CASE REPORT - BETA-THALASSEMIA MAJOR – 23rd November 2010 of thalassemia each year, and scientists predict that thalassemia
nd scientists predict that thalassemia will become a worldwide issue in the
By: Ridhona Tambunan (050100119) & Sarah Barbarakaty (050100321)
Supervisor:
dr. H.Hakimi Sp.A (K)
Department of Pediatrics
Haji Adam Malik General Hospital
Faculty of Medicine
University of Sumatera Utara
INTRODUCTION
Hemoglobinopathies comprise a very large number of genetic biochemical and
physiological entities, most of which are academic curiosities. Several of these conditions (e.g., sickle
ceil anemia and some thalassemias) are common major life-threatening diseases, and some others (e.g.,
most thalassemias, hemoglobin E disease, and hemoglobin O disease) are conditions that produce
clinically noticeable - if not serious - effects and can cause the unaware physician a lot of frustration
and patients a lot of expense and inconvenience.
It was in 1925, Thomas Cooley and Pearl Lee described a form of severe anemia, occurring
in children of Italian origin and associated with splenomegaly and characteristic bone changes. Over
the next decade, a milder form was described independently by several Italian investigators. Because
all early cases were reported in children of Mediterranean origin, the disease was later termed
thalassemia, from the Greek word for sea, thalassa. Over the next 20 years, it became apparent that
Cooley and Lee had described the homozygous or compound heterozygous state for a recessive
mendelian disorder not confined to the Mediterranean, but occurring widely throughout tropical
countries.
The thalassemias are a diverse group of genetic blood diseases. In the past 20 years, the two
important forms of this disorder, alpha and beta-thalassemia, resulting from the defective synthesis of
the alpha and beta-globin chains of hemoglobin, respectively, have become recognized as the most
common monogenic diseases in humans. About 100,000 babies worldwide are, born with severe forms
next century.
Children with thalassemia have a shorter red cell life, fetal hemoglobin in their red cells
until an older age than normal, and red cells that are more sensitive to oxidative stress. There are more
than 200 mutations for beta-thalassemia, but mostly are rare. About 20 common alleles constitute 80%
of the known thalassemias worldwide; 3% of the world's population carry genes for beta-thalassemia.
CHAPTER I –THEORY
1.0. A Physiological Review of Hematopoiesis
1.1. Erythropoiesis
Erythropoiesis (red blood cell production) is controlled by erythropoietin, a hormone made
by the juxtaglomerular apparatus of the kidney in response to local tissue hypoxia. The normally high
hemoglobin (Hb) level of the fetus is a result of fetal erythropoietin production in the liver in response
to low Po2 in utero. Control of erythropoiesis by erythropoietin begins at the time of hepatic
hematopoiesis in early gestation. The earliest recognizable erythroid cell in vivo is the erythroblast,
which forms eight or more daughter cells. The immature red blood cell nucleus becomes gradually
pyknotic as the cell matures and eventually is extruded before being released from the marrow as a
reticulocyte.
The reticulocyte maintains residual mitochondrial and protein synthetic capacity. These
highly specialized red blood cell precursors are engaged primarily in the production of globin chains,
glycolytic enzymes, and heme. Iron is taken up via transferrin receptors and incorporated into the heme
ring, which combines with globin chains synthesized within the immature red blood cell. When the
messenger RNA and mitochondria are gone from the red blood cell, it is no longer capable of heme or
protein synthesis; however, the red blood cell continues to function for its normal life span of about
120 days in older children and adults.
1.2. Hemoglobin
 The combustion essential to life requires that tissues receive a constant supply of oxygen.
The evolutionary development of oxygen-carrying proteins, the hemoglobins, increased the ability of
blood to transport oxygen. Furthermore, the combination of oxygen with hemoglobin and its
dissociation from it are accomplished without expenditure of metabolic energy.
1.2.1. Formation of hemoglobin
First, succinyl-CoA, formed in the Krebs metabolic cycle, binds with glycine to form a
pyrrole molecule. In turn, four pyrroles combine to form protoporphyrin IX, which then combines with
iron to form the heme molecule. Finally, each heme molecule combines with a long polypeptide chain,
a globin synthesized by ribosomes, forming a subunit of hemoglobin called a hemoglobin chain. Each
chain has a molecular weight of about 16,000; four of these in turn bind together loosely to form the
whole hemoglobin molecule.
A dynamic interaction between heme and globin gives hemoglobin its unique properties in
the reversible transport of oxygen. The hemoglobin molecule is a tetramer made up of two pairs of
polypeptide chains, each chain having a heme group attached. The polypeptide chains of various
hemoglobins are of chemically different types. The major hemoglobin of a normal adult (Hb A) is
made up of one pair of alpha (a) and one pair of beta ( β ) polypeptide chains and represented as
α 2β 2. Hemoglobin A2 is a normal variant of hemoglobin A that consists of two alpha and two delta
chains (α 2β 2). Two sets of genes for the a chains are located on human chromosome 16. Two pairs of
alleles provide the genetic information for the structure of the α , β , γ and δ chains, the genes are
closely linked on chromosome 11.
1.2.2. Embryonic Hemoglobins
The blood of early human embryos contains two slowly migrating hemoglobins, Gower-1
and Gower-2, and Hb Portland. The zeta (ι ) chains of Hb Portland and Gower-1 are structurally quite
similar to alpha chains. Both Gower hemoglobins contain a unique type of polypeptide chain, the
epsilon (ε 2) chain. Hb Gower-1 has the structure ι 2ε 2, and Gower-2 a2e2. Hb Portland has the
structure (ι 2γ 2). In embryos of 4-8 wk gestation, the Gower hemoglobins predominate, but by the 3 rd
month they disappear.
1.2.3. Fetal Hemoglobin
The major hemoglobin in the fetus (Hb F) is made up of one pair of alpha (α ) and one pair
of gamma (γ ) polypeptide chains represented by α 2γ 2. Its resistance to denaturation by strong alkali
is the basis for determining the presence of fetal RBCs in the maternal circulation (the Kleihauer-Betke
test). After the 8th gestational week, Hb F is the predominant hemoglobin; at 24 week gestation it
constitutes 90% of the total hemoglobin. During the 3rd trimester, a gradual decline occurs, so that at
birth Hb F averages 70% of the total. Synthesis of Hb F decreases rapidly postnatally, and by 6-12
month of age only a trace is present. Less than 2.0% can be detected in older children and adults.
1.2.4. Adult Hemoglobins
Some Hb A (α 2β 2) can be detected in even the smallest embryos. By the 24th week of
gestation, 5-10% of Hb A is present. A steady increase follows, so that at term, Hb A averages 30%.
By 6-12 months of age, the normal Hb A pattern appears. The minor Hb A component Hb A 2 contains
delta (δ ) chains and has the structure α 2δ 2. It is seen only when significant amounts of Hb A are
also present. At birth, less than 1.0% of Hb A 2 is seen, but by 12 months of age the normal level of 2.0-
3.4% is attained. Throughout life, the normal ratio of Hb A to Hb A2 is about 30:1.
The rate at which hemoglobin is synthesized depends on the availability of iron for heme
synthesis. Most of the functional iron (80%) is found in hemoglobin, with small amounts being found
in the myoglobin of muscle, the cytochromes, and iron containing enzymes such as catalase.
