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X-linked sideroblastic anaemia in a female fetus: a case report and a literature review

Research output: Contribution to journalArticlepeer-review

Diane Nzelu, Panicos Shangaris, Lisa Story, Frances Smith, Chinthika Piyasena, Jayanthi Alamelu, Amira Elmakky, Maria Pelidis, Rachel Mayhew, Srividhya Sankaran

Original languageEnglish
Article number296
JournalBmc Medical Genomics
Issue number1
Early online date20 Dec 2021
E-pub ahead of print20 Dec 2021
Published20 Dec 2021

Bibliographical note

Funding Information: The research time which allowed P.S. to collect and analyzed data was funded by an NIHR Clinical Lectureship (CL-2018-17-002) and an Academy of Medical Sciences Starter Grant for Clinical Lecturers (SGL023\1023). The funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Funding Information: We would like to thank Professor John Simpson, Dr Thomas Day and the rest of the team at Guy's and St Thomas' NHS Trust, who cared for this patient. In addition we would like to thank Dr N.Deole, consultant obstetrician in Ipswich, for monitoring the patient during her pregnancy. The abstract has been previously published in Poster abstracts of the ISPD 25th International Conference on Prenatal Diagnosis and Therapy, Virtual, 6?8 June 2021. Prenat Diagn 2021; 41: 10?153. Publisher Copyright: © 2021, The Author(s).


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King's Authors


Background: X-linked sideroblastic anaemia (XLSA) is commonly due to mutations in the ALAS2 gene and predominantly affects hemizygous males. Heterozygous female carriers of the ALAS2 gene mutation are often asymptomatic or only mildly anaemic. XLSA is usually characterized by microcytic erythrocytes (reduced mean corpuscular volume (MCV)) and hypochromia, along with increased red cell distribution width. However, in females with XLSA the characteristic laboratory findings can be dimorphic and present with macrocytic (elevated MCV) in addition to microcytic red cells. Case presentation: We report a case of fetal anaemia, presenting in the early third trimester of pregnancy, in a female fetus. Ultrasound findings at 29 weeks were of cardiomegaly, prominent umbilical veins, a small rim of ascites, and mean cerebral artery peak systolic velocity (PSV) value above 1.5 Multiples of the Median (MoM). She underwent non-invasive prenatal testing that determined the rhesus genotype of the fetus to be rhesus B negative. No red blood cell antibodies were reported. Other investigations to determine the underlying cause of fetal anaemia included microarray comparative genomic hybridization, serology to exclude congenital infection and a peripheral blood film and fetal bilirubin to detect haemolysis. The maternal grandmother had a history of sideroblastic anaemia diagnosed at the age of 17 years. The mother had mild macrocytic anaemia with haemoglobin of 10.4 g/dl and MCV of 104 fl. The fetal anaemia was successfully treated with two in utero transfusions (IUTs), and delivery occurred via caesarean section at 37 weeks of gestation. The red cell gene sequencing in both the mother and fetus were heterozygous for an ALAS2 mutation causing in utero manifestations of XLSA. The haemoglobin on discharge to the local hospital at five days of age was 19.1 g/dl. Subsequently, the infant became anaemic, requiring regular 3–4 monthly blood transfusions and demonstrating overall normal development. Her anaemia was unresponsive to pyridoxine. Conclusions: This is one of four cases reporting multiple female members presenting with discordant clinical features of XLSA from being entirely asymptomatic to hydropic in utero. Our report is novel in that there are no previous cases in the literature of anaemia in a female fetus heterozygous for ALAS2 mutation.

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