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Chen Y, Lv J, Qian J. Case Report: A case report and literature review of hemoglobin variation associated with neonatal cyanosis. Front Pediatr 2024; 12:1334757. [PMID: 38415208 PMCID: PMC10897016 DOI: 10.3389/fped.2024.1334757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/29/2024] [Indexed: 02/29/2024] Open
Abstract
We will discuss a recent case of unexplained neonatal cyanosis, evaluate its origin, clinical presentation, diagnosis, and treatment, and share with you some of our clinical insights. We report a transient cyanosis in a newborn due to a mutation in the globulin gene (HBG2), as well as diagnosis and treatment. Clinically, the infant was in good overall health, and despite low oxygen saturation, the arterial oxygen partial pressure was always normal. Early respiratory support includes mechanical ventilation, nasal tube oxygen, and eventually stopping oxygen therapy. With the above treatment measures, the blood oxygen saturation of the child always fluctuated at 85%, but the arterial blood oxygen partial pressure was up to 306 mmHg. Further improvement of laboratory tests revealed elevated methemoglobin levels, reticulocytosis, mild anemia, and basically normal on chest x-ray and echocardiography. To clarify the etiology, WES testing was performed. The results showed heterozygous variation in HBG2 gene (c.190C>T. p.H64Y). There is heterozygous variation at this site in the proband father, and no variation at this site in the proband mother. Given the age of the affected infants, we hypothesized that the mutation originated in the gamma peptide chain of the head protein. The baby was discharged from the hospital 10 days after birth, with blood oxygen saturation fluctuating around 90%. The cyanosis disappeared 2 months after discharge, and the blood oxygen saturation level returned to normal.
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Affiliation(s)
- Yanru Chen
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jingwen Lv
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jihong Qian
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Chandran S, Ross BJ, Kumar M. The journey from blue to pink–a rare cause for self-limiting methemoglobinemia in an Indian baby. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
To describe a rare case of methemoglobinemia in a newborn baby with excellent prognosis. Methemoglobinemia in the neonatal period is very rare and when present is usually caused by environmental toxicity from strong oxidizing agents and rarely due to enzyme deficiency or inherited disorders of hemoglobin metabolism.
Case presentation
We report a newborn baby presented with cyanosis and desaturation right from birth, later found to have methemoglobinemia and started medication. Genetic evaluation revealed a mutation in the gamma chain of fetal haemoglobin (HbF) causing abnormal hemoglobin. Physiologically significant mutations in gamma-globin genes cause symptoms in the fetus and neonate that gradually abate in the first few months of life.
Conclusions
Genetic evaluation is advisable in babies with unexplained methemoglobinemia as the prognosis of the condition depends on the underlying mutation. Early diagnosis of methemoglobinemia due to gamma chain mutation in HbF as in our case helps in reassuring the parents and also in preventing unnecessary aggressive investigations.
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Affiliation(s)
- Shanu Chandran
- Department of Neonatology , Christian Medical College , Vellore , Tamil Nadu , India
| | - Benjamin J. Ross
- Department of Neonatology , Christian Medical College , Vellore , Tamil Nadu , India
| | - Manish Kumar
- Department of Neonatology , Christian Medical College , Vellore , Tamil Nadu , India
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Yuan J, Zhu XP. Clinical characteristics on manifestation and gene mutation of a transient neonatal cyanosis: A case report. World J Clin Cases 2020; 8:217-221. [PMID: 31970190 PMCID: PMC6962074 DOI: 10.12998/wjcc.v8.i1.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/16/2019] [Accepted: 11/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We analyzed the main features of an infant diagnosed with temporary neonatal cyanosis in order to strengthen our understanding of the disease.
CASE SUMMARY We report a patient diagnosed with temporary neonatal cyanosis. The main clinical characteristics, gene mutation and treatment are discussed and a review of related literature was conducted. The neonate aged 1 d and 5 h was admitted to hospital due to cyanosis after birth. The main clinical manifestation was cyanosis, which was not improved by auxiliary ventilation and the patient showed no obvious shortness of breath or methemoglobinemia. Gene mutation analysis showed a heterozygous c.190C>T mutation in the HBG2 gene associated with transient neonatal cyanosis, which was derived from his mother. Symptomatic supportive treatment was given for 2 mo. The neonate was discharged and gradually improved with oral administration of vitamin C and vitamin B2 for 2 wk.
CONCLUSION There is no special treatment for temporary neonatal cyanosis caused by heterozygous mutation of the HBG2 gene.