Approximately 15% to 20% is stored in the bone marrow, liver, spleen, and other organs. Iron in the
hemoglobin compartment is recycled.
1.3. Iron metabolism
Red cell destruction normally occurs in the spleen, liver, bone marrow, and lymph nodes. In
the process of destruction, the iron from the hemoglobin is returned to the bone marrow for reuse in
red cell production or taken to the liver or other tissues for storage. When body stores of iron are
diminished or red cell production is stimulated, absorption is increased. In iron overload, excretion of
iron is accelerated. Normally, some iron is sequestered in the intestinal epithelial cells and is lost in the
feces as these cells slough.
The iron that is absorbed enters the circulation, where it immediately combines with a β -
globulin, called apotransferrin, to form transferin, which is then transported in the plasma. From the
plasma, iron can be deposited in tissues such as the liver. There it is stored as ferritin, a protein-iron
complex, which can easily return to the circulation. Transferin can also deliver iron to the developing
red cell in bone marrow by binding to membrane receptors. The iron is taken up by the developing red
cell, where it is used in heme synthesis.
The heme portion of the hemoglobin molecule is converted to bilirubin. Bilirubin, which is
insoluble in plasma, attaches to plasma proteins for transport in the blood. It is removed from the blood
by the liver and conjugated to a water-soluble form so that it can be excreted in the bile. The red blood
cell, which lacks mitochondria, relies on glucose and the glycolytic pathway for its metabolic needs.
The end-product of the glycolytic pathway, 2,3-DPG, increases the release of oxygen to the tissues
during conditions of hypoxia by reducing hemoglobin's affinity for oxygen.
2.0. Definition
Thalassemia is a hereditary anemia resulting from defects in hemoglobin production." Beta-
thalassemia (β -thalassemia) syndromes are a group of hereditary blood disorders characterized by
reduced or absent beta globin chain synthesis. Most thalassemias are inherited as recessive traits, β -
thalassemia results in microcytic hypochromic anemia, an abnormal peripheral blood smear with
nucleated red blood cells, and reduced amounts of hemoglobin A (Hb A) on hemoglobin analysis.
3.0. Etiology
More than 200 mutations have been so far reported; the large majority are point mutations
in functionally important regions of the β globin gene. Deletions of the β globin gene are
uncommon. The β -globin gene mutations cause a reduced or absent production of β globin chains.
4.0. Epidemiology
The β -thalassemias are widespread throughout the Mediterranean region, Africa, the
Middle East, the Indian subcontinent and Burma, Southeast Asia including southern China, Indonesia
and the Peninsular of Malaysia. Estimates of gene frequencies range from 3 to 10 percent in some
areas. Within each population at risk for β -thalassemia a small number of common mutations are
found, as well as rarer ones; each mutation is in strong linkage disequilibrium with specific
arrangements of restriction-fragment- length polymorphisms, or haplotypes, within the β -globin
cluster.
A limited number of haplotypes are found in each population, so that 80 percent of the
mutations are associated with only 20 different haplotypes, There is evidence that 'the high frequency
of β -thalassemia throughout the tropics reflects an advantage of heterozygotes against Plasmodium
falciparum malaria, as has already been demonstrated in α -thalassemia.
5.0. Pathophysiology
The thalassemias are inherited disorders of hemoglobin synthesis that result from an
alteration in the rate of globins chain production. A decrease in the rate of production of a certain
globins chain or chains (α , β , γ , δ ) impedes hemoglobin synthesis and creates an imbalance with
the other, normally produced globins chains. Because two types of chains (a and non-α ) pair with
each other at a ratio close to 1:1 to form normal hemoglobin’s, an excess of the normally produced
type is present and accumulates in the cell as an unstable product, leading to the destruction of the cell.
This imbalance is the hallmark of all forms of thalassemia.
The type of thalassemia usually carries the name of the under produced chain or chains. The
reduction varies from a slight decrease to a complete absence of production. For example, when β
chains are produced at a lower rate, the thalassemia is termed β +, whereas β -0 thalassemia indicates
a complete absence of production of B chains from the involved allele. The consequences of impaired
production of globin chains ultimately result in the deposition of less hemoglobin into each red blood
cell, leading to hypochromasia. The hemoglobin deficiency causes red blood cells to be smaller,
leading to the classic hypo chromic and microcytic picture of thalassemia. This is true in almost all
anemia’s caused by impairment in production of either of the two main components of hemoglobin:
heme or globin. However, this does not occur in the silent carrier state, since both hemoglobin level
and red blood cell indices remain normal.
In the most common type of β thalassemia trait, the level of Hb A2 (δ 2/α 2) is usually
elevated. This is due to the increased use of δ chains by the excessive free α chains, which results
from a lack of adequate β chains with which to pair. The δ gene, unlike p and a genes. is known to
have a physiologic limitation in its ability to produce adequate δ chains; by pairing with the α
chains, δ chains produce HbA2 (approximately 2.5-3% of the total Hb), Some, but not all, of the
excessive a chains are used to form HbA2 with the δ chains, whereas the remaining α chains
precipitate in the cells, reacting with cell membranes, intervening with normal cell division, and acting
as foreign bodies, leading to destruction of red blood cells.
Molecular Pathology
5.1. Structure and Synthesis of Hemoglobin
The β -like globin genes, a linked cluster on chromosome 11. are arranged over
approximately 60,000 nucleotide bases (Figure 5). Promoter elements upstream from the initiation
codon of each active gene are involved in the initiation of transcription. The cluster also contains other
regulatory elements that interact to promote erythroid-specific gene expression and to coordinate the
developmental regulation of each gene.
5.2. Hemoglobin Switching
As an adaptation to changing oxygen requirements, different hemoglobins, all composed of
two different pairs of globin chains each attached to a heme moiety, are synthesized in the embryo,
fetus, and adult. Severe β -thalassemia usually becomes manifest as a result of the decline in the
synthesis of fetal hemoglobin during the first year of life (Figure 5). The precise mechanisms that
control the switch from the production of fetal hemoglobin to that of adult hemoglobin are not folly
understood.
5.3. Mutations Causing β -Thalassemia
Nearly 200 different mutations have been described in patients with β -thalassemia and
related disorders. Although most are small nucleotide, substitutions within the cluster, deletions may
also cause β -thalassemia. All the mutations result in either the absence of the synthesis of β -globin
chains (β 0-thalassemia) or a reduction in synthesis (β +thalassemia). Mutations in or close to the
conserved promotersequences and in the 5 untranslated region down-regulate transcription, usually
resulting in mild β +-thalassemia. Transcription is also affected by deletions in the 5 region, which
completely inactivate transcription and result in β 0-thalassemia. Both splicing of the messenger RNA
(mRNA) precursor and ineffective cleavage of the mRNA transcript result in β -thalassemia.
In some mutations, no normal message is produced, whereas other mutations only slightly
