Review article
Hemoglobin H disease: not necessarily a benign disorder
David H. K. Chui, Suthat Fucharoen, and Vivian Chan
Introduction
The hemoglobin molecule is a tetramer consisting of 2 pairs of
globin chains, each of which contains a heme group. During fetal
development, the major hemoglobin is Hb F (␣2␥2). In a normal
adult, the major hemoglobin is Hb A (␣2␤2). The ␣-globin gene
cluster is located on chromosome 16pter-p13.3 and is made up of
one embryonic ␨-globin and 2 ␣-globin genes in tandem (in cis):
5⬘-␨2-␣2-␣1-3⬘.1 Because each person has 2 chromosomes 16,
most people have 4 ␣-globin genes. The ␤-globin gene cluster,
5⬘-⑀-G␥-A␥-␦-␤-3⬘ is located on chromosome 11p15.5.
␣-Thalassemia is caused by mutations or deletions affecting
either one or more ␣-globin genes, leading to decreased or absent
␣-globin chain production from the affected gene(s).2 The deletion
or inactivation of only one ␣-globin gene usually results in
insignificant hematologic findings. When 2 ␣-globin genes are
deleted or inactivated, either both on the same chromosome 16 (in
cis) or one on each of the 2 chromosomes 16 (in trans), the affected
person is well but has borderline anemia, as well as microcytic and
hypochromic red blood cells.3
When 3 ␣-globin genes become inactive because of deletions
with or without concomitant nondeletional mutations, the affected
individual would have only one functional ␣-globin gene. These people
usually have moderate anemia and marked microcytosis and hypochro-
mia. In affected adults, there is an excess of ␤-globin chains within their
erythrocytes that will form ␤4 tetramer, also known as Hb H. This
hereditary disorder is known as Hb H disease.3
The most severe form of ␣-thalassemia is that of fetuses lacking
all ␣-globin genes. Some succumb early in gestation. Most develop
hydrops fetalis syndrome and die in utero during the second or the
third trimester of pregnancy, or shortly after birth.3-5
␣-Thalassemia mutations
Deletional mutations
Deletions removing one ␣-globin gene, such as the rightward
(-␣3.7) or leftward (-␣4.2) single ␣-globin gene deletions, are results
of misalignment crossovers during meiosis (Figure 1). These
deletions are very common and are found in 30% of African
Americans and up to 60% to 80% of people living in parts of Saudi
Arabia, India, Thailand, Papua New Guinea, and Melanesia.6,7
These single ␣-globin gene deletions and other point mutations
involving a single ␣-globin gene (see “Nondeletional mutations”)
are known as the ␣⫹-thalassemia mutations.2
There are more than 20 known natural deletions that remove
both ␣-globin genes on the same chromosome 16 (in cis) or the
From the Department of Pathology and Molecular Medicine, McMaster
University Faculty of Health Sciences, Hamilton, ON, Canada; Thalassemia
Research Center, Institute of Science and Technology for Research and
Development, Mahidol University, Salaya Campus, Puttamonthon,
Nakornpathom, Thailand; and University Department of Medicine, University of
Hong Kong and Queen Mary Hospital, Hong Kong, China.
BLOOD, 1 FEBRUARY 2003 䡠 VOLUME 101, NUMBER 3
complete ␨-␣-globin gene cluster, and they are known as the
␣0-thalassemia mutations.2 Some deletions might measure 100 to
300 kb or more in length. In addition, there are rare deletions that
silence ␣-globin gene expression by removing the HS-40 regula-
tory sequences upstream of the ␨-␣-globin gene cluster.2
The (--SEA) type of ␣0-thalassemia deletion of approximately 19.3 kb
in length removing both ␣-globin genes in cis but sparing the embryonic
␨-globin gene is common in Southeast Asia. It is found in 14% of people
living in Northern Thailand, for example.5 This mutation is the most
common cause for Hb H disease (Table 1) and hydrops fetalis syndrome
in that part of the world. In addition, the (--FIL), (--MED), and ⫺(␣)20.5
deletions are relatively common in the Philippines and in the Mediterra-
nean region, respectively (Figure 1).
Nondeletional mutations
In contrast to ␤-thalassemia, nondeletional ␣⫹-thalassemia muta-
tions are relatively uncommon. There is an inherent difficulty in
deciphering these mutations, because nucleotide sequencing of the
␣-globin genes with their high GC content is not an easy task. In
recent years, increasing numbers of nondeletional ␣⫹-thalassemia
mutations have been described. More than 30 of these mutations
are tabulated in the human globin gene mutation database on the
World Wide Web (http://globin.cse.psu.edu). The ␣2-globin gene
normally accounts for 2 to 3 times more ␣-globin mRNA and ␣-globin
chain production than the ␣1-globin gene.8 Therefore, ␣-thalassemia
point mutations of the ␣2-globin gene generally cause more severe
anemia than the same mutations involving the ␣1-globin gene.
Most of these mutations affect the transcriptional or transla-
tional processes of ␣-globin chain production. Others, notably Hb
Constant Spring (␣2 codon 142 TAA⬎CAA or Ter3Gln) lead to
markedly decreased and abnormally elongated ␣-globin chains.2
Recently, it was reported that as many as 15% of patients
previously thought to be carriers of Hb Constant Spring based on
hemoglobin analysis were in fact carriers of Hb Pakse (␣2 codon
142 TAA⬎TAT or Ter3Tyr).9,10,141 Other mutations produce
highly unstable ␣-globin chains or hemoglobins, such as Hb
Agrinio (␣2 codon 29 CTG⬎CCG or Leu3Pro), Hb Suan-Dok
(␣2 codon 109 CTG⬎CGG or Leu3Arg), Hb Quong Sze (␣2
codon 125 CTG⬎CCG or Leu3Pro), and Hb Pak Num Po (␣1
codon 131/132 ⫹T), and result in an ␣-thalassemia phenotype.11-14
Genotypes of Hb H disease
Deletional and nondeletional Hb H disease
Hb H disease is commonly caused by a deletion removing both
␣-globin genes on one chromosome 16, plus a deletion removing
Submitted July 3, 2002; accepted August 15, 2002. Prepublished online as Blood
First Edition Paper, September 12, 2002; DOI 10.1182/blood-2002-07-1975.
