Académique Documents
Professionnel Documents
Culture Documents
P. H. B. Bolton-Maggs1, R. F. Stevens2, N. J. Dodd3, G. Lamont4, P. Tittensor5and M.-J. King6 on behalf of the General
Haematology Task Force of the British Committee for Standards in Haematology
1
Manchester Royal Infirmary, Manchester, 2Royal Manchester Children’s Hospital, Manchester, 3The Ipswich Hospital NHS Trust,
Ipswich, 4Royal Liverpool Children’s Hospital, Alder Hey, Liverpool, 5Patient Representative, and 6International Blood Group Reference
Laboratory, Bristol, UK
Hereditary spherocytosis (HS) was described in 1871 and the The definitions of the types of evidence and the grading
first recorded splenectomy was performed soon after. It is the recommendations used in this guideline are listed in Appendix.
commonest cause of inherited chronic haemolysis in Northern
Europe and North America with a quoted incidence of 1 in Search strategy
5000 births (Morton et al, 1962). However, studies of osmotic
In addition to personal archives and consultation of standard
textbooks (together with relevant cited references therein), the
writing group searched Medline and Embase to identify relevant
literature including meta-analyses (none found), reviews and
Correspondence: BCSH Secretary, British Society for Haematology, original papers in any language, using the following key words
100 White Lion Street, London, N1 9PF, UK. and combinations of them: hereditary spherocytosis; red cell
E-mail: jules@b-s-h.org.uk membrane; spectrin, ankyrin, band 3, spherocytes; haemolysis;
RF Stevens sadly died prior to the final revisions of these guidelines. folate; folic acid; splenectomy; splenectomy in haematological
ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474 doi:10.1111/j.1365-2141.2004.05052.x
Guideline
conditions, cholecystectomy; cholecystostomy; laparoscopic; which binds to beta-spectrin. In addition to binding protein
gallstones; pneumococcal; vaccination; penicillin prophylaxis, 4Æ1 on its cytoplasmic N-terminal domain, band 3 interacts
postsplenectomy sepsis, non-operative approaches to gall with protein 4Æ2 to provide additional stability for the
stones. Only the abstracts were read of papers published in cytoskeleton (Rybicki et al, 1996). Glycophorin C interacts
languages other than English. with protein p55 and protein 4Æ1, which in turn binds to beta
spectrin. Thus a deficiency of, or a dysfunction in, any one of
these membrane components within the vertical attachment
The biochemical basis of HS
can weaken or destabilize the cytoskeleton, resulting in
The clinical expression of HS is relatively uniform within a abnormal red cell morphology and a shorter lifespan for
given family, but the disease severity varies considerably the affected red cells in the circulation.
between the different families.
Biochemical abnormalities associated with HS
Organization of red cell cytoskeleton
The abnormal red cell morphology (resulting in shortened
The abnormal morphology and shorter lifespan of the red cells cell survival) is due to a deficiency of, or a dysfunction in,
in HS are attributable to a deficiency or dysfunction of one of spectrin, ankyrin, band 3 and/or protein 4Æ2 (reviews
the constituents of the red cell cytoskeleton (Delaunay et al, Delaunay et al, 1996; Tse & Lux, 1999). Severe haemolytic
1996; Tse & Lux, 1999) whose role is to maintain the shape, anaemia is often associated with a greater reduction of the
deformability and elasticity of the red cell (Fig 1). affected membrane protein(s). There is an apparent correla-
The red cell cytoskeleton is a spectrin-based network of tion between clinical and protein phenotypes (Miraglia del
proteins located immediately on the cytoplasmic side of the Giudice et al, 1994). HS red cells are found to have single or
membrane lipid bilayer. Each spectrin protein (alpha and combined protein deficiencies as determined by sodium
beta) consists mainly of repeating units (106 amino acids dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-
long) that fold into triple helices. The paired alpha/beta PAGE). An analysis of 174 HS patients from 123 families in
spectrin heterodimers form head-to-head tetramers while the the UK uncovered a larger proportion of spectrin-deficient
other end of the spectrin heterodimer is associated with probands whose parents are apparently normal when com-
protein 4Æ1 and actin (Fig 1). The vertical attachment of the pared with other protein deficiencies. Autosomal dominant
spectrin network to the lipid bilayer involves two transmem- HS is often found to have primary mutations in the genes of
braneous proteins, band 3 and glycophorin C. Band 3, ankyrin, band 3 or b spectrin. Primary mutations in these
existing as dimer and tetramers in situ in red cells, has three genes can lead to a secondary protein deficiency
multiple protein-binding sites. It can interact with ankyrin, detected by SDS-PAGE (Table I).
Fig 1. Schematic presentation of the structural organization of red cell cytoskeleton (Bolton-Maggs, 2004). b Spectrin is the key component in that it
pairs with a spectrin to form a heterodimer, and it has binding sites for ankyrin and protein 4Æ1. The common protein defects are associated with
spectrin (a and/or b), ankyrin, band 3 protein and protein 4Æ2. Although protein 4Æ1 abnormality and spectrin mutations are usually associated with
hereditary elliptocytosis, a subset of hereditary spherocytosis was found to have b spectrin mutant proteins that had defective interaction with protein
4Æ1 (Goodman et al, 1982; Wolfe et al, 1982). This figure is a preprint from an article accepted for publication by Archives of Disease in Childhood,
and may not, save under the fair dealing of the provision of the Copyright Designs and Patents Act (1988), be reproduced without the consent of the
BMJ publishing group.
456 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
Table II. Membrane molecules associated with erythrocyte cytosk- (Miraglia del Giudice et al, 2001) has shown that the
eleton. occurrence of de novo non-dominant mutations in HS
Band Mr Chromosomal Number patients with normal parents is six times more common
Protein on gel (kD) Gene location of exons than recessive mutations (level III evidence). The distribu-
tion of the nd-HS clinical phenotypes nearly overlapped
a Spectrin 1 240 SPTA1 1q22-q23 52 with the group of dominant HS.
b Spectrin 2 220 SPTB 14q23-q24Æ1 32
Ankyrin 2Æ1 210 ANK1 8p11Æ2 42 The SpaLEPRA allele (LEPRA: Low Expression PRAgue) is
Band 3 (AE1) 3 90–100 AE1 17q21-q22 20 prevalent among nd-HS (Boivin et al, 1993; Wichterle et al,
(SLC4A1) 1996; Dhermy et al, 2000). This allele remains silent when
Protein 4Æ1 4Æ1 80 EPB41 1p36Æ2-p34 ‡22 inherited by a normal individual. However, mutations in the
Protein 4Æ2 4Æ2 72 EPB42 15q15-q21 13 spectrin gene (SPTA1), both homozygous and compound
Glycophorin C GPC 32 GYPC 2q14-q21 4 heterozygous (co-inherited with a pathogenic HS allele),
result in severe HS with very low spectrin levels in the red
cells.
De novo mutations are mostly found in recessive HS
Molecular genetics of HS
associated with the ankyrin gene (ANK1) (Eber et al, 1996)
The genes encoding membrane proteins of the red cell and b spectrin (SPTB) (Miraglia del Giudice et al, 1998).
cytoskeleton and their respective chromosomal locations are The transmission of these ankyrin mutations to subsequent
known (Table II). Further information can be accessed from generations occurs in a dominant manner. A recurrent
websites such as http://www.kidscancer.net/membrane/ and frameshift mutation, Ankyrin Florianópolis, has been found
the Human Gene Mutation Database at http://www.hgmd.org in three unrelated probands with severe dominant HS from
(Stenson et al, 2003). different genetic backgrounds (Gallagher et al, 2000).
