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Homozygous sickle cell disease with coexistent hereditary spherocytosis in three siblings
February, 1972 T h e ]ournal of P E D I A T R I C S
235
Homozygous sickle cell disease Mtb coexistent hereditary spberocytosis in three siblings Three siblings with the combination of hereditary spherocytosis and,sickle cell anemia are described. Two of the children demonstrated a striking degree of hemolysis and massive splenomegaly. In response to repeated transfusions of packed red cells their spleens decreased in size and symptoms were relieved. One child had a splenectomy, which was followed by marked improvement of anemia.
Helen S. Maurer, M.D., Loyda N. Vida, B.S., and George R. Honlg, M.D., Ph.D., ~ Chicago, Ill.
C o N O E N IT A L
hemolytic d i s e a s e
in
the
Negro is most frequently due to one of the forms of sickle cell hemoglobinopathy. In the heterozygous state (sickle trait) clinical manifestations are usually minimal or absent, and red cell survival is normal. However, variants of heterozygous sickle cell disease produced by combinations of hemoglobin S with hemoglobin C, or /?-thalassemia, are often associated with a symptomatic course and with variable degrees of premature red cell destruction. Homozygous sickle cell disease usually produces a sigFrom the Department of Pediatrics, The Abraham Lincoln School of Medicine, University of Illinois Medical Center. Supported by Grant RO-I-AM-12895 from the National Institute of Arthritis and Metabolic Diseases, Grant RG-HD-O0568 from the National Institute of Child Health and Human Development, and Grant RG-HE-07418 from the National Heart Institute, United States Public Health Service. Reprint address: 840 S. Wood St., Chicago, Ill. 60612. ~Reclpient of a Research Career Development Award (KO-4-AM-41188) [rote the National Institute of Arthr~tls and Metabolic Di.~easea.
nificant degree of hemolytic anemia together with a clinical course characterized by frequent painful crises and other complications. In rare instances sickle hemoglobinopathy has been found to occur together with other hemolytic disorders to produce, in most cases, a more accelerated rate of red cell destruction than that ordinarily resulting from the sickle hemoglobinopathy alone. Recently Smits and associates, 1 for example, reported a group of patients with sickle cell disease in whom more severe recurrent hemolytic episodes were attributed to the presence of concomitant glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. Hereditary spherocytosis, although generally considered rare in Negroes, 2-4 has also been described in a number of individuals in association with sickle hemoglobin. In most of the cases reported hereditary spherocytosis was present together with heterozygous sickle hemoglobinopathy. 5-1~ A single example of hereditary spherocytosis in a patient with homozygous sickle cell disease has VoL 80, No. 2, pP. 235-242
236
Maurer, Vida, and Honig
The Journal o[ Pediatrics February t972
Fig. 1. Hemoglobin electrophoresis in starch gel Tris-EDTA-boric acid buffer pH 8.6:1 and 8 ~- normal hemoglobin A control; 2, II-1; 3, II-2; 4, III-2; 5, III-1; 6, III-3; 7, III-4.
also been described? 1 In this report we present hematologic findings of a family in w h o m congenital spherocytosis coexisted with heterozygous sickle hemoglobinopathy in the father, with homozygous sickle cell anemia in three children, and with normal hemoglobin in one child. METHODS
Hematologic measurements were performed by standard methods. Glucose-6phosphate dehydrogenase activity of lysates of washed erythrocytes was determined by the method of Zinkham and associates? ~ Hemoglobin electrophoresis was carried out in starch gel prepared in Tris-EDTA-boric acid buffer at p H 8.6 (Fig. 1). 13 Concentrations of fetal hemoglobin were determined by a one-minute alkaline denaturation procedure. 1~ For estimations of the percentages of hemoglobins S and A2, the red cell hemolysates were subjected to acryIamide gel disc electrophoresis? ~ After completion of the electrophoresis the hemoglobin bands were excised and eluted with Drabkin's solution, and quantitated spectrophotometrically at 540 m/x. Autohemolysis and osmotic fragility studies were carried out with sterile defibrinated blood as described by D a c i e ? 6
CASE
REPORTS
Of the five children in Family W., three were found to have homozygous sickle cell disease, one had sickle cell trait, and in one only hemoglobin A was present. Evidence of spherocytosis was present in four of the children, including the child with normal hemoglobin and the three children with homozygous sickle hemoglobinopathy. Both of the parents exhibited the findings of sickle cell trait, and in the father concomitant hereditary spherocytosis was also demonstrated (Fig. 2). The hematologic findings of the family members are presented in Table I, and stained smears of their peripheral blood are shown in Fig. 3. The blood smears of the children who had sickle cell anemia with hereditary spherocytosis differed from those of patients with uncomplicated sickle cell disease by the presence of fewer fixed sickled cells and only occasional target cells; although there was some degree of poikilocytosis, the predominant cell type was the spherocyte (Fig. 3). Case 1. Patient F. W. (III-3), born March 27, 1965, was first seen at the University of Illinois Hospital Pediatric Clinic at the age of 7 months for evaluation of anemia. Hemoglobin concentration was 4.6 Gm. per 100 ml., hematocrit 17 per cent, white blood cell count 14,700 per cubic millimeter, reticulocyte count 26 per cent, and platelet count 129,000 per cubic milli-