Reprints: David H. K. Chui, Department of Medicine, Evans 211, Boston
University School of Medicine, 88 East Newton St, Boston, MA 02118.
© 2003 by The American Society of Hematology
791
792 CHUI et al BLOOD, 1 FEBRUARY 2003 䡠 VOLUME 101, NUMBER 3

Figure 1. Common deletions in the ␨-␣-globin gene

cluster. The 3 red boxes represent the 3 active globin
genes, the one embryonic ␨2-globin gene, and the ␣2-
and ␣1-globin genes. They span approximately 26 Kb in
length from ␨2 to ␣1 globin genes. The blue lines
represent the common ␣-thalassemia deletions. Figure
adapted with permission from Cambridge University
Press2 and Blood.5

only a single ␣-globin gene on the other chromosome 16 such as Among the 638 chromosomes examined in these 319 patients
the (-␣3.7) or (-␣4.2) deletions. These are known as “deletional Hb H with Hb H disease, (--SEA) is found in 263 chromosomes (41%),
disease.”11,15-33 (-␣3.7) in 224 chromosomes (35%), (-␣4.2) in 42 chromosomes
In a smaller proportion of patients, Hb H disease is caused by a (7%), (--FIL) in 38 chromosomes (6%), and (␣Constant Spring ␣) in 32
deletion removing both ␣-globin genes on one chromosome 16, chromosomes (5%). The remaining 14 other mutations are found in
plus an ␣⫹-thalassemia point mutation, or small insertion/deletion, 39 chromosomes (6%).
involving either the ␣2- or ␣1-globin gene on the other chromo- In the Mediterranean region, the most common deletion remov-
some 16. These are collectively labeled as the “nondeletional Hb H ing both ␣-globin genes in cis is the (--MED) deletion. Among 78
disease.” Patients with nondeletional Hb H disease usually are Cypriot patients with Hb H disease, 79% had the (--MED) deletion
more anemic, more symptomatic, more prone to have significant and 17% had the ⫺(␣)20.5 deletion.28
hepatosplenomegaly, and more likely to require transfu-
sions.11,18,20,24,25,31,32
Rarely, homozygosity or compound heterozygosity of nondele- Pathophysiology
tional ␣⫹-thalassemia mutation(s) involving ␣2-globin gene on
each of the 2 chromosomes 16, can lead to a phenotype similar to In Hb H disease, there is a deficiency of ␣-globin mRNA and
Hb H disease. They include initiation codon mutation (ATG⬎ACG), ␣-globin chains. These are reflected in the ␣/␤ globin mRNA ratio
Hb Sallanches (codon 104 TGC⬎TAC or Cys3Tyr), or polyade- being below 0.5, and the ␣/␤ globin chain synthetic ratios ranging
nylation signal mutation (AATAAA⬎AATAAG).25,29,34-37 Even in from 0.2 to 0.7.3,11,15,18 During fetal development, the excess
this small subset of patients, their phenotypes can vary from ␥-globin chains form ␥4 tetramers (Hb Bart). In adults, the excess
relatively mild to very severe, requiring regular transfusions.
Table 1. ␣-Globin genotypes in 319 patients with Hb H disease from California,
Population genetics Hong Kong, and Ontario31,33,41
Hb H disease No. of patients %
Hb H disease is found in many parts of the world, including
Southeast Asian, Middle Eastern, and Mediterranean populations. Deletional 266 83
(--SEA/-␣3.7) 175 55
It is particularly prevalent in Southeast Asia and in southern China,
(--SEA/-␣4.2) 37 12
because of high carrier frequencies of the (--SEA), and to a lesser
(--FIL/-␣3.7) 36 11
extent, the (--FIL) types of ␣-thalassemia deletions there.5,38,39 In (--MED/-␣3.7) 8 2
Thailand with a population of 62 million people, it is estimated that (--THAI/-␣3.7) 2 ⬍1
7000 infants with Hb H disease are born annually, and that there are (--BRIT/-␣3.7) 1 ⬍1
420 000 patients with Hb H disease in that country.40 (--SA/-␣3.7) 1 ⬍1
The genotypes of 319 patients with Hb H disease from (--de novo/-␣3.7) 1 ⬍1
California, Hong Kong, and Ontario were reported during the past (--SEA/-␣4.2 Q-Thailand [Codon 74 GAC⬎CAC or Asp3His]) 4 1
(--FIL/-␣4.2 Q-Thailand [Codon 74 GAC⬎CAC or Asp3His]) 1 ⬍1
2 years.31,33,41 These genotypes are summarized in Table 1 and
serve to illustrate the heterogeneity of Hb H disease genotypes, Nondeletional 53 17
especially in many multicultural communities in North America (--SEA/␣Constant Spring [Codon 142 TAA⬎CAA or Ter3Gin]␣) 31 10

and elsewhere. Of those patients, 266 patients or 83% (95% (--SEA/␣Quong Sze [Codon 125 CTG⬎CCG or Leu3Pro]␣) 7 2
(--SEA/␣Codon 30 deletion of GAG␣) 3 ⬍1
confidence interval [CI], 79%-87%) have deletional Hb H disease.
