HAEMOGLOBINOPATHIES

Dr G.O Ogun
Department of Pathology,
College of Medicine,
University of Ibadan
 Introduction
 The haemoglobinopathies refer to a diverse
group of inherited disorders characterized by a
reduced synthesis of one or more globin chains
(thalassaemias) or the synthesis of a structurally
abnormal haemoglobin (Hb).
 In prevalent regions, the thalassaemias often
coexist with a variety of structural Hb variants
giving rise to complex genotypes and an
extremely wide spectrum of clinical and
haematological phenotypes.
 Main Categories of
Haemoglobinopathies
 Sickle cell disease (major genotypes Hb S/S, Hb
S/C and Hb S/β-thal, and less common
genotypes Hb S/DPunjab, Hb S/OArab and Hb
S/Lepore)
 β -thalassaemia syndrome; including δ β –
thalassaemias and Hb E/ β -thalassaemia
 α-thalassaemia syndrome
 Hb variants resulting in haemolytic anaemias,
polycythaemias and, more rarely, cyanosis
Sickle Cell disease

A pathologist perspective
 Sickle Cell Disease
SCD Genotype

Genotype Genotype prevalence

 Sickle cell anemia 65%
(SS) 25%
 Sickle Hb C disease
(SC) 8%
 Sickle S beta plus
(Sβ+ thalassemia )
2%
 Sickle Beta zero
(Sβ° thalassemia)
 Pathophysiology
 Sickle cell trait is benign, because the
cellular concentration of haemoglobin S is
too low for polymerization to occur under
most conditions
 It is haemoglobin S polymers that cause
the cellular injury responsible for the
clinical manifestations of sickle cell disease
Pathophysiology of SCD
 Pathophysiology
 Vaso-occlusion is initiated and sustained by
interactions among sickle cells, endothelial cells,
and constituents of plasma.
 Deoxygenation of sickle cells induces potassium
efflux, which increases cell density and the
tendency of hemoglobin S to polymerize.
 Adhesive interactions between sickle cells and
endothelial cells occur as a result of injury to cell
membranes.
Pathophysiology
 Pathophysiology
 As sickle cells perturb the endothelium, the
balance of vasodilators and vasoconstrictors may
be changed to favour vasoconstriction.
 The adherence of sickle cells to endothelial cells
may slow blood flow enough that the successive
processes of haemoglobin S polymerization, cell
sickling, and vaso occlusion occur before the
passage of blood through the micro vessels is
completed.
 High granulocyte counts are a risk factor for
death in sickle cell anemia- because the white
cell are sources of inflammatory cytokines- TNF,
IL 1
 Pathophysiology
 Granulocytes interact with sickle cells and
endothelial cells and are stimulated to release
injurious cytokines.
 Activated platelets release thrombospondin,
which promotes the adherence of sickle cells to
endothelial cells.
 Reticulocytes that are prematurely released from
the bone marrow (“stress” reticulocytes) in
haemolytic disease display additional adhesive
ligands that facilitate interactions between sickle
cells and endothelial cells.
Pathophysiology (Summary)
 Abnormal red blood cell cytoskeleton
 Haemoglobin polymerization
 Impaired red cell deformability
 Impaired microvascular flow
 increased endothelial activation
Normal Vs. Sickle Red Cells
Normal Sickle
 Disc-Shaped  Sickle-Shaped
 Deformable  Rigid
 Life span of 120  Lives for 20 days
days or less
 Hemolysis and Vaso-occlusion
Haemolysis:
The anemia in SCD is caused
by red cell destruction, or
hemolysis, and the degree of
anemia varies widely
between patients. The
production of red cells by the
bone marrow increases
dramatically, but is unable to
keep pace with the
destruction.
Vaso-occlusion:
Occurs when the rigid sickle
shaped cells fail to move
through the small blood
vessels, blocking local blood
flow to a microscopic region of
tissue. Amplified many times,
these episodes produce tissue
hypoxia. The result is pain,
and often damage to organs.
 Acute Manifestations
 Bacterial Sepsis or meningitis*
 Recurrent vaso-occlusive pain (dactylitis-
hand and foot syndrome; muscoskeletal or
abdominal pain)
 Acute Osteomyelitis
 Splenic Sequestration* *Potential
cause of
 Aplastic Crisis*
mortality
 Acute Chest Syndrome*
 Stroke*
 Priapism
 Hematuria, including papillary necrosis
 Chronic Manifestations
 Anemia /Jaundice
 Splenomegaly
 Functional asplenia
 Cardiomegaly and functional murmurs
 Hyposthenuria and enuresis
 Cholelithiasis
 Delayed growth and sexual maturation
 Restrictive lung disease*
 Pulmonary Hypertension*
 Avascular necrosis
 Proliferative retinopathy
 Leg ulcers
 Transfusional hemosiderosis*
 Acute Chest Syndrome
 Pulmonary infiltrates
 sometimes with effusion
 with one or more of the following:
 Chest pain
 40% also have abdominal pain
 Fever/Cough
 Impaired oxygenation
 May also have chills
 Often preceded by vaso-occlusive crisis
 high phospholipase A-2 levels
Acute Chest Syndrome

