Diagnosis and Management of
Hereditary Spherocytosis in
Neonates
Israel Neonatology Association
Robert Christensen, MD
Hereditary Spherocytosis
• A heterogeneous disorder where abnormalities of
RBC structural proteins lead to loss of RBC
membrane surface area.
• Spherical-shaped, hyperdense, poorly deformable
red cells with a
shortened life span.
• Occurs world-wide
& affects all racial and
ethnic groups.
• A common genetic
cause of extreme
neonatal jaundice.
STATE-OF-THE-ART REVIEW ARTICLE
A Pediatrician’s Practical
Guide to Diagnosing and
Treating Hereditary
Spherocytosis in Neonates
Robert D. Christensen, Hassan M. Yaish, and Patrick G. Gallagher
2015
Large Fresh Water Lake
The River Jordan
Dead Sea
Outline
1. Hereditary Spherocytosis in Israel
2. Pathogenesis & responsible mutations
3. Making the diagnosis in the Newborn
Nursery or NICU
4. Natural history during the neonatal
period
5. Treatment
Outline
1. Hereditary Spherocytosis in Israel
2. Pathogenesis & responsible mutations
3. Making the diagnosis in the Newborn
Nursery or NICU
4. Natural history during the neonatal
period
5. Treatment
Ballin A, Waisbourd-Zinman O, Saab H, Yacobovich J
et al. Steroid
therapy may be effective
in augmenting hemoglobin levels
during hemolytic crises in children
with hereditary spherocytosis. Pediatr
Blood Cancer. 2011 Aug;57(2):303-5
Department of Pediatrics, Edith Wolfson
Medical Center, Holon, Israel.
118 children with Hereditary Spherocytosis
cared for at Edith Wolfson Medical Center.
Streichman S, Gescheidt Y. Cryohemolysis
for
the detection of hereditary
spherocytosis: correlation studies with
osmotic fragility and autohemolysis.
American J. Hematology 1998 Jul;58(3):206-12.
Department of Hematology, Rambam Medical
Center, Haifa, Israel.
Developed a diagnostic test based on a
unique sensitivity of HS cells to hypertonic
cryohemolysis and analyzed blood samples
of 55 HS patients.
Tamary H, Aviner S, Freud E, et al. High
incidence of
early cholelithiasis detected by
ultrasonography in children and young
adults with hereditary spherocytosis. J
Pediatr Hematol/Oncol 2003 Dec;25(12):952-4.
Department of Hematology-Oncology, Schneider
Children's Medical Center of Israel, Petah Tikva.
41% of patients with HS (18/44) developed
cholelithiasis as demonstrated by gallbladder
ultrasonography. In most patients (94%) the test
first proved positive at age 4 to 13 years. Patients
with HS and Gilbert syndrome tended to be
younger at the time of cholelithiasis.
Did these children with HS
have the typical course of
severe neonatal jaundice?
How many are autosomal
dominant? Which
mutations? How many are
autosomal recessive
varieties or de novo
mutations? Would there be
value in identifying these as
newborns and providing
anticipatory guidance
regarding development of
jaundice, anemia, gall
bladder disease?
Outline
1. Hereditary Spherocytosis in Israel
2. Pathogenesis & responsible mutations
3. Making the diagnosis in the Newborn
Nursery or NICU
4. Natural history during the neonatal
period
5. Treatment
HEREDITARY SPHEROCYTOSIS
Spherocyte
Prevalence in the
Utah, USA = 1/1000
Red Blood Cell Membrane Proteins
Protein
Gene
Chromosomal
location
Percent of
HS cases
Typical
severity
Inheritance
Ankyrin-1
ANK1
8p11.2
40-50%
Mild to
moderate
Autosomal
dominant
Band 3
SLC4A1
17q21
20-35%
Mild to
moderate
Autosomal
dominant
Beta
Spectrin
SPTB
14q23-24.1
15-30%
Mild to
moderate
Autosomal
dominant
Alpha
Spectrin
SPTA1
1q22-23
<5%
Severe
Autosomal
recessive
Protein 4.2
EPB42
15q15-21
<5%
Mild to
moderate
Autosomal
recessive
Outline
1. Hereditary Spherocytosis in Israel
2. Pathogenesis & responsible mutations
3. Making the diagnosis in the Newborn
Nursery or NICU
4. Natural history during the neonatal
period
5. Treatment
Making the Diagnosis in a Neonate
•First step in making the diagnosis of HS is considering it
in the differential diagnosis.
Making the Diagnosis in a Neonate
•First step in making the diagnosis of HS is considering it
in the differential diagnosis.
