HEMOGLOBIN

Hemoglobin (Hb) is the red blood pigment,

pigment, exclusively found in
erythrocytes.

 The normal concentration of Hb in blood in males is 14 ± 16 g/dl & in

females is 13 ± 15 g/dl.

FUNCTIONS:

Delivery of O2 from the lungs to the tissues.

Transport of CO2 and protons from tissues to lungs for excretion.

 ë
 
E
 Hemoglobin is a conjugated protein containing globin ± the
apoprotein part & the heme ± the non-
non-protein part (prosthetic group).

 Hemoglobin is a tetrameric allosteric protein.

ë
 
E OF GLOBIN

 wlobin consists of four polypeptide chains of two different primary

structures (monomeric units).

 The common form of adult hemoglobin (HbA ) is made up of two Į-

1
chains & two ȕ-chains ((Į
Į2ȕ2).

 Each Į-chain contains 141 aminoacids while ȕ-chain contains 146

aminoacids. Thus HbA1 has a total of 574 aminoacid residues.
 The four subunits of hemoglobin are held together by non-covalent
interactions primarily hydrophobic, ionic & hydrogen bonds. Each subunit
contains a heme group.
ë
 
E OF HEME
 The characteristic red colour of hemoglobin is due to heme.
Heme contains a porphyrin molecule namely protoporphyrin IX, with
iron at its center. Protoporphyrin IX consists of four pyrrole rings to
which four methyl, two propionyl & two vinyl groups are attached.
O HE
FO
Më OF HEMOGLOBIN
Õesides the adult hemoglobin (HbA1), other minor hemoglobins are found in
humans.

À
 
  







   

HbA1 Į2ȕ2 -

HbA2 Į2į2 

HbF Į2Ȗ2 

HbA1C Į2ȕ2-glucose 

 £BNO
M£L HEMOGLOBINë
 Abnormal hemoglobins are the resultant of mutations in the genes
that code for Į or ȕ chains of globin.

 As many as 400 mutant hemoglobins are known ,about 95% of them

are due to alterations in a single aminoacid of globin.

ÕASIC CONCEPTS OF w OÕIN SYNTHESIS

 The globin genes are organised in to two gene families or clusters.

 Į -wene family : There are two genes for Į-globin chain present on
each one of chromosome 16.The ȗ-gene, other member of Į-gene
cluster is also found on chromosome 16 & is active during the
embryonic development.
 ȕ -wene family : The synthesis of ȕ-globin occurs from a single gene
located on each one of chromosome 11.

This chromosome also contains four other genes.

One İ-gene expressed in the early stages of embryonic

development.

Two Ȗ-genes (w
(wȖ
Ȗ & AȖ
AȖ) synthesize Ȗ-globin chains of fetal
hemoglobin (HbF).

One į-gene producing į-globin chain found in adults to a minor

extend (HbA2).
 It is a term used to describe the disorders caused by the synthesis
of abnormal hemoglobin molecule or the production of insufficient
quantities of normal hemoglobin or rarely both.

 Hemoglobinopathies are inherited single-

single-gene disorders; in most
co--dominant traits©
cases, they are inherited as autosomal co

 Sickle
Sickle--cell anemia(HbS) & hemoglobin c disease (HbC) are the
classical examples of abnormal hemoglobins.

 Thalassemias
Thalassemias,, on the other hand, are caused by decreased
synthesis of normal hemoglobin.
 




†

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 Ô
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î   !" 
X Abnormal polymerization-
polymerization- Sickle cell disease
X Altered oxygen affinity ± polycythemia
X Readily oxidized ± unstable hemoglobins, methemoglobinemia

G  
X Alpha thalassemia
X Õeta thalassemia
X Alpha
Alpha--beta,delta
beta,delta--beta,gamma
beta,gamma--delta
delta--beta thalassemia

x   !# !

X HbE
X Hb constant Spring
X Hb epore
 Ô
Ô
Ô


$ %&
 ''
()

* † $ !" 

