154 Case Report

Hemoglobin sickle D Punjab—a case report

M. B. Mukherjee, R. R. Surve, R. R. Gangakhedkar, D. Mohanty, R. B. Colah Institute of Immunohaematology, Parel, Mumbai, India.

Case History Compound heterozygosity for βS/βD results in a severe hemolytic anemia and a clinical syndrome similar to that of . Here, we report a case of HbSD Punjab disease. A 10 year old female child residing at Nagpur, A 10 year old female child from Nagpur was referred Maharashtra presented with severe hemolytic anemia, to us with severe hemolytic anemia, occasional episodes hepatosplenomegaly and occasional pains in bones and of pains (predominantly bones and abdomen) associ- abdomen. Initially, she was thought to be a case of sickle cell anemia, however, with the help of HPLC and molecu- ated with fever. She had also received three units of lar analysis it was confirmed as HbSD Punjab disease. blood. Physical examination revealed short stature

Key words: HbSD Punjab, Sickle cell disease, Haplotype, (weight 12.5 kg and height 105 cm), pallor, hepatome- α-geonotype galy (2 cm) and splenomegaly (3 cm) below the right and left costal margins respectively. Cardiovascular, res- piratory and nervous systems were normal. HbD Punjab also known as HbD Los Angeles is a β- chain variant and is characterized by a Glu→Gln sub- Investigations stitution at codon 121 with a GAA→CAA change at the DNA level and the electrophotetic mobility at alkaline Her Hb was 5.9 g/dl and the reticulocyte count was pH is similar to HbS (β6, Glu→Val).[1] HbD has been 3.3%. Solubility test was positive. Hence, it was pre- described in both the heterozygous and homozygous sumed that this patient is a case of sickle cell trait/ states as well as in combination with HbS or β-thalas- anemia. HPLC analysis revealed the presence of both semia. Simple heterozygous and homozygous individu- HbS and HbD (HbS-52.3%, HbD-40.8% and HbF- als with HbD are asymptomatic, whereas association 4.2%). The parents of the proband were also investi- with HbS is characterized by a mild to moderate gated. The father was found to be HbD trait while the hemolytic anemia.[2] HbD-β is also gener- mother was sickle cell trait. The βS and βD mutations ally a very mild condition. However, HbSD disease may were confirmed by PCR followed by restriction enzyme manifest with variable clinical features.[3] HbS and HbD digestion with DdeI and EcoR1 respectively. Haplo- are one of the commonly encountered Hb variants type analysis was done using eight restriction enzymes: worldwide.[4] In India, the prevalence of HbS var- XmnI (5’Gγ), HindIII (Gγ), HindIII (Aγ), HincII (υβ), HincII ies from 0 – 34% in different tribal and some sched- (3’υβ), RsaI (5’β), AvaII (β) and HinfI (3’β) of the β- uled caste groups[5] whereas the average gene fre- gene cluster by PCR and Southern blot hybrid- quency of HbD has been observed to be 0.86% with a ization. The βS gene was linked to the Arab-Indian hap- higher frequency of 3.6% seen in Punjab followed by lotype (#31) [+ + - + + + + -] whereas βD mutation was Jammu and Kashmir (3.3%) and Uttar Pradesh associated with haplotype 1 [- - - - - + + +]. α-genotyping (2.3%).[6] We describe a case of sickle cell by Southern blot hybridization showed four normal α- D (HbSD) Punjab disease. gene (αα/αα).

Address for Correspondence : R. B. Colah, Institute of Immunohaematology (ICMR), 13th Floor, N M S Building, K E M Hospital Cam- pus, Parel, Mumbai–400 012, India. E-mail: [email protected]

Indian Journal of Genetics September-December 2005 Volume 11 Issue 3 Hemoglobin sickle D Punjab 155

Discussion ported to be the most common one in Mediterraneans as well as in all populations studied worldwide so far.[10] There are several variants of hemoglobin D such as Earlier studies[1,2,8] also revealed the same haplotype1 HbD Punjab (Los Angeles), HbD Iran, HbD Ibadan. Of to be associated with βD in different popu- these variants, HbD Punjab only interacts with HbS, lation groups which probably indicates the unicentric however, the nature of this interaction is not known.[7] origin of the βD mutation. Since, there are very few stud- HbD has also been reported with other hemoglobino- ies on haplotype linkege of βD chromosome and haplo- pathies like β-thalassemia without any additional clini- type1 is the most frequently observed one in world popu- cal or hematological abnormalities.[2] Earlier studies from lations, more intensive studies are required to deter- Pakistan, Iran, UAE and Mexico have shown that the mine the true origin of the βD mutation in the world popu- clinical presentation of HbSD disease cases is similar lations. to that of patients with the severe form of sickle cell anemia.[2,3] On the other hand, reports from India have References shown variable clinical manifestations of HbSD dis- ease.[6,8] 1. Fioretti G, De Angioletti M, Pagano L. DNA polymorphism associated with Hb Los Angeles [b121(GH4) GluàGln] in In HbSD disease, HbD does not take part in the sick- Southern Italy. Hemoglobin 1993;17:9-17. ling process, as patients homozygous for HbD do not 2. Perea FJ, Casas-Castaneda M, Villalobos-Arambula AR. [9] HbD-Los Angeles associated with HbS or β-thalassemia sickle. However, an earlier study has indicated that in four Mexican Mestizo families. Hemoglobin although HbD itself does not polymerize, it facilitates 1999;23:231-237. the polymerization of HbS, thus enhancing the severity 3. El-Kalla S, Mathews A R. HbD Punjab in the United Arab Emirates. Hemoglobin 1997;21:369-75. of the disease. At the same time, the co-inheritance of 4. Winter W P. in human populations. α-thalassemia and enhanced HbF levels also have an CRC Press, Boca Raton, Vol 1 and 2, 1986. inhibitory effect on the clinical expression of sickle cell 5. Mohanty D, Mukherjee MB. Sickle cell disease in India. Curr Opin Hematol 2002;9:117-22. disease. Earlier, it has been observed that the inherit- 6. Tyagi S, Marwaha N, Parmar V, Basu S. Sickle cell he- ance of α-thalassemia with sickle cell anemia and high moglobin–D Punjab disease (Compound Heterozygous state). Ind J Hematol Blood Transf 2000;18:31-2. HbF levels often results in milder clinical manifestations. 7. Cawein MJ, Lappat EJ, Brangle RW. Hemoglobin S-D On the other hand, normal or excess α-globin disease. Ann Intern Med 1996;62:70. could increase the severity of sickle cell disease.[5] Our 8. Panigrahi I, Agarwal S, Signhal P. HbD-Punjab associ- ated with HbS:A report of two cases from India. Ind J patient had a normal α-genotype (αα/αα) along with low Hematol Blood Transf 2000;18:86-7. HbF levels which could be the possible explanation for 9. Winford CW, John NL. Wintrobe’s Clinical Hematology, 11th edn. Philadephia; 2004. pp. 1347-81. the severity in this case. 10. Flint J, Harding RM, Boyce AJ, Clegg JB. The population The Arab-Indian haplotype observed in our patient genetics of the hemoglobinopathies. In: Higgs DR, Weatherall DJ, editors. The Haemoglobinopathies. S [5] have been shown to be linked to the β gene in India. Bailliere’s Clinical Hematology, International Practice and Haplotype1, linked to the βD chromosome has been re- Research. London: Bailliere Tindall; 1993, pp 215-62.