Volume 80 Number 2
meter. Many spherocytes and an occasional sickle cell were noted on peripheral blood films. A sickle preparation was positive and hemoglobin electrophoresis demonstrated the presence of hemoglobins S and F with no detectable hemoglobin A. Fetal hemoglobin concentration was 23 per cent. Both of her parents were found at that time to have positive sickle cell preparations, and electrophoresis of their hemoglobin confirmed the presence of sickle cell trait. At the age of 10 months the child was admitted to the hospital because of fever and vomiting. Physical examination revealed pallor and a spleen palpable 1 cm. below the left costal margin. Hemoglobin concentration was 3.8 Gm. per 100 ml., hematocrit 13 per cent, white blood cell count 10,000 per cubic millimeter, reticulocyte count 11 per cent, and platelet count 109,000 per cubic millimeter. A transfusion of packed red cells was given. Over the next three years she was admitted on five occasions because of severe anemia with hemoglobin concentrations ranging from 3 to 4 Gm. per 100 ml. On each of these admissions she was given transfusions of red ceils. During this period the spleen gradually increased in size until it finally reached 13 cm. below the left costal margin and extended into the pelvis. The platelet count ultimately fell to 30,000 per cubic millimeter, white cell count to 6,700 per cubic millimeter, hemoglobin 3.0 Gm. per 100 ml., and hematocrit i0 per cent. Red cell transfusions were administered thereafter on a regular monthly schedule. With this regimen the spleen gradually decreased in size and 6 months later was paIpabIe 5 cm. below the costal margin. At the same time the platelet count increased to 200,000 per cubic millimeter and the white cell count to 8~800 per cubic millimeter. A splenectomy was then performed, and following surgery the hemoglobin concentration remained between 8 and 10 Gin. per 100 ml. without further transfusions. Case 2. Patient T. W. (III-4) had appeared entirely normal, but because of the findings in the other family members was examined at the age of 3 years and was found to have homozygous sickle cell disease as well as spherocytosis. The liver and spleen were not palpable and the remainder of the physical examination was within normal limits. Hemoglobin concentration was 8.4 Gm. per 100 ml., hematocrit 26 per cent, and reticulocyte count 27 per cent. Case 3. Patient C. W. (III-5), born April 8, 1969, was observed from birth and was noted to be icteric beginning at 24 hours of age. Serum
Sickle cell disease with spherocytosis
237
%
11
111 1
2
L~
3
4
5
HEREDITARY SPHEROCY[OSIS
F--] NORMAL Ell SS HEMOGLOBIN i~
AS HEMOGLOBIN
Fig. 2. Pedigree of Family W.
bilirubin concentration increased to reach a maximum of 16 rag. per 100 ml. at 3 days of age, and spherocytes were observed in peripheral blood smears. A Coombs test was negative. At three weeks of age the hemoglobin concentration was 9.3 Gm. per 100 ml., hematocrit 25 per cent, and reticulocyte count 3.5 per cent. A sickle cell preparation was positive and hemoglobin, electrophoresis studies showed the presence of hemoglobins S and F with no detectable hemoglobin A. At the age of 4 months he was admitted to the hospital because of a respiratory infection; the spleen was palpable 2 cm. below the left costal margin and the hemoglobin concentration was 5 Gin. per 100 ml., hematocrit 19 per cent, reticulocyte count 48 per cent, white blood cell count 19,600 per cubic millimeter, and platelet count 141,000 per cubic miilimeter. At age I0 months he was again admitted because of pneumococcal sepsis and meningitis. At this time the spleen was palpable 4 cm. below the left costal margin. He was severely ill for one week, but with antibiotic therapy and general supportive measures gradually recovered. Subsequently the spleen progressively enlarged to reach 8 cm. below the costal margin, and the hemoglobin concentration again fell to 5 Gin. per 100 ml. Regular monthly transfusions were then instituted. Six months after initiating transfusion therapy the child appeared to be developing normally and the spleen was no longer paIpable.
238
Maurer, Vida, and Honig
The Journal o[ Pediatrics February 1.972
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Volume 80 Number 2
Sickle cell disease with spherocytosis
Fig. 3. Peripheral blood smears from family members with spherocytosis. The numbers on the bottom of the photographs represent the pedigree numbers in Fig. 1. A, Blood smear of the father who has the sickle trait and spherocytosis; note normal morphology except for spherocytes. B, C, and D, Photographs of the blood smears of the three children who have both spherocytosis and homozygous sickle cell anemia. There are spherocytes and a few fixed sickled cells. Target cells are absent.
