Slemani Technical College Lect. No.

12
MLT Dept. Theoretical hematology Lecture Sunday Aprl. 2. 2023

Hemolytic Anemias:
Hereditary Hemolytic anemia:
Thalassemias

Hemoglobinopathes: Structural hemoglobinopathies (often simply called hemoglobinopathies) are

caused by mutations in the gene for a globin chain, resulting in the synthesis of structurally
abnormal hemoglobin. In most cases, this is due to substitution of a single amino acid. The majority
of hemoglobinopathies that are clinically detected are β-chain mutations.
Hundreds of different hemoglobin mutations have been described; fortunately, most of these are
clinically silent. The consequences of a hemoglobinopathy can include:
1. hemolytic anemia,
2. increased or decreased oxygen affinity, and a
3. decrease in hemoglobin stability or a tendency for hemoglobin to oxidize to methemoglobin.

Terminology for the hemoglobinopathies can be confusing. The normal hemoglobins are
hemoglobin A (α2β2), hemoglobin A2 (α2δ2), and hemoglobin F (fetal hemoglobin; α2γ2).
In the adult, hemoglobin A represents ≥95% of the hemoglobin, A2 represents ≤3 to 4%, and F
represents ≤1 to 2%. Sickle hemoglobin is designated S because erythrocytes with hemoglobin S can
transform into a sickle shape. Hemoglobins that tend to oxidize to methemoglobin are designated
hemoglobin M.

➪ Hemoglobins are also given scientific names based on the specific amino acid sequence
abnormality and the part of the protein where the abnormality is located. For example, the scientific
name for hemoglobin S is β6 (A3) Glu Val—in other words, substitution of valine for glutamic acid
in the sixth amino acid of the β chain, which is the third amino acid of the A helix.
An important but sometimes confusing difference is between hemoglobin genotype and phenotype:
• Genotype: The genotypic designation is based upon the specific globin chains that are present.
Heterozygous sickle cell would be designated α2ββS (two normal α chains, one normal β chain, one β
chain with the sickle mutation). Homozygous sickle cell anemia would be designated α2β2S (two
normal α chains, two β chains with the sickle mutation).

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 Slemani Technical College Lect. No. 12
MLT Dept. Theoretical hematology Lecture Sunday Aprl. 2. 2023

The thalassemias are characterized by a quantitative abnormality

of globin chain synthesis. The thalassemia syndromes consist of a
diverse group inherited disorders, which clinically manifest themselves
as anemia of varying degrees. These disorders are the result of defective
production of the globin portion of the Hb.

* In 1925 Thomas B. Cooley and Pearl Lee described the 1st cases of severe thalassemia in several
North American children of Mediterranean origin. “Cooley’s anemia” is still a commonly used term for
this form of severe thalassemia, which is also termed Thalassemia major. The term is derived from the
Greek word thalassa, which means sea, because at that time, all of the cases described were from the
Mediterranean coastal region. It is now well known that the distribution of thalassemia is worldwide
and not restricted to the Mediterranean Sea area.

It was later realized that the original severe clinical disease described by Cooley was the result
of a homozygous defect in Hb production, whereas many milder cases described as “thalassemia
minima” or “thalassemia minor” were manifestations of a heterozygous defect.

In contrast with hemoglobinopathies such as sickle cell disease, Hb C (β6 Glu Lysin ), or Hb E
GluLysin
(β26 ) which the genetic defect results in structurally abnormal globin chain, the thalassemia
syndromes result from an abnormality in the rate of synthesis of one of the globin chains. With a few
exceptions, the globin chains produced are structurally normal, but there is an imbalance in
production of the two deferent types of chain, resulting in an absolute decrease in the amount of
normal Hb formed, as well as an excess production of one type of chain that may precipitate and
induce hemolysis.

The decrease in globin chain synthesis has two consequences:

1. Decreased hemoglobin synthesis, resulting in anemia and microcytosis
2. Aggregation of the excess free globin chains produced by the non-thalassemic gene (α chains in
the case of β-thalassemia; β chains in the case of α-thalassemia). The aggregates of unpaired
globin chains attach to and damage the erythrocyte cell membrane, resulting in hemolysis. In
severe cases, the majority of erythroid precursors are destroyed in the arrow (ineffective
erythropoiesis). Those that escape into the circulation prematurely destroyed by macrophages in
the spleen and liver.
α-Thalassemia
Pathophysiology
Most cases of α -thalassemia are due to deletions in the α globin genes.