reduce the amount of normally spliced mRNA, Mutations within invariant dinucleotides at intron-exon
junctions, critical to the removal of intervening sequences and the splicing of exons to produce
functional mRNA, result in β 0-thalassemia. Mutations in highly conserved nucieotides flanking these
sequences, or in "cryptic" splice sites, which resemble a donor or acceptor splice site, result in severe
as well as mild β +-thalassemia. Substitutions or small deletions affecting the conserved AATAAA
sequence in the 3' untranslated region result in ineffective cleavage of the mRNA transcript and cause
mild β +-thalassemia.
Mutations that interfere with translation involve the initiation, elongation, or termination of
globin-chain production and result in β 0-thalassemia. Approximately half of all β -thalassemia
mutations interfere with translation; these include frame-shift or nonsense mutations, which introduce
premature termination codons and result in (30-thalassemia. A more recently identified family of
mutations, usually involving exon 3 (Figure 6), results in the production of unstable globin chains of
varying lengths that, together with a relative excess of β -globin chains, precipitate in red-cell
precursors and lead to ineffective rythropoiesis, even in the heterozygous state. This is the molecular
basis for dominantly inherited β +-thalassemia. In addition, missense mutations, resulting in the
synthesis of unstable β -globin chains, cause β -thalassemia.
6.0. Inheritance of Thalassemia
Thalassemia is an inherited condition. The genes received from one's parents before birth
determine whether a person will have thalassemia. Thalassemia cannot be caught or passed on to
another person. The clinical severity of thalassemia varies tremendously depending on the exact nature
of the genes that a person inherits.
6.1. Gene inheritance
At the time of conception, a person receives one set of genes from the mother (egg) and a
corresponding set of genes from the father (sperm). The combined effects of many genes determine
some traits (hair color, and height for instance). Traits determined by a combination of genes often
have gradations in magnitude. Other characteristics are determined by a single gene pair (a person's
sex, for instance). The inheritance pattern is complicated in patients with thalassemia because two sets
of genes on different chromosomes cooperate to produce hemoglobin. A defect anywhere in this
complex can produce thalassemia. The expression of thalassemia, therefore, more closely resembles
that of height, with gradations in effect.
6.2. Inheritance of Hemoglobin
The genes involved in thalassemia control the production of hemoglobin. A pair of genes
located on chromosome 16 controls the production of the alpha subunits of hemoglobin. A single gene
located on chromosome 11 controls the production of the hemoglobin beta subunit. All cells contain
pairs of idential chromosomes, one from the father and one from the mother. Each chromosome
contains thousands of genes lined up in sequence. The two chromosomes 11 have one beta globin gene
each (for a total of two genes). The two chromosomes 16 have two alpha globin genes each (for a total
of four genes). Each alpha globin gene produces only about half the quantity of protein of a single beta
globin gene. This keeps the production of protein subunits equal. Thalassemia occurs when a globin
gene fails, and production of globin protein subunits is thrown out of balance.
As illustrated, the couple has one chance in four that a child will inherit two thalassemia
genes. (Figure 8).
7.0. Clinical manifestations
Clinical presentation of thalassemia major occurs between ages six and 24 months.
Affected infants fail to thrive and become progressively pale. Feeding problems, diarrhea, irritability,
recurrent bouts of fever, and progressive enlargement of the abdomen caused by splenomegaly may
occur. If the diagnosis of thalassemia major is established at this stage and if a regular transfusion
program that maintains a minimum Hb concentration of 95 to 105 g/L is initiated, growth and
development are normal until age 10 to 11 years.
The phenotypes of the homozygous β -thalassemias include thalassemia major and
thalassemia intermedia. The clinical severity of the p-thalassemia syndromes depends on the extent of
alpha globin cham/non-alpha globin chain imbalance. The non-assembled alpha globin chains that
result from unbalanced alpha globin chain or non-alpha globin chain synthesis precipitate in the form
of inclusions. These alpha globin chain inclusions damage the ervtbroid precursors in the bone marrow
and in the spleen, causing ineffective erythropoiesis. Individuals with thalassemia major usually come
to medical attention within the first two years of life; they subsequently require regular red blood cell
transfusions to survive. Those who present later and rarely require transfusion are said to have
thalassemia intermedia.
The classic clinical picture of thalassemia major is presently only seen in some developing
countries, in which the resources for carrying out long-term transfusion programs are not available.
The most relevant features of untreated or poorly transfused individuals are growth retardation, pallor,
jaundice, brown pigmentation of the skin, poor musculature, genu valgum, hepatosplenomegaly. leg
ulcers, development of masses from extramedullary hematopoiesis, and skeletal changes that result
from expansion of the bone marrow These skeletal changes include deformities of the long bones of
the legs and typical craniofacial changes (bossing of the skull, prominent malar eminence, depression
of the bridge of the nose, tendency to a mongoloid slant of the eye, and hypertrophy of the maxillae,
which tends to expose the upper teeth), and osteoporosis.
In Classic Cooley’s anemia, the ineffective erythropoiesis dominates the clinical picture by
producing tremendous expansion of the marrow space, manifested by the so-called "tower skull” with
an x-ray showing innumerable vertical bony striae between the inner and outer tables of the calvarium
This radiographic feature is fancifully called the "hair-on-end appearance" b radiologists, individuals
who have not been regularly transfused usually die before the third decade. Extramedollary
hematopoiesis and hemolysis causes splenomegaly, which produces hypersplenism, and more
hemolysis.
8.0 Diagnosis
8.1. Clinical Diagnosis
Thalassemia major is usually suspected in an infant younger than two years of age with
severe microcytic anemia, mild jaundice and hepatosplenomegaly. Thalassemia intermedia presents at
a later age with similar but milder clinical findings. Carriers are usually asymptomatic, but sometimes
may have mild anemia.
8.2. Hematologic Diagnosis
Red blood cell indices show microcytic anemia. Thalassemia major is characterized by
reduced Hb level (<7 g/dl), mean corpuscolar volume (MCV) > 50 < 70 fl and mean corpuscolar Hb
(MCH) > 12< 20 pg. Thalassemia intermedia is characterized by Hb level between 7 and 10 g/dl,
MCV between SO and 80 fl and MCH between 16 and 24 pg. thalassemia minor is characterized by Tabel 2. Hemoglobin Patterns in Beta-Thalassemia (Age >12 Months)
2
reduced MCV and MCH, with increased Hb A level. Affected Carrier
Hemoglobin
Table 1. Red Blood Cell Indices in Beta-Thaiassemia Type Normal
Normal Affected Carrier β 0-Thal Homozygotes or β +/β ° β -Thal
Red Blood Cell Index 5 Homozygotes Compound Heterozygotes Minor
Male Female Thal Maj Thal Minor HbA 96% 0 10%-30%
MCV (fl) 89.1±5.01 87.6±5.5 50-70 <79 92%-95%
MCH (pg) 30.9=1.9 30.2±2.1 12-20 <27 98%
Males: 11.5- HbF <1% 95%-98% 70%-90%
Hb (g/dL) 15.9±1.0 14.0±0.9 <7 15.3 0,5%-4%
Females: 9.1-14 HbA2 2%-3% 2%-5% 2%-5%
>3.5%

