Diagnosis of Thalassemia and

Related Hemoglobin Disorders

Dr. Akhil Ranjon Biswas
Associate Professor, BMT
Dept. of Hematology
Dhaka Medical College & Hospital
[email protected]
Thalassemia Spectrum
Thalassemia Spectrum
Thalassemia Spectrum
 Thalassemia: Phenotypes

Thalassemia
Minor
 Thalassemia: Phenotypes

ThalassemiaI
ntermedia

Thalassemia
Minor
 Thalassemia: Phenotypes
Thalassemia
Major

Thalassemia
Intermedia

Thalassemia
Minor
Pathophysiology of Phenotypic Heterogenecity: A
Glimpase

Stable hemoglobin molecule in adult is a tetramer formed of-

2 alpha globin chain, with,
2 beta (Hb A), gamma (Hb F) or delta (Hb A2) globin chain.

Quantitative imbalance between alpha and non-alpha globin

chain are responsible for clinical expression of thalassemia.
Pathophysiology of Phenotypic Heterogenecity of β Thalassemia:
A Glimpase
Present talk will principally cover β
thalassemia and related disorders
According to Disease Potential Thalassemias are

1.Symptomatic Thalassemia: Thalassemia Major &

Thalassemia Intermedia
2.Asymptomatic and silent carrier

From here on, term ‘thalassemia’ will be used for

symptomatic thalassemias.
Diagnosis of symptomatic thalassemia (Thalassemia Major &
Thalassemia Intermedia) typically relies on
1. Clinical features (symptoms and signs): Few unique but
mostly non-specific
2. Typical lab findings
Clinically Popular Features of Thalassemia
1. Moderate to severe pallor/anemia
2. Mild jaundice
3. Splenomegaly
4. Hepatomegaly
5. Stunted growth
6. Typical facial changes: frontal bossing, prominent maxilla
and zygoma, depressed nasal bridge.
7. Poorly developed or undeveloped secondary sexual
character
8. Typical radiological finding
Most of those popularly known pictures are associated with
mostly irreversibly complicated thalassemia major,
certainly destined to deadly outcome shortly.

For successful and meaningful management of thalassemia

we must be able to diagnose symptomatic thalasemmia
before appearance of those popular picture

So, clinical features of thalassemias to be redefined

Clinical features of thalassemia
Clinical features of thalassemia necessarily mean clinical
features of symptomatic thalassemias, namely
thalassemia major and thalassemia intermedia. Though
thalassemia major and intermedia present generally
almost similar features but in significantly different
spectrum.
Clinical features of thalassemia
 Features of thalassemia major
Should present within 2 years of age if addressed properly
Failure to thrive
Repeated infection
Pallor
Splenomegaly (and hepatomegaly if not transfused
sufficiently)
May have clinically evidenced jaundice
Regular transfusion required before 2 year of age for normal
growth and development
Bony expansion causing frontal bossing, malar prominence
etc along with growth retardation revealed later in childhood
if not transfused sufficiently.
Clinical features of thalassemia
Features of thalassemia intermedia
Very diverse spectrum of expression, in one end it merge with
thalassemia major and on the milder end it merge with thalassemia
minor.
 Pallor, splenomegaly etc become clinically evident after 2 year of
age
Heterogeneous clinical expression: some patients require
transfusion since early childhood and some patient may be able to
maintain normal growth and development without any transfusion.
Some patient may present in adulthood with paraplegia due to
extramedullary hemopoiesis in spinal canal, with features related to
iron loading, chronic jaundice, episodic or chronic fatigue etc.
Growth retardation, bone deformity, hepatomegaly only seen in
more severe form of poorly treated or untreated cases.
 Laboratory investigation

1. CBC:
1. Hb <9 g/dl
2. MCV - low/variable
3. MCH- low
4. MCHC- low or normal
5. RDW- markedly raised
6. WBC & Plt generally
normal
2. PBF : Gross anisopoikilocytosis,
tear drop cells, target cells,
normoblast, basophilic
stippling etc
Laboratory Diagnosis
Hemoglobin electrophoresis:
Common thalassemia genotypes are
 Compound heterozygous HbE/ β thalassemia
 Double heterozygous/homozygous β thalassemia (β/β thalassemia)
Less common genotypes are
 δβ thalassemia compound heterozygote with Hb E or β thalassemia or
homozygous δβ
 Hb Lepore/Hb E, Hb Lepore/β, Hb Lepore/Hb Lepore
 Hb H disease