239
2 40
Maurer, Vida, and Honig
The Journal of Pediatrics February 1972
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Fig. 4. Osmotic fragility studies of family members with spherocytosis. A and C, Studies done with fresh blood. B and D, Studies done with blood incubated for 24 hours at 37 ~ C. The shaded areas in the graphs are mean values for the controls + one standard deviation. A and B, Results of studies of two family members with homozygous sickle hemoglobinopathy: ( ), III-3, ( . . . . ), III-4. The control values were obtained with blood from five individuals with sickle cell anemia. C and D, Results of studies of Mood from the father (II-1), who has sickle cell trait ( - - ) , and the child (III-1) with spherocytosis and normal hemoglobin ( . . . . ). The control values in C and D were obtained with blood from individuals with normal hemoglobin. Case 4. Patient H. W. (II-1), the father, had been relativeIy asymptomatic until his early twenties when he first began to experience recurrent episodes of abdominal pain. At age 25 he was admitted to another hospital where the diagnosis of hereditary spherocytosis and sickle cell trait was made. Following splenectomy and cholecystectomy in November, 1970, abdominal symptoms subsided. The hemoglobin concentra~ tion subsequently increased to 15.0 Gm. per 100 ml., and reticulocyte count fell to less than 1 per cent. Case 5. Patient H. W. (III-1) appeared nor~ mal, but was examined at the age of 8 years as part of the family study. The liver and spleen were not palpable and the physical examination was within normal limits. Spherocytes were noted on peripheraI blood smear and a sickle cell preparation was negative. Hemoglobin concentration was 10.0 Gm. per 100 ml., hematocrit 28 per cent, and reticulocyte count 19 per cent. A splenectomy was performed, after which the hemoglobin concentration increased to 13 Gm.
per 100 ml., hematocrit to 40 per cent, and reticulocyte count decreased to 2 per cent. In the two family members who did not have spherocytes but had the sickle trait (II-2 [the mother] and III-2), osmotic fragility studies indicated slightly more resistance to osmotic lysis than normal with both fresh and incubated red cells; this is a characteristic finding in sickle trait. 17 All of the individuals with spherocytosis demonstrated the characteristic increase in erythrocyte osmotic fragility, which was accentuated after incubation of the cells for 24 hours (Fig. 4). In patients with sickle cell anemia the red ceils are known to be more resistant than normal red cells to osmotic lysisl~; accordingly, in the osmotic fragility studies of the family members having homozygous sickle hemoglobinopathy and spherocytosis the results obtained were also compared with those found with cells from sickle cell anemia patients who were otherwise normal. In each of the children with sickle cell anemia and spherocytosis in whom this study was performed a significant increase in osmotic fragility was obtained, with both fresh and incubated cells (Fig. 4). DISCUSSION Although hereditary spherocytosis is widely stated to be rare in the Negro, 2-~ we have encountered this disorder in 7 Negro patients from 4 unrelated families. I n view of the high frequency of sickle hemoglobino p a t h y a m o n g Negroes, the coexistence of these two disorders m a y be more c o m m o n t h a n has been generally appreciated. O u r observations emphasize the need for seeking additional causes for u n u s u a l hemolytic m a n i festations in patients with sickle cell disease. I n the family described here spherocytosis was identified in the father a n d in 4 of his 5 children. This p a t t e r n of i n h e r i t a n c e is consistent with the general observation that hereditary spherocytosis is transmitted as a M e n d e l i a n d o m i n a n t trait, r8 T h e p a t e r n a l g r a n d p a r e n t s (I-1 a n d I-2) were n o r m a l except for the sickle cell trait in the grandmother. However, this is not necessarily a n inconsistent finding as absence of demonstrable spherocytosis has been reported in both parents of as m a n y as 25 per cent of patients with spherocytosis, s
Volume 80 Number 2
Sickle ceil disease with spherocytosis
I n patients with u n c o m p l i c a t e d sickle cell a n e m i a the p e r c e n t a g e of r e d cell autohemolysis is m i l d l y a b n o r m a l ( T a b l e I ) . I n two of the children w i t h sickle cell a n e m i a a n d spherocytosis, a m a r k e d increase in erythrocyte hemolysis was observed a n d was only p a r t i a l l y corrected by the a d d i t i o n of glucose. R e d cells f r o m the t h i r d doubly affected child ( I I I - 5 ) , however, showed only 5.4 p e r cent autohemolysis, which is within the r a n g e we observed in the sickle cell a n e m i a control patients. A n e x p l a n a t i o n for this disparity is not a p p a r e n t ; however, we conclude t h a t the autohemolysis test is not reliable for detection of this p a i r of disorders. A n a d d i t i o n a l notable finding in the children with sickle cell a n e m i a a n d spherocytosis was an u n e x p e c t e d l y high percentage of fetal hemoglobin, r a n g i n g f r o m 13 to 30 p e r cent ( T a b l e I ) . A l t h o u g h elevated levels of fetal hemoglobin are detectable in nearly all patients with sickle cell a n e m i a prior to the age of puberty, 19, ~0 quantities of more than 10 p e r cent beyond the age of two are rare. E x a m i n a t i o n of p e r i p h e r a l blood cells of the patients by the slide elution procedure of K l e i h a u e r a n d associates 21 disclosed a n u n e q u a l distribution of the fetal hemoglobin, which is the usual finding in sickle cell anemia. ~ I n individuals with spherocytosis the percentage of fetal hemoglobin is usually within the range of normal. I n young children with this disorder, however, an a p p r e c i a b l e percentage of fetal hemoglobin can persist in the blood b e y o n d infancy. 2s T h e increased concentration of fetal h e m o g l o b i n in the doubly affected children, therefore, m a y refleet changes related to b o t h the spherocytosis a n d the sickle cell h e m o g l o b i n o p a t h y .
