Hemoglobin D Punjab Research Articles

Hemoglobin D and Coinheritance with Hb S, β-thalassemia

Objective: Hb D-Punjab (also known as D-Los Angeles) is a recessively inherited variant of hemoglobin. It is one of the most common hemoglobin variants worldwide. In this study, we aimed to evaluate the hematological features of our homozygous and heterozygous Hb D patients and patients with compound heterozygosity for Hb D and other hemoglobinopathies in terms of clinical and laboratory findings. Methods: In this study, cases with Hb D-Punjab have been identified in both the heterozygous and homozygous states, as well as coinheritance with Hb S or β-thalassemia. We presented the clinical and laboratory characteristics of 18 cases (Hb D/D (n=2), Hb D/β-thalassemia (n=3), and Hb S/D (n=3) and Hb D traits (n=10)). Results: As a result of the study, it was observed that Hb D was asymptomatic in both heterozygous and homozygous forms. Hb D/β thalassemia cases showed mild microcytic and hypochromic anemia, but they were clinically normal. Compound heterozygosity for Hb S/D showed moderate hemolytic anemia, but a severe clinical picture with painful crises, just like sickle cell patients. Conclusion: Hemoglobin D-Punjab, which is asymptomatic even in homozygous conditions, can cause a variety of clinical pictures from mild to severe when inherited in combination with other hemoglobinopathies.

A Case of Compound Heterozygous HbS and HbD Disease in Premarital Screening

Introduction: Among the inherited disorders of blood, haemoglobinopathy and thalassaemia constitute a major bulk of non-communicable genetic diseases in India. They cause a high degree of morbidity in affected individuals. Moderate to severe haemolytic anaemia among vulnerable segments of the society like infants and children, adolescent girls, pregnant women, etc. may result in many deaths in India. Hemoglobinopathies are a vast group of inherited disorders of hemoglobin production and function. Compound heterozygous HbSD-Punjab is an uncommon hemoglobinopathy encountered in Indians. In premarital screening, molecular testing is mostly inconvenient and diagnosis often relies on the abnormal hemoglobin analysis, family studies and epidemiological facts. We present the clinical and laboratory characteristics of hemoglobin D-Punjab with sickle cell disease found on premarital screening. Case Report: Blood sample of a 22 year old patient for high-performance liquid chromatography was received. A complete blood count (CBC) showed mild anemia with Hb of 8.3 g/dl with mild microcytic hypochromic red cell indices.The HPLC showed HbD and S-window on BIO RAD D10 machine. The high-performance liquid chromatography showed normal hemoglobin Hb F and Hb A2, which indicates presence of a Compound heterozygous for HbSD-Punjab. Conclusion: Compound heterozygous state for HbD-Punjab with S-window is a rare disorder. HbSD-Punjab has a heterogeneous clinical presentation. Anemia and sickle crises are quite common. The data obtained from the clinical findings, blood picture and electrophoresis or HPLC will help in diagnosis. Genetic counseling is advisable in patients with presence of a Compound heterozygous HbSD-Punjab.

Thalassemia and Hemoglobinopathy Screening in Women Attending Antenatal Clinic at a Tertiary Care Center in Uttarakhand, India: A Re-look at the Laboratory Parameters Mandating High-Performance Liquid Chromatography Workup.

