Hereditary Spherocytosis Case Report PDF

**Hereditary Spherocytosis type1 with Novel mutation in ANK1 gene a missed diagnosis for decades: A Case Report** **Abstract** **Background** Hereditary spherocytosis (HS) is a common congenital haemolytic anaemia and (HS-1) is most common among (HS), caused by genetic defect in at least one of th...

**Hereditary Spherocytosis type1 with Novel mutation in ANK1 gene a missed diagnosis for decades: A Case Report** **Abstract** **Background** Hereditary spherocytosis (HS) is a common congenital haemolytic anaemia and (HS-1) is most common among (HS), caused by genetic defect in at least one of the five genes encoding membrane anchoring proteins of red blood cells resulting in osmotically fragile dense spherocytes with reduced life span, destroyed by spleen and characterized by triad of jaundice, haemolytic anaemia and splenomegaly, presentation ranges from asymptomatic to severe form depending on defective protein involved. **Clinical presentation** Our patient presented with recurrent jaundice from day 3 of life and splenomegaly, no anaemia and no family history. **Methods:** Genomic DNA obtained from peripheral blood, analysed by whole exome sequencing, a NGS platform **Results:** Tests revealed unconjugated hyperbilirubinemia, reticulocytosis and spherocytosis on blood film and increased RBC osmotic fragility. Whole exome sequencing revealed de novo heterozygous frameshift mutation at c.3181\_3190del (p. Leu1061 Ter) in exon 28 of ANK1 gene. **Conclusion** Clinical heterogeneity in haemolytic diseases often pose challenges for clinical diagnosis by clinicians, mandating molecular diagnosis. Key words HS: Hereditary Spherocytosis, WES: whole exome sequencing, NGS: Next-Generation sequencing, HGMD: Human Genome Mutation Database **Introduction** Hereditary spherocytosis (HS) is most common congenital haemolytic anaemia was first described by Oskar Minkowsky in early part of 1900.(1), caused by genetic defect in at least one of the five genes ( ANK1, SLC4A1, SPTA1, SPTB, EPB42) encoding membrane anchoring protein of red blood cells, inherited in both autosomal dominant manner (75%) and remaining (25%) cases include autosomal recessive inheritance and denovo mutations and characterised by triad of jaundice, splenomegaly and haemolytic anaemia with heterogeneity in clinical presentations (2).The complications, haemolytic crises, aplastic crises and cholelithiasis may be observed in natural course of the disease (3,4,5). Hereditary spherocytosis is common in northern European descends with prevalence rate of 1:2000 (6) Hereditary spherocytosis type1(\#182900) is due to defect in ankyrin-1 protein on RBC, encoded by ANK1(\*612641) gene mapped on 8p11.2. ANK1 gene consist of 43 exons and comprises three domains membrane binding domain, spectrin binding and regulatory domain and encodes protein ankyrin-1 (6) consisting of 1880 amino acids. So far, 340 mutations have been reported in ANK1 gene (HGMD). Literature review showed that laboratory parameters observed in (HS) are reticulocytosis, spherocytosis in blood film, unconjugated hyperbilirubinemia, increased osmotic fragility and negative direct Coombs test. (8) Folic acid supplementation as a supportive treatment and aggressive treatment in aplastic crises, splenectomy with splenomegaly related severe haemolysis and cholecystectomy in gallstones related complications. To the best of our knowledge this mutation described in this case report has been not reported in earlier published data. highlights the utility of NGS technology in identification of mutations to arrive at definitive molecular diagnosis. **Case presentation** A Twenty-two years old young man with negative family history born to nonconsanguineous parents presented with recurrent yellowish discolouration of sclera from day three of life first noticed by mother. On examination height measuring () and weight (), there was yellow discoloration of sclera, no pallor and no dysmorphic facies. His haematological work up showed haemoglobin (), reticulocyte count 18.59% (normal:0.5-2.5%), peripheral blood picture revealed spherocytes, increased osmotic fragility and total unconjugated bilirubin 6.41 (normal) and direct (). increased spleen size 17cms (normal) on ultrasonography. Autoimmune work up showed ANA and direct Coombs test negative His Genetic analysis, the Whole Exome Sequencing (WES) a Next-Generation Sequencing (NGS) revealed frameshift c.3181\_3190del (p. Leu1061 Ter) a heterozygous 10 base pair deletion in exon 28 of ANK1 gene on chromosome 8 leading stop codon with premature truncation of protein at codon 1061(p.Leu 1061Ter) of transcript ENST00000289734.13, not reported in 1000 genome, gnomAD and other clinical databases (ClinVar, HGMD). In slilico prediction, MutationTaster2 revealed disease causing variant. He was provided genetic counselling and started on folate supplementation and