Alpha-thalassemia

Alpha-thalassemia
Alpha-thalassemia inheritance pattern
Specialty Hematology Edit this on Wikidata
Symptoms Jaundice, Fatigue[1][2]
Causes Deletions of chromosome 16p.[3]
Diagnostic method Haemoglobin electrophoresis[4]
Treatment Blood transfusion, possible splenectomy[1][5]

Alpha-thalassemia (α-thalassemia, α-thalassaemia) is a form of thalassemia involving the genes HBA1[6] and HBA2.[7] Alpha-thalassemia is due to impaired production of alpha chains from 1, 2, 3, or all 4 of the alpha globin genes, leading to a relative excess of beta globin chains. The degree of impairment is based on which clinical phenotype is present (how many genes are affected).[4][2]

Signs/symptoms

The presentation of individuals with alpha-thalassemia consists of:[2][1]

Cause

Alpha-thalassemias are most commonly inherited in a Mendelian recessive manner. They are also associated with deletions of chromosome 16p.[3] Alpha thalassemia can also be acquired under rare circumstances.[8]

Pathophysiology

The mechanism sees that α thalassemias results in decreased alpha-globin production, therefore fewer alpha-globin chains are produced, resulting in an excess of β chains in adults and excess γ chains in newborns. The excess β chains form unstable tetramers called hemoglobin H or HbH of four beta chains. The excess γ chains form tetramers which are poor carriers of O2 since their affinity for O2 is too high, so it is not dissociated in the periphery. Homozygote α0 thalassaemias, where numerous γ4 but no α-globins occur at all (referred to as Hb Barts), often result in death soon after birth.[4][1][9]

Diagnosis

Diagnosis of alpha-thalassemia is primarily by laboratory evaluation and molecular diagnosis. Alpha-thalassemia can be mistaken for iron-deficiency anaemia on a full blood count or blood film, as both conditions have a microcytic anaemia. Serum iron and serum ferritin can be used to exclude iron-deficiency anaemia.[4]

Types

Two genetic loci exist for α globin, thus four alleles are in diploid cells. Two alleles are maternal and two alleles are paternal in origin. The severity of the α-thalassemias is correlated with the number of affected α-globin; alleles: the greater, the more severe will be the manifestations of the disease. When noting the genotype, an "α" indicates a functional alpha chain, and '-' a pathological one.[2][1][9]


Alleles affected Description Genotype
One This is known as alpha thalassemia silent and with this type, the effect on hemoglobin synthesis is minimal. Three α-globin genes are enough to permit normal hemoglobin production, and no clinical symptoms present. It occurs due to a deletion or non-deletion mutation.[1] - α/α α
Two
Haematopoiesis(production of blood cells)

The condition is called alpha thalassemia trait; two α genes permit nearly normal production of red blood cells, but a mild microcytic hypochromic anemia is seen. The disease in this form can be mistaken for iron-deficiency anemia and treated inappropriately with iron.[4][1]

Alpha-thalassemia trait can exist in two forms:[1]

  • Alpha-thal-1 (- -/α α), involves cis deletion of both alpha genes on the same chromosome.
  • Alpha-thal-2 (- α/- α), involves trans deletion of alpha genes; this occurs on different (homologous) chromosomes.
 - -/α α
or
- α/- α
Three This condition is called hemoglobin H disease; two unstable hemoglobins are present in the blood; hemoglobin Barts (tetrameric γ chains) and hemoglobin H (tetrameric β chains). Both of these unstable hemoglobins have a higher affinity for oxygen than normal hemoglobin.[10] A microcytic hypochromic anemia with target cells and Heinz bodies (precipitated HbH) on the peripheral blood smear can occur, as well as hepatosplenomegaly. The disease is noticed in childhood or in early adult life; anemia and hepatosplenomegaly are noted. - -/- α
Four This is known as alpha thalassemia major; these fetuses are edematous, have little circulating hemoglobin, and the hemoglobin that is present is all tetrameric γ chains. When all four alleles are affected, the fetus likely will not survive gestation without in utero intervention; most infants with alpha-thalassemia major are stillborn with hydrops fetalis. Fetuses treated with intrauterine transfusions throughout pregnancy starting at an early gestational age can survive to birth with acceptable morbidity. After birth, the treatment options include bone marrow transplantation or continued chronic transfusions.[11] - -/- -
α α/α α = normal: 'α α' before the '/' represents one chromosome, and 'α α' after the '/', its homologous chromosome.