Very different molecular mechanisms can generate the same In the case of band 3 gene defect, additive effects of two
membrane protein deficiency in HS. Most of the reported unequally expressed AE1 mutant alleles can aggravate the
protein gene mutations in HS are ‘private’ or sporadic clinical features of an affected individual (Alloisio et al,
occurrences, i.e. they are specific to one family or found in a 1996, 1997; Bracher et al, 2001). The mutations associated
few families from different countries. Knowledge of the gene with band 3 are heterogeneous with no apparent founder
mutation does not influence the clinical management of the effect.
patient but analysis of mutant protein gene in family studies
can clarify one of the following conditions.
Clinical features and diagnosis
1 To identify the primary gene defect. Family study will yield Hereditary spherocytosis is a heterogeneous group of disorders
information on whether the abnormal protein in the with regard to clinical severity, protein defects and mode of
proband is encoded by a mutant candidate gene or due to inheritance. The clinical severity of HS varies from symptom-
a secondary event resulting from a mutation in a different free carrier to severe haemolysis. Mild HS can be difficult to
protein gene (examples shown in Table I). identify because individuals may have a normal haemoglobin
2 To confirm recessive or non-dominant (r/nd)-HS when and bilirubin. The presence of spherocytes and a reticulocy-
both parents are apparently normal. Different genetic tosis will support the diagnosis. If there are no spherocytes seen
backgrounds can give rise to r/nd-HS, which have been on the film, no abnormalities in the red cell indices and the
found in association with a spectrin, ankyrin and b spectrin reticulocyte count is normal, a ‘carrier’ state cannot be
genes. Recent analysis of nd-HS in an Italian population excluded, but the individual is unlikely to have any clinical
sequelae. Occasionally mild HS can be exacerbated by illnesses ubinaemia. There may be an interval of several days before
that cause splenomegaly, such as infectious mononucleosis bilirubin reaches its peak, so infants born to known parents
(Gehlbach & Cooper, 1970). with HS should be carefully monitored over several days.
Co-inheritance of other haematological disorders, such as beta
thalassaemia trait or SC disease, can lead to confusion in the
Age at diagnosis
diagnosis and variable clinical effects (Gallagher et al, 1998).
Although the diagnosis of HS is often made in childhood and Iron, folate or vitamin B12 deficiencies can mask the labor-
young adult life, it may be diagnosed at any time, even in the atory features. Obstructive jaundice alters the lipid composi-
seventh to ninth decades of life (Friedman et al, 1988). It is tion of the red cell membrane, masking the film appearances
perhaps surprising that the diagnosis of HS is not always and reducing the haemolysis.
considered as a cause of gallstones and splenomegaly in adult
life, and that even in recent years there may be a considerable
Family history
interval between the onset of symptoms and diagnosis
(Reinhart et al, 1994). Asymptomatic HS may also be uncov- Most cases (75%) will have a family history of HS. In clear-cut
ered (usually in childhood) after an aplastic crisis, particularly cases [typical history and physical findings, spherocytes on the
when associated with Parvovirus B19 (Summerfield & Wyatt, blood film with a reticulocytosis and negative direct antiglob-
1985; Lefrere et al, 1986; Cohen et al, 1991), or influenza ulin test (DAT)] there is no indication to perform further
infection (Jensson et al, 1977). Hydrops fetalis or stillbirth can special laboratory tests to arrive at the diagnosis. In the absence
occur when a fetus has inherited defects in membrane proteins of a family history the most important differential diagnosis is
from both parents (Whitfield et al, 1991; Gallagher et al, autoimmune haemolysis. This is rare in children, but can
1995). Very mild HS may be first detected during investigation follow a viral infection and is usually transient. Usually (but
of asymptomatic relatives of a known case or during pregnancy not always) this can be excluded by a negative DAT (see
(Kohler et al, 1960; Pajor et al, 1993). below). Other membrane abnormalities must be considered if
the morphology is atypical, and in these, further investigations
may be required (see below).
Clinical features
The diagnosis of HS is generally straightforward. The patient,
Consideration of individual clinical features
usually a child, has a variable degree of anaemia, jaundice and
splenomegaly. It is important to ask for a family history of
Anaemia
jaundice and/or splenectomy, as families may not realize that
the cause involves their red blood cells. The severity of anaemia is closely associated with the severity
Neonatal jaundice is common and may be severe enough to of haemolysis and spleen size. Many individuals have com-
require exchange transfusion, but is not clearly related to the pensated haemolysis and have a normal haemoglobin level
subsequent severity of HS. The mechanism for this is not with a reticulocytosis. During pregnancy some non-splenec-
clearly understood. It should be noted that the diagnosis of HS tomized HS patients may present with sufficiently severe
in neonates may be difficult (Schroter & Kahsnitz, 1983). The anaemia to warrant blood transfusion.
film appearances may not be typical and the osmotic fragility Symptoms of HS may appear in the perinatal period:
test is unreliable. As potential parents, adult patients need to be jaundice is common in the first 2 d of life. Some neonates with
advised of the risk of neonatal jaundice, as occasionally HS may be transfusion-dependent due to their inability to
exchange transfusion has been required for severe hyperbilir- mount an adequate erythropoietic response in the first year of
Table III. Classification of spherocytosis and indications for splenectomy (modified from Eber, S.W., Armbrust, R. & Schroter, W. Variable clinical
severity of hereditary spherocytosis: relation to erythrocytic spectrin concentration, osmotic fragility and autohemolysis. Journal of Pediatrics, 177,
409–411 (copyright 1990, with permission from Elsevier).
*Data on spectrin content are provided for interest; it is not necessary to measure this.
458 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
life (Delhommeau et al, 2000) (level III evidence). Continued Table IV. Diagnostic parameters for hereditary spherocytosis.
transfusion dependence is unusual and it is important to avoid
Parameter Features
repeated transfusion where possible. Recent evidence suggests
that erythropoietin may be of benefit in reducing or avoiding Clinical features Splenomegaly almost always
transfusion, and can usually be stopped by the age of 9 months Laboratory red cell indices (flHb, flMCV, ›MCHC, ›% hyperdense
(Tchernia et al, 2000). Many older children with Hb levels of cells, ›RDW, ›reticulocyte count)
5–6 g/dl do not require transfusion. Children who require one Blood film Abnormal morphology – spherocytes
or two transfusions early in life frequently become transfusion Direct antiglobulin test Negative
independent. Evidence of haemolysis Raised bilirubin; reticulocytosis
Table V. Elevated automated red cell parameters in the prediction of hereditary spherocytosis and its severity.
Combined MCHC and RDW (or HDW) Significantly higher in HS Pati et al (1989), Michaels et al (1997)§
Combined % hyperdense* cells and RDW Excellent diagnostic efficacy and Pilar Ricard & Gilanz (1996)
indication of HS severity
% Microcytes The best indicator of HS severity Cynober et al (1996)
Combined MCHC and % hyperdense cells A discriminating feature of the HS phenotype Cynober et al (1996)
1997), and pincered (or mushroom-shaped) cells have been can be used to predict or identify HS with a typical clinical
found in unsplenectomized HS with band 3 deficiency (Jarolim presentation during the routine full blood count (Tables IV
et al, 1996; Dhermy et al, 1997). In a case of severe haemolytic and V) without requiring additional laboratory tests (such as
HS with a combined deficiency of spectrin and ankyrin, red osmotic fragility or the EMA binding test) to confirm the
cells with an irregular contour (resembling red cells of diagnosis. These parameters are more pronounced in splenec-
hereditary pyropokilocytosis) were seen (Palek & Sahr, tomized than in non-splenectomized HS patients.