Thalassemia and hemoglobinopathies are the most common inherited hematological disorders. Of these, β thalassemia is the commonest disorder reported in India, followed by certain hemoglobinopathies encountered in different regions of the country. The data pertaining to the incidence of these disorders in the Uttarakhand region of India are sparse. To ascertain the prevalence and spectrum of thalassemia/hemoglobinopathies amongst antenatal women in Uttarakhand. The study also aimed to analyze the ability of red cell indices in differentiating beta thalassemia trait (BTT) from mild iron deficiency anemia (IDA). A total of 460 pregnant women in the first trimester of pregnancy were screened by cation exchange high-performance liquid chromatography. Retention time and proportions of normal/abnormal hemoglobin peaks were documented in all cases. Hemoglobin A2 (HbA2) values of ≥4% were taken as a cut-off for diagnosing BTT. Blood samples were also collected for complete blood counts, reticulocyte counts, and serum ferritin. The ability of the various discriminatory indices to differentiate between IDA and BTT was also assessed. The prevalence of BTT and hemoglobin D-Punjab trait amongst pregnant women was found to be 2.6% and 0.2%, respectively. RBC count, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) were found to be moderately strong predictors of BTT, with an area under the curve of 0.860, 0.857, and 0.842, respectively, which were comparable to the discriminatory indices found to be most useful in this study. In view of the 2.6% prevalence of BTT in antenatal women in this region of Uttarakhand, a routine screening will be helpful in detecting carriers early in the antenatal period. Careful interpretation of red cell indices is crucial to the distinction between BTT and IDA. Discriminatory indices are reasonably accurate in differentiating BTT from mild iron deficiency, but for practical purposes, MCV and MCH provide equivalent information to identify cases that require further workup.

Hematological Parameters and Demographic Distribution of Hemoglobinopathies and Various Hemoglobin Variants.

Background The study was conducted to find the prevalence of hemoglobinopathies along with their geographical/ethnic distribution to highlight the region of high prevalence that can be used to guide screening. Method Results of blood samples received for hemoglobin variants determination by high-performance liquid chromatography (HPLC) were retrospectively analyzed at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore. Blood samples were assayed for CBC (complete blood count), red blood cell morphology, and hemoglobin analysis by HPLC. CBC was performed on Sysmex XN 9000 analyzer (Sysmex, Kobe Japan), peripheral smears to review RBC morphology were stained with Wright-Giemsa stain, and HPLC was performed on BIO-RAD variant II (Bio-Rad Laboratories, Hercules, USA). Results Hemoglobinopathies were identified in 9.7% (n=997) out of 10,297 samples. Beta thalassemia trait was the most common hemoglobinopathy recognized with a prevalence of 5% (n=516), with the maximum number of cases in the Lahore district of Punjab province. The next most common hemoglobinopathy identified was sickle cell disease with a frequency of 1.43% (n=148) and the maximum cases from the Dera Ismail Khan district of the Khyber Pakhtunkhwa province. The additional important hemoglobinopathies found were sickle cell trait, hemoglobin-D Punjab trait, and compound heterozygote for sickle and beta thalassemia. Conclusion Hemoglobinopathies are the most common inherited disorders in Pakistan and worldwide. Screening for hemoglobinopathies is recommended in high-prevalence districts of Pakistan. Sickle cell screening is also recommended in newborns in the high prevalence area of Pakistan, such as the northwest regions.

Real-world efficacy and safety of direct-acting antiviral drugs in patients with chronic hepatitis C and inherited blood disorders.

BackgroundPatients with inherited blood disorders (IBLD) have a high risk of hepatitis C virus (HCV) infection. The aim of this work was to assess the efficacy and safety of HCV direct-acting antiviral (DAA)-based treatment in patients with IBLD and chronic HCV infection.MethodsTwenty-seven patients (25 with sickle cell disease, 1 with β-thalassemia and 1 with hemoglobin D-Punjab), including 3 with compensated cirrhosis, were included. They were treated with sofosbuvir in combination with ribavirin, daclatasvir, ledipasvir, or velpatasvir or with grazoprevir/elbasvir for 8 or 12 weeks. In the case of treatment failure, in-vitro assessment of resistance-associated substitutions (RASs) and full-length genome sequence analysis by means of deep sequencing were performed.Results:Treatment was safe and well-tolerated and there were no drug discontinuations due to DAA-related adverse events. Twenty-five out of the 27 patients (93%) achieved sustained virological response 12 weeks post-treatment. One patient discontinued after 18 days due to adverse events unrelated to the antiviral treatment. One patient infected with ‘unusual’ genotype 2 subtype 2m relapsed. Subtype 2m naturally carries the NS5A L31M RAS. In a genotype 2a subgenomic replicon model, L31M increased daclatasvir effective concentration 50% (EC50) by 97-fold, but velpatasvir EC50 by only 3-fold, without altering the replication capacity. This patient was successfully retreated with sofosbuvir/velpatasvir for 12 weeks.ConclusionDAA-based regimens are well tolerated and highly efficacious in patients with chronic hepatitis C and IBLD in the real-world setting. Thus, DAA-based antiviral treatment should be prioritized in this thus far neglected population of HCV-infected patients.

