Diagnosis Of Sickle Cell Trait Research Articles

Risk and Protective Factors for COVID-19 Infection Among Pregnant Women with Sickle Cell Trait

BACKGROUND: Pregnant women and individuals with sickle cell trait (SCT) and underlying comorbidities are more vulnerable to severe illness from the coronavirus disease of 2019 (COVID-19) compared to nonpregnant women and those without SCT (PMID: 35916859, 34129519). However, the impact of the pandemic and factors affecting susceptibility to COVID-19 among pregnant women with SCT is unknown. This study aims to examine various factors that can alter the likelihood of COVID-19 among pregnant women with SCT, including vaccination against COVID-19 and influenza and the presence of underlying comorbidities such as cardiac disease, diabetes, obesity, renal disease, and stroke. In addition, the study aims to provide insights into the fetal outcomes among pregnant women with SCT who have contracted COVID-19. METHODS: A total of 295 individuals with the diagnosis of SCT who had encounters at three large hospitals in Michigan from January 1, 2022, to December 31, 2022, were screened in this retrospective study. 151 women with SCT met the inclusion criteria and are within the reproductive age group between 15-49 years old. Demographics, underlying comorbidities, fetal outcomes, and other clinical information were collected by electronic medical records review. COVID-19 and influenza vaccination were verified from the immunization records registry in Michigan. Multivariable regression analysis was used to analyze the protective or risk factors associated with COVID-19 infection. Statistical analyses were performed using the SPSS version 29 statistical software, and a p-value of <0.05 was considered statistically significant. RESULTS: Data was collected from 151 women with SCT, with 34% being pregnant and 66% being non-pregnant. Approximately 85% of the participants were Black, and their mean age was 32 years. 35% contracted COVID-19 among pregnant women, while 31% among non-pregnant women (p>0.05). In a multivariable regression analysis, the study found that pregnant women with SCT who received COVID-19 vaccine were 90% less likely to have a COVID-19 infection (OR=0.102 with 95%CI: 0.011-0.950) and 9 times more likely to have a COVID-19 infection if they had a history of pulmonary conditions such as asthma, chronic obstructive pulmonary disease, or obstructive sleep apnea (OR=9.375 with 95% CI: 1.090-80.627). There were no other protective or risk factors that showed a significant statistical association with COVID-19 infection among pregnant women, including influenza vaccination, obesity, underlying cardiac history, diabetes mellitus, renal disorder, stroke, or transient ischemic attack (p>0.05). Most pregnant women with SCT who contracted COVID-19 in the study had mild-moderate disease, except for one patient who developed severe disease in the third trimester, warranting premature delivery of an infant via emergency cesarean section. 72% did not have fetal complications, except for 3 newborns who were delivered preterm (<37 weeks) and 2 with low birth weight (<2500 grams). While 2 newborns initially had a low Apgar score (APGAR<7) at 1 minute, their condition eventually improved after 5 minutes. Overall, all newborns delivered to COVID-19-infected women with SCT had a good 5-minute Apgar score. CONCLUSION: The study further emphasizes the importance of encouraging COVID-19 vaccination among individuals with SCT, particularly pregnant, reproductive age group women and those with underlying comorbidities. Pregnant women with SCT and underlying comorbidities should be carefully monitored to prevent severe disease, as they may be more vulnerable to COVID-19 infection. Further studies with larger sample sizes are recommended to investigate factors associated with severe COVID-19 infection among these populations.

A stepwise diagnostic approach for undiagnosed Anemia in children: A model for low-middle income country

