Thalassemias are a group of inherited blood disorders that manifest as the production of reduced hemoglobin. Symptoms depend on the type of thalassemia and can vary from none to severe, including death. Often there is mild-to-severe anemia (low red blood cells or hemoglobin), as thalassemia can affect the production of red blood cells and also affect how long the red blood cells live. Symptoms include tiredness, pallor, bone problems, an enlarged spleen, jaundice, pulmonary hypertension, and dark urine. A child's growth and development may be slower than normal.
Thalassemias are genetic disorders. Alpha thalassemia is caused by deficient production of the alpha globin component of hemoglobin, while beta thalassemia is a deficiency in the beta globin component. The severity of alpha and beta thalassemia depends on how many of the four genes for alpha globin or two genes for beta globin are faulty. Diagnosis is typically by blood tests including a complete blood count, special hemoglobin tests, and genetic tests. Diagnosis may occur before birth through prenatal testing.
Treatment depends on the type and severity. Clinically, thalassemia is classed as Transfusion-Dependent Thalassemia (TDT) or non-Transfusion-Dependent Thalassemia (NTDT), since this determines the principal treatment options. TDT requires regular blood transfusions, typically every two to five weeks. TDTs include beta-thalassemia major, hemoglobin H disease, and severe HbE/beta-thalassemia. NTDT does not need regular transfusions but may require transfusion in case of an anemia crisis. Complications of transfusion include iron overload with resulting heart or liver disease. Other symptoms of thalassemias include enlargement of the spleen, frequent infections, and osteoporosis.
The Global Burden of Disease Survey found that 1.31 million people worldwide have severe thalassemia while thalassemia trait occurs in 358 million people, causing 11,100 deaths per annum. It is slightly more prevalent in males than females. It is most common among people of Greek, Italian, Middle Eastern, South Asian, and African descent. Those who have minor degrees of thalassemia, in common with those who have sickle-cell trait, have some protection against malaria, explaining why sickle-cell trait and thalassemia are historically more common in regions of the world where the risk of malaria is higher.
Etymology and synonym The word thalassemia () derives from the Greek (), 'sea',. and Neo-Latin (from the Greek compound stem [], from [], 'blood').. It was coined because the condition called "Mediterranean anemia" was first described in people of Mediterranean ethnicities. "Mediterranean anemia" was renamed thalassemia major once the genetics were better understood. The word thalassemia was first used in 1932.
Hemoglobin structural biology
Normal human hemoglobins are tetrameric proteins composed of two pairs of globin chains, each of which contains one alpha-like (α-like) chain and one beta-like (β-like) chain. Each globin chain is associated with an iron-containing heme molecular component. Throughout life, the synthesis of the alpha-like and the beta-like chains is balanced so that their ratio is relatively constant and there is no excess of either type.Weatherall DJ. The New Genetics and Clinical Practice, Oxford University Press, Oxford 1991.
The specific alpha and beta-like chains that are incorporated into hemoglobins are highly regulated during development: Embryonic hemoglobins are expressed as early as four to six weeks of embryogenesis and disappear around the eighth week of gestation as they are replaced by fetal hemoglobin.Huisman TH. The structure and function of normal and abnormal haemoglobins. In: Baillière's Clinical Haematology, Higgs DR, Weatherall DJ (Eds), W.B. Saunders, London 1993. p.1.Natarajan K, Townes TM, Kutlar A. Disorders of hemoglobin structure: sickle cell anemia and related abnormalities. In: Williams Hematology, 8th ed, Kaushansky K, Lichtman MA, Beutler E, et al. (Eds), McGraw-Hill, 2010. p.ch.48. Fetal hemoglobin (HbF) is produced from approximately eight weeks of gestation through to birth and constitutes approximately 80 percent of hemoglobin in the full-term neonate. It declines during the first few months of life and constitutes <1 percent of total hemoglobin by and past early childhood. HbF is composed of two alpha globins and two gamma globins (α2γ2). Adult hemoglobin (HbA) is produced at low levels through embryonic and fetal life and is the predominant hemoglobin in children by six months of age and onward; it constitutes 96-97% of total hemoglobin in individuals without a hemoglobinopathy. It is composed of two alpha globins and two beta globins (α2β2). Hemoglobin A2 (HbA2) is a minor adult hemoglobin that normally accounts for approximately 2.5-3.5% of total hemoglobin. It is composed of two alpha globins and two delta globins (α2δ2).
Symptoms
Symptoms depend on the type and severity of thalassemia. Carriers of thalassemia genes may have no symptoms (thalassemia minor) or very mild symptoms with occasional crisis (thalassemia intermedia); individuals who are homozygous for the mutation have severe and life threatening symptoms (thalassemia major).
Alpha thalassemia major is generally fatal to the unborn child, as the absence of alpha globin means that zero functional hemoglobin is produced during gestation. Unmatched gamma globin chains cluster to form hemoglobin Barts, which is ineffective at transporting oxygen. In this situation, a fetus will develop hydrops fetalis, a form of edema, which can be detected on prenatal ultrasound. The child will normally die before or shortly after birth, unless intrauterine blood transfusion is performed. Less severe alpha thalassemia may affect growth and development.
Beta thalassemia symptoms typically begin to show during the first six months of life, as the body winds down production of fetal hemoglobin HbF. In a normal individual, this would be replaced by adult hemoglobin HbA.
