RESUMO
INTRODUCTION: Hereditary pyropoikilocytosis (HPP) is a heterogeneous inherited disorder of red blood cell (RBC) membrane and cytoskeletal proteins that leads to hemolytic anemia. HPP is characterized by marked poikilocytosis, microspherocytes, RBC fragmentation, and elliptocytes on peripheral blood smear. Mutations in SPTA1 can cause HPP due to a quantitative defect in α-spectrin and can lead to profound fetal anemia and nonimmune hydrops fetalis, which can be managed with intrauterine transfusion. CASE PRESENTATION: We present a case of a 26-year-old G4P2102 woman of Amish-Mennonite ancestry with a pregnancy complicated by fetal homozygosity for an SPTA1 gene variant (SPTA1c.6154delG) as well as severe fetal anemia and hydrops fetalis, which was managed with four intrauterine transfusions between 26 and 30 weeks gestation. Pre-transfusion peripheral smears from fetal blood samples showed RBC morphology consistent with HPP. The neonate had severe hyperbilirubinemia at birth, which has resolved, but remains transfusion-dependent at 6 months of life. DISCUSSION/CONCLUSION: To our knowledge, this is the first report that correlates homozygosity of the SPTA1c.6154delG gene variant with RBC dysmorphology and establishes the diagnosis of HPP.
Assuntos
Anemia Hemolítica , Eliptocitose Hereditária , Doenças Fetais , Doenças Hematológicas , Gravidez , Feminino , Recém-Nascido , Humanos , Adulto , Hidropisia Fetal/diagnóstico , Hidropisia Fetal/genética , Hidropisia Fetal/terapia , Eliptocitose Hereditária/complicações , Eliptocitose Hereditária/diagnóstico , Eliptocitose Hereditária/genética , Proteínas do Citoesqueleto , Anemia Hemolítica/complicaçõesRESUMO
Red blood cell (RBC) membrane disorders represent a significant category of hereditary hemolytic anemia; however, information from Southeast Asia is limited. We established a national registry aiming to characterize RBC membrane disorders and their molecular features in Thailand. A total of 100 patients (99 kindreds) diagnosed with RBC membrane disorders between 2011 and 2020 from seven university hospitals were enrolled. The most prevalent disorders observed were hereditary elliptocytosis (HE; n=33), hereditary pyropoikilocytosis (HPP; n=28), hereditary spherocytosis (HS; n=19), Southeast Asian ovalocytosis (SAO; n=10 of 9 kindreds), and two cases of homozygous SAO. The remaining cases were grouped as unclassified membrane disorder. Seventy-six patients (76%) were molecularly confirmed by PCR, direct DNA sequencing, or hi-throughput sequencing. The primary causative gene for HE and HPP was SPTB, accounting for 28 out of 29 studied alleles for HE and 56 of 56 studied alleles for HPP. In the case of HS, dominant sporadic mutations in the ANK1 gene (n=4) and SPTB gene (n=3) were identified as the underlying cause. Notably, the four most common variants causing HE and HPP were SPTB Providence (c.6055 T>C), SPTB Buffalo (c.6074 T>G), SPTB Chiang Mai (c.6224 A>G), and SPTB c.6171__82delins TGCCCAGCT. These recurrent SPTB mutations accounted for 79 out of 84 mutated SPTB alleles (94%). In summary, HE and hereditary HPP associated with recurrent SPTB mutations are the predominant types of RBC membrane disorders observed in Thailand. These findings have significant implications for the clinical management and future research of RBC membrane disorders in the region.
Assuntos
Eliptocitose Hereditária , Esferocitose Hereditária , Humanos , Eliptocitose Hereditária/epidemiologia , Eliptocitose Hereditária/genética , Eliptocitose Hereditária/diagnóstico , Membrana Eritrocítica/genética , Membrana Eritrocítica/metabolismo , Mutação , Esferocitose Hereditária/epidemiologia , Esferocitose Hereditária/genética , Esferocitose Hereditária/diagnóstico , Tailândia/epidemiologia , Estudos Multicêntricos como Assunto , Sistema de RegistrosRESUMO
Background: The available literature on intrauterine transfusion focuses largely on its application in fetal alloimmunization rather than hereditary red cell disorders, with limited illustration of its associated histopathologic findings. Case report: We present the histologic findings in a placenta associated with preterm delivery of an infant with autosomal SPTA1 mutation following multiple intrauterine transfusions, including appropriate villous maturation, subchorionic organizing hematomas, hemosiderin-laden macrophages, and dysmorphic fetal erythrocytes within villous capillaries. Conclusion: Intrauterine transfusion is associated with placental histologic findings that reflect procedural changes without significant disruption of placental membranes or villous maturation.