BackgroundReaching a precise diagnosis in rare inherited anemia is extremely difficult and challenging, especially in areas with limited use of genetic studies, which makes undiagnosed anemia a unique clinical entity in tertiary hematology centers. In this study, we aim at plotting a stepwise diagnostic approach in children with undiagnosed anemia while identifying indications for genetic testing. Patients and methodsA one-year cross-sectional study involved 44 children and adolescents with undiagnosed anemia after undergoing an initial routine panel of investigations. They were classified based on mean corpuscular volume (MCV) into 3 groups: microcytic (n = 19), normocytic (n = 14) and macrocytic (n = 11). An algorithm that included four levels of investigations was devised for each category. ResultsAfter applying a systematic diagnostic approach, 33 patients (75 %) were diagnosed of whom 7 (15 %) had combined diagnoses, while 11 (25 %) patients remained undiagnosed. Based on the first, second, third and fourth levels of investigations, patients were diagnosed, respectively, as follows: of the 11 patients, 7 were microcytic, 3 normocytic and 1 macrocytic; of the 7 patients, 2 were microcytic, 2 normocytic, and 3 macrocytic; of 10 patients, 5 were microcytic, 4 normocytic and 1 macrocytic; finally, of the 16 patients, 8 were microcytic, 6 normocytic and 2 macrocytic. Numbers recorded appear higher than the actual number of the patients because some of them were diagnosed by more than one level of investigation. The diagnoses obtained in the microcytic group showed hemoglobinopathies, iron refractory iron deficiency anemia (IRIDA), membrane defects, sideroblastic anemia, hypo-transferrinemia, a combined diagnosis of sickle cell trait and pyropoikilocytosis. The diagnoses also showed a combined diagnosis of hereditary spherocytosis (HS) and alpha thalassemia minor, and a combined diagnosis of iron deficiency anemia and beta thalassemia minor, while 15 % remained undiagnosed. In the normocytic group, the diagnosis revealed autosomal recessive (AR) HS, vitamin B12 deficiency, pyruvate kinase deficiency (PKD), congenital dyserythropoietic anemia (CDA) type I, Diamond Blackfan anemia and beta thalassemia major. In addition, it showed a combined diagnosis of AR HS and CDA type II, a combined diagnosis of AR HS and PKD, and a combined diagnosis of dehydrated stomatocytosis (DHS) and G6PD carrier, meanwhile 20 % remained undiagnosed. Finally, the macrocytic group was diagnosed by vitamin B12 deficiency, sideroblastic anemia, PKD, a combined diagnosis of PKD and G6PD deficiency carrier, while 45 % remained undiagnosed. ConclusionConducting a stepwise approach with different levels of investigations may help reach the diagnosis of difficult anemia without having to resort to unnecessary investigations. Combined diagnosis is an important cause of undiagnosed anemia, especially in countries with high frequency of consanguinity. The remaining 25 % of the patients continued to be undiagnosed, requiring more sophisticated investigations.

Closing Knowledge Gaps Among Parents of Children with Sickle Cell Trait

BackgroundNearly 8% of African Americans carry sickle cell trait (SCT) and approximately 2000 infants in the United States are born with sickle cell disease (SCD) annually. SCT knowledge is necessary for individuals with SCT to make informed reproductive decisions since they are at risk of having children with SCD. Despite state programs that inform parents of their child's SCT status via telephone call, >80% of adults with SCT do not know their status. This may be because many parents have low health literacy (HL), low baseline SCT knowledge, and/or may not achieve high sustained SCT knowledge after non-standardized phone encounters.The SCTaware education program was designed to improve SCT education to close knowledge gaps that may exist after telephone-only education. It also aims to increase parents' SCT status awareness and their ability to inform their affected children in the future.ObjectivesThe objectives of this interim analysis were to assess central Ohio parents' SCT knowledge after being educated about their child's SCT status by telephone (standard of care) and to explore if SCTaware improves parents' knowledge immediately and one month after receiving it.MethodsA multidisciplinary team (hematologists, a genetic counselor, HL experts, SCT educators, parent stakeholders, and visual design experts) developed SCTaware, a videoconference-administered education program that is delivered by a trained educator and includes SCT knowledge objectives, HL-informed communication strategies (e.g., teach-back), visuals scoring highly for understandability, and access to narrated post-education review materials.Through electronic medical record review, we identified English-speaking biological parents of infants with SCT who were informed of their child's SCT by telephone. Adult parents who were able to be contacted by telephone were invited to participate if they did not have SCD or a child with SCD, had not received SCT education in central Ohio for another child, were not (or partner was not) currently pregnant, and had access to an electronic device capable of videoconferencing.After informed consent, parents reported their and their child's SCT status, completed a demographic survey, a HL assessment, and the published Sickle Cell Trait Knowledge Assessment (SCTKA) consisting of eight questions. Participants then received SCTaware and repeated the SCTKA and report of their and their child's SCT status immediately and one month later. SCTKA scores <75% correct were considered low. Data were summarized descriptively. Linear mixed effects models with random intercept for each parent were used to assess scores longitudinally.ResultsOf the 297 children with SCT whose parent received telephone education between March 2020-April 2021, 114 had a parent who was able to be contacted, 22 were ineligible when contacted, and five declined participation because they reported having adequate knowledge. To date, 63 parents have enrolled, 54 have completed baseline surveys (Table 1), 44 have completed SCTaware, and 35 have completed the one-month follow-up.Following telephone education, 44% of participants had high SCT knowledge. Participants' mean SCTKA scores post-telephone education did not significantly differ whether they had received telephone education ≤3 months or >3 months before enrolling in the study (64% correct vs. 71% correct, p=0.30).Of those who had completed SCTaware, 42 (95%) achieved high SCT knowledge immediately after. Of those who have completed the one-month follow-up, 94% continue to have high knowledge. Participants with low HL had significantly lower SCTKA scores post-telephone education but those with high and low HL achieved and maintained high sustained knowledge one month after receiving SCTaware (Figure 1).DiscussionOur interim analysis shows that over half of parents, especially those with low HL, have low SCT knowledge after receiving education by telephone regarding their infant's diagnosis of SCT. SCTaware is a scalable tool that could be widely implemented as an initial program or as a follow-up to telephone education if final analyses confirm that SCTaware leads to sustained knowledge gains. Future studies, however, need to determine parent access to and satisfaction with SCTaware and if individuals use the knowledge gained to inform their reproductive decision-making and to inform their affected children. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Splenic Infarction Due to Sickle Cell Trait while Visiting a Hill Station

