Thalassemia ??.???? ?????????????

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Thalassemia??.???? ?????????????
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Thalassemia

• common genetic disease
• variable severity
• difficult to diagnosis and councelling
• decrease prevalence by PND

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Thalassemia

• ???????????????????????? ?????????????????????????
  ??????????????????????????????? ??????? ????
  ????????? ???????????????????????????????
  ????????????????????????????? ????????????????????
  ???????????????????????
• ??????????????????????????
• thalassemia minor
• thalassemia intermedia
• thalassemia major

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???????????????????

• ???????? (thalassemia trait, trait)
• ??????????
• ???????????????
• ??????? (thalassemia disease, disease)
• ?????????????????
• ????????????????????

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?????????????????

• Chronic hemolytic anemia
• Pallor and jaundice
• Thalassemic facies
• Hepatosplenomegaly
• Hemochromatosis
• Skin, heart, endocrine glands

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?????????????????

• Bone change
• Endocrine dysfunction
• Growth retardation
• Delayed secondary sexual development
• Hemolytic crisis

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???????????

• ????? ????????????
• ??? ?????? ??? ?????????
• CBC anemia, low MCV, characteristic RBC
  morphology
• Hb typing
• DNA analysis a thal

8
????????????

• Transfusion-transmitted infections
• Bone expansion
• Endocrine dysfunction
• Hypopituitarism, hypothyroidism, diabetes
  millitus, short stature, delayed puberty
• Pulmonary hypertension and embolism

9
????????????

• Hemosiderosis/cirrhosis of liver
• Extramedullary hematopoiesis
• Arthropathy
• Osteopenia
• Venous thrombosis
• Cardiomyopathy

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?????????????????????

• ?????????????????????????????? ???????????????????
  ?????????????
• ???????????????????????? ?????????????
  ?????????????
• ?????????????????????????????
• ????????????????? ferritin ??????? ???? ??./??.
  ??????????????????? ????????????????????

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??????????????? Thalassemia

• ???????????
• ????????????????????
• ??????????
• ???????????????????

12
????????????

• ?????????? ??? ??? ????????? ??????? ??????????
• ??? ?????????????????????
• ???????????????????????????
• ?????????? ? ????? ?????????? ? ??? ??? ?
  ?????????
• ????????????????????????????????????? ??????????

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• Heterozygote ?????????????????????????????????????
  ???????? ???????????????? trait
• Homozygote ????????????????????????????
  ???????????????????????????????
• Double heterozygote ???????????????????? a ???
  ß????????????????????

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• ß0-thal ??????????????????????????????????? ß
  globin chain ???
• ß-thal ???????????????? ??????????? ß globin
  chain ???????
• HbE ???? Hb ?????????? ????????????????? ß-thal
• a-thal1 ??? alpha globin gene ????2???????????????
  ????????????????????????????
• a-thal2 ??? alpha globin gene 1???????????????????
  ????????????????????????
• HbCS ???? Hb ?????????? ????????????????? a-thal2

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a-thalassemia

• aa/aa normal
• -a/aa a thal-2 trait
• --/aa a thal-1 trait
• -a/-a homozygous a thal-2
• --/-a Hb H disease
• --/-- Hb Barts disease

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Hb Constant Spring

• ???????????????????????????????????????????? a
  thal
• ??????????????????????????? ?? ???
• ?????????? a thal 2
• --/aCSa Hb H disease with constant spring

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b-thalassemia

• b/b normal
• b0/b b thal trait
• b0/b, b0/b, b/b b thal major
• b0/bE, b/bE b thal/E disease

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a and b thalassemia

• AE Barts disease
• --/-a, Hb E trait
• EF Barts disease
• --/-a, homozygous Hb E

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Thalassemia minor

• Heterozygote
• Homozygous a-thal2
• Homozygous HbE
• a/ß thal double hetrozygote
• ??????????????