(--TOT/␣Codon 30 deletion of GAG␣) 1 ⬍1
The most common genotype is (--SEA/-␣3.7) found in 175 patients
(--SEA/␣Initiation codon ATG⬎AG␣) 1 ⬍1
(55%), followed by (--SEA/-␣4.2) 37 patients (12%), and (--FIL/ (--THAI/␣Initiation codon ATG⬎AG␣) 1 ⬍1
-␣3.7) 36 patients (11%). (--SEA/␣Codon 31 AGG⬎AAG or Arg3Lys␣) 2 ⬍1
Fifty-three patients or 17% (95% CI, 13%-21%) have nondele- (--FIL/␣Codon 35 TCC⬎CCC or Ser3Pro␣) 1 ⬍1
tional Hb H disease. The most prevalent genotype among this (--MED/␣IVS I deletion of TGAGG␣) 1 ⬍1
subgroup is (--SEA/␣Constant Spring ␣) found in 31 patients (10%). In (--SEA/␣Codon 59 GGC⬎GAC or Gly3Asp␣) 1 ⬍1
Thailand, nondeletional Hb H disease with ␣Constant Spring is even (--SEA/␣Pakse [Codon 142 TAA⬎TAT or Ter3Tyr)␣) 2 ⬍1
(--THAI/␣Constant Spring [Codon 142 TAA⬎CAA or Ter3Gln]␣) 1 ⬍1
more common, reportedly found in 40% to 50% of patients with Hb
(␣Hb Sallanches [Codon 104 TGC⬎TAC or Cys3Tyr] ␣/␣Hb Sallanches␣) 1 ⬍1
H disease.18
BLOOD, 1 FEBRUARY 2003 䡠 VOLUME 101, NUMBER 3
␤-globin chains form ␤4 tetramers (Hb H). These homotetramers
have high oxygen affinity, lack heme-heme interaction, and deliver
only insignificant amounts of oxygen to tissues.
Hb H (␤4) is relatively unstable and can be oxidized to form
intracellular precipitates. If present within developing erythro-
blasts, these precipitates are thought to cause intramedullary early
erythroid cell death and ineffective erythropoiesis. More often,
these precipitates are formed in circulating erythrocytes with time
and become attached to cell membrane. They cause local oxidative
damage, membrane dysfunction, and shortened red cell survival.42
Hb H disease erythrocytes are rigid, and their membrane is more
stable than normal.43 The membrane associated with Hb Constant
Spring is even more rigid.44 These properties retard the passage of
red blood cells through microvasculature and can promote eryth-
rophagocytosis.45
There is evidence that pyrexia can enhance formation of
intraerythrocytic Hb H inclusion bodies that might account for the
acute hemolytic crisis and precipitous drop in hemoglobin associ-
ated with infections in some patients.11,46-48 Loss of normal
membrane phospholipid asymmetry, particularly the exposure of
phosphatidylserine on thalassemic cell surface, likely mediates
intramedullary erythroblast apoptosis and engulfment of abnormal
or aging circulating erythrocytes by macrophages.49-52 Erythrocyte
membrane–associated immunoglobulin G (IgG) and complement
components may also have similar roles in promoting erythro-
phagocytosis.45
It is generally accepted that hemolysis is the major cause of
anemia in Hb H disease, although ineffective erythropoiesis also
plays a pathogenetic role in this syndrome.15,51,53-56 In contrast,
ineffective erythropoiesis is the dominant cause for the anemia in
␤-thalassemia intermedia and major.
Nondeletional Hb H disease is generally more se-
vere.11,18,20,24,25,31,32 Given that ␣2-globin gene produces 2.5 times
more ␣-globin mRNA than the ␣1-globin gene, the combined
␣-globin mRNA production from both ␣-globin genes on a normal
chromosome 16 could be assigned 3.5 “arbitrary units” for this
discussion.8,45 In an ␣-globin gene cluster harboring a point
mutation inactivating ␣2-globin gene, the ␣-globin mRNA produc-
tion by the remaining and normal ␣1-globin gene is merely 1.0
“unit.” However, with the single ␣-globin gene deletion of the
(-␣3.7) type as a result of a misalignment crossover event during
meiosis, the ␣-globin mRNA production by the remaining single
hybrid ␣-globin gene is 2.0 “units.”45 This consideration provides
at least partial explanation for the observation that patients with
nondeletional Hb H disease such as (--SEA/␣Constant Spring␣) are more
severely affected than those with deletional Hb H disease such as
(--SEA/-␣3.7).31,45
In some cases, the nondeletional ␣-globin gene mutation leads
to highly unstable ␣-globin chains or variant hemoglobin, such as
Hb Quong Sze (␣2 codon 125 CTG⬎CCG or Leu3Pro).13 In
Table 2. Hemoglobin, MCV and MCH in patients with Hb H disease
Hemoglobin, g/L (n)
Hb H disease Male Female Male
Deletional 111 ⫾ 11 (28) 94 ⫾ 12 (59)
105 ⫾ 10 (40) 88 ⫾ 11 (47) 63 ⫾ 5 (40)
106 ⫾ 13 (10) 91 ⫾ 9 (41) 62 ⫾ 4 (10)
100 ⫾ 12 (67)
Nondeletional 105 ⫾ 10 (6) 85 ⫾ 7 (5)
86 ⫾ 19 (11) 83 ⫾ 20 (14) 73 ⫾ 7 (11)
96 ⫾ 11 (64)
Hb H DISEASE 793
addition to the more severe ␣-globin chain deficiency, the intracel-
lular aggregates of hyperunstable variant ␣-globin chains or
hemoglobins might also cause additional membrane damage and
dysfunction. In one report, patients with nondeletional Hb H
disease were found to have higher malonyldialdehyde levels, which
is a secondary product of lipid peroxidation, and lower levels of
vitamin E.57
Clinical and laboratory findings
Hb H disease is generally thought to be a mild disorder. However,
there is a marked phenotypic variability, ranging from asymptom-
atic, to need for periodic transfusions, to severe anemia with
hemolysis and hepatosplenomegaly, and even to fatal hydrops
fetalis syndrome in utero. Patients with identical ␣-globin geno-
types can have different phenotypes,30 suggesting that there are
other yet undefined genetic and/or environmental factors that can
affect phenotypic expression of Hb H disease.58,59
Anemia
The hemoglobin level, mean erythrocyte corpuscular volume
(MCV), and mean corpuscular hemoglobin (MCH) of patients with
