Case 1

A one year old infant presents at a clinic with lassitude, poor muscle tone, and delayed motor

development. Physical examination reveals tachycardia, tachypnea, pallor, partial alopecia,

ulceration of skin at the corners of the mouth, and a smooth tongue. The nails break easily and

are spoon shaped.

The peripheral blood smear shows abnormally small and pale RBCs, and RBCs of different sizes

and different shapes. Further laboratory testing reveals decreased serum iron, increased total iron

binding capacity, increased tranferrin, and low serum ferritin.

Diagnosis
CASE 2

A 7 year old male is brought to the emergency room because of weakness and the spontaneous

appearance of painful swelling of both knee joints, as well as black tarry stools. The child has a

history of prolonged bleeding following minor injuries. His maternal uncle died of a “bleeding

disorder.”

Physical examination reveals pallor, swollen, erythematous, tender knee joints with blood

accumulation in the synovial capsule. Numerous bruises are seen at areas of minimal repeated
trauma. The bleeding time and prothrombin time are normal, while partial thromboplastin time is

prolonged. The synovial fluid was hemorrhagic. Further laboratory work-up shows reduced

levels of factor VIII on immunoassay.

QUESTIONS:

1. What is the most likely diagnosis? Justify your answer.

2. Explain the biochemical basis for the patient’s condition.

Hemophilia A is referred to as classic hemophilia and was first recognized

in the second century AD. The disease is an X-linked recessive bleeding
disorder caused by defects in the clotting cascade enzyme factor VIII. Factor
VIII serves as a cofactor in the activation of factor X to Xa in a reaction
referred to as the "tenase" complex. The actual enzyme responsible for
activating factor X to Xa is activated factor IX (factor IXa). Deficiencies in
factor IX result in the related bleeding disorder, hemophilia B.
The factor VIII gene (symbol: F8) resides near the telomeric end of the
long arm of the X chromosome (Xq28). The gene spans 186 kilobases (kb)
and is composed of 27 exons that generate two alternatively spliced mRNAs.
These two mRNAs encode factor VIII isoform a (2351 amino acids) and
isoform b (216 amino acids). The mRNA that encodes factor VIII isoform b
contains a 5' exon that is within intron 22 , that codes for eight amino acids,
that is spliced to exons 23–26. Multiple mutations have been identified leading
to hemophilia A. These include frameshift mutations, missense mutations,
nonsense mutations, gene inversions, large deletions and splicing errors.
Patients with hemophilia A suffer from joint and muscle hemorrhage, easy
bruising and prolonged bleeding time from wounds. Almost all patients with
hemophilia A have normal platelet function so the bleeding from minor cuts
or abrasions is generally not severe. Hemophilia A can be divided into severe
or moderate disease. Approximately 50%–60% of hemophilia A patients
suffer from the severe form of the disease and have <1% normal factor VIII
activity. Patients with moderate hemophilia A have from 1%–20% of normal
factor VIII. Because hemophilia A is an X-linked disease almost all patients
are male and the occurrence world-wide is 1 in 5,000 male births. It is possible
that an affected female can result from the mating of an affected male with a
carrier female but the Mendelian frequency for such a situation is
approximately 1 in 50 million female births. Nonetheless, there have been
cases described of female hemophilia A patients. A more common
mechanism for presentation of hemophilia A in females is the process of X
chromosome inactivation which could lead to inactivation of the X
chromosome that harbors the wild-type factor VIII gene. Other rare
 possibilities also exist for the generation of female hemophilia A but are not
discussed here.