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Affiliation(s)
- Jing Yuan
- Department of Neonatology, Children’s Hospital of Soochow University, Suzhou 215025, Jiangsu Province, China
| | - Xue-Ping Zhu
- Department of Neonatology, Children’s Hospital of Soochow University, Suzhou 215025, Jiangsu Province, China
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Young A, Dandekar U, Pan C, Sader A, Zheng JJ, Lewis RA, Farber DB. GNAI3: Another Candidate Gene to Screen in Persons with Ocular Albinism. PLoS One 2016; 11:e0162273. [PMID: 27607449 PMCID: PMC5015898 DOI: 10.1371/journal.pone.0162273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/21/2016] [Indexed: 11/18/2022] Open
Abstract
Ocular albinism type 1 (OA), caused by mutations in the OA1 gene, encodes a G-protein coupled receptor, OA1, localized in melanosomal membranes of the retinal pigment epithelium (RPE). This disorder is characterized by both RPE macro-melanosomes and abnormal decussation of ganglion cell axons at the brain's optic chiasm. We demonstrated previously that Oa1 specifically activates Gαi3, which also signals in the Oa1 transduction pathway that regulates melanosomal biogenesis. In this study, we screened the human Gαi3 gene, GNAI3, in DNA samples from 26 patients who had all clinical characteristics of OA but in whom a specific mutation in the OA1 gene had not been found, and in 6 normal control individuals. Using the Agilent HaloPlex Target Enrichment System and next-generation sequencing (NGS) on the Illumina MiSeq platform, we identified 518 variants after rigorous filtering. Many of these variants were corroborated by Sanger sequencing. Overall, 98.8% coverage of the GNAI3 gene was obtained by the HaloPlex amplicons. Of all variants, 6 non-synonymous and 3 synonymous were in exons, 41 in a non-coding exon embedded in the 3' untranslated region (UTR), 6 in the 5' UTR, and 462 in introns. These variants included novel SNVs, insertions, deletions, and a frameshift mutation. All were found in at least one patient but none in control samples. Using computational methods, we modeled the GNAI3 protein and its non-synonymous exonic mutations and determined that several of these may be the cause of disease in the patients studied. Thus, we have identified GNAI3 as a second gene possibly responsible for X-linked ocular albinism.
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Affiliation(s)
- Alejandra Young
- Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States of America
- Molecular Biology Institute, UCLA, Los Angeles, CA, United States of America
| | - Uma Dandekar
- UCLA-GenoSeq Core, UCLA, Los Angeles, CA, United States of America
| | - Calvin Pan
- UCLA-GenoSeq Core, UCLA, Los Angeles, CA, United States of America
| | - Avery Sader
- Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States of America
| | - Jie J. Zheng
- Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States of America
| | - Richard A. Lewis
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States of America
| | - Debora B. Farber
- Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States of America
- Molecular Biology Institute, UCLA, Los Angeles, CA, United States of America
- Brain Research Institute, UCLA, Los Angeles, CA, United States of America
- * E-mail:
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Schiemsky T, Penders J, Kieffer D. Failing blood gas measurement due to methemoglobin forming hemoglobin variants: a case report and review of the literature. Acta Clin Belg 2016; 71:167-70. [PMID: 27098765 DOI: 10.1080/17843286.2016.1148299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION We present a case of an arterial blood gas sample analysis from a 33-year old woman where no oximetry results could be obtained using the Radiometer ABL800 FLEX device. Clinical history of this patient learned that she was carrier of a methemoglobin forming hemoglobin variant type Hyde Park (HbM Hyde Park) and raised the question whether or not this variant could be the cause of the errors obtained during analysis. MATERIALS AND METHODS A literature search was performed, focusing on methemoglobin forming hemoglobin variants and their influence on oxygenation measurements. An overview of the currently described methemoglobin forming hemoglobin variants is also included. RESULTS AND DISCUSSION In the presence of dyshemoglobins such as methemoglobin, techniques used to obtain parameters that reflect the patient oxygenation status, such as pulse oximetry and CO-oximetry can be influenced. In these cases, CO-oximetry is the preferred technique because it can compensate for this, in contrast to pulse oximetry. In case of the presence of methemoglobin originating from a hemoglobin variant, it is possible that CO-oximetry data cannot be calculated because the absorbance spectrum of this methemoglobin can differ from regular methemoglobin. Moreover, pulse oximetry devices are actually prone to erroneous results since pulse oximetry data will be calculated in these cases, but unreliable and should be avoided. CONCLUSION Methemoglobin forming hemoglobin variants are rare genetic mutations. However, they can possibly interfere with the calculation of CO-oximetry values. In these cases, pulse oximetry data should be avoided because they could lead to incorrect medical decisions.
