ABNORMAL HEME AND GLOBIN SYNTHESIS

When you read the following names what do you think about?

Count Dracula Stefan Salvatore Edward Bella

Porphyria

Disorder in heme synthesis Enzyme defects necessary for the heme molecule Leads to the accumlation of porphyrin precursor or of one or more phorphyrinogens in the bone marrow (erythropoietic porphyria) and in the liver (hepatic porphyria) Leads to decrease Hb production Increased in the production and accumulation of the porphyrins and/or their precursors above the sire of the enzyme defect Will cause photocutaneous sensitivity and or

Congenital erythropoietic porphyria

A.k.a Gunthers disease Causes cutaneous photosensitivity (dematitic lesion) Rare type Autosomal recessive trait Decreased production in uroporpjurinogen III cosynthetase which results in the overproduction of uropophyrinogen I and to a lesser extent of coproporphyrinogen I This excess porphyrins accumlates in the BM and some are excreted in the urine Manifestatons: normocytic,normochromic anemia, ineffective erythropoiesis ,shortened RBC life span, reddish or burgundy urine

Porphyria Cutanea Tarda

Inherited as an autosomal dominant trait Decreased production of uroporphyrinogen decarboxylase Manifestations: sensitivity to sunlight and minor trauma, urine is reddish or brownish due to increased uroporphyrin I May only be evident n the presence of a liver disorder there is no CNS involvement

Erythropoietic protoporphyria

Autosomal dominant trait Decreased of heme ferrochelatase (heme synthetase) resulting in increased concentrations of porphyrin IX and will show fluorescent cytoplasm No anemia is present Mild sensitivty to sunlight , mild trauma and lesions Tx: beta-carotene beadlets and cholestyramine

Acute intermittent hepatic porphyria

Autosomal dominant Neurologic symptoms Deficiency in uroporpyrinogen I synthetase Most common Symptoms are intermittent and may occur several times in one year or as rarely as 2-3 times in patients life time During acute and active phase patient may experience abdominal pain becaused of porphyrin precursor diposition in the liver Psychologic disturbances and neurologic symptoms may occur Active phase: increase WBC, urine contain delta-

Heridetary coproporphyria

Acute intermittent hepatic porphyria in its clinical picture Decrease in copropophyrinogen oxidase, which results in increased amounts of coproporphyrin III in the urine and feces and accumulation in the liver Tx: hematin

Variegate porphyria

Autosomal dominant trait South African descecdants of Dutch family Similar to porphyria cutanea tarda with accompanying neurological involvement Acute attacks of this disorder are generally precipitated by exposure to such drugs such as sulfonamides, barbiturates, anesthetics and alcohol Deficiency in protoporphyrinogen oxidase Feces contain large amounts of of protopophyrinogen and coproporphyrin Urine contains large amount of porphobilinogen and D-ALA

Acquired porphyrias

Several of the enzymes controlling heme synthesis are inhibited Lead poisoning= inhibits ferrochelatase and DALA dehydratase , erythrocyte protoporphyrin IX levels are increased, resulting in increase in excreted D-ALA and coproporphyrin III Hexachlorobenze = chemical used in mold in wheat. Toxic exposure wil lead to inhibition of the enzyme uroporphyrinogen decarboxylase. Uroporphyrin I levels are increased, indivuals are photosensitive and have reddish urine.

Hemoglobinopathies

Decrease, lack of, or abnormal globin May be severe hemolytic anemia Abnormal Hb with low functionality Mutation may be deletion, substitution, elongation Hb electrophoresis may be helpful

Hemoglobinopathy

An inherited mutation of the globin genes leading to a qualitative or quantitative abnormality of globin synthesis

Hb S

Sickling Hb Autosomal Sickle crisis in low oxygen condition 6 glutamate to valine substitution Prevalent in Eastern Africa Solubility test Sickling test (metabisulfite)

Sickle cell anemia (Hb S disease):

Valine residues aggregate together by hydrophobic interactions leading to precipitation of Hb within RBCs. RBCs assume sickle-shaped leading to fragility of their walls and high rate of hemolysis.

Such sickled cells frequently block flow of blood in narrow capillaries and block blood supply to tissue (tissue anoxia) causing pain and cell death. Note: The lifetime of erythrocyte in sickle cell is less than 20 days, compared to 120 days for normal RBCs. Patients may be : - Heterozygotes (Hb AS): mutation occurs only in one globin chain. These patients have sickle cell trait with no clinical symptoms and can have normal life span. Homozygotes (Hb SS): mutation occurs in both -globin chain with apparent anemia and its symptoms

Hb C disease: Like HbS, Hb C is a mutant Hb in which glutamic acid in 6th position of -chain is replaced by lysine. RBCs will be large oblong and hexagonal.
Cigar-like crystals Billiard ball cells Folded cells Normocytic,normochromic anemia Hb 8-12 g/dL

The heterozygous form (HbAC) is asymptomatic. The homozygous form (Hb CC) causes anemia, tissue anoxia and severe pain.

