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Understanding Beta-Thalassemia with Focus on the Indian Subcontinent and

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Article in The Open Hematology Journal · October 2008

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 The Open Hematology Journal, 2008, 2, 5-13 5

Understanding Beta-Thalassemia with Focus on the Indian Subcontinent

and the Middle East
P. Lahiry§, S.A. Al-Attar§ and R.A. Hegele*

Vascular Biology Research Group, Robarts Research Institute and the University of Western Ontario, Canada

Abstract: Beta-thalassemia is one of the most prevalent autosomal disorders in the world. Mutations in the HBB gene un-
derlie deficiencies in hemoglobin production, which can interfere with oxygen delivery resulting in wide range of disease
severity. Although >535 mutations have been characterized in the HBB gene, beta-thalassemia is broadly classified into
three groups, based on clinical severity: beta-thalassemia major, beta-thalassemia intermedia and beta-thalassemia minor.
In this article we review: 1) the molecular and biochemical basis of beta-thalassemia; 2) clinical features; 3) the range of
common molecular variants of beta-thalassemia in a subset of geographic regions within the Indian Subcontinent and the
Middle East; 4) potential molecular diagnostics; and 5) current and future treatments. We suggest that efforts to more
completely characterize the HBB mutation distribution in high-risk areas, such as the Indian Subcontinent and the Middle
East, may lead to improved diagnosis with earlier and more effective intervention strategies.

INTRODUCTION borns affected per year worldwide [14]. Most frequently, this
disorder is found in the malarial, tropical and sub-tropical
Beta-thalassemia is an important disorder that has at-
regions of Mediterranean countries, the Middle East, Tran-
tracted the attention of medical research towards the various
scaucasus, Central Asia, the Indian Subcontinent (South
paradigms of this multifaceted disease [6-12]. Beta-
Asia) and Southeast Asia [15] (Fig. 1).
thalassemia is an autosomal hematological disorder that is
the result of genetically deficient synthesis of the beta-globin Hemoglobin (Hb) is responsible for oxygen delivery
from the lungs to peripheral tissues [16]. Hb is a tetrameric

Fig. (1). Most common beta-thalassemia mutations in at-risk populations. Highlighted regions displaying the highest gene mutation fre-
quencies of beta-thalassemia on a global scale. Mutations listed are those which are most common and represent 91-95% of affected indi-
viduals from these regions (or 75-80% of the population for individuals of African/African-American descent). Listed in brackets are the
approximate upper ranges of beta-thalassemia carrier frequencies in each region [1-5].

chains of hemoglobin [13]. Beta-thalassemia is one of the iron-containing protein, composed of two alpha-globin and
most common single-gene disorders with >400,000 new- two beta-globin chains. The alpha-globin and beta-globin
chains join to form Hb in developing erythrocytes, or red
*Address correspondence to these authors at the Vascular Biology Research
blood cells (RBCs), and remain together for the life of the
Group, Robarts Research Institute and the University of Western Ontario, RBC [17]. In the event of altered beta-globin chain structure
Canada; E-mail: [email protected] or function, in which one or both copies fail to quantitatively
§
These authors contributed equally to this work or qualitatively produce normal beta-globin, the alpha-globin

1874-2769/08 2008 Bentham Science Publishers Ltd.

6 The Open Hematology Journal, 2008, Volume 2 Lahiry et al.

gene continues to produce quantitatively and qualitatively globin production decreases while beta-globin synthesis in-
normal alpha-globin [16, 17]. The imbalance of the globin creases such that most individuals have only trace amounts
chains results in beta-thalassemia [16], with the precipitation of Hb-F detectable 7 or 8 months after birth [21, 22]. The
of excess alpha-chains contributing to excessive destruction combination of two alpha-globin genes and two beta-globin
of RBCs, which begins a cascade that ends with significant genes comprises a normal adult Hb, which becomes the pre-
morbidity and mortality [16]. dominant form within 18 to 24 weeks after birth [21, 22].
Less than 3% of adult hemoglobin is Hb type A2, which is
THE BETA-GLOBIN LOCUS composed of two
-globin chains and two alpha-globin
The beta-globin chain is encoded by the HBB gene, chains [22].
which spans 1.6 kb on the short-arm of chromosome 11
VARIANTS OF BETA-THALASSEMIA
(11p15.4; MIM: 141900) [18, 19]. The genomic sequence of
HBB contains three exons, two intervening sequences (IVS1 There are >535 HBB gene mutations [21, 23] with a sub-
and IVS2) and the 5' and 3' untranslated regions (UTRs) set of ~40 mutations responsible for the majority of beta-
(Fig. 2a). The HBB gene is regulated by a 5' promoter region thalassemia cases globally, as defined by population studies
that contains the classical TATA, CAAT and duplicated [15]. Moreover, frequencies of beta-thalassemia are very
CACCC boxes (Fig. 2a). Upstream of the beta-globin cluster high in malarial, tropical and sub-tropical regions such as the
is another regulatory element for HBB, namely the locus Indian Subcontinent and the Middle East, a fact hypothe-
control region (LCR). The expression of individual globin sized to be the result of a thalassemia heterozygote advan-
genes is governed by direct physical interaction between the tage against severe forms of malaria [24].
LCR and globin promoters, mediated by the binding of tis-
Different classes of HBB mutations underlie beta-
sue-restricted and ubiquitous transcription factors [20]. The
thalassemia, in descending order of frequency: mis-
most important transcription factor for HBB is the erythroid
sense/nonsense [25, 26], splicing [27], regulatory [28], small
Kruppel-like factor (EKLF), which binds the proximal
or gross gene deletions [27, 29], including the common dele-
CACCC box [18]. tion of the terminal portion of HBB [30], gene insertions
The beta-globin locus harbors, in addition to the HBB [31], small insertion-deletions [32], and complex rearrange-
gene, the -globin (HBE) gene, the two -globin (HBG) ments [33]. In rare instances, the causative defect is due to a
genes (HBG-G and HBG-A), and the
-globin (HBD) gene deletion of the LCR [18], mutations in another gene within
(Fig. 2b) [21]. Most genes at this locus are expressed at spe- [34] or outside [16] the beta-globin locus. Beta-thalassemia
cific time points in development. During embryonic devel- rarely arises due to the complete loss of the HBB gene [34].
opment, the HBE gene is expressed along with the alpha-
In the past, a descriptive, non-molecular ontology for
globin gene to form embryonic-hemoglobin or Hb-E [21].
beta-thalassemia deduced the existence of two disease-
Twelve weeks post-conception, the fetus primarily uses fetal
related alleles, B0 and B+. The B0 allele was considered to
hemoglobin (Hb-F) which is composed of two -globin and
produce non-functional beta-globin protein [16, 21]. Subse-
two alpha-globin chains [21]. Around the time of birth, -