X Methemoglobinemia
X Sulfhemoglobinemia
X Carboxyhemoglobinemia
X Hbh in erythroleukemia
X Elevated HbF in erythroid stress,bone marrow dysplasia
 ëILE-ELL £NEMI£ O

ëILE-
ëILE--ELL HEMOGLOBIN
ëILE

 This is the most common form of abnormal hemoglobins.

hemoglobins.
  a general term for a group of

genet
d order
au ed by 
le hemoglobn (Hgb ë or
Hb ë©

 It is so named because the erythrocytes of these patients

adopt a sickle shape (crescent like) at low oxygen
concentration.
 OVE
VIEW
X An autosomal
recessive inherited
defect.

X The disease is
chronic and lifelong.

X ifespan is often
shortened with
sufferers living to an
average of 40 years.
 À


  


 
 
 



 

 

  


 





    
   





 


 







 


   
   


       





  
 
 
Figure A shows normal red blood
cells flowing freely in a blood vessel.
The inset image shows a cross-
section of a normal red blood cell
with normal hemoglobin.

Figure Õ shows abnormal, sickled

red blood cells clumping and
blocking blood flow in a blood vessel.
(Other cells also may play a role in
this clumping process.) The inset
image shows a cross-section of a
sickle cell with abnormal hemoglobin.
Homozygou & Heterozygou Hbë
HOMOZYwOUS:
If caused by inheritance of two mutant
genes (one from each parent) that code
for ȕ ± chains.

HETEROZYwOUS:
Only one gene of (ȕ(ȕ ± chains ) is affected
while the other is normal.
  mo t
ommon form of ë
´ ëILE ELL
£I  The erythrocytes of
heterozygotes contain both HbS & HbA & the
disease is reffered to as sickle
sickle--cell trait which is
more common in blacks.

´ £NEMI£- al o nown a
ëILE ELL £NEMI£-
hemoglobn ëë d ea e,  the homozygou form
n wh
h the affe
ted nddual ha
predomnantly 
le hemoglobn (Hb ëë©
O
£NE
Sickle--cell anemia is largely confined to tropical areas of the world.
Sickle

It primarily occurs in the black population.

It is estimated that 1 in 500 newborn black infants in the USA are affected
by sickle-
sickle-cell anemia.

MO ECU AR ÕASIS OF HbS

The structure of hemoglobin contains two Į- & two ȕ-globin chains.In case
of sickle-
sickle- cell anemia, the hemoglobin (HbS) has two normal Į ±globin
chains & two abnormal ȕ-globin chains
chains..

Sickle- cell anemia is due to the change (missense mutation) in the single
Sickle-
nucleotide (thymine Adenine ) of ȕ-globin gene.

This error causes the formation of altered codon (wUw in place of wAw )
which leads to the incorporation of valine instead of glutamate at the sixth
position in ȕ- chain.
hara
ter t
of ë
led ell
Normal
B ë
led ell

 -day lfe pan 3 - to 4 - day

lfe pan

Hgb ha normal Hb ha
O
arryng de
rea ed O

apa
ty
arryng
apa
ty
 to 4 g/ml of 6 to - g/ml of Hb
Hb

B de troyed at Ê Ô

normal rate 

  !"#

"$!! $#$!!#"!$!
%%&$

 ëgn and ymptom of 
le
ell anema u ually how
up after an nfant  4 month old and may n
lude
X 
+ Sickle cells are fragile.
fragile. They break apart easily and die, leaving
you chronically short on red blood cells. Sickle cells die after 10 to 20
days. The result is a chronic shortage of red blood cells,
cells, known as
anemia. Without enough red blood cells in circulation, your body can't get
the oxygen it needs to feel energized. That's why anemia causes fatigue.

X &  '&
+ (Vaso

&  '&
+ (Vaso--occlusive) Periodic episodes of pain, called
crises,, are a major symptom of sickle cell anemia. Pain develops when
crises
sickle--shaped red blood cells block blood flow through tiny blood vessels
sickle
to your chest, abdomen and joints.

X U'!( It is a yellowing of the skin and eyes that occurs because of

U'!(It
liver damage or dysfunction. Occasionally, people who have sickle cell
anemia have some degree of jaundice because the liver, which filters
harmful substances from the blood, is overwhelmed by the rapid
breakdown of red blood cells. In people with dark skin, jaundice is visible
mostly as yellowing of the whites of the eyes.
X ¦
, ' +
' + Sickle cells can damage your spleen,
spleen, an organ
that fights infection. This may make you more vulnerable to infections.
infections.
Doctors commonly give infants and children with sickle cell anemia
antibiotics to prevent potentially life-
life-threatening infections, such as
pneumonia.

