1

.. 2549
(Clinical practice guidelines for diagnosis and management of thalassemia syndromes)
*( 2/7 ..2548 )

(thalassemia syndromes)
(thalassemia) (hemoglobinopathy)
(hemolytic anemia) autosomal
(thalassemia
trait, carrier, heterozygote)
2 (genotypic diagnosis)
1
(phenotypic diagnosis) 2
( 1)
1. Barts hydrops fetalis homozygous alpha-thalassemia 1 genotype
-thal 1/-thal 1 - - /- -
()

2. (Homozygous beta-thalassemia; -thal/-thal)

3-6
thalassemic facies

3. - (Beta-thalasemia/Hb E, -thal/ E)
Homozygous beta-thalassemia
4. Hb H disease (-thal 1/ -thal 2, or -thal 1/Hb CS)

1.

2. (complete blood count, CBC) (red cell indices)
(morphology) homozygous
-thalassemia, -thalassemia/Hb E Hb H disease (hypochromia)

(microcytic) (poikilocytosis) MCV MCH

3.

inclusion body Hb H

(definite diagnosis) (Hemoglobin analysis)

high performance liquid chromatography (HPLC), low -pressure liquid chromatography
(LPLC), hemoglobin electrophoresis (
1) 3

Baseline
Hb level
g/dl 14
13
12
11
10
9
8
7
6
5
4
3
2
1

normal
trait
0

E trait

thal2
HbH
AEBart HbH-CS

mild

thal1
trait moderate

severe

/E
0

0/0

1 (baseline Hb level)
(phenotypic diagnosis) (mild) (moderate)
(severe)

Alpha-thalassemia syndromes

Hb Barts
hydrops
Hb H disease

genotype
(- - / - -)

(- - / - )

CS

Hb H Constant
Spring (Hb HCS)

(- -/ )

Homozygous Hb
CS

(CS/CS)

-thal 1 trait

(- -/)

-thal 2 trait

(- /)

Homozygous thal
-thalassemia/Hb
E
Homozygous Hb
E (HbEE)
Hb E trait

-thalassemia
trait

Phenotype

Hb typing

Cord blood Hb Barts > 80%

(MCV
)

Hb CS= 2-3% & Hb H= 1015%

Cord blood Hb Barts= 1030%

> 1 Hb H= 4-20%

Hb CS ~ 5%

Cord blood Hb Barts= 2-10%

> 1 normal A2A

Normal Hb A2A

Beta-thalassemia syndromes

genotype
( /0), (0/+)
0

(+/+)
(0/E)
(+/E)
(E/E)
(E/)

(0/) or
(+/)

Phenotype

Hb typing

Hb A2F; HbA

Hb EF or Hb EFA

(MCV )

(MCV
)

Hb EA (E=25-35%)

Hb E (E=80-100%)

Hb A2A (A2>3.5%)

Alpha & Beta-thalassemia interaction

Phenotype

Hb typing
Hb AE Barts
disease

genotype
(- -/- )
(E/)

Hb AE Barts CS

(- -/CS)
(E/)

Hb EF Barts
disease

(--/-) (E/E)
(--/-) (0/E

Hb AE Barts

Hb AE CS Barts

Hb EF Barts

(baseline Hb/Hct)

(most severe)

(severe)

2
()

Hb < 7 g/dL
(Hct < 20 %)

(Asymptomatic)

-thal/Hb E disease (

Hb > 7 9 g/dL
(Hct >20 27 %)

-thal/ -thal ()
-thal/ Hb E ()
Hb H disease ()

Hb 9 g/dl
(Hct 27 %)

(mild)

-thal/ -thal ()

(moderate)

Hb Barts hydrops fetalis

-thal/ Hb E ,
Hb H disease ,
Hb A-E-Barts disease,
Homozygous Hb CS

Hb (low
normal)