advised periodic follow up. **Discussion:** This 22 years old young man, non-blood transfusion dependent born to non-consanguineous parents with no similar illness in family, presented with recurrent jaundice from day 3 of life without anaemia, had splenomegaly on abdominal ultrasonography. Possibility considered was haemolytic disease. At this point, the close differentials considered were, Autoimmune haemolytic anaemia, G6PD deficiency, Gilbert syndrome and other hereditary spherocytosis For confirmation of diagnosis, battery of laboratory investigations was performed, ANA and direct Coombs test were negative, ruled out autoimmune haemolytic anaemia. G6PD and Gilbert syndrome are non-spherocytic haemolytic disorders and they are distinguished by genetic testing. In our patient there were reticulocytosis, spherocytosis, unconjugated hyperbilirubinemia and increased osmotic fragility of red blood cells, collating all findings, Hereditary spherocytosis was strongly suspected For definitive molecular diagnosis, Whole exome sequencing revealed heterozygous 10 base pairs deletion in exon 28 of ANK1 gene, likely pathogenic mutation consistent with Hereditary Spherocytosis type1. Validation of parents and younger sister by Sanger sequencing was performed, neither parents nor younger sister were carrying this mutation and is unreported in clinical databases suggesting novel denovo mutation associated with mild clinical presentation He was started on folic acid supplementation, in case develops severe anaemia and haemolysis and refractory to supportive treatment, would need splenectomy and cholecystectomy for gallstones as a treatment of choice. Parents and proband were provided genetic counselling. This case report highlights that any haemolytic disease, also consider Hereditary spherocytosis and warranting a definitive molecular diagnosis by utilizing affordable and accessible NGS technology to detect mutation of clinical significance to provide basis for effective Genetic counselling, risk associated with transmission and course of the disease. Need more published data to understand Genotype-Phenotype correlation in individuals with this novel mutation 1.Manciu S, Matei E, Trandafir B. Hereditary Spherocytosis - Diagnosis, Surgical Treatment and Outcomes. A Literature Review. Chirurgia (Bucur). 2017 Mar-Apr;112(2):110-116. \[[PubMed](https://pubmed.ncbi.nlm.nih.gov/28463670)\] 2.Tole S, Dhir P, Pugi J, Drury LJ, Butchart S, Fantauzzi M, et al. Genotype-phenotype correlation in children with hereditary spherocytosis. Br J Haematol. 2020;191:486--96. 3.Tamary H, Aviner S, Freud E, Miskin H, Krasnov T, Schwarz M, Yaniv I. 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 4.Hereditary spherocytosis: Retrospective evaluation of 65 children Ali Güngör, Neşe Yaralı, Ali Fettah, İkbal Ok-Bozkaya, Namık Özbek, Abdurrahman Kara Department of Pediatric Hematology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey. E-mail: gungorali19\@gmail.com Received: 27th February 2017, Revised: 13th October 2017, Accepted: 28th November 2017 ( aplastic crisis+cholelithiasis\_ 5.Hereditary Spherocytosis: Evaluation of 68 Children C¸ apan Konca Murat So¨ker Mehmet Ali Tas¸ Ruken Yıldırım Received: 24 September 2013 / Accepted: 25 March 2014 Indian Society of Haematology & Transfusion Medicine 2014 hamo+apals\_chole) Indian J Hematol Blood Transfus DOI 10.1007/s12288-014-0379-z 6.Ciepiela O. Old and new insights into the diagnosis of hereditary spherocytosis. Ann Transl Med. 2018 Sep;6(17):339. \[[PMC free article](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174190/)\] \[[PubMed](https://pubmed.ncbi.nlm.nih.gov/30306078)\] 7.Structure and organization of the human ankyrin-1 gene. Basis for complexity of pre-mRNA processing ===================================================================================================== [P G Gallagher](https://pubmed.ncbi.nlm.nih.gov/?term=Gallagher+PG&cauthor_id=9235914)^ (https://pubmed.ncbi.nlm.nih.gov/9235914/#full-view-affiliation-1)^, [W T Tse](https://pubmed.ncbi.nlm.nih.gov/?term=Tse+WT&cauthor_id=9235914), [A L Scarpa](https://pubmed.ncbi.nlm.nih.gov/?term=Scarpa+AL&cauthor_id=9235914), [S E Lux](https://pubmed.ncbi.nlm.nih.gov/?term=Lux+SE&cauthor_id=9235914), [B G Forget](https://pubmed.ncbi.nlm.nih.gov/?term=Forget+BG&cauthor_id=9235914) ========================================================================================================================================================================================================================================================================================================================================================================================================================================================================================== 8, The diagnostic protocol for hereditary spherocytosis-2021 update Yangyang Wu \| Lin Liao \| Faquan Lin