Fig. (2). Schematic representation of beta-globin locus. (a) Schematic structure of the beta-globin gene, with 3 exons (grey boxes) and the
two intervening sequences (IVS). The gene is flanked by the 3’ and 5’ UTR regions (white boxes). The promoter region upstream of the 5’
UTR (stripped box) contains the following regulatory sequences: TATA, CAAT, and duplicated CACCC boxes. (Adapted from Thein 2005);
(b) Schematic structure of the beta-globin locus that resides on chromosome 11p15.4. From 5’ the first gene, HBE (), is expressed at the
embryonic stage to produce embryonic-hemoglobin (Hb-E). The next two genes, HBG-G (-G) and HBG-A (-A), are expressed during fetal
development (12 weeks post-conception) to form fetal-hemoglobin (Hb-F). After 7 or 8 months after birth, adult-hemoglobin (Hb-A) is pro-
duced due to initiation of expression of the HBB () gene. 3% of adult-hemoglobin is adult-hemoglobin-type 2 (Hb-A2), composed of the
-
globin chain.
Understanding Beta-Thalassemia with Focus The Open Hematology Journal, 2008, Volume 2 7

quent molecular characterization showed that the absent result without chronic blood transfusions. Other clinical
beta-globin chain from the putative “B0 allele” was actually manifestations include listless, fatigue, dyspnea, poor appe-
due to a variety of nonsense, frameshift, or sometimes splic- tite, hepatosplenomegaly, heart failure and bone deformation
ing mutations [34]. In contrast, the B+ allele was a consid- and delayed puberty [16, 21, 35]. Laboratory abnormalities
ered to be mutation that resulted in reduced quantity of beta- include microcystic anemia with abnormally shaped RBCs
globin protein [16, 21]. Subsequent molecular characteriza- and abnormal Hb electrophoresis. Thalassemia major pre-
tion showed that reduced beta-globin production related to sents within the first two years of life and, with treatment
the “B+ allele” resulted from mutations in the HBB promoter affected individuals can live five decades or more [35].
region, polyadenylation signal, 5’ or 3’ untranslated region,
or splicing sites [34]. Thalassemia Intermedia

Moreover, three classes of beta-thalassemia have long Patients with beta-thalassemia intermedia have mild to
been recognized clinically: beta-thalassemia major, interme- moderate anemia and in most cases do not require blood
dia and minor. The three thalassemia types are differentiated transfusions [36]. This condition is milder than thalassemia
clinically by the degree of anemia, with thalassemia major major due to inheritance of a HBB mutation associated with
and minor having the most and least severe anemia, respec- reduced beta-globin chain production (Fig. 3b) [18]. The
tively. Subsequent molecular characterization has shown deduced genotype is most commonly B+/B+ [34]. The clinical
some genotype-phenotype correlation, with clinical severity phenotype of thalassemia intermedia is roughly intermediate
roughly related to the mutation type (Fig. 3) [34]. between thalassemia major and minor [37]. Common clinical
features include splenic enlargement due to entrapment of
Thalassemia Major damaged RBCs, with risk of iron overload due in part to in-
creased intestinal absorption [16, 21, 36]. Although thalas-
Thalassemia major, also known as Cooley’s anemia and
semia intermedia can be associated with poor growth and
Mediterranean anemia, is the most severe form of beta-
bone abnormalities, it presents later in life and rarely affects
thalassemia, since both mutations of both HBB alleles results
in severely impaired beta-globin chain production [21, 35]. longevity [16, 36]. Patients require regular monitoring be-
cause the clinical severity varies widely between patients and
Three of the general allele combinations are responsible for
within a patient over time, with possible deterioration to the
this thalassemia phenotype — B0/B0, B0/B+, and sometimes
thalassemia major phenotype.
B+/B+ (Fig. 3a) [34].
Several rare HBB variants phenotypically manifest tha-
In thalassemia major, the excess unpaired alpha-globin
chains aggregate to form inclusion bodies [18]. These chain lassemia intermedia. For instance, individuals with domi-
nantly inherited beta-thalassemia or inclusion body beta-
inclusion bodies damage RBC membranes, leading to in-
thalassemia clinically exhibit thalassemia intermedia [38,
travascular hemolysis [18]. In addition, there is damage and
39]. These patients have moderate anemia and splenomegaly.
premature destruction of RBC precursors, causing ineffec-
More than 30 dominantly inherited beta-thalassemia cases
tive erythropoiesis [18]. Anemia is severe and oxygen trans-
have been described, resulting from a spectrum of molecular
port is compromised [35]. In some patients, death would
lesions ranging from missense mutations to nonsense muta-

Fig. (3). Schematic representation of inherited beta-globin variants and related beta-chain and red blood cell (RBC) phenotype. The
HBB variants are represented in grey exons while the wild type alleles are represented in blue exons. Production of beta-globin from a sin-
gle/double wild type alleles are represented by one/two colored schematic of the beta-globin protein respectively. Grey colored beta-globin
diagrams refer to below-normal synthesis levels of the protein, created by mutant HBB variants. Bright red-colored RBCs represent normal
cell phenotype, while pink colored ones represent microcytic, hypochromic cells characteristic of beta-thalassemia phenotype. Relative num-
ber of RBC reflects relative levels of anemia amongst the three classes of beta-thalassemia and in comparison to the wild type RBC pool.
8 The Open Hematology Journal, 2008, Volume 2 Lahiry et al.