Assuntos
Transfusão de Sangue Intrauterina , Placenta , Humanos , Feminino , Gravidez , Transfusão de Sangue Intrauterina/métodos , Placenta/patologia , Recém-Nascido , Adulto , Eliptocitose Hereditária/genética , Eliptocitose Hereditária/patologia , Eliptocitose Hereditária/diagnóstico , Doenças Fetais/patologiaRESUMO
Objective: To report gene mutations in nine patients with hereditary elliptocytosis (HE) and analyze the characteristics of pathogenic gene mutations in HE. Methods: The clinical and gene mutations of nine patients clinically diagnosed with HE at Institute of Hematology & Blood Diseases Hospital from June 2018 to February 2022 were reported and verified by next-generation sequencing to analyze the relationship between gene mutations and clinical phenotypes. Results: Erythrocyte membrane protein gene mutations were detected among nine patients with HE, including six with SPTA1 mutation, one with SPTB mutation, one with EPB41 mutation, and one with chromosome 20 copy deletion. A total of 11 gene mutation sites were involved, including 6 known mutations and 5 novel mutations. The five novel mutations included SPTA1: c.1247A>C (p. K416T) in exon 9, c.1891delG (p. A631fs*17) in exon 15, E6-E12 Del; SPTB: c.154C>T (p. R52W) ; and EPB41: c.1636A>G (p. I546V) . Three of the six patients with the SPTA1 mutation were SPTA1 exon 9 mutation. Conclusion: SPTA1 is the most common mutant gene in patients with HE.
Assuntos
Eliptocitose Hereditária , Esferocitose Hereditária , Humanos , Mutação , Eliptocitose Hereditária/genética , Eliptocitose Hereditária/diagnóstico , Eliptocitose Hereditária/metabolismo , Membrana Eritrocítica/genética , Membrana Eritrocítica/metabolismo , Éxons , Sequenciamento de Nucleotídeos em Larga Escala , Esferocitose Hereditária/genética , Esferocitose Hereditária/metabolismoRESUMO
INTRODUCTION: Hereditary hemolytic anemias (HHA) comprise a heterogeneous group of disorders resulting from defective red blood cell (RBC) cytoskeleton, RBC enzyme deficiencies, and hemoglobin (Hb) synthesis disorders such as thalassemia or sideroblastic anemia. MATERIALS AND METHODS: Our hemolytic anemia diagnostic next-generation sequencing (NGS) panel includes 28 genes encoding RBC cytoskeletal proteins, membrane transporter, RBC enzymes, and certain bilirubin metabolism genes. The panel covers the complete coding region of these genes, splice junctions, and, wherever appropriate, deep intronic or regulatory regions are also included. Four hundred fifty-six patients with unexplained hemolytic anemia were evaluated using our NGS panel between 2015 and 2019. RESULTS: We identified pathogenic/likely pathogenic variants in 111/456 (24%) patients that were responsible for the disease phenotype (e.g., moderate to severe hemolytic anemia and hyperbilirubinemia). Approximately 40% of the mutations were novel. As expected, 45/456 (10%) patients were homozygous for the promoter polymorphism in the UGT1A1 gene, A(TA)7 TAA (UGT1A1*28). 8/45 homozygous UGT1A1*28 cases were associated with additional pathogenic mutations causing hemolytic anemia, likely exacerbating hyperbilirubinemia. The most common mutated genes were membrane cytoskeleton genes SPTA1, and SPTB, followed by PKLR. Complex interactions between SPTA1 low expression alleles, alpha-LELY and alpha-LEPRA alleles, and intragenic SPTA1 variants were associated with hereditary pyropoikilocytosis and autosomal recessive hereditary spherocytosis in 23/111 patients. CONCLUSIONS: Our results demonstrate that hemolytic anemia is underscored by complex molecular interactions of previously known and novel mutations in RBC cytoskeleton/enzyme genes, and therefore, NGS should be considered in all patients with clinically unexplained hemolytic anemia and in neonates with hyperbilirubinemia. Moreover, low expression alleles alpha-LELY and alpha-LEPRA should be included in all targeted HHA panels.