 intravascular clogging
 fat embolism
 atelectasis
 infection
 thromboembolism
 Infectious : Aetiolgy
 Strep pneumoniae
 Hemophilus influenzae
 Klebsiella pneumoniae
 E.coli
 Chlamydia
 Mycoplasma
 Viral
 Salmonella
 Infections: Why SCD px are
prone
• INFECTIONS
• Early loss of splenic function

• the inability to make specific G (IgG) to polysaccharide antigens

• Reduced phagocytic activity

• Defective alternate pathway of complement activation

• Prone to infection by encapsulated organisms, eg, S. pneumoniae,

H. influenza, meningococcus
 Infections lead to death through
several intermediate and immediate
causes
 sepsis
 myocarditis with probable arrhythmias
 splenic sequestration with hypovolaemic
shock
 meningitis with brainstem compression/RICP
 Massive pulmonary inflammatory infiltrates
or mucus plugging with respiratory
insufficiency
 Cases in which infections led to
sepsis, the immediate causes of
death
 Cardiogenic shock
 Pulmonary emboli/thrombi with acute cor
pulmonale
 Cerebral oedema
 Massive haemolysis
 In cases where infections lead to
respiratory insufficiency, the immediate
causes of death can include
1. pulmonary oedema,
2. asphyxia,
3. pneumonia and diffuse alveolar damage
Cerebral Vascular Accident
 300X > control patients without sickle cell disease
 11% with HbSS will have CVA by age 15yrs
 2% of patients with HbSC
 17-22% of Hb SS patients have “silent” CVAs
 Abnormal MRIs in 1/3 of patients by age 15
  risk if baseline Hb low or WBC high
 Higher risk if BP normal to high
 Higher if patient has moya-moya collaterals
 Strokes reduced with chronic exchange transfusion
 keep % Hb S < 30%
 Renal Disease
 Proteinuria/Nephrotic syndrome
 40% of SCD patients with nephrotic syndrome
develop end-stage renal disease
 Occurs in ~ 20% of all patients
 Renal failure common in adults
 Leg Ulcers
 Occurs in about 25% of
all hemoglobin SS
patients
 Predominantly males
 Incidence increased with
 Age

 Decreased hemoglobin

 Incidence decreased with

alpha thalassemia
 Recurrence rate is ~ 75%
 Morphological organ injury (%) in 306
autopsies of sickle cell disease.
( Manci et al 2003)
 Pulmonary thrombi/emboli  Not specified 51.1
24  Chronic renal
 Thrombi/thromboemboli failure/papillary necrosis
65.3 14.5
 Fat/bone marrow 34.7  Renal infarcts/atrophy
 Chronic lung disease/cor 23.4
pulmonale 36.3  Splenic atrophy/infarcts
 Pulmonary infarcts 20.1 58.8
 Cardiomegaly 58.4
 Splenomegaly/
splenectomy 25.4
 Congestive heart failure  Cholelithiasis/
9.9 cholecystectomy 29
 Myocardial microinfarcts  Liver failure/hepatitis 10
20.1  Haemosiderosis 61
 Strokes 18.2  Bone
 Haemorrhagic 34.6 infarcts/osteomyelitis 12.5
 Thrombotic 14.3
 ‘CRISIS’ i.e VASH
1. Vaso- occulusive
2. Aplastic
3. Sequestration
4. Hyper-haemolytic
Thalassaemias
 Thalassemias
 The thalassemia syndromes are a
heterogeneous group of inherited
disorders caused by genetic lesions
leading to decreased synthesis of either
the α- or β-globin chain of HbA (α2β2)
 Introduction
 β-Thalassemia is caused by deficient synthesis of the β
chain
 α-thalassemia is caused by deficient synthesis of the α
chain.
 The haematologic consequences is due to diminished
synthesis of one globin chain stem not only from low
intracellular hemoglobin (hypochromia), but also from a
relative excess of the unimpaired chain.
 Clinical classification of β-thalassemias is based on the
severity of the anemia, which in turn depends on the
type of genetic defect (β+ or β0) and the gene dosage
(homozygous or heterozygous).
 Clinical and Genetic Classification of
Thalassaemias
Clinical
Nomenclature Genotype Disease Molecular Genetics

