Mazoun Juma Saeed Ali Alteneiji(H00442921)

HML 2143 Clinical Hematology II

LO 1.1 Thalassemia
• Normal hemoglobin
Phase In embryo In fetus In adults
Type of Gower I (2 𝜻, 2 𝜺) Hb F (2 𝜶, 2 𝜸) Hb A (2 𝜶, 𝟐 𝜷)
Hb Gower II (2 𝜶, 2 𝜺) Hb A2 (2 𝜶, 𝟐 𝝈)
Portland (2 𝜻, 2 𝜸) Hb F (2 𝜶, 2 𝜸)

• Classification of hemoglobinopathies
§ Quantitative à Correct Hb synthesis but low amount.
- Thalassemia.
§ Qualitative à Wrong Hb structure but correct amount.
- Sickle cell Anemia.
UAE has high prevalence of the most common hemoglobinopathies which are
Sickle cell disease and Thalassemia.
• Thalassemia à Group of disorders caused by low amount of globin chain
synthesis, result in anemia.
§ Mode of inheritance à Genetic disease (Autosomal recessive).
§ Type of Anemia à Microcytic hypochromic anemia.
§ Pathophysiology
- DNA mutation of globin gene (in chromosome 11 or 16) cause
reduction/absence of globin chain synthesis leading to insufficient pairing
of globin chain.
• 𝜶-thalassemia (Alpha) à Low synthesis of 𝜶-globin chain.
- Common in Africa and Middle East.

§ Type of mutation à 𝜶 gene deletion.

§ Pathophysiology
- Normally there’s 4 𝜶 genes copies in chromosome 16, the deletion of 1 or
more 𝜶-genes causes mutation leading to 𝜶-thalassemia.

§ 4 classes of Alpha thalassemia

- 1 𝜶-gene deletion à 𝜶-thalassemia trait/ silent carrier (𝜶𝜶, 𝜶-).

- 2 𝜶-gene deletion à 𝜶-thalassemia minor (𝜶 -, 𝜶 -), (𝜶𝜶 , - -).

- 3 𝜶-gene deletion à Hb H disease (𝜶 -, - -).

- 4 𝜶-gene deletion à Hydrops fetalis (- -, - -).

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Mazoun Juma Saeed Ali Alteneiji(H00442921)

• Classification of 𝜶-thalassemia
§ 𝜶-thalassemia trait or minor
- 1 or 2 𝜶-gene deletion (𝜶𝜶, 𝜶-) or (𝜶 -, 𝜶 -), (𝜶𝜶 , - -).
- Asymptomatic carrier with mild anemia.
§ Diagnosis
CBC Blood film Iron profile test Hb electrophoresis
Hb à Normal or Microcytic Normal Normal
slightly low. hypochromic.
MCV/MCH à Low
RBC count à
Normal or slightly
high.

§ 𝜶-thalassemia major (Hb H disease)

- 3 𝜶-gene deletion (𝜶 -, - -).
- Hb H consist of 4 beta globin.
- Moderate to severe anemia.
- Splenomegaly
§ Diagnosis
CBC Blood film HPLC Hb electrophoresis
Hb à Low 1. Microcytic hypochromic. Hb H (2-40%) Hb H (High) 5-30%
MCV/MCH à Low 2. Poikilocytosis Hb A2 low Hb A (Low)
Reticulocytosis Target cells, schistocytes, Hb Bart’s (25%) at birth
polychromasia and NRBCs.
3. Golf ball inclusions.

§ 𝜶-thalassemia major (Hydrops fetalis)

- 4 𝜶-gene deletion (- -, - -).
- Hb barts consist of 4 gamma globin.
- Death in uterus or at birth “stillbirth”
§ Diagnosis
A. Hb electrophoresis
- Hb barts (High) 70 - 80%
- Some Hb H and Portland
- No Hb F, Hb A, Hb A2
B. Blood film
- Poikilocytosis and Anisocytosis

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Mazoun Juma Saeed Ali Alteneiji(H00442921)

• 𝜷-thalassemia (Cooley Anemia) à Low synthesis of 𝜷-globin chain.