tions [40]. A rare variant form called “silent beta- cholelithiasis are common complications among beta-
thalassemia” results from a mild imbalance of globin chain thalassemia patients, since bilirubin is the breakdown prod-
synthesis due to reduced beta-globin synthesis, leading to uct of RBCs and can be a component of certain gallstone
thalassemia intermedia. Silent beta-thalassemia mutations types. There appears to be an increased incidence of these
are found mainly in the regulatory regions, HBB promoter complications in patients who carry an insertion polymor-
and 5’ and 3’ UTRs. The most common silent mutation is the phism in the promoter region of the uridine diphosphate-
nt -101C>T (c.-151C>T) transition in HBB [41], which un- glucoronyltransferase IA (UGT1A) gene [13]. Also, common
derlies most thalassemia intermedia cases in the Mediterra- polymorphisms of the vitamin D receptor (VDR) and colla-
nean region [42]. Thalassemia intermedia has also been ob- gen type alpha1 (COL1A1) genes [13] can modulate the se-
served in patients with a retro-transposition insertion of a L1 verity of progressive osteoporosis and osteopenia in beta-
family transposable element in the HBB gene. This ~7 kb thalassemia. In addition, decreased frequency of the APOE
DNA insertion in IVS2 expresses ~15% of the full length (apolipoprotein E) E4 allele has been shown to be a risk fac-
beta-globin chain [43]. In addition, trans-acting genetic de- tor for development of ventricular failure in beta-thalassemia
terminants, independent of the beta-globin locus, can cause [13].
the thalassemia intermedia phenotype [44]. For instance,
mutations in the XPD/ERCC2 gene, which is causative for PREVALENCE OF BETA-THALASSEMIA IN THE
INDIAN SUBCONTINENT (SOUTH ASIA)
trichothiodystrophy (MIM 601675) [19], have also been as-
sociated with the beta-thalassemia phenotype [45], as dem- Within the Indian Subcontinent (or South Asia), which
onstrated by reduced levels of beta-globin synthesis and includes the countries of Pakistan, Sri Lanka and India, there
mRNA levels. The XPD protein coded by this gene is a are ~45 million carriers (carrier rate of ~1:20) of beta-
subunit of the TF11H transcription factor, involved in basal thalassemia [46]. There are four common beta-thalassemia
transcription and DNA repair [45]. mutational ‘hotspots’ in the HBB gene found in this popula-
tion: g.63201_63819del619 (619bp deletion), c.27_28insG,
Thalassemia Minor c.92+1G>A and c.92+5G>C [18] (Fig. 1).
Thalassemia minor is most common form of beta- In beta-thalassemia patients from Pakistan, there was a
thalassemia, and is also known as the ‘thalassemia trait’, in high consanguinity rate (81%) [47, 48]. The polymorphism
which affected individuals are asymptomatic (Fig. 3c) [18, at c.92+5G>C, in the HBB gene, was the most common mu-
21]. These subjects are typically heterozygous for beta- tation (37.0%), followed by c.27_28insG and 619bp deletion
thalassemia since they carry one normal HBB allele and one with allele frequencies of 21.0% and 12.0%, respectively
thalassemia allele - either B0 or B+ [34]. Asymptomatic pa- [48] (Table 1).
tients are usually detected through routine hematologic test-
In Sri Lanka, the two most prevalent HBB mutations
ing, but in retrospect some newly diagnosed patients are ob-
were c.92+5G>C and c.92+1G>A with allele frequencies of
served to have mild anemia and small RBCs [16]. The pri-
56.0% and 27.0%, respectively [48] (Table 1).
mary caution for individuals with thalassemia minor is a
potential risk of having children affected with more serious In Indian patients, five mutations accounted for 92% of
thalassemia if their partner is also a carrier of thalassemia the beta-thalassemia alleles (Table 1). The most common
minor [34]. mutation was c.92+5G>C, as in Pakistan and Sri Lanka. The
other four mutations were c.92+1G>T, 619bp deletion,
GENETIC SUSCEPTIBILITY UNDERLYING BETA- c.27_28insG, and at c.124_127delTTCT. Regional differ-
THALASSEMIA COMPLICATIONS ences in prevalence across north, east and south India, has
Complications in older patients with beta-thalassemia also been demonstrated [48]. Within the Northern states,
appear to develop in part as a result of certain genetic sus- including Punjab, the mutations and allele frequencies are
ceptibilities [13]. For instance, hyperbilirubinemia and quite similar to those of Pakistan where the two most com-

Table 1. Frequency (in percentage) of common
-globin (HBB) gene mutation in Indian Subcontinent countries. All mutation de-
tected were homozygous

Mutation Pakistan Sri Lanka North India East India South India

c.27_28insG* 21 N/A+ N/A+ N/A+ N/A+

c.92+1G>A* N/A+ 27 38.5 N/A+ N/A+

c.92+5G>C* 37 56 43.5 48.8 N/A+

c.92+5G>T N/A+ N/A+ N/A+ N/A+ 74

c.124_127delTTCT N/A+ N/A+ N/A+ N/A+ N/A+

619bp deletion‡ 12 N/A+ 6.8 N/A+ N/A+

[Ref] [47] [48] [47, 48] [49] [50]

+ ‡
N/A—data not available; 619bp deletion: g.63201_63819del619.
*mutational hot spots shared with the Middle East.
Understanding Beta-Thalassemia with Focus The Open Hematology Journal, 2008, Volume 2 9

