What is Thalassemia and how to approach

1. WELCOME TO
SEMINAR
Dr. Aysha Sabiha
Dr. Maimuna Sayeed
Dr. Sharmin Akter Luna
Residents (Phase-A)

2.  Halima, a 11 years old girl of consanguineous parents
presented with complaints of not growing well, gradual
pallor & abdominal distension for 7 years.
 On examination she was severely pale, facial
dysmorphism & hepatosplenomegaly were present.
She had history of repeated blood transfusion.
Case Scinerio

3. Hereditary hemolytic anemia
Diagnosis

4. SEMINAR
ON
THALASSEMIA

5. Introduction
The term “Thalassemia” refers to a genetic disorder of
hemoglobin synthesis characterized by a lack or
decreased synthesis of one or more of the four Globin
chains causing excessive breakdown of RBC.
"Thalassemia" is a Greek term derived from “Thalassa”,
which means "the sea" and “Emia” means "related to
blood."

6. World:
• Beta thalassemia trait - 8% of
population
• More than - 100 million
carrier
• Hb E - 53 millions
Bangladesh:
• Beta thalassemia trait- 4.1%
• Hb E trait - 6.1%
• Hb E Beta thalassemia-
10.2%
(Source: DSH Thalassemia
center)
Incidence

8. Site of synthesis of globin

9. Normal hemoglobin component
Hb type Name Components
Adult A α2β2
A2 α2δ2
Fetal F α2γ2
Embryonic Portland ξ2γ2
Gower 1 ξ2ε2
Gower 2 α2ε2

10. 
 

HbA
98%
HbA2
<3.5%
HbF
~1%








Hemoglobin in normal adult

11. • α Thalassemia
• β Thalassemia
Types of thalassemia

12. Autosomal recessive
Inheritance

13. α-THALASSEMIA

14. Chromosome 16 defect
2 1 2 1
2
2 1
2 1
2 1
2 1
2 1
2 1
Normal Hb
One α gene deletion
silent carrier
Two α gene deletions-
α-Thal. Minor
Four α gene deletions
Hydrops fetalis or also
called: Erythroblastosis
Fetalis.
Three α gene deletions
Hb-H disease

15. CLINICAL PRESENTATION
Variants of alpha
thalassemia
Signs &Symptoms
Silent carrier Asymptomatic
Trait Asymptomatic
Hb H disease
Moderate to severe hemolytic anemia
Modest degree of ineffective erythropoiesis
Splenomegaly
Variable bone changes
Hb Bart's Born with massive generalized edema, usually fatal

16. Diagnosis of α-Thalassemia
CBC:
• Silent Carrier: no microcytosis , no anaemia.
• α-Thalassemia trait: microcytosis, hypochromia,
mild anaemia.
• Hb H disease: variable severity of anaemia &
hemolysis.
PBF: Hb H inclusion body (brilliant cresyl blue) in Hb H
disease.

17. Hb electrophoresis –
Hb H:
• (2-40%) Hb H
• others Hb A
• Hb F & Hb A2
Hb Bart's:
• (80-90%) Bart's,
• no Hb A, Hb F, Hb A2
Diagnosis of α-thalassemia

18. Treatment of α-thalassemia
• Silent carrier & trait: do not require treatment.
• Hb H disease: usually does not require regular
transfusions. But, with intercurrent illnesses, patient
may require transfusion .

19. β-Thalassemia

20. With a mutation on one of the 2 beta globin
genes , a carrier is formed with lower protein
production but enough hemoglobin
Without a mutation enough
hemoglobin
No
carrier
With one mutation
less hemoglobin
Beta
thalassemia
carrier but less
hemoglobin
Slight anemia
With two mutation
No beta globin
Beta
thalassemia
major pt with
severe anemia
Gene from father
Gene from mother
Chromosome 11 gene defects

21. Clinical syndrome Genotype Sign & symptom
Minor
/ 
+
or
/ °
Asymptomatic
Intermedia 
+
/
+
Variable degree of severity
Major

+
/°
or
°/°
- Present within 1 year of age
- Severe anemia
- Growth retardation
- Organomegaly
- Skeletal deformities
-Transfusion require within 2 year
Variants of β-thalassemia