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Hooven TA, Hooper EM, Wontakal SN, Francis RO, Sahni R, Lee MT. Diagnosis of a rare fetal haemoglobinopathy in the age of next-generation sequencing. BMJ Case Rep 2016; 2016:10.1136/bcr-2016-215193. [PMID: 27095814 DOI: 10.1136/bcr-2016-215193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Neonatal cyanosis resulting from a fetal methaemoglobin variant is rare. Most such variants are only described in a few published case reports. We present the case of a newborn with unexplained persistent cyanosis, ultimately determined to have a γ-chain mutation causing Hb FM-Fort Ripley. This neonatal haemoglobinopathy can be challenging to diagnose, as significant oxygen desaturation may result from barely detectable levels of the mutant haemoglobin and co-oximetry studies may show a falsely normal methaemoglobin level. Our analysis of the infant's haemoglobin included high-performance liquid chromatography, cellulose acetate electrophoresis and citrate agar electrophoresis, which showed trace amounts of a suspected variant. Ultimately, the diagnosis was made through a novel application of next-generation sequencing (NGS). NGS-based diagnostic approaches are becoming increasingly available to clinicians, and our case provides a framework and evidence for the utilisation of such testing paradigms in the diagnosis of a rare cause of neonatal cyanosis.
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Affiliation(s)
- Thomas A Hooven
- Department of Pediatrics, New York University Langone Medical Center, New York, New York, USA Department of Pediatrics, Columbia University, New York, New York, USA
| | - Ellen M Hooper
- Department of Pediatrics, Columbia University, New York, New York, USA
| | | | - Richard O Francis
- Department of Pathology, Columbia University, New York, New York, USA
| | - Rakesh Sahni
- Department of Pediatrics, Columbia University, New York, New York, USA
| | - Margaret T Lee
- Department of Pediatrics, Columbia University, New York, New York, USA
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Abstract
Methemoglobinemia, including the inherited or congenital form, is a known but infrequent cause of neonatal cyanosis. We present the case of a newborn patient with neonatal cyanosis, who was diagnosed with F-M-Osaka methemoglobinemia, and an up-to-date literature review of the disease.
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Kutlar F, Ameri A, Patel NH, Zhuang L, Johnson LE, Cheng ML, Kutlar A. Two new γ chain variants: Hb F-Augusta GA [(G)γ59(E3)Lys → Arg; HBG2: c.179A > G] and Hb F-Port Royal-II [(A)γ125(H3)Glu → Ala; HBG1: c.377A > C]. Hemoglobin 2015; 38:376-80. [PMID: 25271994 DOI: 10.3109/03630269.2014.960526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The total number of hemoglobin (Hb) variants so far reported to the HbVar database is 1598 (April 9 2014) and 130 of them are fetal Hb variants. Fetal Hb are categorized as two different subunits, (G)γ- and (A)γ-globin chains, and γ chain variants can be observed in both subunits. There are 72 (G)γ- and 58 (A)γ-globin chain variants. Most of them are clinically silent and detected during newborn screening programs in the USA and outside the USA. In this report, we discuss the molecular characteristics and diagnostic difficulties of two new γ-globin chain variants found in an African American baby with no clinical symptoms. One is a new (G)γ-globin chain variant, Hb F-Augusta GA [(G)γ59(E3)Lys → Arg; HBG2: c.179A > G] and the other one is Hb F-Port Royal-II [(A)γ125(H3)Glu → Ala; HBG1: c.377A > C].
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Affiliation(s)
- Ferdane Kutlar
- Department of Medicine, Georgia Regents' University at Augusta , Augusta, Georgia , USA and
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Patel N, Fixler J, Unguru Y, Kutlar A, Kutlar F. A new Aγ-globin chain variant: Hb F-Sykesville MD [Aγ113(G15)Val → Ile; HBG1: c.340G>A] detected in a Caucasian baby. Hemoglobin 2015; 39:52-4. [PMID: 25565447 DOI: 10.3109/03630269.2014.986276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The total number of hemoglobin (Hb) variants currently included in the globin gene server database is 1626 (November 12 2014), of which 131 are fetal Hb variants. These variants are observed as two different subunits of fetal Hb, (G)γ- and (A)γ-globin chains. Of the 131 documented fetal Hb variants, 73 are (G)γ- and 58 are (A)γ-globin chain variants. Although they are easily detected at birth, as the quantity of γ chains progressively decreases over the first few months of life, they are essentially undetectable after 6 months of age. In this report we discuss the molecular characteristics and diagnostic criteria of a new (A)γ chain variant that was detected during newborn screening and named Hb F-Sykesville MD [(A)γ113(G15)Val → Ile; HBG1: c.340G>A].