Hb H disease are tabulated in Table 2. There are significant
variations in these values between individuals. For example, in one
report, hemoglobin levels ranged between 70 and 129 g/L among
10 male patients and between 70 and 114 g/L among 41 female
patients, all with deletional Hb H disease.33 MCV ranged from 51
to 73 fL. There are elevated reticulocyte counts (5%-10%),
polychromasia, and moderate anisopoikilocytosis.60
The MCV in nondeletional Hb H disease is higher than in
deletional Hb H disease (Table 2). Anemia is more pronounced in
nondeletional Hb H disease and so is reticulocytosis. This finding
may partially account for the higher MCV. ␣-Thalassemic erythro-
cytes are hyperhydrated, especially those inherited with Hb Con-
stant Spring.43 In 15 patients with nondeletional Hb H disease/Hb
Constant Spring, their Hb was 82 ⫾ 19 g/L, and MCV was 76 ⫾ 7
fL. In 5 other patients with nondeletional Hb H disease/Hb Quong
Sze, their Hb was 86 ⫾ 10 g/L, and MCV was 71 ⫾ 7 fL. (V.C.,
unpublished observations, August 2002). It is postulated, although
unproven, that the early closing of the K-Cl cotransporter in
␣-thalassemic erythrocytes, in contrast to ␤-thalassemic erythro-
cytes, prevents loss of K-Cl and water and leads to erythrocyte
hyperhydration and higher MCV.45
There are occasions, such as increased hemolysis secondary to
infections, fever, ingestion of oxidative compounds or drugs,
aregenerative anemia as a result of Parvovirus B19 and other
infections, hypersplenism, and pregnancy, when severe anemia
may ensue and transfusions become necessary. In Thailand, 29% of
MCV, fL (n) MCH, pg (n)
Female Male Female Reference
65 ⫾ 7 (121) 19 ⫾ 2 (120) 3
64 ⫾ 6 (47) 19 ⫾ 1 (40) 19 ⫾ 2 (47) 31
62 ⫾ 5 (41) 19 ⫾ 2 (10) 19 ⫾ 2 (41) 33
67 ⫾ 7 (56) 19 ⫾ 2 (56) 18
68 ⫾ 6 (14) 19 ⫾ 2 (14) 3
72 ⫾ 7 (14) 21 ⫾ 2 (11) 20 ⫾ 2 (14) 31
77 ⫾ 5 (47) 21 ⫾ 2 (47) 18
794 CHUI et al
221 patients with deletional Hb H disease and 50% of 136 patients
with nondeletional Hb H disease had been transfused.18 In Hong
Kong, 46% of 114 patients with Hb H disease had been transfused,
but only very few patients required regular transfusions.31
The microcytic and hypochromic anemia found in Hb H disease
might lead to the erroneous diagnosis of iron deficiency anemia. On
occasions, inappropriate iron supplement treatment or invasive investi-
gations to rule out possible gastrointestinal bleeding are prescribed.
Iron overload
Iron overload as manifested by markedly elevated serum ferritin
levels is present in 70% to 75% of adult patients with Hb H
disease.61-63 Raised serum ferritin levels are correlated with increas-
ing age but are unrelated to previous history of transfusions, iron
supplement, or herbal medicine treatment.22,31 It is likely that iron
absorption is increased in Hb H disease, secondary to enhanced
erythropoiesis as a result of hemolysis and anemia.64 Excessive
alcohol consumption is an additional risk factor.62
In Hong Kong, 60 patients underwent computed tomographic
(CT) scan of liver, and 51 of them (85%) had a signal-intensity ratio
of less than 1, indicative of iron overload.31,65 In others, liver biopsy
revealed increased liver iron content and hepatic fibrosis and/or
cirrhosis, without serologic evidence of either hepatitis B or C.22,31
In addition, 25 asymptomatic adult patients had cardiac echocardi-
ography done, and all showed abnormal left ventricular diastolic
function.31 There was a trend of increasing cardiac abnormality
with increasing serum ferritin levels. Three patients had heart
failure as a result of cardiac iron overload. Another patient
developed hemosiderosis and diabetes mellitus.66 These findings
underscore the importance of monitoring adult patients with Hb H
disease for iron overload and to initiate iron chelation therapy
when indicated.
There are reports from the Mediterranean region that iron
overload in Hb H disease is uncommon.11,30,67 The apparent
discrepancy might be due to differences in other genetic or
environmental factors. In Sardinia, some adult patients had serum
ferritin levels at or close to 1000 ␮g/L.25 Long-term follow-up on
those apparently unaffected patients should be informative.
Hepatosplenomegaly
Hepatomegaly was present in 70% of 502 patients in Thailand,
60% of 153 patients in Sardinia, and 14% of 88 patients in
Taiwan.15,22,25 Jaundice was found in 25% of patients in Thailand,
20% to 30% in Sardinia, and 43% in Taiwan.18,22,25 Splenomegaly
is also prevalent in Hb H disease, found in 79% of patients in
Thailand, 60% in Sardinia, and 47% in Taiwan.15,22,25 In Hong
Kong, a third of 27 patients with nondeletional Hb H disease had
undergone splenectomy. In contrast, only 5% of 87 patients with
deletional Hb H disease were splenectomized.31
Cholelithiasis
Seventy-seven adult patients in Hong Kong had abdominal ultra-
sonography done. Twenty-six patients (34%) were found to have
cholelithiasis, and 5 of them underwent cholecystectomy.31 Nine-
teen percent of 88 patients in Taiwan and 15% of 81 patients in
Thailand had cholelithiasis.22,68 A promoter polymorphism in
uridine diphosphate (UDP)–glucuronosyl-transferase, as in Gilbert
disease, is a risk factor for cholelithiasis in hereditary spherocyto-
BLOOD, 1 FEBRUARY 2003 䡠 VOLUME 101, NUMBER 3
sis, ␤-thalassemia, and sickle cell disease.69-73 Whether this correla-
tion also holds true for Hb H disease awaits confirmation.
