Chapter 12

Thalassemia

Thalassemia
In

Chapter 12, you will be introduced

to the thalassemias. You will learn
about the pathophysiology, clinical
signs and symptoms, laboratory test
results, and treatments for both the
alpha and beta formsof thalassemia.
Subclasses of each major form of
thalassemia will be discussed.
3

Introduction to
Thalassemia
4

Thalassemia

1 of 2

Diverse

group of disorders which manifest as

anemia of varying degrees.
Result of defective production of globin
portion of hemoglobin molecule.
Distribution is worldwide.
May be either homozygous defect or
heterozygous defect.
Defect results from abnormal rate of
synthesis in one of the globin chains.
Globin chains structurally normal (is how
differentiated from hemoglobinopathy), but
have imbalance in production of two
different types of chains.

Thalassemia

2 of 2

Results

in overall decrease in amount of

hemoglobin produced and may induce
hemolysis.
Two major types of thalassemia:
Alpha () - Caused by defect in rate of
synthesis of alpha chains.
Beta () - Caused by defect in rate of
synthesis in beta chains.
May

contribute protection against

malaria.
6

Genetics of Thalassemia
Adult

hemoglobin composed two alpha

and two beta chains.
Alpha thalassemia usually caused by
gene deletion; Beta thalassemia
usually caused by mutation.
Results in microcytic, hypochromic
anemias of varying severity.
7

Beta
Thalassemia
8

Classical Syndromes of Beta

Thalassemia
Silent

carrier state the mildest form of

beta thalassemia.
Beta thalassemia minor - heterozygous
disorder resulting in mild hypochromic,
microcytic hemolytic anemia.
Beta thalassemia intermedia - Severity
lies between the minor and major.
Beta thalassemia major - homozygous
disorder resulting in severe transfusiondependent hemolytic anemia.
9

Silent Carrier State for

Thalassemia
Are

various heterogenous beta

mutations that produce only small
decrease in production of beta chains.
Patients have nearly normal
beta/alpha chain ratio and no
hematologic abnormalities.
Have normal levels of Hb A2.
10

Beta Thalassemia Minor

1 of 2

Caused

by heterogenous mutations that affect

beta globin synthesis.
Usually presents as mild, asymptomatic
hemolytic anemiaunless patient in under
stress such as pregnancy, infection, or folic
acid deficiency.
Have one normal beta gene and one mutated
beta gene.
Hemoglobin level in 10-13 g/dL range with
normal or slightly elevated RBC count.
11

Beta Thalassemia Minor

2 of 2

Anemia

usually hypochromic and microcytic

with slight aniso and poik, including target cells
and elliptocytes; May see basophilic stippling.
Rarely see hepatomegaly or splenomegaly.
Have high Hb A2 levels (3.5-8.0%) and normal
to slightly elevated Hb F levels.
Are different variations of this form depending
upon which gene has mutated.
Normally require no treatment.
Make sure are not diagnosed with iron
deficiency anemia.
12

Beta Thalassemia Intermedia

1 of 2

Patients

able to maintain minimum hemoglobin

(7 g/dL or greater) without transfusions.
Expression of disorder falls between
thalassemia minor and thalassemia major. May
be either heterozygous for mutations causing
mild decrease in beta chain production, or may
be homozygous causing a more serious
reduction in beta chain production.
See increase in both Hb A 2 production and Hb F
production.
Peripheral blood smear picture similar to
thalassemia minor.
13

Beta Thalassemia Intermedia

2 of 2

Have

varying symptoms of anemia, jaundice,

splenomegaly and hepatomegaly.
Have significant increase in bilirubin levels.
Anemia usually becomes worse with infections,
pregnancy, or folic acid deficiencies.
May become transfusion dependent as adults.
Tend to develop iron overloads as result of
increased gastrointestinal absorption.
Usually survive into adulthood.
14

Beta Thalassemia Major

1 of 3

Characterized

by severe microcytic,
hypochromic anemia.
Detected early in childhood:
Infants fail to thrive.
Have pallor, variable degree of jaundice,
abdominal enlargement, and hepatosplenomegaly.
Hemoglobin

level between 4 and 8 gm/dL.