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Thalassemia intermedia

• ???????????? ??????????????????????????
  ?????????? Hb 8-10g/dl ?????????????
  ?????????????? ?????????? ????????????????????????
  ????????
• ß-thal/HbE ???????
• EA Barts
• homozygous Hb CS
• HbH

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Thalassemia major

• Hb Barts hydrops fetalis
• Homo. ß-thalassemia
• ß-thal/HbE ???????

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Hb Barts hydrops fetalis

• ????????????????????????????????????
  ??????????????????????? Hb ???
• ?????????????????????????????????? ????
  ???????????????? ??????????????????????????????
  ??????????????????

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Hemoglobin Barts hydrops fetalis
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Homo. ß-thalassemia??? ß-thal/HbE

• ?????? Hb 3-4 g/dl ????????????????????
  ?????????????????????????????????
  ???????????????? ??? ???????????????????????
• 6-10 ????????????????
• 30-40 ?? ????????????????? ???????????? ???????
  ???????
• ?????????????????????????????? ?????????????????
  ????????????????????????????? Stem cell
  ???????????????????? ????????????????????????
  ???????????????????????????????????????????????

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Hemoglobinopathy

• ß-chain (ß0, ß)
• ß-trait
• E trait
• ß/E disease
• ß-thal homo.
• HbE homo.
• a-chain (a-thal1, a-thal2)
• a-trait
• HbH(a-thal1/a-thal2 or a-thal1/HbCS)
• Hb Barts hydrops fetalis
• ??????
• EA Barts disease (HbHHbE heterozygote)
• EF Barts disease (HbHHbE homo.or ß0 thal/HbE)

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important diseases for PND

• ß-thal/E disease
• ß-thal. homozygote
• Hb Barts hydrops fetalis

?????????????????????-?????

• ß-thal Hb
• HbE
• a-thal1 Hb

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??????????????

• OF ???? MCV ?????? ß-thal ??? a-thal1
• DCIP ?????? HbE

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female
male
¼ ¼
¼
¼
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female(ß tr.)
male(E tr.)
¼ normal ¼ ß tr.
¼ E tr.
¼ ß/E Dz
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male (ß/E Dz)
female (E tr.)
¼ ß tr. ¼ ß/E Dz.
¼ E tr. ¼ EE
homo.
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Punnett Square
?thal ?N
?N ?N / ?thal ?N / ?N
?E ?E / ?Thal ?E / ?N
F
M
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????? ????
ß-trait E trait
a-thal1 trait HbH
a-thal2 trait HbH
E trait E trait
ß-trait HbCS trait
ß/E disease EF Barts disease
E trait EA Barts disease
ß-trait/ a-thal1 trait EA Barts disease
ß-thal homo. HbE homo.
Hb Barts HbH
PND
v
v
X
X
X
v
X
v

?
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???????? Hb typing ?????????? HPLC
Hb typing Hb F Hb A2(E)
Normal(A2A) 0.5 0.7 2.6 0.4
a-thal trait (A2A) 0.5 0.74 2.3 0.47
ß-thal trait (A2A) 1.5 1.43 5.5 1.26
HbE trait (EA) 1.2 0.86 27.8 7.5
ß-thal/HbE (EF) 31.1 14.5 61.2 13.6
Homo HbE E(F) 4.3 2.7 90.2 4.9
EA Barts EA(Barts) 2.6 1.4 14.9 1.6
EF Barts EF(Barts) 10.2 6.73 79.7 8.7
HbH(A2A Barts H) 0.6 0.61 1.6 1.21
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?????????????????

• ??????????? ? ?? ??????????
• Hb A a2b2 97
• Hb A2 a2d2 lt3.5
• Hb F a2g2 lt1
• ???????????
• Hb F ????????????