1992). Ovalostomatocytosis is a consistent feature for Japanese
HS patients whose red cells have a protein 4Æ2 deficiency
Additional tests for the diagnosis of HS
resulting from a protein 4Æ2 gene mutation in nt
142GCT fi ACT (Yawata et al, 1994). Additional testing for confirmation of HS is indicated when
It is important to differentiate HS from hereditary stomat- the diagnostic criteria are not met, and other causes of
ocytosis and related disorders with abnormal permeability of haemolysis have been excluded. For instance, the film appear-
sodium and potassium ions. These disorders are rare; the ances are atypical, there is no clear pattern of inheritance, or
morphology may not be typical, particularly where films are the proband has an on-going mild haemolytic process, albeit
not freshly made. Such families have been labelled as ‘atypical’ with an apparently normal full blood count result. The
HS. Splenectomy is not effective and is associated with a high diagnosis may be particularly difficult in the neonatal period
risk of thrombosis (Stewart et al, 1996; Stewart & Turner, because spherocytes are commonly seen in neonatal blood
1999; level III evidence). films (Schroter & Kahsnitz, 1983).
An artefact showing ‘macrospherocytosis’ on a blood film
can be produced as a result of cold storage of blood samples Screening tests. All the laboratory tests currently in use can
from patients with cryohydrocytosis, which is a variant form of detect typical HS (Table VI). The acid glycerol lysis test has a
hereditary stomatocytosis (Haines et al, 2001). This blood higher detection rate in asymptomatic relatives of known
picture may inadvertently suggest a diagnosis of ‘atypical HS’. affected individuals than the osmotic fragility test. The
Although hereditary stomatocytosis and related disorders with drawback of both tests is an apparent lack of specificity
abnormal permeability of sodium and potassium ions are rare, under certain circumstances. In addition to detecting HS, they
their differentiation from HS is essential because HS red cells give positive results with a wide spectrum of clinical disorders
have also been found to have abnormal cation membrane or red cells in which abnormalities are unrelated to structural
permeability, unrelated to a specific membrane protein defect protein defects (Table VI). For instance, the osmotic fragility
(De Franceschi et al, 1997). Moreover, splenectomy is not test cannot differentiate between causes of spherocytosis
effective for the dehydrated and overhydrated forms of (immune versus non-immune).
hereditary stomatocytosis, and is associated with a high risk A normal osmotic fragility result does not exclude the
of thrombosis (Stewart et al, 1996; Stewart & Turner, 1999). diagnosis of HS and may occur in 10–20% of cases of HS (Dacie
et al, 1991). The test may also be normal in the presence of iron
deficiency, obstructive jaundice, and in the recovery phase from
Red cell indices
an aplastic crisis when the reticulocyte count is increased
Haematology analysers using the principle of flow cytometry (Korones & Pearson, 1989). Cell dehydration occurring in the
(i.e. dual angle laser light scattering method) produce a more spherocytes of a patient with HS can be one of the causes of
accurate determination of red cell volume (MCV) and normal osmotic fragility results for non-splenectomized HS
haemoglobin concentration (MCHC) than those blood cell patients (Cynober et al, 1996). Furthermore, a positive osmotic
analysers using the principle of electrical aperture impedance fragility result can be obtained in patients with hereditary
(Mohandas et al, 1986). These automated red cell parameters elliptocytosis (HE) and haemolysis.
460 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
Osmotic fragility (OF) test* Heparinized whole blood (50 ll) per tube. Measure Affected by elevated reticulocyte count: increased
(Parpart et al, 1947) absorbance at 540 nm for fresh blood and after OF in 66% of non-splenectomized HS patients.
24 h incubation. Plot a graph of % haemolysis Also increased OF found in immune-mediated
versus NaCl concentration and other haemolytic conditions
Acidified glycerol lysis test EDTA (20 ll )whole blood per tube. Measure the Also detects autoimmune haemolytic anaemia,
(AGLT) (Zanella et al, 1980) time taken for absorbance of red cell suspension at hereditary persistence of fetal haemoglobin,
The Pink test (Bucx et al, 1988) 625 nm in glycerol to fall to half of its original pyruvate kinase deficiency, severe glucose-
is a modified AGLT value before glycerol addition (AGLT50) 6-phosphate dehydrogenase deficiency,
pregnant women (one-third), chronic renal
failure on dialysis (some), and myelodysplastic
syndrome. Reagent preparation: special attention
to pH and osmolality
Osmotic gradient ektacytometry A laser diffraction viscometer that measures red cell Distinct deformability curves for red cells from
(Clark et al, 1983) deformability at constant shear stress as a patients with HS, hereditary elliptocytosis,
continuous function of suspending osmolality hereditary pyropoikilocytosis, stomatocytosis
(hypotonic to hypertonic) and sickle disease (Mohandas et al, 1980)
Hypertonic cryohaemolysis test Packed red cells (50 ll) per tube. % cryohaemolysis Positive results for HS, some CDAII and
(Streichman & Gescheidt, 1998) at 540 nm after transfer of red cells from 37C to Melanesian elliptocytosis
0C for 10 min
Eosin-5-maleimide (EMA) binding§ Packed red cells (5 ll; EDTA sample) per tube. Distinct histograms for red cells of HS
(King et al, 2000) Reduced fluorescence (green) intensity of (sensitivity of 92Æ7% for HS and a specificity of
EMA-labelled red cells by flow cytometry 99Æ1%) and HPP. Reduced fluorescence with
CDAII, cryohydrocytosis, SAO. Reagent:
solution of EMA (light-sensitive) must be
stored at )20C (max. 3 months)
*The shift of OF curve reflects the red cell response to hypotonic medium due to reduced cell volume and surface area.
The red cell lipid composition regulates the membrane permeability to glycerol. The added glycerol slows down the rate of water entry into the red
cells. This allows the measurement of time taken for cell lysis to occur.
There is no ektacytometer in the UK. Measurement of red cell membrane resistance to fragmentation under shear stress.
§EMA binds to band 3, Rh blood group proteins, Rh glycoprotein and CD47 on membrane molecules in intact red cells (King et al, 2004).
