Early detection of spherocytosis by CBC test is necessary in children before starting school
Editors:
- Dr. Praful B. Godkar (Ph.D)
Eminent Author, Medical Biochemist and Scientist, Technical Education consultant. AGD Biomedicals (Pvt) LTD. - Dr. Gauri Kulkarni MD (Pathology)
Vice President, AGD Biomedicals (Pvt) LTD.
Spherocytic acute hemolytic anemia is linked to liver failure and may be a manifestation of Wilson’s Disease (WD), in which inorganic copper accumulates in the body(1,2). The excessive breakdown of red blood cells in WD constantly increases in the liver and spleen, causing hepato-splenomegaly with high inorganic copper and can eventually damage liver tissue and liver functions, leading to hepatic jaundice(1,2). WD also causes neurological complications due to copper buildup in the brain(6). Early diagnosis of Wilson’s disease is essential, as the condition is both treatable and preventable. Delayed identification of WD can result in irreversible organ damage or death(3,4). Without treatment, WD is universally fatal, mainly due to liver, kidney and brain related complications(5). Wilson’s disease may be identified at an early stage by performing a complete blood count (CBC) using advanced hematology analyzers such as the AGD HT 340 , which incorporates fifth-generation technology(7,8).
Q1. What is Wilson’s disease?
ANS(6) : Wilson’s disease (WD) is a rare inherited disorder, in which two genes of ATP7B are mutated. The ATP7B genes are located on chromosome 13 (13q14.3). The expression of normal ATP7B genes is necessary for synthesizing copper-transporting ATPase 2 enzyme, when copper concentration increases in the body and in general blood circulation. Copper-transporting ATPase 2 facilitates transport of excess copper into bile for excretion in feces. When the ATP7B genes are altered in Wilson’s disease (WD), excess copper accumulates in various organs, including the liver, kidneys, and brain.
Q2. What is the incidence of Wilson's disease?
ANS(6) : The incidence of Wilson’s disease is approximately 1 in 35,000 live births, with clinical presentations typically occur between 5-35 years(6).
NOTE
(1) WD is an autosomal recessive disorder. Affected patient inherits mutated copy of ATPase7 gene from each parent at birth.
(2) Diagnosis of WD involves genetic testing of both the parents for the detection of mutated ATP7B gene.
Q3. What are the early symptoms of Wilson’s disease?
ANS(6) : The following general symptoms are first noticed in children and teenagers, due to accumulation of inorganic copper in the liver: Loss of appetite, nausea, vomiting, weakness, fatigue, yellowish skin (due to jaundice), swelling in the legs (edema), easy bruising, and neurological complications in the advanced stage of the disease.
Q4. What are the neurological complications of Wilson’s disease?
ANS(6) : Neurological complications occur because copper accumulates in the brain, causing movement problems such as unsteady walking (ataxia), tremors similar to Parkinson’s disease, muscle spasms (dystonia), excessive drooling, and difficulty in swallowing (dysphagia).
CASE STUDY
A five-year-old boy presented with loss of appetite, nausea, vomiting, weakness, fatigue, pallor, weight loss, scleral icterus (yellow eyes), and leg edema (swelling). He had no fever and abdominal examination showed enlarged liver. His complete hemogram report was as follows:
COMPLETE BLOOD COUNT
| PARAMETER | RESULT | NORMAL RANGE |
| Hemoglobin | 4.6 g/dl | 13–18 g/dl |
| Total erythrocyte count | 1.8 X 1012/l | 5.0 ± 0.5 X 1012 /l |
| Total leukocyte count | 9.5 X 109/l | 7.0 ± 3.0 X 109/l |
| Differential leukocyte count | ||
| Neutrophils | 82% | 40–75% |
| Lymphocytes | 14% | 20–45 % |
| Eosinophils | 4% | 1–4 % |
| Monocytes | ||
| PCV | 18% | 36–48% |
| MCV | 106 fL | 82–92 fL |
| MCH | 34 pg | 27–32 pg |
| MCHC | 28% | 32–36 % |
| RDW-CV | 18.0 | 12–14 |
| Platelet count | 145 X 109/l | 150–400 X 109/l |
| Metzer Index (MI) | 58.8 | < 13 |
Stained blood smear: Microscopic observations
Stained peripheral blood smear showed presence of large numbers of spherocytes, reticulocytes, anisocytes and occasional target cells.