Growth and development in children
Thirteen percent of children with Hb H disease in Hong Kong had a
growth rate below the third percentile.31 In another report, 2 infants
with Hb H disease were followed from birth to 6 months of age.74
At birth, the total hemoglobin was approximately 155 g/L, but only
110 to 120 g/L represented functional hemoglobins (Hb F and Hb
A). The other 30 to 40 g/L were Hb Bart (␥4) and some Hb H (␤4),
which have markedly impaired ability to deliver oxygen to tissues.
At 1 to 2 months of age, the functional hemoglobin fractions fell to
70 g/L. By 3 months, these fractions had returned to 85 to 95 g/L.
These anecdotal reports underscore the importance of a systematic
investigation of the natural history of Hb H disease during early
infancy and childhood.37
Pregnancy
There is usually an increasing severity of anemia during pregnancy,
possibly related to expansion of blood volume. Hb level may
sometimes fall to 60 g/L or even less, necessitating the need for
blood transfusion to maintain the health of the mother and the
developing fetus.15,25,75,76 However, other women go through
pregnancies without the need for transfusions.77
In 34 pregnancies among 29 Thai women, Hb fell to 71 ⫾ 20
g/L during the second and third trimesters.75 Preeclampsia occurred
in 18% of the cases, and 9% developed congestive heart failure.
There was one case each of miscarriage and perinatal death and 3
cases of premature births. Galanello et al25 reported that there were
7 miscarriages (12%) among 58 pregnancies in 24 Italian women
with Hb H disease. It is vitally important to carry out prospective
and in-depth studies of pregnancies in women with Hb H disease to
define the risks and criteria for treatment.
Another important issue is related to testing the woman’s
partner and genetic counseling. This issue is discussed in more
detail in “Genetic counseling.”
Hb H hydrops fetalis syndrome
This devastating syndrome represents the most severe form of Hb
H disease and was first described in detail in 1985.78 It is the subject
of a recent review.79 The ␣-globin genotypes of the affected fetuses
consist of deletion of both ␣-globin genes in cis or the complete
␨-␣-globin gene cluster on one chromosome 16 and a nondeletional
mutation involving ␣2-globin gene on the other chromosome
16.79-81 These fetuses suffer from severe anemia and hypoxia in
utero, with its sequelae such as edema, pericardial effusion,
congenital anomalies, and even death.
The pathophysiology of this serious inherited disorder is not
well understood. One hypothesis is that the nondeletional ␣-globin
gene mutations, such as ␣2 codon 35 TCC⬎CCC or Ser3Pro,
codon 59 GGC⬎GAC or Gly3Asp, or codon 66 CTG⬎CCG or
Leu3Pro, result in highly unstable hemoglobin and severe anemia,
akin to the dominant ␤-thalassemia syndrome.79-82
With the mutation ␣2 codon 30 ⌬GAG, hydrops fetalis occurs
only with the coinheritance of a deletion removing the complete
␨-␣-globin gene cluster.80 Other individuals who have inherited the
same ⌬GAG mutation together with the Southeast Asian type of
deletion removing both ␣-globin genes in cis, but sparing the
embryonic ␨-globin gene, survive to adulthood, albeit with moder-
ate to severe anemia (Hb, 72-105 g/L).31,80,83
BLOOD, 1 FEBRUARY 2003 䡠 VOLUME 101, NUMBER 3
More recently, another case of this severe syndrome was
reported in a Turkish newborn, who died despite active resuscita-
tion, soon after birth at the 30th week of gestation. This infant’s
␣-globin genotype was (--MED/␣AATAAA⬎AATAAG␣).84,142
Hb H disease in combination with other hemoglobinopathies
Patients with both Hb H disease and heterozygosity for ␤-globin
variants such as Hb S, Hb C, or Hb E have hemoglobin levels
similar to most patients with Hb H disease.85-89 The proportions
of the variant hemoglobins are low (20%-25%), because of the
lower affinity of the ␣-globin chains for the variant ␤-globin
chains as compared with the normal ␤-globin chains.90 There are
exceptions, such as ␤J-Iran (codon 77 CAC⬎GAC or His3Asp)
that is a negatively charged variant ␤-globin chain.91 With Hb H
disease, the proportion of this variant Hb increases to 65%.91
These patients with variant ␤-globin chains as well as those with
␤-thalassemia trait have low Hb H levels and scanty Hb H
inclusion bodies.
Hb E is very common in Southeast Asia. In Thailand, interac-
tions of Hb H disease with Hb E and/or ␤-thalassemia give rise to
many different complex genotypes. They are broadly known as
AE-Bart disease (Hb H disease and heterozygosity for Hb E), and
EF-Bart disease (Hb H disease and homozygosity for Hb E or Hb
E/␤-thalassemia).88,89 They present with thalassemia intermedia
phenotype with moderate to severe anemia and with decreased or
no Hb H and inclusion bodies detected.