8.2.1 Peripheral blood smear 8 23. Molecular Generic Analysis

Affected individuals show RBC morphologic changes [microcytosis, hypochromia, The prevalence of a limited number of mutations in each population has greatly facilitated
anisocytosis, poikilocytosis (spiculated tear-drop and elongated cells)], and nucleated RBC (i.e., molecular genetic testing. Commonly occurring mutations of the beta globin gene are detected by
erythroblasts). The number of erythroblasts is related to the degree of anemia and is markedly FCR-based procedures. The most commonly used methods are reverse dot blot analysis or primer-
increased after splenectomy. Carriers have less severe red blood cell morphologic changes than specific amplification, with a set of probes or primers complementary to the most common mutations
affected individuals. Erythroblasts are normally not seen. in the population from which the affected individual originated. If targeted mutation analysis fails to
detect the mutation, beta globin gene sequence analysis can be used to detect mutations in the beta
8.2.2. Qualitative and quantitative hemoglobin analysis (by cellulose acetate electrophoresis and DE- globin gene.
52 microchromatography or HPLC) identifies the amount and type of Hb present. The Hb pattern in
beta-thalassemia varies according to beta-thalassemia type. In beta0 thalassemia, homozygotes HbA is Table 3 : Summary of Molecular Genetic Testing Used in Beta-Thalassemia
absent and HbF constitutes the 92-95% of the total Hb, In beta+ thalassemia homozygotes and Mutation detection
+ 0
Geme Test Mutations
beta /beta genetic compounds HbA levels are between 10 and 30% and HbF between 70-90%. HbA2 frequency by test Test availability
symbol metod Detected
is variable in beta thalassemia homozygotes and it is enhanced in beta thalassemia minor. Hb metod
electrophoresis and HPLC also detect other hemoglobinopathies that may interact with beta- Targeted mutation Mutation panels Variable depending