genase deficiency, J. PEDIATR. 74: 544, 1969. 2. Wintrobe, M. M.: Clinical hematology, Philadelphia, 1951, Lea & Febiger, Publishers, p. 598. 3. Young, L. E.: Hereditary spherocytosis, Am. J. Med. 18: 486, 1955. 4. Kfine, A. H., and Holman, G. H.: Hereditary spherocytosis in the Negro, Am. J. Dis. Child. 94: 609, 1955. 5. Martin, W. W., Jr., Kough, R. H., and Branche, G. C., Jr.: Hereditary spherocytosissicklemia in the Negro: Case report and study of a Negro family having multiple instances of hereditary spherocytosis, Blood 14: 688, 1959. 6. Jones, B., and Klingberg, W. G.: Hemoglobin S-hereditary spheroeytosis, J. PEDIAT~. 54: 375, 1959. 7. Cohen, F., Zuelzer, W. W., Neel, J. V., and Robinson, A. R.: Multiple inherited erythro k cyte abnormalities in an American Negro family: Hereditary spheroeytosis, sickling, and thalassemla, Blood 14: 816, 1959. 8. de Torregrosa, M. V., Ortlz, A., and Vargas, D.: Sickle cell-spherocytosis associated with hemolytic anemia, Blood 11: 260, 1956. 9. Smith, E. W., and ConIey, C. L.: ClinicaI features of the genetic variants of sickle cell disease, Bull. Hopkins Hosp. 94: 289, I954. 10. Whitaker, J. A., Windmiller, J., Vietti, T., and Sartain, P.: Hereditary spherocytosis associated with sickle trait and cholelithiasis, J. PEDIATa. 63: 65, 1963. 11. Thompson, R. B., and Robertson, M. G.: Three inherited intra-erythrocytic defects: Hereditary spherocytosis, Hb S and Hb C, Acta Haematol. 32: 233, 1964. 12. Zinkham, W. H., Lenhard, R. E., and Childs, B.: A deficiency of glucose-6-phosphate dehydrogenase activity in erythrocytes from patients with favism, Bull. Hopkins Hosp. 102: 169, 1958. 13. Smithies, O.: Zone electrophoresis in starch gels: Group variations in the serum proteins of normal human adults, Biochem. J. 61: 629, 1955. 14. Singer, K., Chernoff, A. I., and Singer, L.: Studies on abnormal hemoglobins. I. Their demonstration in sickle cell anemia and other hematologic disorders by means of "alkali denaturation, Blood 6: 413, 1951. 15. Neerhout, R. C., Kimmel, J. R., Wilson, J. F., and Lahey, M. E.: Quantitative determination of Hemoglobin A2 with use of disc electrophoresis, J. Lab. Clin. Med. 67: 314, 1966. I6. Dacie, J. V.: Practical haematology, ed. 2, New York, 1956, Chemical Publishing Co., Inc., p. 94. 17. Harris, J. W., Brewster, H. A., Ham, T. H., and Castle, W. B.: Studies on the destruction of red blood cells. X. The biophysics and biology of sickle cell disease, Arch. Intern. Med. 97: 145, 1956, 18. Race, R. R.: On the inheritance and linkage
We thank Miss Alvina Terronez and Miss Tomoko Yoshida for valuable technical assistance with these studies. REFERENCES
1. Smits, H. L., Oski, F. A., and Brody, J. I.: The hemolytic crisis of sickle cell disease: The role of glucose-6-phosphate dehydro-
241
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relation of acholuric jaundice, Ann. Eugenet. 11: 365, 1942. 19. Haggard, M. E., and Schneider, R. G.: Sickle cell anemia in the first two years of life, J. PEmATR. 58: 785, 1961. 20. Bickers, J. N.: Alkall-resistant hemoglobin in sickle cell disease, Ann. Intern. Med. 64: 1028, 1966. 21. Kleihauer, E., Braun, H., and Betke, K.: Demonstration yon fetalem hgmoglobin in den Erythrocyten elnes Blutausstrlchs, Klin. Woenschr. 35: 637, 1957.
The ]ournal o[ Pediatrics February 1972
22. Shepherd, M. K., Weatherall, D. J., and Conley, C. L.: Semi-quantitative estimation of distribution of fetal hemoglobin in red cell populations, Bull. Hopkins Hosp. 110: 293, 1962. 23. Beaven, G. H., Ellis, M. J., and White, J. C.: Studies on human foetal haemoglobin. II. Foetal haemoglobin levels in healthy children and adults and in certain haematological disorders, Br. J. Haematol. 6: 201, 1960.
