Vincenzo Sabato

Survival and Disease Complications in Thalassemia Major

Abstract: We studied survival and disease complications in 1,146 patients with thalassemia major, born from January 1, 1960 to December 31, 1987. At last follow‐up, in March 1997, probability of survival to age 20 years was 89% and to age 25 years was 82% for patients born in the years 1970‐1974. Patients who died had a serum ferritin level, measured the year before death, significantly higher than those who survived. Diabetes was present in 5.4% of the patients; heart failure in 6.4%; arrhythmias in 5.0%, thrombosis in 1.1%, hypothyroidism in 11.6%, HIV infection in 1.8%. Hypogonadism was diagnosed in 55% of 578 patients who had reached pubertal age: 83.5% of hypogonadic females and 78.6% of males were receiving substitutive hormonal therapy. In conclusion, the survival of patients with thalassemia major is good and improving, but the prevalence of severe complications is still high.

Membrane cation and anion transport activities in erythrocytes of hereditary spherocytosis: Effects of different membrane protein defects

Hereditary spherocytosis (HS) is due to different membrane protein defects (i.e., deficiency of spectrin and ankyrin, band 3, or band 4.2). In order to gain new insight into the relationships between band 3 function and proteins associated with the cytoskeleton, we studied erythrocyte anion transport activity in HS characterized by different membrane protein defects. Anion transport activity was increased in HS due to partial band 4.2 deficiency or to band 4.2 absence, while in HS associated with deficiency of spectrin + ankyrin or band 3, the anion transport results were normal or decreased, respectively. Moreover, since HS erythrocytes are characterized by an increased Na and a decreased K, we studied the principal membrane cation transport pathways. Activity of the Na/K pump was increased in all HS studied, while no changes in Na/K/2Cl cotransport and Na/Li exchange were evident between control and HS as well as between forms of HS associated with different membrane protein defects. K/Cl cotransport activity was decreased in all HS studied compared to normal red cells. In all HS, passive membrane permeability to Na and K was increased compared to normal erythrocytes. The increased Na and the low K content can be attributed to the abnormal membrane permeability to cations, which is not related to a specific membrane protein defect. Am. J. Hematol. 55:121–128, 1997.

Bone marrow transplantation in a case of severe, type II congenital dyserythropoietic anaemia (CDA II)

Type II congenital dyserythropoietic anaemia (CDA-II or HEMPAS) is an autosomal recessive disorder, representing the most frequent form of congenital dyserythropoiesis. It is characterised by normocytic anaemia, variable jaundice and hepato-splenomegaly. Gallbladder disease and secondary haemochromatosis are frequent complications. We report a case characterised by severe transfusion-dependent anaemia. The proband inherited CDA-II in association with beta-thalassaemia trait. Splenectomy did not abolish the transfusion dependence and this, in association with poor compliance to iron-chelation therapy, prompted us to consider bone marrow transplantation (BMT) from his HLA-identical sibling. The preparative regimen included busulfan, thiotepa and fludarabine, and graft-versus-host disease prophylaxis consisted of cyclosporin A and short-term methotrexate. Engraftment of donor cells was prompt and the post-transplant course uncomplicated. The patient is alive and transfusion-independent 36 months after allograft. This is the first case of severe CDA-II to undergo BMT. Analysis of this pedigree suggests that interaction with beta-thalassaemia enhanced the clinical severity of CDA-II, making BMT an attractive therapy for patients with transfusion dependence. Bone Marrow Transplantation (2001) 27, 213–215.

