Clinical Information

Beta-globin gene sequencing is useful in the evaluation of beta-globin chain variants and beta thalassemia. It detects almost all beta-globin variants and the most common beta-thalassemia sequence variants, although prevalence is ethnicity dependent. Because these conditions are often complex, this test should always be interpreted in the context of protein studies, such as hemoglobin electrophoresis and red blood cell indices.

The majority of beta-globin chain variants are clinically and hematologically benign; however, some have important clinical consequences, such as erythrocytosis, cyanosis/hypoxia, chronic hemolysis, or unexplained microcytosis. Most of the common clinically significant hemoglobin (Hb) variants (ie, HbS, HbC, HbE, and others) are easily distinguished by hemoglobin electrophoresis and do not require molecular analysis. In addition, they are frequently found in complex hemoglobin disorders due to multiple genetic variants, and accurate classification requires sequencing data within the context of protein data. In some instances, beta-globin sequencing is necessary to identify or confirm the identity of rare variants, especially those associated with erythrocytosis and chronic hemolytic anemia. Rare hyper-unstable variants (also termed dominant beta thalassemia mutations) result in hemolytic anemia and do not create protein stable enough to be detectable by protein methods, including stability studies. They are not always associated with elevated HbA2 or microcytosis and, therefore, can be electrophoretically silent. These require a high degree of clinical suspicion as all electrophoretic testing as well as stability studies cannot exclude this condition.

Beta thalassemia is an autosomal recessive condition characterized by decreased or absent synthesis of beta-globin chains due to alterations in the beta-globin gene (HBB). No abnormal protein is present and diagnosis by electrophoresis relies on hemoglobin fraction percentage alterations (ie, HbA2 or HbF elevations).

Beta-thalassemia can be split into 3 broad classes (categorized by clinical features):

1. Beta thalassemia trait (also called beta thalassemia minor and beta thalassemia carrier) (B[A]B[+] or B[A]B[0]).

2. Beta thalassemia intermedia (B[+]B[+] or B[+]B[0])

3. Beta thalassemia major (B[+]B[0] or B[0]B[0])

Beta thalassemia trait is typically a harmless condition with varying degrees of microcytosis and hypochromia and sometimes mild anemia. Transfusions are not required. Beta thalassemia intermedia is a clinical distinction and is characterized by a more severe degree of anemia than beta thalassemia trait with few or intermittent transfusions required. Later in life, these individuals are at risk for iron overload even in the absence of chronic transfusion due to increased intestinal absorption of iron. Beta thalassemia major typically comes to medical attention early in life due to severe anemia, hepatosplenomegaly, and failure to thrive. Skeletal changes are also common due to expansion of the bone marrow. Without appropriate treatment these patients have a shortened lifespan.

The majority of beta-thalassemia variations (>90%) are point alterations, small deletions, or insertions, which are detected by beta-globin gene sequencing. The remaining beta-thalassemia sequence variants are either due to large genomic deletions of HBB or, very rarely, trans-acting beta thalassemia variations located outside of the beta-globin gene cluster. Some rare beta-chain variants can be clinically or electrophoretically indistinguishable from beta thalassemia and cannot be confirmed without molecular analysis.