Patients who have Hb H disease together with heterozygosity
for ␤New York (codon 113 GTG⬎GAG or Val3Glu) have severe
anemia (Hb between 34 and 68 g/L) and hepatosplenomegaly.92
The variant ␤New York has higher affinity for the ␣-globin chains
to form Hb New York that is an unstable hemoglobin. This
worsens the deficiency of ␣-globin chains already present in Hb
H disease and causes even more severe anemia. Coinheritance
of Hb H disease and several other uncommon variant ␤-globin
chains has been described, such as Hb J Bangkok (codon 56
GGC⬎GAC or Gly3Asp), Hb Pyrgos (codon 83 GGC⬎GAC
or Gly3Asp), and Hb Hope (codon 136 GGT⬎GAT or
Gly3Asp).93-95
Coinheritance of Hb H disease and ␤-thalassemia heterozygos-
ity leads to anemia usually more severe than ␤-thalassemia
heterozygote alone, but less than common Hb H disease.96-98
However, there are exceptions and some patients require transfu-
sions.28,98 They have marked microcytosis and hypochromia, but
low or absent Hb H and Hb H inclusion bodies. Hb A2 levels are
elevated, as in most other ␤-thalassemia heterozygotes.96-98
Other findings
The following findings associated with Hb H disease have been
reported: dysmorphic facial features, skeletal changes, retinopathy,
extramedullary hematopoietic tumors, risk of thromboembolic
disorders, and leg ulcers.3,99-102
Erythrocyte glucose-6-phosphate dehydrogenase (G6PD) defi-
ciency is prevalent in the same populations in whom thalassemias
are prevalent. Therefore, coinheritance of both Hb H disease and
G6PD deficiency is to be expected.47,103 Recently in Hong Kong, a
newborn was found to have Hb H disease (--SEA/␣Constant Spring␣) and
G6PD deficiency (0.1 U/g Hb in cord blood). At birth, the infant
was anemic with Hb of 125 g/L and had hepatosplenomegaly. At 1
year of age, his Hb fell to 42 g/L soon after an episode of infection
and fever (E. S. K. Ma, unpublished observations, August 2002).
Hb H DISEASE 795
Alpha-thalassemia/mental retardation (ATR)
syndromes
ATR-16 syndrome
The affected children have chromosomal rearrangements that
delete as much as 1 to 2 Mb of chromosome 16 short-arm (16p)
telomere, including the ␨-␣-globin gene complex, resulting in
monosomy for the 16p telomere, and ␣-thalassemia phenotype.104
In some, the chromosomal abnormalities can be visualized by
cytogenetic analysis or fluorescent in situ hybridization (FISH). In
most cases, one parent carried a balanced translocation that the
child inherited in an unbalanced fashion. In others, the abnormality
arose as de novo events. If the affected child also inherited a
common single ␣-globin gene deletion from the other parent, the
child would have Hb H disease.105
It is thought that mental retardation and other congenital
anomalies observed in this syndrome are caused by the deletion of
dosage-sensitive genes on one 16p telomere and other concomitant
chromosomal abnormalities. Children with deletions of up to 350
kb in length from one 16p telomere, including the complete
␨-␣-globin gene complex, have ␣-thalassemia trait but are develop-
mentally normal.106 It is critical for understanding the genetic basis
of mental retardation to identify these genes on 16p telomere that
can affect severe cognitive and developmental abnormalities when
only one copy is deleted.105,107
ATR-X syndrome
This syndrome is an X-linked disorder, caused by mutations of the
ATRX gene located on chromosome Xq13.3.108 It is more common
than the ATR-16 syndrome. The affected males usually have very
severe intellectual and physical handicaps and many other congeni-
tal anomalies. They often have characteristic facial features.
Genital abnormalities, such as ambiguous genitalia, and skeletal
deformities are present in 90% of these patients.109 They present
with an ␣-thalassemia phenotype but with considerable variations
with Hb H inclusion bodies found in none to up to 32% of
circulating erythrocytes.105
The functions of ATRX protein in vivo are not yet understood
and are under active investigation.110 It contains motifs that have
been implicated in the regulation of transcription mediated by
chromatin modification, protein-protein interaction, adenosine
triphosphatase (ATPase), and helicase activities and that affect
genomic methylation pattern.111,112 The highly variable phenotypes
in patients suggest that ATRX interacts with other genetic factors to
bring about normal expression of many genes of developmental
importance, including the ␣- but not the ␤-globin genes.105
Acquired Hb H disease in
myeloproliferative disorders
This syndrome has been described mostly in elderly men who have
primary marrow disorders such as erythroleukemia, myelodyspla-
sia, refractory anemia with excessive blasts, acute leukemia, and so
forth. Its molecular pathology has not been defined, although it is
conceivable that the down-regulation of ␣-globin gene expression
in these patients is the result of somatic mutation(s) in
transcription factor(s).
This and the relatively rare ATR syndromes provide important
insight into the biology of ␣-globin gene regulation and expression,
796 CHUI et al
as well as other developmental pathways. They are the subjects of 2
recent reviews3,105 and are beyond the scope of the present
manuscript.
Diagnosis
Hb H disease is characterized by moderate hypochromic and
microcytic anemia (see “Anemia”). Formation of Hb H (␤4)
precipitates within red cells (Hb H inclusion bodies) can be induced
by incubation with mild oxidants such as Brilliant Cresyl Blue.113
These inclusion bodies are numerous and can easily be seen by
light microscopy in most circulating erythrocytes. In addition, Hb
H ranging between 5% and 30% can be detected by hemoglobin
electrophoresis, isoelectric focusing (IEF), or high-performance
liquid chromatography (HPLC).60 Hb H levels are usually higher in
nondeletional Hb H disease than in deletional Hb H disease. It
should be noted that some commercial electrophoretic methods are
incapable of detecting Hb H.114 Hb A2 level is usually down in the
1.0% to 2.0% range.60
Patients who have Hb H disease and concomitant heterozygous
␤-hemoglobinopathies, such as Hb S, Hb C, Hb E, or ␤-thalassemia,
have low or absent Hb H (␤4) and many fewer Hb H inclusion
bodies.85-89,96-98 These hematologic findings may confound the
diagnosis of the underlying Hb H disease.
