Interaction of an alpha(+)-thalassemia deletion with either a highly unstable alpha-globin variant (alpha2, codon 59, GGC-->GAC) or a nondeletional alpha-thalassemia mutation (AATAAA-->AATAAG): comparison of phenotypes illustrating "dominant" alpha-thalassemia

Thalassemia syndromes and unstable hemoglobins traditionally represent two phenotypically separate disorders of hemoglobin synthesis. Highly unstable hemoglobin variants, however, often have phenotypic characteristics associated with both ineffective erythropoiesis (thalassemias) and peripheral hemolysis (unstable hemoglobins). Many highly unstable beta chain variants cause a dominant thalassemia-like phenotype, in which simple heterozygotes for such mutations have a clinical expression similar to thalassemia intermedia. The phenotypic expression of highly unstable alpha-globin variants is usually less severe, due mainly to a gene dosage effect, and they are often only characterized on interaction with other alpha-thalassemia mutations, whence they are classified as nondeletional alpha-thalassemia determinants. This study reports the clinical and hematological findings in five cases with rare alpha-thalassemia genotypes: a single patient with the thalassemic alpha2-globin gene codon 59 Gly-->Asp hemoglobin variant in trans to an alpha(+)-thalassemia deletion, and four compound heterozygotes for the nondeletional alpha-thalassemia polyadenylation mutation (alpha2 gene AATAAA-->AATAAG or alpha(T-Saudi)alpha/-alpha) and an alpha(+)-thalassemia deletion. Evaluation of the clinical and hematological features in these two analogous genotypes clearly demonstrates the more severe clinical expression associated with the alpha-thalassemic unstable hemoglobin variant. In addition, the case in this study with the codon 59 alpha chain variant provides a further example illustrating the spectrum of phenotypes associated with the alpha-thalassemic hemoglobinopathies.     

The types and distribution of alpha-thalassemia-2 in China

We studied 111 cases of Hb H disease from different families using Bam HI and Bgl II restriction enzymes. The results showed that 76 cases (68.5%) were of the deletion type, eight cases (7.2%) had Hb Constant Spring (Hb CS), and 27 cases (24.3%) were of the nondeletion and Hb CS types (alpha T). Distribution of the alpha-thalassemia-2 (alpha-thal-2) gene varies with the different regions in China. The rightward deletion (alpha -3.7) is found chiefly in Guangdong Province, the leftward deletion (alpha -4.2) mostly in Jiangxi Province, and the nondeletional type in Guangxi Province where the Han nationality is most prominent. We studied the nondeletional Hb H type by DNA gene mapping, digestion with Msp I, and hybridization with a 32P-alpha probe for the presence of the Hb Quong Sze [alpha 125(H8)Leu----Pro] mutation. It appears that none of these alpha-thal-2 genes contain the Hb Quong Sze mutation.     

Misdiagnosis of Hb constant spring (alpha142, Term-->Gln, TAA-->CAA in alpha2) in a Hb H (beta4) disease child

Hb Constant Spring (Hb CS; alpha142, Term-->Gln, TAA-->CAA in alpha2) is the most prevalent nondeletional alpha-thalassemia (thal) in Southeast Asian populations. It is difficult to detect on electrophoresis in its heterozygous state because of the low Hb CS levels. We found a case with Hb H (beta4) disease who, at birth, was initially assumed to have deletional alpha-thal mutations, but eventually proved to have a Hb CS defect.     

Unusual molecular basis of Hb H disease in the Azores Islands, Portugal

An Azorean family with Hb H disease (10% Hb H) was studied in order to elucidate its molecular basis. DNA studies on the patient only revealed a 4.2 kb "leftward" deletion of paternal origin which implies the co-inheritance of a nondeletional alpha-thalassemia determinant. Restriction endonuclease and oligonucleotide analysis allowed the exclusion of five point mutations: initiation codon (at both alpha 1- and alpha 2-globin genes), IVS-I donor splice junction pentanucleotide deletion, codon 125 CTG----CCG substitution, and Saudi Arabian polyadenylation signal mutation. These findings suggest that the molecular basis of this form of Hb H disease is probably different from those described previously.     

A novel splice acceptor site mutation of the alpha2-globin gene causing alpha-thalassemia

A novel nondeletional alpha-thalassemia mutation that affects RNA processing, changing the alpha2 IVS-II-142 splice acceptor consensus sequence from AG to AA, has been detected in an Argentinian patient with Hb H disease and her daughter.     