Homozygous -thal2,
Homozygous Hb E

( 2)
(severe beta-thalassemia) baseline Hb 7.0 g/dl (Hct <20 %) -thal/
-thal -thal/Hb E disease
(stem cell transplantation)
(high transfusion) (iron chelation)
(low transfusion)
(moderately severe thalassemia) baseline Hb 7-9 g/dl (Hct 2027 %) -thal/ Hb E , -thal/ -thal Hb H disease

(high transfusion + iron chelation)

(low transfusion) acute hemolysis
(mild thalassemia) baseline Hb > 9 g/dl (Hct > 27 %) Hb H disease
Hb A-E-Barts disease, Homozygous Hb CS, -thal/ Hb E acute hemolysis
(Asymptomatic) Homozygous -thal 2, Homozygous Hb E,

1.

- 5

-
-

folic acid

- > 1 1 (5 )
- < 1 1/2
(high transfusion)

2.

3. (Packed red cell transfusion)

(PRC)
leukocyte-poor PRC) (leukocyte depleted/ filtered PRC)
(HIV antibody, HIV antigen, Hepatitis C, Hepatitis B, Syphilis)
cross-match
PRC 12-15 mL/kg 2
HCC syndrome ( 7.3)
minor blood groups minor group red cell antigens
(C, c, E, e, Lea, Leb, Mia) PRC
5
2
3.1 (high transfusion)
homozygous beta-thalassemia Beta-thalassemia/Hb E
(suppression of erythropoiesis)


L-PRC 12-15 mL/kg
10 g/dL. L-PRC 2 4 12-15 mL/kg
(pre-transfusion Hb) 10 g/dL
10 g/dl 12-15
180-225 mL/kg ( 4)

high-transfusion

3.2 (Low transfusion)

high-transfusion

7 g/dL high-transfusion
(acute hemolysis)
Hb < 7 g/dL (Hct < 20%) L-PRC 10 mL/kg 412

3.3
pretransfusion Hb < 5 g/dL
1. PRC 2 Hb 5 mL/kg
2. < 2 mL/kg / ( 2448 .)
3. PRC
4. BP, PR 30 PRC
febrile non-hemolytic transfusion reaction (FNHTR) Chlorpheniramine Paracetamol
1/2-1 . FNHTR vital signs
I.V. fluid NSS 5% D/NSS
(leukocyte
depleted PRC leukocyte filtered PRC)
4. (Iron chelation)

regular (high) transfusion

(1 mL 1.16 mg)

(serum ferritin) serum ferritin 2,500 ng/mL 15 mL/g

(serum ferritin) 1,000 ng/mL 3

1
PRC 15
Desferrioxamine (Desferal)
20-40 mg/kg/ 5 7 /
(infusion pump) 8-12 serum ferritin 6

continuous intravenous infusion cardiac problems iron overload 50

70 // 5-6 / continuous intravenous infusion 12-24 infusion pump
Deferiprone (L1) second line
monotherapy Desferrioxamine 75 mg/kg/

5.

hypersplenism

6 .
250 mL/kg/
hypersplenism

Pneumococcal vaccine 1

aspirin 2 4 / > 800x109/L

penicillin (250 ) 1 2 .5
6. (stem cell transplantation: SCT)

1.
2. HLA
HLA 1 4
1 10,000 1 100,000
3. 500,000 1,5000,000
HLA
75-92 (

)

10

7.
7.1

pneumococci

upper respiratory tract infection, diarrhea, pneumonia, gram negative septicemia

Pythium insidiosum arterial occlusion, gangrene

7.2 Liver and gall bladder

extramedullary erythropoisis
liver cirrhosis B C

elective surgery cholecystitis ascending
cholangitis
7.3 Hypertension

2 unit
hypertension, convulsion cerebral hemorrhage (HCC syndrome)
2 diuretic antihypertensive drugs

7.4 Hypoxemia and Pulmonary hypertension

hypoxemia arterial
partial oxygen autopsy pulmonary
hypertension pulmonary hypertension thrombocytosis chronic
hypercoagulability aspirin
-thal/Hb E

7.5 Extramedullary erythropoiesis

erythropoiesis 10-15 bone resorption

extramedullary erythropoisis paravertebra
paravertebra paraplegia spinal
cord erythopoietic mass
bone density

Hydroxyurea

11

7.6 Chronic leg ulcer

medial lateral malleolus

skin graft

skin graft growth factor G-CSF
8. (genetic counseling)

1.