X   & ,  


&)'
The spleen is an organ in the abdomen that filters out abnormal red
blood cells and helps fight infection. Sometimes,
Sometimes, the spleen traps many
cells that should be in the bloodstream and it grows large. This causes
anemia. Õlood transfusions may be needed until the body can make
more cells and recover. If the spleen becomes too clogged with sickle
normally. It begins to shrink and stop working.
cells, it can¶t work normally.

X $
-)
.(+
$
-)
.(+ A shortage of healthy red blood cells can slow growth
in infants and children and delay puberty in teenagers.

X # &
 + Tiny blood vessels that supply your eyes may
# &
 +
become plugged with sickle cells.
cells. This can damage the retina.
X 


 


.



. Sickle-
Sickle-shaped red blood cells may stick to the
walls of the tiny blood vessels in the brain. This can cause a stroke.
stroke. Occurs
mainly in children. Can cause learning disabilities

X   (  -
.
 (  -
. It's similar to pneumonia and is caused by an
infection or by sickle cells trapped in the lungs. People with this condition
usually have chest pain, fever, and an abnormal chest x ray. Over time, lung
damage may lead to pulmonary arterial hypertension.
X 
/' -


/ ' -
++
Swollen hands and feet may be the
first signs of sickle cell anemia in
babies. The swelling is caused by
sickle--shaped red blood cells blocking
sickle
blood flow out of their hands and feet.
 £
 


    






 




 agno 

In HbSS, the full blood count reveals Hb levels in the range 6 -8 g/dl
with a increased reticulocyte count.

A mixture of HbS in a reducing solution (sodium dithionate) gives a

turbid appearance, where as normal Hb gives a clear solution.

Abnormal hemoglobin forms are detected on ()


&(
  ,, a form of gel electrophoresis on which the various

&(
 
types of hemoglobin move at varying speed
 reatment
Õlood transfusion

Õone marrow transplantation.

Oral antibiotics ± oral penicillin.

Hydroxyurea.

PREVENTION

Regular health maintanance, proper nutrition, protection against

infections.
 HEMOGLOBIN  IëE£ëE
Cooley¶s hemoglobinemia (HbC)(HbC) is
characterized by substitution of glutamate
by lysine in the sixth position of ȕ-chain.

Hgb C has decreased solubility and in

the deoxyhemoglobin state, the RÕCs
form intracellular crystals leading to a
rigid RÕC with a decreased survival
time (33-
(33-35 days).

The disease is usually asymptomatic

although patients may have joint or
abdominal pain.

This disease is common in malarial

regions of West Africa

Diagnosis by Hgb electrophoresis.

 HEMOGLOBIN  IëE£ëE

This is caused by the substitution of glutamine in place

of glutamate in the 121st position of ȕ-chain.

Several varients of HbD are identified from different

places indicated by the suffix. For instance, HbD
(Punjab), HbD ( os Angeles).

HbD, on electrophoresis moves along with HbS.

 HEMOGLOBIN E IëE£ëE
This is the most common abnormal hemoglobin after
HbS.

It is estimated that about 10% of the population in

South-East Asia (Õangladesh, Thailand, Myanmar)
suffer from HbE disease.

HbE is characterized by replacement of glutamate by

ysine at 26th position of ȕ-chain.

The individuals of HbE (either homozygous or

heterozygous) have no clinical manifestations.
 H£L£ëëEMI£ë

 Thalassemias are a group of hereditary hemolytic

disorders characterized by impairment/ imbalance in the
synthesis of globin chains of Hb.

 Mostly occur in the regions surrounding the

Mediterranean sea, hence the name.

 Thalassemias are characterized by a defect in the

production of Į- & ȕ-globin chain.
 Thalassemias occur due to a variety of molecular
defects.

´wene deletion or substitution.

´Underproduction or instability of mRNA.
´Defect in the initiation of chain synthesis.
´Premature chain termination.
 Į-Thalassemia
Caused by a decreased synthesis or total absence of Į-globin chain
of Hb. There are four copies of Į-globin gene, two on each one of
the chromosome 16. Four types of Į-thalassemias occur which
depend on the number of missing Į-globin genes.