235
Homozygous sickle cell disease Mtb coexistent hereditary spberocytosis in three siblings Three siblings with the combination of hereditary spherocytosis and,sickle cell anemia are described. Two of the children demonstrated a striking degree of hemolysis and massive splenomegaly. In response to repeated transfusions of packed red cells their spleens decreased in size and symptoms were relieved. One child had a splenectomy, which was followed by marked improvement of anemia.
Helen S. Maurer, M.D., Loyda N. Vida, B.S., and George R. Honlg, M.D., Ph.D., ~ Chicago, Ill.
C o N O E N IT A L
hemolytic d i s e a s e
in
the
Negro is most frequently due to one of the forms of sickle cell hemoglobinopathy. In the heterozygous state (sickle trait) clinical manifestations are usually minimal or absent, and red cell survival is normal. However, variants of heterozygous sickle cell disease produced by combinations of hemoglobin S with hemoglobin C, or /?-thalassemia, are often associated with a symptomatic course and with variable degrees of premature red cell destruction. Homozygous sickle cell disease usually produces a sigFrom the Department of Pediatrics, The Abraham Lincoln School of Medicine, University of Illinois Medical Center. Supported by Grant RO-I-AM-12895 from the National Institute of Arthritis and Metabolic Diseases, Grant RG-HD-O0568 from the National Institute of Child Health and Human Development, and Grant RG-HE-07418 from the National Heart Institute, United States Public Health Service. Reprint address: 840 S. Wood St., Chicago, Ill. 60612. ~Reclpient of a Research Career Development Award (KO-4-AM-41188) [rote the National Institute of Arthr~tls and Metabolic Di.~easea.
nificant degree of hemolytic anemia together with a clinical course characterized by frequent painful crises and other complications. In rare instances sickle hemoglobinopathy has been found to occur together with other hemolytic disorders to produce, in most cases, a more accelerated rate of red cell destruction than that ordinarily resulting from the sickle hemoglobinopathy alone. Recently Smits and associates, 1 for example, reported a group of patients with sickle cell disease in whom more severe recurrent hemolytic episodes were attributed to the presence of concomitant glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. Hereditary spherocytosis, although generally considered rare in Negroes, 2-4 has also been described in a number of individuals in association with sickle hemoglobin. In most of the cases reported hereditary spherocytosis was present together with heterozygous sickle hemoglobinopathy. 5-1~ A single example of hereditary spherocytosis in a patient with homozygous sickle cell disease has VoL 80, No. 2, pP. 235-242
236
Maurer, Vida, and Honig
The Journal o[ Pediatrics February t972
Fig. 1. Hemoglobin electrophoresis in starch gel Tris-EDTA-boric acid buffer pH 8.6:1 and 8 ~- normal hemoglobin A control; 2, II-1; 3, II-2; 4, III-2; 5, III-1; 6, III-3; 7, III-4.
also been described? 1 In this report we present hematologic findings of a family in w h o m congenital spherocytosis coexisted with heterozygous sickle hemoglobinopathy in the father, with homozygous sickle cell anemia in three children, and with normal hemoglobin in one child. METHODS
Hematologic measurements were performed by standard methods. Glucose-6phosphate dehydrogenase activity of lysates of washed erythrocytes was determined by the method of Zinkham and associates? ~ Hemoglobin electrophoresis was carried out in starch gel prepared in Tris-EDTA-boric acid buffer at p H 8.6 (Fig. 1). 13 Concentrations of fetal hemoglobin were determined by a one-minute alkaline denaturation procedure. 1~ For estimations of the percentages of hemoglobins S and A2, the red cell hemolysates were subjected to acryIamide gel disc electrophoresis? ~ After completion of the electrophoresis the hemoglobin bands were excised and eluted with Drabkin's solution, and quantitated spectrophotometrically at 540 m/x. Autohemolysis and osmotic fragility studies were carried out with sterile defibrinated blood as described by D a c i e ? 6
CASE
REPORTS
Of the five children in Family W., three were found to have homozygous sickle cell disease, one had sickle cell trait, and in one only hemoglobin A was present. Evidence of spherocytosis was present in four of the children, including the child with normal hemoglobin and the three children with homozygous sickle hemoglobinopathy. Both of the parents exhibited the findings of sickle cell trait, and in the father concomitant hereditary spherocytosis was also demonstrated (Fig. 2). The hematologic findings of the family members are presented in Table I, and stained smears of their peripheral blood are shown in Fig. 3. The blood smears of the children who had sickle cell anemia with hereditary spherocytosis differed from those of patients with uncomplicated sickle cell disease by the presence of fewer fixed sickled cells and only occasional target cells; although there was some degree of poikilocytosis, the predominant cell type was the spherocyte (Fig. 3). Case 1. Patient F. W. (III-3), born March 27, 1965, was first seen at the University of Illinois Hospital Pediatric Clinic at the age of 7 months for evaluation of anemia. Hemoglobin concentration was 4.6 Gm. per 100 ml., hematocrit 17 per cent, white blood cell count 14,700 per cubic millimeter, reticulocyte count 26 per cent, and platelet count 129,000 per cubic milli-