There are two genes for the α globin chain on chromosome 16; the mutation may involve only one

or both α genes on each chromosome. The haplotype (single chromosome) is indicated by α α / (normal),

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 Slemani Technical College Lect. No. 12
MLT Dept. Theoretical hematology Lecture Sunday Aprl. 2. 2023

- α / (one gene mutation), or -- (two gene mutation). Since each person has four α genes, there can be a

deletion in one, two, three, or all four α genes. The severity of illness depends on the number of α genes
with mutations.
• Single-gene mutation (-α / α α): Clinically silent, without microcytosis or anemia

• Two-gene mutation (-α /- α or ––/ α α; _-thalassemia minor or α –thalassemia trait): Mild

microcytic anemia; serious complications are uncommon.
• Three-gene mutation (--/-α; hemoglobin H disease): Moderately severe, microcytic anemia. The
excess β chains precipitate as β4 tetramers (hemoglobin H). The clinical picture is variable; patients may
or may not have splenomegaly, iron overload, and the skeletal complications seen in severe thalassemia.
• Four-gene mutation (--/--; hydrops fetalis): Incompatible with life. Most pregnancies spontaneously
terminate prematurely. Those infants that survive to delivery have gross anasarca and usually die of
congestive heart failure shortly after birth. There is a high incidence of maternal preeclampsia during
the pregnancy.
β -Thalassemia
Pathophysiology
There is a single gene for the β globin chain on chromosome 11. Most mutations in β -thalassemia
are single-nucleotide substitutions. The mutation may result in a complete lack of β chain synthesis (βo-
thalassemia) or a decrease in β chain synthesis (β+-thalassemia). The severity of illness depends on how
much β chain is synthesized and whether the person is heterozygous or homozygous for the mutation.
The β -thalassemias have been divided into three main clinical syndromes:

1. β -Thalassemia minor (Figure 1): Heterozygosity for β-thalassemia results in a mild clinical
syndrome designated β-thalassemia minor. The hemoglobin and the MCV are mildly or
moderately decreased (hemoglobin ~9–12 g/dL and MCV ~65–75 fL), and the patient has few
symptoms or complications.

bizarre

Figure 1 Thalassemia minor. Spherocytes and Figure 2 _-Thalassemia major (Cooley’s anemia).
Note the bizarre erythrocyte morphology and the
basophilic stippling in one erythrocyte.
nucleated erythrocyte.

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 Slemani Technical College Lect. No. 12
MLT Dept. Theoretical hematology Lecture Sunday Aprl. 2. 2023

2. β -Thalassemia major (Cooley’s anemia) (Figure 2): Homozygosity for β-thalassemia results in
a severe clinical syndrome characterized by severe anemia and microcytosis (hemoglobin ~3–5
g/dL and MCV <65 fL), total or near total absence of Hb A, marked ineffective erythropoiesis,
marked expansion of the bone marrow with skeletal complications, splenomegaly, and iron
overload due to hyperabsorption of iron.
3. β-Thalassemia intermedia: β-Thalassemia intermedia is homozygous β-thalassemia that is not
transfusion dependent. It is genetically and clinically heterogeneous. The Hb is intermediate
between β-thalassemia major and minor (~6–9 g/dL), as is the incidence of clinical complications.
Diagnosis of Thalassemia:
Need to start with patient's individual history and family history. Ethnic background important.
➢ Perform physical examination:
• Pallor indicating anemia.
• Jaundice indicating hemolysis.
• Splenomegaly due to pooling of abnormal cells.
• Skeletal deformity, especially in beta thalassemia major.
➢ CBC with Differential
• See decrease in hemoglobin, hematocrit, mean corpuscular volume (MCV), and mean corpuscular
hemoglobin (MCH). See normal to slightly decreased Mean Corpuscular Hemoglobin
Concentration (MCHC).
• Will see microcytic, hypochromic pattern.
• Have normal or elevated RBC count with a normal red cell volume distribution (RDW).
• Decrease in MCV very noticeable when compared to decrease in Hb and Hct.

➢ PBS in thalassemia
• Thalassaemias are typically microcytic and hypochromic anemia's.
• Thalassemia causes a uniform microcytosis without increase in RDW (vs iron deficiency).
• Hb H and β thal major however can cause an increased RDW
• RBC often increased in thal but decreased in iron deficiency
• Hb typically normal in thal minor but decreased in intermedia and major syndromes. MCV is the
most valuable parameter in predicting thalassemia.
Reticulocyte Count
• Usually elevated.
• Degree of elevation depends upon severity of thalassemia.

➢ Brilliant Cresyl Blue Stain

• Incubation with brilliant cresyl blue stain causes Hemoglobin H to precipitate.
• Results in characteristic appearance of multiple discrete inclusions -golf ball appearance of RBCs.
• Hb H Inclusions smaller than Heinz bodies and are evenly distributed throughout cell.

➢ Hemoglobin Electrophoresis
• Important role in diagnosing and differentiating various forms of thalassemias.
• Can differentiate among Hb A, Hb A2, and Hb F, as well as detect presence of abnormal
• hemoglobins such as Hemoglobin Lepore, hemoglobin Bart's, or Hemoglobin Constant Spring.
• Also aids in detecting combinations of thalassemia and hemoglobinopathies.