Background: Sickle-cell trait (SCT) is a common genetic abnormality in the Indian population. Though SCT is largely a benign disorder, it can rarely present with complications such as splenic infarction. Case Presentation: Here, we report the case of a 27-year-old Muslim male developed acute left upper quadrant abdominal pain and constipation while visiting a hill station, Ooty (Tamil Nadu, India). The patient had a history of similar complaint while visiting the same hill station while he was a student and was hospitalized and treated as acute gastritis. He also gave a history of abdominal pain while traveling in the airplane to Qatar where he works. Conclusion: Our patient had multiple episodes of abdominal pain while flying and visiting hill station, but the diagnosis of SCT was not suspected probably due to the above reasons. However, it is very important to evaluate patients with recurrent abdominal pain in higher altitudes for SCT as it can result in its early diagnosis of splenic infarction and timely initiation of appropriate management, which can lead to good prognosis.

Red urine, updated for the nephrologist: a case report

BackgroundSickle cell trait is not completely benign, and some renal complications can occur. The baseline rate of admission for gross hematuria in normal males carrying the sickle cell trait is 2%.Case presentationA 35-year-old non-smoking African man experienced a 2-week history of painless, profuse and persistent gross hematuria. Laboratory tests showed normal renal function, hematuria and mild proteinuria. Abdominal ultrasonography and computed tomography angiography revealed no renal abnormalities; the bladder appeared pristine under cystoscopy. The diagnosis of sickle cell trait associated with gross hematuria was made using hemoglobin electrophoresis; renal biopsy and its complications were avoided. Urine was clear after 2 weeks of oral hydration and gamma epsilon-aminocaproic acid.ConclusionHemoglobin electrophoresis should be performed in cases of gross hematuria. Coupled with other non-invasive evaluation, this could avoid renal biopsy and its associated complications.

Splenic Infarction Induced By Epstein-Barr Virus Infection in a Patient with Sickle Cell Trait

IntroductionAlthough sickle cell trait (SCT) is considered a benign condition, evidence has been accumulating for related complications, including isothenuria, hematuria, exercise-induced death and splenic infarction.Most splenic infarctions are reported during a hypoxic state.Non-hypoxic related splenic infarction in a patient with SCT and EBV infection has been reported once.Here we present the second case of such association.Case ReportAn otherwise healthy 7-year-old African American male presented with worsening LUQ abdominal pain associated with emesis, dark-colored urine and low-grade fever. There was no history of trauma. Family history was positive for SCD.On presentation, the patient had a temperature of 38.2 °C and was tachycardic. Physical examination revealed scleral icterus and conjunctival pallor. Abdomen was soft, but the spleen was tender and palpable 6 cm below the costal margin.Laboratory studies showed hemoglobin of 7.2 g/dL, MCV 72.6 fL, leukocytes 14 X 109/L with 73% neutrophils, platelet count 136 X 109/L, and reticulocyte count 8%. Peripheral blood smear didn't reveal sickling, spherocytosis nor elliptocytosis. Total bilirubin was 3.5 mg/dL, direct bilirubin 0.6 mg/dL, ALT 13 U/L, AST 57 IU/L, LDH 476 IU/L. The Direct Coombs were negative. The D-dimer was positive. The Abdominal X-ray was negative, however abdominal ultrasound showed an enlarged spleen, 13.1 cm in longitudinal diameter.An Abdominal MRI showed splenic enlargement, 13 cm in longitudinal diameter, with non-enhancing 4 cm density in anterior aspect and minimal left pleural effusion.The thrombophilia work-up was negative. EB VCA IgG and IgM antibodies levels were high (> 8 and 1 AI, respectively), consistent with late acute infection. The CMV serology was negative. G6PD screening was negative. Hemoglobin electrophoresis revealed HbA 63.9%, HbA2 3.1%, HbF 0.0%, and HbS 33%. Patient was managed conservatively with RBCs transfusion, hydration and pain control and discharged home once stable.DiscussionSCT is generally considered a benign hematological condition, still evidence has been accumulating for related complications. In United States, SCT affects 6-9% of the African American population, and 0.01-0.05% of the remaining population.Splenic infarction is commonly associated with SCD, but rarely with SCT. Reported cases of splenic infarction in SCT have been predominantly related to hypoxic states, primarily in a high altitude setting. Still there have been limited reports in non-hypoxic conditions. (Kark JA and Ward FT Semin Hematol1994).One case of non-hypoxic related splenic infarction in a patient with SCT and acute EBV infection was reported (Symeonidis A et al Acta Haematol 2001). Here we report the second case.We present a non-obese, previously healthy male with no evidence of hypoxia, high altitude setting, or intensive exercise. He suffered a splenic infarction during the acute phase of EBV infection. His initial presentation was consistent with hemolytic anemia and indirect hyperbilirubinemia, which led to further work-up and the diagnosis of SCT. We postulate that hemolysis resulted from hypersplenism.Possible factors leading to infarction in SCT are the induction of sickling and the presence of a hypercoagulable state. The exposure of these HbAS erythrocytes to lower pH and hypoxia in the splenic circulation likely promotes sickling and, as a consequence, splenic infarcts. Subjects with HbAS have significantly increased levels of D-dimer, thrombin-antithrombin TAT complexes, prothrombin fragment 1.2 (F1.2) and absolute monocytosis. The African American population has a 7% risk of VTE attributable to HbAS compared to an attributable risk of 3% for prothrombin G20210A mutation in the Caucasian population.Contributing factors to splenic infarction in the presence of acute EBV infection can be thrombophilia, thrombotic microangiopathy and rapid splenic enlargement. Moreover, during an EBV infection, acute expansion of splenic red and white pulp, as well as increased blood flow and loosening of the reticular network, make the organ friable. HbS existing under such conditions may be quite unstable, which can induce sickling. DisclosuresNo relevant conflicts of interest to declare.