Volume 80 Number 2
meter. Many spherocytes and an occasional sickle cell were noted on peripheral blood films. A sickle preparation was positive and hemoglobin electrophoresis demonstrated the presence of hemoglobins S and F with no detectable hemoglobin A. Fetal hemoglobin concentration was 23 per cent. Both of her parents were found at that time to have positive sickle cell preparations, and electrophoresis of their hemoglobin confirmed the presence of sickle cell trait. At the age of 10 months the child was admitted to the hospital because of fever and vomiting. Physical examination revealed pallor and a spleen palpable 1 cm. below the left costal margin. Hemoglobin concentration was 3.8 Gm. per 100 ml., hematocrit 13 per cent, white blood cell count 10,000 per cubic millimeter, reticulocyte count 11 per cent, and platelet count 109,000 per cubic millimeter. A transfusion of packed red cells was given. Over the next three years she was admitted on five occasions because of severe anemia with hemoglobin concentrations ranging from 3 to 4 Gm. per 100 ml. On each of these admissions she was given transfusions of red ceils. During this period the spleen gradually increased in size until it finally reached 13 cm. below the left costal margin and extended into the pelvis. The platelet count ultimately fell to 30,000 per cubic millimeter, white cell count to 6,700 per cubic millimeter, hemoglobin 3.0 Gm. per 100 ml., and hematocrit i0 per cent. Red cell transfusions were administered thereafter on a regular monthly schedule. With this regimen the spleen gradually decreased in size and 6 months later was paIpabIe 5 cm. below the costal margin. At the same time the platelet count increased to 200,000 per cubic millimeter and the white cell count to 8~800 per cubic millimeter. A splenectomy was then performed, and following surgery the hemoglobin concentration remained between 8 and 10 Gin. per 100 ml. without further transfusions. Case 2. Patient T. W. (III-4) had appeared entirely normal, but because of the findings in the other family members was examined at the age of 3 years and was found to have homozygous sickle cell disease as well as spherocytosis. The liver and spleen were not palpable and the remainder of the physical examination was within normal limits. Hemoglobin concentration was 8.4 Gm. per 100 ml., hematocrit 26 per cent, and reticulocyte count 27 per cent. Case 3. Patient C. W. (III-5), born April 8, 1969, was observed from birth and was noted to be icteric beginning at 24 hours of age. Serum
Sickle cell disease with spherocytosis
237
%
11
111 1
2
L~
3
4
5
HEREDITARY SPHEROCY[OSIS
F--] NORMAL Ell SS HEMOGLOBIN i~
AS HEMOGLOBIN
Fig. 2. Pedigree of Family W.
bilirubin concentration increased to reach a maximum of 16 rag. per 100 ml. at 3 days of age, and spherocytes were observed in peripheral blood smears. A Coombs test was negative. At three weeks of age the hemoglobin concentration was 9.3 Gm. per 100 ml., hematocrit 25 per cent, and reticulocyte count 3.5 per cent. A sickle cell preparation was positive and hemoglobin, electrophoresis studies showed the presence of hemoglobins S and F with no detectable hemoglobin A. At the age of 4 months he was admitted to the hospital because of a respiratory infection; the spleen was palpable 2 cm. below the left costal margin and the hemoglobin concentration was 5 Gin. per 100 ml., hematocrit 19 per cent, reticulocyte count 48 per cent, white blood cell count 19,600 per cubic millimeter, and platelet count 141,000 per cubic miilimeter. At age I0 months he was again admitted because of pneumococcal sepsis and meningitis. At this time the spleen was palpable 4 cm. below the left costal margin. He was severely ill for one week, but with antibiotic therapy and general supportive measures gradually recovered. Subsequently the spleen progressively enlarged to reach 8 cm. below the costal margin, and the hemoglobin concentration again fell to 5 Gin. per 100 ml. Regular monthly transfusions were then instituted. Six months after initiating transfusion therapy the child appeared to be developing normally and the spleen was no longer paIpable.
238
Maurer, Vida, and Honig
The Journal o[ Pediatrics February 1.972
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Volume 80 Number 2
Sickle cell disease with spherocytosis
Fig. 3. Peripheral blood smears from family members with spherocytosis. The numbers on the bottom of the photographs represent the pedigree numbers in Fig. 1. A, Blood smear of the father who has the sickle trait and spherocytosis; note normal morphology except for spherocytes. B, C, and D, Photographs of the blood smears of the three children who have both spherocytosis and homozygous sickle cell anemia. There are spherocytes and a few fixed sickled cells. Target cells are absent.