The cryohaemolysis test, the osmotic gradient ektacytometry Melanesian elliptocytosis) and cryohydrocytosis – these can be
and the EMA binding test have a higher predictive value in the distinguished from HS on the basis of their distinct clinical
diagnosis of HS because there have been no reports of positive features (Table VII). Other atypical cases with spherocytosis can
results in immune or non-membrane-associated disorders. produce anomalous histograms, which are identified by over-
However, these tests are not specific, and can also detect red laying the test histogram with those of normal and HS controls
cells with rare membrane disorders, such as aberrant band 3 (King et al, 2003). Normal fluorescence results are obtained for
proteins [e.g. CDAII, Southeast Asian ovalocytosis (SAO)], a individuals presenting a reticulocytosis or an autoimmune
change in intracellular viscosity (e.g. sickle cells), and tempera- haemolytic anaemia (King et al, 2000).
ture-sensitive monovalent cation transport (e.g. cryohydrocy- In conclusion, when selecting an appropriate test for
tosis) (Table VI). In mild or atypical cases, difficulty in determining mild or atypical HS condition in a patient, the
interpretation is likely to occur with results that fall between sensitivity and specificity of the test for HS, the complexity of
normal and typical HS reference ranges. Therefore, ektacytom- the protocol, and the total cost of instrument(s) and its
etry has an advantage in that results are plotted as a deformability maintenance should be taken into consideration. As HS is a
curve, which has a distinct shape for each type of abnormal red structural defect of the red cell cytoskeleton, the test result is
cells tested (Mohandas et al, 1980). In EMA binding by flow expected to give a clear distinction between a membrane-
cytometry, hereditary pyropoikilocytosis (HPP, MCV < 60 fl) associated and a non-membrane-related red cell disorder.
and HE can be differentiated from HS, based on the graded
reduction in fluorescence intensity for HPP (the lowest)< SDS-PAGE. Identifying a deficiency in a membrane protein
HS < HE £ normal controls (King et al, 2000, 2003). Although associated with erythrocyte cytoskeleton confirms the
similar fluorescence readings to the red cells of HS are obtained diagnosis of HS. Quantitation of membrane proteins by
with some rare red cell disorders – CDAII, SAO (also known as SDS-PAGE is, however, not necessary for the majority of HS
Table VII. Features of South-East Asian ovalocytosis (SAO), congenital dyserythropoietic anaemia type II (CDAII), and hereditary stomatocytosis
(HSt.) and related disorders.
SAO* Autosomal Asymptomatic of any haemolysis Rigid and hyperstable. (a) SDS-PAGE detects a slower
dominant 25% or more ovalocytes. migrating Band 3 Memphis
Some SAO cells show a (Lys56 fi Glu) protein
‘slit’ in the cells (b) Detect deletion of
27 nts in band 3 gene
CDAII (HEMPAS) Autosomal Mild and intermittent jaundice, Bi- and multinucleated A more compact and faster
recessive and splenomegaly. Hepatomegaly erythroblasts (usually migrating band 3 (due to
and gallstones are less frequent. 15–30%). Mild to incomplete N-glycosylation)
Anaemia, liver cirrhosis and moderate Hb level, normal by SDS-PAGE. Confirmation of
secondary tissue siderosis to mild elevated MCV. CDA by electron microscopy of
Low reticulocyte count bone marrow sample
Overhydrated HSt. Dominant Frequency 1 in 1 million births. Stomatocytes (some have Stomatin absent (band 7Æ2 in
(hydrocytosis) Indistinguishable from HS 30%) decreased MCHC, SDS-PAGE); intracellular
(atypical HS) macrocytosis [Na+] > 60 mmol/l red cells
Dehydrated HSt. Dominant Frequency 1 in 10 000; heterogeneous: Lack deformability: some Normal stomatin. Measure
(xerocytosis) combined with pseudohyperkalaemia stomatocytes and target intracellular [Na+] and [K+]
and/or perinatal oedema cells; increased MCHC
Familial pseudo- Dominant Non-haemolytic (normal haematology Normal Normal or near normal
hyperkalaemia without jaundice) intracellular Na+, net loss of [K+]
when stored at room temperature;
apparently normal cation
fluxes at 37C
Cryohydrocytosis Dominant Rare, mild stomatocytic haemolytic Red cell lysis when stored Measure intracellular [Na+] and [K+]
state with hyperbilirubinaemia, at 4C (increased
gallstones intracellular Na+)
*Also known as Melanesian hereditary elliptocytosis. Found mainly in Malaysia, Indonesia, Papua New Guinea, the Philippines. Occasionally in South
African (White), one Afro-American family.
462 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
spread in food, especially in fresh fruit and vegetables (which aware of the disorder it is unnecessarily disruptive to insist on
must not be overcooked). Breakfast cereals are also an regular review. There is however perhaps some benefit in
important source in children aged 1–4 years. The National regular annual review of those with moderate disease (and to
Diet and Nutrition Survey in the UK showed that at all ages the monitor by ultrasound examination for the development of
average daily intake in 1995 was well above the reference gallstones) or those who have had splenectomy, if only to
nutrient intake, being 143% for children over 4 years, and discuss current views about postsplenectomy management (re-
184% in children under 4 years, suggesting that folate vaccination, antibiotic prophylaxis). It is also worth checking
supplementation is unnecessary in mild HS. fasting iron status annually (transferrin saturation) in non-
splenectomized cases. Chronic anaemia will enhance iron
absorption, and co-inheritance of the haemochromatosis gene
(C282Y) even in the heterozygous state can lead to severe iron
Recommendation overload. (grade C recommendations, based on level IV
evidence.)
Folate therapy is recommended in severe and moderate HS,
but is probably not necessary in mild HS. (level III and IV
evidence, grade C recommendation). A reasonable daily Clinical management of individuals with HS:
dose would be 2Æ5 mg/d up to the age of 5 years, and 5 mg/ surgery
d thereafter.
This section will address the following questions:
464 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
combined splenectomy and cholecystectomy in terms of life badly needed (Reid, 1994). The recent update of the BCSH
expectancy. However, this model assumed 100% compliance guidelines (Davies et al, 2002) did not recommend any
with penicillin prophylaxis, and if only 10% of splenectom- changes to the current policy with the introduction of new
ized patients are non-compliant (which is likely) then pneumococcal vaccines, but this needs regular review as more
splenectomy is considered too risky for patients with mild evidence is gathered.
HS at any age. A difficult group are those with visible
jaundice but no stones, and who want splenectomy for Antibiotic prophylaxis. Penicillin prophylaxis is recommended
cosmetic reasons, but who have well compensated HS by for life postoperatively, but there is little published evidence
other criteria. However, these children often have a significant of efficacy (Reid, 1994). The guidelines indicate that
reticulocytosis and splenectomy may be justified on the basis antibiotic prophylaxis should be for life, although the
that they are therefore likely to have symptomatic gallstones evidence base for this is not strong (BCSH, 1996; Davies
later in life. et al, 2002). Urgent medical attention (even hospital
admission) should be sought in the event of a febrile
Infection risks and their management. The risk of illness – however it is difficult to translate this into a
postsplenectomy sepsis is not completely eliminated by the practical reality with children who are often febrile with
currently recommended preoperative vaccinations and minor viral illnesses.
postsplenectomy antibiotic prophylaxis (BCSH, 1996; Davies Despite recommendations for vaccination and antibiotic
et al, 2002). There are numerous studies documenting an prophylaxis (BCSH, 1996), ignorance persists in affected
increased mortality from sepsis; particularly notable was a families, and compliance with antibiotic advice is poor
study of more than 1400 children in the US (Eraklis & Filler, (Waghorn & Mayon-White, 1997; Keenan et al, 1999; Spickett
1972) and an early UK study of more than 800 children et al, 1999). Although preventive measures are very successful
demonstrating an age-related risk (Walker, 1976), which was (Konradsen & Henrichsen, 1991) it is clear that they do not
highest in the younger children, <2 years of age, and early after completely eliminate the risk. The risk of infection remains
splenectomy. A study of 456 children who had splenectomies highest in the youngest patients but was reported to be reduced
in Denmark between 1969 and 1978 also demonstrated an by 47%, and the mortality by 88% in one study (Jugenburg
incidence of pneumococcal bacteraemia and meningitis in the et al, 1999). Fatal pneumococcal infections have occurred
splenectomized children that was 284 times that of non- despite both vaccination and compliance with penicillin
splenectomized children (Pedersen, 1983). Although the risk is prophylaxis (Deodhar et al, 1993; Spickett et al, 1999). A
maximal in young children and early after splenectomy, it recent study references at least 19 severe postsplenectomy
persists for life (Ein et al, 1977; Evans, 1985; Holdsworth et al, infections, six fatal, in vaccinated patients (Eber et al, 1999)
1991; Deodhar et al, 1993; Eber et al, 1999). The risk has been (level III evidence).