*Hb S/β thalassemia is a sickling disorder rather than thalassemia

 Laboratory Diagnosis: Hb Electrophoresis

β/β thalassemia:
Hb A: 0 to variable
Hb F: >15 to 99%
Hb A2: Variable but <8%

Most likely β thalassemia major

 Laboratory Diagnosis: Hb Electrophoresis

β/β thalassemia:
Hb A: 0 to variable
Hb F: >15 to 99%
Hb A2: Variable but <8%

Most likely β thalassemia intermedia

 Laboratory Diagnosis: Hb Electrophoresis

Hb E/β thalassemia:
Hb A: 0 to variable
Hb F: >15 to variable
Hb E: > 40 to variable
Hb A2: Variable but <8%
 Laboratory Diagnosis: Hb Electrophoresis

Hb E/β thalassemia:
Hb A: 0 to variable
Hb F: >15 to variable
Hb E: > 40 to variable
Hb A2: Variable but <8%
Laboratory Diagnosis: Hb Electrophoresis

δβ/β or δβ/ δβ thalassemia: Conditions tricky to diagnose

β/β thalassemia: δβ/β or δβ/ δβ thalassemia:

Hb A: 0 to variable Hb A: 0 to variable
Hb F: >15 to 99% Hb F: >15 to 99%
Hb A2: Variable but Hb A2: <3%
<8%
 Laboratory Diagnosis: Hb Electrophoresis

•26 year old lady

•Height 160 cm
•Well developed 2ndary sexual character
•Occasional transfusion requirement
•Hb 7.5 gm/dl with typical PBF of
thalassemia

Diagnosis?
 Laboratory Diagnosis: Hb Electrophoresis

This type of electrophoretic

pattern with thalassemia
intermedia like clinical
expression suggest δβ/β or
δβ/ δβ thalassemia
Laboratory Diagnosis: Hb Electrophoresis

Significant aberration from classical electrophoretic pattern

is not uncommon.

So, electrophoresis pattern should always be interpreted in

the context of clinical features, PBF and transfusion
history.

Parent screening may be needed in some cases.

Laboratory Diagnosis: Additional
Serum bilirubin: total (raised but not >5 mg/dl), direct
(normal unless complicated) & indirect (raised)
Retculocyte count: relative reticulocytopenia
Serum ferritin: usually raised

*Lot more investigations are related to management issues

and to be discussed in relevant sections
 Carrier Detection
• Detection of asymptomatic/silent carriers are primarily driven by
CBC and almost certainly confirmed by Hb Electrophoresis
(capillary preferred)
• There are some other cheaper and easily accessible methods
those are less specific and sensitive
• Relevant types in Bangladesh are
• Hb E trait
• β thalassemia trait
• Homozygous Hb E (Hb E disease)
• δβ thalassemia trait
• Hb Lepore trait

* α thalassemia traits can’t be diagnosed but suspected from blood picture and electrophoresis.
 •Apparently Healthy
•Age >12 year
•No red cell transfusion in preceding 4 month

CBC MCV <78 fl or MCH <27 pg

MCV <72fl + Normal MCHC

Capillary A2+E >12% A2 >3.7% Hb A= 0% A2 <3.2 A2 <3.3 Other

Hemoglobin F <1% F <5% Hb F= <5% F= 5-20% F <1 patterns
Electrophor A= Rest A= Rest A2+E= Rest A=Rest A= Rest
esis (Normal pattern)

Hb E trait β Homozygou δβ Probable α thal

thalasse s Hb E (Hb E thalassemia trait when iron
mia trait disease) trait deficiency is
excluded

Expert Consultation
Red cell indices in thalassemia minor
Mentzer index ≤12 is most specific but not very
sensitive predictor of thalassemia minor
 Mentzer Index = MCV÷ RBC (million/cmm)
MCV cut off value <72 fl is the most sensitive but very
unspecific predictor of thalassemia minor
 Red cell indices in thalassemia minor

Mentzer index = 12 Mentzer index = 10

Carrier Detection: Hb Electrophoresis (capillary)

β thalassemia trait
Carrier Detection: Hb Electrophoresis (capillary)

δβ thalassemia trait
 Carrier Detection: Hb Electrophoresis (capillary)

Homozygous Hb E (Hb E disease)

Carrier Detection: Hb Electrophoresis (capillary)

Hb E trait
Carrier Detection: Hb Electrophoresis (capillary)

Hb E trait
Interpretation of Hb Electrophoresis sometimes may be
tricky rather than straightforward.

Hope to discuss few such tricky tracing in last session.

Carrier Detection: Hb Electrophoresis (capillary)

Question?