Treatment

Treatment for alpha-thalassemia may consist of blood transfusions, and possible splenectomy; additionally, gallstones may be a problem that would require surgery. Secondary complications from febrile episode should be monitored, and most individuals live without any need for treatment[1][5]

Additionally, stem cell transplantation should be considered as a treatment (and cure), which is best done in early age. Other options, such as gene therapy, are still being developed.[12]

A study by Kreger et al combining a retrospective review of three cases of alpha thalassemia major and a literature review of 17 cases found that in utero transfusion can lead to favorable outcomes. Successful hematopoietic cell transplantation was eventually carried out in four patients.[13]

Epidemiology

Malaria

In terms of epidemiology, worldwide distribution of inherited alpha-thalassemia corresponds to areas of malaria exposure, suggesting a protective role. Thus, alpha-thalassemia is common in sub-Saharan Africa, the Mediterranean Basin, and generally tropical (and subtropical) regions. The epidemiology of alpha-thalassemia in the US reflects this global distribution pattern. More specifically, HbH disease is seen in Southeast Asia and the Middle East, while Hb Bart hydrops fetalis is acknowledged in Southeast Asia only.[14] The data indicate that 15% of the Greek and Turkish Cypriots are carriers of beta-thalassaemia genes, while 10% of the population carry alpha-thalassaemia genes.[15]

See also

References

  1. 1 2 3 4 5 6 7 8 9 Origa, Raffaella; Moi, Paolo; Galanello, Renzo; Cao, Antonio (1 January 1993). "Alpha-Thalassemia". GeneReviews(®). University of Washington, Seattle. Retrieved 22 September 2016. update 2013
  2. 1 2 3 4 Reference, Genetics Home. "alpha thalassemia". Genetics Home Reference. Retrieved 8 September 2016.
  3. 1 2 BRS Pathology (4th ed.). Lippincott Williams & Wilkins medical. December 2009. p. 162. ISBN 978-1451115871.
  4. 1 2 3 4 5 "Alpha Thalassemia Workup: Approach Considerations, Laboratory Studies, Hemoglobin Electrophoresis". emedicine.medscape.com. Retrieved 2016-05-24.
  5. 1 2 "Complications and Treatment | Thalassemia | Blood Disorders | NCBDDD | CDC". www.cdc.gov. Retrieved 22 September 2016.
  6. ↑ Online Mendelian Inheritance in Man (OMIM) Hemoglobin—Alpha locus 1; HBA1 -141800
  7. ↑ Online Mendelian Inheritance in Man (OMIM) Hemoglobin—Alpha locus 2; HBA2 -141850
  8. ↑ Steensma DP, Gibbons RJ, Higgs DR (January 2005). "Acquired alpha-thalassemia in association with myelodysplastic syndrome and other hematologic malignancies". Blood. 105 (2): 443–52. doi:10.1182/blood-2004-07-2792. PMID 15358626.
  9. 1 2 Galanello, Renzo; Cao, Antonio (5 January 2011). "Alpha-thalassemia". Genetics in Medicine. 13 (2): 83–88. doi:10.1097/GIM.0b013e3181fcb468. ISSN 1098-3600. Retrieved 22 September 2016.
  10. ↑ "Hemoglobin H disease". Orphanet. Retrieved 22 September 2016.
  11. ↑ Vichinsky, Elliott P. (2009-01-01). "Alpha thalassemia major—new mutations, intrauterine management, and outcomes". ASH Education Program Book. 2009 (1): 35–41. doi:10.1182/asheducation-2009.1.35. ISSN 1520-4391. PMID 20008180.
  12. ↑ "Thalassaemia | Doctor | Patient". Patient. Retrieved 22 September 2016.
  13. ↑ Kreger E, Singer S, Witt R, Sweeters N, Lianoglou B (2016). "Favorable outcomes after in utero transfusion in fetuses with alpha thalassemia major: a case series and review of the literature". Prenatal Diagnosis. 36: 1242–1249. doi:10.1002/pd.4966.
  14. ↑ Harteveld, Cornelis L; Higgs, Douglas R (2010). "α-thalassaemia". Orphanet Journal of Rare Diseases. 5 (1): 13. doi:10.1186/1750-1172-5-13. ISSN 1750-1172. PMC 2887799. PMID 20507641.
  15. ↑ Haematology Made Easy. AuthorHouse. 2013-02-06. ISBN 9781477246511.page 246

Further reading

  • Anie, Kofi A; Massaglia, Pia (6 March 2014). "Psychological therapies for thalassaemia". Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd002890.pub2. Retrieved 15 September 2016.
  • Galanello, Renzo; Cao, Antonio (5 January 2011). "Alpha-thalassemia". Genetics in Medicine. 13 (2): 83–88. doi:10.1097/GIM.0b013e3181fcb468. ISSN 1098-3600. Retrieved 15 September 2016.
Classification
External resources
  • "What Are Thalassemias? - NHLBI, NIH". www.nhlbi.nih.gov. Retrieved 15 September 2016.

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