Alpha-thalassemia phenotype induced by the new IVS-II-2 (T --> A) splice donor site mutation on the alpha2-globin gene

We present a family of North European extraction referred for a refractory non iron depleted microcytic anemia. The proband, a 36 year-old male, presented with chronic borderline anemia and microcytic hypochromic parameters. No abnormal hemoglobin (Hb) fractions were observed on high performance liquid chromatography (HPLC) or on alkaline electrophoresis. Gap-polymerase chain reaction (gap-PCR) excluded the seven common alpha-thalassemia (thal) deletion defects. However, the beta/alpha-globin chain synthesis ratio measured in vitro was unbalanced, indicating a reduced expression of the alpha-globin genes. Direct sequencing of the alpha-globin genes revealed heterozygosity for a T --> A transversion at the IVS-II-2 position of the alpha2 gene. This is the first IVS-II splice donor site mutation described on the alpha2-globin gene.     

Molecular defects in 2 examples of severe Hb H disease

Severe Hb H disease presented in unexpected ways in 2 families of Greek origin. In 1, Hb H disease led to neonatal death. The underlying molecular defect was double-heterozygosity for the --Med/ alpha thalassaemia haplotype and a nondeletional alpha thalassaemia defect (alpha alpha T'Karditsa'/). The 2nd family requested antenatal diagnosis. The husband had mild nondeletional alpha thalassaemia. Initial investigations in the wife demonstrated unexpected gene mapping patterns. These have recently been shown to result from the (-alpha)Med 20.5/ haplotype.     

Hb Bleuland [alpha108(G15)Thr-->Asn, ACC-->AAC (alpha2)]: a new abnormal hemoglobin associated with a mild alpha-thalassemia phenotype

We report a new structural defect of the alpha2-globin chain, not detectable on high performance liquid chromatography (HPLC) or electrophoresis, characterized in a 12-year-old boy of Surinamese-Hindustani origin. The child was suspected to be a carrier of alpha-thalassemia (thal) because of microcytic hypochromic parameters in the absence of iron depletion. Gap-polymerase chain reaction (gap-PCR) revealed only normal fragments in the proband, and the pattern of a -alpha4.2 (leftward) deletion in his father and sister. Direct sequencing of the alpha-globin genes revealed an ACC-->AAC transversion at codon 108 of the alpha2-globin gene in the proband, in his mother and in a younger sister. The new mutation predicts a Thr -->Asn amino acid substitution at the corresponding residue. Threonine, a covalent binder with an R-active OH group, situated in the G helix of the alpha-globin chain, is involved in alpha1beta1 contacts. Asparagine, being an equally covalent binder but with a different R-active H2N-C=O group, could make the mutated chain less suitable for tetramer cooperation. Alternatively, an absent or reduced interaction with the alpha hemoglobin (Hb) stabilizing protein (AHSP) could lead to loss of alpha chains. Hb Bleuland is the first mutation described at codon 108 and is therefore interesting in regard to the possible effects and genetic risk. The nearest variant, Hb Suan-Dok [alpha109(G16)Leu -->Arg, CTG-->CGG (alpha2)] was originally observed in a Thai patient affected with Hb H, in combination with an alpha0-thal allele. The same Hb Suan-Dok mutation, recently described in our laboratory in a carrier of African ancestry, was also not detectable as a protein and presented with an alpha-thal phenotype similar to Hb Bleuland.     

Molecular characterization of Hb Val de Marne [alpha133(H16)Ser-->Arg; AGC-->AGA; (alpha2)] in a Chinese family

There have been two previous reports on Hb Val de Marne (Hb Footscray) [alpha133(H16)Ser-->Arg] in the literature, but the molecular characterization has hitherto not been described. Based on the Ser-->Arg transition, the presumed mutation was cited as AGC-->CGC of the alpha2- or alpha1-globin gene. We have found this variant in a 15-year-old Chinese girl and her father, and automated DNA sequencing revealed an AGC-->AGA mutation at codon 133 of the alpha2-globin gene. Since an increasing number of alpha-globin gene variants have been reported with the same protein alteration but with different mutations on the alpha1- or alpha2-globin genes, the mutation identified in the present family does not preclude the presence of other alpha-globin gene mutations leading to this hemoglobin (Hb) variant.     