22. An absence or deficiency of β-
chain synthesis of adult HbAg
Pathophysiology of β-thalassemia
β Chain synthesis Hb-A
α , γ and δ chain
Hb A =
α2β2

23. Pathophysiology of β-thalassemia

24. An approach to thalassemia
• Severe Anemia
• Thalassemic facies
• Hepatosplenomegaly
• Growth retardation, etc
• Symptoms of anemia
• +ve family history
• H/0 blood transfusion
• FTT

25. Thalassemia Major
Child with no
transfusion or
inadequate transfusion
Child with regular
blood transfusion but
no chelation
Child with regular
blood transfusion &
chelation
Leads natural course
of disease, may die
within 5 yrs of age
Manifestation of iron
overload at the end of
1st decade
May enter into normal
puberty & have
normal life expectancy
Clinical features

26. Natural course
General features
Weakness
Gradual Pallor
Fatigue
Dyspnoea on exertion
Poor appetite
Palpitation
Poor growth
Features of
marrow expansion

27. Features of
extramedullary
hematopoiesis
Features of
hemolysis
Jaundice
Hyperurecemia-Gout
Gallstone
Scoliosis,Kyphosis,vertebral collapse with cord
compression

28. Features of iron overload
Cirrhosis
Diabetes
Infertility
Pituitary failure
Hypothyroidism
Arrythmia
Heart failure
Dark skin
Liver Heart Endocrine organs

29. Hb E β-Thalassemia
• Most prevalent thalassemia variant in Southeast Asia &
Bangladesh.
• Double heterozygous state.
• Lysine substitutes glutamic acid in 26th position.
• Divided into mild, moderate & severe form with clinical
features varying from thalassemia intermedia to
thalassemia major

30. Types Sign & symptom
Mild Hb E β
Thalassemia
Asymptomatic , Hb :9 -12 gm/ dl , require no treatment .
Moderately severe Hb E
β Thalassemia
Majority of patient are in this group, Hb : 6 -7 gm/dl ,
resemble Thalassemia intermedia.
Severe Hb E β -
Thalassemia
Clinical manifestation resemble Thalassemia major
(severe anaemia, growth retardation,
hepatosplenomegaly, skeletal deformities).
Hb: 4-5 gm/dl , treated as thalassemia major.
Variants of Hb E β-thalassemia

31. Complications of thalassemia
A. Excessive erythropoiesis
B. Iron overload
C. Chronic hemolysis
D. Hypercoagulable disease
E. Infection
F. Treatment of related complications

32. Facial changes:
• Maxillary over growth
• Malocclusion of teeth
• Frontal bossing
• Chronic sinusitis
• Impaired hearing
A. Excess erythropoiesis

33. • Medullary expansion – cortical
thinning, risk of fracture,
osteopenia, osteoporosis, back
ache.
• Vertebral expansion lead to
spinal cord compression –
neurological manifestations.
Bone Changes

34. • Hepatosplenomegaly
• Lymphadenopathy

35. Endocrine failure:
• Short stature
• Delayed puberty
• Estrogen/ testosterone
deficiency
• Diabetes mellitus
• Hypoparathyroidism
B. Iron Overload

36. B. Iron overload
Cardiac involvement:
• Cardiomyopathy
• Pericarditis
• Arrhythmia
• CCF

37. Hepatic involvement:
Cirrhosis
Hepatic fibrosis
B. Iron overload

38. C. Chronic hemolysis
• Gallstone 50-70% by around 15 years.

39. D. Hypercoagulable disease
Impaired platelet function Deep venous thrombosis
Elevated endothelial adhesion
protein level
Pulmonary embolism
Activation of coagulation cascade by
damage RBC
Cerebral ischemia

40. E. Infection
• Anemia
• Iron overload – Yersinia, Klebsiella
• Hypersplenism
• Splenectomy – Pneumococci, Meningococci,
Hemophilus influenzae
• Transfusion related – HBV, HCV, HIV etc.