β-Thalassemias

Thalassemia Homozygous β0- Severe; requires blood

major thalassemia transfusions
0 0 Rare gene deletions in
(β /β )
β0/β0
Defects in transcription,
Homozygous β+- processing, or translation
thalassemia of β-globin mRNA
(β+/β+)

Thalassemia β0/β Severe, but does not

intermedia β+/β+ require regular blood
transfusions

Thalassemia β0/β Asymptomatic with mild

minor β+/β or absent anemia; red cell
abnormalities seen
 Clinical and Genetic Classification of
Thalassaemias
α-Thalassemias

Hydrops fetails -/--/- Lethal in utero without

transfusions
Mainly gene
HbH disease -/--/α Severe; resembles β-thalassemia deletions
intermedia

α-Thalassemia -/-α/α (Asian) Asymptomatic, like β-thalassemia

trait -/α-/α (black minor
African)

Silent carrier -/αα/α Asymptomatic; no red cell

abnormality
 β-Thalassemias
 β-Thalassemia is most common in
Mediterranean countries and parts of North
Africa and Southeast Asia.
 In β-thalassemia, there is diminished synthesis
of structurally normal β-globin chains, coupled
with unimpaired synthesis of α chains.
 The excess free α chains aggregate into
insoluble inclusions within red cells and their
precursors, leading to
1. premature destruction of maturing
erythroblasts in the marrow (ineffective
erythropoiesis)
2. lysis of mature red cells in the spleen
 The clinical severity of the anemia varies due
to heterogeneity in the causative mutations.
 β-Thalassaemias
 Impaired β-globin synthesis results in
anemia by two mechanisms
1. "under-hemoglobinized," hypochromic,
microcytic red cells with subnormal
oxygen transport capacity.
2. A more important factor is diminished
survival of red cells and their precursors,
resulting from the imbalance in α- and β-
chain synthesis.
 Free α chains precipitate within the
normoblasts, forming insoluble inclusions.
 β-Thalassaemias
 These inclusions cause a variety of untoward effects, but
cell membrane damage is the proximal cause of most
red cell pathology.
 Many developing normoblasts in the marrow succumb to
these membrane lesions, undergoing apoptosis.
 In severe β-thalassemia, it is estimated that 70% to
85% of normoblasts suffer this fate, leading to
ineffective erythropoiesis.
 The inclusion-bearing red cells derived from precursors
escaping intramedullary death are prone to splenic
sequestration and destruction due to cell membrane
damage and decreased deformability
 β-Thalassaemias
 In severe β-thalassaemia, marked anemia
produced by ineffective erythropoiesis and
hemolysis leads to several additional
problems.
 Erythropoietin secretion in the setting of
severe uncompensated anemia leads to
massive erythroid hyperplasia in the
marrow and sites of extramedullary
hematopoiesis.
 β-Thalassaemias
 The expanding mass of erythropoietic marrow
invades the bony cortex, impairs bone growth,
and produces other skeletal abnormalities.
 Extramedullary hematopoiesis involves the liver,
spleen, and lymph nodes, and in extreme cases
produces extraosseous masses in the thorax,
abdomen, and pelvis.
 β-Thalassaemias
 The metabolically active erythroid progenitors ‘steal’
nutrients from other tissues that are already oxygen
starved, causing severe cachexia in untreated patients.
 Another disastrous complication seen in severe β-
thalassaemia (as well as in other causes of ineffective
erythropoiesis) is excessive absorption of dietary iron.
 Coupled with the iron accumulation due to the repeated
blood transfusions required by these patients, leads to a
state of severe iron overload.
 Secondary injury to parenchymal organs, particularly the
iron-laden liver, often follows and sometimes induces
secondary haemochromatosis
 β-Thalassaemias
 The genotype of affected patients can be β+/β+, β0/β0,
or β0/β+.
 With all these genotypes, the anemia manifests 6 to 9
months after birth, as hemoglobin synthesis switches
from HbF to HbA.
 In untransfused patients, hemoglobin levels range
between 3 and 6 gm/dL.
 The peripheral blood smear shows severe red cell
morphologic abnormalities, including marked
anisocytosis and poikilocytosis,microcytosis and
hypochromia (poor hemoglobinization).
 Target cells (so called because hemoglobin collects in the
center of the cells), basophilic stippling, and fragmented
red cells are also common.
 β-Thalassaemias
 Inclusions of aggregated α chains are efficiently
removed by the spleen and not easily found in peripheral
blood smears.