Correct DNA-based genotyping is necessary for genetic coun-
seling and prenatal diagnosis. Southern blotting is often used for
diagnosing deletional mutations. More recently, Gap-polymerase
chain reaction (PCR) methods have been developed for many of the
common deletions.115-117 In large deletions that remove the com-
plete ␨-␣-globin gene cluster, the diagnosis is more difficult and
often depends on family studies and Southern blotting analysis
using probes distal to the deletional breakpoints.118,119
For point mutations, or small deletion/insertion mutations, the
diagnosis is often based on direct nucleotide sequencing of the
PCR-amplified product of either ␣2- or ␣1-globin gene.79-81,83,84
Reverse dot-blot by hybridization with allele specific oligonucleo-
tide probes and multiplex ARMS (PCR-based amplification refrac-
tory mutation system) assays have been developed for rapid
diagnosis of several ␣⫹-thalassemia point mutations.120,121
Hb Bart (␥4) is a fast-moving hemoglobin that can be deter-
mined by electrophoresis, IEF, or HPLC. Newborns who have
inherited Hb H disease have 20% to 40% of Hb Bart at birth.60
Universal newborn screening for Hb H disease was implemented in
1996 in California, based on an elevated level of a fast-moving
peak on HPLC of hemolysates eluted from newborn blood spots
impregnated on filter papers.41 Of 101 newborns found to have
25% or more of this peak, 89 were confirmed by DNA diagnostics
to have Hb H disease. Table 3 shows that in California, there are
many more newborns with Hb H disease than with other commonly
screened for inherited metabolic disorders such as phenylketonuria
and galactosemia.
The (--SEA) type of ␣0-thalassemia deletion is very common in
Southeast Asia. An enzyme-linked immunosorbent assay (ELISA)
to detect embryonic ␨-globin chains in peripheral blood erythro-
cytes was reported to be a simple, rapid, and reliable screening
test to identify adult carriers of the (--SEA) ␣0-thalassemia
deletion.122-125 This test should help to identify couples at risk of
conceiving fetuses with Hb H disease and also homozygous
␣0-thalassemia hydrops fetalis syndrome.
BLOOD, 1 FEBRUARY 2003 䡠 VOLUME 101, NUMBER 3
Table 3. Number of newborns diagnosed annually through the universal
newborn screening program in California41
Disorders No. of newborns %
Congenital hypothyroidism 190 53.4
Sickling disorders (Hb SS, SC, S/␤-thalassemia) 112 31.5
Hb H disease 36 10.1
Phenylketonuria 13 3.6
Galactosemia 5 1.4
Treatment
The treatment for Hb H disease is primarily preventive and
supportive in nature. With hemolysis and increased erythropoiesis,
folic acid supplement is usually recommended. Avoidance of
oxidative compounds and medications, prevention of unnecessary
iron therapy unless iron deficiency is documented, prompt treat-
ment of infections, and alertness to the possibility of either
hypersplenism or aregenerative anemia are indicated. In adults,
periodic monitoring for possible iron overload and related organ
dysfunction is necessary.31 When indicated, iron chelation therapy
may have to be instituted.
Most patients are asymptomatic despite their moderate anemia and
often do not require blood transfusions. However, when anemia
becomes severe, as in hemolytic crises secondary to infections, pyrexia,
oxidative challenge, aregenerative anemia, hypersplenism, or during
pregnancy, transfusion therapy may be indicated.
Some patients with unusually severe Hb H disease require
regular transfusions and, therefore, will also need to have iron
chelation therapy. Careful documentation of baseline hemoglobin
levels of these patients, in the absence of other extraneous
conditions such as infection, and thorough clinical assessment are
critically important before committing these patients to a long-term
transfusion program with its inherent and potentially harmful
complications.3
Special attention for pregnant women with Hb H disease is
required, as they might have anemia severe enough to adversely
affect their health and that of the developing fetuses. There is a
suggestion that the risk of fetal neural tube defect is increased in
pregnant women who are either ␣- or ␤-thalassemia carriers,
possibly because of relative folic acid deficiency secondary to
increased erythropoiesis.126 For pregnant women with Hb H
disease, it is especially prudent to prescribe folic acid supplement
during the periconceptional period and beyond.
In those pregnant women found to have iron deficiency, iron
supplement is indicated. However, it is very important to ensure that
these women do not continue iron supplement therapy unnecessarily
once the pregnancy is over, because as patients with Hb H disease, they
are prone to develop iron overload with time.22,31,61-63
In patients with marked splenomegaly and hypersplenism,
splenectomy can result in highly significant hematologic and
clinical improvements.127 Postoperative complications include
septicemia, deep venous thrombosis, and pulmonary embo-
lism.128,129 Cholecystectomy may have to be done whenever
surgically indicated.
Genetic counseling
When an individual near or at reproductive age is found to have Hb
H disease, screening his or her partner and other family members
BLOOD, 1 FEBRUARY 2003 䡠 VOLUME 101, NUMBER 3
for their ␣- and ␤-thalassemia carrier status is highly recom-
mended. If the partner is a carrier of either a deletion or point
mutation affecting one single ␣-globin gene, there is a 25% risk in
each pregnancy of conceiving a fetus with Hb H disease (Table 4).
Individuals who have single ␣-globin gene deletion or inactiva-
tion usually have normal or near normal hematologic findings,
including MCV.33,130 It is necessary whenever indicated to carry out
DNA-based genotypic analysis regardless of hematologic parame-
ters.130 A recent case report is instructive in this regard.81 A woman
of Asian ancestry was a carrier of the (--SEA) ␣0-thalassemia
deletion. Her partner of Scottish-Irish ancestry had near normal
hematologic findings (Hb, 140 g/L; MCV, 79 fL) and was a carrier
of a novel mutation of the ␣2-globin gene, Hb Dartmouth (codon
66 CTG⬎CCG or Leu3Pro). Their twin sons inherited both
parental mutations, were born with severe anemia (Hb, 50 and 57
g/L), and had transfusion-dependent Hb H disease.