41. F. Complications due to blood transfusion
• Acute hemolytic reactions
• Delayed transfusion reaction
• Autoimmune hemolytic anemia
• Febrile transfusion reaction
• Allergic reaction
• Transfusion related acute lung injury (TRALI)
• Graft versus host disease (GVHD)
• Volume overload
• Transfusion of disease – HAV, HBV, HIV

42. Causes of death in thalassemia
• Congestive heart failure
• Arrhythmia
• Sepsis due to increase susceptibility to infection
• Multiple organ failure due to hemochromatosis

43. INVESTIGATIONS

44. Investigations
CBC:
• Hb level - Depends on severity
– β-thalassemia minor: 10-13 gm/dl
– β-thalassemia intermedia: 7-10 gm/dl
– β-thalassemia major: 3-6 gm/dl
• TC/DC– normal / increased / decreased
• Platelet- normal / decreased
• RBC Indices- MCV, MCH, MCHC are low
• RDW- Normal or raised
• Reticulocyte count- Increased(5-10%)
PBF: Microcytic hypochromic cells with marked anisocytosis,
poikilocytosis and other abnormal cells.

45. Abnormal RBCs in PBF
1. Target cell
2. Tear drop cell
3. Elliptocyte
4. Hypochromic
5. Microcyte

46. PBF: Normal

47. PBF: β-thalassemia major

48. PBF: β-thalassemia minor

49. Investigations
• Osmotic fragility: Decrease
• Iron Profile:
 S. Iron & ferritin- Increased
 TIBC- Decreased
 High % saturation of transferrin
• S. bilirubin (indirect): Increased

50. Hb electrophoresis
Hb NORMAL MAJOR MINOR INTERMEDIATE
Hb F <1% 90-98% 1-5 % Variable
Hb A 97% Absent 90-95% Variable
Hb A2 1-3% Variable 3.5-7% >3.5%

51. Normal Hb electrophoresis

52. Hb electrophoresis of homozygous β° thalassemia

53. • Widened diploic
spaces
• Hair-on-end
appearance
• Thinning of cortex
X-ray Skull

54. • Rectangular appearance
• Medullary portion of bone is
widened
• Bony cortex thinned out
• Coarse trabecular pattern in
medulla
X-ray of hand

55. Investigations
• DNA analysis:
Determine specific defect at molecular DNA level.
• HPLC (High Performance Liquid Chromatography):
Identify & quantify large number of abnormal Hb.

56. Normal
10% (33)
β thalassemia trait
44% (145)
homozygous β
thalassemia
5% (18)
Hb E β
Thalassemia
16% (52)
Hb E talassemia
trait
21% (71)
Hb E disease
2% (5)
β-Thalassemia
major
2% (7)
Unknown
0% (1)
Patient diagnose as different variety of thalassemia by DNA analysis in BSMMU
during the period of Sept 2007 to Aug 2016 (Total=332)

57. Diagnosing Thalassemia
Full medical and family history, CBC and RBC indices and PBF
Low MCV (< 80fl)
± Low MCH (< 27pg)
Other cause of
anemia?
Serum ferritin
≤12 ng/ml
Consider iron deficiency
anemia
Adequate iron supplement for
3 months
Hb electrophoresis and HPLC
Improved
Not
improved
Hb A2 variable
Hb F > 90-98%
Hb A2 ≥ 4%
Hb F ≤ 0.1-5%
Hb A2 > 4%
Hb F variable
Hb A2 < 4%
Hb F < 1%
+ Other normal Hb
variant
ß-Thalassemia
major
ß-Thalassemia
minor
ß-Thalassemia
intermedia
𝛼-Thalassemia
Hb S, Hb E,
Hb C and others
DNA analysis for 𝛼-globin ß-globin chain mutation
Serum ferritin
>12 ng/ml
Microcytosis, Hypochromia, Target cells
± inclusion bodies (Hb H)

58. To see complications
• Liver function test
• Thyroid function test
• FSH, LH, Testosterone, Estradiol
• Blood Sugar
• Bone profile
• Ca, Phosphate, PTH
• Liver Iron Concentration (LIC): T2 MRI, Liver Biopsy
• Cardiac Iron Measurement by: T2 MRI

59. • Bright areas represent high iron concentration.
• Dark areas represent low iron concentration.
Monitoring iron overload by MRI