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Affiliation(s)
- Niren Patel
- Department of Medicine, Georgia Regent's University Augusta , Augusta, Georgia , USA
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Abstract
Neonatal cyanosis in healthy newborns can be associated either with methemoglobin due to cytochrome b5 reductase deficiency or to M-hemoglobin, a group of hemoglobin variants resulting from mutations in the globin chain genes. We report the clinical case of a neonate with cyanosis and normal cardiac and respiratory function. At birth the hematological parameters were normal; however, the methemoglobinemia was 16%. Spontaneously, the cyanosis gradually decreased and by the fifth month of age the methemoglobin level was normal. A heterozygous Gγ-globin gene (HBG2) missense mutation 87 C-A (Leu28Met) was identified. His father, with a history of transfusion in the neonatal period, is heterozygous for the same mutation. This hemoglobin variant, not previously described, was called Hb F Viseu and is the sixth Gγ-chain variant reported in association with neonatal cyanosis.
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Charon A, Henrion E, Delpire S, Redondi A, Lecart C. Cyanose néonatale due à une hémoglobine fœtale M-Osaka. Arch Pediatr 2011; 18:1107-9. [DOI: 10.1016/j.arcped.2011.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/14/2011] [Accepted: 07/21/2011] [Indexed: 11/30/2022]
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Verhovsek M, Henderson MP, Cox G, Luo HY, Steinberg MH, Chui DH. Erratum to: Unexpectedly low pulse oximetry measurements associated with variant hemoglobins: A systematic review. Am J Hematol 2011. [DOI: 10.1002/ajh.22074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Crowley MA, Mollan TL, Abdulmalik OY, Butler AD, Goodwin EF, Sarkar A, Stolle CA, Gow AJ, Olson JS, Weiss MJ. A hemoglobin variant associated with neonatal cyanosis and anemia. N Engl J Med 2011; 364:1837-43. [PMID: 21561349 PMCID: PMC3632254 DOI: 10.1056/nejmoa1013579] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Globin-gene mutations are a rare but important cause of cyanosis. We identified a missense mutation in the fetal Gγ-globin gene (HBG2) in a father and daughter with transient neonatal cyanosis and anemia. This new mutation modifies the ligand-binding pocket of fetal hemoglobin by means of two mechanisms. First, the relatively large side chain of methionine decreases both the affinity of oxygen for binding to the mutant hemoglobin subunit and the rate at which it does so. Second, the mutant methionine is converted to aspartic acid post-translationally, probably through oxidative mechanisms. The presence of this polar amino acid in the heme pocket is predicted to enhance hemoglobin denaturation, causing anemia.
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Affiliation(s)
- Moira A Crowley
- Division of Neonatology, Case Western Reserve University, Cleveland, USA
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Verhovsek M, Henderson MPA, Cox G, Luo HY, Steinberg MH, Chui DHK. Unexpectedly low pulse oximetry measurements associated with variant hemoglobins: a systematic review. Am J Hematol 2010; 85:882-5. [PMID: 20890907 DOI: 10.1002/ajh.21810] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulse oximetry estimates arterial blood oxygen saturation based on light absorbance of oxy- and deoxy-hemoglobin at 660 and 940 nm wavelengths. Patients with unexpectedly low SpO₂ often undergo cardio-pulmonary testing to ascertain the cause of their hypoxemia. However, in a subset of patients, a variant hemoglobin is responsible for low SpO₂ measurements. The extent of this problem is unclear. We performed a systematic literature review for reports of low SpO₂ associated with variant hemoglobins. We also reviewed unpublished cases from an academic hemoglobin diagnostic reference laboratory. Twenty-five publications and four unpublished cases were identified, representing 45 patients with low SpO₂ and confirmed variant hemoglobin. Fifty-seven family members of patients had confirmed or suspected variant hemoglobin. Three low oxygen affinity variant hemoglobins had concordantly low SpO₂ and SaO₂. Eleven variant hemoglobins were associated with unexpectedly low SpO₂ measurements but normal SaO₂. Hemoglobin light absorbance testing was reported in three cases, all of which showed abnormal absorption spectra between 600 and 900 nm. Seven other variant hemoglobins had decreased SpO₂, with unreported or uncertain SaO₂. Twenty-one variant hemoglobins were found to be associated with low SpO₂. Most variant hemoglobins were associated with spuriously low SpO₂. Abnormal absorption spectra explain the discrepancy between SpO₂ and SaO(2) for some variants. The differential diagnosis of possible variant hemoglobin ought to be considered in asymptomatic patients found to have unexpectedly low SpO₂. The correct diagnosis will help to spare patients from unnecessary investigations and anxiety.
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Affiliation(s)
- Madeleine Verhovsek
- Section of Hematology and Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA.
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