University of the Visayas

Gullas College of Medicine

Group 16
Case Study: Sickle Cell Disease/Anemia

Sickle Cell Disease/ Anemia

1. Describe the structure of hemoglobin and relate to its function

Hemoglobins are tetramers comprised of pairs of two different polypeptide subunits. Greek
letters are used to designate each subunit type. The subunit composition of the principal
hemoglobins are α2β2 (HbA; normal adult hemoglobin), α2γ2 (HbF; fetal hemoglobin), α2S2
(HbS; sickle cell hemoglobin), and α2δ2 (HbA2; a minor adult hemoglobin). The primary
structures of the β, γ, and δ chains of human hemoglobin are highly conserved.

Different hemoglobins are produced during embryonic, fetal, and adult life. Each consists of a
tetramer of globin polypeptide chains: a pair of α-like chains 141 amino acids long and a pair of
β-like chains 146 amino acids long. The major adult hemoglobin, HbA, has the structure α2β2.
HbF (α2γ2) predominates during most of gestation, and HbA2 (α2δ2) is minor adult hemoglobin.
Embryonic hemoglobins need not be considered here.

Each globin chain enfolds a single heme moiety, consisting of a protoporphyrin IX ring
complexed with a single iron atom in the fer- rous state (Fe2+). Each heme moiety can bind a
single oxygen molecule; a molecule of hemoglobin can transport up to four oxygen molecules.

The amino acid sequences of the various globins are highly homolo- gous to one another. Each
has a highly helical secondary structure. Their globular tertiary structures cause the exterior
surfaces to be rich in polar (hydrophilic) amino acids that enhance solubility, and the interior to
be lined with nonpolar groups, forming a hydrophobic pocket into which heme is inserted. The
tetrameric quaternary structure of HbA contains two αβ dimers. Numerous tight interactions (i.e.,
α1β1 contacts) hold the α and β chains together. The complete tetramer is held together by
interfaces (i.e., α1β2 contacts) between the α-like chain of one dimer and the non-α chain of the
other dimer.

The hemoglobin tetramer is highly soluble, but individual globin chains are insoluble. Unpaired
globin precipitates, forming inclusions that damage the cell and can trigger apoptosis. Normal
globin chain synthesis is balanced so that each newly synthesized α or non-α globin chain will
have an available partner with which to pair.

Solubility and reversible oxygen binding are the key properties deranged in hemoglobinopathies.
Both depend most on the hydrophilic surface amino acids, the hydrophobic amino acids lining
the heme pocket, a key histidine in the F helix, and the amino acids forming the α1β1 and α1β2
contact points. Mutations in these strategic regions tend to be the ones that alter oxygen affinity
or solubility.

The function of hemoglobin is to support oxygen transport, hemoglobin must bind O2 efficiently
at the partial pressure of oxygen (Po2) of the alveolus, retain it in the circulation, and release it to
tissues at the Po2 of tissue capillary beds. Oxygen acquisition and delivery over a relatively
narrow range of oxygen tensions depend on a property inherent in the tetrameric arrange- ment
of heme and globin subunits within the hemoglobin molecule called cooperativity or heme-heme
interaction.

At low oxygen tensions, the hemoglobin tetramer is fully deoxygenated. Oxygen binding begins
slowly as O2 tension rises. However, as soon as some oxygen has been bound by the tetramer,
an abrupt increase occurs in the slope of the curve. Thus, hemoglobin molecules that have
bound some oxygen develop a higher oxygen affinity, greatly accelerating their ability to
combine with more oxygen. This S-shaped oxygen equilibrium curve, along which substantial
amounts of oxygen loading and unloading can occur over a narrow range of oxygen tensions, is
physiologically more useful than the high-affinity hyperbolic curve of individual monomers.

Oxygen affinity is modulated by several factors. The Bohr effect is the ability of hemoglobin to
deliver more oxygen to tissues at low pH. It arises from the stabilizing action of protons on
deoxyhemoglobin, which binds protons more readily than oxyhemoglobin because the latter is a
weaker acid. Thus, hemoglobin has a lower oxy- gen affinity at low pH. The major small molecule
that alters oxygen affinity in humans is 2,3-bisphosphoglycerate (2,3-BPG; formerly 2,3- DPG),
which lowers oxygen affinity when bound to hemoglobin. HbA has a reasonably high affinity for
2,3-BPG. HbF does not bind 2,3- BPG, so it tends to have a higher oxygen affinity in vivo.
Hemoglobin also binds nitric oxide reversibly; this interaction influences vascular tone, but its
clinical relevance remains incompletely understood.
Proper oxygen transport depends on the tetrameric structure of the proteins, the proper
arrangement of hydrophilic and hydrophobic amino acids, and interaction with protons or 2,3-
BPG.