thalassemia. analysis vary by on mutations

laboratory included in panel
 and individual’s
ethnicity
HBB Clinical testing
Sequence analysis Sequence 99%
variants
Deletion/duplication Delition of HBB Variable depening
analisys gene of beta- on individual’s
globin gene ethnicity
cluster
8.2.4. Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require
prior identification of the disease-causing mutations in the family.
9.0. Differential Diagnoses
Few conditions share similarities with homozygous beta-thalassemia:
• The genetically-determined sideroblastic anemias are easily differentiated because of ring
sideroblasts in the bone marrow and variably elevated serum concentration of erythrocyte
protoporphyrin. Most sideroblastic anemias are associated with defects in the heme biosynthetic
pathway, especially delta-aminolevulinic acid synthase.
• Congenital dyserythropoietic anemias do not have high HbF and do have other distinctive
features, such as multinuclearity of the red blood cell precursors.
• A few acquired conditions associated with high HbF (juvenile chronic myelomonocytic
leukemia with normal kariotype, aplastic anemia both congenital and acquired during the
recovery phase) may be mistaken for beta-thalassemia, even though- they have very
characteristic clinical and hematoiogical features.
• Typical beta-thalassernia carriers are identified by analysis of RBC indices, which shows
microcytosis (low MCV) and reduced content of hemoglobin per red cell (low MCH), and by
qualitative and quantitative hemoglobin analysis, which displays the increase of HbA2.
Pitfalls in carrier identification by hematologic testing are:
• Coinheritance of alpha-thalassemia, which may normalize the RBC indices. However, in
alpha/beta double heterozygotes, the HbA; concentration remairs in the beta-thalassemia carrier
range and thus is diagnostic. Therefore, HbAz determination should always be performed for
betathalassemia carrier identification.
• Coinheritance of delta-thalajsemia, which may reduce to normal the increased Hb A2
levels typical of the beta-thalassemia earner state. Double heterozygosity for delta- and
betathalassemia can be distinguished from the most common alpha-thalassemia carrier state by
globin chain synthesis or globin gene analysis.
• Silent mutations, i.e., very wild mutations associated with consistent residual output of
hemoglobin beta chains and with normal red blood cell indices and normal or borderline HbA2.
The above reported groups of carriers are referred to as atypical carriers.
10.0 Management
10.1. Transfusions
The goals of transfusion therapy are correction of anemia, suppression of erythropoiesis and
inhibition of gastrointestinal iron absorption, which occurs in non transfteed patients as a consequence
of increased, although ineffective, erythropoiesis. The decision to start transfusion in patients with
confirmed diagnosis of thalassemia should be based on the presence of severe anemia (Hb < 7 g/dl for
more than two weeks, excluding other contributory causes such as infections). However, also in
patients with Hb > 7 g/dl, otter fectors should be considered, including facial changes, poor growth,
evidence of bony expansion and increasing splenomegaly.
When possible, the decision to start regular transfusions should not be delayed until afler
the second- third year, due to the risk of developing multiple red cell antibodies and subsequent
difficulty in finding suitable blood donors. Several different transrusional regimens have been
proposed over the years, but the most widely accepted aims at a pre-transfusional Hb level of 9 to 10
g/dl and a post-transfusion level of 13 to 14 g/dl. This prevents growth impirment organ damage and
bone deformities, allowing normal activity and quality of life.
The frequency of transfusion is usually every two to four weeks. Shorter intervals might
further reduce the overall blood requirement, but are incompatible with an acceptable qoBhly of life.
The amount of blood to be transfused depends on several factors including weight the patient target
increase in Hb level and hematocrit of blood unit. In general, the janorof transfused RBC should not
exceed 15 to 20 ml/kg/day, infused at a maximum rate of 5 ml/kg/hour, to avoid a fast increase in
blood volume. To monitor the effectiveness of I therapy, some indices should be recorded at each
transfusion, such as pre- and post-transfusion Hb, amount and hematocrit of the blood unit, daily Hb
fall and transfusional. These measurements enable two important parameters to be calculated: red cell
land iron intake.
10.2. Iron Chelation
After ten to 12 transfusions, chelation therapy is initiated with desferrioxamine B (DFO)
administered five to seven days a week by 12-hour continuous subcutaneous infusion via portable
pump. Recommended dosage depends on the individual's age and the serum ferritin concentration
Young children start with 20-30 mg/kg/day, increasing up to 40 ngtg/day after age five to six years.
The maximum dose is 50 mg/kg/day after growth is ooKpfeted. The dose may be reduced if serum
ferritin concentration is low. By maintaining Ac total body iron stores below critical values (i.e.,
hepatic iron concentration <7.0 mg per gram of dry weight liver tissue), desferrioxamine B therapy
prevents the secondary effects of nor overload, lesulting in a consistent decrease in morbidity and
mortality.
Ascorbate repletion (daily dose not to exceed 100-150 mg) increases the amount of moo
removed after DFO administration. Side effects of DFO chelation therapy are more common in the
presence of relatively low iron burden and include ocular and auditory touchy, growth retardation, and,
rarely, renal impairment and interstitial pneumonitis. DFO admiriscation also increases susceptibility
to Yersinia infections. The major drawback of DFO chelation therapy is low compliance resulting from
complications of administration.
In clinical practice, the effectiveness of DFO chelation therapy is monitored by routine
determination of serum ferritin concentration. However, serum ferritin concentration is not always
reliable for evaluating iron burden because it is influenced by other factors, the most important being
the extent of liver damage.
10.3. Splenectomy
If the annual red cell requirement exceeds 180-200 ml/Kg of RBC (assuming that the Hct of
the unit of red cells is about 75%), splenectomy should be considered, provided that other reasons for
increased consumption, such as hemolytic reactions, have been excluded. Other indications for
splenectomy are symptoms of splenic enlargement, leukopenia and/or thrombocytopenia and
increasing iron overload despite good chelation.
10.4. Bone marrow and cord blood transplantation
Bone marrow transplantation (BMT) remains the only definitive cure currently available for
patients with thalassemia. The outcome of BMT is related to the pretransplantation clinical conditions,
specifically the presence of hepatomegaly, extent of liver fibrosis, history of regular chelation and