Hemoglobin D-Punjab Homozygotes and Double Heterozygotes in Premarital Screening: Case Presentations and Minireview

Hemoglobin D-Punjab is the most common variant of hemoglobin D. In premarital screening, molecular testing is often unavailable, and diagnosis (and marriage guidance) often relies on the hemoglobin analysis, family studies and epidemiological facts. The use of latter methods sometimes results in hemoglobin D-Punjab/β-thalassemia double heterozygote being mistaken for its homozygote, which could be costly. We present the clinical and laboratory characteristics of hemoglobin D-Punjab phenotypes/genotypes in 15 individuals and review similar reports in the literature. We find that the quantity of hemoglobin D-Punjab in homozygotes is higher than in hemoglobin D-Punjab/β-thalassemia double heterozygotes, its fraction > 92% being consistent with homozygosis. The limitations of this diagnostic criterion are discussed, and clinical severity of this and other hemoglobin D-Punjab double heterozygotes reviewed.

Spectrum of hemoglobin disorders in southern Odisha, India: a hospital based study.

Background:Hemoglobin disorders are the leading health concern in the world including India. There is a paucity of literature on the spectrum of hemoglobin disorders in southern districts of Odisha state. This study was undertaken to elucidate the occurrence of different hemoglobin disorders in a tertiary health care facility of Odisha state, India.Methods:The study cases were suspected patients of all age groups advised for screening of different hemoglobin disorders. Hemoglobin disorders were screened by sickling slide test and high-performance liquid chromatography (HPLC) using the Variant-II hemoglobin testing system as per the manufacturer's guidelines.Results:Over 2 years, 2332 blood samples (including 1102 pediatric and 1230 adult cases) were investigated, out of which, 1380 (59.2%) of cases had abnormal hemoglobin disorders. The most common was sickle cell disorders (48.67%, 1135/2332) followed by β-thalassemia (11.32%, 264/2332). Some rare variants were detected as hemoglobin D-Punjab, hemoglobin E, hemoglobin Lepore, hereditary persistence of fetal hemoglobin, hemoglobin with high P2 window, hemoglobin with high P3 window etc, Among the cases with abnormal hemoglobin disorders, 744 (53.9%), 545 (39.5%) and, 91 (6.6%) cases were found to have the heterozygous, homozygous and, double heterozygous state. Of the 188 ante-natal cases screened, 31.4% of cases had abnormal hemoglobin variants with sickle cell disorders being the most prevalent one.Conclusion:Along with the high occurrence of sickle cell disorders in the study area, some other rare hemoglobin disorders are also prevalent which calls for a large community-based cohort study.

Mean corpuscular volume/mean corpuscular hemoglobin values are not reliable predictors of the β-thalassemia carrier status among healthy diverse populations of Himachal Pradesh, India.

BACKGROUND:Himachal Pradesh is a hill state in North India in the Western Himalayas. β-thalassemia is a genetic disorder of hemoglobin inherited in an autosomal recessive manner that results in defective globin production leading to the early destruction of red blood cells. β-thalassemia has long been neglected in Himachal Pradesh due to popular belief that it runs along “Lahore-Gujarat-Punjab” belt in India. Therefore, there is no β-thalassemia testing facility currently in the state.METHODS:To estimate the prevalence of β-thalassemia carriers, we calculated the sample size based on probability proportional to size self-weighing design. In each of 20 selected colleges, 111 students having an age of 18–25 were tested for high-performance liquid chromatography (HPLC) and complete blood count. Some were further tested for the mutations. We computed sensitivity, specificity, positive predictive value (PPV) and negative predictive value, and receiver operating characteristic curve for mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) red cell parameters.RESULTS:Of the 2220 students, 57 were found to be β-thalassemia carrier by HPLC. The overall prevalence rate was 2.6% which translates to probable 180,000 β-thalassemia carriers in Himachal Pradesh. Six districts bordering highly endemic Punjab had a higher prevalence. Hemoglobin D-Punjab, Heterozygous-Iran Trait, and raised fetal hemoglobin were found. Thalassemia major and sickle cell disease were not found. Anemic status or MCV/MCH parameters were not found to be reliable predictors of thalassemia carrier status among the healthy populations of HP. The predominant mutation found was IVS 1–5 G > C.CONCLUSION:Popular ongoing strategy for screening with MCV and MCH has low-PPV and can miss upto 37% of true thalassemia carriers. HPLC is better strategy for screening carriers and reduces further spread of thalassemia.

