Coexistence of Malaria and Thalassemia in Malaria Endemic Areas of Thailand

Hemoglobinopathy and malaria are commonly found worldwide particularly in malaria endemic areas. Thalassemia, the alteration of globin chain synthesis, has been reported to confer resistance against malaria. The prevalence of thalassemia was investigated in 101 malaria patients with Plasmodium falciparum and Plasmodium vivax along the Thai-Myanmar border to examine protective effect of thalassemia against severe malaria. Hemoglobin typing was performed using low pressure liquid chromatography (LPLC) and alpha-thalassemia was confirmed by multiplex PCR. Five types of thalassemia were observed in malaria patients. The 2 major types of thalassemia were Hb E (18.8%) and alpha-thalassemia-2 (11.9%). There was no association between thalassemia hemoglobinopathy and malaria parasitemia, an indicator of malaria disease severity. Thalassemia had no significant association with P. vivax infection, but the parasitemia in patients with coexistence of P. vivax and thalassemia was about 2-3 times lower than those with coexistence of P. falciparum and thalassemia and malaria without thalassemia. Furthermore, the parasitemia of P. vivax in patients with coexistence of Hb E showed lower value than coexistence with other types of thalassemia and malaria without coexistence. Parasitemia, hemoglobin, and hematocrit values in patients with coexistence of thalassemia other than Hb E were significantly lower than those without coexistence of thalassemia. Furthermore, parasitemia with coexistence of Hb E were 2 times lower than those with coexistence of thalassemia other than Hb E. In conclusion, the results may, at least in part, support the protective effect of thalassemia on the development of hyperparasitemia and severe anemia in malaria patients.

“Seroprevalence of transfusion associated hepatitis c virus (Hcv) in multi-transfused thalassemic children of the tertiary care hospital.”

Aim: To know the seroprevalence of Hepatitis C Virus (HCV) in Multi-transfused Thalassemic Children attending a tertiary care hospital, Ahmedabad, Gujarat. Material and Methods: Serum sample were tested by Enzyme Linked Immuno Sorbent Assay (ELISA) test for Anti HCV antibody from the thalassemic children over a period of 4 years from January 2006 to December 2009. Result: A total of 163 thalassemic children were tested for antibody of HCV. Out of these HCV antibodies were positive in 38 (23.31 %) patients. Conclusion: Prevalence of HCV infection among the thalassemic cases is much higher than the routine blood donors. in the light of this result a nationwide survey is recommended to confirm this pattern in the other areas and more sophisticated diagnostic tool should be employed to rule out window period of these Transfusion Associated infections.

Hyperdynamic circulatory response to iron deficiency, thalassaemia and sickle cell a anaemias

One of the most interesting areas of research in erythrocyte physiology is the interaction of haemoglobin with nitric oxide [NO]. These two molecules independently fulfill diverse and complex physiological roles, while together they delicately modulate microvascular perfusion in response to second-by-second changes in local metabolic demand, contributing to hypoxic vasodilatation. To highlight on pathophysiological mechanisms of hyperdynamic state in anemic patients as well as to investigate the relation between haemoglobin, NO, endothelin-1 [ET-1], cyclic guanosine monophosphate [c GMP] and endotoxins with hyperdynamic circulatory states in different anaemic patients. Forty five anaemic patients categorized in three groups each fifteen [Iron Deficiency Anaemic, Thalassaemic and Sickle Cell Anaemic patients] in addition to ten healthy controls. Pulse rate, systolic and diastolic blood pressure values were recorded for all subjects. Also, Haemoglobin types and level, serum iron and TIBC, NO, ET-1, c GMP and Endotoxin levels were measured for all. Significant increase in pulse rate and pressure, decrease in diastolic pressure in addition to elevation of NO, cGMP and Endotoxins whereas ET-1 significantly decline in all anemic patients. NO levels when correlated with Hb, ET-1 levels and diastolic blood pressure showed negative significant correlation, while. It was positively correlated with c GMP, Endotoxins, systolic blood pressure and pulse pressure in different anemic groups. Vasodilatation, the main cause of hyperdynamic accompanying anemia contributed to increase NO levels joint with reduction of ET-1 which mediated through c GMP pathway. Besides, en do endotoxemia may have some role in amplifying of NO production

Spectrin interactions with globin chains in the presence of phosphate metabolites and hydrogen peroxide: implications for thalassaemia.

