Pallavi Mehta

Feasibility of a newborn screening and follow-up programme for sickle cell disease among South Gujarat (India) tribal populations.

Objectives To evaluate the feasibility of a newborn screening and follow-up programme for sickle cell disease (SCD) among tribal populations of south Gujarat, India. Methods A total of 5467 newborn babies were screened over 2 years using High-performance liquid chromatography, with diagnosis by molecular analysis. The SCD babies were followed-up clinically and haematologically regularly for 1.5 to 5 years to describe the course of the disease. Results Thirty-three babies (0.60%) were sickle homozygous, 13 (0.23%) were-sickle-β-thalassaemia, 687 (12.5%) were sickle heterozygous, and 4736 were unaffected. The parents of SCD babies were educated and counselled for home care. There were 32 babies (69.5%) who could be clinically and haematologically followed-up; 7 babies (21.8%) presented with severe clinical complications, whereas 18 (56.2%) babies were asymptomatic till the last follow-up. The variation in clinical presentation was seen in spite of the presence of ameliorating factors, such as high fetal haemoglobin, Xmn-I polymorphism, and α-thalassaemia. Conclusion In addition to demonstrating the possibility of establishing a newborn screening programme for sickle cell disorders among tribal populations, this study has shown that the disease is not always mild among tribal groups in India, as previously believed. There is a need, therefore, for increasing awareness among these tribal groups about the disease, and for regular monitoring of affected babies to reduce morbidity and mortality and to understand the natural course of the disease.

Challenges in prenatal diagnosis of beta thalassaemia: couples with normal HbA2 in one partner

To undertake β‐genotyping in couples having normal/borderline HbA2 levels in one partner to offer the possibility of prenatal diagnosis of thalassaemia.

Haplo-identical Hematopoietic Stem Cell Transplant is a Possible Cure in a Patient with Relapsed Hemophagocytic Lymphohistiocytosis Syndrome

Hemophagocytic lymphohistiocytosis (HLH) is a lifethreatening hyperinflammatory syndrome of uncontrolled immune responses resulting in hypercytokinemia because of underlying primary or acquired immune defect. Currently, the only cure for primary or relapsed HLH is allogenic stem cell transplantation (AlloSCT) [1]. Our report concerns a 13-year-old boy with a relapsed distinctively blurred HLH [2], who achieved prolonged complete remission (CR) after haplo-identical stem cell transplant (Haplo-SCT) following salvage chemotherapy. A previously healthy 11-year-old boy, the youngest son of a healthy nonconsanguineous parents without family history of HLH/similar disorders in first/second-degree relatives was hospitalised at a local hospital with complaints of 106 F fever and hepatosplenomegaly and found to have Brucella infection and histiocyte proliferation in bone marrow (BM). On further investigations, he had raised serum triglyceride, serum ferritin, and low fibrinogen levels, on the basis of which he was diagnosed with HLH. Cerebrospinal fluid was normal. The genetic mutations of HLH were not tested for parents did not give consent for same. He received chemotherapy using HLH2004 protocol and achieved CR. On routine follow up, he was found to have relapse of HLH without any underlying infective stimulus, after 25 months of initial therapy for which he received etoposide-based salvage chemotherapy and attained a second complete remission. Thereafter he was referred to us for alloSCT. He had no HLA matched donor in the family, but had 3/6 HLA match with his mother with negative donor specific anti-HLA antibodies screen. Considering the relapsed nature of HLH and in need of alloSCT lacking a matched HLA donor from family, he received a Haplo-SCT using T cell replete peripheral blood stem cell (PBSC) from his mother with a CD34 cell dose of 6.06 9 10 cells/kg after Fludarabine, cyclophosphamide and TBI (FluCyTBI) conditioning. For GvHD prophylaxis, cyclophosphamide at day ? 3 and ? 4 post SCT was employed. ANC and Platelet Engraftment was achieved at day ? 16 and ? 21 of SCT respectively, and was further confirmed by 100% donor karyotype on FISH for XX analysis of peripheral blood at day ? 30. Acute GvHD (aGvHD), overall grade II with skin and gut involvement, became apparent at day ? 16 which was managed with corticosteroids. By day ? 120, he developed aGvHD of liver, which progressed to grade IV despite being on corticosteroids, etanercept and basiliximab and was controlled after Anti thymocyte globulin (ATG) therapy. He had no major infections except for chronic otitis media and UTI with Enterococcus fecalis. Currently, he has mild chronic GvHD involving oral mucosa and eyes requiring minimal immunosuppression and is disease free with maintenance of complete chimerism at day ? 840 of Haplo-SCT. Use of alloSCT for HLH has remarkably improved the survival and prognosis of patients. Henter et al. [3] demonstrated 62% survival rate at 3 years and 10% of graft failure (GF) among 65 HLH patients treated with alloSCT. Ouachée-Chardin et al. [4] reported a series of 48 primary HLH patients who received alloSCT out of which 60% received haplo-SCT, was found associated with increased treatment related toxicity, poor prognosis and 22% GF rate. Uppuluri et al. [5] reported a case of 2 young children with & Rayaz Ahmed rayazhemat@gmail.com

