Thalassemia &

Hemoglobinopathy:
Pathophysiology and
Clinical Manifestation
Tri Ratnaningsih
Dept. of Clinical Pathology and Medical
Laboratory
Universitas Gadjah Mada
 Content

Introduction

Pathophysiology

Diagnosis: Clinical manifestation & lab test

Conclusion
Phlebotomy – composition of blood
Blood smear
normal blood cells
 Red Blood Cell

Biconcave disc shape:

• which is suited for gas exchange
• flexible
Primary cell content is hemoglobin (95%) - the
protein that binds oxygen and carbon dioxide.
Remaining 5% consist of enzymes, salts and
other protein
No nucleus nor mitochondria
Haemoglobin structure

Hemoglobin consists of :
globin and heme pigment

Globin:
- Consists of two α and two β
subunits
- Each subunit binds to a
heme group

Heme:
Each heme group bears an
atom of iron, which binds
reversibly with one molecule
of oxygen
https://www.123rf.com/photo_99797133_stock-vector-red-blood-cell-erythrocytes-
life-cycle-and-circulation-scheme-in-human-body-vector-illustration-biol.html
Composition of haemoglobine

δ
γ
Globine synthesis
 Globine synthesis
Sintesis Globin
 Content

Introduction: Haemoglobinopathy Basics

Pathophysiology

Diagnosis: Clinical manifestation & lab test

Conclusion
 Hb pathy

Sindrom
Hb varian
Thalassemia

Thalassemia Thalassemia
Hb S Hb C Hb E Hb D
alfa beta

Silent
carrier,trait, Minor,
AS, SS, SC AC, CC AE, EE AD, DD
HbH disease, Mayor, HPFH
hydrops
Beta Thalassemia
 ONE PARENT IS A CARRIER OF β-THALASSAEMIA
AND THE OTHER HAS UNAFFECTED β-GLOBIN GENES)
BOTH PARENTS ARE CARRIERS OF β-THALASSAEMIA

Most Likely Case tobe Missed Due to

Lack of Screening and Both Parents
Asymptomatic Carriers
ONE PARENT WITH THALASSAEMIA MAJOR/INTERMEDIA
AND THE OTHER WITH UNAFFECTED GENES
ONE PARENT WITH THALASSAEMIA MAJOR/INTERMEDIA
AND THE OTHER A CARRIER
BOTH PARENTS ARE PATIENTS WITH β-THALASSAEMIA
MAJOR/INTERMEDIA
 Haemoglobin E (HbE)

One of the most common abnormal haemoglobin variants

HbE carrier is a healthy individual

HbE becomes important only when the child inherits from

one parent the β-thalassaemia gene and from the other
parent the HbE gene  HbE/β-thalassaemia
Perempuan Usia : 11 bulan
Hematologi
17/07/2019
Hb : 6.8
AE : 2.83
MCV : 72 1
MCH : 24.0
RDW : 18.22
Iron : 57
Saturasi :43
TIBC : 132
Feritin : 975,06

Eritrosit : Anisopoikilositosis, mikrosit, normosit, sel target,

fragmentosit, sel tear drop, mikrosferosit, sferosit, ovalosit,
sel sigar, normohipokromik, NRBC (+) 6 sel dlm 100 sel lekosit
 ONE PARENT IS A CARRIER OF HbE
AND THE OTHER OF β-THALASSAEMIA
 Pathophysiology of β Thalassemia

Defect in globin β synthesis

‘excessive’ α globin
deposit in cell membrane
α
β Deformability/liability↓
Fragility↑

SPLEEN
δ
γ Destruction M∅,
physical HEMOLYSIS
 Pathophysiology of 𝛼𝛼 Thalassemia

Defect in globin 𝛼𝛼 synthesis

β ↓ α globin production
α Newborn: excess γ → γ 4 (Hb Barts)
After infancy (γ to β) excess β → β4 (Hb H)
δ Hb Barts, H: ↑ oxygen affinity
γ
𝛼𝛼 Thalassemia Genetics and Clinical
Consequences
BOTH PARENTS ARE SILENT CARRIERS OF
α-THALASSAEMIA (α+THALASSAEMIA)
 BOTH PARENTS ARE CARRIERS OF αο-THALASSAEMIA
THALASSAEMIA GENES ON DIFFERENT CHROMOSOMES (trans)
 BOTH PARENTS ARE CARRIERS OF αο-THALASSAEMIA
THALASSAEMIA GENES ON SAME CHROMOSOMES (cis)
 ONE PARENT CARRIER OF αο-THALASSAEMIA AND THE
OTHER A SILENT CARRIER OF α-THALASSAEMIA (α+ THAL)
THALASSAEMIA GENES ON SAME CHROMOSOMES (cis)
 Content

Introduction: Haemoglobinopathy Basics

Pathophysiology

Diagnosis: Clinical manifestation & lab test

Conclusion
 History
Electrophoresis
hemoglobino
Race/ethnicity
pathy with
ANALISIS
HPLCGLOBIN high
Clinical findings probability
Capillary
electrophoresis
Hematology