Clinical Features of Hemophilia A

The frequency and severity of the bleeding in hemophilia A patients is
inversely correlated to the level of residual factor VIII protein circulating in the
blood. The weight bearing joints are the ones most affected in the disease
and include the hips, knees, ankles and elbows. If the bleeding in the joints is
left untreated it will lead to severe swelling and pain, joint stiffness and
inflammation. Blood in the synovial fluid of the joints is highly irritating causing
synovial overgrowth and a tendency to cause additional bleeding from the
vascular tissues of the joint. The bleeding results in the deposition of iron in
chondrocytes with the consequences being the development of degenerative
arthritis. Muscle bleeding, like joint bleeding, is most prevalent in large load-
bearing muscle groups such as in the thigh, calf, buttocks and posterior
abdominal wall. Since all of these untoward clinical symptoms are the result
of a lack of factor VIII in the blood, replacement of factor VIII by intravenous
infusion completely normalizes the hemophiliac's blood coagulation
(hemostasis) processes.

CASE 3

A 9 month old infant is brought to the pediatrician because of jaundice, lethargy, and easy

fatigability. The parents of the child are of northern European origin. Physical examination

reveals pallor, mild jaundice, and palpable splenomegaly.

Complete blood count with peripheral blood smear shows microcytic anemia; and small,

rounded, dark, RBCs lacking central pallor. Coomb’s test was negative. There was elevated

indirect bilirubin, increased reticulocytes, increased mean corpuscular hemoglobin count,

decreased MCV, and an abnormal RBC osmotic lysis test.

QUESTIONS:

1. What is the most likely diagnosis? Justify your answer.

2. Explain the biochemical basis for the patient’s condition.

Hereditary spherocytosis is a common inherited disorder that is characterised by anaemia, jaundice, and
splenomegaly. It is reported worldwide and is the most common inherited anaemia in individuals of
northern European ancestry. Clinical severity is variable with most patients having a well-compensated
haemolytic anaemia. Some individuals are asymptomatic, whereas others have severe haemolytic
anaemia requiring erythrocyte transfusion. The primary lesion in hereditary spherocytosis is loss of
membrane surface area, leading to reduced deformability due to defects in the membrane proteins
ankyrin, band 3, β spectrin, α spectrin, or protein 4.2. Many isolated mutations have been identifi ed in
the genes encoding these membrane proteins; common hereditary spherocytosis-associated mutations
have not been identifi ed. Abnormal spherocytes are trapped and destroyed in the spleen and this is the
main cause of haemolysis in this disorder. Common complications are cholelithiasis, haemolytic
episodes, and aplastic crises. Splenectomy is curative but should be undertaken only after careful
assessment of the risks and benefi ts.

Introduction Hereditary spherocytosis refers to a group of heterogeneous inherited anaemias that are
characterised by the presence of spherical-shaped erythrocytes (spherocytes) on the peripheral blood
smear.1–3 This disorder, including the very mild or subclinical forms, is the most common cause of
inherited chronic haemolysis in northern Europe and North America where it aff ects about one person
in 2000.4–11 It has also been frequently described in other populations, notably in Japan.12 Although
the disease arises in all racial and ethnic groups, on the basis of clinical reports, it seems to be less
common in African-American and southeast Asian people; however, comprehensive population survey
data are unavailable for these populations
CASE 4

A 25-year-old Mediterranean female presents to her obstetrician at 12-weeks gestation for her

first prenatal visit. This is her first pregnancy, and she is concerned about her baby and the risk

of inheriting a “blood disease” like others in her family. The patient reports a personal history of

mild anemia but nothing as severe as her brother who required frequent transfusions and died at

age 10. The patient was told by her physician that she did not need to take iron supplementation

for her anemia. Patient denies having any anemic symptoms.

Her physical exam is consistent with a 12-week pregnancy and ultrasound confirmed an

intrauterine pregnancy at 12-weeks gestation. The patient’s hemoglobin level shows a

hypochromic, microcytic anemia, (hemoglobin, 9g/dL), and hemoglobin electrophoresis

demonstrated increased hemoglobin A2 level (4.0 percent) and increased fetal hemoglobin level.

QUESTIONS:

1. What is the most likely diagnosis? Justify your answer.

2. Explain the biochemical basis for the patient’s condition.