Klara Kleman

Concurrent sickle-cell anemia and α-thalassemia: effect on severity of anemia.

Abstract We studied 47 patients with sickle-cell anemia to determine the effect of α-thalassemia on the severity of their hemolytic anemia. We diagnosed α-thalassemia objectively by using α-globin-gene mapping to detect α-globin-gene deletions, studying 25 subjects with the normal four α-globin genes, 18 with three, and four with two. The mean hemoglobin, hematocrit, and absolute reticulocyte levels (±S.D.) were 7.9±0.9 g per deciliter (4.9±0.6 mmol per liter), 22.9±2.9 per cent, and 501,000±126,000 per cubic millimeter, respectively, in the non-thalassemic group; 9.8±1.6 g per deciliter (6.1±1.0 mmol per liter), 29.0±5.0 per cent, and 361,000±51,000 per cubic millimeter in the group with three α-globin genes; and 9.2±1.0 g per deciliter (5.7±0.6 mmol per liter), 27.5±3.0 per cent, and 100,000±15,000 per cubic millimeter in the group with two α-globin genes. Deletion of α-globin genes was also accompanied by a decreased mean corpuscular hemoglobin concentration (MCHC) in post-reticulocyte erythrocytes and...

GROWTH RETARDATION IN SICKLE-CELL DISEASE TREATED BY NUTRITIONAL SUPPORT

The effect of increased nutritional intake was evaluated in 5 growth-retarded children with sickle-cell disease. Growth on recommended daily calorie and protein intakes had been inadequate in all 5. Fat absorption and intestinal mucosal morphology were normal in all 5. 2 children were given nutritional supplementation by nasogastric intubation, 1 received nightly oral formula supplements, and 2 were supplemented with zinc, iron, folate, and vitamin E only. Nutritional supplementation by the nasogastric route produced a rapid sustained increase in growth rate, associated with striking reductions in pain crises and infections which had previously necessitated many hospital admissions. Oral supplementation improved the clinical course but had no effect on growth rate. Mineral and vitamin supplements influenced neither the growth rate nor the clinical course. The observations indicate that nasogastric nutritional supplementation may accelerate growth and reduce the incidence and severity of complications in growth-retarded children with sickle-cell disease.

PEROXIDATION, VITAMIN E, AND SICKLE‐CELL ANEMIA*

In summary, we propose the following scheme (Figure 5) to describe the role of peroxidation in the pathophysiology of SCA. Sickle erythrocytes are more susceptible to peroxidation than are normal erythrocytes. This increased susceptibility to peroxidation is, in part, due to decreased blood vitamin E levels and abnormal membrane phospholipid organization induced by sickling. The peroxidative damage of sickle erythrocytes may accelerate or contribute to loss of cell deformability and to chronic hemolysis. Peroxidative damage can produce abnormal cellular properties, such as potassium leak and reduced filterability, and contribute to formation of ISCs. Increased red cell rigidity can initiate episodes of capillary obstruction, leading to vasoocclusive painful crises and to tissue infarction. Liver dysfunction as well as increased production of bilirubin secondary to hemolysis could result in bile sludging and decreased secretion of bile salts into the intestinal lumen. Reduced bile salt secretion leads to partial fat and vitamin E malabsorption. Vitamin E deficiency enhances red cell susceptibility to peroxidation and promotes a vicious cycle in SCA. Although we have not studied factors that might initiate peroxidative damage, sickle hemoglobin and excess body iron should be considered as potential sources. Our studies suggest that vitamin E supplementation to sickle-cell patients could be of clinical benefit.

Chlamydia pneumoniae and acute chest syndrome in patients with sickle cell disease

