Hereditary spherocytosis. Recent experience and current concepts of pathophysiology

Malignant systemic hypertension, encephalopathy and bradycardia following splenectomy for hereditary spherocytosis

An 8-year-old girl suffering from hereditary spherocytosis underwent splenectomy for chronic severe anaemia. Surgery was uneventful and the patient had a good early postoperative recovery. On the third postoperative day, however, she developed severe headache with associated abnormal movements of upper limbs and nystagmus. She had a heart rate of 50 bpm and a blood pressure of 180/110 mm Hg. She was managed with triple antihypertensives, antiepileptics and sedatives. She recovered slowly over 2 weeks and is fine at 5 months follow-up.

Gallstone disease in children

CONTEXT

little is known about the epidemiology of cholelithiasis in children. Cholelithiasis and choledocholithiasis were considered to be uncommon in infants and children but have been increasingly diagnosed in recent years due to wide- spread use of ultrasonography. However, there is not much of information from India and no consensus among Indian pediatricians and pediatric surgeons regarding management of gallstones in children. Hence, the purpose of this review is to increase awareness about the management of gallstones in children.

METHODS

extensive electronic (PubMed) literature search was made for this purpose and literature (original articles, clinical trials, case series, review articles) related to gallstones in children were reviewed.

CONCLUSIONS

the etiologies of cholelithiasis are hemolytic (20% -30%), other known etiology (40%-50%) such as total parenteral nutrition, ileal disease, congenital biliary diseases, and idiopathic (30-40 %). Spontaneous resolution of gallstones is frequent in infants and hence a period of observation is recommended even for choledocholithiasis. Children with gallstones can present with typical biliary symptoms (50%), nonspecific symptoms (25%), be asymptomatic (20%) or complicated (5% -10%). Cholecystectomy is useful in children with typical biliary symptoms but is not recommended in those with non-specific symptoms. Prophylactic cholecystectomy is recommended in children with hemolytic disorders.

Hereditary haemolytic anaemias: unexpected sequelae of mutations in the genes for erythroid membrane skeletal proteins

Although the haemolytic anaemia may be the primary concern for hereditary spherocytosis and elliptocytosis patients, it is clear that their situation can be compromised by primary and secondary defects in erythroid and non-erythroid systems of the body. All seven of the red cell membrane skeletal proteins discussed in this review are also expressed in non-erythroid tissues, and mutations in their genes have the potential to cause non-erythroid defects. In some instances, such as the protein 4.1R and ANK1 neurological deficits, the diagnosis is clear. In other instances, because of the complex expression patterns involved, the non-erythroid effects may be difficult to assess. An example is the large multidomain, multifunctional band 3 protein. In this case, the location of the mutation can cause defects in one functional domain or isoform and not the other. In other cases, such as the beta-adducin null mutation, other isoforms may partially compensate for the primary deficiency. In such cases, it may be that the effects of the deficit are subtle but could increase under stress or with age. To be completely successful, treatment strategies must address both primary and secondary effects of the anaemia. If gene replacement therapy is to be used, the more that is known about the underlying genetic mechanisms producing the multiple isoforms the better we will be able to design the best replacement gene. The various animal models that are now available should be invaluable in this regard. They continue to contribute to our understanding of both the primary and the secondary effects and their treatment.

Anemia and the liver. Hepatobiliary manifestations of anemia

Many types of hemolytic anemia may be associated with liver disease. Liver injury can be caused by the adherence of deformed or hemolyzed erythrocyses to hepatic vascular endothelium. Adhesion of large numbers of hemolyzed red blood cells to hepatic macrophages, or occlusion of hepatic sinusoids by fragmented red cells, can also result in injury of the liver. Thrombosis of the hepatic or portal vein is associated with some types of hemolytic anemia, and can cause severe liner injury. These are some examples of hepatic injury that can be caused by hemolytic anemias. This article discusses some aspects of liver disease that is associated with sickle cell anemia, paroxysmal nocturnal hemoglobinuria, glucose-6-phosphate dehydrogenase deficiency, hereditary spherocytosis, and HELLP syndrome.