SA IENT FEATURES

Silent carrier: state is due to loss of one of the four Į-globin genes
with no physical manifestations.

Į-Thalassemia trait: caused by loss of two genes(both from the same

gene pair or one from each gene pair). Minor anemia is observed.

Hemoglobin H disease: due to the missing of three genes, is

associated with moderate anemia.

Hydrops fetalis: is the most severe form of Į-Thalassemia due to

lack of all the four genes. The fetus usually survives until birth and
then dies.
 Õeta ±Thalassemia
Caused by the decreased synthesis or total lack of formation of ȕ-
globin chain.

Classical Syndromes of Õeta Thalassemia

!  the mlde t form of beta thala ema©

#! - heterozygou d order re ultng n mld

hypo
hrom
, m
ro
yt
hemolyt
anema©

#!- ëeerty le between the mnor and

major©

#
0r - homozygous disorder resulting in severe

transfusion-dependent hemolytic anemia.
 ë


(







1

Usually no signs or symptoms are apparent, except for a mild

anemia.
Carriers are usually initially detected through screening, or when
performing routine CÕC (complete blood count). ater it can be
confirmed using hemoglobin electrophoresis

(



0
1

Signs such as paleness and growth retardation, are readily

detectable since the first year of life. Those are mainly due to severe
anemia. ater bone deformities and hepato-splenomegaly develops.
 









î+ (


 ' (

&-/ maintain hematocrit at 25-30% to
suppress erythropoiesis, prevent anaemia
G+ &-- in splenomegaly with hypersplenism signs & child
is >5yrs of age
x+ "
&(-
&therapy continued life ± long.
+ ¦
supplement ± 1 mg /day
*+ (
(

&-- prevention and treatment of iron overload
2+ #

 against Pneumococcus
7. Õone marrow transplantation
8. Cord blood transfusion
3+ (

&-± insertion of normal genes in the stem cells of
recepients
"#! !
X Antenatal diagnosis possible
X Amniocentesis,chorionic villus biopsy
X wenetic counselling
 

  


X Acquired hemoglobinopathy

X Methemoglobin is HbA where iron exists in ferric rather

than normal ferrous form

X Ferric form- unable to bind with oxygen, so O2 carrying

capacity of arterial blood decreased

X Shifts oxyhemoglobin dissociation curve to left

X Normal concentration < 1%, due to methhemoglobin

reductase enzyme .Congenital absence predisposes in
patients receiving nitrate containing compounds

-& 1 ethargy,dizziness,headache

 $
) 

X Hypoxic patient with cyanosis,normal Pao2

X Pulse oximetry ± decrease in Spo2 with normal Pao2

X Characteristic muddy appearance of freshly drawn blood

X Diagnostic test of choice ± methemoglobinemia content





X Methylene blue 1mg/kg IV over 5 mins,dose can be repeated every

60 mins if cyanosis persists

X > 7mg/kg can oxidize Hb to methemoglobin

  
  


X
are
au e of
yano  ,drug ndu
ed,oxdaton of ron n Hb o

ur

due to drug

X Ntrate
ontanng
ompound ,meto
lopramde therapy
an
au e

X ëulfhemoglobn
annot
arry oxygen©Hgh
on
entraton tolerated

due to hft of oxyhemoglobn d o
aton
ure to rght©

$!

X e
rea e n ëpo alue de pte normal PaO

X ln
al
yano 

X Blu h tnge of fre hly drawn blood

 Ê




X No pharmacological treatment available

X Only means to remove sulfhemoglobin is

eventual destruction of affected RÕCs
 Ô
Ê )*
  

X Acquired hemoglobinopathy due to carbon-monoxide poisoning

X CO has 200 times higher affinity for Hb than oxygen,it can displace
oxygen and diminish oxygen delivery.


' 


Dyspnea, headache, nausea, vomiting , emotional lability,confusion,

impaired judgement

X Cherry red colour of skin , mucous membrane

X Masks development of cyanosis associated with poor oxygen

delivery to tissues
 !$!

X 100% oxygen via a tight fitting mask until

CO levels decrease < 10% and
symptoms resolve

X Hyperbaric oxygen in comatose patient

with CO level >40%. And in patients with
CO levels > 25% who had seizures.

EFE
ENE