Assuntos
Anemia Hemolítica Congênita , Eliptocitose Hereditária , Esferocitose Hereditária , Humanos , Anemia Hemolítica Congênita/diagnóstico , Anemia Hemolítica Congênita/genética , Eliptocitose Hereditária/diagnóstico , Eliptocitose Hereditária/genética , Esferocitose Hereditária/diagnóstico , Esferocitose Hereditária/genética , Proteínas do Citoesqueleto/genética , Hiperbilirrubinemia , Sequenciamento de Nucleotídeos em Larga EscalaRESUMO
RATIONALE: Hereditary spherocytosis (HS) has a defect in the vertically connected proteins on the cell membrane of red blood cells (RBC). Hereditary elliptocytosis (HE) has a defect in proteins that connect the cell membrane horizontally. We reported two families of RBC membrane disorders in Taiwanese, one was HS and the other was HE. PATIENT CONCERNS: Case 1. A 19-year-old male student with chronic jaundice and splenomegaly. His mother, maternal uncle, grandmother, and many members of older generations also had splenomegaly and underwent splenectomy. Case 2. A 40-year-old man has experienced pallor and jaundice since the age of 20 and was found to have splenomegaly, and gall bladder stones in the older age. His younger sister also had pallor and jaundice for a long time. DIAGNOSES: In case 1, a peripheral blood smear showed 20% spherocytes. Eosin-5-maleimide labeled RBC by flow cytometry showed a result of 30.6 MCF (cutoff value: 45.5 MCF). He was diagnosed with HS. The gene analysis identified a heterozygous mutation with c.166A > G (p.Lys56Glu) in the SLC4A1 gene in this proband, his mother, and maternal uncle. In case 2, more than 40% of ellipsoid RBC present in the peripheral blood smear. He was diagnosed with HE. Genetic analysis of the SPTA1 gene identified a novel heterozygous exon2, c.86A > C, p.Gln29Prol mutation. INTERVENTIONS: The two patients had compensated anemia, clinical follow-up instead of splenectomy was done. OUTCOMES: The two patients had normal daily activities and lives. LESSONS: We reported two Taiwanese families, one was hereditary spherocytosis affected by a heterozygous mutation with c.166A > G (p.Lys56Glu) in SLC4A1, and the other was hereditary elliptocytosis caused by a novel heterozygous SPTA1 gene mutation, c. 86A > C, p.Gln29Prol. These 2 seemingly common hereditary red blood cell membrane protein defects induced by hemolysis are usually underdiagnosed or misdiagnosed.
Assuntos
Eliptocitose Hereditária , Icterícia , Esferocitose Hereditária , Adulto , Feminino , Humanos , Masculino , Adulto Jovem , Proteínas do Citoesqueleto/genética , Eliptocitose Hereditária/diagnóstico , Eliptocitose Hereditária/genética , Mutação , Palidez , Esferocitose Hereditária/genética , Esferocitose Hereditária/diagnóstico , Esplenomegalia/genética , TaiwanRESUMO
Hereditary Elliptocytosis (HE) and Hereditary Pyropoikilocytosis (HPP) are clinically and genetically heterogeneous red cell membranopathies that result from the defects in the horizontal linkage between RBC (red blood cell) membrane and cytoskeletal proteins affecting its mechanical stability and deformability thereby reducing its lifespan. The principal defect in HE and HPP is due to dysfunction or deficiency of RBC cytoskeletal proteins namely, α-spectrin (SPTA1), ß-spectrin (SPTB) and protein 4.1R (EPB41R). This study reports the genetic and phenotypic heterogeneity of 10 Indian patients (5 with HE and 5 with HPP)harboringSPTA1 gene variants. We used targeted next-generation sequencing (t-NGS) to characterize the causative genetic variants in 10 HE/HPP suspected patients and studied the correlation between the identified variants with their corresponding phenotypic features.t-NGS detected 12 SPTA1 variants, out of which 8 are novel. Nearly all of the detected variants have a damaging effect on the protein stability and function, as shown by the insilico analysis. The possible effect of the detected variants on the protein structure was studied using the HOPE software and DynaMut tools wherever possible. To the best of our knowledge, this is the first report on HE/HPP cases confirmed by a genetic study from India. To conclude, HE is caused by monoallelic mutations while HPP, the more severe form, is typically caused by biallelic (homozygous or compound heterozygous) mutations justifying the phenotypic heterogeneity associated with patients. Moreover, analysis at the molecular level by NGS permits diagnosis in these disorders with highly variable heterogeneity requiring regular transfusions and may facilitate prognostic contemplations.
