Incidental Detection of Hemoglobin Variants During Evaluation of HbA1c.

HemoglobinA1c (HbA1c) is used to diagnose Diabetes mellitus and monitor glycemic control over the previous eight to twelve weeks in diabetic patients. Detection of HbA1c by cation exchange-high performance liquid chromatography (CE-HPLC) gives a chromatogram by which abnormal hemoglobin variants are also picked up. Some of these may interfere with HbA1c values affecting clinical management. Due to increased inter-state migration as well as medical tourism, there is a high possibility of finding various hemoglobin variants in any part of India. We did a prospective analysis over 1.5 years, of the hemoglobin variants detected during all the HbA1c runs. The HbA1c was tested on Bio-Rad D10 dual HbA2/F/A1c platform, which uses the CE-HPLC method. Every chromatogram was carefully studied to look for unknown peaks. The samples showing unknown peaks >6% were re-run in extended HbA2/F mode to categorize the hemoglobin variants. We had 9595 HbA1c samples, of which 70 cases showed a variant window. There were 40 males and 30 females, age ranging from 28 to 76 years. The different hemoglobin variants detected were HbD, HbE and HbS in heterozygous state, high HbF (with a differential diagnosis of HPFH heterozygous and delta-beta thalassemia heterozygous), HbE homozygous, HbQ heterozygous and HbJ heterozygous. We conclude that in the process of monitoring glycemic control using HbA1c, we can also pick-up hemoglobin variants. Hence, it is essential to review HbA1c graphs, so that the diagnosis of hemoglobin variants is not missed and the HbA1c reported is reliable.

Strawberry Pink Blood.

Blood need not always be red. We report a case of a 3 month old boy whose blood was strawberry pink before centrifugation and white (profusely lipemic) after centrifugation. The differential diagnosis was familial hypercholesterolemia or familial combined hyperlipidemia.

Vitamin B12 deficiency in India: mean corpuscular volume is an unreliable screening parameter.

BACKGROUND: Vitamin B12 deficiency is thought to be more common than was previously believed, but there are little data from India on this. It has protean clinical manifestations, and raised mean corpuscular volume (MCV) is commonly used by physicians as an indicator for megaloblastic anaemia caused by vitamin B12 deficiency. We evaluated the clinical profiles of our patients with vitamin B12 deficiency and tried to ascertain how useful MCV and the peripheral smear were in diagnosis. METHODS: We evaluated the clinical picture, haematology indices and peripheral smear findings of 117 patients with low vitamin B12 levels. Serum folic acid, ferritin values and biopsy findings of some patients were also assessed. RESULTS: Patients were commonly detected to have reduced levels of serum vitamin B12 during the work-up for anaemia (n=45) or for neurological symptoms (n=31). Of the 94 cases in which smears were examined, 26 showed macrocytes and hypersegmented neutrophils were present in 24. Twentysix patients showed a raised MCV, 50 patients had an MCV within the reference range and 28 had low MCV. Pancytopenia was present in 5 patients. Concomitant iron deficiency, as judged by serum ferritin levels, was present in 18 patients. CONCLUSION: Vitamin B12 deficiency is not uncommon in India. It is often diagnosed during the work-up for a haematological disorder or for neurological symptoms. MCV is unreliable as a screening parameter for the presumed diagnosis of macrocytic anaemia, which is associated with vitamin B12 deficiency.