Infarto esplénico no relacionado con la altura en un paciente con rasgo falciforme: reporte de caso

Presentamos el caso de un hombre mestizo de 51 años, habitante de Medellín, Colombia, con dolor agudo repentino en hipocondrio izquierdo. La tomografía contrastada de abdomen reveló la presencia de múltiples zonas de infarto esplénico. Después de una evaluación exhaustiva se descartó enfermedad cardioembólica, infecciones y trombofilia. Se solicitó una electroforesis de hemoglobina que demostró la condición de portador del rasgo falciforme. Este es uno de los pocos reportes en la literatura de un paciente con rasgo falciforme e infarto esplénico no asociado con la exposición a grandes alturas.

Magnetic resonance urography of renal papillary necrosis

Sir, Renal papillary necrosis is a well-described entity on intravenous pyelogram (IVP) and CT urogram in both the adult and pediatric populations [1–3]. However pediatric renal papillary necrosis is less frequently encountered, particularly on magnetic resonance urogram [4–6]. Indeed, to the best of our knowledge renal papillary necrosis has yet to be described on MR urogram. We present a case of renal papillary necrosis demonstrated by MR urogram in a child with previously undiagnosed sickle cell trait. A 17-year-old previously healthy African-American girl presented to our institution with a 3-day history of gross hematuria. Her medical history was unremarkable except for recent streptococcal pharyngitis. After 2 months of extensive and inconclusive evaluation, including laboratory analysis, renal US, and a renal biopsy, the hematuria persisted, with hemoglobin decreasing to 4 g/deciliter. The girl was subsequently evaluated by cystoscopy, which demonstrated hemorrhage from the left ureteral orifice. Retrograde pyelogram and cystoureteroscope showed irregularity of the left upper pole papillary urothelium (Fig. 1). At this point, the pediatric urologist was suspicious but not confident of the diagnosis of renal papillary necrosis. Symptoms persisted, so MR urography was performed. MR urogram demonstrated classic changes of bilateral papillary necrosis (Fig. 2). Given these findings, a hemoglobin electrophoresis led to the diagnosis of sickle cell trait. The girl was placed on aminocaproic acid with cessation of hematuria. Imaging of renal papillary necrosis, which is most commonly caused by sickle cell disease and nonsteroidal anti-inflammatory medications in the pediatric population, is well documented within the radiology literature, with Praetorius first describing its radiologic appearance in 1937 [2]. Classically, intravenous pyelogram has been the examination of choice. From its appearance on intravenous pyelogram, multiple classic radiographic signs have been elucidated, e.g., ballon-tee, lobster claw, and signet ring. Recently several authors have demonstrated the imaging appearance and diagnosis of renal papillary necrosis in adults using CT urography [3]. However, given the use of iodinated contrast agent and the radiation dose of both CT and intravenous pyelogram, alternative imaging modalities are helpful for pediatric imaging in suspected renal papillary necrosis. In 1995 Rothpearl et al. [6] reported the techniques and application of MR urography in the depiction of the kidney and bladder pathology. One patient included in this study population had pathologically proven renal papillary necrosis. However, the authors did not elucidate whether the changes of renal papillary necrosis were demonstrable on MR urogram [6]. In a subsequent invited commentary, Hattery and King [7] called into question the utility of MR urogram in the detection of papillary necrosis given the resolution requirements for depicting the subtle changes of renal papillary necrosis at the caliceal and forniceal levels [7]. The authors did J. Schroeder Medical University of South Carolina, College of Medicine, Charleston, SC, USA