•The triad of anemia, splenomegaly, and jaundice, found in
older children and adults with HS, is rare in neonates.
Making the Diagnosis in a Neonate
•First step in making the diagnosis of HS is considering it
in the differential diagnosis.
•The triad of anemia, splenomegaly, and jaundice, found in
older children and adults with HS, is rare in neonates.
•Most neonates with HS are not anemic in the first week of
life.
Making the Diagnosis in a Neonate
•First step in making the diagnosis of HS is considering it
in the differential diagnosis.
•The triad of anemia, splenomegaly, and jaundice, found in
older children and adults with HS, is rare in neonates.
•Most neonates with HS are not anemic in the first week of
life.
•Jaundice is the most common presenting feature of HS in
neonates.
Making the Diagnosis in a Neonate
•First step in making the diagnosis of HS is considering it
in the differential diagnosis.
•The triad of anemia, splenomegaly, and jaundice, found in
older children and adults with HS, is rare in neonates.
•Most neonates with HS are not anemic in the first week of
life.
•Jaundice is the most common presenting feature of HS in
neonates.
•The typically sluggish erythropoietic response of neonates
in the first months often renders the reticulocyte count low
relative to the degree of anemia.
Making the Diagnosis in a Neonate
•First step in making the diagnosis of HS is considering it
in the differential diagnosis.
•The triad of anemia, splenomegaly, and jaundice, found in
older children and adults with HS, is rare in neonates.
•Most neonates with HS are not anemic in the first week of
life.
•Jaundice is the most common presenting feature of HS in
neonates.
•The typically sluggish erythropoietic response of neonates
in the first months often renders the reticulocyte count low
relative to the degree of anemia.
•Sometimes in neonates with HS, spherocytes are not
clearly discerned on the early blood smears.
Making the Diagnosis in a Neonate
• 65 percent of neonates with HS have a parent with HS.
• When a parent has HS it is important that this
information be placed prominently in the prenatal record
and communicated verbally, before birth, to the
physicians and the hospital staff who will be providing
neonatal care.
• Failure to communicate this information sometimes
occurs when the affected parent has been asymptomatic
since splenectomy as a child, and has all but forgotten
about the condition and fails to consider that it might be
problematic for their newborn infant.
Evaluating a neonate, during the birthhospitalization, whose parent has HS
● Follow the serum bilirubin level and treat according to
the AAP guidelines during and for several days after the
birth hospitalization as if this were a known case of
hemolysis.
● During the birth hospitalization initiate the evaluation
(next slide) or as suggested by hematology consultation.
● Consider that the neonate could have more severe
jaundice than the parent did as a neonate, particularly if
there has been co-inheritance of a polymorphism retarding
bilirubin uptake or conjugation.
A screening test for
HS in neonates
MCHC mean corpuscular hgb
concentration (g/dL), the
concentration of hemoglobin in an
erythrocyte. The MCHC is HIGH
in neonates with HS.
MCV mean corpuscular volume
(fL = 10-15L), the size of
circulating erythrocytes. The
MCV is LOW in neonates with
HS.
Dr. Maxwell M. Wintrobe
A screening test for
HS in neonates
MCHC mean corpuscular
hgb concentration (g/dL), the
concentration of hemoglobin
in an erythrocyte. The MCHC
is HIGH in neonates with HS.
MCHC/MCV
MCV mean corpuscular
volume (fL = 10-15L), the size
of circulating erythrocytes.
The MCV is LOW in neonates
with HS.
Dr. Maxwell M. Wintrobe
BLACK LINE = neonates with HS
GREY LINE = neonates who do not have HS
Neonate with
MCHC/MCV
>0.37
98% sensitivity
98% specificity for
HS
ORIGINAL ARTICLE
A Simple Screen to Detect
Hereditary Spherocytosis in
Jaundiced Newborn Infants
RD Christensen, HM Yaish, E Henry
Neonate with MCHC/MCV
>0.37
98% sensitivity
98% specificity for HS
Obtain CBC & Blood Smear
High MCHC/MCV
ratio (≥0.37)
Likely to have
autosomal dominant HS
● EMA Flow
● Incubated osmotic fragility
● Hematology consultation
Intermediate (0.35-0.36)
or Normal (<0.35)
MCHC/MCV ratio
Spherocytes
No Spherocytes
Might have
autosomal
dominant HS
Less likely to have
autosomal
dominant HS (but
sometimes
spherocytes are not
prominent on blood
films of neonates
with HS)
Evaluating a neonate with “problematic
jaundice” where the etiology is unclear.