Hb Sun Prairie or alpha(2)130(H13)Ala----Pro beta 2, a new unstable variant occurring in low quantities

A severe hemolytic anemia with microcytosis and hypochromia was present in a young adopted Indian patient. Reversed phase high performance liquid chromatographic methodology and heat stability tests detected an unstable alpha chain which was present in 3 to 5% of the total hemoglobin. A larger quantity of the alpha X chain was obtained by preparative reversed phase high performance liquid chromatography. Structural analyses identified an Ala----Pro replacement at position 130 of the alpha chain. The instability of the variant, named Hb Sun Prairie, is comparable to that of Hb Bibba [alpha 136 (H19)Leu----Pro]. Gene mapping failed to detect an alpha-thalassemia deletion (alpha alpha/alpha alpha), while dot-blot analysis of amplified DNA with synthetic probes localized a G----C mutation in codon 130 (resulting in the Ala----Pro mutation) of the alpha 2-globin genes of both chromosomes. These results suggest a homozygosity for the G----C mutation and the condition alpha 2(G----C)alpha 1/alpha 2(G----C)alpha 1 adequately explains the rather severe clinical status of this child, including the marked microcytosis and hypochromia. Unfortunately, family studies to exclude the presence of a large deletion involving all zeta- and alpha-globin genes were not possible.     

Interaction of rare illegitimate recombination event and a poly A addition site mutation resulting in a severe form of alpha thalassemia

The clinical diversity of thalassemia depends on interaction of diverse genetic defects. We have characterized a severe form of alpha thalassemia caused by coinheritance of a rare alpha-globin gene deletion and a nondeletional defect in a southern Italian family. The proband, a 7-year-old girl, exhibited an abnormal hemoglobin electrophoresis pattern with hemoglobin H and hemoglobin Barts, indicating inheritance of H and hemoglobin Barts, indicating inheritance of a severe form of alpha thalassemia. Southern blot analysis of DNA showed normal as well as aberrant alpha-globin gene fragments indicating heterozygosity for a deletional form of alpha thalassemia in the proband and her mother. The coinheritance of a nondeletional form of alpha thalassemia (alpha alpha T) was suspected because of the severity of the proband's phenotype and the presence of normal alpha-globin gene fragments in the father. Selective polymerase chain reaction of the paternal alpha 1- and alpha 2-globin genes in the proband followed by DNA sequence analysis showed an AATAAA to AATGAA mutation in the polyadenylation signal sequence of the alpha 2-globin gene. Genomic DNA mapping and sequence analysis of a unique polymerase chain reaction product generated across the deletion breakpoint of the maternal allele showed a 5,201-bp deletion extending from 870 nucleotides 5' of the alpha 2-globin gene to nucleotide +519 in the alpha 1-globin gene. This deletion is similar to that previously suggested by blotting studies in a Greek family (Pressley et al, Nucleic Acids Res 8:4889, 1980) and removes the entire alpha 2-globin gene and a portion of the 5' end of the alpha 1-globin gene. Sequence characterization of the resultant aberrant truncated alpha 1-globin gene from the proband showed a 27 nucleotide duplication corresponding to the 3' end of the alpha-globin gene IVS-2 region separated by the insertion of a tetranucleotide (GGTT), suggesting that this deletion is caused by an illegitimate recombination event.     

A novel missense mutation in the human plasmin inhibitor (alpha2-antiplasmin) gene associated with a bleeding tendency

Heterozygosity for a G --> A mutation converting Val384(GTG) to Met(ATG) associated with plasmin inhibitor (alpha2-antiplasmin) deficiency was identified in three family members with bleeding tendency. The proband had traumatic breast haematoma and per-/postoperative bleeds. An affected daughter required a blood transfusion after a normal delivery and a son had prolonged bleeding after tooth extraction. The plasma plasmin inhibitor activities of the affected family members were reduced to 49-66% of normal. The antigenic concentrations determined by electroimmunoassay were reduced to 57-68% of normal. Crossed immunoelectrophoresis of plasma from the proband showed a normal pattern. The amino acid Val384 is located eight residues C-terminal (P8') of the P1 residue (Arg376) in the reactive site. The P8' residues of bovine and mouse plasmin inhibitor are both Val. Among other serpins the P8' residue is unconserved. The mutation was not present in the non-affected family member or 30 blood donors. In addition to the Val384Met mutation two new polymorphisms Ala-26(GCG)/Val(GTG) and Arg407(AGG)/Lys(AAG) and one previously reported polymorphism Arg6(CGG)/Trp(TGG) were identified in the plasmin inhibitor gene of the family. The allelic frequencies among 30 blood donors with normal values of plasma plasmin inhibitor (functional) were 0.84/0.16 for C/T in codon -26, 0.81/0.19 for C/T in codon 6 and 0.83/0.17 for G/A in codon 407.     