- Common in Far East and Middle East.
§ Type of mutation à Point mutation in 𝜷-gene.
§ Pathophysiology
- Normally there’s 2 𝜷 genes copies in chromosome 11, point mutation leads to
reduction or absence of 𝜷 genes synthesis.
§ 2 classes of Beta thalassemia
- Reduction of β-chain synthesis (b+) → β-thalassemia trait (minor)
- Absence of β-chain synthesis (b0) → β-thalassemia major
• Classification of 𝜷-thalassemia
§ 𝜷-thalassemia trait or minor à one gene is affected.
- Reduction of β-chain synthesis (b+).
- Asymptomatic carrier.
§ Diagnosis
CBC Blood film Iron profile test Hb electrophoresis
Hb à Slightly low. 1. Microcytic Normal High Hb F (70-80%)
MCV/MCH à Low hypochromic. High Hb A2 (3.8 - 8%)
RBC count à 2. Target cells. Low Hb A (10 - 20%)
Normal or high. 3. Basophilic
stippling.

§ 𝜷 -thalassemia major à two genes are affected.

- Absence of β-chain synthesis (b0).
- Severe anemia.
§ Diagnosis
CBC Blood film Bone marrow Hb electrophoresis
Hb à low. Erythroid High Hb F
1. Microcytic hypochromic.
MCV/MCH à Low. hyperplasia Variable Hb A2
2. Poikilocytosis
Reticulocytosis No Hb A
Target cells, schistocytes,
polychromasia, NRBCs and
Basophilic stippling.
3. Anisocytosis.

§ Chemistry lab
- Bilirubin à Increased
- Urine urobilinogen à Increased
- Fecal stercobilinogen à Increased
- LDH à Increased

- Ferritin, iron à Normal

- Transferrin receptor à Normal

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Mazoun Juma Saeed Ali Alteneiji(H00442921)

§ Clinical features of 𝜷 -thalassemia major

- Severe anemia and mild jaundice.
- Hepatomegaly or splenomegaly (excessive RBCs destruction,
extramedullary hematopoiesis and iron overload)
- BM hyperplasia.
- Iron overload→ due to repeated blood transfusion.
- Viral or bacterial infections.

§ Treatment of 𝜷 -thalassemia major

- Regular blood transfusion.
- Iron chelation therapy→ to remove excess iron.
- Splenectomy.
- Folic acid therapy.
- BM transplantation or Gene therapy.

• 𝜷 -thalassemia Intermediate
- Symptomatic from anemia.
- Hb à 7– 8 g/dL
- Moderate to severe microcytic anemia.
- More severe than β thalassemia trait.
- Polychromasia & NRBC’s maybe present.
- Splenomegaly & sometimes bone deformities.

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Mazoun Juma Saeed Ali Alteneiji(H00442921)

HML 2143 Clinical Hematology II

LO 1.2 Sickle Cell Anemia
• Sickle Cell Anemia à Hemoglobinopathy with defect in beta globin chain.
- Glutamic acid (Glu) is replaced by valine (Val) in the 6th position in 𝜷-chain.
- Produce sickle cells and Hb S.
§ Mode of inheritance à Autosomal recessive.
- Homozygous à Hb SS (defect in both 𝜷-genes) à Sickle Cell Anemia.
- Heterozygous à Hb AS (defect in one 𝜷-genes) à Sickle Cell Trait.
§ Hb S in normal O2 tension à Release oxygen to the tissue easily (shift to right
with low O2 affinity).
§ Hb S in low O2 tension à Hb S crystalizes and thee deoxygenated sickle Hb
polymerize and form sickled RBCs (may cause thrombosis or organ failure).
§ Pathophysiology of Sickle Cell Anemia
- Glutamic acid (Glu) is replaced by valine (Val) in the 6th position forming
Hb S.
- In low O2 tension Hb S polymerize and form long fibre.
- Sickled RBCs are formed and cannot pass through small vessels.
§ Clinical features (Crises) of Sickle Cell Anemia
1. Painful vaso-occlusive crises à Caused by sickle cells in small vessels.
- Severe pain (4-7 days).
- Result in damage and organ failure.
- Hand-foot syndrome caused by bone infraction (first clinical presentation).
2. Visceral sequestration crises à Caused by sickled RBCs within the organ.
- Acute chest syndrome (Death after puberty).
- Splenic sequestration (Enlarged spleen in infants).
3. Aplastic crises à Caused by parvovirus infection or folate deficiency.
- Result in Hb and retics fall due to marrow aplasia.
4. Hemolytic crises à Increased rate of hemolysis with low Hb and high retics.
- Accompanied by painful crises.

§ Other clinical features of Sickle Cell Anemia

- Severe hemolytic anemia.
- Splenomegaly.
- Infections.
- Abnormal growth.
- Skin ulcers.
- Stroke.
- Pigment gall stones (Bilirubin).
- Affect the eyes (Blindness).

