Chapt e r
11
Principles of Molecular Disease:
Lessons from the Hemoglobinopathies
A molecular disease is one in which the primary disease-
causing event is a mutation, either inherited or acquired.
This chapter outlines the basic genetic and biochemical
mechanisms underlying genetic disease, using disorders
of hemoglobin—the hemoglobinopathies—as exam-
ples. This overview of mechanisms is expanded in
Chapter 12 to include other genetic diseases that are
important because they illustrate additional principles
of genetics in medicine.
Knowledge of molecular pathology is the founda-
tion of rational therapy and management for genetic
diseases. Moreover, such knowledge is also often
instructive about normal function. The study of pheno-
type at the level of proteins, biochemistry, and metabo-
lism constitutes the discipline of biochemical genetics.
A genetic disease occurs when an alteration in the DNA
of an essential gene changes the amount or function, or
both, of the gene products—messenger RNA (mRNA)
and protein. Single-gene disorders almost always result
from mutations that alter the function of a protein. The
few known exceptions to this generalization are muta-
tions found in genes for RNAs that do not encode pro-
teins, including mitochondrial genes that encode
transfer RNAs (tRNAs); these mitochondrial tRNA
mutations can lead to serious neurological conditions
affecting muscle or brain (see Chapter 12).
Understanding the pathogenesis of a genetic disease
is not possible without knowledge of the primary bio-
chemical abnormalities that result from the alteration
in gene function. By 2007, the online version of Men-
delian Inheritance in Man (OMIM) listed just over
3900 diseases (both autosomal and X-linked) with
mendelian patterns of inheritance. Of these, 3310 or
about 85% are known to be caused by mutations in
over 1990 genes, and new disease gene identifications
are being made weekly. Although it is impressive that
the basic molecular defect has been found in so many
disorders, it is sobering to realize that the pathophysi-
ological process is not entirely understood for any
genetic disease. Sickle cell disease (Case 37) , discussed
later in this chapter, is among the best characterized of
inherited disorders, but even here, knowledge is incom-
plete—despite its being the fi rst molecular disease to be
recognized more than 50 years ago. Nevertheless, the
study of genetic disease at its various phenotypic levels
(gene, protein, cell, tissue, whole body) has not only
greatly informed medicine but also, as described in
Chapter 13, led to increasingly promising treatment,
including protein and gene therapy, of inherited
disorders.
THE EFFECT OF MUTATION ON
PROTEIN FUNCTION
Mutations have been found to cause disease through
one of four different effects on protein function (Fig.
11-1). The most common effect by far is a loss of func-
tion of the protein. Many important conditions arise,
however, from one of three other mechanisms: a gain
of function; the acquisition of a novel property by the
mutant protein; or the expression of a gene at the wrong
time (heterochronic expression) or in the wrong place
(ectopic expression), or both.
Loss-of-Function Mutations
The loss of function of a gene may result from altera-
tion of its coding, regulatory, or other critical sequences
due to the introduction of nucleotide substitutions,
323
 324 Thompson & Thompson GENETICS IN MEDICINE

MUTATION

Mutations in Mutations disrupting Mutations affecting

coding region RNA stability gene regulation
or or dosage
RNA splicing

Protein abnormal Protein structure normal

Decreased
• Hb Hammersmith (if unstable decreased amount) amount

CAUSE OF DISEASE • α-thalassemias

• β-thalassemias • Monosomies
• Tumor-suppressor
Increased
mutations
Loss of protein function amount
• Hb Kempsey
(the great majority)
• Achondroplasia • Trisomies
• Charcot-Marie-Tooth
Gain of function disease type 1A

• HPFH
• Hb S
Novel property • Many oncogenes
(infrequent)
Inappropriate
expression
(wrong time, place)
Ectopic or
heterochronic expression
(uncommon, except in cancer)

Figure 11-1 ■ A general outline of the mechanisms by which disease-causing mutations produce disease. Mutations in the
coding region result in structurally abnormal proteins that have a loss or gain of function or a novel property that causes
disease. Mutations in noncoding sequences are of two general types: those that alter the stability or splicing of the mRNA,
and those that disrupt regulatory elements or change gene dosage. Mutations in regulatory elements alter the abundance of
the mRNA or the time or cell type in which the gene is expressed. Mutations in either the coding region or regulatory domains
can decrease the amount of the protein produced. HPFH, hereditary persistence of fetal hemoglobin.