Long-term persistence of anti-HBs after hepatitis B immunization in thalassaemic patients

SummaryAn epidemiological study was carried out on 114 β-thalassaemics in order to select those subjects susceptible to hepatitis B virus (HBV) infection for hepatitis B vaccination. The results confirmed the high risk of HBV infection in these patients: 9.6% were HBsAg positive, 29.8% were anti-HBs positive/anti-HBc positive, and 9% were anti-HBc positive. In 60 HBV-negative patients, 20 µg doses of hepatitis B vaccine were administered on a schedule of 0, 1 and 6 months. Sera were collected for six years to determine the seroconversion rate and the anti-HBs titre. Seroconversion reached a maximum rate of 93% 12 months after the first vaccination dose and was 80% at the final control (72 months). Highly protective anti-HBs titres were observed until the last control in a high percentage of subjects. The HBVax hepatitis B vaccine has been shown to be safe, immunogenic and effective in β- thalassaemics.ZusammenfassungBei 114 Patienten mit β-Thalassämie wurde eine epidemiologische Studie durchgeführt, um diejenigen mit Empfänglichkeit gegen die Hepatitis B Virus (HBV)-Infektion für eine Impfung auszuwählen. Die Untersuchung bestätigte, daß bei diesen Patienten ein hohes Risiko für eine HBV-Infektion besteht: 9,6% waren HBsAg-positiv, 29,8% anti-HBs- und anti-HBc-positiv und 9% anti-HBc-positiv. 60 HBV-negative Patienten erhielten 20 µg einer Hepatitis B Vakzine, die dreimal zum Zeitpunkt 0, 1 und 6 Monate appliziert wurde. Über eine Verlaufszeit von sechs Jahren wurden die Serokonversionsrate und anti-HBs-Titer verfolgt. 12 Monate nach der ersten Dosis erreichte die Serokonversionsrate mit 93% ihr Maximum und lag nach 72 Monaten bei 80%. In der Mehrzahl der Fälle hatten sich Titerhöhen von mehr als 100 IU/l bis zur letzten Kontrolle nach 72 Monaten erhalten. Die Hepatitis B Vakzine erwies sich bei Patienten mit β-Thalassämie als sicher, immunogen und wirksam.

South-Italy β°-thalassemia: a novel deletion not removing the γ-globin silencing element and with 3′ breakpoint in a hsRTVL-H element, associated with β°-thalassemia and high levels of HbF

Hereditary persistence of fetal hemoglobin (HbF) in adulthood may be due to: mutations in the γ-globin genes promoter, mutations in the transcriptional factors involved in their regulation, polymorphic sequences or large deletions in the β-globin cluster.[1][1] Recently, Sankaran clarified the

A Transverse and Longitudinal Study of Pancreatic Function and Glucose Tolerance in Thalassemic Patients

Poly transfused thalassemia major (Th) patients show a high prevalence (frequently reported > 50%) of impairment of β-pancreatic function (PF) and of overt diabetes mellitus (10–25%). The impairment of liver function, the hyperinsulinemia following insulin resistance, the hyperglucagonemia, the β-pancreas exhaustion, the genetic predisposition, and the increased frequency of viral infections could play a role in the pathogenesis of the PF derangement [1–7]. The prevalence of diabetes mellitus has been reported to be lower in regularly (16%) than in irregularly (23%) ironchelated Th patients [7]. In this retrospective transverse and longitudinal study we have evaluated the effect of the improvement of chelation and transfusion protocols on the prevalence of PF and of impaired glucose tolerance (GT) in Th patients.

Coagulation Contact Phase Factors and Inhibitors in β-Thalassemia Major Children

Selected hemostatic parameters of 23 children affected by β-thalassemia major were studied and compared to an age- and sex-matched group. Plasma prekallikrein level was reduced in all patients, splenectomized or not. In splenectomized patients, platelet count and in vitro platelet aggregability were significantly increased and Protein C was slightly increased. The activated partial thromboplastin time was prolonged and the normotest reduced. Finally, a reduction in the plasma levels of fibrinogen and of vitamin K-dependent proteins, including the antithrom-botic Protein C, was observed in nonsplenectomized patients. Our data indicate that the hemostatic system in patients with thalassemia major may be altered. The relationship between these laboratory changes and clinical manifestations remains to be established.