Deciding when to intervene: a Markov decision process approach

The aim of this paper is to point out the difference between static and dynamic approaches to choosing the optimal time for intervention. The paper demonstrates that classical approaches, such as decision trees and influence diagrams, hardly cope with dynamic problems: they cannot simulate all the real-world strategies and consequently can only calculate suboptimal solutions. A dynamic formalism based on Markov decision processes (MPPs) is then proposed and applied to a medical problem: the prophylactic surgery in mild hereditary spherocytosis. The paper compares the proposed approach with a static approach on the same medical problem. The policy provided by the dynamic approach achieved significant gain over the static policy by delaying the intervention time in some categories of patients. The calculations are carried out with DT-Planner, a graphical decision aid specifically built for dealing with dynamic decision processes.

Combined laparoscopic splenectomy and cholecystectomy for the treatment of hereditary spherocytosis: is it safe and effective?

Hereditary spherocytosis is the most common red blood cell membrane disorder and often is associated with hemolytic crisis and premature cholelithiasis. Splenectomy is the only effective therapy for this disorder and often it is performed in combination with cholecystectomy. Conventional surgery requires a wide upper abdominal incision for correct exposure of the gallbladder and spleen. Laparoscopic cholecystectomy and splenectomy have been performed safely worldwide. We report our experience with seven patients (one male and six female, average age 12 years) who underwent combined laparoscopic splenectomy and cholecystectomy for hereditary spherocytosis. The patient was placed in supine position and the procedure performed with a five-trocar technique. Cholecystectomy was performed first, then splenectomy was achieved and the spleen removed by morcellation into a retrieval bag (five cases) or via a 4- to 5-cm left subcostal incision (two cases). No patient required conversion to open technique or blood transfusion. The mean blood loss was 162 mL, mean operative time 207 minutes, mean spleen size 14.5 cm, and median postoperative hospital stay 4 days. No perioperative mortality or major complications occurred in our series. After a median follow-up of 18 months all patients showed sharp hematologic improvement. Despite the small number of cases, we consider the combined laparoscopic approach safe and effective for the treatment of hereditary spherocytosis.

The role of prophylactic cholecystectomy during splenectomy in children with hereditary spherocytosis

BACKGROUND/PURPOSE

Hereditary spherocytosis is an autosomal dominant disorder associated with an intrinsic defect in the red blood cell membrane often necessitating splenectomy to prevent sequestration of spherocytes. When cholelithiasis is present, these patients undergo cholecystectomy at the same surgical setting as splenectomy. After splenectomy alone, it is uncertain whether the amount of hemolysis is adequately decreased to prevent subsequent gallstone formation. This study set out to evaluate the frequency in which symptomatic cholelithiasis subsequently develops in children treated by splenectomy alone.

METHODS

All patients less than 18 years old with hereditary spherocytosis who underwent splenectomy without cholecystectomy at our institution during the past 27 years were included in this study. A retrospective chart review and telephonic patient follow-up was performed. Gallstones were excluded in these patients either by preoperative ultrasound scan, or by intraoperative palpation of the gallbladder. The main study outcomes of this group included documented cases of cholelithiasis, subsequent need for cholecystectomy secondary to cholelithiasis, and questionnaire to determine the incidence of "subclinical" cholelithiasis (not reported to a physician).

RESULTS

Twenty-three subjects were identified who met the inclusion criteria. Complete follow-up data were obtained for 17 of these patients (74%). The mean age at splenectomy was 6.6 +/- 0.69 years, and the mean follow-up was 15.65 +/- 2.03 years (median, 18 years). None of the patients in this series subsequently have undergone cholecystectomy, nor have any had either clinical or subclinical evidence of cholelithiasis since splenectomy.

CONCLUSION

Prophylactic cholecystectomy at the time of splenectomy is not indicated in patients with hereditary spherocytosis who do not have gallstones.

Prophylactic splenectomy and cholecystectomy in mild hereditary spherocytosis: analyzing the decision in different clinical scenarios

OBJECTIVES

Patients with mild hereditary spherocytosis (HS), i.e. with haemolysis without anaemia. have an increased risk of gallstone formation, erythroid aplasia and haemolytic crisis. Since the effect of prophylactic splenectomy on life expectancy has not been established, we conducted a decision analysis comparing prophylactic splenectomy and cholecystectomy with no surgery.