deletions, insertions, or rearrangements. A loss of func-
tion due to deletion, leading to a reduction in gene
dosage, is exemplified by the α-thalassemias (Case 39) ,
which are most commonly due to deletion of α-globin
genes (see later discussion); by chromosome-loss
diseases (Case 24) , such as monosomies like Turner syn-
drome (see Chapters 5 and 6 and Case 42 ); and by
acquired somatic mutations—often deletions—that
occur in tumor-suppressor genes in many cancers (such
as retinoblastoma (Case 34) ; see Chapter 16). Many
other types of mutations can also lead to a complete
loss of function. These include the introduction of a
premature stop codon or of a missense or other muta-
tion in the coding sequence that abolishes or impairs
protein function, or that renders the protein unstable,
thereby reducing its abundance. All of these classes of
mutation, and others, are illustrated by the β-
thalassemias (Case 39) (see later discussion), a group of
hemoglobinopathies that result from a reduction in the
abundance of β-globin, one of the major adult hemo-
globin proteins in red blood cells. As might be expected,
the severity of a disease that results from loss-of-
function mutations can generally be correlated to the
amount of function lost. In many instances, the reten-
tion of a small degree of residual function by the mutant
protein greatly reduces the severity of the disease, a
situation illustrated by the enzyme defects associated
with hyperphenylalaninemia, the most severe form of
which is phenylketonuria (see Chapter 12).
Gain-of-Function Mutations
Mutations may also alter the biochemical phenotype by
enhancing one or more of the normal functions of a
protein. In a biological system, more is not necessarily
better, however, and disease may result. A gain in
protein function may be due to either an increase in the
abundance of the protein, usually from an increase in
its expression or that of its cognate gene, or an increase
in the ability of each protein molecule to perform one
or more normal functions. It is critical to recognize
when a disease is due to a gain-of-function mutation
 CHAPTER 11 ● Principles of Molecular Disease: Lessons from the Hemoglobinopathies
because treatment of the resulting disease must neces-
sarily differ from disorders that arise from other mech-
anisms, such as loss-of-function mutations. Moreover,
gain-of-function mutations often provide insight into
the regulation of the expression of the affected gene or
protein and the molecular mechanism of the protein’s
function.
Mutations That Enhance One Normal Function of a
Protein Rarely, a mutation in the coding region may
increase the ability of each protein molecule to perform
a normal function even though it is detrimental to the
overall physiological activity of the protein. Once again,
mutations in globin genes are among the best under-
stood of mutations of this type and include missense
mutations such as hemoglobin Kempsey, which locks
hemoglobin in its high oxygen affi nity state, thereby
reducing oxygen delivery to tissues. Another example
of this phenomenon occurs in the form of short stature
called achondroplasia (Case 1) . Mutations of this type,
which lead to the increase of a normal function, should
be distinguished from novel property mutations (see
later), which result in the acquisition of a completely
new function by the mutant protein.
Mutations That Increase Production of a Normal Pro-
tein Some mutations cause disease by increasing the
synthesis of a normal protein in cells in which the
protein is normally present (in contrast to ectopic
expression). The most common mutations of this type
are due to increased gene dosage, as with the presence
of three or more copies of an autosomal gene, which is
generally the result of the duplication of part or all of
a chromosome, as in trisomy 21 (Down syndrome; see
Chapter 6). Other important diseases that arise from
the increased dosage of single genes include one form
of familial Alzheimer disease, which is due to a duplica-
tion of the amyloid precursor protein (βAPP) gene (see
Chapter 12), and the peripheral nerve degeneration
Charcot-Marie-Tooth disease type 1A (Case 6) , which
generally results from duplication of only one gene, the
gene for peripheral myelin protein 22 (PMP22).
Increases in gene dosage are also prevalent as somatic
mutations in cancer cells, where they result from
increased copies of part or all of a chromosome;
mutations of this type more often contribute to tumor
progression than to initiation (discussed in Chapter
16).
Novel Property Mutations
In a few diseases, a change in the amino acid sequence
causes disease by conferring a novel property on the
protein, without necessarily altering its normal func-
tions. The classic example is sickle cell disease (Case 37)
(see later discussion), which is due to an amino acid
substitution that has no effect on the ability of sickle
hemoglobin to transport oxygen. Rather, unlike normal
325
hemoglobin, sickle hemoglobin chains aggregate when
they are deoxygenated to form polymeric fibers that
deform red blood cells. This behavior has not been
observed with any other hemoglobin mutant. That
novel property mutations are infrequent is not surpris-
ing because most amino acid substitutions are either
neutral or detrimental to the function or stability of a
protein that has been fi nely tuned by evolution. Only
rarely does a mutation introduce a new property of
pathological significance.
The difficulty in placing every type of mutation
into one or another of the classes discussed in this
section is demonstrated by a recently discovered group
of mutations, those that lead to gains of glycosylation.
In disorders of this type, a mutation in the coding
sequence creates a novel N-glycosylation site in the
mutant protein, conferring on it a novel property, the
ability to be N-glycosylated. However, the increased
glycosylation leads to a loss of function of the mutant
protein, as has been documented in some individuals
with mutations in the R2 subunit of the interferon-γ
receptor, leading to a mendelian susceptibility to myco-
bacterial infection (see Chapter 12).
Mutations Associated with Heterochronic or
Ectopic Gene Expression
An interesting and important class of mutations includes
those that alter the regulatory regions of a gene to cause
its inappropriate expression, at an abnormal time or
place. One of the most common genetic diseases, cancer,
is frequently due to the abnormal expression of a gene
that normally promotes cell proliferation—an onco-
gene—in cells in which the gene is not normally
expressed, resulting in malignant neoplasia (see Chapter
16). Comparably, some mutations in hemoglobin regu-
latory elements lead to the continued expression in the
adult of the γ-globin gene, which is normally expressed
at high levels only in fetal life. Such γ-globin gene muta-
tions lead to a phenotype called the hereditary persis-
tence of fetal hemoglobin (see later discussion).
HOW MUTATIONS DISRUPT THE
FORMATION OF BIOLOGICALLY
NORMAL PROTEINS
For development of a biologically active protein, infor-
mation must be transcribed from the nucleotide
sequence of the gene to the mRNA and then translated
into the polypeptide, which then undergoes progressive
stages of maturation (see Chapter 3). Mutations can
disrupt any of these steps (Table 11-1). Abnormalities
in five of these stages are illustrated by various hemo-
globinopathies; the others are exemplified by diseases
presented in Chapter 12.