We have shown the differential interactions of the erythroid skeletal protein spectrin with the globin subunits of adult haemoglobin (HbA); these indicate a preference for alpha-globin over that for beta-globin and intact HbA in an adenosine 5'-triphosphate (ATP)-dependent manner. The presence of Mg/ATP led to an appreciable decrease in the binding affinity of the alpha-globin chain to spectrin and the overall yield of globin-spectrin cross-linked complexes formed in the presence of hydrogen peroxide. Similar effects were also seen in the presence of 2-,3-diphosphoglycerate (2,3 DPG), the other important phosphate metabolite of erythrocytes. The binding affinity and yield of cross-linked high molecular weight complexes (HMWCs) formed under oxidative conditions were significantly higher in alpha-globin compared with intact haemoglobin, HbA and the beta-globin chain. The results of this study indicate a possible correlation of the preferential spectrin binding of the alpha-globin chain over that of the beta-globin in the haemoglobin disorder beta-thalassaemia.

HPLC studies in hemoglobinopathies.

An accurate diagnosis of beta -thalassemia carriers, homozygous patients and identification of different structural hemoglobin variants is important for epidemiological studies as well as for management and prevention of the major hemoglobin disorders. There are many electrophoretic and chromatographic approaches for estimation of HbA2 and Hb F but cation exchange HPLC (CE-HPLC)using automated dedicated machines like the Variant Hb testing system have become the method of choice for these investigations. CE-HPLC also helps in the presumptive identification of many abnormal hemoglobin variants and has been useful for both neonatal screening of sickle cell disease as well as second trimester prenatal diagnosis of thalassemia by fetal blood analysis. Other applications of HPLC in hemoglobinopathies include separation of globin chains, measuring the ratio of gamma globin chains (Ggamma/Agamma) and the recently described denaturing HPLC for detecting mutations in both alpha and beta globin genes.

Identification of hemoglobin AC heterozygote status in a Malay family: a decision between hemoglobin electrophoresis and high performance liquid chromotography.

Thalassemia is a common public health problem among Malays. Hemoglobin C (Hb C) is a hemoglobin beta variant resulting from a single base mutation at the 6th position of the beta-globin gene leading to the substitution of glycine for glutamic acid. Hb C is commonly detected in West Africans and in African American but has not been reported in Malaysia. It can be falsely diagnosed as HbE trait in the Malaysian Thalassemia Screening Program which utilizes cellulose acetate hemoglobin electrophoresis. This is the first reported case of Hb AC heterozygote status in a Malay family, with unusual splenomegaly in one of the family members.

Thalassemia among blood donors at the Hospital Universiti Sains Malaysia.

The aim of this study was to screen and identify the types of thalassemia among blood donors at the Hospital Universiti Sains Malaysia (HUSM). Thalassemia screening was performed by hemoglobin electrophoresis. A total number of 80 blood samples were obtained from donors at the Transfusion Medicine Unit, HUSM. The ethnic origins of the donors were Malays (n=73, 91.3%) and non-Malays (n=7, 8.75%). Males comprised 88.1% of the donors. Thalassemia was detected in 16.25% (n=13) of the blood donors. Of those with thalassemia, 46.2% (6/13) were anemic. Microcytosis and hypochromia were detected in 84.6% (n=l1) and 84.6% (n=l1) of these donors, respectively. The types of thalassemias detected were Hb E, 11.25% (n=9/80) and beta thalassemia trait, 5% (n=4/80). Among the thalassemias detected, the Hb E hemoglobinopathy was comprised of Hb E/ alpha-thalassemia (38.5%: n=5), Hb E /beta-thalassemia (23.1%: n=3), Hb E trait (7.6%: n=1) and beta-thalassemia (30.8%: n=4). In conclusion, screening for thalassemia trait should be included as part of a standard blood testing before blood donation. Further studies are required to look at the effects of donated thalassemic blood.

Preliminary study of the effect of vitamin E supplementation on the antioxidant status of hemoglobin-E carriers.