Severe anemia causes marked bone changes
due to expansion of marrow space for
increased erythropoiesis.
See characteristic changes in skull, long
bones, and hand bones.

15

Beta Thalassemia Major

2 of 3

Have

protrusion upper teeth and Mongoloid

facial features.
Physical growth and development delayed.
Peripheral blood shows markedly
hypochromic, microcytic erythrocytes with
extreme poikilocytosis, such as target cells,
teardrop cells and elliptocytes. See marked
basophilic stippling and numerous NRBCs.
MCV in range of 50 to 60 fL.
Low retic count seen (2-8%).
Most of hemoglobin present is Hb F with
slight increase in Hb A2.
16

Beta Thalassemia Major

3 of 3

Regular

transfusions usually begin around

one year of age and continue throughout life.
Excessive number of transfusions results in
tranfusional hemosiderosis; Without iron
chelation, patient develops cardiac disease.
Danger in continuous tranfusion therapy:
Development of iron overload.
Development of alloimmunization (developing
antibodies to transfused RBCs).
Risk of transfusion-transmitted diseases.

Bone

marrow transplants may be future

treatment, along with genetic engineering
and new drug therapies.
17

Comparison of Beta
Thalassemias

GENOTYPE

HGB A

HGB A2

HGB F

NORMAL

Normal

Normal

Normal

SILENT
CARRIER

Normal

Normal

Normal

MINOR

Dec

INTERMEDI
A
MAJOR

Dec

Normal to
Inc
Normal to
Inc
Usually
Inc

Normal to
Inc
Usually Inc

Dec

Usually Inc
18

Other Thalassemias Caused by

Defects in the Beta-Cluster
Genes

1.

Delta Beta Thalassemia

2. Hemoglobin Lepore
3. Hereditary Persistence of Fetal
Hemoglobin (HPFH)

19

Delta Beta Thalassemia

Group

of disorders due either to a gene

deletion that removes or inactivates only
delta and beta genes so that only alpha
and gamma chains produced.
Similar to beta thalassemia minor.
Growth and development nearly normal.
Splenomegaly modest. Peripheral blood
picture resembles beta thalassemia.
20

Hemoglobin Lepore

Rare

class of delta beta thalassemia.

Caused by gene crossovers between
delta locus on one chromosome and
beta locus on second chromosome.

21

Hereditary Persistence of Fetal

Hemoglobin (HPFH) 1 of 2
Rare

condition characterized by continued

synthesis of Hemoglobin F in adult life.
Do not have usual clinical symptoms of
thalassemia.
Little significance except when combined
with other forms of thalassemia or
hemoglobinopathies.
If combined with sickle cell anemia,
produces milder form of disease due to
presence of Hb F.

22

Hereditary Persistence of Fetal

Hemoglobin (HPFH) 2 of 2
Hb

F more resistant to denaturation

than Hb A. Can be demonstrated on
blood smears using Kleihauer Betke
stain. Cells containing Hb F stain.
Classified into two groups according to
distribution of Hb F among red cells:
Pancellular HPFH - Hemoglobin F
uniformly distributed throughout red cells.
Heterocellular HPFH - Hemoglobin F found
in only small number of cells.

23

Beta Thalassemia with Hbg S

Inherit

gene for Hb S from one parent and

gene for Hb A with beta thalassemia from
second parent.
Great variety in clinical severity. Usually
depend upon severity of thalassemia
inherited. Production of Hb A ranges from
none produced to varying amounts. If no Hb A
produced, see true sickle cell symptoms. If
some Hb A produced, have lessening of sickle
cell anemia symptoms.
24

Beta Thalassemia with Hgb C

Shows

great variability in clinical

and hematologic symptoms.
Symptoms directly related to which
type thalassemia inherited.
Usually asymptomatic anemia
25

Beta Thalassemia with Hgb E

Is

unusual because results in more

severe disorder than homozygous E
disease.
Very severe anemia developing in
childhood.
Transfusion therapy required.
26

Alpha
Thalassemia
27

Alpha Thalassemia

1 of 2

Has

wide range clinical expressions.

