A case report of hereditary
spherocytosis affecting mother and child with varied severity
Venkatamurthy M.1, B
Aditya Kumar2
1Dr Venkatamurthy M, Professor, 2Dr B Aditya Kumar, Postgraduate, both
authors are affiliated with Department of Paediatrics, Adichunchanagiri
Institute of Medical Sciences, B.G. Nagara, Nagamangala Taluk, Mandya
District, Karnataka, India.
Address for
correspondence: Dr B Aditya Kumar, E-mail:
bandariaditya59@gmail.com
Abstract
Hereditary spherocytosis (HS) is a genetically transmitted form of
spherocytosis, an autohemolytic anemia characterized by the production
of red blood cells that are sphere-shaped rather than biconcave disc,
and therefore more prone to hemolysis. It is a result of heterogeneous
alterations in one of six genes (most often the ankyrin gene) that
encode for proteins involved in vertical associations that tie the
membrane skeleton to the lipid bilayer. We report a case of Heriditary
spherocytosis affecting both mother and the baby with varied severity.
Keywords:
Hereditary spherocytosis (HS), Hemolytic anemia, Autosomal Dominant
Manuscript received:
20th March 2017, Reviewed:
30th March 2017
Author Corrected:
9th April 2017, Accepted
for Publication: 16th April 2017
Introduction
Hereditary spherocytosis (HS) is the most common hemolytic anemia due
to a red cell membrane defect, especially in people of North European
or Japanese descent, where prevalence may be as high as 1/5000.It is a
result of heterogeneous alterations in one of six genes (most often the
ankyrin gene) that encode for proteins involved in vertical
associations that tie the membrane skeleton to the lipid bilayer.
Family studies indicate autosomal dominant inheritance in approximately
75 percent of patients, with recessive and spontaneous mutations
occurring in most of the remaining patients [1].
Anemia, jaundice, and splenomegaly are the common clinical features of
hereditary spherocytosis (HS). The degree of anemia is extremely
variable and may be absent, mild, moderate, or severe to the point of
threatening life [2]. The diagnosis of hereditary
spherocytosis (HS) may be suspected at any age in a patient with
evidence of hemolysis (eg, elevated serum lactate dehydrogenase [LDH],
elevated indirect bilirubin, reduced haptoglobin). The critical
findings suggesting the diagnosis of HS as the underlying cause of the
hemolysis include a positive family history of HS, an elevated mean
corpuscular hemoglobin concentration (usually >36 g/dL), and the
presence of spherocytes on the peripheral blood smear. Anemia and
jaundice may not be present if the degree of hemolysis is minimal.
Case
Report
Two and half months old male child born out of a non consanguineous
marriage was brought for regular follow up, on examination baby was
found to have pallor, icterus, and splenomegaly. Baby had severe anemia
with Hb 4 gm % which required two units of blood transfusion. His
peripheral smear examination showed significant amount of spherocytes
(20 to 30 spherocytes per high power field) with features suggestive of
hemolytic anaemia. His Direct coombs Test was negative.His Red cell
variables were MCV 84fl, MCHC 36%, MCH 32pg, Red cell Distribution
Width (RDW- 15), Reticulocyte count 10.2%. His Total Bilirubin was 6.5
mg/dl, Direct bilirubin 1 mg/dl.LDH was also elevated. Babies
electrolyte levels were normal. Iron Profile, Folate , HB
electrophoresis were done which were found normal. Osmotic Fragility
started at 0.96% of NaCl and ended at 0.28% of NaCl. (Markedly
increased) .Other tests like eosin-5-maleimide (EMA) binding test,
Acidified glycerol lysis test (AGLT), Osmotic gradient ektacytometry
could not be done because of non availability at our centre and
financial constraints of the patient. Baby was later discharged with
Iron and Folic Acid supplementation and was asked to follow up every
month to consider administering Erythropoietin (EPO) in case of severe
anemia.
Figure-1:
Periphereal smear of the child showing spherocytes
Figure-2:
Periphereal smear of the mother showing spherocytes
Interestingly mother on examination was also found to have mild pallor,
jaundice, splenomegaly. She never required a blood transfusion
throughout her life. When investigated her Hb 9.2 gm%, peripheral smear
showed good number of spherocytes. Direct Coombs Test was negative. Her
Red blood cell variables were MCV 83 fl,MCHC 37%, Reticulocyte count
8%. Her Total bilirubin 3.4mg/dl, Direct bilirubin 1 mg/dl. Osmotic
fragility started at 0.92% of NaCl and ended at 0.38% of NaCl.
(Markedly increased). Other confirmatory investigations could not be
done due to financial reasons.
Discussion
Hereditary Spherocytosis is generally classified into three forms based
upon the severity of the disease process [3]. Mild HS occurs in 20 to
30 percent of cases. These patients have no anemia, modest
reticulocytosis, little in the way of splenomegaly or jaundice, and the
disorder may not be detected until adolescence or adult life. Moderate
HS accounts for 60 to 75 percent of cases. Moderately affected
individuals are anemic, have high reticulocyte counts, and elevated
serum bilirubin concentrations. They may require occasional
transfusions. Severe HS occurs in approximately 5 percent of cases. It
is characterized by marked hemolysis, anemia, hyperbilirubinemia,
splenomegaly, and a regular requirement for red cell transfusions.
When detected in the neonatal period, HS is commonly accompanied by
jaundice, requiring treatment with phototherapy or exchange transfusion
[5]. However, most neonates have little or no anemia, reticulocytosis,
or spherocytosis on the peripheral blood smear [6,7]. This is followed
by a reduction in the hemoglobin concentration over the ensuing three
weeks that is transient, but may be severe enough to require
transfusions [7].
Two factors are thought to be responsible for the delay in the
appearance of anemia:
1. An initial failure to produce an appropriate
erythropoietin response, as an adequate reticulocytosis cannot be
mounted for several months after birth.
2. Development of splenic filtering function, with
progressive red blood cell trapping and destruction [7].
The diagnosis of HS is almost always made on clinical grounds, based
upon the presence of spherocytes in the setting of familial hemolytic
anemia and an abnormal osmotic fragility test or other screening
test. A number of tests are available for identifying
individuals with HS with varying sensitivity and specificity [4].
• The sensitivity of the osmotic
fragility test was 68 and 81 percent on fresh and incubated blood,
respectively.
• The eosin-5-maleimide (EMA)
binding test had a sensitivity and specificity of 93 and 98 percent,
respectively.
• The acidified glycerol lysis
test (AGLT) and Pink tests had a sensitivity and specificity of 95 and
91 percent, respectively. A combination of the EMA binding test and
AGLT enabled all patients with HS to be identified.
As with most congenital hemolytic anemias, no specific treatment for
the underlying red cell defect is available. Supportive care consists
of the following: Folic acid supplementation, Blood transfusions,
Erythropoietin, Hematopoietic stem cell transplantation and splenectomy
at a later life [5].
Conclusion
The goal of the present article is to highlight that the clinical
presentation of a genetic disorder can be different in the same family
members depending on the gene penetration.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Venkatamurthy M, B Aditya Kumar.A case report of hereditary
spherocytosis affecting mother and child with varied severity. J
PediatrRes.2017;4(07):494-496.doi:10.17511/ijpr.2017.07.10.