hence severity of iron accumulation. In patients without the above risk factors, stem cell
transplantation from an HLA identical sibling has a disease-free survival rate over 90%. The major
limitation of allogenic BMT is the lack of an HLA-identical sibling donor for the majority of affected
patients. In fact, approximately 25-30% of thalassemic patients could have a matched sibling donor.
Cord blood transplantation from a related donor offers a good probability of a successful
cure. For couples who have already had a child with thalassemia and who undertake prenatal diagnosis
in a subsequent pregnancy, prenatal identification of HLA compatibility between the affected child and
an unaffected fetus allows collection of placental blood at delivery and the option of cord blood
transplantation to cure the affected child. On the other hand, in cases with an affected fetus and a
previous normal child, the couple may decide to continue the pregnancy and pursue BMT later, using
the normal child as the donor.
11.0 Complications
11.1. Megaloblastic anemia and hyperuricemia
The high turnover state caused by the tremendous erythroproliferative activity causes
wastage of folate and may produce a complicating megaloblastic anemia. Another effect of the high
turnover state is hyperuricemia (due to catabolism of the purine content of cellular DNA).
11.2. Systemic diseases
First iron (as hemosiderin) fills the cytoplasm of the RES phagocytes and then starts to be
deposited in the parenchymal cells of just about every organ of the body. The pancreas, liver,
myocardium, adrenals, and gonads are among the organs most sensitive to iron toxicity. The clincial
result is diabetes mellitus, hepatic cirrhosis, congestive heart failure, adrenal insufficiency, and failure
to undergo puberty.
11.3. Iron overload
 After age ten to 11 years, affected individuals are at risk of developing severe complication
related to iron overload, depending on their compliance with chelatton therapy. Iron overload causes
most of the mortality and morbidity associated with thalassemia. Iron deposition occurs in visceral
organs (mainly in the heart, liver, and endocline glands). Causing tissue damage and ultimately organ
dysfunction and failure. Cardiac events due to iron overload are still the-primary cause of death, Both
transfusional iron overload and excess gastronintestnial absorption are contributory. Paradoxically,
excess gastrointestinal iron absorption persists despite massive increases in total body iron load.
11.4. Growth retardation
Complications of iron overload in children include growth retardation and failure of sexual
maturation and in adults include involvement of the heart (dilated cardiomyopathy), liver (fibrosis and
cirrhosis), and endocrine glands (resulting in diabetes mellitus and insufficiency of the parathyroid,
thyroid, pituitary, and, less commonly, adrenal glands). In who have been regularlv transfused, iron
overload results mainly from transfusion.
Other complications are hypersplenism, chronic hepatitis (resulting from infection with the
viruses that cause hepatitis B and/or hepatitis C), cirrhosis (from iron overload and chronic hepatitis)
HIV infection, venous thrombosis, and osteoporosis. The risk for hepatocellular carcinoma is increased
secondary to liver viral infection, iron overload, and longer survival.
12.0. Prognosis
The survival of individuals who have been well transfused and treated with appropriate
extends beyond age 30 years. Myocardial disease caused by transfusional siderosis is the most
important life-limiting complication of iron overload in β -thalassemia. In fact, cardiac complications
are reported to cause 71% of the deaths in individual with β -thalassemia major.
Classically in thalassemia major, the treatment is the cause of death. The children are
maintained by transfusions until about age ten years, at which time they start to show of excess iron
loading. This happens because the transfusion bypasses the body's normal gastrointestinal mechanism
of iron intake and excretion. The iron is poured into the directly; the body cannot excrete it fast
enough. Death used to occur in the or third decade of life, the most common immediate cause being
complications of Nowadays, thalassemia major patients live longer because of advances in chelation
therapy.
Chapter II
A. Objective
The aim of this paper work is to report a case of a 5 year 2 month old male child diagnosed
with β -Thalassemia major.
B. Case
AH, a 5 year 2 month old male child with body weight of 14 kg and body length of 99 cm,
came to the Pediatric Departement of Adam Malik General Hospital on October 26th 2010 at 13.30
hours with the chief complains of pallor. It has occured since the child was around 1 year old, and got
worst in the last 1 week. History of spontaneous bleeding was not found. Appetite is good. Nausea and
vomiting were not found. Fever was not found. Non productive cough for the past one week. Urination
is normal. Defecation is normal. Patient is the 3rd child of 3 siblings with the other siblings in good
health condition. No family members reported of having any blood disorders.
He is a routine patient of the hemato-oncology department of Pirngadi General Hospital
with the diagnosis of β -thalassemia major (diagnosed when patient was around 13 months), and has
been getting blood transfusions around half a year once. He got his last blood transfusion about 1 year
ago and since then discontinued his treatment in Pirngadi General Hospital and went on consuming
traditional medicines for the past one year which did not give any major benefit to the condition. Now
he has been brought to continue his medication at Haji Adam Malik General Hospital. He last checked
his ferritin serum level about 1 year ago, but the result is unknown by the family members.
History of disease : β -Thalassemia major
History of medication : Packed Red Cell (PRC) transfusion about 1 year ago, Desferal
Prenatal history : Diabetes (-) hypertension (-),
obscured history of taking drugs and herbal medicines
Birth history : Normal delivery by midwife, spontaneous cry, birth weight: 3200 gram
History of Immunization : Complete
Child growth : BW/BL(B5/TS): 93% (normoweight) - Spleen : Palpable at Schuffner IV – V.
BW/Age{B,B/Lr): 73,68%; BL/Age(7Vf): 89,2% Extremities : Warm, pulse : 102 bpm, regular, adequate
pressure/volume, CRT <3”.
Child development: 3 month old : Patient could roll to side, Pale palms and soles (+) Skin : Darker than usual tone.
9 - 10 month old : Crawl,
14 month old ; Walk and talk Laboratory result : 26th October 2010
Now(62 months): Able to dress on his own, do colouring and simple
Complete blood count Results Normal value
maths.
Feeding history : 0 - 2 months : Exclusively breast milk Hemoglobin (Hgb) 6,1g % 11,3-14,1g%
2-6 months : Breast milk + porridge
Erythrocyte (RBC) 3,65x 106/mm3 4,40-4,48 x 106/mm3
6 months onwards : Soft rice, Now : Rice
Leukocyte (WBC) 10,59 x 103/mm3 4,5-13,5 x 103/mm3