mon mutations were c.92+5G>C (43.5%) and c.27_28insG In Iraq, beta-thalassemia is an evident health problem,
(38.5%) [47]. The similarity in mutation frequencies in these specifically in the Dohuk region located in the northern part
regions reflects their geographical proximity. In addition, of the country [51]. The Dohuk region lies midway between
6.6% of confirmed cases in northern India harbored the HBB Iran, Turkey and Syria, countries also characterized by a
c.124_127delTTCT mutation [47]. Within the Eastern region relatively high frequency of beta-thalassemia. The disease
of India, including the state of West Bengal, the frequency of prevalence in Dohuk is reinforced by the high rate of con-
HBB c.92+5G>C was 48.8% [49]. Interestingly, 31.9% of sanguineous marriages in the region, which were estimated
mutations involved the HBE gene, a pattern that was particu- at 25.3% [51]. Molecular testing of 104 (50 male, 54 female)
lar for the eastern region of India. In South India, including registered beta-thalassemia patients from Dohuk detected 12
the province of Andhra Pradesh, the HBB c.92+5G>T muta- mutations. The eight most common mutations observed ac-
tion frequency was 74% [50]. Other important South Indian counted for 81.7% of the thalassemia alleles [51]. The muta-
HBB mutations were not found among other common South tions in descending order of frequency were: c.315+1G>A,
Asian HBB mutations, indicating regional differences in the c.135delC, c.17_18delCT, c.92+1G>A, c.92+6T>C,
genetic architecture of beta-thalassemia. Such differences in c.118C>T, c.27_28insG, and c.92+5G>C (Table 2). The re-
HBB mutation may reflect a high prevalence of consanguin- maining four infrequent mutations were: c.25_26delAA,
ity and non-random mating that occurs within some rural c.68_74delAAGTTGG, c.93G>C and c.93-21G>A. Further
South Indian communities [50]. studies are required to provide a more thorough and accurate
representation of common beta-thalassemia mutations in
Overall these studies in the Indian Subcontinent demon-
other Iraqi subpopulations. The frequencies of observed
strate the importance of collecting and replicating HBB mu-
beta-thalassemia mutations in neighboring countries sug-
tation frequencies, since this is the first step in establishing a
gested mutational flow from Iraq; for instance, the HBB
successful prenatal diagnosis program [48].
c.135delC mutation was much more frequent (12.5%) in
PREVALENCE OF BETA-THALASSEMIA Dohuk than in the neighboring regions of Syria, Turkey and
THROUGHOUT THE MIDDLE EAST Iran (0-2.6%), suggesting it originated in Dohuk.
There is a high prevalence of beta-thalassemia in coun- In Lebanon, beta-thalassemia is the most common ge-
tries of the Middle East including Iraq, Lebanon, Egypt and netic disorder [52]. In a recent study of 255 patients from
Morocco, with an average carrier rate of ~1:30. More than Lebanon, 6 HBB mutations were found in >85% of beta-
90% of affected individuals in the Middle East have HBB thalassemia patients [52]. These mutations in descending
mutations within one of several mutational ‘hotspots’, in- order of prevalence, were: c.93-21G>A, c.92+1G>A,
cluding: c.25_26delAA, c.27_28insG, c.92+5G>C, c.92+6T>C, c.90C>T, c.315+1G>A, and c.17_18delCT [52]
c.118C>T, c.135delC, and c.315+1G>A (Fig. 1). (Table 2). The Lebanese population also has a religious gra-

Table 2. Allele frequency (in percentage) of common
-globin (HBB) gene mutation in Middle Eastern countries

Mutation Iraq Lebanon Egypt Morocco

c.-79A>G N/A+ N/A+ N/A+ 7

c.17_18delCT 10.6 5 N/A+ N/A+

c.20delA N/A+ N/A+ N/A+ 10

+ + +
c.25_26delAA N/A N/A N/A 15.5
+ +
c.27_28insG* 7.7 N/A N/A N/A+

c.90C>T N/A+ 9.6 N/A+ N/A+

c.92+1G>A* 8.7 15 19 13
+ +
c.92+5G>C* 6.7 N/A N/A N/A+

c.92+6T>C 8.7 14.4 36.3 14

+
c.93+21G>A N/A 34.2 25.8 N/A+

c.118C>T 8.7 N/A+ N/A+ 15.5

c.135delC 12.5 N/A+ N/A+ N/A+

c.315+1G>A 18.3 8.6 N/A+ N/A+

c.316-106C>G N/A+ N/A+ 6.4 N/A+

[Ref] [51] [52] [53-56] [57, 58]

+
N/A—data not available.
*mutational hot spots shared with the Indian Subcontinent.
10 The Open Hematology Journal, 2008, Volume 2 Lahiry et al.

dient of HBB mutational diversity. Sunni Muslims had the of cases, enabling relatively cost-effective molecular diagno-
highest beta-thalassemia carrier rate and also the greatest sis of carriers and prenatal diagnosis [48].
mutational heterogeneity, with 16 HBB different mutations.
Unknown HBB mutations must be discovered using
Shiite Muslims had 13 HBB mutations, while Maronites had
screening methods such as direct sequencing of genomic
7 different HBB mutations, while other religious factions DNA, single strand conformation polymorphism analysis or
including Orthodox, Druze, Greek Catholic and Latin, had
denaturing gradient gel electrophoresis [61]. However, since
progressively less mutational diversity. HBB locus haplotype
these techniques require specialized skill and reagents, they
analysis showed that the observed genetic diversity origi-
are expensive [61]. They are presently not ideal for eco-
nated from both new mutational events and gene flow from
nomically-unstable countries within Indian Subcontinent and
population migration [52].
the Middle East. Therefore, the strategy of developing dedi-
Among Egyptians, beta-thalassemia is the most common cated allele-specific methods to find the most prevalent geo-