239
2 40
Maurer, Vida, and Honig
The Journal of Pediatrics February 1972
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Fig. 4. Osmotic fragility studies of family members with spherocytosis. A and C, Studies done with fresh blood. B and D, Studies done with blood incubated for 24 hours at 37 ~ C. The shaded areas in the graphs are mean values for the controls + one standard deviation. A and B, Results of studies of two family members with homozygous sickle hemoglobinopathy: ( ), III-3, ( . . . . ), III-4. The control values were obtained with blood from five individuals with sickle cell anemia. C and D, Results of studies of Mood from the father (II-1), who has sickle cell trait ( - - ) , and the child (III-1) with spherocytosis and normal hemoglobin ( . . . . ). The control values in C and D were obtained with blood from individuals with normal hemoglobin. Case 4. Patient H. W. (II-1), the father, had been relativeIy asymptomatic until his early twenties when he first began to experience recurrent episodes of abdominal pain. At age 25 he was admitted to another hospital where the diagnosis of hereditary spherocytosis and sickle cell trait was made. Following splenectomy and cholecystectomy in November, 1970, abdominal symptoms subsided. The hemoglobin concentra~ tion subsequently increased to 15.0 Gm. per 100 ml., and reticulocyte count fell to less than 1 per cent. Case 5. Patient H. W. (III-1) appeared nor~ mal, but was examined at the age of 8 years as part of the family study. The liver and spleen were not palpable and the physical examination was within normal limits. Spherocytes were noted on peripheraI blood smear and a sickle cell preparation was negative. Hemoglobin concentration was 10.0 Gm. per 100 ml., hematocrit 28 per cent, and reticulocyte count 19 per cent. A splenectomy was performed, after which the hemoglobin concentration increased to 13 Gm.
per 100 ml., hematocrit to 40 per cent, and reticulocyte count decreased to 2 per cent. In the two family members who did not have spherocytes but had the sickle trait (II-2 [the mother] and III-2), osmotic fragility studies indicated slightly more resistance to osmotic lysis than normal with both fresh and incubated red cells; this is a characteristic finding in sickle trait. 17 All of the individuals with spherocytosis demonstrated the characteristic increase in erythrocyte osmotic fragility, which was accentuated after incubation of the cells for 24 hours (Fig. 4). In patients with sickle cell anemia the red ceils are known to be more resistant than normal red cells to osmotic lysisl~; accordingly, in the osmotic fragility studies of the family members having homozygous sickle hemoglobinopathy and spherocytosis the results obtained were also compared with those found with cells from sickle cell anemia patients who were otherwise normal. In each of the children with sickle cell anemia and spherocytosis in whom this study was performed a significant increase in osmotic fragility was obtained, with both fresh and incubated cells (Fig. 4). DISCUSSION Although hereditary spherocytosis is widely stated to be rare in the Negro, 2-~ we have encountered this disorder in 7 Negro patients from 4 unrelated families. I n view of the high frequency of sickle hemoglobino p a t h y a m o n g Negroes, the coexistence of these two disorders m a y be more c o m m o n t h a n has been generally appreciated. O u r observations emphasize the need for seeking additional causes for u n u s u a l hemolytic m a n i festations in patients with sickle cell disease. I n the family described here spherocytosis was identified in the father a n d in 4 of his 5 children. This p a t t e r n of i n h e r i t a n c e is consistent with the general observation that hereditary spherocytosis is transmitted as a M e n d e l i a n d o m i n a n t trait, r8 T h e p a t e r n a l g r a n d p a r e n t s (I-1 a n d I-2) were n o r m a l except for the sickle cell trait in the grandmother. However, this is not necessarily a n inconsistent finding as absence of demonstrable spherocytosis has been reported in both parents of as m a n y as 25 per cent of patients with spherocytosis, s
Volume 80 Number 2
Sickle ceil disease with spherocytosis
I n patients with u n c o m p l i c a t e d sickle cell a n e m i a the p e r c e n t a g e of r e d cell autohemolysis is m i l d l y a b n o r m a l ( T a b l e I ) . I n two of the children w i t h sickle cell a n e m i a a n d spherocytosis, a m a r k e d increase in erythrocyte hemolysis was observed a n d was only p a r t i a l l y corrected by the a d d i t i o n of glucose. R e d cells f r o m the t h i r d doubly affected child ( I I I - 5 ) , however, showed only 5.4 p e r cent autohemolysis, which is within the r a n g e we observed in the sickle cell a n e m i a control patients. A n e x p l a n a t i o n for this disparity is not a p p a r e n t ; however, we conclude t h a t the autohemolysis test is not reliable for detection of this p a i r of disorders. A n a d d i t i o n a l notable finding in the children with sickle cell a n e m i a a n d spherocytosis was an u n e x p e c t e d l y high percentage of fetal hemoglobin, r a n g i n g f r o m 13 to 30 p e r cent ( T a b l e I ) . A l t h o u g h elevated levels of fetal hemoglobin are detectable in nearly all patients with sickle cell a n e m i a prior to the age of puberty, 19, ~0 quantities of more than 10 p e r cent beyond the age of two are rare. E x a m i n a t i o n of p e r i p h e r a l blood cells of the patients by the slide elution procedure of K l e i h a u e r a n d associates 21 disclosed a n u n e q u a l distribution of the fetal hemoglobin, which is the usual finding in sickle cell anemia. ~ I n individuals with spherocytosis the percentage of fetal hemoglobin is usually within the range of normal. I n young children with this disorder, however, an a p p r e c i a b l e percentage of fetal hemoglobin can persist in the blood b e y o n d infancy. 2s T h e increased concentration of fetal h e m o g l o b i n in the doubly affected children, therefore, m a y refleet changes related to b o t h the spherocytosis a n d the sickle cell h e m o g l o b i n o p a t h y .