Purpose Few studies address the association of Chlamydia pneumoniae infection with pulmonary disease and outcome in patients with underlying pathology such as sickle cell disease (SCD). SCD patients are susceptible to the pulmonary disorder known as acute chest syndrome (ACS), where the etiology remains ill defined. The purpose of this study was to analyze the clinical course and outcome of C. pneumoniae-associated ACS among SCD patients as part of the National Acute Chest Syndrome Study. Patients and Methods This was a longitudinal study of SCD patients presenting with ACS to multiple U.S. medical centers. Two hundred ninety-six SCD patients who developed ACS were tested by PCR for C. pneumoniae and by standard techniques for other respiratory pathogens. These infections were evaluated for association with ACS, clinical course, and complications. Results Forty-one (14%) patients with first episodes of ACS were PCR positive for C. pneumoniae. Compared with other infections, C. pneumoniae-infected patients were older, were more likely to present with chest pain, and had higher hemoglobin levels at diagnosis. Both groups had similar rates of respiratory failure and prolonged hospitalization. Of the 89 patients with single-pathogen infections, 27 (30%) were due to C. pneumoniae, 21% to Mycoplasma pneumoniae, 10% to RSV, 4% to Staphylococcus aureus, and 3% to Streptococcus pneumoniae. Conclusions C. pneumoniae was the most prevalent pathogen in this study of ACS and was responsible for significant morbidity. Additional research is required to develop effective treatment guidelines for ACS.

The levels of ζ, γ, and δ chains in patients with Hb H disease

SummaryDetails are given of a study of blood samples from 24 patients with Hb H disease from different Mediterranean countries and from the Far East. Four different types of α-thal-1 (--) were observed, namely-(α) (∼ 20.5-kb deletion);--MED-I (∼ 17.5-kb deletion);--MED-II (>26.5-kb deletion); and--SEA (∼ 18-kb deletion, in Orientals only). The α-thal-2 was mainly of the deletion type (16 with the 3.7-kb deletion; 1 with the 4.2-kb deletion), while 4 of the 7 patients with a nondeletional type had the five-nucleotide deletion at the donor splice site of the first intron of the α2 gene. All patients had a mild-to-moderate hemolytic anemia; no significant differences in hematology were observed between the groups. Hb A2 was decreased to about one-third of the normal level. The Hb H formation varied considerably and its quantitation was not always satisfactory. Patients with Hb H disease due to any α-thal-1 combined with a nondeletional α-thal-2 had the highest Hb H levels and a more marked anemia. The ζ chain production was small and absent in patients with the MED-II type of α-thal-1 because this deletion included the ζ and ψζ genes. The highest ζ chain levels were present in the four patients with the SEA type of α-thal-1. The γ chain production was increased, particularly in patients with a mutation of C → T at position-158 to the Gγ globin gene. This γ chain was primarily present as Hb Barts (or γ4) and only about 15% was recovered as Hb F or α2γ2. The evaluation of the rate of γ chains produced in these patients was greatly facilitated by data from one patient who had Hb H disease and a heterozygosity for the Aγ-β+. The low levels of Hb A2 and of Hb F (relative to Hb Barts) can be explained by a decreased affinity of α chains for δ and γ chains as compared with β chains in conditions of severe α chain deficiency.

Inadequate erythroid response to hypoxia in cystic fibrosis.

An increase in hemoglobin concentration characterizes the normal compensatory response to chronic tissue hypoxia. We observed no such increase in 42 chronically hypoxic patients with cystic fibrosis, in whom the mean concentration was 12.6 gm/dl; one third of the patients were anemic. Compared with patients with cyanotic heart disease, patients with cystic fibrosis did not have a compensatory increase in P50 or 2,3-diphosphoglycerate. Despite anemia, erythropoietin levels in patients with cystic fibrosis were not significantly different from normal control values. The growth of colony-forming units-erythroid in patients with cystic fibrosis was similar to that in control subjects, and there was no inhibition of growth with the addition of autologous serum. Erythropoietin sensitivity, determined by measuring the CFUe dose response curve, was normal in both patients and controls. Results of iron studies were consistent with iron deficiency in the majority of patients. Impaired absorption of iron was observed in six of 13 iron-deficient patients with cystic fibrosis. An inverse correlation between erythrocyte sedimentation rate and peak serum iron was obtained during the iron absorption study. Eight patients who underwent a therapeutic trial of iron demonstrated a 1.8 gm/dl rise in hemoglobin concentration. Two patients with previously documented iron malabsorption responded to parenteral iron therapy after failure to respond to oral supplementation. These studies demonstrate that patients with cystic fibrosis not only have an impaired erythroid response to hypoxia, but are frequently anemic. Their inadequate erythroid response to hypoxia results in part from disturbances in erythropoietin regulation and iron availability.

