Hemoglobin

international journal for hemoglobin research

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0
Complex Interaction of Hb Q-Thailand with α - and
0
β -Thalassemia in a Chinese Family

Sheng He, Qian Qin, Li Lin, Qiuli Chen, Shang Yi, Honhwei Wei, Juan Du,
Chenguang Zheng, Xiaoxia Qiu & Biyan Chen

To cite this article: Sheng He, Qian Qin, Li Lin, Qiuli Chen, Shang Yi, Honhwei Wei, Juan
Du, Chenguang Zheng, Xiaoxia Qiu & Biyan Chen (2017) Complex Interaction of Hb Q-
0 0
Thailand with α - and β -Thalassemia in a Chinese Family, Hemoglobin, 41:1, 68-72, DOI:
10.1080/03630269.2017.1295985

To link to this article: https://doi.org/10.1080/03630269.2017.1295985

Accepted author version posted online: 17

Feb 2017.
Published online: 05 May 2017.

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HEMOGLOBIN, 2017
VOL. 41, NO. 1, 68–72
http://dx.doi.org/10.1080/03630269.2017.1295985

SHORT COMMUNICATION

Complex Interaction of Hb Q-Thailand with a0- and b0-Thalassemia in a Chinese

Family
Sheng Hea
, Qian Qinb
, Li Lina, Qiuli Chena, Shang Yia, Honhwei Weia, Juan Dua, Chenguang Zhenga,
Xiaoxia Qiua and Biyan Chena
a
Prenatal Diagnostic Center, Guangxi Zhuang Autonomous Region Women and Children Care Hospital, Nanning, Guangxi, People’s Republic
of China; bPrenatal Diagnostic Center, Baise Women and Children Care Hospital, Baise, Guangxi, People’s Republic of China

ABSTRACT ARTICLE HISTORY

Hb Q-Thailand [a74(EF3)Asp!His (a1); HBA1: c.223 G>C] is an abnormal hemoglobin (Hb), variant found Received 9 December 2016
mainly in China and Southeast Asian countries. The association of the aQ-Thailand allele with other glo- Revised 31 December 2016
bin gene disorders has important implications in diagnosis. Here, we report a hitherto undescribed Accepted 12 January 2017
condition of patients with a double heterozygosity for Hb Q-Thailand with a0-thalassemia (a0-thal)
and in combination with b0-thalassemia (b0-thal) in a Chinese family. Our study will provide some KEYWORDS
clinical manifestations, laboratory diagnosis and genetic counseling for complex a0-Thalassemia (a0-thal);
hemoglobinopathies. b0-thalassemia (b0-thal);
genetic counseling;
hemoglobinopathies;
Hb Q-Thailand

Hemoglobinopathies are a group of inherited recessive disor-
ders in which the production of hemoglobin (Hb) is altered,
either as the result of a quantitative (thalassemias) or a
qualitative defect (structural Hb variants) [1]. These disor-
ders are very common in Southern China and other Asian
countries, where Hb variants are often associated with a- or
b-thalassemia (a- or b-thal) [2]. The heterozygotes for Hb
variants can manifest limited clinical effects and may be
asymptomatic, while the double heterozygosity for structural
variants and thalassemias may lead to severe clinical diseases
[3]. In China and other Asian countries, the two most com-
mon Hb variants are Hb E [b26(B8)Glu!Lys;
HBB:c.79 G>A] and Hb Constant Spring (Hb CS, HBA2:
c.427 T>C). In addition to the two most common Hb var-
iants, other abnormal Hbs caused by both a chain and b
chain variants have been reported [4,5]. Among those var-
iants, Hb Q-Thailand [a74(EF3)Asp!His (a1);
HBA1:c.223 G>C], also known as Hbs G-Taichung, Mahidol,
Kurashiki-I and Asabara, has occasionally been documented,
mostly as heterozygotes or compound heterozygotes with a0-
thal [6]. Furthermore, the interactions of Hb Q-Thailand
with other thalassemias or hemoglobinopathies have been
sporadically reported in some regions [7–9].
Heterozygous Hb Q-Thailand usually shows slight red
blood cell (RBC) microcytosis, while coinheritance with a0-
thal leads to a clinical phenotype of the Hb Q-H disease
with clinical features similar to the deletional Hb H (b4) dis-
ease [10]. Complex interaction of Hb Q-Thailand with Hb E
and a0-thal and hereditary persistence of fetal Hb (HPFH)
named Hb QEFBart’s disease can cause an a- or b-thal inter-
media (a- or b-TI) phenotype [9]. Therefore, the association
of Hb Q-Thailand with other globin gene disorders has
important implications in clinical manifestation, laboratory
diagnosis and genetic counseling. We here reported a hith-
erto undescribed condition of patients with double heterozy-
gosity for Hb Q-Tailand and a0-thal and in combination
with b0-thal in a Chinese family.
The proband, a 12-year-old Chinese boy with normal
serum iron ferritin, displayed a moderate anemia phenotype
with the following hematological parameters: RBC count
6.53  1012/L, Hb 9.96 g/dL, mean corpuscular volume
(MCV) 55.3 fL, mean corpuscular Hb (MCH) 15.25 pg.
Hemoglobin analysis in the proband revealed two abnormal
Hb variants. Therefore, this patient and his family members
(four subjects), originally from Guangxi Province with
Chinese Zhuang nationality, were referred to our laboratory
for further investigation after informed consent was obtained.
The medical history indicated that the proband and his
younger sister had mild hepatosplenomegaly and mild hemo-
lytic facies, but none of them had been transfused.
Hematological parameters using an automated blood cell
counter (Sysmex F280; Sysmex, Tokyo, Japan) showed that
the mother had normal RBC indices, while the proband and
his sister as well as his father presented hypochromic micro-
cytic anemia (Table 1). Hemoglobin analysis with an auto-
mated high performance liquid chromatography (HPLC)