60. MANAGEMENT OF
THALASSEMIA

61. Treatment modalities
A. Supportive
B. Curative
C. Preventive

62. A. Supportive management
• Multi-disciplinary approach
• Focus on each patient’s clinical course
Transfusion Iron Chelation
Fetal Hb
Induction
Splenectomy

63. Objectives of supportive management
• Maintenance of growth and development
• Correction of anemia
• Prevention of iron overload
• Treatment of complications
• Counseling and Prevention

64. Blood Transfusion

65. Whom to transfuse?
Confirmed diagnosis of thalassemia major
• Laboratory criteria:
• Hb < 7gm/dl on 2 occasions > 2 weeks apart
or
• Hb > 7gm/dl with:
• Facial changes
• Poor growth
• Fractures
• Extramedullary hematopoiesis

66. Important issues before starting
transfusion
• Blood grouping:
– ABO and Rh(D) compatibility checked
– Extended red cell antigen typing at least C, c, E, e
and Kell.
• Screening of donor blood for HBV, HCV, HIV, Syphilis,
Malaria.
• Avoidance of transfusion first-degree relative donors.
• Quality, adequacy and safety of blood

67. Transfusion protocol
To maintain pre transfusion Hb >9–9.5 gm/dl.
• Typical programs:
• Transfusion of 10–15 cc/kg of packed Leuko-
depleted red cells
• Lifelong regular blood transfusions, every 2–5
weeks

68. A higher pre-transfusion hemoglobin level of 11-12 gm/dl
for patients with:
• Heart disease or other medical conditions
• Patients who do not achieve adequate suppression
of bone marrow activity at lower Hb level.

69. Blood products for transfusion
• Packed red cell
• Leukocyte reduced red cell
• Washed red cell
• Neocyte

70. Target in 
Hb
Haematocrit of Donor Red Cells
50% 60% 75% 80%
1 gm/dl 4.2 ml/kg 3.5 ml/kg 2.8 ml/kg 2.6 ml/kg
2 gm/dl 8.4 ml/kg 7.0 ml/kg 5.6 ml/kg 5.2 ml/kg
3 gm/dl 12.6 ml/kg 10.5 ml/kg 8.4 ml/kg 7.8 ml/kg
4 gm/dl 16.8 ml/kg 14.0 ml/kg 11.2 ml/kg 10.4 ml/kg

71. Regularly
Transfused
Irregularly
Transfused

72. • Normal growth
• Normal physical activities
• Adequately suppresses bone
marrow activity
• Minimizes iron accumulation
Regular transfusion allows

73. Diet and supplementation
• High iron contained food should be avoided.
• Diet which decreases iron absorption such as milk &
milk products should be taken adequately
• Folic acid
• Zinc
• Vit. D, Vit. E

74. Thalassemic diet

75. CHELATION THERAPY

76. Chelator MetalChelator
Toxic
ExcretionMetal
What is chelation therapy?

77. Evaluation of iron overload
Serum ferritin concentration
Liver iron concentration (LIC)
 Liver biopsy
– n=1.8 -7 mg/dry wt , >15-20 mg
 SQUID
 MRI
Others: NTBI and T2*MRI
Guideline- Thalassemia International Federation-2008

78. Guidelines for starting treatment of iron
overload in patients with β-thalassemia major
Thalassemia International Federation
guidelines for the clinical management of
thalassemia (2008)1 recommend that chelation
therapy is considered when patients:
Have received 10–20 transfusion episodes
OR
Have a serum ferritin level of >1000 ng/mL
1Thalassemia International Federation. Guidelines for the clinical management of thalassemia, 2nd Edition revised
2008; 2Angelucci E et al. Haematologica 2008;93:741–752

79. Primary goals of chelation therapy
Complete
chelation
The primary goals of iron chelation therapy are to remove excess iron and provide
protection from the effects of toxic iron
Iron
balance
Removal of iron
at a rate equal
to transfused iron
input
Prevents end-
organ damage due
to iron
Normalization of
stored tissue iron
May take years
in established iron
overload
Safe levels of
tissue iron differs
between organs
Control of toxic iron
over 24-hr period
24-hr control
of NTBI/LPI and
intracellular labile
iron
Prevents end-
organ damage due
to iron