Gen Analysis

Supports the suspicion of a Globine Analysis

prevalent type of variant
https://en.wikipedia.org/wiki/Hemoglobin_E
Clinical Manifestation
 Clinical manifestation of β Thalassemia
Extramedullary
Defect in globin β synthesis erythropoiesis
Ineffective erythropoiesis

SPLENO MEGALI HEMOLYSIS ANEMIA hypoxia

Absorption ↑

IRON ↑ BILIRUBIN ↑ Hyperuricemia,

gout, Folat def.
Gallstone

Endocrine (DM, hypothyroid, hygonadism)

Liver
Myocard (heart failure)
 CLINICAL FINDINGS

• Anemia
• Hyperbilirubinemia
• Splenomegaly
• Iron deposition - hemosiderosis, hemochromatosis
• Ineffective & Extramedullary erythropoiesis
 CLINICAL FINDINGS

https://www.slideshare.net/clinica_qx01/gallbladder-and-
biliary-tract-diseases-10554717
CLINICAL FINDINGS
 CLINICAL FINDINGS

https://cjon.ons.org/cjon/16/6/supplement/management-transfusion-
related-iron-overload-patients-myelodysplastic-syndromes/html/full
Ineffective & Extramedullary erythropoiesis
Ineffective & Extramedullary erythropoiesis

Appearance of typical thalassemic facies

 Hydrops fetalis

Deletion of 4 α globin genes (--/--),

Homozygous α0-thalassemia (Hb Bart’s, γ4)

Sandoz Atlas: Cinical Hematology, 1988 Gower Medical Publishing

Laboratory Test
 Laboratory test result in Alpha Thalassemia
State Geno Pheno type Hematologi Elektroforesis Hb
type
Normal αα/αα Normal Hb N A:97-98% Barts:0 H:0
Hetero α+ αα/ – α Silent Hb N (12-14) A:96-98% Barts: 0-2% (At
Carrier/ MCV 75-85 fL birth) H: 0
minima RDW N
Hetero α° αα/ – – α Anemia ringan (Hb 11-13) A:85-95%,Bart’s 2-8% (lahir)-
Thalassemi Micro / Hypo dewasa (-)
Homo α+ – α/ – α a Trait/ MCV 70-75 fL RDW ↗ Hb H <2%
minor
α+ + α° – α/ – – Hb H Hb 7-10 g/dl MCV 50-60 Hb A turun, Barts <10%
Disease RDW ↗↗,Anemia (lahir: 10-40%), bertahap
sedang, mikro hipo diganti Hb H 5-40%
poikilocytosis target cells.
homo α° ––/–– Hydrops Anemia berat, mikro hipo, Hb A 0%, Bart’s 70-80%
Fetalis banyak NRBC Portland 10-20%, HbH 0-
20%

Elisabeth Kohne, Dtsch Arztebl Int 2011; 108(31–32): 532–40

 Hemoglobin (%)
A H (β4) B(γ4) Constant
pada saat lahir spring
Normal 97 0 0 0
α+-Thalassemia silent
-α/αα 98-100 0 (0-2) 0
α0-Thalassemia trait
-α/-α (α+homozigot) 85-95 inklusi (5-15) 0
atau-- 85-95 0 (5-15) 5
/αα(α0heterozigot)
ααCS/ααCS
Hemoglobin H disease
--/-α (α0/α+) 70-95 5-30 Trace Trace
--/ααCS (α0/αCS) 60-90 5-30 Trace 5-10
Hydrops fetalis
--/-- (α0/α0) 0 5-10 90-95 0
HB H Inclusions
 Hb H Inclusions

• In Hb H disease 30 –
100% of RBCS contain
Hb H inclusions.
• In alpha thal minor
there is one cell with
Hb H inclusions per
1000 – 10,000 RBCS.
• When there is a
reticulocytosis a rare
Hb H inclusion may be
missed – operator
experience crucial
 Laboratory test result in Thalassemia Beta
Parameter Minor Intermedia Major
Hb (g/dL) 10-13 6-10 2-8
MCV (fl) 60-78 50-70 50-60
MCH (pg) 28-32 22-28 16-22
RDW (%) Normal S. increased Increased
Micro/hypo blood film Mild Moderate Severe
Polychromasia V. Little Moderate Marked
Anisocytosis None Moderate Marked
Poikilocytosis None Moderate Marked
Targetting Present Present Present
Hb A Dec Dec Dec
Hb A2 N to Inc N to Inc Usually Inc
Hb F N to Inc Increased Increased
 HB TYPING of β THALASSEMIA