The antioxidant status of hemoglobin-E carriers was studied pre- and post-treatment with vitamin E for 3 months. Fourteen hemoglobin-E carriers (age = 21.36 +/- 1.08 years, BMI = 18.32 +/- 1.22 kg/m2) were treated with vitamin E 200 I.U. daily for 3 months. Fasting blood samples were collected and analyzed for erythrocyte superoxide dismutase activity, total antioxidant activity, hemoglobin concentration, hematocrit, MCV, Heinz body formation and osmotic fragility test. The blood parameters before and after vitamin E treatment were compared. The results showed that superoxide dismutase activity in the erythrocytes was significantly decreased, while total antioxidant activity in plasma, and the osmotic fragility of the erythrocytes, was significantly increased after vitamin E supplementation. However, hematocrit, MCV, and Heinz body formation did not change significantly. This demonstrated that vitamin E 200 IU could be used as a lipophilic antioxidant in red blood cells and could help increase the level of antioxidant in hemoglobin-E carriers.

Hemolytic anaemia due to unstable hemoglobin arising from spontaneous mutation--a case report.

9 years old male child presented clinically with thalassaemia intermedia phenotype. Investigations revealed hemolytic anaemia due to an unstable hemoglobin. Parents were found negative for the abnormal hemoglobin, suggesting a spontaneous mutation in the child. This is the third case of unstable hemoglobin to be reported from India. Clinically it is important that unstable hemoglobin should be suspected in a patient with thalassaemia intermedia phenotype even if both parents are haematologically normal.

Validation of osmotic fragility test and dichlorophenol indophenol precipitation test for screening of thalassemia and Hb E.

The strategy for screening of thalassemia and Hb E by a combination of osmotic fragility (OF) test and dichlorophenol indophenol precipitation (DCIP) test was validated with 436 unrelated Thai subjects. Hemoglobin (Hb) typing, Hb A2 quantitation, PCR and DNA sequence analysis were used as confirmatory methods for diagnosis of thalassemia and hemoglobinopathy. The sensitivity and specificity of this strategy was 100% and 79.7%, respectively. The results assessed by two medical scientists were exactly the same with 93.3% accuracy in comparison with the confirmatory methods. A combination of OF and DCIP has been shown to be a reliable, rapid, simple and sensitive strategy for screening thalassemia and Hb E in the Thai population.

Hereditary persistence of foetal haemoglobin in a tribal family of Orissa, India.

BACKGROUND: The hereditary persistence of foetal haemoglobin (HPFH) is an autosomal co-dominant, rare, inherited condition. It occurs due to failure of switching off of the production of gamma-chains during the neonatal period leading to a high level of foetal haemoglobin in adult life but without any anaemia. During screening a randomly selected Paraja Bhuyan tribal population for haemoglobinopathies in the Sundargarh district of western Orissa, HPFH was detected in a family. METHODS: Horizontal haemoglobin electrophoresis was carried out to identify abnormal haemoglobins and quantitation of the haemoglobin A2 fraction was done by the elution method at pH 8.9. Haemoglobin F was estimated. Haematological parameters were studied using an automated blood cell counter. The acid elution-staining test was used to demonstrate the intracellular distribution of haemoglobin F-containing erythrocytes. RESULTS: Four members of the tribal family had a high level (6.5%-13.7%) of foetal haemoglobin--the mother and 3 children. None of them had any apparent clinical or haematological abnormality except for mild pallor in the two younger children. The add elution-staining test revealed pancellular distribution of foetal haemoglobin in the erythrocytes of all the affected family members. CONCLUSION: Genetic traits such as hereditary persistence of foetal haemoglobin, although rare, are prevalent in India.

Red blood cell vesicles in thalassemia.

