Chapter 099. Disorders of Hemoglobin (Part 9) Unstable hemoglobins occur sporadically, often by spontaneous new mutations. Heterozygotes are often symptomatic because a significant Heinz body burden can develop even when the unstable variant accounts for a portion of the total hemoglobin. Symptomatic unstable hemoglobins tend to be β-globin variants, because sporadic mutations affecting only one of the four α-globins would generate only 20–30% abnormal hemoglobin. Hemoglobins with Altered Oxygen Affinity High-affinity hemoglobins [e.g., Hb Yakima (β 99Asp -> His )] bind oxygen more readily but deliver less O 2 to tissues at normal capillary P O2 levels (Fig. 99- 2). Mild tissue hypoxia ensues, stimulating RBC production and erythrocytosis (Table 99-3). In extreme cases, the hematocrits can rise to 60–65%, increasing blood viscosity and producing typical symptoms (headache, somnolence, or dizziness). Phlebotomy may be required. Typical mutations alter interactions within the heme pocket or disrupt the Bohr effect or salt-bond site. Mutations that impair the interaction of HbA with 2,3-BPG can increase O 2 affinity because 2,3- BPG binding lowers O 2 affinity. Low-affinity hemoglobins [e.g., Hb Kansas (β 102Asn -> Lys )] bind sufficient oxygen in the lungs, despite their lower oxygen affinity, to achieve nearly full saturation. At capillary oxygen tensions, they lose sufficient amounts of oxygen to maintain homeostasis at a low hematocrit (Fig. 99-2) (pseudoanemia). Capillary hemoglobin desaturation can also be sufficient to produce clinically apparent cyanosis. Despite these findings, patients usually require no specific treatment. Methemoglobinemias Methemoglobin is generated by oxidation of the heme iron moieties to the ferric state, causing a characteristic bluish-brown muddy color resembling cyanosis. Methemoglobin has such high oxygen affinity that virtually no oxygen is delivered. Levels >50–60% are often fatal. Congenital methemoglobinemia arises from globin mutations that stabilize iron in the ferric state [e.g., HbM Iwata (α 87His -> Tyr ), Table 99-3] or from mutations that impair the enzymes that reduce methemoglobin to hemoglobin (e.g., methemoglobin reductase, NADP diaphorase). Acquired methemoglobinemia is caused by toxins that oxidize heme iron, notably nitrate and nitrite-containing compounds. Diagnosis and Management of Patients with Unstable Hemoglobins, High-Affinity Hemoglobins, and Methemoglobinemia Unstable hemoglobin variants should be suspected in patients with nonimmune hemolytic anemia, jaundice, splenomegaly, or premature biliary tract disease. Severe hemolysis usually presents during infancy as neonatal jaundice or anemia. Milder cases may present in adult life with anemia or only as unexplained reticulocytosis, hepatosplenomegaly, premature biliary tract disease, or leg ulcers. Because spontaneous mutation is common, family history of anemia may be absent. The peripheral blood smear often shows anisocytosis, abundant cells with punctate inclusions, and irregular shapes (i.e., poikilocytosis). The two best tests for diagnosing unstable hemoglobins are the Heinz body preparation and the isopropanol or heat stability test. Many unstable Hb variants are electrophoretically silent. A normal electrophoresis does not rule out the diagnosis. Severely affected patients may require transfusion support for the first 3 years of life, because splenectomy before age 3 is associated with a significantly higher immune deficit. Splenectomy is usually effective thereafter, but occasional patients may require lifelong transfusion support. Even after splenectomy, patients can develop cholelithiasis and leg ulcers. Splenectomy can also be considered in patients exhibiting severe secondary complications of chronic hemolysis, even if anemia is absent. Precipitation of unstable hemoglobins is aggravated by oxidative stress, e.g., infection, antimalarial drugs. High-O 2 affinity hemoglobin variants should be suspected in patients with erythrocytosis. The best test for confirmation is measurement of the P 50 . A high-O 2 affinity Hb causes a significant left shift (i.e., lower numeric value of the P 50 ); confounding conditions, e.g., tobacco smoking or carbon monoxide exposure, can also lower the P 50 . High-affinity hemoglobins are often asymptomatic; rubor or plethora may be telltale signs. When the hematocrit reaches to 55–60%, symptoms of high blood viscosity and sluggish flow (headache, lethargy, dizziness, etc.) may be present. These persons may benefit from judicious phlebotomy. Erythrocytosis represents an appropriate attempt to compensate for the impaired oxygen delivery by the abnormal variant. Overzealous phlebotomy may stimulate increased erythropoiesis or aggravate symptoms by thwarting this compensatory mechanism. The guiding principle of phlebotomy should be to improve oxygen delivery by reducing blood viscosity and increasing blood flow rather than restoration of a normal hematocrit. Modest iron deficiency may aid in control. . Chapter 099. Disorders of Hemoglobin (Part 9) Unstable hemoglobins occur sporadically, often by spontaneous new mutations. Heterozygotes are often symptomatic because. nitrite-containing compounds. Diagnosis and Management of Patients with Unstable Hemoglobins, High-Affinity Hemoglobins, and Methemoglobinemia Unstable hemoglobin variants should be suspected in patients. treatment. Methemoglobinemias Methemoglobin is generated by oxidation of the heme iron moieties to the ferric state, causing a characteristic bluish-brown muddy color resembling cyanosis. Methemoglobin