Genotype Syndrome Hb A Hb A2 Hb F
β+ / β minima 95 3.5-8.0 0-6
β° / β minor 95 3.5-8.0 0-6
β+ / β+ intermedia 25-65 1-4 30-70
β° / β° major 0 1-4 >95
β° / β+ major <20 1-4 >75
Haemoglobinopathies
 Hemoglobin
Hemoglobi A F S C D E Kelainan klinis
nopati % % % % % %
Hb CC 1-7 >90 ringan
Hb AC 50-60 <2 40-50 -
Hb SC 1-7 50 50 Sedang-berat
Hb SS 1-10 80-90 berat
Hb AS 55-70 <2 30-45 ringan
Hb DD <2 95 -
Hb AD 50-65 <2 35-50 -
Hb EE 1-5 95 ringan
Hb AE 60-80 20-40 -
 Hb Hemoglobin
pati A F S C D E Kelainan klinis
% % % % % %
Hb CC 1-7 >90 ringan
Hb AC 50-60 <2 40-50 -
Hb SC 1-7 50 50 Sedang-berat
Hb SS 1-10 80-90 berat
Hb AS 55-70 <2 30-45 ringan
Hb DD <2 95 -
Hb AD 50-65 <2 35-50 -
Hb EE 1-5 95 ringan
Hb AE 60-80 20-40 -
 Pola hemoglobin pada hemoglobinopati kombinasi
Hemoglobin
A F A2 E/S/C
Normal 97 <1 2-3 0
Hemoglobin E E
Trait β/ βE 60-65 1-2 2-3 30-35
β E/βE homozigot 0 0 5 95
E/ β Thal βE/β0 0 45 1-5 40-50
E/ α Thal 70 0 2-3 30
Hemoglobin S S
Trait β/ βS 60-70 1-2 2-3 30-40
β S/βS homozigot 0 5-10 - 90-95
S/ β Thal βS/β0 0 5-10 4-7 80-90
βS/β+ 20-30 5-10 4-7 50-70
Hemoglobin C C
Trait β/ βC 55-65 3-5 30-40
β C/βC homozigot 0 5-10 - 90-95
C/ β Thal βC/β0 0 5-10 - 90-95
βC/β+ 20-30 5-10 - 60-75
 Hemoglobin
A F A2 E/S/C
Normal 97 <1 2-3 0
Hemoglobin E E
Trait β/ βE 60-65 1-2 2-3 30-35
β E/βE homozigot 0 0 5 95
E/ β Thal βE/β0 0 45 1-5 40-50
E/ α Thal 70 0 2-3 30

E/ β Thal βE/β+ E/ β Thal βE/β0

 Blood Film
Heterozygous A-thal Mild hypochromia and Microcytosis but less
poikilocytosis
Heterozygous B-thal and HbH disease Microcytic with mild to moderate poikilocytosis

Homozygous and double Extreme poikilocytosis (target cells, ellips,

Heterozygous B-thal polchromasia, basophilic stippling, and nRBCs)

Thalassemia intermedia

https://medical-dictionary.thefreedictionary.com/Thalassaemia+minor
Hemoglobin E trait Homozygous Hb E

Mild hypochromic microcytic red blood cell Mild hypochromic microcytic red blood cell
may be found in some case. Usually found and target cell may be found more than
target cells hemoglobin E triat

http://www.mt.mahidol.ac.th/elearning/Thalassemia%20Term%20Paper%202556/Eng%20blood.html
Beta-thalassemia/Hb E
Beta-thalassemia/Hb E splenectomy
Thalassemic blood picture include hypochromic
microcytic red blood cell, anisocytosis,
poikilocytosis such as ovalocyte, schistocyte, Blood smear like beta-thalassemia/Hb E
spherocyte, target cell, tear drop cell were before splenectomy, however more NRC
found. Basophilic stippling and nucleated rbc and Howell jolly body could be found.
(NRC) could be found

http://www.mt.mahidol.ac.th/elearning/Thalassemia%20Term%20Paper%202556/Eng%20blood.html
Hemoglobin constant spring

Mild hypochromic microcytic red blood cell and

basophillic stippling were found

http://www.mt.mahidol.ac.th/elearning/Thalassemia%20Term%20Paper%202556/Eng%20blood.html
http://www.mt.mahidol.ac.th/elearning/Thalassemia%20Term%20Paper%202556/Eng%20blood.html
 Interpretation of Hb typing

http://www.mt.mahidol.ac.th/e-
learning/Thalassemia%20Term%20Paper%202556/Eng%20Hb%20typing.html
 TREATMENT

Life-long
Transfusion, Iron chelating agent, folic acid
Stem cell, genes therapy

Problems
Iron deposition (hemosiderosis)
Growth-development, productivity
Transmission of pathogens (HIV, hepatitis)
Side effects of iron chelating agent
Economy, psychosocial
Therapy and Complication
 PROGNOSIS

B-thalassemia major
Sharp increase in death after age 15
Survival prolonged if iron loaded is significantly
lowered

B-thalassemia intermedia
Sharp increase in death after 3-4 decades
 Content

Introduction: Haemoglobinopathy Basics

Pathophysiology

Diagnosis: Clinical manifestation & lab test

Conclusion
 Conclusion

The umbrella term “hemoglobinopathy” includes all genetic

hemoglobin disorders
The two main groups are thalassemia syndromes and
structural Hb variants (abnormal hemoglobins)
The main types of thalassemia are α- and β-thalassemia.
The main types of Hb variants are HbS, HbE, and HbC.
Within these main types there are several subtypes, with
differing disease patterns
Stem-cell transplantation is the first-line treatment for β-
thalassemia major. Conventional treatment consists of lifelong
transfusions, consistent iron chelation therapy, and long-term
follow-up care.