CASE 5

HEREDITARY SPHEROCYTOSIS

TIM AKADEMIK
DIVISI SOOCA
2012
 CASE REVIEW

Abel, 12 y.o., female

CC : fatigue

History taking Physical Examination Lab Examination

• brought to hospital by • pale • RBC count ↓

her father because of • skin color jaundiced • Hemoglobin ↓
fatigue • sclerae icteric • Reticulocyte % ↑
• conyunctiva anemis • Hematokrit % ↓
• no cyanosis
• abdomen splenomegaly

Diagnosis : Hemolytic anemia due to Hereditary Spherocytosis

MECHANISM
Abel, 12 y.o., female

mutation in ANK-1 gene

cytoskeleton (spectrin can-

not bind w/ cell membrane

defect in RBC membrane

abnormal RBC
 MECHANISM
Abel, 12 y.o., female
mutation in ANK-1 gene
cytoskeleton (spectrin can-
not bind w/ cell membrane
defect in RBC membrane
abnormal RBC
RBC is fragile osmotic fragility test ↑
Heme RBC considered foreign shorter RBC life span
substance
biliverdin RBC disintegrated before
RBC disintegrated in time
unconjugated bilirubin ↑ spleen
has to produce more RBC erythrocyte ↓
spleen overworked
plasma hypertonic skincolor jaundiced icteric
sclerae reticulocyte ↑ Hb ↓
splenomegaly
crenation ↑
pale fatigue anemic conyunctiva
 1. Difference between prokaryotes & eukaryotes
2. Structure of cell membrane
3. Function of cell membrane
4. Structure & function of cytoskeleton
5. Structure of organelles
6. Function of organelles
7. Structure of nucleus
8. Function of nucleus
9. BHP & PHOP
10. Hemolytic Anemia
11. Hereditary spherocytosis

CLINICAL SCIENCE
HEMOLYTIC ANEMIA

Definition
An anemia that characterized by shortened survival of mature erythrocytes and inability of bone
marrow to compensate for the decreased lifespan.
Features • The causes will denatured the membrane
• Premature destruction of RBC and the and the RBC cell is broke down.
lifespan of RBC less than 120 days
• Elevated erythoprotein levels and a com- Clinical features
pensatory increase in erythropoiesis • Anemia
• Accumulation of hemoglobin and degrada- • Splenomegaly
tion products of hemoglobin • Jaundice

Classification
• Extravascular hemoloysis: Extravascular
hemolysis is generally caused by altera-
tion that renders the RBC less deformable.
This make the RBC can’t pass the spinal
cord and makes the RBC will be phagocyte
by the phagocytic cell. Because destruc-
tion of RBC in spleen increases dramati-
cally, the spleen will work harder and the
result is splenomegaly.
• Intravascular hemolysis: Intravascular
hemolysis is caused by mechanical injury,
complement fixation and parasites or
toxic.
 HEREDITARY SPHEROCYTOSIS

definition
The inherited disorder is caused by intrinsic defects in the RBC membrane skeleton that
render red cells spheroid, less deformable and vulnerable to splenic sequestration and de-
struction.

clinical features
• Anemia symptom
• Splenomegaly
• Jaundice

examination
• Physical (skin colour jaundice, pale, conjunctiva anemis, sclerae was icteric and
abdomen splenomegaly)
• Lab (blood smear, blood value test, osmotic fragility test and autohemolysis)

How it developed from gene?

DNA from parent brings some trigger to make mutation in the development of major
RBC membrane skeletal proteins. The mutation occurs in the development of α-spectrin,
β-spectrin, anykrin, band 4.2 or band 3 that weaken the interaction between these pro-
teins, cause RBC loose membrane fragments. Because of that, the shape of the RBC adopts
the spherical shape. This makes the RBC called as spherocytic cells; these cells are less
deformable than normal ones and therefore become trapped in the splenic cords, where they
are phagocytized by macrophages.
Why the jaundice skin and splenomegaly symptom comes?
After the spherocytic RBC is phagocytized by macrophages, the hemoglobin in the cell will
be broke down to haem group and globin group. Globin will be break down to amino acids
and reused in protein synthesis. Haem will broke down to polyphirin group and Fe, Fe will
be used to make new hemoglobin. The polyphirin will be broke down to biliverdin and bili-
verdin will be broke down to bilirubin. In the spherocytic RBC, the number of cell which is
broke down by macrophages is beyond normal limit so, many cells is broke down.