CONTACT Biyan Chen danlao197811@163.com Prenatal Diagnostic Center, Guangxi Zhuang Autonomous Region Women and Children Care Hospital, No.
59 Xiangzhu Road, Nanning, Guangxi 530012, People’s Republic of China; Xiaoxia Qiu Qiuxiaoxia1958@163.com Prenatal Diagnostic Center, Guangxi
Zhuang Autonomous Region Women and Children Care Hospital, No. 59 Xiangzhu Road, Nanning, Guangxi 530012, People’s Republic of China

S. He and Q. Qin have contributed equally to this study.
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
 HEMOGLOBIN 69

analyzer (VARIANT IITM; Bio-Rad Laboratories, Hercules,
CA, USA) revealed a specific peak in the S window in the
proband (Figure 1(a)), the sister (Figure 1(c)) and the mother
(Figure 1(b)), with a retention time (RT) of 4.61 min.,
4.61 min. and 4.63 min., respectively. The automated capillary
electrophoresis (CE) (Capillarys 2; Sebia, Lisses, France)
showed that each of the three members contained a dominant
peak at zone 7 (Figure 2a, 2b and 2c)). The expression of the
Hb fractions estimated from the spectra is summarized in
Table 1.
Identification of common a-thal alleles including the
Southeast Asian (– –SEA/), Thailand (– –THAI/), the (–a3.7/)
(rightward) and (–a4.2/) (leftward) deletions and common
b-thal genes in the Chinese populations were performed as
described previously [11]. The results revealed that the father
carried a – –SEA deletion on the a-globin gene and a 4 bp
deletion on the b-globin, while the mother had a (–a4.2) dele-
tion on the a-globin gene. Both the proband and his sister
inherited the (– –SEA) deletion and the 4 bp deletion on the
b-globin from their father and acquired the (–a4.2) deletion
from their mother. The a- and b-globin genes were then
amplified and analyzed by direct sequencing. This showed
that the proband and his younger sister were both homozy-
gotes for the aQ-Thailand mutation, whereas his mother was
heterozygous for the aQ-Thailand mutation (Figure 3).
Therefore, we concluded that the genotypes of the proband
and his sister were both – –SEA/-a4.2-Q-Thailand, bcodons 41/42/
bA, their father’s genotype was – –SEA/aa, bcodons 41/42/bA
and the mother’s genotype was aa/–a4.2-Q-Thailand.
Hb Q-Thailand is an a-globin chain variant that is the
result of a point mutation (GAC>CAC; Asp!His) at codon
74 (HBA1: c.223 G>C) of the a1-globin gene on chromo-
some 16p. The aQ-Thailand gene is strongly linked to a left-
ward single a-globin gene deletion (–a4.2). Individuals
heterozygous for Hb Q-Thailand are usually clinically
asymptomatic and have normal or slight RBC microcytosis
because of the linked (–a4.2) aþ-thal allele [12]. The data
presented for the father in Table 1 confirmed this matter.
The codons 41/42 (–TTCT) (HBB: c.126_129delCTTT) is
a frameshift mutation resulting in a stop codon at the new

Table 1. The hematological and molecular data of the family members under study.
Parameters Proband Sister Mother Father
Sex-age (years) M-12 F-8 F-38 M-40
Hb (g/dL) 9.96 9.70 11.27 11.92
RBC (1012/L) 6.53 6.87 3.90 4.50
MCV (fL) 55.0 49.6 88.0 81.0
MCH (pg) 15.25 15.00 28.90 26.48
Hb A (%) 0.0 0.0 68.6 94.6
Hb A2 (%) 0.0 0.0 1.8 4.6
Hb F (%) 0.0 0.0 0.0 0.8
Hb Q-T (%) 95.8 96.2 28.7 0.0
Hb Q-A2 (%) 4.2 3.8 0.9 0.0
Serum ferritin (ng/mL) 286.8 196.3 73.5 97.3
a Genotype – –SEA/–a4.2-Q-Thailand – –SEA/–a4.2-Q-Thailand a/–a4.2-Q-Thailand – –SEA/a
b Genotype bc d ns 41/42/bA bc d ns 41/42/bA bA/bA bc d ns 41/42
/bA
Hb: hemoglobin; RBC: red blood cell counts; MCV: mean corpuscular volume; MCH: mean corpuscular Hb; Hb Q-T: Hb Q-Thailand.