reduced by deferring splenectomy until a child is over 6 years
of age, together with vaccination and antibiotic prophylaxis
(Konradsen & Henrichsen, 1991). The small but definite
Recommendations
remaining risk of sepsis must be clearly explained to the
1 Patients and parents should be informed about the
parents and the child, and the indications for splenectomy
lifelong small risk of overwhelming sepsis after splenec-
must be clear. Many adults who themselves may have had
tomy, and provided with a splenectomy card.
splenectomy in the past may be unaware of the risks.
2 National guidelines for management should be followed
Conversely, adults who have received vaccinations and
(BCSH, 1996; Davies et al, 2002). The need for reim-
antibiotics may perceive that there is no risk of infection and
munization and its frequency are unclear as are the
also need appropriate education.
optimal duration of postsplenectomy antibiotic prophy-
laxis and choice of drug.
Presplenectomy vaccination and postsplenectomy follow-
up. Patients should be vaccinated according to national
guidelines (BCSH, 1996; Davies et al, 2002). Fatal infection
When should splenectomy be performed?
may occur with a serotype not covered by the vaccine, or there
may not have been an adequate response to some of the 23 No published evidence of the optimum timing for any type of
serotypes in the face of an adequate global response in terms of resection exists. All the major texts essentially state that the
functional antibody testing. Although repeat pneumococcal timing is one of clinical judgement and that it depends on the
vaccination is recommended at 5-year intervals, there is no severity of the patient’s symptoms as judged by the effects of
clear evidence in the literature. Some data exist demonstrating anaemia, or the need for transfusion, or symptoms related to
that antibody levels may fall off quite quickly (Spickett et al, cholelithiasis. More severe clinical disease (transfusion-
1999). Good longitudinal follow-up studies of splenectomized dependent) will benefit from early splenectomy but the risks
or hyposplenic patients to look at some of these issues are must be balanced.
466 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
A significant number of children with HS develop pigment of their cohort of patients had shown either overt or sub-
stones in the first decade of life. The risk is increased in clinical gall bladder disease after a median follow-up of
individuals who co-inherit Gilbert syndrome with HS – these 18 years.
individuals have a fivefold increased risk of developing The surgical management of HS is thus largely founded on
gallstones (Miraglia del Giudice et al, 1999) (level III evi- ‘custom and practice’ (level III and IV evidence) rather than
dence). An Italian survey of 468 children with HS showed that the evidence of controlled trials. There are a number of
79 had gallstones, about half of them were diagnosed before questions that could be answered by well-designed observa-
the age of 11 years (level III evidence) (Pinto et al, 1995). A tional studies, although to have any statistical meaning they
recent study of 103 unsplenectomized children has shown that would have to be multi-centred.
the pigmented stones seen in haemolytic diseases are radio-
opaque in 50%, but ultrasound has an accuracy of 96%
(Miraglia del Giudice et al, 1999). Regular ultrasound exam- Recommendations
ination of the biliary system from the age of about 5 years may 1 There is no evidence that one surgical approach is
identify individuals more likely to have troublesome symp- superior to another, and the choice of the laparoscopic
toms later in life, and who may benefit from splenectomy route would be dependent on the availability of
prior to puberty. It is not clear whether adults with mild HS appropriately trained surgeons, and suitable equipment
should be regularly screened by ultrasound for asymptomatic (level III evidence, grade B recommendation).
gallstones, particularly as it is not clear whether these should 2 Partial splenectomy may be of benefit in very young
be removed. One study has shown chronic inflammatory children with severe disease, but it is likely that further
changes in the gall bladder mucosa in individuals with surgery may need to be undertaken for either recurrence
asymptomatic stones (Csendes et al, 1998). However, there of haematological problems or symptomatic cholelith-
are no good longitudinal studies of the outcome in children iasis (level IV evidence, grade C recommendation).
with silent stones, if left alone. One study of 123 adults with 3 In children undergoing splenectomy for symptoms of
silent stones (not relative to haemolytic conditions) found that cholelithiasis, the gall bladder should be removed. If
only 15–20% developed symptoms over a prolonged follow-up stones are an incidental finding, a cholecystostomy may
(Gracie & Ransohoff, 1982). In both adults and children, be sufficient, although follow-up to include ultrasound
regular follow-up should include assessment of possible examination of the gall bladder will be necessary (level
symptoms (typical and atypical) suggestive of gall bladder III evidence, grade B recommendation).
disease. Individuals with symptomatic gallstones usually have a 4 In children who require cholecystectomy for symptoms
cholecystectomy at the same time as the splenectomy; however of gallstones, the spleen should always be removed as
some surgeons prefer cholecystostomy (simple removal of well, otherwise the risk of stones persists (level IV
stones, leaving the gall bladder) in young children, as the risk evidence, grade C recommendation).
of stones is markedly reduced after splenectomy and there is 5 When splenectomy is indicated, ideally it should be
evidence that cholecystectomy may lead to alterations in bile performed after the age of 6 years, but before puberty
salt metabolism that predisposes to colon carcinoma later in (level IV evidence, grade C recommendation).
life, but the evidence for this is controversial (Robertson et al,
1988).
There are no randomized controlled trials comparing
different approaches to management but, in general, there is
What is the risk of late post splenectomy thrombosis?
a consensus for removing the gall bladder in the presence of
stones, if there have been symptoms of gall bladder disease Adults undergoing splenectomy should receive standard
(biliary colic, cholecystitis). The consensus is less clear about thromboprophylaxis where indicated. Splenectomy is usually
the appropriate action when stones are asymptomatic, and an followed by a reactive thrombocytosis that may be quite
incidental finding. Although some authors have suggested that spectacular in children, with counts rising to more than
all patients with stones, even the asymptomatic ones, should 1000 · 109/l (Hirsh & Dacie, 1966; Boxer et al, 1978; Coon
undergo cholecystectomy (Gotz et al, 1977), there is enough et al, 1978). Current evidence suggests that the only individ-
evidence to suggest that removal of stones may alone be uals in whom there is an increased risk of late (i.e. not
sufficient after splenectomy. Robertson et al (1988) reported related to the surgery itself) thrombosis after splenectomy are
on the clinical and ultrasound follow-up of five children with those with myeloproliferative disorders (Gordon et al, 1978),
HS who had cholecystotomy with stone removal at the time of or persisting anaemia with abnormal red blood cells (Hirsh &
splenectomy. In four of the cases there were no stones, but in Dacie, 1966), and has been demonstrated for beta thalassae-
one an asymptomatic stone was discovered. However, the mia intermedia (Cappellini et al, 2000) and for forms of
follow-up period was short (1–2 years), and there have been hereditary stomatocytosis (Delaunay et al, 1999). It is there-
no further reports of systematic follow-up of this cohort. In a fore vital to differentiate these membrane disorders from HS
study of 17 patients, Sandler et al (1999) identified that none and to avoid splenectomy. Thrombotic events have anecdo-
468 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
3 The current Department of Health advice concerning throcyte spectrin deficiency in hereditary spherocytosis. New Eng-
postsplenectomy sepsis needs review in the light of emer- land Journal of Medicine, 315, 1579–1583.