This condition can make spleen work harder and make inflammation in spleen so it become
splenomegaly. The over limit number cells will increase the hemoglobin release. The hemo-
globin will directly broke down to another form, like biliverdin. Biliverdin must be denatur-
ized by liver to make bilirubin, because the over limit biliverdin, so it makes excess in our
body. The excess will be bound by lipid because lipophilic and the biliverdin will attach in
the adipose tissue near skin and make the skin jaundice.
 BASIC SCIENCE
STRUCTURE & FUNCTION OF
CELL MEMBRANE

Major function of cell membrane

• Communication: contains receptors that recognize and respond to molecular signals.
• Intercellular connection: establishes a flexible boundary, protects cellular contents,
supports cell structures.
• Physical barrier: separate substances inside and outside cell.
• Selective permeability: regulates entries and exits of ions, nutrients, and waste mol-
ecules through the membrane.

Cell membrane structure

• Cell membrane lipids
ƒƒ Phospholipid: major component of the cell membrane. It forms a bilayer which
is semipermeable, allowing only certain molecules to pass through.
ƒƒ Cholesterol: helps to stiffen the cells membrane.
ƒƒ Glycolipid: located on cell membrane surfaces and has a carbohydrate sugar
chain attached to it. It helps the cell to recognize other cells of the body.
• Cell membrane proteins
ƒƒ Structural proteins: help to give support to the membrane shape. Channel
Proteins - form small openings for molecules to diffuse through
 ƒƒ Carrier Proteins: binding site on protein surface “grabs” certain molecules and
pulls them into the cell
ƒƒ Gated Channel proteins: similar to carrier proteins, not always “open”
ƒƒ Receptor Proteins: molecular triggers that set off cell responses (such as
release of hormones or opening of channel proteins), binding site. help cells com-
municate with their external environment through the use of hormones, neurotrans-
mitters and other signaling molecules.
ƒƒ Recognition Proteins: identify cells to the body’s immune system
ƒƒ Enzymatic Proteins: carry out specific reactions
ƒƒ Transport proteins: transport molecules across cell membranes.
ƒƒ Glycoproteins: increasing hydrophilic characters stabilize the cell membrane.

Transport Across Plasma Membrane

1. Kinetic Energy Transport
• Diffusion
ƒƒ Trough lipid bilayer (free diffusion): solutes move down the concentration gra-
dient. Important for movement of oxygen and carbon dioxide.
ƒƒ Trough membrane ion channels: allow passage of small, inorganic ions that are
too hydrophilic to penetrate the nonpolar interior of the lipid bilayer. Slower than
free diffusion.
• Osmosis: Net movement of solvents down the concentration gradient. Occur only
when a membrane is permeable to water but not permeable to certain solutes.
2. Transport by Transporter Membrane
• Facilitated Diffusion: Transport for too polar or highly charged or too big solutes.
Passive transport. To move a solute the carrier binds with a molecule on one side of the
plasma membrane. The carrier protein changes shape and releases the molecule on the
other side of the plasma membrane
• Active Transport: solutes move against concentration gradient.
ƒƒ Primary: requires energy in form of ATP. Energy changes the shapes of the
transporter protein and pump substance. Example: Na-K pump (Na out, K in)
ƒƒ Secondary: indirectly uses energy derived from hydrolysis of ATP. It binds to a
substrate and another, then changes its shape that substances cross the membrane
in the same time. Transporting both substances in the same direction called sym-
port (co-transport) or in opposite direction called antiport (counter-transport).
3. Transport in vesicles
• Endocytosis: taking substance into the cell
ƒƒ Phagocytosis: for solid molecules
ƒƒ Pinocytosis: for water
ƒƒ Receptor-mediated: a form of pinocytosis, occurs when specific receptor helps
substances across
• Exocytosis: pushing substance out of the cell
 Structure & function of
cytoskeleton

Basic function
• Maintain cell structure
• Allow whole-cell movement
• Permit cell shape change
• Mediate muscle contraction
• Machinery to move organelles from one place to another place in cytoplasma

Microfilaments
• Diameter : 8nm
• Referred as filamentous of F-actin
• Polar
• Monomer : G- actin
• Actin-based cytoskeletal structure first describe in muscle tissue
• Six different isoform of action :
ƒƒ α-skeletal in skeletal muscle
ƒƒ α-cardiac in heart muscle
ƒƒ α-vascular in smooth muscle of vasculature
ƒƒ γ-enteric in smooth muscle of viscera
ƒƒ β-cytoplasmic in non muscle cell
ƒƒ γ-cytoplasmic in non muscle cell
• Action polymerization requires ATP and Mg+
• Other protein also contained in this filament are : tropomyosin and troponin
ƒƒ Tropomyosin: domain of the myosin molecule. Stabilizing and stiffening the
filaments
ƒƒ Troponin : Troponon T, C, and I
• Actin myosin contractile structures which found in non-muscle cells :
ƒƒ For cell division
ƒƒ Fibroblast contact with extracellular matrix
ƒƒ Adhesion belt of epithelial cells
ƒƒ Folding of cells into tubes : developmental tissue