Double heterozygosity for hemoglobin S and D Punjab in Basra, Iraq: A Clinical and hematological study of 42 patients

BACKGROUND: Patients with compound heterozygosity for sickle hemoglobin (HbS) and hemoglobin DPunjab (Hb SDPunjab) may present with a variable clinical course and may be indistinguishable from those with homozygous HbS. OBJECTIVES: The objective was to identify Hb SDPunjab phenotypes and the association of fetal Hb with disease severity. PATIENTS AND METHODS: This descriptive, cross-sectional study included 42 (17 males and 25 females) patients with double heterozygosity for HbS and D. In addition to full clinical data, the complete blood count and Hb quantitation were assessed. Statistical analyses were performed using SPSS software version 20.0. RESULTS: The mean age at diagnosis was 4.6 ± 0.7 years. Pallor and acute painful episodes (>90%) were the most common presenting symptoms, followed by jaundice (76.2%). Six patients (14.3%) had acute splenic sequestration crises and five (11.9%) had cardiac complications. Of the 42 studied patients, 17 (40.5%) had nonsevere disease and 25 (59.5%) had severe disease. Patients with severe disease had statistically significantly more blood transfusions (47.4 ± 10.27) than those with nonsevere disease (17.14 ± 1.82, P Conclusion: Double heterozygosity for Hb S and DPunjab in Basra results in SCD with a severe phenotype, and the Hb F level did not modulate the disease severity.

Hemoglobin-D Punjab—rare hemolytic anemia in the elderly: a case report

A 62-year-old woman with no comorbidity presented with dyspnea since 2 months and fatigue since 1 month. She was having severe anemia with hepatosplenomegaly and icterus. Anemia due to blood loss was ruled out. With a history of blood transfusions and episodes of jaundice in the past, evaluation of hemolytic anemia was carried out. Her serum iron level was normal. Serum lactate dehydrogenase level was raised, and extracorpuscular causes were absent. Hemoglobin electrophoresis was performed in view of suspected hemoglobinopathy. It showed hemoglobin-D Punjab homozygous type, which is very rare. Its presentation in older age is even rarer to warrant this report.

Clinical, hematological and genetic data of a cohort of children with hemoglobin SD.

IntroductionThe hemoglobin FSD is very uncommon in newborn screening programs for sickle cell disease. In the program of Minas Gerais, Brazil, the clinical course of children with hemoglobin SD was observed to be heterogeneous. The objective of this study was to estimate the incidence (1999–2012) and to describe the natural history of a cohort of newborns with hemoglobin SD.MethodsIsoelectric focusing was the primary method used in newborn screening. Polymerase chain reaction-restriction fragment length polymorphism and gene sequencing were used to identify mutant alleles and for haplotyping. Gap-polymerase chain reaction was used to detect alpha-thalassemia.ResultsEleven cases of hemoglobin S/D-Punjab and eight of Hb S-Korle Bu were detected. Other variants with hemoglobin D mobility were not identified. All hemoglobin D-Punjab and hemoglobin Korle Bu alleles were associated with haplotype I. Among the children with hemoglobin S/D-Punjab, there were four with the βS CAR haplotype, six with the Benin haplotype, and one atypical. Results of laboratory tests for hemoglobin S/D-Punjab and hemoglobin S-Korle Bu were: hemoglobin 8.0 and 12.3 g/dL (p-value <0.001), leukocyte count 13.9 × 109/L and 10.5 × 109/L (p-value = 0.003), reticulocytes 7.5% and 1.0% (p-value <0.001), hemoglobin F concentration 16.1% and 6.9% (p-value = 0.001) and oxygen saturation 91.9% and 97% (p-value = 0.002), respectively. Only hemoglobin S/D-Punjab children had acute pain crises and needed blood transfusions or hydroxyurea. Those with the Benin βS haplotype had higher total hemoglobin and hemoglobin F concentrations compared to the CAR haplotype. Transcranial Doppler was normal in all children.ConclusionThe clinical course and blood cell counts of children with hemoglobin S/D-Punjab were very similar to those of hemoglobin SS children. In contrast, children with hemoglobin S-Korle Bu had clinical course and blood cell counts like children with the sickle cell trait.

