelation. Allogeneic stem cell transplantation represents the
only curative treatment at present.
Homozygous mutation in the GLRX5 gene The reported case regards a middle-aged male affected with
(chromosome 14q32) pyridoxine-refractory sideroblastic anemia and iron overload.

Hereditary syndromic conditions

X-linked sideroblastic anemia Germline mutation in the ABCB7 gene Hemizygous males have moderate hypochromic microcytic anemia
and spinocerebellar ataxia (chromosome Xq13.1-q13.3) and tend to develop non-progressive ataxia and incoordination
(XLSA/A, MIM ID #301310) early in life.
Myopathy, lactic acidosis and Homozygous germline mutation in the PUS1 Myopathy, lactic acidosis, and anemia (progressive exercise
sideroblastic anemia gene (chromosome 12q24.33) intolerance during childhood).
(MLASA1, MIM ID #600462)
Myopathy, lactic acidosis and Homozygous germline mutation in the Myopathy, lactic acidosis, and anemia (progressive exercise
sideroblastic anemia YARS2 gene (chromosome 12p.11.21) intolerance during childhood).
(MLASA2, MIM ID #613561)
Thiamine-responsive Germline mutations in the SLC19A2 gene Thiamine-responsive macrocytic anemia, diabetes mellitus,
megaloblastic anemia encoding a thiamine transporter protein and sensorineural deafness.
(TRMA, MIM ID #249270) (chromosome 1q23.3)
Pearson marrow-pancreas Mitochondrial DNA deletion Refractory sideroblastic anemia with vacuolization of marrow
syndrome (MIM ID #557000) precursors and exocrine pancreatic dysfunction.

Myeloid neoplasms with refractory sideroblastic anemia

Refractory anemia with ring Abnormal expression of genes of heme synthesis Myelodysplastic syndrome with isolated erythroid dysplasia and
sideroblasts (RARS) and mitochondrial iron metabolism benign clinical course. A variant with worse prognosis is
(overexpression of ALAS2 and reduced expression represented by the condition defined as refractory cytopenia with
of ABCB7). Overexpression of FTMT multilineage dysplasia and ring sideroblasts (RCMD-RS).
Refractory anemia with ring Abnormal gene expression as in RARS plus Myelodysplastic/myeloproliferative neoplasm with mild anemia and
sideroblasts and marked somatic mutations of JAK2 and/or MPL in about thrombocytosis (platelets ≥ 450x109/L), resembling essential
thrombocytosis (RARS-T) two-thirds of patients thrombocythemia.
Acquired sideroblastic anemias
Ethanol-induced and – –
drug-induced sideroblastic anemia

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 Editorials and Perspectives

A B Figure 2. Representative peri-

pheral blood and bone mar-
row smears from a patient
with refractory anemia with
ring sideroblasts. (A). Peri-
pheral blood smear showing
dimorphic red cells with a
population of macrocytes and
a population of hypochromic
microcytes. MGG, x1,000. (B)
Bone marrow smear showing
a marked erythroid hyperpla-
sia with megaloblastoid fea-
tures. The rare granulocytic
cells look normal. Upper right,
a late erythroblast with defec-
tive hemoglobinization; lower
C D right, an early erythroblast
with vacuolated cytoplasm
and a late erythroblast with
Pappenheimer bodies. MGG,
x1,000. (C) Bone marrow
smear stained by Perls’ reac-
tion showing several ring side -
roblasts. MGG x1,250. (D)
Bone marrow smear. Mito-
chondrial ferritin is detected
in granules surrounding the
nucleus. Immunoalkaline phos-
phatase reaction, MGG x1250.