Anemia and hemoglobinopathies in Southeast Asian refugee children.

Hematologic evaluations of 254 Southeast Asian refugee children from 163 families are reported. Hemoglobin E trait was common in Cambodians (19%) and Laotians (18%), but rare in Vietnamese (1%). beta-Thalassemia trait was most prevalent in Vietnamese (8%), and less common in Cambodians and Laotians (3%). alpha-Thalassemia was prevalent in all three groups. Hemoglobin concentrations and mean corpuscular volumes seen with hemoglobinopathies were compared with those of Southeast Asian children with normal hemoglobin. Both Hb AE and Hb EE were shown to be benign conditions resulting in microcytosis and mild, if any, anemia. In children with Hb AE, mean corpuscular volume ranged from 64 to 78 ft and Hb E from 27% to 34%. In those with Hb EE, microcytosis was more marked (50 to 63 ft). In 15 children with Hb EE, there was a delayed fall in fetal hemoglobin, which can cause diagnostic difficulties in infants.

The types of hemoglobins and globin chains in hydrops fetalis.

Details are presented of analyses of hemoglobins in blood samples from four newborn babies with hydrops fetalis using reversed phase and anion exchange high performance liquid chromatographic methodology. Three were homozygous for the alpha-thalassemia-1 (SEA) deletion, and one was a compound heterozygote for the same deletion and the larger alpha-thalassemia-1 (Fil) deletion. All four babies had beta, G gamma, A gamma, and zeta chains; these chains were present in Hb Barts or gamma 4, Hb Portland-I (zeta 2 gamma 2), and Hb Portland-II (zeta 2 beta 2). Hb H (beta 4) could not be detected. The level of zeta was directly related to the level of beta and, thus, the fetal age. A lower level of zeta chain was present in the baby with the compound heterozygosity because the large deletion (Fil) on one chromosome included the zeta and psi zeta genes. Circulating red cells, i.e. reticulocytes and nucleated red cells, were unable to synthesize zeta chains, indicating that this capability must have ceased a few months prior to birth. Quantitative data obtained by chromatographic procedures were greatly influenced by the condition of the blood sample and the way it was stored. Hb Portland-II (zeta 2 beta 2) and Hb Barts (gamma 4) are rather unstable when a red cell lysate is stored at 4 degrees C; this is in contrast to Hb Portland-I (zeta 2 gamma 2) which appears to be stable. Samples can be stored as washed red cells or red cell lysates at -70 degrees C.

Laboratory diagnosis of hemoglobinopathies

Diagnostic tests for most common hemoglobinopathies and recent advances in structural analysis of variant hemoglobins are reviewed. Routine and newly introduced methods that apply to the diagnosis of sickle cell anemia, thalassemia and the hemoglobin E disorders are presented. A brief description of the clinical course for each of these disorders is given, and potential pitfalls in diagnosis are discussed. Application of high-performance liquid chromatography and various mass spectrometric techniques (electrospray ionization mass spectrometry, liquid secondary ion mass spectrometry, and tandem mass spectrometry) for evaluation of hemoglobinopathy is presented.

NUTRITION IN SICKLE CELL ANEMIA |[lpar]|HB SS|[rpar]|

To evaluate the role of nutrition in Hb SS we performed anthropometric and laboratory measurements on 95 Hb SS patients and determined the effects of caloric supplementation on these parameters and on clinical course. Height and weight were both below the 5th percentile in 17% of patients. Laboratory studies included vitamin C (ng/108 cells), vitamin E (mg/dl), zinc (μg/ml), selenium (ng/ml), and lipids (mg/dl).Immune status was measured as a reflection of nutritional adequacy. Total T cell (patient/control, 44%/78%), helper T cell (23%/55%), and suppressor T cells (17%/32%) as well as skin test reactivity were depressed. Two patients with marked growth retardation, multiple laboratory abnormalities and frequent sickle cell complications received dietary supplementation with nasal gastric hyperalimentation for 4-10 months. Improvements in growth, weight, skin test reactivity, T cell numbers, and clinical status were noted. We conclude that nutritional assessment and intervention may minimize complications associated with sickle cell disease.