ging pneumococcal penicillin resistance and poor compli- Alloisio, N., Maillet, P., Carre, G., Texier, P., Vallier, A., Baklouti,
ance with long-term penicillin therapy. F., Philippe, N. & Delaunay, J. (1996) Hereditary spherocytosis
with band 3 deficiency. Association with a nonsense mutation of
4 Further research is required to establish which pneumo-
the band 3 gene (allele Lyon), and aggravation by a low-expres-
coccal vaccine should be used, and how often it needs
sion allele occurring in trans (allele Genas). Blood, 88, 1062–
repeating, and whether measurement of pneumococcal 1069.
antibodies has any role. Alloisio, N., Texier, P., Vallier, A., Ribeiro, M.L., Morle, L., Bozon, M.,
5 Collaborative studies of the surgical management of HS that Bursaux, E., Maillet, P., Goncalves, P., Tanner, M.J., Tamagnini, G.
compare standard versus laparoscopic splenectomy would & Delaunay, J. (1997) Modulation of clinical expression and band 3
be helpful. In addition, further information is required from deficiency in hereditary spherocytosis. Blood, 90, 414–420.
long-term studies of asymptomatic pigment gallstones – do Bader-Meunier, B., Gauthier, F., Archambaud, F., Cynober, T., Mielot,
they inevitably result in symptoms, or can patients be left F., Dommergues, J.P., Warszawski, J., Mohandas, N. & Tchernia, G.
alone, particularly in those in whom splenectomy would not (2001) Long-term evaluation of the beneficial effect of subtotal
otherwise be indicated? Is it safe to do a cholecystostomy splenectomy for management of hereditary spherocytosis. Blood, 97,
399–403.
alone? (Is there a role for national societies to collaborate
Bagdasarian, R.W., Bolton, J.S., Bowen, J.C., Fuhrman, G.M. &
here?) From a patient perspective, the research priorities
Richardson, W.S. (2000) Steep learning curve of laparoscopic sple-
centre on surgical intervention. nectomy. Journal of Laparoendoscopic and Advanced Surgical Tech-
6 To determine whether or not abnormal cation efflux, niques, 10, 319–323.
detected in red cells of some HS patients, is a consistent Baird, R.N., Macpherson, A.I.S. & Richmond, J. (1971) Red-blood-cell
indicator of increasing risk of thromboembolism post- survival after splenectomy in congenital spherocytosis. Lancet, ii,
splenectomy. As abnormal cation efflux has been repor- 1060–1061.
ted in some HS patients, could there be a subset of Bardill, B., Mengis, C., Tschopp, M. & Wuillemin, W.A. (2003) Severe
patients who present overlapping features between HS IgA-mediated auto-immune haemolytic anaemia in a 48-yr-old
and the red cell disorders associated with hereditary woman. European Journal of Haematology, 70, 60–63.
stomatocytosis? Bastion, Y., Coiffier, B., Felman, P., Assouline, D., Tigaud, J.D.,
Espinouse, D. & Bryon, P.A. (1990) Massive mediastinal extra-
7 An audit should be performed on all splenectomized
medullary hematopoiesis in hereditary spherocytosis: a case report.
patients to determine whether there is a higher incidence
American Journal of Hematology, 35, 263–265.
of thromboembolism in HS patients than in other groups of BCSH (1996) Guidelines for the prevention and treatment of infection
splenectomized individuals. It would be ideal to have a in patients with an absent or dysfunctional spleen: Working Party of
national splenectomy register to collect this and other the British Committee for Standards in Haematology Clinical
information regarding postsplenectomy sepsis. Haematology Task Force. British Medical Journal, 312, 430–434.
Boivin, P., Galand, C., Devaux, I., Lecomte, M.C., Garbarz, M. &
Dhermy, D. (1993) Spectrin alpha IIa variant in dominant and non-
Disclaimer dominant spherocytosis. Human Genetics, 92, 153–156.
Bolton-Maggs, P.H.B. (2004) Hereditary spherocytosis – new guide-
While the advice and information in these guidelines is lines. Archives of Disease in Childhood, in press.
believed to be true and accurate at the time of going to press, Boxer, M.A., Braun, J. & Ellman, L. (1978) Thromboembolic risk of
neither the authors, the British Society for Haematology nor postsplenectomy thrombocytosis. Archives of Surgery, 113, 808–809.
the publishers accept any legal responsibility for the content of Bracher, N.A., Lyons, C.A., Wessels, G., Mansvelt, E. & Coetzer, T.L.
these guidelines. (2001) Band 3 Cape Town (E90K) causes severe hereditary spher-
ocytosis in combination with band 3 Prague III. British Journal of
Haematology, 113, 689–693.
Source of funding Bucx, M.J., Breed, W.P. & Hoffmann, J.J. (1988) Comparison of
acidified glycerol lysis test, Pink test and osmotic fragility test in
None.
hereditary spherocytosis: effect of incubation. European Journal of
Haematology, 40, 227–231.
Conflict of interest Cappellini, M.D., Robbiolo, L., Bottasso, B.M., Coppola, R., Fiorelli, G.
& Mannucci, A.P. (2000) Venous thromboembolism and
None of the authors have received any funding from hypercoagulability in splenectomized patients with thalassaemia
companies related to the disorder or its treatment. intermedia. British Journal of Haematology, 111, 467–473.
Caprotti, R., Franciosi, C., Romano, F., Codecasa, G., Musco, F.,
Motta, M. & Uggeri, F. (1999) Combined laparoscopic splenectomy
References and cholecystectomy for the treatment of hereditary spherocytosis: is
it safe and effective? Surgical Laparoscopy Endoscopy and Percuta-
Agre, P., Asimos, A., Casella, J.F. & McMillan, C. (1986) Inheritance neous Techniques, 9, 203–206.
pattern and clinical response to splenectomy as a reflection of ery-
Chapman, R.G. & McDonald, L.L. (1968) Red cell life span after Delhommeau, F., Cynober, T., Schischmanoff, P.O., Rohrlich, P.,
splenectomy in hereditary spherocytosis. Journal of Clinical Delaunay, J., Mohandas, N. & Tchernia, G. (2000) Natural history of
Investigation, 47, 2263–2267. hereditary spherocytosis during the first year of life. Blood, 95, 393–
Chilcote, R.R., Le Beau, M.M., Dampier, C., Pergament, E., Verlinsky, 397.
Y., Mohandas, N., Frischer, H. & Rowley, J.D. (1987) Association of Deodhar, H.A., Marshall, R.J. & Barnes, J.N. (1993) Increased risk of
red cell spherocytosis with deletion of the short arm of chromosome sepsis after splenectomy. British Medical Journal, 307, 1408–1409.