Physical Examination Hematocrite 19,90% 37-41%

Presence sta us: Sensorium: Compos mentis,
Trombocyte (PLT) 290 x 103/mm3 150-450 x 103/mm3
Body temperature : 36,8"C
Anemic (+), dyspnea (-), icteric (+), cyanosis (-), oedema (-) - Blood MCV 54,5fl 81-95fl
pressure : 90/60 mmHg
MCH 16,7 pg 25-29pg
Locallized status : Eye: light reflexes (+/+), isochoric pupil righ,t=left),
pale inferior conjungtiva palpebra (+/+). MCHC 30,7g% 29-31g%
Eair/Nose: Within normal limit
RDW 35,2% 11,6-14,8%
Mouth : Pale lips.
face : Faceis cooley : (+)
neck : Lymph node enlargeme.it (-) Complete blood count Results Normal value
- Neck Stiffness (-)
SGOT/SGPT 29/18/U/L <38/41U/L
Chest : - Symmetrical fusiform - Retraction (-)

- Heat rate : 108 bpm, reguler, gallop rhythm (-) KGD 118,1 mg/dl <200 mg/dl

Ureum/creatinin 18,4/0,5 mg/dl <50/0,320,59 mg/dl

- Respiratory rate: 28 bpm, reguler, rales (-)

Abdomen : soepel, peristaltic (+) N,

- Liver : Palpable (2 cm below costal margin), smooth Serum electrolytes Results Normal value
surface, consistency slightly tender, blunt edge
 Head: Eye: light reflexes (+/+), isochoric pupil, pale inferior conjungtiva palpebraf (+/+).
Natrium 136 mEq/L 135-155 mEq/L
Ear/Nose: within normal limit
Kalium 4,0 mEq/L 3,6 – 4,5 mEq/L Mouth: Pale lips Face : Facies cooley : (+) Neck: -Lymph node enlargement (-) Chest: -Symmetrical

Chloride 105 mEq/L 96 – 106 mEq/L fusiform - Retraction (-)

- HR: 88 bpm, regular, gallop rhythm (-) - RR: 24 bpm, reguter, rales (-/-)
Abdomen: Soepel, peristaltik (+) N, -Liver: palpable (2 cm below costal margin), smooth surface,
Hemostatic function Results Normal value consistency slightly tender, blunt
-Spleen: SIV-V
Ferritin 481 ng/mL 15 – 240 ng/mL
Extremities : Warm, Pulse;88bpm, reguler, adequate pressure/volume, CRT <3".
Pale palms and soles (+) Skin : Darker than usual tone
Working diagnosis : β -Thalassemia major
Therapy: -PRC transfusion as needed
A: β -Thatassemia major.
- Vit E 1 x 100 IU
Therapy: - PRC transfusion ½ bag in 12 hours
- Folic acid 1 x 1 tab
- Vit E 1 x 100 IU
- Diet MB 1100 kkal with 30 gr protein
- Folic acid 1 x 1 tab
- Desferal 30-50mg/kgBW/day (750mg in 250cc NaCl 0,9% in 4hrs)
- Diet MB 1100 kkal with 30 gr protein
Transfusion need : (11 -6,1) x 14(BW) x 4 = 2 74,4 cc - 1,5 bag
- Ambroxol 3 x ½ CI
Transfusion capability : Sec/kg BW = 70 cc - 0,5 bag
- Desferal 20-50mg/kgBW/hour (500mg in 250cc NaCl 0,9% to be finished in 4
Blood Group : A+
hours)
PRC transfusion procedure (0.5 bag):
Work up : Echocardiography
1. Wash with 20 cc Nacl 0,9% 50cc
- 2nd PRC Transfusion (half bag PRC) on 27th October 2010 at 13.30 hours.
2. Furosemide Injection 14 mg IV
- Patient consulted to the Hemato-oncology division.
3. Dexametasone Injection 6 mg IV
4. Transfusion of PRC ½ bag
Follow Up October 28th 2010
5. Wash with 20 cc Nacl 0,9% 50cc.
S: Pallor (+), Cough (-)
- 1st PRC Transfusion (half bag PRC) on 26th October 2010 at 22.35 hours. 0: Sensorium: compos mentis, body temperature:370 C; BW: 14 kg; BL:99 cm;
BW/BL: 93% (normsweight), BSA: 0,65 m2

Follow Up October 27th 2010 Head: Eye: light reflexes (+/+), isochoric pupil, pale inferior Conjungtiva palpebra (+/+)

S: Pallor (+), Cough (V) Ear/Nose: within normal limit

O: Sensorium: compos mentis, body temperature:36,8"C; BW:14 kg; BL:99 cm; Mouth: Pale lips Face : Facies cooley : (+)