If the partner is homozygous or compound heterozygous for
single ␣-globin gene deletion or inactivation, there is a 50% risk in
each pregnancy that the fetus might have Hb H disease.
If the partner is heterozygous for deletion involving both ␣-globin
genes in cis on the same chromosome 16, there is a 25% risk that the
fetus will have Hb H disease and another 25% risk that the fetus will
have the devastating Hb Bart hydrops fetalis syndrome lacking all
␣-globin genes. It should be noted that some heterozygous carriers of
␤-thalassemia mutation with low MCV and elevated Hb A2 levels might
also be heterozygous for ␣0-thalassemia deletion. Depending on the ␣-
and ␤-globin genotypes of their partners, these individuals are poten-
tially at risk of having offspring with Hb H disease, homozygous
␣0-thalassemia, and ␤-thalassemia major.5,131
If both members of the couple have Hb H disease, there is a 50%
risk in each pregnancy that the fetus might have Hb H disease and
another 25% risk that the fetus might have inherited the Hb Bart
hydrops fetalis syndrome.
It is generally accepted that prenatal diagnosis is not warranted in
pregnancies at risk of fetuses with Hb H disease alone. However, in
cases at risk for possible Hb H hydrops fetalis syndrome, genetic
counseling and prenatal diagnosis ought to be offered to the couple,
according to accepted ethical principles and local cultural consideration.
Prenatal diagnosis is usually performed by analysis of fetal
DNA obtained by chorionic villus sampling (CVS) at 9 to 12 weeks
of gestation or amniocentesis at 16 to 18 weeks of gestation,
respectively. The risk of miscarriage following either procedure is
0.5% to 1.0% for amniocentesis and 1% to 2% for CVS, respec-
tively.132-134 There is no convincing evidence that the risk of limb
reduction defects is increased after CVS.135 In general, DNA-based
prenatal diagnostics are highly accurate and specific.
For those couples who are reluctant to undergo an invasive
testing, ultrasound monitoring of hydropic changes may be offered
as an alternative.136,137 In most cases, hydropic changes should be
evident by the second trimester. Recent reports of using fetal DNA
found in maternal plasma for prenatal diagnosis offers a novel
noninvasive approach in the future.138-140
Population-wide perinatal screening and diagnosis of Hb H
disease can be readily carried out, especially in jurisdictions where
Table 4. Potential risks of fetuses with inherited ␣-thalassemia syndromes
␣-Globin genotypes
One parent with Hb H disease ␣-Globin genotype of the other parent
(--/-␣) or (--/␣Th␣) (-␣/␣␣) or (␣Th␣/␣␣)
(-␣/-␣) or (␣Th␣/-␣) or (␣Th␣/␣Th␣)
(--/␣␣)
(--/-␣) or (--/␣Th␣)
Hb H DISEASE 797
newborn screening for sickle cell diseases is already in place as in
California.41 The early diagnosis will facilitate implementation of
proper preventive health care measures to ensure the well-being of
the affected infants, to ensure prompt treatment of potentially
serious hemolytic crises and infections, to alleviate unnecessary
parental distress, and also to help heighten awareness of other
devastating ␣- and ␤-thalassemia syndromes in the communities.
Summary
Hb H disease is a form of ␣-thalassemia often manifested clinically
as thalassemia intermedia with moderate anemia. It is commonly
found in Southeast Asian, Middle Eastern, and Mediterranean
populations. There is a wide spectrum of genotypes and phenotypic
presentations. These range from those who appear clinically to be
asymptomatic, to others who are more anemic, having significant
hepatosplenomegaly and requiring occasional or even regular
transfusions, to the severe Hb H hydrops fetalis syndrome that can
cause death in the affected fetuses late in gestation.
This hereditary disorder is usually caused by deletions
removing all but one single ␣-globin gene (deletional Hb H
disease). A small proportion of patients have deletions removing
2 ␣-globin genes plus a nondeletional mutation affecting a third
␣-globin gene (nondeletional Hb H disease). In general, nonde-
letional Hb H disease has a more severe clinical course than the
deletional form.
Review of recent literature suggests that Hb H disease is not as
benign a disorder as previously thought. It can bring about growth
retardation during childhood and iron overload in adults regardless of
previous transfusion history, leading to hepatic, cardiac, and endocrine
dysfunction. Significant anemia might occur during infections, fever,
hypersplenism, or pregnancy that may necessitate the need for blood
transfusions. An essential part of the maternal/child health care should
include screening the partners of all pregnant women with Hb H disease
for their thalassemia carrier status, and providing these and other couples
who are at risk of conceiving offspring with Hb H disease with
appropriate genetic counseling.
Prospective and systematic studies of the natural history of Hb H
disease, particularly during infancy and childhood, as well as during
pregnancy, have not been carried out and are much needed. Information
derived from these investigations can lead to better insight to potential
risk factors associated with severe disease and can help to formulate
future medical interventions and treatment strategies.
Acknowledgments
We are indebted to our many clinical and laboratory colleagues for
their collaboration and support throughout many years. We thank
Prof Michael C. Brain143 and Dr Man-Chiu Poon, both of Calgary,
and Dr Edmond S. K. Ma of Hong Kong for their critical reading of
this manuscript and helpful suggestions. S. F. is a Senior Research
Scholar of the Thailand Research Fund.
Potential risks of fetuses, %
Hb H disease (--/-␣) or (--/␣Th␣) Homozygous ␣0-thalassemia (--/--)
25 Nil
50 Nil
25 25
50 25
798 CHUI et al
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