DESIGN

The available data on surgery and disease outcomes were modelled to estimate the effects of the different interventions on the quality-adjusted life expectancy. The early phase outcomes depicted surgery-related mortality and incorporated compliance and the adverse effects of prophylaxis against post splenectomy infections. The late phase outcomes were framed by a Markov cohort analysis.

RESULTS

For patients without gallstones, surgery was of no benefit. For those with gallstones the preferred strategies were found to be splenectomy and cholecystectomy before the age of 39 when asymptomatic, and before 52 when accompanied by occasional biliary colic. Cholecystectomy alone proved to be the preferred strategy in older patients with occasional biliary colic. For patients of up to 52 years of age and candidates for cholecystectomy because of recurrent biliary colic, the best strategy was to combine this procedure with splenectomy. Sensitivity analysis showed that the results were sensitive to the incidence of post cholecystectomy syndrome. Most remarkably an extreme sensitivity to compliance with post splenectomy infection prophylaxis was demonstrated.

CONCLUSIONS

Our model suggested that combined prophylactic splenectomy and cholecystectomy provide a substantial gain in quality-adjusted life expectancy for young patients and adults with mild HS and gallstones.

[Hereditary spherocytosis. Course and value of subtotal splenectomy]

BACKGROUND

Effectiveness of subtotal splenectomy, a procedure recently advocated as an alternative treatment to total splenectomy for patients with hereditary spherocytosis (HS), has been evaluated.

METHODS AND PATIENTS

Eighty-eight patients (74 children) with HS were included in this series. Clinical presentations ranged from asymptomatic cases to severe transfusion-dependent forms. Stunting of growth occurred in four cases; chronic fatigue was observed in 30 cases and cholelithiasis in 21 cases. Among the red cell indices measured by laser light scattering on Technicon H2, the most reliable for diagnosis was the abnormal percentage of hyperdense red cells (98% of HS patients). Osmotic gradient ektacytometry, used to measure membrane deformability and impairment of maximal deformability due to a reduction of erythrocyte surface, always showed the characteristic curves of HS.

RESULTS

Subtotal splenectomy was performed in 24 patients leading to a remnant spleen of about 25% of normal for age volume. This decreased the hemolytic rate while adequately sustaining the phagocytic function of the spleen (assessed by percentage of "pitted erythrocytes" and technetium 99n scans of the remnant). However, the observed reduction in hemolytic rate was not as extensive as that observed after total splenectomy (six cases) and subtotal splenectomy did not entirely prevent risk of cholethiasis (three cases).

CONCLUSION

This subtotal splenectomy (+/-cholecystectomy) has to be particularly considered for children with transfusion-dependent forms of HS, in order to obtain the benefits of increased hemoglobin levels without the pending risk throughout life of overwhelming post-splenectomy infections.

Hereditary spherocytosis: a review of the clinical and molecular aspects of the disease

Hereditary spherocytosis is a common and very heterogeneous hemolytic anemia caused by defects of the red cell membrane proteins. In recent years, major advances in our understanding of the red cell membrane skeleton and a better characterization of its individual components have allowed a brighter insight into the pathogenesis of the disease. In this article, we present an overview of the erythrocyte skeleton and its individual constituents. We also review the clinical aspects of the disease and describe the currently known molecular defects involving the membrane proteins which have been shown to play an essential role in the underlying mechanism of hereditary spherocytosis. Finally we examine several models that have been proposed in an attempt to clarify the mechanism leading from the initial molecular insult to the clinical phenotype.

Open heart operation in a young child with spherocytosis

Open heart operations on patients with hereditary spherocytosis have been reported rarely. Young children who have not yet undergone splenectomy have a high risk of intraoperative hemolysis because of the heart-lung machine and secondary renal failure. We report the case of a 15-month-old child with spherocytosis who underwent an open heart operation without serious complications as a result of careful and appropriate perioperative management.