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Mazoun Juma Saeed Ali Alteneiji(H00442921)

§ Laboratory diagnosis of Sickle Cell Anemia

1. CBC
- Hb à 6 - 9 g/dL
- MCV/MCH à Normal
- WBC à Increased
2. Blood film
- Normocytic normochromic anemia.
- Anisocytosis.
- Poikilocytosis (Target cells and sickle cells less than 10%).
- Howell-jolly bodies.
- Polychromasia (5 - 20%).
- NRBCs.
3. Screening test for Hb S (Sickling test)
- Positive test à O2 is removed and Hb S forms crystals à Sickled RBCs.
4. Solubility test à RBCs lysed by saponin and Hb S reduced, so it becomes
insoluble and form crystals that produce turbid solution.
a) Positive result à Turbid solution and lines cannot be seen.
b) Negative result à Clear solution and lines can be seen.
c) After centrifugation à Positive result will show dark red band at the top
with pink or colorless solution.
5. Hb electrophoresis à Confirm the presence of Hb S.
a) Alkaline electrophoresis (pH 8.9) on cellulose acetate
- S and D migrate together.
- A2, C and E migrate together.
b) Acid electrophoresis (pH 6.0) on agarose gel
- Hb S is predominant (80%).
- Hb F (5 - 15%).
- Hb A2 (2 - 5%).
- No Hb A.
6. High performance liquid chromatography (HPLC)
- Confirm Hb S and measures various types of Hb.

§ Treatment of Sickle Cell Anemia

Supportive Therapeutic Curative
Anti-infection drugs. Drugs like hydroxyurea to Bone marrow transplant.
Folic acid treatment. increase Hb F. Gene therapy.
Blood transfusion.
Hydration.

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Mazoun Juma Saeed Ali Alteneiji(H00442921)

• Sickle Cell Trait (Hb AS)

- No anemia.
- Normal RBCs (some sickled).
§ Symptoms
- Hematuria
§ Electrophoresis in Hb AS
- Hb A (60%)
- Hb S (40%)
- Hb A2 (slightly high)
- Hb F (Normal)
• Management /Antenatal care
- Molecular testing
a) Prenatal diagnosis à (0.5 - 1%) Risk of miscarriage.
- Chronic villus sampling (10-12 weeks) à one semester.
- Amniocentesis test (14-20 weeks) à 2 semesters.
b) Preimplantation test à Avoid pregnancy termination.
- Require vitro fertilization (IVF) to obtain embryo.

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 Mazoun Juma Saeed Ali Alteneiji(H00442921)

HML 2143 Clinical Hematology II

LO 1.3 Hb Variants

Hb Variant Hb C Hb D Hb E Hb M
Replacement Glu replaced by Lys in Glu replaced by Gln Glu replaced by Lys Fe2+ oxidized to Fe3+.
6th position. in 121st position. in 26th position.
Homozygous Hb C > 90% Asymptomatic Mild hemolytic -
Hb F slight ↑ (up to 7%) (Benign) anemia.

Heterozygous Asymptomatic Asymptomatic Asymptomatic -

Hb A (60-70%) (Benign)
Hb C (30-40%)
Changes 1. Decrease Hb No changes - 1. Cannot bind oxygen.
solubility Normal solubility 2. Brownish color in
2. Crystals form Hb C properties. blood.
3. Cyanotic
Blood film Target cells. Increased target Target cells. Hb M is rarely >30%.
Folded & irregular cells.
contracted cells.
• Common β-chain hemoglobin variants (Hb S and Hb C)
§ Trait à Abnormal Hb < 50% of total Hb (60% Hb A & 35-40% Hb S or Hb C).
§ Homozygous à Abnormal Hb is 90-95% of total Hb.

• Double or compound heterozygosity

- Inheriting one abnormal gene from both parents.
1. Hb SC à Hb S from one parent & Hb C from another parent.
2. Hb SD à Hb S from one parent & Hb D from another parent.
3. Hb S/β-Thalassemia à Sickle cell disease
4. Hb E/ Thalassemia à Hb E & thalassemia (α or β)
- Moderate to severe anemia (similar to thalassemia major).

Hb variant Hb Constant Spring Hereditary Persistence Hb Lepore

of Fetal Hb (HPFH)
Defect α-chain stretched by 31 a. Both β & δ are defective Unequal crossing over
a., so it reduces α Impair production of of globin gene.
production (unstable Hb). Hb A & Hb A2.
Homozygous Hb Constant Spring Only Hb F is produced Hb Lepore (8 -30) %
Hb F the remaining

Heterozygous Asymptomatic Hb F (10-30%) increases Silent carrier

Hb F & A2 normal, Hb CS Hb A2 (1-1.5 %) decreases Hb Lepore 10%
& Hb A Hb A the rest Hb A 80-90%

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