2. Discuss the molecular genetics of sickle cell anemia

In sickle cell hemoglobin (HbS), Val replaces the β6 Glu of HbA, creating a “sticky patch” that has
a complement on deoxyHb (but not on oxyHb). De- oxyHbS polymerizes at low O2
concentrations, forming fibers that distort erythrocytes into sickle shapes.

3. Explain the effect of genetic abnormality in sickle cell anemia in hemoglobin structure and
 function in red blood cells.

The sickle cell syndromes are caused by a mutation in the β-globin gene that changes the sixth
amino acid from glutamic acid to valine. HbS (α2β26 Glu→Val) polymerizes reversibly when
deoxygenated to form a gelatinous network of fibrous polymers that stiffen the RBC membrane,
increase viscosity, and cause dehydration due to potassium leakage and calcium influx. These
changes also produce the sickle shape. Sickled cells lose the pliability needed to traverse small
capillaries. They possess altered “sticky” membranes that are abnormally adherent to the
endothelium of small venules. These abnormalities provoke unpredictable episodes of
microvascular vasoocclusion and premature RBC. The rigid adherent cells clog small capillaries
and venules, causing tissue ischemia, acute pain, and gradual end-organ damage. This
venoocclusive component usually dominates the clinical course. Prominent manifestations
include episodes of ischemic pain (i.e., painful crises) and ischemic malfunction or frank infarction
in the spleen, CNS, bones, joints, liver, kidneys, and lungs.

4. Differentiate sickle cell disease and sickle cell anemia

Sickle cell disease refers to not only patients with sickle cell anemia, but also to compound
heterozygotes where one β-globin allele includes the sickle cell mutation and the second β-
globin allele includes a gene mutation other than the sickle cell mutation, such as HbC, β-
thalassemia, HbD, and HbOArab. Sickle cell anemia , the most common of the RBC sickling
diseases, is a genetic disorder of the blood caused by a single nucleotide substitution in the gene
for β-globin. In sickle cell anemia, HbS is commonly as high as 90% of the total hemoglobin;
whereas as in sickle cell disease, HbS is >50% of all hemoglobin.

5. Explain the pathophysiologic mechanism behind the manifestations of patients with sickle
cell anemia

There will be vaso-occlusion, then ischemia, then myocardial infarction and organ damage, which
would lead to pain.

Some manifestations would also be:

Acute sickle cell pain may be precipitated by physical stress, infection, dehydration, hypoxia, local
or systemic acidosis, exposure to cold and swimming for prolonged periods. This is again due to
the decrease in Oxygen levels in the rbc’s that causes vaso-occlusion. The pain here is due to
acidosis and becomes toxic to the muscle therefore elicits pain.

Intravascular sickling primarily occurs in the postcapillary venules and is a function of both
mechanical obstruction by sickled red blood cells and increased adhesion between red blood
cells, leukocytes and the vascular endothelium. Sickle cell disease is also an inflammatory disease
based on nonspecific markers of inflammation, including, but not limited to, elevated baseline
white blood cell count and cytokines.

7. State and discuss the advantage of patients with sickle cell disease over those without
disease in connection with malaria infection

People with heterozygous sickle cell trait (i.e. people with one defective Hb allele and one healthy
Hb allele. Also known as “carriers”) can still contract malaria but with milder symptoms, due to
the protective effect of sickle cell trait against malaria (Serjeant, 2010). In a carrier, the
plasmodium parasite causes RBCs with defective Hb to rupture prematurely, thus the parasite is
unable to reproduce. Therefore, people with the sickle cell trait have a higher chance to survive
malaria. However, people with homozygous sickle cell disease are more vulnerable to malaria
(Oniyangi & Omaru, 2006). Mortality and morbidity are increased in people with both sickle cell
anemia and malaria (Alouch, 1997; Ashley-Koch, 2000).

8. Discuss the modalities in the management of sickle cell and its rationale

Hydroxyurea (10-30 mg/kg per day) increases HbF levels and suppresses the granulocyte and
reticulocyte counts (which play major roles in the pathogenesis of sickle cell crisis).

Bone marrow transplant can also help treat sickle cell anemia, however this is effective and safe
for children only.

Blood transfusion can also be used to manage acute cases of sickle cell disease.