An alpha-thalassemia phenotype in a Dutch Hindustani, caused by a new point mutation that creates an alternative splice donor site in the first exon of the alpha2-globin gene

The proband is an elderly woman (79 years of age) of Surinamese-Hindustani origin, suspected of being a carrier of a nondeletional alpha-thalassemia (thal) because of a moderate microcytic hypochromic anemia at normal ferritin levels and in the absence of any other alpha-thal deletions. Sequence analysis revealed a silent mutation (GGC-->GGT) at codon 22 of the alpha2-globin gene. This mutation generates a splice donor site consensus sequence (GGTGAG) between codons 22 and 23. The abnormally spliced mRNA leads to a premature termination between codons 48 and 49. The presence of a downstream intron may induce the intracellular degradation of the affected mRNA, a pathway known as nonsense mediated decay (NMD), and this explains the alpha(+)-thal phenotype observed in the patient. The codon 22 (GGC-->GGT) transition described in this report is the first mutation creating a splice donor site in one of the alpha-globin genes.     

Hb Coimbra or alpha 2 beta (2)99(G1)Asp----Glu, a newly discovered highoxygen affinity variant.

We have identified a new high oxygen affinity hemoglobin variant in members of a Portuguese family; it is characterized by an Asp----Glu replacement at codon 99 of the beta chain which is in the alpha 1 beta 2 interface. The altered functional properties of Hb Coimbra likely result from the inability to form a hydrogen bond between beta 99Glu and alpha 42Tyr; such a bond is formed in deoxy Hb A between the normally occurring beta 99Asp and alpha 42Tyr. The two affected members of the family have a distinct erythrocytosis with hemoglobin levels of 18 to 20 g/dl. The mutation in the beta-globin gene (GAT----GAA at codon 99) resulting in the Asp----Glu replacement is the seventh type at this specific location. A review of the many variants of the alpha and beta chains identifies primarily aspartic acid and glutamic acid residues as being most frequently replaced; it is speculated that codons GAC and GAT (for Asp), and GAG and GAA (for Glu) are most susceptible to mutational events.     

Triple genetic variation in the HNF-4alpha gene is associated with early-onset type 2 diabetes mellitus in a philippino family

Maturity-onset diabetes of the young-type 1 (MODY1) is a form of monogenic type 2 diabetes mellitus (T2DM) with long-term complications due to mutations in the HNF-4alpha gene. The HNF-4alpha gene is involved in hepatic differentiation and expression of genes regulating glucose transport, glycolysis, and lipid metabolism. The abnormal glucose-stimulated insulin secretion in MODY1 subjects may be due to reduced glucose transport and glycolysis. To date, 14 mutations in the HNF-4alpha gene have been identified as a cause of either MODY1 or late-onset type 2 diabetes. So far, no screening has been performed in subjects from the Philippines. We recruited a Philippino family with autosomal dominant early-onset type 2 diabetes and screened the proband for mutations in the genes for HNF-1alpha, GCK, HNF-4alpha, IPF-1, HNF-6, and NGN3. We identified a new missense mutation in exon 5 (V199I) of the HNF-4alpha gene and 2 new single-nucleotide substitutions in intron 4, IVS4-nt4 (G --> A) and IVS4-nt20 (C --> T), all cosegregating with diabetes in the 3 affected available siblings. These variations were not present in 100 normal healthy subjects. Bioinformatic analysis suggests that these variations in the whole, and overall the IVS4-nt4 variation located at splicing site, may affect the splicing potential of intron 4. We have biochemically and clinically characterized the Philippine-1 family. We suggest that the V199I missense mutation located in the ligand binding/dimerization domain of HNF-4alpha contributes to type 2 diabetes in the Philippine-1 family. The intron variations may contribute susceptibility to diabetes.     