2.

(pre-natal

diagnosis) ( ?)

1.
autosomal recessive
2.
(in-vitro fertilization, IVF)
3. (artificial insemination)
(IVF) (embryo transfer) ovum
4.

1. (demographic data) (13 )

(pedigree)
2.

3.

12

1.

serial CBC baseline Hb level

2.

Hemoglobin analysis

3.

Blood group (ABO, Rh(D)) minor blood groups (C, c, E, e, Lea, Leb, Mia)

1. (Hb Hct)

2. liver function test (SGOT, SGPT), serum ferritin 3-6

3. HIV antibody, hepatitis profile (HBsAg, HCVAb) 6 - 1
4.

. Hb typing

HbH

Thalassemia clinic

BMT/SCT
& Prenatal diagnosis (PND)

Comprehensive
Thalassemia center

BMT/SCT&PN

()

13

(Quality Control)

Hb H disease

(PND)
comprehensive thalassemia center
comprehensive thalassemia center

(screening) -thalassemia, -thalassemia 1 Hb E

3 homozygous -thalassemia, -thalassemia/Hb E Hb Barts
hydrops fetalis
(screening test) 3
1. (red cell indicies) MCV (mean corpuscular volume), MCH (mean
corpuscular hemoglobin) MCV
2 MCV 2
(mean 2 S.D) MCV < 80 fl MCH
27 pg
2. (one tube osmotic fragility test OF)
0.36
90 -thalassemia 93

14

-thalassemia 1 5

3.
(dichlorophenol-indolphemol
(DCIP)
precipitation test) DCIP (unstable hemoglobin)

95
KKU-DCIP-Clear 100

1. (hemoglobin analysis) HbA2
-thalassemia HbA2 3.5
Hb E Hb CS
2. serum ferritin
3. PCR (polymerase chain reaction) -thalassemia 1

MCV DCIP 1 OF DCIP

2
3

Hb, MCV *

Age
Birth (cord blood)
1 to 30 days
1 week
2 weeks
1 month
2 months
3 to 6 months
0.5 to 2 years
2 to 6 years
6 to 12 years
12 to 18 years
Female
Male
Adults
Female
Male
* From Nathan and Oski, 1993

Hb (g/dl)
Mean (-2 S.D.)
16.5 (13.5)
18.5 (14.5)
17.5 (13.5)
16.5 (12.5)
14.0 (10.0)
11.5 (9.0)
11.5 (9.5)
12.0 (10.5)
12.5 (11.5)
13.5 (11.5)

MCV (fl)
Mean (-2 S.D.)
108 (98)
108 (95)
107 (88)
105 (86)
104 (85)
96 (77)
91 (74)
78 (70)
81 (75)
86 (77)

14.0 (12.0)
14.5 (13.0)

90 (78)
88 (78)

14.0 (12.0)
15.5 (13.5)

90 (80)
90 (80)