•Not all neonates with problematic jaundice have
hemolytic jaundice.
•If hemolytic jaundice is suspected, the following
algorithm for step-wise evaluation of etiology
might be useful.
PROBLEMATIC NEONATAL JAUNDICE?
To evaluate potential underlying causes, obtain blood group on
mother and baby, DAT, and CBC with peripheral blood smear
DAT Positive
In ABO hemolytic
disease, if the jaundice
is severe or atypical,
consider the possibility
of a co-existing
condition – consider
additional diagnostic
testing sequencing
DAT Negative
RBC Enzymology or
Other Intrinsic
Defect
G6PD
Pyruvate Kinase
Other
Pathogenesis Still Unclear?
● Additional diagnostic testing
● Next generation DNA sequencing
● Hematology consultation
Suspicious for HS?
(MCHC/MCV >0.37)
EMA Flow or
Incubated osmotic
fragility
ORIGINAL ARTICLE
Evaluating eosin-5-maleimide binding
as a diagnostic test for hereditary
spherocytosis in newborn infants
RD Christensen, AM Agarwal, RH Nussenzveig, N Heikal, MA Liew and HM Yaish
•EMA-flow on the blood of 31 neonates; 20
healthy newborns and 11 suspected of HS.
•The 20 healthy newborns and the 2 in whom
HS was suspected but later excluded all had
normal EMA-flow.
•All nine in whom HS was confirmed had
abnormal EMA-flow results.
2015
NEXTGEN High
Through-put Gene
Sequencing
Gene Symbol
SPTA1
SPTB
ANK1
SLC4A1
Spectrin alpha
182860
Elliptocytosis, spherocytosis, pyropoikiolocytosis
Spectrin beta
182870
Elliptocytosis, spherocytosis
Ankyrin 1
612641
Spherocytosis
Erythrocyte membrane protein band 3
109270
Spherocytosis, stomatocytosis, ovalocytosis
EPB41
EPB42
PIEZO1
Erythrocyte membrane protein band 4.1
130500
Elliptocytosis
Erythrocyte membrane protein band 4.2
177070
Spherocytosis
Piezo-type mechanosenitive ion channel component
611184
Xerocytosis
CYB5R3
G6PD
GPI
GSR
HK1
NT5C3
PGK1
PKLR
PKM
TPI1
GSS
ADA
AK1
PFKM
PFKL
UGT1A1
UGT1A6
UGT1A7
SLCO1B1
SLCO1B3
Cytochrome b reductase 3
613213
Methemoglobinemia type 1 and 2
Glucose-6-phosphate dehydrogenase
305900
G6PD deficiency
Glucose phosphate isomerase
172400
GPI deficiency
Glutathione reductase
138300
GSR deficiency
Hexokinase 1
142600
Hemolytic anemia
Pyrimidine 5’ nucleotidase
606224
Hemolytic anemia
Phosphoglycerate kinase 1
311800
PGK1 deficiency
Pyruvate kinase (liver and red cell)
609712
PKLR deficiency
Pyruvate kinase (muscle)
179050
Bloom syndrome
Triosephosphate isomarase 1
190450
TPI1 deficiency
Glutathione synthase
601002
GSS deficiency
Adenosine deaminase
608958
ADA deficiency
Adenylate kinase 1
103000
AK1 deficiency
Phosphofructokinase (muscle)
610681
PFKM deficiency, Glycogen storage dis type 7
Phosphofructokinase (liver)
171860
UDP glycosyltransferase 1 family, polypeptide A1
19174
Crigler-Najar syndrome 1 and 2
UDP glycosyltransferase 1 family, polypeptide A6
606431
UGT1A6 deficiency
UDP glycosyltransferase 1 family, polypeptide A7
606432
UGT1A7 deficiency
?
Solute carrier organic anion transporter family, member 1B1 604843
Rotor Syndrome
Solute carrier organic anion transporter family, member 1B3 605495
Rotor syndrome
ORIGINAL ARTICLE
Causes of hemolysis in neonates
with extreme hyperbilirubinemia
RD Christensen, RH Nussenzveig, HM Yaish, E Henry, LD Eggert, AM Agarwal
•12 neonates with bilirubin ≥ 25 mg/dL.
•Explanations for the jaundice were found in all.
•Five had hereditary spherocytosis, three of
which also had ABO hemolytic disease. Two had
pyruvate kinase deficiency. One had severe
G6PD deficiency. The other four had ABO
hemolytic disease.
2014
Making the Diagnosis in a Neonate
Could end
tidal carbon
monoxide
measurement
be of any
value in
treating
jaundiced
neonates?