A mismatched-primer polymerase chain reaction-restriction fragment length polymorphism strategy for rapid screening of the polyadenylation signal mutation alpha(T-Saudi) (AATAAA-->AATAAG) in the alpha2-globin gene.

The most common nondeletional alpha-thalassemia allele, namely alpha(T-Saudi) (AATAAA-->AATAAG), in the Arabian peninsula and neighboring countries is responsible for a number of cases of Hb H disease. It is expected to alter significantly the clinical manifestations of beta-thalassemia and sickle cell disease, also quite prevalent in these regions. Recognition of the alpha(T-Saudi) allele has so far relied on technically-demanding procedures. Here we report a simple, rapid, and robust polymerase chain reaction-based detection procedure for this allele. This involves priming of the polymerase chain reaction with a deliberately introduced mismatch in one of the primers so that the mutant allele, after amplification, would introduce a StuI restriction enzyme site, the presence of which can be recognized by digesting the polymerase chain reaction product with this enzyme.     

Hb H disease in a Turkish family resulting from the interaction of a deletional alpha-thalassaemia-1 and a newly discovered poly A mutation.

We have analysed the alpha-globin gene defects present in several members of a large family from Southern Turkey. One deletional alpha-thalassaemia-1 (type MED-II) was found in 10 subjects: this deletion is in excess of 26.5 kb and includes all zeta- and alpha-globin genes. Besides the common types of deletional alpha-thalassaemia-2 (-3.7 kb and -4.2 kb) we observed a nondeletional alpha-thalassaemia-2 that results from an A----G mutation (AATAAA----AATGAA) in the polyadenylation signal of the alpha 2-globin gene: the same A----G replacement is present in the psi alpha l gene. The mutation must cause a considerable alpha-chain deficiency as is evidenced by the haematological data for five members with Hb H disease due to a compound heterozygosity for alpha-thalassaemia-1 (MED-II) and the newly discovered poly A mutation. Several members had additional beta-chain abnormalities (Hb S, Hb D-Los Angeles, beta-thalassaemia); the 11 persons with a Hb S heterozygosity and various alpha-globin gene defects (-alpha/alpha alpha; alpha T alpha/alpha alpha, - -/alpha alpha, -alpha/-alpha and - -/alpha T alpha) showed a decrease in the level of Hb S that was directly related to the severity of the alpha-chain deficiency.     

Hb Jeddah [alpha68(E17)Asn-->His (alpha1)]: a newly recognized alpha chain variant, seen in combination with Hb S [beta6(A3)Glu-->Val], and found in three separate families of middle eastern origin

We report a previously unrecognized alpha chain variant identified in three families from Saudi Arabia, Yemen and Abu Dhabi. The index patient presented for hemoglobinopathy screening and was identified to have both this novel alpha chain variant and Hb S [beta6(A3)Glu-->Val, GAG(-->)GTG]. Hb Jeddah results from a point mutation (AAC(-->)CAC) at codon 68 in exon 2 of the alpha1 gene. There were no apparent hematological abnormalities or clinical symptoms in the three individuals identified as heterozygotes for Hb Jeddah, as well as the index case with both Hb S and Hb Jeddah. As we have found this variant in three separate families, the incidence may be greater than currently recognized.     

The nondeletional types of Hb H disease in Guangxi.

Three primers were designed, one specific for alpha 1-globin DNA, a second for alpha 2-globin DNA, and a third that is common for both alpha 1- and alpha 2-globin DNA. These three primers can be applied for selective amplification of the two globin DNA fragments, which is useful for identification of nondeletional types of Hb H disease. Fifty-nine DNA samples of Hb H patients from Guangxi were studied by selective amplification, and 27 cases (45.8%) were confirmed as nondeletional types. Of these, 22 (81.5%) had the Hb Constant Spring (CS) mutation and one had the Hb Quong Sze (QS) mutation; both were identified by hybridization with synthesized oligonucleotide probes. Nondeletional Hb H disease in Guangxi seems to be more severe than the deletional types. The average hemoglobin level of the nondeletional Hb H/CS (--/alpha alpha) is 6.8 g/dl, which is lower than that of the deletional types (7.9 g/dl), while the levels of Hb H and Hb Bart's were much higher in the patients with Hb H/CS than in those with the deletional types.