Assuntos
Eliptocitose Hereditária , Proteínas do Citoesqueleto/genética , Proteínas do Citoesqueleto/metabolismo , Eliptocitose Hereditária/diagnóstico , Eliptocitose Hereditária/genética , Membrana Eritrocítica/química , Membrana Eritrocítica/metabolismo , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Mutação , Espectrina/genéticaAssuntos
Cromossomos Humanos Par 14 , Cromossomos Humanos Par 20 , Eliptocitose Hereditária/diagnóstico , Eliptocitose Hereditária/etiologia , Eritrócitos/patologia , Síndromes Mielodisplásicas/complicações , Síndromes Mielodisplásicas/genética , Translocação Genética , Cariótipo Anormal , Idoso de 80 Anos ou mais , Humanos , Masculino , Síndromes Mielodisplásicas/diagnóstico , FenótipoRESUMO
Heterogeneous red blood cell (RBC) membrane disorders and hydration defects often present with the common clinical findings of hemolytic anemia, but they may require substantially different management, based on their pathophysiology. An accurate and timely diagnosis is essential to avoid inappropriate interventions and prevent complications. Advances in genetic testing availability within the last decade, combined with extensive foundational knowledge on RBC membrane structure and function, now facilitate the correct diagnosis in patients with a variety of hereditary hemolytic anemias (HHAs). Studies in patient cohorts with well-defined genetic diagnoses have revealed complications such as iron overload in hereditary xerocytosis, which is amenable to monitoring, prevention, and treatment, and demonstrated that splenectomy is not always an effective or safe treatment for any patient with HHA. However, a multitude of variants of unknown clinical significance have been discovered by genetic evaluation, requiring interpretation by thorough phenotypic assessment in clinical and/or research laboratories. Here we discuss genotype-phenotype correlations and corresponding clinical management in patients with RBC membranopathies and propose an algorithm for the laboratory workup of patients presenting with symptoms and signs of hemolytic anemia, with a clinical case that exemplifies such a workup.
Assuntos
Anemia Hemolítica Congênita/diagnóstico , Eliptocitose Hereditária/diagnóstico , Membrana Eritrocítica/patologia , Hidropisia Fetal/diagnóstico , Esferocitose Hereditária/diagnóstico , Anemia Hemolítica Congênita/genética , Anemia Hemolítica Congênita/patologia , Anemia Hemolítica Congênita/terapia , Gerenciamento Clínico , Eliptocitose Hereditária/genética , Eliptocitose Hereditária/patologia , Eliptocitose Hereditária/terapia , Testes Genéticos , Humanos , Hidropisia Fetal/genética , Hidropisia Fetal/patologia , Hidropisia Fetal/terapia , Lactente , Masculino , Mutação , Esferocitose Hereditária/genética , Esferocitose Hereditária/patologia , Esferocitose Hereditária/terapiaAssuntos
Eliptocitose Hereditária/genética , Síndromes Mielodisplásicas/genética , Idoso , Deleção Cromossômica , Cromossomos Humanos Par 20 , DNA Metiltransferase 3A/genética , Proteínas de Ligação a DNA/genética , Dioxigenases/genética , Eliptocitose Hereditária/diagnóstico , Humanos , Masculino , Síndromes Mielodisplásicas/diagnóstico , Fator de Processamento U2AF/genéticaAssuntos
Eliptocitose Hereditária/complicações , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicações , Medula Óssea/patologia , Pré-Escolar , Eliptocitose Hereditária/diagnóstico , Eritrócitos Anormais/patologia , Humanos , Masculino , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnósticoRESUMO
Systematic screening for congenital erythrocyte disorders is not a common practice, due to a lack in the accuracy of the methods and to the costs of the analyses. As a consequence, the diagnosis is usually made when a severe complication occurs. This study introduces an innovative method to perform the screening of a hereditary disease characterized by erythrocyte membrane defects such as hereditary spherocytosis (HS) and hereditary elliptocytosis (HE). Blood samples from healthy donors and patients affected by HS and HE were processed by thermogravimetric analysis (TGA) and the resulting curves were analyzed by chemometrics in order to develop a model of prediction. A novel test was developed and validated by chemometrics and results were found to be in accordance with the genetic diagnosis, confirming the prediction ability of the optimized model that uses few microliters of whole non pretreated blood to perform the diagnosis of HS/HE in less than one hour.