Immunological Characterization in Malaria Patients with and without the Sickle-Cell Trait

Background: Malaria is one of the main causes of mortality in tropical zone. Specific immune responses are induced by parasite, including the release of cytokines from peripheral blood mononuclear cells. Sickle cell trait confers a high degree of resistance to severe and complicated malaria. The present study aims to assess immunological response of P. falciparum infection by measuring of total IgG level and IL-6, IL-12 & IL-18 levels for P. falciparum among Saudi Arabian patients with and without sickle-cell trait. Patients and Methods: Thirty patients who had clinical suspicion of malaria and sickle-cell trait attending Jazan general hospital in KSA were included in the study. Malaria patients with sickle-cell trait will be matched with a control (thirty patients diagnosed to have malaria but without sickle-cell trait). Diagnosis of malaria was done by Immunochromatography strip and blood film. Diagnosis of Sickle-cell trait was done by hemoglobin electrophoresis assessment of total IgG titre and Interleukin 6, 12, 18 levels using ELIZA. Results: Cytokines and IgG in uncomplicated clinical malaria (n = 22) and severe malaria (n = 7) were IL6 (83.1 pg/mL) versus (75.2 pg/mL), IL12 (19.4 pg/mL) versus (16.3 pg/mL), IL18 (22.45 pg/mL) versus (24.2 pg/mL) and IgG (13.3 SD) versus (4.5 SD). Differences in the IL6, IL12 and IgG were statistically significant (p value >0.02, >0.004 & >0.002 respectively). Among malaria patients with sickle cell trait, Cytokines and IgG in asymptomatic (n = 19) and uncomplicated clinical malaria (n = 11) were IL6 (88.9 pg/mL) versus (79.2 pg/mL), IL12 (24 pg/mL) versus (22.9 pg/mL), IL18 (24.2 pg/mL) versus (31.2 pg/mL) and IgG (27 SD) versus (7.35 SD). Differences in IgG were statistically significant (p value ≥ 0.003). Serum IL6 levels were higher in patients with uncomplicated clinical malaria without sickle cell trait (median 83.1 ± 5.1 pg/mL) than in patients with uncomplicated clinical malaria with sickle cell trait (medians 79.2 ± 4.5 pg/mL). This difference was statistically significant (p value = 0.003). Serum IgG levels were higher in patients with uncomplicated clinical malaria without sickle cell trait (median 13.3 ± 10.84) than in patients with uncomplicated clinical malaria with sickle cell trait (medians 7.35 ± 2.95) while in asymptomatic malaria and severe malaria, medians (27 ± 11.13 versus 4.5 ± 2.75). This difference was statistically highly significant (p value = 0.0009). Conclusion: Malaria protection by HbAS involves the enhancement of not only innate but also of acquired immunity to the parasite. Cytokins (IL6, IL12) and IgG play an important role in protection against severe malaria. The presence of HbAS is associated with increased acquired immunity to malaria. Further work will be done to work out how this change in immunity occurs but treatment of anyone with malaria, whatever their sickle cell status, is essential.

Alpha chain hemoglobins with electrophoretic mobility similar to that of hemoglobin S in a newborn screening program