Hemoglobin D-Punjab: origin, distribution and laboratory diagnosis.

This review discusses hemoglobin D-Punjab, also known as hemoglobin D-Los Angeles, one of the most common hemoglobin variants worldwide. It is derived from a point mutation in the beta-globin gene (HBB: c.364G>C; rs33946267) prevalent in the Punjab region, Northwestern Indian. Hemoglobin D-Punjab can be inherited in heterozygosis with hemoglobin A causing no clinical or hematological alterations, or in homozygosis, the rarest form of inheritance, a condition that is commonly not related to clinical symptomatology. Moreover, this variant can exist in association with other hemoglobinopathies, such as thalassemias; the most noticeable clinical alterations occur when hemoglobin D-Punjab is associated to hemoglobin S. The clinical manifestations of this association can be similar to homozygosis for hemoglobin S. Although hemoglobin D-Punjab is a common variant globally with clinical importance especially in cases of double heterozygosis, hemoglobin S/D-Punjab is still understudied. In Brazil, for example, hemoglobin D-Punjab is the third most common hemoglobin variant. Thus, this paper summarizes information about the origin, geographic distribution, characterization and occurrence of hemoglobin D-Punjab haplotypes to try to improve our knowledge of this variant. Moreover, a list of the main techniques used in its identification is provided emphasizing the importance of complementary molecular analysis for accurate diagnosis.

Co-inheritance of HbD Iran/Beta Thalassemia IVS1–5 (G &gt; C) Trait in a Punjabi Lady with Diabetes

The present report describes the molecular study of HbD (Iran) (beta) 22 Glu→Gln associated with β-Thalassemia IVS1-5 (G>C) found in India, and the first case in which mutation has been identified using mass spectrometry. Given the apparent ethnic origin and the mobility of the variant hemoglobin at alkaline pH, hemoglobin D-Punjab would be suspected, but HPLC excluded this possibility. Further characterization of hemoglobinopathy was made by using nondenaturing gel electrophoresis and matrix assisted laser desorption ionization mass spectrometry and IVS1-5 being validated by reverse dot blot hybridization followed by sequencing of the β-globin gene.

Case Report: A Rare Presentation of Haemoglobin D Disease

Haemoglobin D (Hb D) is the fourth most common haemoglobin variant. With the exact chemical analysis of hemoglobin variants, it became apparent that hemoglobin DLos Angeles was identical to hemoglobin DPunjab, both manifesting a substitution of glutamate for lysine at the 121st position in the β -chain. Another “D” hemoglobin, G Philadelphia , is, on the other hand, an β-chain variant with a substitution of asparagine for lysine at the 68th position. Like the other structural mutations of hemoglobin, hemoglobin D trait is the heterozygous state for hemoglobin D and hemoglobin A, whereas the homozygous state for hemoglobin D is designated hemoglobin D disease. Hb D disease is usually clinically silent with no special treatment required. Homozygous Hb DD is rare and a relatively mild disease. Though Hemoglobin D is not very uncommon in India, its homozygous form is very rare and very few case reports have been reported. I hereby present a case of symptomatic Hb D homozygous, who presented with hemolytic anemia and hepatospleenomegaly from Turvekere, Karnataka which is a rare phenomenon.

