Haemolytic anemias

α Thalassemia
Overview

• Normal Structure and types of haemoglobin

• Molecular basic of haemoglobin synthesis
• Thalassemia definition and types
• α thalassemia
• Pathogenesis
• Types
• Clinical features
• Diagnosis
• Treatment
Normal structure of Haemoglobin

 Haemoglobin is a tetrameric protein found

in red blood cells and composed of four
polypeptide globin chains .

 Each globin chain is folded into a three-

dimensional globular structure creating a
pocket for the heme group .
Types of Haemoglobin
• HbA (α2β2 )
• HbA2 (α2δ2)
• Hb F (α2γ2)
• Hb Gower 1 (ζ2ε2)
• Hb Gower 2 (α2ε2)
• Hb Portland (ζ2γ2 )
 In normal adult
• HbA - 95 to 98%
• HbA2- 2 to 3.5 %
• HbF - <1%

In embryo and fetus stage

• Hb Gower 1 and HbF dominant at different stages

• Hb Portland and Hb Gower 2 as minor haemoglobin during early stage of

development
Different types of globin chains in prenatal and postnatal life
Molecular basic of haemoglobin synthesis

• The genes for the globin chains and their regulatory elements occur in two
clusters.
• ε, Gγ, Aγ, δ and β (the ‘β-globin cluster’) located on chromosome11q.
• ζ and α (the ‘α- globin cluster ‘ ) on chromosome 16p.
• The α-globin gene is duplicated and both α genes (α1 and α2) are present on
each chromosome 16.
• In normal person , there are four α- globin genes and two β- globin genes.
• All the globin genes have three exons (coding regions) and two introns (non-­coding
regions)
• An initial globin RNA is transcribed from both introns and exons, and from this
transcript the RNA derived from introns is removed by splicing .

• Introns always begin with a G-­T dinucleotide and end with an A- ­G dinucleotide; the
introns in the globin genes are typical in this regard.
• The pre-­mRNA splicing machinery recognizes these sequences as well as neighboring
conserved sequences and excises the introns from the newly formed transcript.

• The sub-sequent mature mRNA resulting from transcription is polyade-nylated at the

3′ end and this stabilizes it.
• Thalassaemia may arise from mutations or deletions of any of these sequences
• Regulatory sequences influence gene transcription and specify sites
for the initiation and termination of transcription and ensure the
stability of newly synthesized mRNA.

• Mutations at these sites may also give rise to thalassaemia by reducing

synthesis of one or other of the globin chains.
• Promoters are found 5′ of the gene.
• Enhancers occur either 5′ or 3′ to the gene.
• They are important in the tissue-­specific regulation of globin gene expression
and in regulation of the ­synthesis of the various globin chains during fetal
and postnatal life.
• The locus control region (LCR) is a genetic regulatory element situated
upstream of the β-globin cluster, which controls genetic activity at this cluster
by opening up the chromatin to allow several key transcription factors.
• HS-­40 which is 40 kilobases 5′ to the α gene cluster regulates α-globin
synthesis.
• Mutations in transcription factors such as GATA 1 which bind to regulatory
sequences of α and β globin gene cluster can cause altered globin
synthesis.

Transcription factor GATA1

Switch from adult haemoglobin to fetal haemoglobin

• The β-globin gene is expressed at a low level in early foetal life, but the main
switch to adult haemoglobin occurs 3–6 months after birth when synthesis of
the γ chain is largely replaced by β chains.

• BCL11A is a major transcriptional regulator of this switch by surpressing γ

globin genes .

• Transcription factor KLF1 also binds to promoter region of the beta globin
gene activating its transcription .
Thalassemia Definition and Types

• Thalassemia is a heterogenous group of genetic disorder that result

from a reduced rate of synthesis of α or β globin chains .