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red cell indices and Hb typing
normocyte
microcyte
Thal.Dz. ß-thal Homo ß-thal/HbE HbH EA Barts EF
Barts
HbA2A
HbA2A DxNormal a-thal2 tr.
Hb ACS DxHb CS
HbEA
Hb EE DxHbE Homo
HbA2 Determination
HbE Determination
HbA2gt3.5 Dx ß-thal tr.
HbA2lt3.5
HbE25-30 DxHbE a-thal2/HbE
HbElt21
Hbgt10g/dl Dx a-thal1/HbE
Hblt10g/dl Dx iron def. iron def. on top of
thal tr.
Hbgt10g/dl Dx a-thal1 tr.
Hblt10g/dl DxHbE tr. with iron def.
a-thal1/HbE with iron def.
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OF
pos.
neg.
DCIP
DCIP
pos. Dx HbE tr.
neg. Dx a-thal1 tr ß-thal tr.
ß-thal homo iron def.
pos. Dx HbE tr. HbE homo
ß-thal/HbE HbH Others
neg. Dx normal a-thal2 tr.
HbCS tr.
Clinical RBC morphology ß-thal homo
HbA2 Determination
-Clinical -Rbc morphology -Hb typing -Inclusion
body (HbH) -F cell stain (ß-thal/HbE)
HbA2gt3.5 Dx ß-thal tr.
HbA2lt3.5 Dx a-thal1 tr. iron def.
Repeated study after iron supplementation X 3 mo.
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a-thal1 trait ?????? iron def. ??????

• a-thal1 trait ???? MCV ??? ?????????????? (Hb
  12-13 g/dl)

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??????????? a-thal1

• HbH
• EA Barts
• EF Barts

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???????????????? a-thal1

• case OF ve or MCVlt 80 ??? Hb typing ????
• E homo ??? ß / E disease ????? ??? a-thal1
  ???????
• ß-thal trait ????? ??? a-thal1 ???????
• E trait ????? HbE 20-25 ????? ??? a-thal1
  ???????
• E trait ????? HbE lt 20 ??????? AE Barts ????
  EF Barts ????????? a-thal1

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???????????

• Homo E ???????? Hb E gt 80 ??? MCV gt 60
• Homo E ????? Hb E lt80 ??? MCV lt 60
• ????????? ß / Hb E disease

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??? OF -ve ???? MCV gt 80????????? a-thal1 trait
?????? ?
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??????????? a-thal1 trait ??????? DNA mapping
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Prenatal diagnosis (PND)

• ?????????????????
• ?????????????????????????????????????????????
  ??????????????
• ????????????????? ????????????????????????
• ?????????????? ??????????????????????

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???????????????????????????????

• Hb Barts hydrops fetalis
• Beta thal / beta thal
• Beta thal / Hb E disease

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?????????????????

• Ultrasound
• Amniocentesis
• Fetal blood sampling
• Chrorionic villus sampling

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Ultrasound

• ???????????????????????????????
  ???????????????????????????
• ?????????????????????????? ???????????????
  Hydrops fetalis ?????????? 20-24 ???????
• ??????????????????????? ?? ??????????????????
  ??????????????????????????????????????

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??????????????????? ????????????? (Ultrasound)

• ??????????????????????????????????? Hb Barts
  hydrops fetalis
• ?? fetal ascites, cardiomegaly, skin edema,
  dilated umbilical vein
• ????? pericardial effusion ???? pleural effusion
• ???????????????? ???????????????????

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??????????????????? ????????????? (Ultrasound)

• ??????? second trimester (14-28 weeks) ??????????
  32 ???????
• ???????? confirm ??????????????????????
  ???????????????
• ?? maternal complication ???? preclampsia,
  eclampsia, placenta previa

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Prenatal Diagnosis Ultrasound (Ascites)
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Fetal hydrops

• Immune hydrops (??????????????????? ???????? Rh
  blood group)
• Non-immune hydrops
• Hemoglobin Barts hydrops fetalis
• ???????????? ????????????
• ????????????????????????? ???? ???????
• ?????????????? chromosome ???? malformations
  ???????
• TTTS (Twin-to-twin transfusion syndrome)
• ???