cause of chronic hemolytic anemia and represents a major graphically-relevant mutations causing beta-thalassemia
health concern. A recent study of 95 Egyptian beta- based on screening for a small number of known mutations
thalassemic cases illustrated that the three most common that underlie a majority of cases is a more realistic goal [47].
HBB mutations observed were at c.92+6 (36.3%), c.93-21
Current technologies for clinical detection of specific
(25.8%), and c.92+1 (19.0%) [53], similar to the findings in mutant alleles include: 1) Amplification Refractory Mutation
other studies carried out on Egyptians [54-56] (Table 2).
System-Polymerase Chain Reaction (ARMS-PCR) and 2)
Moreover, the seven most frequent alleles in this study ac-
Reverse Dot-Blot (RDB) analysis, among many others.
counted for 84.2% of the observed thalassemic alleles in
ARMS-PCR amplifies both wild-type and mutant alleles,
Egypt.
together with a control fragment, in a single tube reaction
Finally, in a study of beta-thalassemia in Morocco, six [62]. Two allele-specific (inner) primers and two non–allele-
HBB mutations were seen in >75% of patients [57, 58]. specific (outer) primers amplify both the wild-type and the
These were in descending order of frequency: c.118C>T, mutant amplicons, resulting in products of different lengths
c.25_26delAA, c.92+6T>C, c.92+1G>A, c.20delA, and c.- that can be easily identified using agarose-gel electrophoresis
79A>G (Table 2). Regional predominance was observed in [62]. In contrast, RDB involves amplification and biotin-
the Gharb and West regions for the c.92+6T>C mutation. labeling of the DNA sequence of interest, followed by hy-
The distribution of mutations was suggested to correlate with bridization of the amplified products to oligonucleotide
historical migration patterns of Berbers, Phoenicians, Car- probes immobilized on a membrane [63]. Indeed in many
thaginians, Romans, Arabs, and Vandals, Byzantines and studies, fetal DNA from chorionic villus sampling was
Sub-Saharan Africans [57]. screened tests including ARMS-PCR method and by RDB
analysis [47-50]. Once fetuses were diagnosed, the option of
Studies in the Middle East and Indian Subcontinent re-
pregnancy termination can be offered, within the boundaries
veal an overlap in mutational hotspots for beta-thalassemia
(Tables 1 and 2). Such overlap may be due to genetic relat- of consideration given to appropriate cultural and ethical
sensitivities.
edness and intermarriages between these two regions. More
importantly, it may be indicative of starting points for devel- CURRENT TREATMENTS FOR BETA-
opment of effective molecular therapy methods for both THALASSEMIA
geographical regions.
The outlook for patients with beta-thalassemia has im-
MOLECULAR DIAGNOSTIC TESTING proved steadily during the last two decades due to develop-
While beta-thalassemia is observed in most global popu- ments in treatment [11, 64]. In addition, newer treatments
lations, each population or subpopulation has its own unique currently under investigation will have a great impact in the
spectrum of beta-thalassemia mutations [48]. In both the next few years and ease the clinical burden of this disorder
Indian Subcontinent and the Middle East, beta-thalassemia is [22]. However, as a result, some treatments have been asso-
a major public health problem [46, 48]. It has been estimated ciated with an increase in the development of iatrogenic
that 10% of the world’s beta-thalassemia major infants are complications.
born either in the Indian Subcontinent or the Middle East [5, Blood Transfusion Therapy and its Complications
46]. In fact, there are ~12,300 total beta-thalassemia births
per year in Indian Subcontinent and the Middle East. The The commonest form of life-long treatment for individu-
cost for blood transfusions for beta-thalassemia major has als with beta-thalassemia major is regular blood transfusions
been projected at ~3200 USD per child per year [46] while in order to maintain a Hb blood concentration >90 g/L and to
the lifetime healthcare costs of caring for a person born with compensate for ineffective erythropoiesis [16, 65]. Moreover
thalassaemia major has been projected at 284,154 USD [59]. for beta-thalassemia major, patients are unable to grow and
Since this exceeds the economic reach of most families in develop at infancy and may die if untreated by regular trans-
the Indian Subcontinent and Middle East, genetic counseling fusions [66]. However, regular and recurring blood transfu-
and prenatal diagnosis are an important component of multi- sions can be complicated by high rates of blood-borne infec-
pronged strategy to reduce the burden of beta-thalassemia in tion; for instance ~70% of transfused children in some de-
these jurisdictions [46, 60]. Thus, it is important to collect, veloping countries may acquire hepatitis C and even hepati-
replicate and corroborate the frequencies of specific HBB tis B [13, 24]. Aggressive treatment approaches for hepatitis
mutations in these jurisdictions, especially when the pres- are being used to avoid eventual liver cirrhosis and hepato-
ence of a few common mutations explains a large proportion cellular carcinoma [35].
Understanding Beta-Thalassemia with Focus The Open Hematology Journal, 2008, Volume 2 11