BW/BL: 93% (normoweight), BSA: 0,65 m2, BP : 90/60mmHg Neck: - Lymph node enlargement (-)
Chest: - Symmetrical fusiform pallor of face came to concern of patient's parents when patient was around 1 year old and patient was
- Retraction (-) diagnosed with thalasemia β -major at the age of 18 months.
- HR: 96 bpm, .reguler, gallop rhythm (-) Severe lethargy was not reported but patient gets tired easily after a light exercise or a short
- RR: 24 bpm, reguler, rales (-/-) period of playing compared to friends of his age. From the physical examination, pale inferior
Abdomen: Soepel, peristaltik (+) N, - Liver: palpable (2 cm inferior of arcus costae), smooth surface, conjungtiva palpebra and pale mucous membrane of lips, pale palms and soles; signs of anemic
rough consistency, dull edge condition were found positive on toe patient. The severe ineffective erythropoiesis results in erythroid
- Spleen: S IV-V marrow expansion to as much as 30 times the normal level. Both an increase in plasma volume as a
Extremities: Warm, pulse: 96 bpm, reguler, adequate pressure/volume, CRT <3". result of shunting through expanded marrow and progressive splenomegaly exacerbate anemia.
Skin : Darker than usual tone Apart from that, slight icteric discoloration of the sclera was found on the patient's eye.
A: β -Thalassemia major With excessive red cell destruction and consequent bilirubin production occurs as in the patient,
Therapy: - PRC transfusion ½ bag in 12 hours –Vit E 1 x 100 IU unconjugated bilirubin accumulates in the blood. This results in a yellow discoloration of the skin,
- Folic acid 1 x 1 tab called jaundice or icteric sclera.10 Abdomen enlargement with palpable liver and spleen or in other
- Diet MB 1100 kkal with 30 gr protein word; hepatosplenomegaly was found through the physical examination.
- Ambroxol 3 x ½ CI (off) If the disorder is not identified and treated with blood transfusions, thalassemia β -major
children grow poorly and develop massive hepatosplenomegaly, and enlargement of the medullary
- 3rd PRC Transfusion (half bag PRC) on 28th October 2010 at 16.30 hours. space with thinning of the bony cortex. The skeletal changes cause characteristic facial deformities
- Post-transfusion hemoglobin : 10,3% gr (prominent forehead and maxilla) and predispose the child to pathologic fractures. In this patient,
- Patient discharged with the term of consultation at the hemato-oncology policlinic 1 month after. enlargement of liver and spleen is found. Facial fractures potray the 'facies-cooley' image.
Medication to be brought back home : Fe Tab 1 x-100 UI and Folic acid Tab 1x1mg Increased erythropoietin synthesis may stimulate the formation of extramedullary
erythropoietic tissue, primarily in the thorax and paraspinal region. Marrow expansion also results in
Chapter III characteristic deformities of the skull and face, as well as osteopenia and focal defects in bone
A. Discussion mineralization, and may aggravate a painful periarticular syndrome characterized histologically by
This is a case of a 5 year 2 month old male child with body weight of 14 kg and body microfractures and osteomalacia. Marrow hyperplasia leads ultimately to increased iron absorption and
length of 99crn, who was brought to the Pediatric Department of Adam Malik General Hospital on progressive deposition of iron in tissues. In the case, this is cause of the patient to have a darker skin
October 26th 2010 at 1330 hours with the chief complaint of pallor. It has occured since the child was than normal.
about 1 year old, and got worst in the last 1 week. From the laboratory work up, theory says that raised bilirubin (chiefly indirect), evidence of
This is due to the progressive bemolytic anemia suffered by the patient. Those with thalassemia β - liver dysfunction (late, as cirrhosis develops) and evidence of endocrine abnormalities, for example,
major are normal at birth but develop significant anemia during the first year of life. Profound diabetes (typically late), hypogonadism (low estrogen and testosterone) may occur in thalassemic
weakness and cardiac decompensation during the second 6 month of life in thalassemie patients may children. In this case, bilirubin value is not available, SCOT and SGPT values are within normal range.
be found if not treated accordingly. Generally, fatigue, poor appetite, and lethargy are late findings of From the hematological aspect that plays a vital role in diagnosing thalassemia patients,
4
severe anemia in an infant or child. In this patient, pallor was not obvious during birth. Significant theory says that changes seen include hypochromic, microcytic anemia, reticulocytoais, leukopenia and
thrombecytopenia (may develop with hypersplenism), target cells and nucleated red cells in blood
smear, extreme anisocytosis, contracted red cells, 51Cr-labeled red cell life span reduced, hemoglobin
F raised; hemoglobin A2 increased, bone marrow: may be megaloblastic (due to folate depletion);
erythroid hyperplasia, osmotic fragility decreased and serum ferritin raised. In this patient, serum
ferritin level is raised double than the upper normal limit. Decreased values of MCV and MCH gives
the resultant interpretation of hypocromic microcytic anemia.
According to theory, failure to thrive in early childhood is often seen in thalassemic patient
who may also suffer growth retardation, delayed puberty, primary amenorrhea in females, and other
endocrine disturbances secondary to chronic anemia and iron overload. But, upon anamnssis and
examination, the development of patient in the case report has been normal. For the growth, the
patient's height according to agu is 90%. And body weight according to height is 93 %.
Depending on the mutation and degree of fetal hemoglobin production, transfusions in
thalassemia major are necessary in the second month of life or the second year of life but rarely later.
The decision to transfuse depends on the child's ability to compensate for the degree of anemia. Most
infants and children have cardiac decompensation at hemoglobins of 4g% or less. This patient came
with a hemoglobin value of 6,1g%. The need of transfusion was 1 and a half bag of packed red cell.
Many of these features became less severe and infrequent with transfusion therapy, but
transfusional hemosiderosis is a consequent complication. Many of the complications of thalassemia
seen in developed countries today are the result of iron overload. It can be avoided by the consistent
use of an iron chelator though chelation therapy also has associated complications. In this case, the use
of desferal is seen as the chelator agent.
B. Summary
A case of a 5 year 2 month old boy suffering from thalassemia β -major is reported. The
diagnosis was established based on anamnesis, clinical manifestation and laboratory values. The
definite diagnosis would have most probably done through hemoglobin analysis using the
electrophoresis method. Advances in red cell transfusion, and the introduction of new iron chelators
and chelation regimes have further prolonged survival in recent years. This is how the patient in this
case is managed. However, bone marrow transplantation is at present the only available definitive cure
for patients with thalassemia major.
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