mutations. SLC25A38 encodes the erythroid specific mito- isolated anemia, erythroid dysplasia only, less than 5%
chondrial carrier protein, which is important for the blasts, and 15% or more ring sideroblasts in the bone mar-
biosynthesis of heme in eukaryotes. row.14 The natural history of RARS is characterized by an
Following the identification of mutant SLC25A38 as a initial phase of erythroid hyperplasia and ineffective ery-
novel cause of inherited sideroblastic anemia, Bergmann et thropoiesis, which is usually stable for many years but in a
al.12 systematically analyzed a cohort of 60 previously unre- proportion of patients may be followed by a phase of mar-
ported patients with congenital sideroblastic anemia, look- row failure, with or without the later emergence of
ing for ALAS2, SLC25A38, PUS1, GLRX5, and ABCB7 leukemic blasts.15,16 Since the vast majority of patients with
mutations. Twelve probands had biallelic mutations in this syndrome have no cytogenetic abnormalities, the clon-
SLC25A38, while 7 had ALAS2 mutations and one had a al nature of RARS has been questioned. However, a few
novel homozygous null PUS1 mutation. studies of X-chromosome inactivation patterns performed
In this issue of the journal, Kannengiesser et al.13 report on in female patients have suggested that RARS derives from
a study of 24 patients with congenital sideroblastic anemia the clonal proliferation of a multipotent hematopoietic
who did not have ALAS2 mutations. Eleven patients of sev- stem cell with the potential for myeloid and lymphoid dif-
eral different ancestral origins carried SLC25A38 mutations: ferentiation.17
9 patients were homozygous and 2 were compound het- Unfortunately none of the candidate genes, i.e. genes
erozygotes. All patients required blood transfusions that mutated in the different types of congenital sideroblastic
inevitably became regular within the first few years of life. anemia, has been found to be mutated in RARS. Of note,
Two patients underwent allogeneic stem cell transplanta- CD34+ cells from patients with RARS have a particular gene
tion with complete correction of anemia. Since the clinical expression profile characterized by upregulation of mito-
course of congenital sideroblastic anemia associated with chondria-related genes and, in particular, genes involved in
SLC25A38 mutations is very similar to that of thalassemia heme synthesis (e.g., ALAS2),18 and reduced expression of
major, conservative therapy includes regular red cell trans- ABCB7, a gene encoding a protein involved in the transport
fusion and iron chelation. However, as in thalassemia of iron/sulfur clusters from mitochondria to the cyto-
major, allogeneic stem cell transplantation represents the plasm.19 In addition, RARS is characterized by over-expres-
only curative therapy at present, and should, therefore, be sion of mitochondrial ferritin (Figure 2D), encoded by the
considered for young patients with this congenital siderob- FTMT gene.3,20-22
lastic anemia. RARS-T is a myelodysplastic/myeloproliferative neo-
plasm characterized by anemia with ring sideroblasts and
Refractory anemia with ring sideroblasts marked thrombocytosis.23 Our recent studies suggest that
What are the implications of recent advances in our RARS-T is indeed a myeloid neoplasm with both
understanding of the molecular basis of congenital siderob- myelodysplastic and myeloproliferative features at the
lastic anemia for the acquired forms, i.e. refractory anemia molecular and clinical levels, and that it may develop from
with ring sideroblasts (RARS) and its variant with marked RARS through the acquisition of somatic mutations of
thrombocytosis (RARS-T)? JAK2, MPL, or other as-yet-unknown genes.24
RARS is a myelodysplastic syndrome characterized by Thus, the available evidence suggests that the clonal

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 Editorials and Perspectives