Iron overload is an important complication due to the and severe cases of thalassemia intermedia include folate
iron present in the transfused blood as well as excessive iron supplements [18] and splenectomy to decrease transfusion
absorption [67]. Iron overload - acquired hemochromatosis - requirements [35]. Severe infections, such as pneumococcal
produces reactive oxygen species that damage the heart (car- meningitis and pneumonia, may possibly complicate sple-
diomyopathy), liver (fibrosis and cirrhosis), nervous system, nectomy [24, 70]. As a result patients would benefit from
can lead to diabetes mellitus, hypothyroidism, hyperparathy- prophylactic antibiotics and vaccinations.
roidism as well as adrenal and pituitary insufficiencies [21].
The only treatment that can cure thalassemia major is
Susceptibility to specific endocrinopathies should be moni-
allogeneic bone marrow (stem cell) transplantation. Since it
tored and treated as they develop. Iron overload also plays a
was developed by the Pesaro group in 1981 there have been
pivotal role in cochlear siderosis and is the cause of various
more than a 1000 patients with transplantations with a tha-
neurological disorders [18]. Pituitary iron overload, which lassemia-free survival rate of 68% [71]. Thus far, allogeneic
results in hypogonadotrophic hypogonadism, may lead to
bone marrow transplantation seems to provide a definitive
low fertility [22].
cure of this disease. Due to the high risks involved, careful
In order to minimize iron overload and its complications, decision-making is necessary when considering such trans-
iron chelation is provided as an adjunct to regular blood plants. When transplantation is the treatment of choice, it is
transfusion. Chelators inertly and tightly bind iron ions and pursued only for patients with human leukocyte antigen-
remove excess iron. Deferoxamine (Desferal®), an iron matched donors [72].
chelator, is administered parenterally [67]. Chelator treat-
ment is expensive because of the dosage, equipment and skill FUTURE THERAPIES
required [64]. To decrease expense and dosage requirement A novel approach that provides an alternative to high-risk
while increasing effectiveness, a combination of chelators donor transplantation for severe beta-thalassemic patients is
should be employed, such as deferoxamine together with the transfer of normal human beta-globin gene in autologous
such orally-active chelators as deferiprone or deferasirox hematopoietic stem cells [73]. Another approach to improve
(ICL670) [22]. However, secondary complications have the clinical status of beta-thalassemia patients aims to in-
arisen from deferoxamine therapy. For instance deferoxam- crease the synthesis of Hb-F, an alternative source of Hb.
ine predisposes patients to Yersinia septicemia, which is This treatment option is especially used in cases of beta-
problematic in regions with endemic Yersinia such as the thalassemia intermedia and can help alleviate anemia [74].
Middle East or Indian Subcontinent [24]. In addition, side Production of Hb-F was noted to be reactivated during the
effects of deferoxamine include ocular and auditory toxicity, recovery from marrow suppression after treatment of hema-
growth retardation, and occasionally, renal impairment and tologic malignancies with cytotoxic drugs. Thus, it was pos-
interstitial pneumonitis [18]. Thus, patients with beta- tulated that the hypomethylating agent 5-azacytidine, which
thalassemia who receive regular blood transfusions together switches off expression of adult to fetal Hb form in adult
with deferoxamine should be monitored. Magnetic resonance baboons, and butyrate may alter the pattern of erythropoeisis
imaging (using the T2* relaxometry method) can be utilized in humans with beta-thalassemia and increase the expression
for non-invasive, safe and accurate assessment of affected of
-chain genes [64]. Although the mechanism is unknown,
tissues, such as cardiac tissue, since iron overload causes hydroxyurea treatment has been observed to increase Hb
deposition in vulnerable areas such as ventricular walls and levels, reduce brain masses and leg ulcers [65]. Also, studies
epicardial layer, potentially leading to serious arrhythmias or in mouse models are being pursued for gene correction in
congestive heart failure [22, 68]. hematopoietic stem cells using lentiviral vectors [64].
Depressed Immunity But while advances in therapy continue to be made, man-
agement of primary and secondary complications has had a
Beta-thalassemia patients, having survived severe anemia
major impact on the quantity and quality of life in patients
due to early management and diagnosis often have depressed
with beta-thalassemia. Further investigations as well as indi-
immunity [22]. As a result, bacterial and fungal infections
vidual-based therapies may allow for more efficient treat-
contribute to high mortality in beta-thalassemia patients [24].
ment methodologies in the future.
Major microbial infections, including Klebsiella (mainly in
Asia), Escherichia coli and Streptococcus pneumonia, have CONCLUSION
been observed [24]. Recently, in Asia, a fungus-like infec-
In conclusion, beta-thalassemia is highly prevalent and is
tion called pythosis from Pythium insidiosum has been ob-
a major public health problem in the malaria endemic areas
served in patients with beta-thalassemia [24]. Treatment has
of the Indian Subcontinent and Middle East. Cross-sectional
been difficult because anti-fungal drugs and anti-fungal vac-
surveys indicate that in many regions of the Indian Subcon-
cines are often ineffective. Moreover, many of these infec-
tinent and Middle East, only a few prevalent HBB mutations
tions are endemic in the Indian Subcontinent and the Middle
East and pose a risk to immune-suppressed beta-thalassemia underlie the majority of patients with beta-thalassemia. This
suggests that relatively cost-effective dedicated carrier
patients.
screening methods could be implemented in these areas.
Other Common Therapies However, imminent application of molecular screening in
the Indian Subcontinent and Middle East is complicated by
Adults with beta-thalassemia are susceptible to thrombo-
regional differences and the fact that sizable minorities of
sis, the most serious clinical outcome of which is pulmonary
patients with beta-thalassemia in some areas do not result
embolism and pulmonary hypertension [7, 69]. A daily low- from previously known HBB mutations. Although early di-
dose of aspirin prescribed prophylactically can reduce this
agnosis and treatment measures are available, they can be
risk [6, 16]. Other forms of treatment for thalassemia major
12 The Open Hematology Journal, 2008, Volume 2 Lahiry et al.