If thalassemia is untreated or undetected in an infant, developmental issues such as slowed growth, delayed puberty, bone abnormalities and intellectual impairment are likely.
More generally, impaired production of hemoglobin causes anemia, resulting in tiredness and a general lack of energy, shortness of breath, rapid or irregular heartbeat, dizziness, pale skin, yellowing of the skin and eyes (jaundice).
In thalassemia, ineffective erythropoiesis causes the bone marrow to expand. This expansion is a compensatory response to the damage caused to red blood cells by the imbalanced production of globin chains. Bone marrow expansion can lead to abnormal bone structure, particularly in the skull and face. Expansion of the bone marrow in the developing child leads to a distinctive facial shape often referred to as "Chipmunk facies". Other skeletal changes include osteoporosis, growth retardation, and malformation of the spine.
People with thalassemia can get too much iron in their bodies, either from the disease itself as red blood cells are destroyed, or as a consequence of frequent blood transfusions. Excess iron is not excreted, but forms toxic non-transferrin-bound iron. This can lead to organ damage, potentially affecting the heart, liver, endocrine system, bones and spleen. Symptoms include an irregular heartbeat, cardiomyopathy, cirrhosis of the liver, hypothyroidism, delayed puberty and fertility problems, brittle and deformed bones, and an enlarged spleen.
The spleen is the organ which removes damaged red blood cells from circulation; in thalassemia patients it is abnormally active, causing it to enlarge and possibly become hyperactive, a condition called hypersplenism.
The immune system can become compromised in a number of ways; anemia, iron overload, and hypersplenism may affect the immune response and increase the risk of severe infection.
Pathophysiology
Hemoglobin is a protein containing iron that facilitates the transportation of oxygen in red blood cells. Hemoglobin in the blood carries oxygen from the lungs to the other tissues of the body, where it releases the oxygen to enable metabolism. A healthy level of hemoglobin for men is between 13.2 and 16.6 grams per deciliter, and in women between 11.6 and 15 g/dl.
Normal adult hemoglobin (HbA) is composed of four protein chains, two α and two β-globin chains arranged into a heterotetramer. In thalassemia, patients have defects in the noncoding region of either the α or β-globin genes, causing ineffective production of normal alpha- or beta-globin chains, which can lead to ineffective erythropoiesis, premature red blood cell destruction, and anemia.Baird DC, Batten SH, Sparks SK. Alpha- and Beta-thalassemia: Rapid Evidence Review. Am Fam Physician. 2022 Mar 1;105(3):272-280. PMID 35289581. The thalassemias are classified according to which chain of the hemoglobin molecule is affected. In α-thalassemias, production of the α-globin chain is affected, while in β-thalassemia, production of the β-globin chain is affected.
Evolutionary advantage
Having a mild form of alpha thalassemia has been demonstrated to protect against malaria and thus can be an advantage in malaria endemic areas, thus conferring a selective survival advantage on carriers (known as heterozygous advantage), and perpetuating the mutation. There are suggestions that mild beta thalassemia may provide similar protection but this has not been proven.
α-thalassemia genes have a high prevalence in populations of sub-Saharan Africa, Mediterranean, Middle East, and southeast and east Asia. β-thalassemias are prevalent in the populations of the Mediterranean, Middle East, and Southeast Asia.
Alpha-thalassemia
The α-globin chains are encoded by two closely linked genes HBA1 and HBA2 on chromosome 16; in a person with two copies on each chromosome, a total of four loci encode the α chain.Robbins Basic Pathology, Page No:428 Two alleles are maternal and two alleles are paternal in origin. Alpha-thalassemias result in decreased alpha-globin production, resulting in an excess of β chains in adults and excess γ chains in fetus and newborns.
In infants and adults, the excess β chains form unstable tetramers called hemoglobin H or HbH comprising 4 beta chains. In the fetus, the excess γ chains combine hemoglobin Bart's comprising 4 gamma chains
Both HbH and Hb Bart's have a strong affinity for oxygen but do not release it, causing oxygen starvation in the tissues. They can also precipitate within the RBC damaging its membrane and shortening the life of the cell.
The severity of the α-thalassemias is correlated with the number of affected α-globin alleles: the greater, the more severe will be the manifestations of the disease.
+Severity of alpha thalassemia# of faulty allelesTypes of alpha thalassemiaSymptoms1Silent carrierNo symptoms2Alpha thalassemia traitMinor anemia3Hemoglobin H diseaseMild to moderate anemia; may lead normal life4Hemoglobin Bart's hydrops fetalisDeath usually occurs in utero or at birth
Beta-thalassemia
β-globin chains are encoded by the HBB gene on chromosome 11; in a healthy person with two copies on each chromosome, two loci encode the β chain. In beta thalassemia, a single faulty gene can be either asymptomatic or cause mild disease; if both genes are faulty this causes moderate to severe disease.
Mutated alleles are called β+ when partial function is conserved and some beta-globin is generated, or βo when no functioning protein is produced.
The situation of both alleles determines the clinical picture: β thalassemia major (Mediterranean anemia or Cooley anemia) is caused by a βo/βo genotype. No functional β chains are produced, and thus no hemoglobin A can be assembled. This is the most severe form of β-thalassemia. β thalassemia intermedia is caused by a β+/βo or β+/β+ genotype. In this form, some hemoglobin A is produced.