HTLV‐1 Infection in a Thalassemic Patient from Apulia (Southern Italy)

The human T-lymphotropic virus type 1 (HTLV-I) has been reported to have an etiologic role in the pathogenesis of adult T-cell leukemia/lymphoma and a chronic degenerative neurologic disease, HTLV-I-associated myelopathyitropical spastic paraparesis [I]. A closely related retrovirus, the human Tlymphotropic virus type 11 (HTLV-11) is not associated with any human pathologies, although it is thought to be a potential agent of neurodegenerative diseases [2]. Several cases of HTLV-I infections after blood transfusion have been reported in HTLV-I-endemic areas with a seroconversion rate of 44-63% [3,4]. In Italy, where screening for HTLV-I is not mandatory, the first case of HTLV-I infection after blood transfusion was reported by Nunnari et al. [S] in a polytransfused patient with p-thalassemia major. Four additional cases were reported by Mozzi et al. [6] in polytransfused patients. To further evaluate the risk of HTLV-I and HTLV-II transmission by blood transfusion or blood components, a serosurvey for HTLV-I/ I1 antibodies was done on 105 thalassemics and 180 hemophiliacs from Apulia (southern Italy). All serum samples from these patients were collected during 1993 and tested by ELISA (HTLV-I EIA, Abbott) and a particle agglutination assay (Serodia HTLV-I, Fujirebio). Sera repeatedly reactive by these tests were confirmed by the use of a new Western blot containing recombinant proteins which allow the confirmation and the differentiation between HTLV-I and HTLV-II (HTLV-1/11 Blot 2.3, Diagnostic Biotechnology). Only one serum sample from a thalassemic patient was repeatedly reactive by ELISA and the particle agglutination assay and was confirmed as being positive for HTLV-I by Western blot. It showed an irnmunoreactivity to rgp21, p24 and MTAI, a recombinant typespecific antigen corresponding to HTLV-I gp46 and a very weak reactivity to p19 (fig. I) . No reactivity to HTLV-1/11 was found in hemophiliacs confirming the absence ofthe risk of transmission of HTLV-1/11 by plasma derivatives. To confirm the seroreactivity to HTLV-I, a whole-blood sample was obtained from the patient and polymcrase chain reaction was perfornied using a commercial amplification system (Amplicor HTLV-1/11, Roche). The primers used were SK4321111 of pol gene which delimitates a 195-base-pair sequence common to both HTLV-I and HTLV-11. Discrimination between HTLV-I and HTLV-I1 was achieved by differential hybridization to an HTLV-I-specific (SK112) or HTLV-11-specific (SK118) probe. The sample of the patient showed a strong signal for HTLV-I by polymerase chain reaction. The patient was a male young 17-year-old boy affected by (3-thalassemia major who had received blood transfusions since the age of 3 years. In order to approximately determine the time of infection wc looked for formcr serum samples of the patient among sera frozen in our laboratory. We found 4serum specimens of this patient who was monitored for HIV infection. The eldest went back to S years before when the patient was 12 years old. Those 4specimens were already seropositive for HTLV-I. No additional information was available regarding the previous years but a vertical transmission was excluded since his mother was seronegative for Serum Control,

8 NUCLEAR NAGNETIC RESONANCE AND IRON OVERLOAD IN THALASSEMIA MAIOR AFTER BONE MARROW TRANSPLANTATION

Nuclear magnetic resonance (NHR) imaging is a new and noninvasive technique to detect tissue iron. In fact the signal intensity on spin echo images is as low as tissue iron load is high. We used this technique to assess tissue iron load in 10 β-thalassaeaic maior patients (mean age 11 ± 4.8 years) after bone marrow transplantation (BMT); the follow-up ranged between 10 and 54 months (mean 27.3 months) from transplant. In ail patients a significant correlation has been observed between the summation of signals given out from all the organs examined (liver, spleen and pancreas) with iron overload versus serum ferritin levels (r . 0.64; p < 0.05). Signals obtained from each organ were not correlated with serum ferritin levels, but the only exception was the signal obtained from liver (r = 0.69; p < 0.05).We conclude that NMR is of great diagnostic validity for the evaluation of iron load of each organ in patients with β-thalassemia subjected to BUT, while serum ferritin levels are related only with total body iron overload. At last these Findings lead us to speculate about the need in these subjects to continue a chelation therapy or to undergo periodic phlebotomy.