Points to be discussed: Definitions Patho-physiology Signs & Symptoms Diagnosis Options of management. Complications Preventive measures Long term follow up of patients
DEFINITIONS THALASSEMIA MAJOR THALASSEMIA INTERMEDIA THALASSEMIA MINOR, TRAIT, HETEROGENOUS
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An example of inheritance: Marriage between two carriers
Developmental expression of the globin chains Embryonic hemoglobins Fetal hemoglobins HbF Adult hemoglobins HbA2 HbA
Three Normal Hemoglobins Hb A 2 2 96% Hb A2 2 2 3% Hb F 2 2 1%
THALASSAEMIA An abnormality associated with one gene is called -thal minor ( Tm). An abnormality associated with two genes is called -thal major ( TM). chain production may be decreased or absent resulting in excess free chains. If production is decreased we refer to the phenotype as +, if absent o.
HAEMATOLOGICAL PROFILE B T Minor HbN-Dec RCCInc (Marrow compensating for ineffective haematopoiesis MCV Dec MCH Dec Hypochromasia+ Anisocytosis++ (Microcytes) PoikilocytosisTarget Cells+ Immature FormsPolychromasia Coarse basophilic stippling
Mentzer: MCV = if <13 thal minor RBC >13 then iron deficiency Shine - Lal: (MCV) 2 X MCH = if 1530 then iron deficiency England- Frazer : MCV- (Hgb X 5)- RBC- 3.4 = if negative : thal minor positive : iron def
Hb. ELECTROPHORESIS HbA:Present HbF:N-Slightly Inc (Only compensating for 1 chain) HbA2:Inc (4-5%, reason unknown but this feature is used diagnostically differentiating from TM or TM)
TM 0 b 0 – most severe – no chain production. 0 b + - moderately severe – some chain production. + + - Increased HbF with normal or elevated HbA 2 – there is remained HbA. Clinical severity varies accordingly.
CLINICAL ASPECTS Hepatomegaly and splenomegaly. Chronic haemolysis that may be accompanied by gallstones, gout and icterus (jaundice). Not usually detected until 6 months of age. Excess iron from blood transfusions may lead to cardiac and hepatic problems. As with other haemolytic anaemias, more iron is absorbed from the gut exacerbating iron overload. Largely overcome by the use of Desferroxamine.
HAEMATOLOGICAL PROFILE HbDec Anisocytosis+++ (Macrocytes, Microcytes) PoikilocytosisTarget cells +++ Tear drops Schistocytosis Acanthocytes, Howell Jolly Bodies, Target Cells (post splenectomy) Immature FormsPolychromasia ++ Nucleated RBC +++ (bone marrow response)
Blood Film - BTM
X-RAYS IN THAL. PTs
Transfusional Iron TRANSFUSIONAL IRON OVERLOAD IN THALASSEMIA Thalassemia Centre, Dept. of Pediatrics University of Turin, Italy Hepatic Fibrosis --> Cirrhosis Cardiac arrhythmia Hypogonadism Diabetes Hypothyroidism Hypoparathyroidism Death Cardiac Failure
Blood Transfusion mg iron/kg/day Blood Transfusion mg iron/kg/day IRON ACCUMULATION IN TRANSFUSION-DEPENDENT ANEMIAS In a 50 kg person mg/day In a 50 kg person mg/day Iron Excretion (Urine & Feces) 1-2mg/day Iron Accumulation mg/day Iron Accumulation mg/day
Management Medical /Nursing management Social and Behavioral management Management of complications Compliance
Medical Management Blood Transfusion-----Dr. Khawla Chelation Therapy---- Dr Ahmad Bone Marrow Transplant Gene Therapy
TRANSFUSION CARE OF THE CHILD WITH THALASSEMIA MAJOR Transfusion ≥ Hb 9.0 g/dl Extended red cell genotype Match donor blood to ABO, rhesus and Kell filter or wash blood – (white cell depletion) Vaccinate with hepatitis B Pre-tX Transfusion ≥ Hb 9.0 g/dl Extended red cell genotype Match donor blood to ABO, rhesus and Kell filter or wash blood – (white cell depletion) Vaccinate with hepatitis B Pre-tX Red Blood Cell Transfusion:
Bone Marrow Transplant HLA matched Donor Preparation of the patient Consider selection criteria Stem cells could be collected by: Bone Marrow Aspiration Peripheral apheresis Cord Blood
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COMPLICATIONS Cardiac Endocrine Hepatic Renal Skeletal Virus transmission Blood reactions.
Transfusional Iron TRANSFUSIONAL IRON OVERLOAD IN THALASSEMIA Thalassemia Centre, Dept. of Pediatrics University of Turin, Italy Hepatic Fibrosis --> Cirrhosis Cardiac arrhythmia Hypogonadism Diabetes Hypothyroidism Hypoparathyroidism Death Cardiac Failure
CROSS-SECTIONAL STUDY OF 342 PATIENTS IN THE NIH-SPONSORED THALASSEMIA CLINICAL RESEARCH NETWORK REGISTRY* Reference: Adapted from Cunningham, et al. Blood. Online Feb. 26, 2004 DOI % (30/128) 23% (30/128) 5% Cardiac Disease (req. meds) 9% 1% Hypoparathyroidism 17% 8% Thyroid Disease 21% 9% Diabetes Mellitus 62% 41% Hypogonadism (req. meds) 25+ yrs (n=129) 25+ yrs (n=129) yr (n=93) yr (n=93) Age Group
B-THAL. INTERMEDIA
Adapted from B. Modell and V. Berdoukas, 1984 THALASSEMIA MAJOR – SURVIVAL
Prevention Premarietal Screening Prenatal diagnosis Pre Implantation Genetic Diagnosis