expensive and some, such as blood transfusion and treatment [15] Flint J, Harding RM, Boyce AJ, Clegg JB. The population genetics
with iron-chelators, can have potentially serious complica- of the haemoglobinopathies. Bailliere's Clin Haematol 1998; 11(1):
1-51.
tions. Thus, prenatal diagnosis or other preventative ap- [16] Bunn HF FB. Hemoglobin: Molecular, Genetic and Clinical As-
proaches may be the most important strategy to control the pects W.B. Saunders Company 1984.
clinical problems arising from beta-thalassemia. Along with [17] Bridges K. How Do People Get Thalassemia? Information Center
this, millions of abortions are performed annually due to for Sickle Cell and Thalassemic Disorders 1998 [cited 16/11/2007;
Available from: http: //sickle.bwh.harvard.edu/thal_inheritance.
molecular diagnostic testing that raise many ethical and eco- html.
nomical challenges, for which time and financial assistance [18] Cao A GR. Beta-Thalassemia. Gene Reviews 2005 [cited
should be invested to effectively handle this issue. 16/11/2007; Available from: www.genetest.org.
[19] OMIM. Hemaglobin-Beta Locus; HBB. John Hopkins University
AUTHORS’ CONTRIBUTIONS 1986.
[20] Grosveld F, de Boer E, Dillon N, et al. The dynamics of globin
All authors participated in literature review and manu- gene expression and gene therapy vectors. Semin Hematol 1998 ;
script preparation. All authors approved the final version of 35(2): 105-11.
the manuscript. [21] Rund D, Rachmilewitz E. Beta-thalassemia. New Eng J Med 2005;
353(11): 1135-46.
ACKNOWLEDGMENTS [22] Cohen AR, Galanello R, Pennell DJ, Cunningham MJ, Vichinsky
E. Thalassemia. Hematol Education Prog Am Soc Hematol Am
This work was supported by operating grants from the Soc Hematol 2004: 14-34.
Canadian Institutes of Health Research (MT14030), the [23] Patrinos GP, Giardine B, Riemer C, et al. Improvements in the
Heart and Stroke Foundation of Ontario, and Genome Can- HbVar database of human hemoglobin variants and thalassemia
mutations for population and sequence variation studies. Nucleic
ada through the Ontario Genomics Institute. RAH is a Career acids Res 2004 1; 32(Database issue): D537-41.
Investigator of the Heart and Stroke Foundation of Ontario [24] Vento S, Cainelli F, Cesario F. Infections and thalassaemia. The
and holds the Edith Schulich Vinet Canada Research Chair Lancet Infectious Diseases 2006; 6(4): 226-33.
(Tier I) in Human Genetics and the Jacob J. Wolfe Distin- [25] Waye g JS, EnB, Patterson M, Barr RD, Chui DH. De novo muta-
tion of the beta-globin gene initiation codon (ATG-->AAG) in a
guished Medical Research Chair. SAA is supported by the Northern European boy. Am J Hematol 1997; 56(3): 179-82.
Master’s studentship award from the Heart and Stroke Foun- [26] Grignoli CR, Carvalho MH, Kimura EM, et al. beta0-thalassemia
dation of Ontario. PL is supported by a group grant (PRG resulting from a novel mutation: beta66/u-->stop codon. Eur J
5967) from the Heart and Stroke Foundation of Ontario. Haematol 2000; 64(2): 137-8.
[27] Fisher CA, Premawardhena A, de Silva S, et al. The molecular
REFERENCES basis for the thalassaemias in Sri Lanka. Br J Haematol 2003;
121(4): 662-71.
[1] Kham SK, Quah TC, Loong AM, et al. A molecular epidemiologic [28] De Angioletti M, Lacerra G, Sabato V, Carestia C. Beta+45 G -->
study of thalassemia using newborns' cord blood in a multiracial C: a novel silent beta-thalassaemia mutation, the first in the Kozak
Asian population in Singapore: results and recommendations for a sequence. Br J Haematol 2004 ; 124(2): 224-31.
population screening program. J Pediatr Hematol Oncol 2004; 26 [29] Shaji RV, Edison ES, Poonkuzhali B, Srivastava A, Chandy M.
(12): 817-9. Rapid detection of beta-globin gene mutations and polymorphisms
[2] Wong P, Thanormrat P, Srithipayawan S, et al. Risk of a couple by temporal temperature gradient gel electrophoresis. Clin Chem
having a child with severe thalassemia syndrome, prevalence in 2003; 49(5): 777-81.
lower northern Thailand. Southeast Asian J Tropical Med Public [30] Orkin SH, Old JM, Weatherall DJ, Nathan DG. Partial deletion of
Health 2006; 37 (2): 366-9. beta-globin gene DNA in certain patients with beta 0-thalassemia.
[3] Livingstone FB. Frequencies of Hemoglobin Variants: Thalas- Proc Natl Acad Sci USA 1979; 76(5): 2400-4.
semia, the Glucose-6-Phosphate Dehydrogenase Variants, and [31] Flatz G, Wilke K, Syagailo YV, Eigel A, Horst J. Beta-thalassemia
Ovalocytosis in Human Populations. Oxford, UK: Oxford Univer- in the German population: mediterranean, Asian and novel muta-
sity Press 1985. tions. Mutations in brief no.228. Online. Human Mutation. 1999;
[4] Weatherall DJ. Pharmacological treatment of monogenic disease. 13(3): 258.
Pharmacogenomics J 2003; 3(5): 264-6. [32] Agarwal S, Hattori Y, Agarwal SS. Identification of a novel
[5] Weatherall DJ, Clegg JB. Inherited haemoglobin disorders: an frameshift beta-thalassemia mutation in an Asian Indian. Clin Ge-
increasing global health problem. Bulletin of the World Health Or- net 2000; 57(4): 311-2.
ganization 2001; 79(8): 704-12. [33] Zertal-Zidani S, Ducrocq R, Sahbatou M, Satta D, Krishnamoorthy
[6] Aessopos A, Kati M, Farmakis D. Heart disease in thalassemia R. Foetal haemoglobin in normal healthy adults: relationship with
intermedia: a review of the underlying pathophysiology. Haema- polymorphic sequences cis to the beta globin gene. Eur J Hum
tologica 2007; 92(5): 658-65. Genet 2002; 10(5): 320-6.
[7] Ataga KI, Cappellini MD, Rachmilewitz EA. Beta-thalassaemia [34] Thein SL. Genetic insights into the clinical diversity of beta thalas-
and sickle cell anaemia as paradigms of hypercoagulability. Br J saemia. Br J Haematol 2004 ; 124(3): 264-74.
Haematol 2007; 139(1): 3-13. [35] Wonke B. Clinical management of beta-thalassemia major. Semin
[8] Barton JC. Chelation therapy for iron overload. Curr Gastroenterol Hematol 2001; 38(4): 350-9.
Rep 2007; 9(1): 74-82. [36] Taher A, Isma'eel H, Cappellini MD. Thalassemia intermedia:
[9] Efremov GD. Dominantly Inherited beta-Thalassemia. Hemoglobin revisited. Blood cells, molecules & diseases. 2006; 37(1): 12-20.
2007; 31(2): 193-207. [37] Phadke SR, Agarwal S. Phenotype score to grade the severity of
[10] Ghosh K, Ghosh K. Pathogenesis of anemia in malaria: a concise thalassemia intermedia. Indian J Pediatrics 2003; 70(6): 477-81.
review. Parasitol Res 2007; 101(6): 1463-9. [38] Thein SL, Hesketh C, Taylor P, et al. Molecular basis for domi-
[11] Quek L, Thein SL. Molecular therapies in beta-thalassaemia. Br J nantly inherited inclusion body beta-thalassemia. Proc Natl Acad
Haematol 2007; 136(3): 353-65. Sci USA 1990 ; 87(10): 3924-8.
[12] Theodorsson E, Birgens H, Hagve TA. Haemoglobinopathies and [39] Stamatoyannopoulos G, Woodson R, Papayannopoulou T, Hey-
glucose-6-phosphate dehydrogenase deficiency in a Scandinavian wood D, Kurachi S. Inclusion-body beta-thalassemia trait. A form
perspective. Scandinavian J Clin Lab Invest 2007; 67(1): 3-10. of beta thalassemia producing clinical manifestations in simple het-
[13] Thein SL. Genetic modifiers of beta-thalassemia. Haematologica erozygotes. New Eng J Med 1974 25; 290(17): 939-43.
2005; 90(5): 649-60. [40] Thein SL. Is it dominantly inherited beta thalassaemia or just a
[14] Angastiniotis M, Modell B. Global epidemiology of hemoglobin beta-chain variant that is highly unstable? Br J Haematol 1999;
disorders. Ann N Y Acad Sci 1998 30; 850: 251-69. 107(1): 12-21.
 Understanding Beta-Thalassemia with Focus The Open Hematology Journal, 2008, Volume 2 13