15

1. Dumars K W, Boehem C, Eckman JR, et al. Practical guide to the diagnosis of thalassemia. Am J Med Genet.
1996;62:29-37
2. Expect Committee. Current Situation and Strategic Plan for Prevention and Control of Blood Disease in Thailand.
Academia Reports, Ministry of Public Health. 1989-1990; 5-43.
3. Anonymous. The laboratory diagnosis of haemoglobinopathies. Br J Haematol 1998;101:783-92
4. Cao A, Pintus L, leeca U, et al. Control of homozygous -thalassemia by carrier screening and antenatal diagnosis
in Sardinians. Clin Genet. 1984;26:12-22
5. Ghosh A, Woo JSK, Wan CW, Machenry C, Wong V, and Ma HK. Evaluation of a prenatal screening for beta
thalassemia carriers in a Chinese population based on the mean corpuscular in a Chinese population based on the
mean corpuscular volume(MCV). Prenatal Diagnosis 1985;5:59-65
6. , ,
2539;6(2):165-177
7. Rogers M, Plelan L, Bain B. Screening criteria for beta thalassemia trait in pregnant women. J Clin Pathol 1995; 48;
1054-6.
8. Sanguansermsri T, Phumyu N, Chomchuen S, and Steger HF. Screening for Alpha-Thalassemia 1 Heterozygotes in
Expecting Couples by Combination of a Simple Erythrocyte Osmotic Fragility Test and PCR-Based Method.
Community Genet 1999;2:26-29
9. , ,
OF Test KKU-DCIP-Clear
2542;(2):111-118
10. , , thalassemia
screening test Hb typing. 2542;9(1):49-51
11. Fucharoen S, Winichagoon P, Wisedpanuchkit R, et al. Prenatal and postnatal diagnosis of thalassemia and
hemoglobinopathies by HPLC. Clin Chem 1998;44(4):740-8
12. Kattamis C, Efremor G, and Pootrakul S. Effectiveness of one tube osmotic fragility screening in detecting thalassemia trait. J Med Genet. 1981;18:266-70
13. Kulapongs P, Sangunasermsri T, Mertz G, Tawarat S. Dichlorophenol indophenol(DCIP) precipitation test: a new
screening test of Hb E and H. Paediatr Soc Thailand.1976;15;1-7
14. , , , ,

2536; 5:131-7.

16

15. Guidelines for the control of haemoglobin disorders. The sixth annual meeting of the WHO Working Group on
Haemoglobinopathies held in Sardinia. Modell B ed. April 1989.
16. Management protocol for the treatment of thalassemia patients 1997 Editors. Antonio Cao, Vilma Gabutti, Renzo
Galanello, et al. WHO: Thalassemia International Federation. Nicosia, Cyprus.
17. 2532:256-64
18.
6
18-20 2536.

17

1 MCV DCIP test

Step I Screening test

MCV + DCIP

DCIP positive

MCV > 80 fl
DCIP negative

MCV < 80 fl
Serum ferritin

1 month treatment of iron

Recheck MCV

<15 ng/ml

No history, signs
of iron def.

Hb > 10 g/dl

Iron def.

Normal range

Improve
Not improve

Iron def.

Step II. Confirmatory test

Hemoglobin Analysis (HPLC, LPLC) or Hemoglobin electrophoresis

Hb A A2 (A2< 3.5%)

Hb A A2 (A2> 3.5%)

Step III. DNA test

Abnormal Hb (E; CS; H; etc.)

Thalassemia diseases

PCR for alpha-thal 1

Negative

Positive

No significant
thalassemia

Alpha-thal 1 trait

Beta-thal trait

Hb E trait; homozygous Hb E
Hb CS trait; homozygous Hb CS
Hb H disease
Beta-thal/Hb E, ect.

Normal

18

2 OF DCIP test
Step I Screening test

OF + DCIP

DCIP positive

OF negative
DCIP negative

OF positive
1 month treatment of iron

Serum ferritin
<15 ng/ml

No history, signs
of iron def.

Recheck MCV

Hb > 10 g/dl

Iron def.

Normal range

Step II. Confirmatory test

Improve
Not improve

Iron def.

Hemoglobin Analysis (HPLC, LPLC) or Hemoglobin electrophoresis

Hb A A2 (A2< 3.5%)

Hb A A2 (A2> 3.5%)

Step III. DNA test

Abnormal Hb (E; CS; H; etc.)

Thalassemia diseases

PCR for alpha-thal 1

Negative

Positive

No significant
thalassemia

Alpha-thal 1 trait

Beta-thal trait

Hb E trait; homozygous Hb E
Hb CS trait; homozygous Hb CS
Hb H disease
Beta-thal/Hb E, ect.

Normal


*
1.
2.
3.
4.
5.
6.

19