Intermediate Filaments
• Diameter : 10nm
• Composed of heterogenous protein
• Major function : provide resistance to mechanical stress placed upon the cell
• It requires no energy for polymerization
• Non polar
• Stable filaments
• The subunits are fibrous filaments
• Intermediate filaments of human cell
 • Assembly steps of Intermediate filaments :
ƒƒ Two Intermediate filaments monomers form a parallel coiled-coil dimmer
ƒƒ Two dimmers form an anti parallel tetramer by side-to-side interaction
ƒƒ Tetramers continue to associate in a helical array up to eight tetramers wide
ƒƒ Intermediate filaments become longer and wind into ropelike structure

Microtubules
• Diameter : 24nm
• Monomer : α and β tubuline
• Labile (undergo rapid assembly and disassembly, ex : sentriol)
• Specific function :
ƒƒ Involved in intracellular vesicle and organelle
ƒƒ Compose cilia and flagella

Structure & function of

ORGANELLES
Ribosomes
• Are complexes of protein and ribosomal RNA (rRNA). Two-thirds of ribosome’s mass
consists of rRNA (3 molecules in prokaryotes and 4 in eukaryotes). rRNA is responsible
for bith structure and function of the ribosome while the protein supports the shape
changes of the rRNA molecules as they carry out catalysis during translation.
• Two types: bound and free. Bound one found attached with ER (Endoplasmic Re-
ticulum) while the free one found freely in the cytoplasm. Both are identical and can
change role.
• Ribosomes are made up in 2 subunits: large subunits and small subunits. These
subunits are made in nucleolus (in eukaryotes). They will join and make a functional
ribosome only when an mRNA is attached to them.
• Each ribosomes has three binding sites for tRNA: P site (peptidyl-tRNA site); holds
tRNA while holding the growing polypeptide chain, A site (aminoacyl-tRNA site); holds
tRNA carrying next amino acid to be added to the chain, and E site (exit site); where
tRNA leaves ribosome.
Function:
• Place of protein synthesis
• Acts as an ribozyme; it catalyze the peptide bond formation

Endoplasmic Reticulum
Structure
• Accounts for more than half of total membrane in many eukaryotic cells.
• Consists of a network of membranous tubules and sacs called cisternae. The ER
membrane which separates the internal compartment of RE from the cytosol called lu-
men (cavity) or cisternal space. Also there’s a vesicular part which shaped like a bubble
that can be loose one another.
• ER membrane is continuous with the nuclear envelope, so that the space between
the two membranes of the envelope is continuous with the lumen of ER.
• There are two types of ER; though connected, they differ in structure and function:
smooth ER (because of no ribosomes are attached on it) and rough ER (because there
are ribosomes that are attached on it, so that the ER looks rough under the microscope.)
ƒƒ Smooth ER commonly tubular shaped or webbed.
ƒƒ Rough ER have ribosomes attached on its membrane and is connected to the
nuclear envelope. There’s a specialized part of rough ER called transitional ER which
forms vesicles.
Function
• Rough ER functions as a transporter of protein made by ribosomes. Most secretory
proteins are glycoproteins, protein which has carbohydrates covalently bond to them.
The carbohydrates are attached to the protein by specialized molecules built into the
ER membrane. Then, the proteins will be bounded by a vesicle from transitional ER. Also
rough ER is the membrane factory of the cell.
• Smooth ER synthesizes lipids, metabolizes carbohydrates, detoxificates drugs and
poisons (by adding hydroxyl groups to drug molecules), and stores calcium ions.

Lysosome
Structure
• A membranous sac of hydrolytic enzymes.
• Made by rough ER then transported to Golgi apparatus for further processing. Maybe
arise by budding from the trans face of the Golgi apparatus.
• In the inactive state, the shape of lysosome could be oval or round with an average
diameter 0,4 microns.
Function
• Internal digestive organelle. Three mechanisms: phagocytosis (act of eating), au-
tophagy (breaking down of damaged organelles), and autolysis (breaking down cell
when it’s broken).
Mitochondria
Structure
• Mitochondria is 1-10μm in length and 0.5μm in diameter.
• Enclosed by two membranes, each phospolipids are embedded with unique pro-
teins with 6nm in thickness. The outer membrane is smooth, but the inner membrane is
convoluted (berlipat-lipat), with infoldings called cristae. The inner membrane divides
mitochondria into two internal compartments: the intermembrane space, the narrow
region between inner and outer membranes; and the mitochondrial matrix, enclosed by
the inner membrane. Cristae give inner mitochondrial membrane a large surface area, to
support its function.
• In the inner membrane, there’s a particle named elementer particle or F1 particle
which is 8,5nm in diameter and has space 10nm between one another. It contains many
important enzymes for mitochondrial functioning.
• Consists of DNA, RNA, and ribosomes, thus mitochondria can make its own proteins.
Function
• Place of aerob respiration. Called also by house of energy because it produces ATP
from respiration.