Is difficult to classify alpha thalassemias due to
wide variety of possible genetic combinations.
Absence of alpha chains will result in increase
of gamma chains during fetal life and excess
beta chains later in life; Causes molecules like
Bart's Hemoglobin (4) or Hemoglobin H (4),
which are stable molecules but physiologically
useless.
28

Alpha Thalassemia

2 of 2

Predominant

cause of alpha thalassemias is

large number of gene deletions in the alphaglobin gene.
Are four clinical syndromes present in alpha
thalassemia:

Silent Carrier State

Alpha Thalassemia Trait (Alpha Thalassemia Minor)
Hemoglobin H Disease
Bart's Hydrops Fetalis Syndrome
29

Silent Carrier State

Deletion

of one alpha gene, leaving

three functional alpha genes.
Alpha/Beta chain ratio nearly normal.
No hematologic abnormalities present.
No reliable way to diagnose silent
carriers by hematologic methods;
Must be done by genetic mapping.
May see borderline low MCV (78-80fL).
30

Alpha Thalassemia Trait

(Alpha Thalassemia Minor)
Also

called Alpha Thalassemia Minor.

Caused by two missing alpha genes. May be
homozygous (-a/-a) or heterozygous (--/aa).
Exhibits mild microcytic, hypochromic anemia.
MCV between 70-75 fL.
May be confused with iron deficiency anemia.
Although some Bart's hemoglobin (4) present at
birth, no Bart's hemoglobin present in adults.
31

Hemoglobin H Disease

1 of 2

Second

most severe form alpha thalassemia.

Usually caused by presence of only one gene
producing alpha chains (--/-a).
Results in accumulation of excess unpaired
gamma or beta chains. Born with 10-40%
Bart's hemoglobin (4). Gradually replaced
with Hemoglobin H (4). In adult, have about
30-50% Hb H.
4

4
32

Hemoglobin H Disease

1 of 2

Live

normal life; however, infections,

pregnancy, exposure to oxidative drugs may
trigger hemolytic crisis.
RBCs are microcytic, hypochromic with marked
poikilocytosis. Numerous target cells.
Hb H vulnerable to oxidation. Gradually
precipitate in vivo to form Heinz-like bodies of
denatured hemoglobin. Cells been described
has having "golf ball" appearance, especially
when stained with brilliant cresyl blue.
33

Barts Hydrops Fetalis

Syndrome

Most severe form. Incompatible with life. Have no

functioning alpha chain genes (--/--).
Baby born with hydrops fetalis, which is edema and
ascites caused by accumulation serous fluid in fetal
tissues as result of severe anemia. Also see
hepatosplenomegaly and cardiomegaly.
Predominant hemoglobin is Hemoglobin Bart, along
with Hemoglobin Portland and traces of Hemoglobin H.
Hemoglobin Bart's has high oxygen affinity so cannot
carry oxygen to tissues. Fetus dies in utero or shortly
after birth. At birth, see severe hypochromic,
microcytic anemia with numerous NRBCs.
Pregnancies dangerous to mother. Increased risk of
toxemia and severe postpartum hemorrhage.
34

Comparison of Alpha
Thalassemias
Genotype

Hb A

Hb Bart

Hb H

Normal

97-98%

Silent Carrier

96-98%

0-2%

Alpha
Thalassemia
Trait

85-95%

5-10%

Dec

25-40%

2-40%

80% (with
20% Hgb
Portland)

0-20%

Hemoglobin H
Disease
Hydrops Fetalis

35

Alpha Thalassemia with Hgb

S
Alpha

thalassemia can occur in

combination with hemoglobin S. Is
fairly common combination in
populations of African descent.
Patient usually asymptomatic. Have
less Hb S present than those with
sickle cell trait. Have increased
presence of Hb F.
36

Laboratory
Diagnosis of
Thalassemia
37

Laboratory Diagnosis of
Thalassemia
Need

to start with patient's individual

history and family history. Ethnic
background important.
Perform physical examination:
Pallor indicating anemia.
Jaundice indicating hemolysis.
Splenomegaly due to pooling of abnormal
cells.
Skeletal deformity, especially in beta
thalassemia major.