[41] Gonzalez-Redondo JM, Stoming TA, Kutlar A, et al. A C----T [57] Agouti I, Badens C, Abouyoub A, et al. Genotypic correlation
substitution at nt--101 in a conserved DNA sequence of the promo- between six common beta-thalassemia mutations and the XmnI
tor region of the beta-globin gene is associated with "silent" beta- polymorphism in the Moroccan population. Hemoglobin 2007;
thalassemia. Blood 19891; 73(6): 1705-11. 31(2): 141-9.
[42] Maragoudaki E, Kanavakis E, Traeger-Synodinos J, et al. Molecu- [58] Lemsaddek W, Picanco I, Seuanes F, et al. The beta-thalassemia
lar, haematological and clinical studies of the -101 C --> T substitu- mutation/haplotype distribution in the moroccan population. He-
tion of the beta-globin gene promoter in 25 beta-thalassaemia in- moglobin 2004 ; 28(1): 25-37.
termedia patients and 45 heterozygotes. Br J Haematol 1999; [59] Ginsberg G, Tulchinsky T, Filon D, Goldfarb A, Abramov L,
107(4): 699-706. Rachmilevitz EA. Cost-benefit analysis of a national thalassaemia
[43] Galanello R, Dessi E, Melis MA, et al. Molecular analysis of beta prevention programme in Israel. Journal of medical screening.
zero-thalassemia intermedia in Sardinia. Blood 1989 1; 74(2): 823- 1998; 5(3): 120-6.
7. [60] Winichagoon P, Thitivichianlert A, Lebnak T, Piankijagum A,
[44] Giordano PC, Harteveld CL, Haak HL, et al. A case of non-beta- Fucharoen S. Screening for the carriers of thalassemias and abnor-
globin gene linked beta thalassaemia in a Dutch family with two mal hemoglobins at the community level. Southeast Asian J Tropi-
additional alpha-gene defects: the common -alpha3.7 deletion and cal Med Public Health 2002; 33 Suppl 2: 145-50.
the rare IVS1-116 (A-->G) acceptor splice site mutation. Br J Hae- [61] Bhardwaj U, Zhang YH, Lorey F, McCabe LL, McCabe ER. Mo-
matol 1998 ; 103(2): 370-6. lecular genetic confirmatory testing from newborn screening sam-
[45] Viprakasit V, Gibbons RJ, Broughton BC, et al. Mutations in the ples for the common African-American, Asian Indian, Southeast
general transcription factor TFIIH result in beta-thalassaemia in Asian, and Chinese beta-thalassemia mutations. Am J Hematol
individuals with trichothiodystrophy. Human Mol Genet 2001; 2005; 78(4): 249-55.
10(24): 2797-802. [62] Piccioli P, Serra M, Gismondi V, et al. Multiplex tetra-primer
[46] Agarwal S, Gupta A, Gupta UR, Sarwai S, Phadke S, Agarwal SS. amplification refractory mutation system PCR to detect 6 common
Prenatal diagnosis in beta-thalassemia: an Indian experience. Fetal germline mutations of the MUTYH gene associated with polyposis
Diagnosis And Therapy 2003; 18(5): 328-32. and colorectal cancer. Clin Chem 2006; 52(4): 739-43.
[47] Baig SM, Azhar A, Hassan H, et al. Prenatal diagnosis of beta- [63] Steinlein LM, Crawford JT. Reverse dot blot assay (insertion site
thalassemia in Southern Punjab, Pakistan. Prenatal Diagnosis 2006; typing) for precise detection of sites of IS6110 insertion in the My-
26(10): 903-5. cobacterium tuberculosis genome. J Clin Microbiol 2001; 39(3):
[48] Old JM, Khan SN, Verma I, et al. A multi-center study in order to 871-8.
further define the molecular basis of beta-thalassemia in Thailand, [64] Atweh GF, DeSimone J, Saunthararajah Y, et al. Hemoglobi-
Pakistan, Sri Lanka, Mauritius, Syria, and India, and to develop a nopathies. Hematol/Education Prog Am Soc Hematol Am Soc He-
simple molecular diagnostic strategy by amplification refractory matol 2003: 14-39.
mutation system-polymerase chain reaction. Hemoglobin 2001; [65] Morris CR, Singer ST, Walters MC. Clinical hemoglobinopathies:
25(4): 397-407. iron, lungs and new blood. Curr Opin Hematol 2006; 13(6): 407-
[49] Bandyopadhyay A, Bandyopadhyay S, Basak J, et al. Profile of 18.
beta-thalassemia in eastern India and its prenatal diagnosis. Prena- [66] Olivieri NF. The beta-thalassemias. New Eng J Med 1999; 341(2):
tal Diagnosis 2004 15; 24(12): 992-6. 99-109.
[50] Bashyam MD, Bashyam L, Savithri GR, Gopikrishna M, Sangal V, [67] Bridges K. Chelators for Iron Overload. Information Center for
Devi AR. Molecular genetic analyses of beta-thalassemia in South Sickle Cell and Thalassemic Disorders 1999 [cited 16/11/2007;
India reveals rare mutations in the beta-globin gene. J Hum Genet Available from: http: //sickle.bwh.harvard.edu/chelators.html.
2004; 49(8): 408-13. [68] Argyropoulou MI, Astrakas L. MRI evaluation of tissue iron bur-
[51] Al-Allawi NA, Jubrael JM, Hughson M. Molecular characterization den in patients with beta-thalassaemia major. Pediatr Radiol. 2007.
of beta-thalassemia in the Dohuk region of Iraq. Hemoglobin 2006; [69] Eldor A, Rachmilewitz EA. The hypercoagulable state in thalas-
30(4): 479-86. semia. Blood 2002; 99(1): 36-43.
[52] Makhoul NJ, Wells RS, Kaspar H, et al. Genetic heterogeneity of [70] Moshtaghi-Kashanian GR, Gholamhoseinian A, Hoseinimoghadam
Beta thalassemia in Lebanon reflects historic and recent population A, Rajabalian S. Splenectomy changes the pattern of cytokine pro-
migration. Ann Hum Genet 2005; 69(Pt 1): 55-66. duction in beta-thalassemic patients. Cytokine 2006; 35(5-6): 253-
[53] El-Gawhary S, El-Shafie S, Niazi M, Aziz M, El-Beshlawy A. 7.
Study of beta-Thalassemia mutations using the polymerase chain [71] Schrier SL, Angelucci E. New strategies in the treatment of the
reaction-amplification refractory mutation system and direct DNA thalassemias. Ann Rev Med 2005; 56: 157-71.
sequencing techniques in a group of Egyptian Thalassemia patients. [72] Rund D, Rachmilewitz E. Advances in the pathophysiology and
Hemoglobin 2007; 31(1): 63-9. treatment of thalassemia. Crit Rev Oncol/Hematol 1995; 20(3):
[54] Hussein IR, Temtamy SA, el-Beshlawy A, et al. Molecular charac- 237-54.
terization of beta-thalassemia in Egyptians. Hum Mutation 1993; [73] Sadelain M, Boulad F, Galanello R, et al. Therapeutic options for
2(1): 48-52. patients with severe beta-thalassemia: the need for globin gene
[55] Novelletto A, Hafez M, Deidda G, et al. Molecular characterization therapy. Human Gene Therapy 2007; 18(1): 1-9.
of beta-thalassemia mutations in Egypt. Hum Genet 1990; 85(3): [74] Olivieri NF. Reactivation of fetal hemoglobin in patients with beta-
272-4. thalassemia. Semin Hematol 1996; 33(1): 24-42.
[56] Omar A, Abdel Karim E, Gendy WE, Marzouk I, Wagdy M. Mo-
lecular basis of beta-thalassemia in Alexandria. The Egyptian J
Immunol/ Egyptian Associat Immunol. 2005; 12(1): 15-24.

Received: October 28, 2007 Revised: November 21, 2007 Accepted: November 23, 2007

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