Hemoglobin D-Punjab syndromes in India: a single center experience on cation-exchange high performance liquid chromatography

Background: Hemoglobin–D-Punjab (HbDP) is an uncommon structural hemoglobin variant, which is reported to be prevalent in North Western India. There are only a few small series, family studies and anecdotal reports of this entity in the literature. We report the largest single center experience on this entity diagnosed by cation-exchange high performance liquid chromatography (CE-HPLC) from India.Aim: To document and analyze the clinical, hematological and chromatographic parameters of patients with HbDP syndromes.Patients and methods: A total of 6889 blood samples (both pediatric and adult) were screened for hemoglobinopathies and structural hemoglobin variants by CE-HPLC; β thal short program (BTS), Bio-Rad variant for evaluation of anemia and for family and antenatal screening studies.Results and conclusion: A total of 484 cases of structural hemoglobin variants comprising of HbS, E, D-Punjab, D Iran, Lepore, and J-Meerut were detected. HbDP syndromes constituted 38 (7·8%) of all hemoglobin variants and 0·55% of all the samples screened for hemoglobinopathies. Heterozygous HbDP constituted 23 of 38 (61%) cases and homozygous HbD/D, HbS/D and HbD/β constituted 9/38 (24%), 2/38 (5%), and 4/38 (10%) respectively. HbDP syndromes are not uncommon and are relatively underdiagnosed. CE-HPLC has the advantage of rapid detection and accurate quantitation. Electrophoresis and CE-HPLC can be complementary in making accurate diagnosis of these entities.

Double Heterozygosity for Hemoglobin G [formula omitted] and Hemoglobin D [formula omitted

Abstract An electrophoretic pattern which revealed three major hemoglobin components was found in five members of an Afro-American family. The composition of the hemoglobin resulted from heterozygosity both at the α locus for hemoglobin GPhiladelphia, in which lysine replaces the normal asparagine at the 68th residue and at the β locus for hemoglobin DPunjab in which glutamine replaces normal glutamic acid at residue 121. The simultaneous presence of these α and β chain variants did not lead to any well defined clinical abnormalities. The pattern of inheritance of hemoglobin variants in this family provided further evidence for independent segregation of the loci responsible for α and β chain synthesis.

Rate of Sickling of Red Cells during Deoxygenation of Blood from Persons with Various Sickling Disorders

Abstract The clinical severity of various sickle hemoglobinopathies was directly related to the rate of increase of viscosity of blood during deoxygenation. The principal determinants of the rate were the concentration of hemoglobin S in the red cell and the degree of interaction between hemoglobins when more than one major type was present. There was a close correlation between the rate of change of viscosity of blood under the conditions employed and the minimum concentration of the deoxygenated hemolysate required for gelation. Hemoglobin DPunjab showed the most marked interaction with hemoglobin S and hemoglobin F the least, accounting for the striking clinical differences between S-D and S-F heterozygotes. Clinical status of the patients and rate of increase of viscosity of partially deoxygenated blood were not closely correlated with the percentage of hemoglobin S in the hemolysate, the mean corpuscular sickle hemoglobin concentration, or the solubility of the hemoglobin. The viscosity of deoxygenated blood was directly related to the proportion of sickled red cells, but filamentous forms were associated with a greater viscosity than holly leaf forms; accordingly, viscosity could not be predicted precisely from the percentage of sickled erythrocytes in a blood specimen. The viscosity of blood containing sickled erythrocytes was approximately proportional to the square of the hematocrit value, an observation of relevance in explaining the frequent occurrence of vascular occlusive manifestations in patients with certain heterozygous sickling disorders without appreciable anemia. The data of this study support the concept that all of the clinical manifestations of sickle cell disease are attributable to the consequences of intravascular sickling of erythrocytes. Clinical differences between patients whose red cells appear to be similar probably can be explained by extracorpuscular factors influencing rates of sickling.