Two Types Three Syndromes

• α Thalassemia • Thalassemia major (transfusion dependent)

• Thalassemia intermedia (non-transfusion depend)
• β Thalassemia • Thalassemia minor ( carrier state or trait )
Pathogenesis of α Thalassemia

• Alpha thalassemia is mainly caused by the gene deletion of alpha

globin genes located on the chromosome 16p , specifically at gene
cluster 16p 13.3
• It can also be less frequently caused by point mutations of HS-40
which is the part of LCR , a major regulatory DNA element , resulting
in reduced α gene expression .
• Rare forms of alpha thalassemia such as Hb Contstant Spring(Hb CS) are
caused by non-sense mutation in the HBA2 gene, stop codon at the position
142 (UAA) to be replaced by glutamine residue (CAA), preventing the normal
termination and resulting in abnormally long and unstable α globin chain. It is
often found in individuals with α thalassemia trait or Hb H disease.
Types of α Thalassemia
Clinical features of different types of α Thalassemia

One gene deletion (αα/_α )

• These are the silent carriers of α thalassemia .
• No significant clinical symptoms.
• Haemoglobin level is within the normal range but MCV and MCH
maybe mildy reduced .
 Trans deletion of gene on each chromosome (α_ / α_ )
Two genes deletion
Cis deletion of gene on one chromosome (α α /_ _ )

• Called alpha thalassemia trait .

• No significant anemic symptoms .
• Haemoglobin level may be normal or mildy reduced .
• MCV and MCH are reduced
Three gene deletion ( _ _ /_ α )
• This is known as Hb-H disease (β4) .
• Reudced alpha globin chain production leads to an excess of beta
globin chains , forming tetramers with 4 β globin chains which are
unstable and precipitated in red blood cells causing haemolysis .
• Hb-H disease is characterized by moderate degree of anemia with Hb
level of 8-9 g/dl .
• Mild jaundice and splenomegaly maybe observed on some patients .
• Haemoglobin level might drop very low during pregnancy ,
intercurrent infection or ingestion of oxidant drugs.
• MCV and MCH are reduced
• Blood film shows marked hypochromic microcytic cells , target cells ,
mild reticulocytosis and occasionally nucleated RBCs.
 Target cells

Blood film of a patient with Hb-H disease showing marked hypochromic microcytic cells with target cells and poikilocytosis
• When stained with supravital stains such as brilliant cresyl blue ,
precipitation of beta globin aggregates are seen as multiple fine ,
deeply stained deposits ( golf ball cells ) .
Hb Electrophoresis of Hb-H patient
• Hb pattern: Hb - H = 2 - 40%, Hb A, A2, F =decreased, Hb Barts -
small amount (+) in some case
• In Southeast Asia , 40 percent of patients with Hb-H disease also have
small amount of α chain variant , Hb constant spring .
Four genes deletion ( _ _ / _ _ )

• Due to absence of α chains , there will be relatively excess of γ globin

chains in the fetus resulting in formation of Hb Barts (γ4 tetramers ).
• These Hb Barts have extremely high affinity for oxygen leading to
severe tissue hypoxia and death in utero or death shortly after birth .
• Signs of fetal distress usually become evident only by the third
trimester of pregnancy .
• This is due to presence of embryo globin chains ζ chains which pair
with γ globin chains to form ζ2γ2 tetramer also known as Hb Portland before
the third trimester .
• Affected infants are underweight , pale , jaundiced , grossly
edematous and have hepatosplenomegaly and ascites .
• The blood film shows anisopoikilocytosis , target cells,reticulocytosis ,
basophilic stippling and large number of nucleated red cells .

Nucleated red cells

Hb electrophoresis of Hb Barts disease

• Hb pattern: Hb barts - 80-90%, Hb H,portland - small amount,

Hb A,A2,F (-)
 Treatment

α Thalassemia silent carrier and α Thalassemia trait patients

• No special treatment required

• But for the patients with α Thalassemia trait , genetic councelling might be
reqired as they have the chance to give rise to offspring with significant α
thalassemia such as Hb-H disease .
Hb-H disease

• Blood transfusion : Given during periods of severe anemia such as

infection , pregnancy or taking oxidant drugs . Regular transfusion
only needed for severe cases .

• Regular Folic acid supplementation is needed .

• Avoidance of oxidant drugs (e.g drugs containing sulphur ) is

important because they can trigger haemolysis .
• Splenectomy : Required rarely , required only in cases with massive
splenomegaly and increasing anemia .

• Iron Chelation Therapy : Only in severe cases which require regular

multiple blood transfusion .

• Bone marrow transplant : This is the only potential cure but not done on
regular basic due to difficulty in finding of donor .
Thank you for your attention !