Peroxisome
Structure
• Bounded by a single membrane.
• Consists of enzymes that converts peroxidase into water and oxygen.
• Can grow bigger by combining proteins especially which made in cytosol, lipid from
ER, and lipid which produced by peroxisome itself. The amount can increase by dividing
the organelle into two when has reached a certain size.
Function
• Oxidation of excess fatty acid
• Participate in the synthesis of bile acid and cholesterol
• Converting peroxide (H2O2) into H2O and O2. Peroxide is toxic for the body.

Golgi Apparatus
Structure
• Consists of flattened membranous sacs – cisternae – and looks like a stack of pita
bread. There are many, even hundreds of stacks like that. The membrane of each cisterna
in a stack separates its internal space from the cytosol.
• Generally, Golgi apparatus is divided into 3 parts:
ƒƒ Saccula: shaped like a flattened sacs in a stack and are connected each other.
There are two faces: the concave side facing the nucleus called the immature face/
forming face and the other side called mature side.
ƒƒ Secretory vesicle: is a oval or round bubble on the end of mature face.
 ƒƒ Microvesicula/transfer vesicle: is a small bubble on the forming face and are
formed from the smooth ER.
• A golgi stack has a distinct structural polarity, with the membranes of cisternae on
opposite sides ofthe stack differing in thickness and molecular composition. The two
poles of Golgi stack are referred as the cis face and trans face.
ƒƒ Cis face is located near ER, used for receiving vesicles from ribosomes or ER.
ƒƒ Trans face will pinch off and transport the functional proteins made by Golgi
apparatus by using vesicles.
ƒƒ Between cis and trans face, there is a part named medial which converts pro-
tein from ribosome into functional protein.
Function
• Center of manufactoring, warehousing, sorting and shipping proteins. Sorting done
by for example adding phospate groups to Golgi products.

Structure & function of

NUCLEUS
Nuclear membrane
• Inner and outer membrane →
lipid bilayer
• Outer → Perinuclear space
(fluid-filled) → Inner
• Outer layer of the membrane is
connected to Endoplasmic Reticu-
lum
• Nuclear pore → protein selec-
tive transport. (protein and RNA)-
nucleus and cytoplasm

Chromosomes
• Form of strings of DNA and histones called chromatin.
• Chromatin
ƒƒ Heterochromatin: Highly condensed, transcriptionally inactive form, mostly
present adjacent to the nuclear membrane.
ƒƒ Euchromatin: Delicate, less condensed, found abundantly in a transcribing cell

Nucleolus
• The nucleolus is a dense, spherical-shaped structure present inside the nucleus/ <=
4 Nucleoli
• Producing ribosomes
Function of Cell Nucleus
1. Control gene expression
2. Cell compartmentalization
3. Processing of pre-mRNA
4. Regulates all cell activity
5. Store genes on chromosomes
6. Organize genes between cell division
7. Transport regulatory factors and gene products via nuclear pores
8. Produce ribosomes in the nucleolus
9. Organize the uncoiling DNA to replicate key genes.
BHP
Informed Consent, Breaking Bad News, & Patient’s Right
UU No 44 tahun 2009 pasal 31 dan 32
• Meminta konsultasi tentang penyakit yang dideritanya kepada dokter lain yang memunyai
SIP
• Mendapatkan informasi yang meliputi diagnosis & tata cara tindakan medis, tujuan tin-
dakan medis, alternatif tindakan, resiko dan komplikasi yang mungkin terjadi dan prognosis
terhadap tindakan yang dilakukan serta perkiraan biaya pengobatan

PHOP
Education about genetic disorder
• Preventif :
ƒƒ - Edukasi tentang penyakit genetic
ƒƒ - Edukasi tentang pentingnya konsep sel dan kaitannya dengan penyakit
ƒƒ - Menekankan pentingnya genetic screening untuk pasangan yang akan menikah
• Promotif : penyuluhan terapi untuk splenomegaly(splenectomy)
• Kuratif : tranfusi darah untuk meminimalisasi dampak buruk penyakit hereditary spherocy-
tosis
• Genetic counseling

DIFFERENCE BETWEEN
PROKARYOTES & EUKARYOTES