HEME
CO
BILIRUBIN
CO in exhaled breath, minus
ambient CO reflects the
bilirubin production rate.
STUDY #1: Define the reference
range for end-tidal CO in term
neonates during the first days
after birth.
METHOD: Use an FDA approved
CO detector to quantify end-tidal CO in
neonates from first hours after birth to time of
discharge home.
RESULTS: Upper limit 1.7 ppm in the first
week, 1.0 ppm after two weeks.
STUDY #2: End-tidal CO in
neonates and children with a known
hemolytic disorder (n=20 CASES)
vs. age-matched controls who do
not have a hemolytic disorder (n=20
CONTROLS).
Cases: 1.2 – 6.6 ppm
Controls: all ≤ 1 ppm
Hereditary Spherocytosis (n = 8; 1.2 - 6.6 ppm)
ABO Hemolytic Disease (n= 6; 1.8 - 5.6 ppm)
Pyruvate Kinase Deficiency (n = 3; 1.3 - 5.2 ppm)
Hereditary Stomatocytosis (n = 1; 1.4 ppm)
Beta Thalassemia (n = 1; 5.1 ppm)
SCD + Alpha Thalassemia (n = 1; 1.6 ppm)
End Tidal Carbon Monoxide levels in 20 neonates and
children with proven hemolytic conditions
End Tidal CO in Well
Babies with TSB >75th
percentile
N=100
CO
CO
Feature
Non-Hemolytic
Jaundice
Hemolytic
Jaundice
p-value
63
37
<0.001
Birth weight (g)
3276±471
3416±525
0.172
Gestational age (wks)
39.0±1.6
38.4±1.2
0.566
Gender (% male)
40%
46%
0.584
Race (% non-Caucasian)
*21%
**30%
0.345
Age at qualifying bilirubin test (hrs)
34.6±16.7
33.5±13.6
0.442
Qualifying bilirubin value (mg/dL)
10.5±2.8
12.6±3.1
0.016
55%
62%
0.476
1.5±0.3
2.6±0.8
<0.001
Received phototherapy in the
hospital
45%
89%
0.003
Received home phototherapy after
hospital discharge
18%
39%
0.005
Follow-up TB test was not obtained
within 24 hrs of hospital discharge
16
1
<0.001
Number
Mother blood group O
ETCOc (ppm)
TB level
RISK ZONE
in the birth
hospital
Number
Day of life
of hospital
readmission
TB level on
readmission
(mg/dL)
Days of
hospitaliz-ation
(during the
rehospitalization)
Number where
readmission
might have been
averted by
ETCOc testing
Test not
done
2
5.0±1.4
21.0±3.6
3.0±2.8
?
Low risk
zone
6
5.6±1.8
18.8±1.9
1.8±1.0
0
Lowintermediate
risk zone
Highintermediate
risk zone
High risk
zone
34
4.5±1.2
19.2±1.8
1.3±0.4**
0
22
4.1±0.8
19.9±2.6
1.8±1.3**
22
4
3.8±1.0
19.5±0.6
2.8±1.0
4
QUESTIONS
During the birth hospitalization, can we identify
those jaundiced neonates with HEMOLYTIC
jaundice and selectively involve them in a more
rigorous bilirubin follow-up (<24 h after hospital
discharge?.....YES
QUESTIONS
During the birth hospitalization, can we identify
those jaundiced neonates with HEMOLYTIC
jaundice and selectively involve them in a more
rigorous bilirubin follow-up (<24 h after hospital
discharge?....YES
By so doing, can we reduce hospital readmissions
for extreme hyperbilirubinemia, and reduce the
risk of BIND and kernicterus….
?
Outline
1. Hereditary Spherocytosis in Israel
2. Pathogenesis & responsible mutations
3. Making the diagnosis in the Newborn
Nursery or NICU
4. Natural history during the neonatal
period
5. Treatment
Natural history during the neonatal period
•Topic has received relatively little attention in published
series or reviews.
•Delhommeau et al. reported 34 infants with HS during
their first year.
Natural history during the neonatal period
•Topic has received relatively little attention in published
series or reviews.
•Delhommeau et al. reported 34 infants with HS during
their first year.
•Neonatal jaundice was present in all and 3 received
exchange transfusions.
Natural history during the neonatal period
•Topic has received relatively little attention in published
series or reviews.
•Delhommeau et al. reported 34 infants with HS during
their first year.
•Neonatal jaundice was present in all and 3 received
exchange transfusions.
•Transfusions were rarely needed in the first week.