First Observation of Hb Lepore Hollandia in the Baiga Tribal Family

Hemoglobin Lepore (Hb Lepore) is an uncommon hemoglobinopathy with db hybrid chains produced by 7.4 kb deletion in the b-globin gene cluster. The fusion gene results in poor of synthesis of db hybrid chains resulting in heterozygous b-thalassemia phenotype with mild hypochromic microcytic anemia. Homozygosity for Hb Lepore or compound heterozygosity for b-thalassemia and Hb Lepore results in the phenotype of thalassemia major or thalassemia intermedia [1–3]. Five variants of Hb Lepore have been identified, each characterized by different gene deletion breakpoints. Hb Lepore-Boston-Washington (Hb LBW), (HGVS: NG_000007.3: g.63632_71046del) is the most commonly reported variant, worldwide and in many ethnic groups from Mediterranean countries. Hb Lepore-Baltimore, (HGVS: NG_000007.3: g.63564_70978,) is reported from Southern Europe and Latin America [4–6]. Hb Lepore Hollandia (HGVS: NG_000007.3: g.63290_70702del) is mainly found among individuals of Southern and Southeast Asian origin [7, 8]. Here we report the presence of Hb Lepore (d22/b50) for the first time in a family belonging to the Baiga tribe from Dindori District, Madhya Pradesh, India. A 1.6 year old male child with complaints of fever and anemia was referred to us for confirmation and diagnosis. Table 1 summarizes the results of hematological and molecular analysis of the propositus and his parents. On cellulose acetate electrophoresis at alkaline pH 8.9, the propositus and his mother showed a slow moving band not corresponding to the controls of HbS/HbD position but marginally trailing the HbS band. Cation exchange high performance liquid chromatography (HPLC) analysis on the VARIANT II hemoglobin testing system using the bThalassemia Short Program (Bio-Rad Laboratories, USA) showed HbA2 of 3.2% with a RT of 3.42 min along with HbF and HbA0 of 7.6 and 82.3% respectively suggesting the presence of Hb Lepore (Fig. 1). On family screening his father was found to be normal whereas his mother was found to be slightly anemic. Her HPLC chromatogram showed a split HbA2 peak of 11.1% with a retention time of 3.43 min. Her HbF and HbA0 level was 0.9 and 79.9% respectively (Table 1). Earlier studies suggest that the retention time of Hb Lepore ? HbA2 is 3.42–3.43 min. Molecular analysis by PCR showed the presence of the Hb Harsha Lad and Manju Yadav have contributed equally to this work.

Phenotypic expression of HbO Indonesia in two Indian families and its interaction with sickle hemoglobin

Background: Alpha globin chain variants are clinically significant since they directly influence the structure and function of the hemoglobin (Hb) molecules they constitute, either in combination with normal beta globin chains or with variant beta chains, thereby altering the morbidity and mortality associated with the resultant hemoglobinopathies. We describe here two unrelated families from Madhya Pradesh who had a nondeletional alpha-chain variant, HbO Indonesia (CD116 G → A). Members of one of the two families also had coinheritance of sickle hemoglobin (HbS). Aims: The aim was to study the phenotype of HbO Indonesia and its interaction with HbS. Materials and Methods: Hb electrophoresis, high-performance liquid chromatography (HPLC), covalent reverse dot blot hybridization, amplification refractory mutation system, multiplex polymerase chain reaction, and direct gene sequencing were used to identify and characterize the variant Hbs. Results: The abnormal Hb moved in HbS region in Hb electrophoresis at alkaline pH but gave an abnormal peak in HPLC with a retention time (RT) of 4.86–4.89 min. In two members of the family with coinheritance of HbS, it produced small additional abnormal Hb peaks (4.6% in heterozygous and 11.9% in homozygous member) in HPLC with a longer RT (5.15–5.17 min) possibly resulting from a combination of HbO Indonesia alpha chain with HbS beta chain. Conclusions: It appears that depending on the zygosity of HbS, HbO Indonesia would subtract a variable amount of HbS beta chain from the total pool, thereby potentially reducing the clinical severity of HbS disease. HbO Indonesia per se does not cause anemia or alter the red cell indices.