80. Goals of chelation Therapy is achieved by:
• Keeping serum ferritin <1000-2,000 ng/mL or
• LIC <15 mg/g dry weight

81. Iron chelating agents
• Desferrioxamine (DFO)
• Deferiprone
• Deferasirox

82. Management: iron chelators
Agent Route T1/2
hours
Schedule Clearance Toxicity
Deferoxamine IV/SQ
Slow
infusion
0.5 8-24 hours
5-7 days
per week
Renal and
hepatic
Infusion site
reactions,
allergic reactions,
ocular and
auditory
Deferiprone Oral 2-3 3 daily Renal Nausea/
vomiting,
arthropathy,
neutropenia,
agranulocytosis
Desferrioxamine Oral 12-16 1 daily Hepatic Bad taste,
nausea,
epigastric pain,
rash

83. Desferrioxamine
Regular rotation of the site of
infusion allows proper
absorption of the medication
and decreases the risk of skin
breakdown and scar tissue
formation.
The most common sites are
abdomen, thighs and upper
arms.

84. Deferioxamine……contd
Intensive chelation with Desferrioxamine
– continuous 24-hourly infusions IV or
SC.
Indications:
a) Persistently high serum ferritin;
b) LIC > 15 mg/g dry weight;
c) Significant heart disease, and;
d) Prior to pregnancy or bone marrow
transplantation
Dose: 50 mg/kg/day (up to 60
mg/kg/day)
In-dwelling catheters: danger of
infection and thrombosis

85. Fetal Hb Induction

86. Induction of fetal hemoglobin
Hb F enhancement
• Hydroxyurea
• Myelaran
• Butyrate derivatives
• Erythropoietin
• 5-Azacytadine

87. • Increasing the synthesis of fetal hemoglobin can help
to alleviate anaemia and thereby improve the clinical
status of patients with thalassemia intermedia.
• Agents including cytosine arabinoside and hydroxyurea
may alter the pattern of erythropoiesis and increase
the expression of alpha-chain genes.

88. • Erythropoietin has been shown to be effective, with a
possible additive effect in combination with
hydroxyurea.
• Butyrate are a further experimental category, still
unlicensed and with difficult intake.

89. SPLENECTOMY

90. Deferred as long as possible. At least till 5-6 yrs age.
Indications:
• Massive splenomegaly causing mechanical
discomfort
• Blood requirements >200-220 ml/kg/year
• Hypersplenism

91. The risk of splenectomy
Overwhelming infection
Age—(<2 years of age)
Time since splenectomy (1-
4 years after surgery)
Immune status of patient
Commonly associated pathogen
Streptococcus pneumoniae
Haemophilus influenzae
Neisseria meningitidis

92. Preventative measures
Immunoprophylaxis–
 At least 2 weeks before splenectomy
 Pneumococcus/meningococcus/Hemophilus
Chemoprophylaxis-
 Chemoprophylaxis with life-long oral penicillin.
Education

93. Only curative option available.
Overall outcome depends on-
• Inadequate chelation
therapy,
• hepatomegaly,
• presence of portal fibrosis.
Treatment-related mortality is
approximately 10%.
Bone marrow/stem cell transplantation
Guideline- Thalassemia International Federation-2008

94. Risk stratification for BMT
 Hepatomegaly >3cms
 Liver fibrosis
 Inadequate chelation
 Class I – no risk factors
 Class II- one to two risk factors
 Class III- all three risk factors

95. Outcome of BMT in thalassemia
Guideline- Thalassemia International Federation-2008
Class probabilities of
survival (%)
disease-free
survival (%)
risk of
rejection (%)
risk of
mortality (%
I 93 91 2 8
II 87 83 3 15
III 79 58 28 19

96. B. Curative treatment in thalassemia
• Stem cell transplantation
• Gene therapy

97. Stem cell transplantation?

98. Stem cell transplantation

99. Whom to offer?
Stem cell transplantation

100. Cost Vs Risk benefit
of patient
and
Availability of
DONOR
Stem cell transplantation

101. Gene therapy

102. Gene therapy
• Insertion of normal globin genes into marrow stem cell
may ultimately cure Thalassemia .
• Globin gene transfer in autologous CD34+cells is
beginning to be evaluated
• As per FDA recommendation, the current study is
restricted to adults. Paediatric patients will be included
at a later date after reviewing safety and efficacy data
obtained in adults.
Guidelines for the Management of transfusion dependent Thalassemia,3rd