Vesicles are part of the red blood cells membrane which can be found in a small number in normal apoptotic process and increased in some diseases. In the present study, the authors measured the percentage of red blood cell vesicles in healthy subjects (n = 7), patients with alpha-thalassemia or Hemoglobin (Hb) H disease (n = 7), beta-thal/Hb E with nonsplenectomized (n = 5) and splenectomized (n = 7) before and after induction heated at 48.6 degrees C by using flow cytometry. It was found that the percentage of vesicles in every group were not statistically significantly different (p > 0.05) between pre and post incubation at 5 min. The percentage of vesicles of healthy subjects, beta-thal/Hb E nonsplenectomized patients and splenectomized patients were highest when induced by heating for 60 min. For patients with Hb H disease, the percentage of vesicles was maximum at 30 min when compared with healthy subjects, beta-thal/Hb E nonsplenectomized patients and splenectomized patients, respectively. In the present study, the authors report the significant increase of the percentage of vesicles in Hb H disease, beta-thal/Hb E nonsplenectomized and splenectomized after induction by heat when compared with healthy subjects. These findings may support the different pathology of the red blood cells found in alpha- and beta-thalassemia.

Prevention and control of thalassemia at Saraburi Regional Hospital.

OBJECTIVE: To evaluate the program in prevention and control of thalssemia among pregnant women and their spouses, prevention of new cases by screening tests, confirmatory test, genetic counselling, prenatal diagnosis, and selective abortion. SUBJECTS: The pregnant women, attending antenatal care unit, Saraburi center hospital, as well as their spouses. 1 January 2000-31 December 2001 METHOD: As part of the antenatal care assessment, pregnant women before 16 weeks gestation were screened, with pre- and post-test counselling, by osmotic fragility (OF) and dichorophenol indophenol precipitate (DCIP) tests, and confirmed by complete blood count (CBC), mean corpuscular volume (MCV), hemoglobin typing and polymerase chain reaction for alphathal1 (PCR alphathal1) if any of two screening tests was positive. The husbands of those who were carriers of severe thalassemia were encouraged to have thalassemia screening and confirmation. When both the pregnant women and their husbands were carriers of severe thalassemia, the pregnant women would voluntarily perform the prenatal diagnosis. Termination of pregnancy would be offered when the fetus had severe thalassemia. RESULTS: There were 3,739 from 4,214 women (88.7% of all antenatal women), who participated in the program. OF and/or DCIP were positive in 1,742 of 3,739 subjects (46.5%). Of those, 960 from 1,742 (55.1%), had husbands who were willing to have the testing, and OF and/or DCIP were positive in 443 of 960 cases (46.1%). The confirmatory tests revealed carrier and disease of thalassemia, and hemoglobinopathies in 931 of 1,742 women (53.9%), and 135 of 960 husbands (14.0%). The 20 couples who had the possibility of having severe thalassemic newborns, were strongly advised to have prenatal diagnosis. The 12 risk pregnancies had been performed cordocentesis. Finally 3 of 12 (25.0%) fetuses were documented to have severe thalassemia and all of them decided to have selective abortion. CONCLUSIONS: The screening model for thalassemia carriers by using the combination of OF and DCIP is the easy screening model. It can be done quickly, it is inexpensive, therefore it is suitable for large numbers of population screening. The systematic screening, confirmatory of thalassemia diagnosis and prenatal diagnosis are the measure of thalassemia prevention and control, and aims to decrease the number of newborns with severe thalassemia.

HPLC--how necessary is it for haemoglobinopathy diagnosis in India?

Cation exchange high performance liquid chromatography (HPLC) is emerging as the method of choice for the initial screening of thalassemias and haemoglobinopathies and quantification of Haemoglobins (Hbs) like HbA, HbA2 and HbF. Since it is expensive, the present study was conducted to evaluate the need for HPLC in Indian laboratories and identify situations where it would be imperative. Eighty three patients suspected to have thalassemia and haemoglobinopathies were analysed. Both HPLC and alkaline gel electrophoresis detected 14 cases of HbE syndrome and 14 cases of HbS syndrome. However of the 14 cases diagnosed as HbD syndrome by alkaline electrophoresis, eight cases were diagnosed as Hb Q India, 1 case as HbD Iran and 5 cases of HbD Punjab on HPLC. Thirty-one cases were detected to have beta heterozygous thalassemia based on the high HbA2 levels (>3.9%) and eight cases were diagnosed as beta homozygous thalassemia by both HPLC and gel electrophoresis. One of them had an unknown Hb migrating in F-A region. Her mother also had same unknown Hb variant. In view of electrophoretic migration and retention time (RT) on HPLC, possibility of HbG-San Jose was considered. HPLC being an automated instrument is highly sensitive and specific, has high resolution and helps in quantification of various haemoglobins. However in a developing country like India where economical factors play a major role in planning for management of patients, the role of HPLC is limited.