ObjectiveTo characterize alpha-chain variant hemoglobins with electric mobility similar to that of hemoglobin S in a newborn screening program. MethodsβS allele and alpha-thalassemia deletions were investigated in 14 children who had undefined hemoglobin at birth and an electrophoretic profile similar to that of hemoglobin S when they were six months old. Gene sequencing and restriction enzymes (DdeI, BsaJI, NlaIV, Bsu36I and TaqI) were used to identify hemoglobins. Clinical and hematological data were obtained from children who attended scheduled medical visits. ResultsThe following alpha chain variants were found: seven children with hemoglobin Hasharon [alpha2 47(CE5) Asp>His, HbA2:c.142G>C], all associated with alpha-thalassemia, five with hemoglobin Ottawa [alpha1 15(A13) Gly>Arg, HBA1:c.46G>C], one with hemoglobin St Luke's [alpha1 95(G2) Pro>Arg, HBA1:c.287C>G] and another one with hemoglobin Etobicoke [alpha212 84(F5) Ser>Arg, HBA212:c.255C>G]. Two associations with hemoglobin S were found: one with hemoglobin Ottawa and one with hemoglobin St Luke's. The mutation underlying hemoglobin Etobicoke was located in a hybrid α212 allele in one child. There was no evidence of clinically relevant hemoglobins detected in this study. ConclusionApparently these are the first cases of hemoglobin Ottawa, St Luke's, Etobicoke and the α212 gene described in Brazil. The hemoglobins detected in this study may lead to false diagnosis of sickle cell trait or sickle cell disease when only isoelectric focusing is used in neonatal screening. Additional tests are necessary for the correct identification of hemoglobin variants.

Recurrent Acute Splenic Sequestration in Two Children with Coinheritance of Sickle Cell Trait and Hereditary Spherocytosis.

AbstractAbstract 2091 Background:Patients with sickle cell trait (AS) are generally asymptomatic, but they are known to be at risk of developing acute morbidity such as splenic infarction mainly occurring on exposure to high altitude. Much lesser known to most hematologists is that young children with AS who co-inherit hereditary spherocytosis (HS) seem to be at risk of developing acute splenic sequestration crisis (ASSC), which are undistinguishable from those observed in homozygous sickle cell anemia (SCA). Objective:The aim of this abstract is to report 2 patients with sickle cell trait and hereditary spherocytosis, presenting with recurrent episodes of severe hemolytic anemia with features characteristic of ASSC. Patients:Patient 1 is a 4-year-old African American female, whose birth history revealed hemoglobin (Hgb) AS phenotype on newborn screening and hyperbilirubinemia on the 4th day of life requiring phototherapy. At 3 years of age, she presented with severe hemolytic anemia (Hgb 4.6 g/dl, reticulocyte count 9.99%, indirect bilirubin 5 mg/dl, haptoglobin <15 mg/dl) and marked splenomegaly, associated with fever. Blood smear did not show microangiopathic changes or irreversible sickle cells. Hemoglobin electrophoresis confirmed diagnosis of sickle cell trait. Osmotic fragility test revealed increased red cell lysis; band 3 staining on flow cytometry was abnormal. G6PD and pyruvate kinase assays, as well as direct antiglobulin test, were all negative. Subsequently, 4 months apart, she had two similar episodes of severe anemia (Hgb 6.1 and 4.7 g/dl, respectively) and massive splenomegaly, associated with febrile respiratory illnesses. Each time, rapid resolution of splenomegaly and dramatic rise of Hgb following red cell transfusions were observed. On outpatient follow-ups, her baseline Hgb was determined to be 9–10 g/dl. Investigation on both parents disclosed AS phenotype on mother, and mild hemolytic anemia with microspherocytes on blood smear as well as normal Hgb phenotype on father. Due to the recurrent and life-threatening nature of her sequestration crisis, splenectomy was performed recently. Spleen was enlarged and weighed 92 grams; histologic examination showed a markedly congested red pulp and no evidence of recent or remote infarcts, findings felt to be consistent with the diagnosis of HS. Post-splenectomy, Hgb level was 11.8 g/dl.Patient 2 is a 5-year-old African American female with sickle cell trait confirmed by electrophoresis at age 2, when she first presented with fever, splenomegaly and severe hemolytic anemia (Hgb 5.7 g/dl, bilirubin 2.8 mg/dl). Diagnosis of HS was confirmed by abnormal osmotic fragility test. Direct antiglobulin test was negative. Thereafter, she was hospitalized 7 times in the span of 2 years for episodes of severe hemolytic anemia (Hgb ranging 2.6 to 6.3 g/dl and reticulocyte count 10.4 to 29.98%) with marked splenomegaly (as large as 12 cm below costal margin), associated with febrile illnesses. Her baseline Hgb concentration was 8–9 g/dl. She also experienced a dramatic rise in Hgb and rapid resolution of splenomegaly following red cell transfusions. Child underwent splenectomy recently. Her spleen weighed 307 grams; histologic findings were similar as for Patient 1. Conclusion:The above reported cases illustrate that children with combined heterozygosity of AS and HS clinically and hematologically manifest as classical HS (i.e. chronic hemolytic anemia, splenomegaly), but the sickle cell component adds recurrent ASSC to the picture. It has been suggested that the high MCHC characteristic of HS which results in elevated erythrocytic Hgb S concentration might be a predisposing factor for development of ASSC. In addition, we surmise that fever and dehydration during infections worsen the hypoxic and acidotic splenic milieu which predisposes to massive intrasplenic sickling. In a single previously reported experience on two other children with AS and HS whose clinical course was complicated by ASSC, splenectomy was performed. Based on our experience, we suggest that patients with sickle cell trait presenting with hemolytic anemia and splenomegaly should be thoroughly evaluated to exclude HS. Likewise, given the life-threatening nature of the splenic sequestrations observed in our patients, splenectomy (after due immunizations) appears to be the best treatment approach for these children. Disclosures:No relevant conflicts of interest to declare.