Open heart operation in patients suffering from hereditary spherocytosis

Hereditary spherocytosis is a clinically heterogeneous, genetically determined red blood cell membrane disorder resulting in hemolytic anemia. Structural or functional disorders of the cytoskeletal proteins result in the formation of spherocytes, which lack the strength, durability, and flexibility to withstand the stresses of the circulation. This problem can be accentuated by the deleterious effects of the heart-lung machine. Three patients with hereditary spherocytosis underwent open heart operation with no deaths and no serious complications resulting from the hematologic defect. Splenectomy is recommended, although not essential, before a cardiac operation, and mechanical valves should perhaps be avoided.

Hereditary spherocytosis with congestive heart failure: report of a case

We report herein a case of 62-year-old woman with hereditary spherocytosis (HS) and congestive heart failure (CHF). Although her history revealed jaundice in the early neonatal period, she had never undergone a physical examination and thus, the diagnosis of HS and CHF was not made until the age of 61 when she complained of dyspnea and palpitations on exertion. The CHF was subsequently found to be related to severe anemia in the presence of underlying heart disease. Splenectomy was performed in an attempt to relieve the severe hemolytic process. Following this, all the symptoms improved without the need for any cardiovascular drugs and she has been well throughout the 34 months follow up.

Homozygosity for dominant form of hereditary spherocytosis

A 6-month-old male infant with hereditary spherocytosis (HS) who was the first child of a cousin marriage is presented. The patient had splenomegaly and severe anaemia. Examination of the peripheral blood smear revealed spherocytes and the osmotic fragility of red blood cells was greatly increased. Physical examination of the parents revealed that both parents had mild anaemia, jaundice and splenomegaly. Their peripheral blood smears showed spherocytes and a few acanthocytes. Osmotic fragility of red blood cells of both parents were increased. Red cell membrane electrophoresis indicated a deficiency of ankyrin in the propositus; mild deficiency was also detected in both parents. Electrophoretic patterns of red cell membrane proteins suggested that the child was homozygous for the dominant form of HS associated with ankyrin deficiency, while both parents had the simple dominant form of the disease. Red blood cell transfusions were given to the patient starting at the age of 1 month until splenectomy was performed at the age of 1 year that resulted in complete haematological response. This observation indicates that homozygosity for dominant type of HS associated with ankyrin deficiency is life compatible and splenectomy may cure the anaemia.

Current problems in haematology. 2: Hereditary spherocytosis

Hereditary spherocytosis is a relatively common haematological disorder and will be encountered by all haematologists. The abundance of new information, dealing principally with molecular and genetic aspects of pathophysiology, is beginning to have implications for its investigation and management. While these advances have not yet exerted a large influence at therapeutic level, the promise of such advents as prenatal diagnosis make this an exciting field to watch.

Variable clinical severity of hereditary spherocytosis: relation to erythrocytic spectrin concentration, osmotic fragility, and autohemolysis

To determine whether stratifying hereditary spherocytosis by degree of severity could provide guidelines regarding which patients would benefit from splenectomy, we evaluated the clinical characteristics of 80 patients (63 children) and 27 healthy relatives. In addition to routine hematologic determinations, osmotic fragility, autohemolysis, erythrocyte spectrin content, and erythrocyte membrane lipid phosphorus were measured and correlated with the disease severity. Four categories were identified: (1) spherocytosis as a trait in symptom-free relatives of patients with recessively inherited disease; (2) mild and (3) moderate spherocytosis, largely observed in patients with dominantly inherited disease; and (4) severe spherocytosis, observed in only two patients, who were characterized by recessive inheritance and transfusion dependence. By the identification of carriers, a recessive mode of inheritance could be demonstrated in 20% of the families with spherocytosis. The erythrocyte spectrin concentration was normal in carriers and patients with mild spherocytosis, and was significantly reduced in the moderate and severe states of the disease. This difference was not accounted for by reduced membrane area of the cells, as measured by the phospholipid concentration per cell. We conclude that patients with mild spherocytosis usually do not require splenectomy during childhood and adolescence; patients with moderate or severe disease should have splenectomy. Patients with severe spherocytosis have a partial response to splenectomy but a considerable degree of increased hemolysis persists. Most patients with less than 80% of normal spectrin content require splenectomy.