•Thirty-one had pallor and dyspnea during the first month.
.
Natural history during the neonatal period
•Topic has received relatively little attention in published
series or reviews.
•Delhommeau et al. reported 34 infants with HS during
their first year.
•Neonatal jaundice was present in all and 3 received
exchange transfusions.
•Transfusions were rarely needed in the first week.
•Thirty-one had pallor and dyspnea during the first month.
•Twenty-six (76%) required one or more RBC transfusions
during the first year; 12 had a single transfusion and 14 had
two or more.
•Six were splenectomized at 2 to 5 years.
Outline
1. Hereditary Spherocytosis in Israel
2. Pathogenesis & responsible mutations
3. Making the diagnosis in the Newborn
Nursery or NICU
4. Natural history during the neonatal
period
5. Treatment
Treatment
• Reports of recombinant erythropoietin therapy as an
alternative or adjunct to transfusion.
Treatment
• Reports of recombinant erythropoietin therapy as an
alternative or adjunct to transfusion.
• Rationale for rEPO - the relative hypoplastic phase of
erythropoiesis during the first months after birth.
Treatment
• Reports of recombinant erythropoietin therapy as an
alternative or adjunct to transfusion.
• Rationale for rEPO - the relative hypoplastic phase of
erythropoiesis during the first months after birth.
• This phase might be related to the abrupt fall after
birth from the highly-stimulated erythropoiesis during
fetal life, the switch of EPO production from the liver to
the kidney, the switch from fetal to adult hemoglobin, or
the lower serum level of EPO in infants compared with
older children.
Treatment
• Reports of recombinant erythropoietin therapy as an
alternative or adjunct to transfusion.
• Rationale for rEPO - the relative hypoplastic phase of
erythropoiesis during the first months after birth.
• This phase might be related to the abrupt fall after
birth from the highly-stimulated erythropoiesis during
fetal life, the switch of EPO production from the liver to
the kidney, the switch from fetal to adult hemoglobin, or
the lower serum level of EPO in infants compared with
older children.
• We use Darbepoetin 10 µg/k sub Q if hgb <9 g/dL.
Treatment
•Erythrocyte transfusions.
•Folic Acid.
•Darbepoetin.
•Iron status monitoring.
•Splenectomy.
Consistent approaches are needed to guide
treatment of neonates. Organized study groups can
make progress toward evidence-based
improvements in outcomes and reductions in costs
of care.
Outline
1. Hereditary Spherocytosis in Israel
2. Pathogenesis & responsible mutations
3. Making the diagnosis in the Newborn
Nursery or NICU
4. Natural history during the neonatal
period
5. Treatment
Take Home Messages/Questions
•What proportion of severe neonatal jaundice in Israel is
caused by Hereditary Spherocytosis?
Take Home Messages/Questions
•What proportion of severe neonatal jaundice in Israel is
caused by Hereditary Spherocytosis?
•When a child here is found to have HS, what can we learn
from the birth records about the natural history of bilirubin
problems during the early days or transfusion needs in the
early months of life?
Take Home Messages/Questions
•What proportion of severe neonatal jaundice in Israel is
caused by Hereditary Spherocytosis?
•When a child here is found to have HS, what can we learn
from the birth records about the natural history of bilirubin
problems during the early days or transfusion needs in the
early months of life?
•Are the cases of HS in Israel predominantly autosomal
dominant? What are the responsible mutations?
Take Home Messages/Questions
•What proportion of severe neonatal jaundice in Israel is
caused by Hereditary Spherocytosis?
•When a child here is found to have HS, what can we learn
from the birth records about the natural history of bilirubin
problems during the early days or transfusion needs in the
early months of life?
•Are the cases of HS in Israel predominantly autosomal
dominant? What are the responsible mutations?
•What percent of cases are autosomal recessive or de novo
mutations? What are the responsible mutations?
Take Home Messages/Questions
•What proportion of severe neonatal jaundice in Israel is
caused by Hereditary Spherocytosis?
•When a child here is found to have HS, what can we learn
from the birth records about the natural history of bilirubin
problems during the early days or transfusion needs in the
early months of life?
•Are the cases of HS in Israel predominantly autosomal
dominant? What are the responsible mutations?
•What percent of cases are autosomal recessive or de novo
mutations? What are the responsible mutations?
•Can ETCO monitoring of provide any value?
•What “consistent approaches” (guidelines) can we write?
Diagnosis and Management of Hereditary Spherocytosis in Neonates
Thanks for Your Kind
Attention
Israel Neonatology Association
Robert Christensen, MD