Hb SC disease
Washington

monument cells or finger like projections Doubly heterozygous Mitten shape Symptoms appear during the teenage years Splenomegaly occurs from childhood to adulthood

Hb D

16 beta chain variants and 6 alpha chain variants Migrate with S Glysine substituted with glutamic acid in the 121st position of the beta chain

Hb E (26 Glu-Lys) in SEA

Replacement

in the 26 with

glutamic acid 3rd most common Homozygous (EE)and hetero (EA) exist Microcytic and normochromic

Hb SD

Doubly heterozygous Only SD los Angeles produces clinical symptoms Citrate electrophoresis is the definitive test Sickle cell solubility positive

Hb O arab

Same type of substitution as Hb C Substitution point is at the 121st position amino acid 22 121 Glu- Lys

Hb G- Philadelphia

Results in the eplacement of asparginine by lysine in the 68th position of the alpha chain West Africa Homozygous not compatible with life

Hb I

Rare affects both alpha and beta chains Lysine is replaced by glutamic acid Migrates between with Hb Barts and Hb H all of which migrate further from the Hb A I the cellulose acetate

Hb Barts and H
Found in patients with alpha thalassemia who are producing fewer alpha chains than normal Hb Barts consist of four gamma chains Hb H occurs in older children and consist of four normal beta chai

Hb Gun Hill

Deletion of five beta chain amino acids beta 91-95 No heme can bind to the beta chain Unequal crossing over between the beta chain genes

Hb Constant Spring

Elongated alpha chain because 31 amino acids are added to the end of the chain Replacement of a terminator codon, which normally stops amino acid addition with a codon for glutamin

Hb C disease

Hb C disease

Hb SC disease

Hb SC disease

A2 C E O arab C Harle m S D G
Lepor e

+
F A

Cellulose acetate pH 8.6

F A S
C

Citrate agar pH 6.2

Thalassemia

1925: Described by Dr. Thomas Cooley and Dr. Pearl Lee of Detroit 1920s: Osmotic fragility test 1932: Dr. George Whipple of Rochester coined the name thalassa anemia from Greek story about Xenophons army returning from Persia 1930s: Familial pattern recognized 1950s: Alkali denaturation test for Hb F, Hb ELP 1956: Coulter model A 1960s: RBC indices 1980s: Histogram, DNA analysis, PCR

Signs and Symptoms

Hemolytic Bone changes (hair on end) Ethnicity: Mediterranean, Africa, Southeast Asia Hypo-Micro, Poikilocytosis NRBCs, reticulocytosis, basophilic stippling Siderocytes (with repeated transfusions)

Thalassemia: A group of genetic diseases in which a defect occur in the rate of synthesis of one or more of Hb chains, but the chains are structurally normal. This due to defect or absence of one or more of genes responsible for synthesis of or chains leading to premature death of RBCs.

Types: -thalassemia: When synthesis of chains is decreased or absent. There are two copies of the gene responsible for synthesis of chains. Individuals with globin gene defects have either : - -thalassemia minor ( thalassemia trait) : when the synthesis of only one globin gene is defective or absent. Those individuals make some chains and usually not need specific treatment.

--thalassemia: in which synthesis of globin chain is defective or absent. There are four copies of gene responsible for synthesis of globin chains so patients may have: i - Silent carrier of -thalassemia with no symptoms: if one gene is defective

ii- -thalassemia trait: if two genes are defective.

iii- Hb H disease: if 3 globin genes are defective, with mild to moderate anemia. The produced Hb will be 4 which is called HB H. Oxygen delivery to tissues will be blocked because Hb H (4 ) has high affinity to O2 and not deliver it to tissues. iv- Hydrops fetalis: when all 4 globin genes are defective. It causes fetal death because globin chains are required for synthesis of Hb F.

Thalassemia Blood Smears

X-ray of scull n Thalassemia: Hair-on-end

Perls iron stain (Prussian blue) with potassium ferrocyanide

Siderocyte

Sideroblasts

 Thalassemia

Deletion of one or more alpha genes from chromosome 16 -/: silent career with little signs --/: cis double deletion more common in SEA -/-: trans double deletion --/-: Hb H disease --/--: Hb Barts hydrops fetalis Hb Constant-Spring: elongation (discovered in Kingston, Jamaica; 2% of Thai have it)

 Thalassemia Lab Changes

High RBC Low H&H and indices High RDW May need to rule out IDA Hb ELP not useful except in Hb H BCB prep for Hb H

Hb H Prep with Brilliant cresyl blue

thalassemia Hydrops fetalis

Peripheral blood smear: Hb H disea

 Thalassemia

Usually point mutation in the control region + has minimal production o has no production +/+ or o/o is thal major or Cooleys anemia Often not apparent at birth until chain takes over g chain production High Hb A2, Hb F Related: Hb Lepore (d- fusion)s

Hb F preparation with Kleihauer-Betke Fetal Hb resists acid elution