Figure 1. Hemoglobin analysis of the proband and family members with automated HPLC. (a) The proband; (b) the mother; (c) the sister; (d) the father. Hb A, Hb
Q-Thailand, Hb A2 and Hb QA2 are indicated by arrows.
70 S. HE ET AL.

Figure 2. Hemoglobin analysis of the proband and family members using CE. (a) The proband; (b) the mother; (c) the sister; (d) the father. Hb A, Hb Q-Thailand, Hb
A2 and Hb QA2 are indicated by arrows.

Figure 3. DNA sequence analysis of the amplified a1-globin gene from the proband and his family members. (a) The father; (b) the mother; (c) the proband. The
downward arrow indicates the G > C substitution at codon 74 of the a1-globin gene.

codon 59 terminating translation on the b-globin chain. This
mutation causes a b0-thal phenotype [13]. Subjects with dou-
ble heterozygosity for Hb Q-Thailand and b0-thal showed
similar hematological parameters with those usually observed
for simple b-thal carriers with mild hypochromic microcytic
RBCs and slightly reduced Hb values [6]. Hb Q-Thailand
coinherited with a0-thal leads to a clinical phenotype of the
Hb Q-H disease with clinical features similar to deletional
Hb H disease that presents with marked microcytosis,
chronic hemolytic anemia associated with jaundice and hep-
atosplenomegaly [8]. However, due to the absence of free
b-globin chains, patients with Hb H/b-thal have a higher Hb
level, resulting in a better compensated anemia. And the fea-
tures of these subjects form an intermediate clinical pheno-
type between a Hb H and b-thal carrier [14]. In this study,
the proband and his younger sister both presented moderate
hypochromic microcytic anemia and had mild hepatospleno-
megaly, indicating that they showed intermediate clinical
phenotypes (Table 1). The clinical features of patients with
Hb Q-H/b0-thal need further study with larger samples in
the future.
In general, the specific peak of Hb Q-Thailand appears at
the RT of 4.08–4.63 min. and 180–200 seconds (zone 7) on
cation exchange HPLC and CE analyzers, respectively [15].
As shown in Figure 2, similar peaks appeared in the proband
and his younger sister, who both carried three combinations
of Hb Q-Thailand/b0-thal/– –SEA (a-thal-1) type deletions,
and in the mother who was heterozygous for Hb Q-
Thailand, respectively, except for the amount of Hb Q-
Thailand level. In the proband and his sister, the percentage
of Hb Q-Thailand were increased to nearly the total Hb level,
as there was only an aQ-Thailand-globin chain remaining, the
most observed Hb was Hb Q-Thailand (aQ-Thailand2bA2). From
this and other studies [6,15], it was found that it was easy to
discriminate between the heterozygote and compound hetero-
zygote or homozygote for Hb Q-Thailand using HPLC or CE,
while molecular characterization was required to define the
correct genotypes. Moreover, in low resource settings where
molecular analysis is not available, the better understanding of
HPLC chromatogram and/or CE electropherogram patterns of
Hb Q-Thailand and its combination(s) is essential for thalas-
semia diagnosis and genetic counseling. It is also noteworthy
that all glycated fractions comigrated with the main corre-
sponding peaks are not separated (Figure 2), providing an
accurate Hb Q quantitative estimation and a clear profile,
easy to interpret, when using the CE.
The identification of reduced Hb A2 (a2d2) and the pres-
ence of the Hb Q-A2 derivative (aQ-Thailand2d2) in patients with
compound heterozygosity for Hb Q-Thailand or other similar
Hb variants should have clinical implications. Recognition of
this Hb A2 variant is very important for the diagnosis and
exclusion of b-thal minor [16]. The previous study reported
that coinheritance of Hb Q-Thailand and b-thal resulted in a
normal Hb A2 value and that may cause potential pitfalls for
b-thal diagnosis [12]. In the present study, due to no produc-
tion of a-globin chain synthesis in samples with three combi-
nations of Hb Q-Thailand/b-thal – –SEA type deletions, thus,
only two peaks of Hb Q-Thailand and Hb Q-A2 were pre-
sented on CE (Figure 2(a,b)). While, for an accurate diagnosis
HEMOGLOBIN 71
of the case, the levels of Hb A2 and Hb A2-derivative should
be added together [16]. Therefore, the total amount of Hb A2
for the proband and the sister should read 4.2 and 3.8%,
respectively. The Hb A2 levels were still within the diagnostic
range (3.5–10.0%) for a typical b-thal trait.
In conclusion, this is the first report on the clinical and
molecular characterization of Hb Q-Thailand with a0-thal
and b0-thal mutations. Our study will provide some clinical
implications for the molecular diagnosis of complex
hemoglobinopathies.
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
Funding
This study was supported by Natural Science Foundation of China
[81660034, 81260093], Natural Science Foundation of Guangxi
[2016GXNSFAA380078], the Guangxi Science and Technology Project
[Gui 14124004-1-5, Gui 1598012-21] and the Health Department of
Guangxi Province [Z2014146, Z2011060, S201613].
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