 The reticulocyte count is elevated, but because of
ineffective erythropoiesis is lower than expected for the
severity of anemia.
 Variable numbers of poorly hemoglobinized normoblasts
are seen in the peripheral blood due to "stress"
erythropoiesis and abnormal release of progenitors from
sites of extramedullary hematopoiesis.
 The red cells can completely lack HbA (β0/β0 genotype)
or contain small amounts (β+/β+ or β0/β+ genotypes).
 HbF is markedly increased and indeed constitutes the
major red cell hemoglobin. HbA2 levels may be normal,
low, or high.
 β-Thalassaemias
 The clinical course of β-thalassemia major is
brief unless blood transfusions are given.
 Untreated children suffer from growth
retardation and die at an early age from the
profound effects of anemia.
 Blood transfusions not only improve the anemia
but also suppress secondary features related to
excessive erythropoiesis.
 In those who survive long enough, the
cheekbones and other bony prominences are
enlarged and distorted. Hepatosplenomegaly
due to extramedullary hematopoiesis is usually
present.
 β-Thalassaemias
 Cardiac disease resulting from progressive iron overload
and secondary hemochromatosis is an important cause
of death, particularly in heavily transfused patients.
 Administration of iron chelators can forestall or prevent
this complication.
 With transfusions and iron chelation, survival into the
third decade is possible, but the overall outlook remains
guarded.
 Bone marrow transplantation from an HLA-identical
sibling is currently the only therapy offering a cure.
Prenatal diagnosis is possible by molecular analysis of
DNA.
 α-Thalassaemias
 The α-thalassaemia disorders are characterized by
reduced or absent synthesis of α-globin chains.
 There are normally four α-globin genes. The
severity of α-thalassaemia varies greatly
depending on the number of α-globin genes
affected.
 the anemia stems both from lack of adequate
hemoglobin and the effects of excess unpaired
non-α chains (β, γ, δ).
 However, the situation is complicated somewhat
by synthesis of different non-α chains at varying
times of development.
 α-Thalassaemias
 Thus, in the newborn with α-thalassemia, excess
unpaired γ-globin forms γ4-tetramers known as
hemoglobin Barts, whereas in adults excess β-
globin chains form β4 tetramers known as HbH.
 Free β and γ chains are more soluble than free α
chains and form fairly stable homotetramers,
hemolysis and ineffective erythropoiesis are less
severe than in β-thalassemias.
 A variety of molecular lesions result in α-
thalassemia, but the most common cause of
reduced α-chain synthesis is deletion of α-globin
genes.
 Hemoglobin H Disease.
 This is caused by deletion of three α-globin
genes.
 HbH disease is seen most commonly in Asian
populations and rarely in those of African origin.
 With only one normal α-globin gene, the
synthesis of α chains is markedly reduced and
tetramers of excess β-globin, called HbH, form.
 HbH has extremely high affinity for oxygen and
therefore is not useful for oxygen exchange,
leading to tissue hypoxia disproportionate to the
level of hemoglobin.
 Hemoglobin H Disease
 Additionally, HbH is prone to oxidation, leading
to the formation of intracellular inclusions that
can be demonstrated by staining with vital dyes.
 The instability of HbH is a major cause of
anemia, as precipitates of oxidized HbH form in
older red cells, which are then removed by
splenic macrophages. This produces a
moderately severe anemia resembling β-
thalassemia intermedia.
 Hydrops Fetalis.
 This most severe form of α-thalassemia is
caused by deletion of all four α-globin genes.
 In the fetus, excess γ-globin chains form
tetramers (hemoglobin Barts) with such a high
affinity for oxygen that they deliver almost no
oxygen to tissues.
 Survival in early development is due to the
expression of ζ chains, an embryonic globin that
pairs with γ chains to form a functional Hb
tetramer (ζ2γ2).
 Hydrops Fetalis
 Signs of fetal distress usually become evident by
the third trimester of pregnancy.
 Severe tissue anoxia invariably led to
intrauterine fetal death; with intrauterine
transfusion, many of such infants can be saved.
 The fetus shows severe pallor, generalized
edema, and massive hepatosplenomegaly similar
to that seen in erythroblastosis fetalis
Haemoglobin Barts Hydrops fetalis
Syndrome
 References
 Robbin Pathologic basis of diseases 7th
eds- Kumar V, Abbass A, Fausto N