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Earliest ultrasound detection

• Overt features of hydrops fetalis are found in
  only one-third of affected pregnancies at 17-18
  weeks
• Fetal cardiomegaly is a sensitive marker
• 18-21 weeks, in 484 pregnancies at risk, C/T
  ratio of gt 0.5 carries a sensitivity and
  specificity of 95 and 96.1 (Tongsong T et al.
  2000)
• 12-14 weeks, C/T ratio of gt 0.5 provided a
  sensitivity and specificity of 65 and 100 (
  TVS, detected 43 affected pregnancies in 135
  at-risk women at 12-14 weeks with no false
  positive) Lam YH et al 1997 and 1999

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???????????????????????????????????????????????

• ?????????????? (Amniocentesis)
• ??????????????????????????? (Cordocentesis, fetal
  blood sampling FBS, percutaneous umbilical
  blood sampling PUBS)
• ?????????????? (Chorionic villus sampling, CVS)

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Amniocentesis

• ???????????????????? 16-18 ???????
  ?????????????????????? Ultrasound guide
  ??????????????????????
• ????????????? ?? fetal loss 0.5
• ????????????????????? ???????????????????????
  ??????????????????????? ??????????????????????????
  ????

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?????????????? (amniocentesis)

• ????????? 16-20 ???????
• amniotic fluid 5 ml
• fetal loss rate lt1
• DNA study

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?????????????? (amniocentesis)
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Fetal blood sampling

• ?????????????????????? Ultrasound guide
  ??????????????????????????? 17 ???????
• ?? fetal loss 2.5
• ??????????????????????????????????????????????????
  ?????? ????????????????????????

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Prenatal Diagnosis???????????????? Fetal blood
sampling
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??????????????????????? (Fetal blood sampling)

• ????????? 18-22 ???????
• hemoglobin study, DNA study
• ?? confirm ????????????
• fetal loss rate 2.5

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Chrorionic villus sampling (CVS)

• ???????????????????????????????????
  ????????????????????????????????
• ?? fetal loss lt1

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?????????????? (chorionic villus sampling, CVS)

• ????????? 10-13 ???????
• DNA study
• fetal loss rate lt1

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?????????????????????????????
???? ????????? ?????????? ??????????
Amniocentesis 16-20 0.5 DNA study
CVS 10-13 0.5-1 DNA study
cordocentesis 18-22 2.5 DNA study ??? Hb typing
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??????????????????????????
??????????????????????????????????????????????
????????????????
???????????????????????????????????? ?????
????????? ?????????? ???????? ???????????????????
?????
??????????????????????????
???????????????????????
ANC ?????? high risk pregnancy clinic
???????????????????????? ????????????????????????
????? ????????????????????????????????????? ?
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??????????????????????????
????????? Hb Barts hydrops fetalis
First trimester
Second trimester
Serial U/S ANC at high risk pregnancy clinic
CVS for DNA study
Cordocentesis for hemoglobin typing
Specimen to lab ???????????
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??????????????????????????
???????????????????????????? - globin
chain
???????????????? ????? mutation characterization
???? mutation
??????? mutation

• DNA study ???
• 1st trimester CVS ????
• 2nd trimester cordocentesis
• 2nd trimester amniocenthesis

Hemoglobin typing ??? 2nd trimester
cordocentesis
Specimen to lab ???????????
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??????????????????????????
Post-diagnosis counselling
Unaffected fetus
Affected fetus
F/U high risk pregnancy clinic
Choices
Termination of pregnancy
Continue pregnancy
???? ???? specimen ???? confirm
Abortion committee ???? ????
specimen ???? confirm
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??????? PND

• ?????????????????????????????? Thalassemia
  ?????????? ???????????????????????????????????????
  ???????????????????????????? ?????????????????????
  ?? 24 ??????? (?????? Hb Barts
  ?????????????????????????????????????????????)

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????????????????????????
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Preimplantation Embryo in vivo
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Preimplantation Embryo
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Embryo biopsy
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????

• ??? Thalassemia ???????????????????????????
  ????????????????????? ????????????????????????????
  ????????????????????????????? ????????????????????
  ????????? ????????????????????????????????????????
  ??????????????
• ?????????????????????????????????????????????
  ??????????????
• ????????????????? ??????????????
  ?????????????????????? ????????????????????????
• ??????????????????????? ????????????????????????
  ???????????????? counseling ????