Dear Editor, A 30-year-old man was ascertained while evaluating his daughter for transfusion-dependent beta thalassemia. The child was diagnosed to have beta thalassemia major at the age of 1 year and was on regular transfusion. The couple wanted prenatal diagnosis for their second pregnancy. On evaluation, the child was found to inherit IVS1-5 (G>C) mutation (NG_000007.3:g.70691G>C) from her mother and poly A signal (NG_000007.3:g.72128 T>C) mutation from her father. The father was also found to have hemoglobin D Punjab on electrophoresis. Sequencing of his beta-globin genes confirmed him to be compound heterozygote for HbD Punjab mutation (NG_000007.3:g.71938G>C) and poly A signal mutation (Fig. 1). The chorionic villus sample showed only poly A mutation and reported as a carrier for beta thalassemia. The clinical details of the father were reviewed. He did not have anemia, jaundice, and blood transfusion in the past. There was no pallor, hepatomegaly, or splenomegaly. His investigations were as follows: Hemoglobin, 12.9 g% (12.5-18); total leukocyte count, 5,900/mm (4,000– 11,000); erythrocyte count, 5.70million/mm (4.5–6.5); mean corpuscular volume, 69.1 fl (76–96); mean corpuscular hemoglobin, 22.6 pg (27–32); mean corpuscular hemoglobin concentration, 32.7 g/dL (32–36); red cell distribution width, 16.3% (11.5–14.5); platelet count, 179,000/mm (150,000– 400,000). In addition to microcytes, anisocytosis and mild polychromasia were observed on peripheral smear examination. Capillary hemoglobin electrophoresis showed HbA, 22.7%; HbD, 72.3%; and HbA2, 5.0%. No HbF peak was noted (Fig. 1). Total serum bilirubin was 0.7 mg% and the conjugated bilirubin level was 0.2 mg%. Alanine transaminase was 25 U/L (5–40); aspartate transaminase, 22 U/L (5–40); and lactate dehydrogenase, 255 U/L (200–500). The mutation in poly A signal has been shown to extend the transcription of beta globin by at least 900 nucleotides 3′ of the normal polyadenylation site and thus is expected to produce reduction in normal beta chain production [1]. It is a rare mutation in beta-globin gene, but in association with IVS1-5 (G>C), the child had significant anemia requiring regular transfusions. Hb D Punjab (or Hb D-Los Angeles, NG_000007.3: g.71938G>C) is characterized by the substitution of glutamine for glutamic acid at position 121 of the betaglobin polypeptide. It is common in several parts of the world, including India. Carriers of HbD even in homozygous state are asymptomatic. It is known to produce a mild anemia when another beta-globin mutation is present in the same individual. Compound heterozygosity for a beta zero mutation (IVS II.1 G>A) in two individuals produced a minor thalassemia phenotype with moderate anemia and significantly elevated HbF [2, 3]. In another report, a child with HbD and frameshift mutation in codon 8/9 (+G; a beta zero mutation), had 94.5% of Hb D, without Hb A, the hematologic picture was that of thalassemia trait with moderate hemolytic anemia, intense microcytosis and hypochromia and numerous target cells [4]. Perea et al have observed that Hb S/Hb D patients had severe K. M. Girisha (*) Genetics Clinic, Department of Pediatrics, Kasturba Medical College, Manipal 576104, India e-mail: girishkatta@gmail.com
Read full abstract