8. Blood, 69, 156–159. Dhermy, D., Galand, C., Bournier, O., Boulanger, L., Cynober, T.,
Clark, M.R., Mohandas, N.M. & Shohet, S.B. (1983) Osmotic gradient Schismanoff, P.O., Bursaux, E., Tchernia, G., Boivin, P. & Garbarz,
ektacytometry: comprehensive characterization of the red cell M. (1997) Heterogenous band 3 deficiency in hereditary spher-
volume and surface maintenance. Blood, 61, 899–910. ocytosis related to different band 3 gene defects [published erratum
Cohen, H., Walker, H., Delhanty, J.D., Lucas, S.B. & Huehns, E.R. appears in British Journal of Haematology 1997, 99, 474]. British
(1991) Congenital spherocytosis, B19 parvovirus infection and Journal of Haematology, 98, 32–40.
inherited interstitial deletion of the short arm of chromosome 8. Dhermy, D., Steen-Johnsen, J., Bournier, O., Hetet, G., Cynober, T.,
British Journal of Haematology, 78, 251–257. Tchernia, G. & Grandchamp, B. (2000) Coinheritance of two alpha-
Coon, W.W., Penner, J., Clagett, P. & Eos, N. (1978) Deep venous spectrin gene defects in a recessive spherocytosis family. Clinical and
thrombosis and postsplenectomy thrombocytosis. Archives of Laboratory Haematology, 22, 329–336.
Surgery, 113, 429–431. Eber, S.W., Armbrust, R. & Schroter, W. (1990) Variable clinical
Costa, F.F., Agre, P., Watkins, P.C., Winkelmann, J.C., Tang, T.K., John, severity of hereditary spherocytosis: relation to erythrocytic spectrin
K.M., Lux, S.E. & Forget, B.G. (1990) Linkage of dominant hereditary concentration, osmotic fragility and autohemolysis. Journal of
spherocytosis to the gene for the erythrocyte membrane-skeleton Pediatrics, 177, 409–411.
protein ankyrin. New England Journal of Medicine, 323, 1046–1050. Eber, S.W., Pekrun, A., Neufeldt, A. & Schroter, W. (1992) Prevalence
Csendes, A., Smok, G., Burdiles, P., Diaz, J.-C., Maluenda, F. & of increased osmotic fragility of erythrocytes in German blood
Korn, O. (1998) Histological findings of gallbladder mucosa in 95 donors: screening using a modified glycerol lysis test. Annals of
control subjects and 80 patients with asymptomatic gallstones. Di- Hematology, 64, 88–92.
gestive Diseases and Sciences, 43, 931–934. Eber, S.W., Gonzalez, J.M., Lux, M.L., Scarpa, A.L., Tse, W.T., Dorn-
Curran, T.J., Foley, M.I., Swanstrom, L.L. & Campbell, T.J. (1998) well, M., Herbers, J., Kugler, W., Ozcan, R., Pekrun, A., Gallagher,
Laparoscopy improves outcomes for pediatric splenectomy. Journal P.G., Schroter, W., Forget, B.G. & Lux, S.E. (1996) Ankyrin-1
of Pediatric Surgery, 33, 1498–1500. mutations are a major cause of dominant and recessive hereditary
Cynober, T., Mohandas, N. & Tchernia, G. (1996) Red cell abnorm- spherocytosis. Nature Genetics, 13, 214–218.
alities in hereditary spherocytosis: relevance to diagnosis and Eber, S.W., Langendorfer, C.M., Ditzig, M., Reinhardt, D., Stohr, G.,
understanding of the variable expression of clinical severity. Journal Soldan, W., Schroter, W. & Tchernia, G. (1999) Frequency of very
of Laboratory and Clinical Medicine, 128, 259–269. late fatal sepsis after splenectomy for hereditary spherocytosis:
Dacie, J.V., Lewis, S.M. & Luzatto, L. (1991) Investigation of the impact of insufficient antibody response to pneumococcal infection.
hereditary haemolytic anaemias: membrane and enzyme abnorm- Annals of Hematology, 78, 524–528.
alities. In: Practical Haematology (ed. by J.V. Dacie & S.M. Lewis), Ein, S.H., Shandling, B., Simpson, J.S., Stephens, C.A., Bandi, S.K.,
pp. 195–225. Churchill Livingstone, Edinburgh. Biggar, W.D. & Freedman, M.H. (1977) The morbidity and mor-
Dallman, P.R. & Siimes, M.A. (1979) Percentile curves for hemoglobin tality of splenectomy in childhood. Annals of Surgery, 185, 307–310.
and red cell volume in infancy and childhood. Journal of Pediatrics, Eraklis, A.J. & Filler, R.M. (1972) Splenectomy in childhood: a review
94, 26–31. of 1413 cases. Journal of Pediatric Surgery, 7, 382–388.
Danielson, P.D., Shaul, D.B., Phillips, J.D., Stein, J.E. & Anderson, K.D. Esposito, C., Corcione, F., Ascione, G., Garipoli, V., Di Pietto, F. & De
(2000) Technical advances in pediatric laparoscopy have had a Pasquale, M. (1998) Splenectomy in childhood. The laparoscopic
beneficial impact on splenectomy. Journal of Pediatric Surgery, 35, approach. Surgical Endoscopy, 12, 1445–1448.
1578–1581. Evans, D.I. (1985) Postsplenectomy sepsis 10 years or more after
Davies, J.M., Barnes, R. & Milligan, D. (2002) Update of guidelines for operation. Journal of Clinical Pathology, 38, 309–311.
the prevention and treatment of infection in patients with an absent Farah, R.A., Rogers, Z.R., Thompson, W.R., Hicks, B.A., Guzzetta, P.C.
or dysfunctional spleen. Clinical Medicine: Journal of the Royal & Buchanan, G.R. (1997) Comparison of laparoscopic and open
College of Physicians of London, 2, 440–443. splenectomy in children with hematologic disorders. Journal of
De Franceschi, L., Olivieri, O., Miraglia del Giudice, E., Perrotta, S., Pediatrics, 131, 41–46.
Sabato, V., Corrocher, R. & Iolascon, A. (1997) Membrane cation Friedman, E.W., Williams, J.C. & Van Hook, L. (1988) Hereditary
and anion transport activities in erythrocytes of hereditary spher- spherocytosis in the elderly. American Journal of Medicine, 84, 513–
ocytosis: effects of different membrane protein defects. American 516.
Journal of Hematology, 55, 121–128. Gallagher, P.G., Weed, S.A., Tse, W.T., Benoit, L., Morrow, J.S.,
Delaunay, J., Alloisio, N., Morle, L., Baklouti, F., Dalla Venezia, N., Marchesi, S.L., Mohandas, N. & Forget, B.G. (1995) Recurrent fatal
Maillet, P. & Wilmotte, R. (1996) Molecular genetics of hereditary hydrops fetalis associated with a nucleotide substitution in the
elliptocytosis and hereditary spherocytosis. Annals of Genetics, 39, erythrocyte beta-spectrin gene. Journal of Clinical Investigation, 95,
209–221. 1174–1182.
Delaunay, J., Stewart, G. & Iolascon, A. (1999) Hereditary dehydrated Gallagher, P., Forget, B. & Lux, S. (1998) Disorders of the erythrocyte
and overhydrated stomatocytosis: recent advances. Current Opinion membrane. In: Nathan and Oski’s Hematology of Infancy and
in Hematology, 6, 110–114.
470 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
Childhood (ed. by D. Nathan & S. Orkin), Vol. 1, pp. 544–664. Hoeper, M.M., Niedermeyer, J., Hoffmeyer, F., Flemming, P. & Fabel,
Saunders, Philadelphia. H. (1999) Pulmonary hypertension after splenectomy? Annals of
Gallagher, P.G., Ferreira, J.D., Costa, F.F., Saad, S.T. & Forget, B.G. Internal Medicine, 130, 506–509.