38

CBC with Differential

1 of 2

See

decrease in hemoglobin, hematocrit,

mean corpuscular volume (MCV), and mean
corpuscular hemoglobin (MCH). See normal
to slightly decreased Mean Corpuscular
Hemoglobin Concentration (MCHC). Will
see microcytic, hypochromic pattern.
Have normal or elevated RBC count with a
normal red cell volume distribution (RDW).
Decrease in MCV very noticeable when
compared to decrease in Hb and Hct.
39

CBC with Differential

2 of 2

Elevated

RBC count with markedly

decreased MCV differentiates
thalassemia from iron deficiency anemia.
On differential, see microcytic,
hypochromic RBCs (except in carrier
states). See mild to moderate
poikilocytosis. In more severe cases, see
marked number of target cells and
elliptocytes. Will see polychromasia,
basophilic stippling, and NRBCs.
40

Reticulocyte Count

Usually

elevated. Degree of
elevation depends upon severity of
thalassemia.

41

Osmotic Fragility

Have

decreased osmotic fragility.

Is not very useful fact for
diagnosing thalassemia. Is an
inexpensive way of screening for
carrier states.

42

Brilliant Cresyl Blue Stain

Incubation

with brilliant cresyl blue stain

causes Hemoglobin H to precipitate.
Results in characteristic appearance of
multiple discrete inclusions -golf ball
appearance of RBCs. Inclusions smaller
than Heinz bodies and are evenly
distributed throughout cell.
43

Acid Elution Stain

Based

on Kleihauer-Betke procedure.
Acid pH will dissolve Hemoglobin A from
red cells. Hemoglobin F is resistant to
denaturation and remains in cell. Stain
slide with eosin. Normal adult cells
appear as "ghost" cells while cells with
Hb F stain varying shades of pink.
Useful way to differentiate between
pancellular HPFH and heterocellular
HPFH.
44

Hemoglobin Electrophoresis
Important

role in diagnosing and

differentiating various forms of thalassemias.
Can differentiate among Hb A, Hb A2, and Hb
F, as well as detect presence of abnormal
hemoglobins such as Hemoglobin Lepore,
hemoglobin Bart's, or Hemoglobin Constant
Spring.
Also aids in detecting combinations of
thalassemia and hemoglobinopathies.
45

Hemoglobin Quantitation
Elevation

of Hb A2 excellent way to
detect heterozygote carrier of beta
thalassemia. Variations in gene
expression in thalassemias results in
different amounts of Hb A2 being
produced.
Can also quantitate levels of Hb F.
46

Routine Chemistry Tests

Indirect

bilirubin elevated in
thalassemia major and intermedia.
Assessment of iron status, total iron
binding capacity, and ferritin level
important in differentiating
thalassemia from iron deficiency
anemia.
47

Other Special Procedures

Globin

Chain Testing - determines ratio

of globin chains being produced.
DNA Analysis - Determine specific
defect at molecular DNA level.

48

Differential Diagnosis of
Microcytic, Hypochromic
Anemias
RDW

Serum
Iron

TIBC

Serum
Ferritin

FEP

Iron
Deficiency

Inc

Dec

Inc

Dec

Inc

Alpha Thal

Norm

Norm

Norm

Norm

Norm

Beta Thal

Norm

Norm

Norm

Norm

Norm

Hgb E Disease

Norm

Norm

Norm

Norm

Norm

Anemia of
Chronic
Disease

Norm

Dec

Dec

Inc

Inc

Inc

Inc

Norm

Inc

Dec

Norm

Norm

Norm

Norm

Inc

Sideroblastic
Anemia
Lead
Poisoning

49