Continuing Diagnostic Relevance of the Sickling Test in the Era of CE-HPLC

Dear Editor, Cation-exchange high performance liquid chromatography (CE-HPLC) has become the most common method used to screen for hemoglobin variants. However, identification is only provisional and current guidelines emphasize that all chromatographically detected abnormal hemoglobins must subsequently be verified by an independent second technique [1]. Sickle cell hemoglobin (HbS)-related disorders are common in India [2]. CE-HPLC is highly specific for HbS in the Indian setting since the S-window co-eluting variants (retention time 4.3–4.7 min) like HbQ-Thailand, HbG-San Jose, and Hb-Manitoba are few and moreover, are extremely rare in Indians [2–4]. We recently encountered two related patients with a non-sickling hemoglobin eluting in the S-window where a routine time-tested sickling test with sodium metabisulfite–sodium dithionite prevented a misdiagnosis. A Sudanese mother and daughter, who were in India on a business visit, underwent a routine health check-up that revealed very mild hypochromic anemia (Table 1). Their serum iron parameters were within normal limits. CE-HPLC (BioRad variant II system, β-thal short programme) revealed peaks in the HbS-window in both mother (32.9%) and daughter (32.7%) with an identical retention time of 4.61 min (Fig. 1). Although, a diagnosis of sickle cell trait was entirely consistent with their African ancestry, sickling tests with sodium metabisulfite–sodium dithionite were done as is routine in our laboratory for all HbS-window peaks. To our surprise, no sickling occurred at 24 h in either patient. Repeat testing using freshly constituted reagents was also consistently negative. Table 1 Blood count and CE-HPLC parameters in the two patients Fig. 1 CE-HPLC of the mother showing an abnormal hemoglobin peak with a retention time of 4.61 min in the S-window. HbA and HbA2 were also present. The chromatogram of the daughter was very similar Since the second-line modality had failed to confirm HbS, Hb electrophoreses at pH 8.4 was done (SAS-II, Helena BioSciences, Europe). This showed a prominent band for HbA along with a slow-moving band corresponding to the region of Hb S/D/G/Q (Fig. 2). The differential diagnoses at this stage therefore were HbG-San Jose (RT 4.61) and HbQ-Thailand (RT 4.67). Hb-Manitoba was excluded as it migrates just anodal to HbA at alkaline pH [5–7]. Fig. 2 High resolution image of the Hb electrophoresis at alkaline pH. The patients’ samples are in lanes 1 and 2. The other lanes (diagnoses indicated) as well as the adult and fetal controls (lanes 11 and 12) serve as references. The abnormal Hb of ... To differentiate Q-Thailand from G-San Jose, Hb electrophoresis at pH 6.4 was performed. This revealed a band for HbA and another band that merged with it but was faster than HbC and HbS (Fig. 3). This definitively excluded HbS and HbG-San Jose (as G-San Jose migrates between HbC and HbS at acid pH [8]), thereby leading to a presumptive identification of the variant as HbQ-Thailand [9]. Genetic testing was offered, however, the patients declined on being counseled that the variant was unlikely to be of clinical significance to the probands. Fig. 3 High resolution image of the Hb electrophoresis at acid pH. The patients’ samples are in lanes 1 and 2. The other lanes (diagnoses indicated) as well as the adult and fetal controls (lanes 11 and 12) serve as references. The index cases show bands ... HbQ-Thailand occurs due to the mutation α74 (EF3) Asp > His in the α1-globin gene. Its co-inheritance with α2-globin gene deletion is well recognized to yield a high abnormal variant of 30–35% with thalassemic red cell indices as in our cases [9]. In conclusion, our finding of this unusual variant hemoglobin makes a strong argument in favor of the routine confirmation of all S-window CE-HPLC peaks by the simple, cost-effective and rapid test for sickling to avoid misdiagnoses. In addition, it is a reminder to hematopathologists that in this era of medical tourism, one needs to consider rare Hb variants in their differential diagnoses irrespective of ethnic boundaries.