genase deficiency, J. PEDIATR. 74: 544, 1969. 2. Wintrobe, M. M.: Clinical hematology, Philadelphia, 1951, Lea & Febiger, Publishers, p. 598. 3. Young, L. E.: Hereditary spherocytosis, Am. J. Med. 18: 486, 1955. 4. Kfine, A. H., and Holman, G. H.: Hereditary spherocytosis in the Negro, Am. J. Dis. Child. 94: 609, 1955. 5. Martin, W. W., Jr., Kough, R. H., and Branche, G. C., Jr.: Hereditary spherocytosissicklemia in the Negro: Case report and study of a Negro family having multiple instances of hereditary spherocytosis, Blood 14: 688, 1959. 6. Jones, B., and Klingberg, W. G.: Hemoglobin S-hereditary spheroeytosis, J. PEDIAT~. 54: 375, 1959. 7. Cohen, F., Zuelzer, W. W., Neel, J. V., and Robinson, A. R.: Multiple inherited erythro k cyte abnormalities in an American Negro family: Hereditary spheroeytosis, sickling, and thalassemla, Blood 14: 816, 1959. 8. de Torregrosa, M. V., Ortlz, A., and Vargas, D.: Sickle cell-spherocytosis associated with hemolytic anemia, Blood 11: 260, 1956. 9. Smith, E. W., and ConIey, C. L.: ClinicaI features of the genetic variants of sickle cell disease, Bull. Hopkins Hosp. 94: 289, I954. 10. Whitaker, J. A., Windmiller, J., Vietti, T., and Sartain, P.: Hereditary spherocytosis associated with sickle trait and cholelithiasis, J. PEDIATa. 63: 65, 1963. 11. Thompson, R. B., and Robertson, M. G.: Three inherited intra-erythrocytic defects: Hereditary spherocytosis, Hb S and Hb C, Acta Haematol. 32: 233, 1964. 12. Zinkham, W. H., Lenhard, R. E., and Childs, B.: A deficiency of glucose-6-phosphate dehydrogenase activity in erythrocytes from patients with favism, Bull. Hopkins Hosp. 102: 169, 1958. 13. Smithies, O.: Zone electrophoresis in starch gels: Group variations in the serum proteins of normal human adults, Biochem. J. 61: 629, 1955. 14. Singer, K., Chernoff, A. I., and Singer, L.: Studies on abnormal hemoglobins. I. Their demonstration in sickle cell anemia and other hematologic disorders by means of "alkali denaturation, Blood 6: 413, 1951. 15. Neerhout, R. C., Kimmel, J. R., Wilson, J. F., and Lahey, M. E.: Quantitative determination of Hemoglobin A2 with use of disc electrophoresis, J. Lab. Clin. Med. 67: 314, 1966. I6. Dacie, J. V.: Practical haematology, ed. 2, New York, 1956, Chemical Publishing Co., Inc., p. 94. 17. Harris, J. W., Brewster, H. A., Ham, T. H., and Castle, W. B.: Studies on the destruction of red blood cells. X. The biophysics and biology of sickle cell disease, Arch. Intern. Med. 97: 145, 1956, 18. Race, R. R.: On the inheritance and linkage
We thank Miss Alvina Terronez and Miss Tomoko Yoshida for valuable technical assistance with these studies. REFERENCES
1. Smits, H. L., Oski, F. A., and Brody, J. I.: The hemolytic crisis of sickle cell disease: The role of glucose-6-phosphate dehydro-
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relation of acholuric jaundice, Ann. Eugenet. 11: 365, 1942. 19. Haggard, M. E., and Schneider, R. G.: Sickle cell anemia in the first two years of life, J. PEmATR. 58: 785, 1961. 20. Bickers, J. N.: Alkall-resistant hemoglobin in sickle cell disease, Ann. Intern. Med. 64: 1028, 1966. 21. Kleihauer, E., Braun, H., and Betke, K.: Demonstration yon fetalem hgmoglobin in den Erythrocyten elnes Blutausstrlchs, Klin. Woenschr. 35: 637, 1957.
The ]ournal o[ Pediatrics February 1972
22. Shepherd, M. K., Weatherall, D. J., and Conley, C. L.: Semi-quantitative estimation of distribution of fetal hemoglobin in red cell populations, Bull. Hopkins Hosp. 110: 293, 1962. 23. Beaven, G. H., Ellis, M. J., and White, J. C.: Studies on human foetal haemoglobin. II. Foetal haemoglobin levels in healthy children and adults and in certain haematological disorders, Br. J. Haematol. 6: 201, 1960.