103. Role of surgery in thalassemia
• Cholelithiasis – Cholecystectomy
• Choledocholithiasis – Choledocholithotomy
• Cirrhosis (due to iron overload) – Liver biopsy and liver
transplantation
• Leg ulcer – Surgical dressing
• Pathological fracture – Surgical correction
• Spinal cord compression - Laminectomy

104. Follow up

105. Follow up
Monthly:
• Complete blood count
• Complete blood chemistry (including liver function
tests, BUN, creatinine) if taking deferasirox
• Record transfusion volume.

106. Follow up
Every 3 months:
• Measurement of height and weight
• Measurement of ferritin (trends in ferritin used to adjust
chelation);
• Complete blood chemistry, including liver function tests

107. Follow up
Every 6 months:
• Complete physical examination including Tanner
staging,
• Monitor growth and development
• Dental examination

108. Follow up
Every year:
• Cardiac function – echocardiograph, ECG, Holter
monitor (as indicated)
• Endocrine function (TFTs, PTH, FSH/LH, fasting
glucose, testosterone/estradiol, FSH, LH, IGF-1,
Vitamin D levels)
• Ophthalmological examination and auditory acuity
• Viral serologies (HAV, HBV panel, HCV (or if HCV1,
quantitative HCV RNA PCR), HIV)
• Bone densitometry
• Ongoing psychosocial support.

109. Follow up
Every 2 years:
• Evaluation of tissue iron burden
• Liver iron measurement – R2 MRI, SQUID, or biopsy
• T2* MRI measurement of cardiac iron (age .10 years).

110. C. Prevention and control
 Career detection/Screening
 Genetic counseling
 Prenatal diagnosis
 Health education

111. Screening
• RBC indices (MCV, MCH, MCHC)
• NESTROFT
• HbA2

112. Career detection/screening
Mass screening: NESTROFT (Necked Eye Single Tube
Red Cell Osmotic Fragility Test)
• Very cheap and easy to perform require small
amount of blood
• Based on principle that Thalassemic red cell resists
hypotonic solution more than that of normal person
• Give positive result on NESTROFT
• Sensitivity 90-98% and specificity 85-90%

113. NESTROFT

114. Career detection/screening
Automated CBC:
• Thalassemic red cells are microcytic and hypochromic
• WHO recommends MCV <77fl and MCH <27 pg as
screening tools to pick up cases for confirmation by
electrophoresis
DCIP (Di Chloro phenol indol phenol): Screening for Hb
E

115. Genetic counseling
• Index case parents and relatives.
• Antenatal visits of pregnant mothers.

116. Genetic counseling

117. • β/α ratio: <0.025 in fetal
blood
• Chorionic villous biopsy
(10-12 weeks)
• Cordocentesis
• Amniocentesis (15-18th
week) Analysis of fetal DNA
• PCR to detect β globin
gene
Prenatal diagnosis

118. Chorionic Villus Biopsy

119. Health education/awareness
• Knowledge of genetic nature of thalassemia
• Transmission of the disease
• Ways to avoid to have further child with the disease
• Aware about economic burden to the family and govt.

120. Prognosis

121. Thalassemia major-life expectancy:
• Without regular transfusion - Less than 10 years
• With regular transfusion and no or poor iron chelation -
Less than 25 years
• With regular transfusion and good iron chelation - 40
years, or longer?
The commonest cause of death is iron overload

122. Conclusion
• Management needs extensive hands
• Prevention program is rudimentary
• Awareness about thalassemia is though increasing still
very much lacking
• Manpower is developing-good news
• Thalassemia center dedicated to children to be
established

123. Thalassemia day
8th May is the international Thalassemia Day. This day is
dedicated to Thalassemia, to raise public awareness for
prevention of Thalassemia and to highlight the
importance of clinical care for Thalassemia patients in all
countries.

124. Thank You