Sickle Cell Trait as a Cause of Splenic Infarction While Climbing Mt. Fuji

We report a 38-year-old mestizo man with the sudden onset of left upper abdominal pain while climbing Mt. Fuji, which is the highest mountain in Japan. Enhanced computed tomography showed splenic infarction. Although his peripheral blood smear was normal, a hemoglobin S level of 40% established the diagnosis of sickle cell trait (SCT). This trait is common worldwide, but is not well recognized by doctors in Japan because no Japanese patients with SCT have been reported. However, in Japan it is important to consider SCT when assessing foreign patients with splenic infarction.

An unusual case of uveitis-glaucoma-hyphema syndrome

Purpose To report a case of uveitis-glaucoma-hyphema (UGH) syndrome in which anterior chamber paracentesis led to the diagnosis of sickle cell trait. Design Observational case report. Methods A 43-year-old Cuban pseudophakic male was seen multiple times over a 3-year period complaining of floaters and blurry vision in his left eye. He was noted to have an inferotemporally displaced posterior chamber intraocular lens and recurrent microhyphemas with elevated intraocular pressure (IOP) readings between 29 and 46 mm Hg with each episode. He was diagnosed with UGH syndrome. Posterior chamber intraocular lens explantation and anterior chamber washout was performed. The aqueous fluid was submitted for cytopathologic examination. Results Postoperatively, the patient’s symptoms resolved and he had no further hemorrhages or elevated IOP readings. Cytopathology of the aspirate revealed sickled red blood cells. Conclusion Microscopic examination of aqueous fluid can be a valuable tool in diagnosing ophthalmic manifestations of systemic disease.

Hemoglobin A2 levels in healthy persons, sickle cell disease, sickle cell trait, and beta-thalassemia by capillary isoelectric focusing.

Simultaneously measuring major and minor hemoglobin (Hb) variants by capillary isoelective focusing, we obtained HbA2 intervals in healthy volunteers (n = 412) (reference value) and patients with HbS or beta-thalassemia. We classified normal HbA2 reference intervals into three age groups: 5 months or younger (1.2% +/- 1.5%), 6 months to 1 year (2.2% +/- 0.9%), and 1 year or older (2.4% +/- 0.9%). These intervals were comparable to those used with other methods. Patients 1 year of age or older with HbS had significantly higher HbA2 levels (sickle cell trait, 2.9% +/- 0.9%; sickle cell anemia, 2.8% +/- 1.0%; P < .05). Although reference HbA2 intervals overlapped those in patients with HbS, no overlap in HbA2 levels was noted between these groups and patients with beta-thalassemia (observed range, 4.3% to 7.5%). The higher than normal HbA2 interval in patients with HbS must be considered before a diagnosis of sickle cell trait or sickle cell disease with beta-thalassemia is made.

Antenatal Diagnosis of Sickle-Cell Anaemia by D. N. A. Analysis of Amniotic-Fluid Cells

The polymorphism of a restriction endonuclease site has been used for antenatal diagnosis of sickle-cell disease. In a normal person, the beta-globin gene was contained in a Hpa I-digested D.N.A. fragment 7.6 kilobases (kb) in length. In a family where the sickle gene was contained in a variant 13.0 kb fragment, restriction endonuclease mapping was used for antenatal diagnosis. The D.N.A. from amniotic-fluid cells produced both the 7.6 and the 13.0 bk beta-globin gene fragments, indicating the diagnosis of sickle-cell trait. This confirmed the diagnosis reached after investigation of a 100% sample of fetal blood. The method is sensitive and can be performed with cells obtained from 15 ml of uncultured amniotic fluid. This approach may prove useful in antenatal diagnosis of other genetic disorders.

ANTENATAL DIAGNOSIS OF SICKLE-CELL ANÆMIA BY D.N.A. ANALYSIS OF AMNIOTIC-FLUID CELLS

The polymorphism of a restriction endonuclease site has been used for antenatal diagnosis of sickle-cell disease. In a normal person, the β-globin gene was contained in a Hpa I-digested D.N.A. fragment 7·6 kilobases (kb) in length. In a family where the sickle gene was contained in a variant 13·0 kb fragment, restriction endonuclease mapping was used for antenatal diagnosis. The D.N.A. from amniotic-fluid cells produced both the 7·6 and the 13·0 kb β-globin gene fragments, indicating the diagnosis of sickle-cell trait. This confirmed the diagnosis reached after investigation of a 100% sample of fetal blood. The method is sensitive and can be performed with cells obtained from 15 ml of uncultured amniotic fluid. This approach may prove useful in antenatal diagnosis of other genetic disorders.

How Diligently Should the Diagnosis of Sickle Cell Trait Be Pursued? Clinical Case Report with Military Implication

How Diligently Should the Diagnosis of Sickle Cell Trait Be Pursued? Clinical Case Report with Military Implication