INTERPRETATION
Significant decrease in hemoglobin, decreased MCV, presence of spherocytes, anisocytes, target cells, increase in MCV, MCH indicated Spherocytic anemia, which further lead to Hemolytic anemia and related jaundice (as indicated by yellow eyes)(5,7,8).
NOTE
(1) To rule out autoimmune hemolytic anemia, the Coomb’s test was performed and it was negative, which ruled out autoimmune spherocytic hemolytic anemia.
(2) Slit lamp examination revealed Kayser–Fleischer (KF) rings on both corneas.
Results of Points 1 an2 indicated that patient was suffering from Wilson’s disease.
Q5. What are Kayser–Fleischer (KF) rings?
ANS(6) : Kayser–Fleischer (KF) rings are greenish, golden-brown, or grayish-green rings, which appear in the periphery of both corneas, due to deposition of excessive copper in the blood circulation. The presence of Kayser-Fleischer rings in the inner basal membrane of the cornea is a clinical indicator of Wilson’s disease.
NOTE
(1) From the symptoms of the patient in Case study, early indication of spherocytic-hemolytic anemia was possible due to complete blood count test, which with additional laboratory tests and ophthalmic examination, led to the interpretation of Wilson’s Disease.
(2) To confirm Wilson’s disease, the following laboratory tests were advised: Seum ceruloplasmin and 24 hrs excretion of urinary copper.
(3) To confirm jaundice the following Liver Function Tests (LFTs) were advised: Total direct and indirect bilirubin, SGPT, ASOT, Serum alkaline phosphatase, Serum total proteins, Albumin and Globulins, urine bile salts, bile pigments and urobilinogen.
Q6. What are the underlying mechanisms that cause red blood cells to adopt a spherical morphology in Wilson’s disease (WD)?
ANS: In Wilson’s disease, oxidative stress is created due to large amount of copper in general blood circulation, which damages red blood cell (RBC) membrane. When the damaged cell membrane of RBCs is lost, the internal volume of RBCs remains intact by assuming a spherical shape.
Q7. Why do WD patients develop jaundice?
ANS: In WD patients, RBC lifespan is reduced by spherocytosis, resulting in increased early destruction of RBCs and release of hemoglobin (Hb) in blood circulation. End product of heme (from degraded Hb) is bilirubin, which is yellow in color, leading to pre-hepatic jaundice. Moreover, due to toxic effects of excessive copper on liver leads also to hepatic jaundice.
Q8. Why do Wilson's Disease patients develop hepatosplenomegaly?
ANS: Toxic accumulation of copper into liver cells leads to enlargement of liver and due to extra work of removal of excessive damaged RBCs, spleen is enlarged.
Q9. What genetic test is performed to confirm Wilson’s disease?
ANS: Detection of mutated ATP7B genes is performed by RT-PCR test.
References
(1) Roche-Sicot J, Benhemou JP (1977). Acute intravascular hemolysis and acute liver failure associated as a first manifestation of Wilson’s disease. Ann Intern Med 86:301–303
(2) Grudeva–Popova JG, Spasova MI, Chepileva KG, Zaprianov ZH (2000). Acute hemolytic anemia as an initial clinical manifestation of Wilson’s disease. Folia Med (Plovdiv) 42(2):42–46.
(3) Kalra V, Khurana D, Mittal R (2000). Wilson’s disease-Early onset &lessons from a pediatric cohort in India. Indian Pediatr37:595–601.
(4) Yuce A, Kocak N, Demir H, Guracan F et al (2003). Evaluation of diagnostic parameters of Wilson’s disease in childhood. Indian J Gastroenterol 22(1):4–6.
(5) Roberts EA, Schilsky ML (2003). A practical guidelines on Wilson’s disease. Hepatology 37(6):1475–1492.
(6) Kasper DL, Braunwald E, Hauser S, Longo D, Jameson JL, Fauci AS (2005). Harrison’s principles of internal medicine, 16th edn.McGraw Hill, New York.
(7) Pandit A, Bavdekar A, Bhave S (2002). Wilson’s disease. Indian JPediatr 69(9):785–791 Fig. 1 P/S: Showing spherocytes (Wright Stain 9 1000).102 Indian J Hematol Blood Transfus (July-Sept 2010) 26(3):101–102 123.
(8) Godkar PB, Godkar DP. Textbook of Medical laboratory technology (4th edition, 2024), Bhalani Publishers, Mumbai. India.