in the erythroid delta-aminolevulinate synthase (ALAS2) gene in two

hematopoiesis of RARS and RARS-T is associated with pyridoxine-responsive patients initially diagnosed with acquired
refractory anemia and ringed sideroblasts. J Clin Invest. 1995;96(4):
abnormal expression of several genes of heme synthesis 2090-6.
and mitochondrial iron processing. Identifying the somatic 7. Cazzola M, May A, Bergamaschi G, Cerani P, Rosti V, Bishop DF.
mutation(s) that can be responsible for these abnormalities Familial-skewed X-chromosome inactivation as a predisposing factor
represents the current challenge in this field. for late-onset X-linked sideroblastic anemia in carrier females. Blood.
2000;96(13):4363-5.
8. Camaschella C, Campanella A, De Falco L, Boschetto L, Merlini R,
Conclusions Silvestri L, et al. The human counterpart of zebrafish shiraz shows
The two most common forms of congenital sideroblastic sideroblastic-like microcytic anemia and iron overload. Blood. 2007;
110(4):1353-8.
anemia, i.e. the X-linked form due to an ALAS2 mutation 9. Wingert RA, Galloway JL, Barut B, Foott H, Fraenkel P, Axe JL, et al.
and the autosomal recessive form due to SLC25A38 muta- Deficiency of glutaredoxin 5 reveals Fe-S clusters are required for ver-
tions, have similar hematologic pictures but completely dif- tebrate haem synthesis. Nature. 2005;436(7053):1035-9.
ferent clinical courses. Overall, XLSA is a benign disorder 10. Ye H, Jeong SY, Ghosh MC, Kovtunovych G, Silvestri L, Ortillo D, et
al. Glutaredoxin 5 deficiency causes sideroblastic anemia by specifical-
that generally responds to pyridoxine with substantial ame- ly impairing heme biosynthesis and depleting cytosolic iron in human
lioration of anemia; prevention and treatment of iron over- erythroblasts. J Clin Invest. 2010;120(5):1749-61.
load is also important and can be generally achieved 11. Guernsey DL, Jiang H, Campagna DR, Evans SC, Ferguson M, Kellogg
MD, et al. Mutations in mitochondrial carrier family gene SLC25A38
through phlebotomy. By contrast, the congenital autosomal cause nonsyndromic autosomal recessive congenital sideroblastic ane-
recessive congenital sideroblastic anemia due to SLC25A38 mia. Nat Genet. 2009;41(6):651-3.
mutations is a severe disease, not responsive to pyridoxine 12. Bergmann AK, Campagna DR, McLoughlin EM, Agarwal S, Fleming
MD, Bottomley SS, et al. Systematic molecular genetic analysis of con-
and with a clinical course very similar to that of thalassemia genital sideroblastic anemia: evidence for genetic heterogeneity and
major: allogeneic stem cell transplantation should, there- identification of novel mutations. Pediatr Blood Cancer. 2010;54(2):
fore, be considered in young patients with this disease. 273-8.
13. Kannengiesser C, Sanchez M, Sweeney M, Hetet G, Kerr B, Moran E,
et al. Missense SLC25A38 variations play an important role in autoso-
Mario Cazzola is Professor of Hematology at the University mal recessive inherited sideroblastic anemia. Haematologica. 2011;
of Pavia Medical School and Head, of the Division of 96(6):808-13.
Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, 14. Brunning RD, Orazi A, Germing U, Le Beau MM, Porwit A, Bauman I,
et al. Myelodysplastic syndromes/neoplasms, overview. In: Swerdlow
Italy. His studies on myelodysplastic syndromes and myelopro- SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., eds. WHO
liferative neoplasms are supported by AIRC (Associazione Classification of Tumours of Haematopoietic and Lymphoid Tissues.
Italiana per la Ricerca sul Cancro), Fondazione Cariplo and Lyon: IARC, 2008:88-93.
15. Cazzola M, Barosi G, Gobbi PG, Invernizzi R, Riccardi A, Ascari E.
Regione Lombardia, Milan, Italy. Rosangela Invernizzi is Natural history of idiopathic refractory sideroblastic anemia. Blood.
Associate Professor of Internal Medicine at the University of 1988;71(2):305-12.
Pavia Medical School, Pavia, Italy. 16. Malcovati L, Porta MG, Pascutto C, Invernizzi R, Boni M, Travaglino
Financial and other disclosures provided by the author using the E, et al. Prognostic factors and life expectancy in myelodysplastic syn-
dromes classified according to WHO criteria: a basis for clinical deci-
ICMJE (www.icmje.org) Uniform Format for Disclosure of sion making. J Clin Oncol. 2005;23(30):7594-603.
Competing Interests are available with the full text of this paper at 17. Malcovati L, Brisci A, Gallì A, Bruno F, Travaglino E, Pellagatti A, et al.
www.haematologica.org. Mutation analysis of TET2 reveals the clonal nature of refractory ane-
mia with ring sideroblasts. Blood. 2010;116(21):776a. Abstract 1862.
18. Pellagatti A, Cazzola M, Giagounidis AA, Malcovati L, Porta MG,
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