Red cell indices and therapeutic trial of iron in diagnostic work-up for anemic Thai females.

Anemia is common among Thai females. Thalassemia and iron deficiency are highly prevalent in the Thai population. A therapeutic trial of iron has been used to differentiate between the two conditions, however, no previous study on its usefulness in a Thai population has been reported. Otherwise healthy persons who had complete blood count (CBC) as routine 'check-up' and found to be anemic (Hb < 12 g/dl) at a preventive medicine clinic were tested for hemoglobin typing, serum ferritin, serum iron, and were given oral iron sulfate (120 mg elemental iron per day for at least 2 months) and a repeat CBC on a follow-up visit. Sixty-six individuals, all females, with pre-treatment hemoglobin (Hb) level of 9.5 +/- 1.7 g/dl (mean +/- SD), had complete data for analysis. Final diagnoses were isolated iron deficiency in 23 (34.8%), iron deficient thalassemia traits in 6 (9.1%) and iron-sufficient thalassemia syndromes in 29 (43.9%) anemic subjects. After a therapeutic trial of iron, Hb rose to 12.8 +/- 1.0 g/dl (n = 16, p = 2 x 10(-8)) among the iron deficient group, but not in thalassemia. The authors have identified that the most useful red cell indices that will discriminate between iron deficiency and thalassemia is a combination of red blood cell counts (RBC) > 4.4 x 10(6)/microl and mean corpuscular volume (MCV) < 69 fl. High RBC (> 4.4 x 10(6)/microl) and very low MCV (< 69 fl) is a sensitive (92.9%) and highly specific (100%) criteria for diagnosis of mild thalassemia diseases (Hemoglobin H (HbH), Hemoglobin H-Constant Spring (HbH-CS), and homozygous Hemoglobin E (HbEE)). Conversely, a low RBC (> 4.4 x 10(6)/microl) and/or low to normal MCV (69-85 fl) is highly sensitive (91.3%) but not specific (60%) for the diagnosis of iron deficiency. The authors conclude that a therapeutic trial of iron is useful as a diagnostic test in anemic females except those with high RBC (> 4.4 x 10(6)/microl) and very low MCV (< 69 fl), a subgroup which most likely has thalassemia and are least likely to benefit from iron treatment.

Common transfusion-transmitted infectious agents among thalassaemic children in Bangladesh.

Transfusion-dependent children are more prone to acquiring various transfusion-transmitted infections (TTIs), such as hepatitis B (HBV), hepatitis C (HCV), HIV, and others. Since the magnitude of these infections among thalassaemic children in Bangladesh is not well-known, this study was conducted to assess the prevalence of TTIs among them (who received more than three blood transfusions) compared to their age- and sex-matched controls (non-thalassaemics and those who had never had a transfusion). Seromarkers for HBV, HCV, HDV, Treponema pallidum, and HIV were tested, and the results were analyzed using SPSS/Windows 10.5. Of 259 children studied, 152 (58.69%) were thalassaemic (mean age 6.8 +/- 3.6 years), and 107 were controls (mean age 6.7 +/- 3.53 years). The HBV and HCV-markers were found significantly more often among multi-transfused thalassaemic children than among the controls in terms of HBsAg (13.8% vs 6.5%, p < 0.04), anti-HBc total (39.5% vs 9.4%, p < 0.0001), and anti-HCV (12.5% vs 0.9%, p < 0.0001). HBeAg did not differ (p = 0.82) between the thalassaemics (9.52%) and the controls (14.28%), whereas anti-HBe differed (0% vs 57.14%, p < 0.003). Neither the thalassaemics nor the controls were positive for HDV, HIV, or T. pallidum. Since more thalassaemic children acquired hepatitis B and C infections through multiple blood transfusions, it is recommended that the safe blood-transfusion programme be strengthened and mass vaccination against HBV (even who suffer from HCV) in Bangladesh be undertaken.