(2000) A recurrent frameshift mutation of the ankyrin gene Holcomb, G.W., III (1998) Laparoscopic cholecystectomy. Seminars of
associated with severe hereditary spherocytosis. British Journal of Laparoscopic Surgery, 5, 2–8.
Haematology, 111, 1190–1193. Holdsworth, R.J., Irving, A.D. & Cuschieri, A. (1991) Postsplenectomy
Garbarz, M., Bibas, D., Cynober, T., Galand, C., Bournier, O., Devaux, I., sepsis and its mortality rate: actual versus perceived risks. British
Tchernia, G. & Dhermy, D. (1996) Search for the candidate genes in Journal of Surgery, 78, 1031–1038.
dominant hereditary spherocytosis using linkage analysis. Comptes Iolascon, A., Miraglia del Giudice, E., Perrotta, S., Alloisio, N., Morle,
Rendus de l’ Academie des Sciences, Paris, Sciences de la Vie III, 319, L. & Delaunay, J. (1998) Hereditary spherocytosis: from clinical to
913–919. molecular defects. Haematologia, 83, 240–257.
Garbarz, M., Galand, C., Bibas, D., Bournier, O., Devaux, I., Jarolim, P., Rubin, H.L., Brabec, V. & Palek, J. (1995) Comparison of
Harousseau, J.L., Grandchamp, B. & Dhermy, D. (1998) A 5¢ splice the ankyrin (AC)n microsatellites in genomic DNA and mRNA
region G–>C mutation in exon 3 of the human beta-spectrin gene reveals absence of one ankyrin mRNA allele in 20% of patients with
leads to decreased levels of beta-spectrin mRNA and is responsible hereditary spherocytosis. Blood, 85, 3278–3282.
for dominant hereditary spherocytosis (spectrin Guemene-Penfao). Jarolim, P., Murray, J.L., Rubin, H.L., Taylor, W.M., Prchal, J.T.,
British Journal of Haematology, 100, 90–98. Ballas, S.K., Snyder, L.M., Chrobak, L., Melrose, W.D., Brabec, V. &
Gehlbach, S.H. & Cooper, B.A. (1970) Haemolytic anaemia in Palek, J. (1996) Characterization of 13 novel band 3 gene defects in
infectious mononucleosis due to inapparent congenital spher- hereditary spherocytosis with band 3 deficiency. Blood, 88, 4366–
ocytosis. Scandinavian Journal of Haematology, 7, 141–144. 4374.
Godal, H.C. & Heisto, H. (1981) High prevalence of increased osmotic Jensson, O., Jonasson, J.L. & Magnusson, S. (1977) Studies on
fragility of red blood cells among Norwegian blood donors. hereditary spherocytosis in Iceland. Acta Medica Scandinavica, 201,
Scandinavian Journal of Haematology, 27, 30–34. 187–195.
Goodman, S.R., Shiffer, K.A., Casoria, L.A. & Eyster, M.E. (1982) Jugenburg, M., Haddock, G., Freedman, M.H., Ford-Jones, L. & Ein,
Identification of the molecular defect in the erythrocyte membrane S.H. (1999) The morbidity and mortality of pediatric splenectomy:
skeleton of some kindreds with hereditary spherocytosis. Blood, 60, does prophylaxis make a difference? Journal of Pediatric Surgery, 34,
772–784. 1064–1067.
Gordon, D.H., Schaffner, D., Bennett, J.M. & Schwartz, S.I. (1978) Keenan, R.D., Boswell, T. & Milligan, D.W. (1999) Do post-
Postsplenectomy thrombocytosis: its association with mesenteric, splenectomy patients take their penicillin. British Journal of
portal, and/or renal vein thrombosis in patients with myeloproli- Haematology, 105, 509–510.
ferative disorders. Archives of Surgery, 113, 713–715. Kelleher, J.F., Luban, N.L., Mortimer, P.P. & Kamimura, T. (1983)
Gotz, M., Granditsch, G., Helmer, F., Howanietz, L. & Wagner, I.U. Human serum ‘parvovirus’: a specific cause of aplastic crisis in
(1977) Cholelithiasis in children and adolescents (authors transl) children with hereditary spherocytosis. Journal of Pediatrics, 102,
Wien Klin Wochenschr, 89, 686–690. 720–722.
Gracie, W.A. & Ransohoff, D.F. (1982) The natural history of silent Kerr, R., Rawlinson, T.S. & Cachia, P.G. (2000) Direct antiglobulin test
gallstones: the innocent gallstone is not a myth. New England Journal negative, non-spherocytic autoimmune haemolytic anaemia. Clin-
of Medicine, 307, 798–800. ical and Laboratory Haematology, 22, 365–367.
Granjo, E., Bauerle, R., Sampaio, R., Manata, P., Torres, N. & Quin- King, M.J., Behrens, J., Rogers, C., Flynn, C., Greenwood, D. &
tanilha, A. (2002) Extramedullary hematopoiesis in hereditary Chambers, K. (2000) Rapid flow cytometric test for the diagnosis of
spherocytosis deficient in ankyrin: a case report. International membrane cytoskeleton-associated haemolytic anaemia. British
Journal of Hematology, 76, 153–156. Journal of Haematology, 111, 924–933.
Haines, P.G., Jarvis, H.G., King, S., Noormohamed, F.H., Chetty, King, M.-J., Chapman, L., Mackinnon, H., Mills, W., Psiachou-
M.C., Fisher, J., Hill, P., Nicolaou, A. & Stewart, G.W. (2001) Leonnard, E. & Murrin, R. (2003) Examination of flow cytometric
Two further British families with the ‘cryohydrocytosis’ form of histograms of eosin-5-maleimide labelled red cells can assist in
hereditary stomatocytosis. British Journal of Haematology, 113, differential diagnosis of membranopathy. British Journal of Hae-
932–937. matology, 121(Suppl. 1), 75.
Hassoun, H., Vassiliadis, J.N., Murray, J., Njolstad, P.R., Rogus, J.J., King, M.-J., Smythe, J. & Mushens, R. (2004) Eosin-5-maleimide
Ballas, S.K., Schaffer, F., Jarolim, P., Brabec, V. & Palek, J. (1997) binding to band 3 and Rh-related proteins forms the basis of a
Characterization of the underlying molecular defect in hereditary screening test for hereditary spherocytosis. British Journal of Hae-
spherocytosis associated with spectrin deficiency. Blood, 90, 398– matology, 124, 106–113.
406. Kohler, H., Meynell, M. & Cooke, W. (1960) Spherocytic anaemia
Hayag-Barin, J.E., Smith, R.E. & Tucker, F.C., Jr (1998) Hereditary complicated by megaloblastic anaemia of pregnancy. British Medical
spherocytosis, thrombocytosis, and chronic pulmonary emboli: a Journal, 1, 779–781.
case report and review of the literature. American Journal of Konradsen, H.B. & Henrichsen, J. (1991) Pneumococcal infections in
Hematology, 57, 82–84. splenectomized children are preventable. Acta Paediatrica Scandi-
Hirsh, J. & Dacie, J.V. (1966) Persistent post-splenectomy thrombo- navica, 80, 423–427.
cytosis and thrombo-embolism: a consequence of continuing Korones, D. & Pearson, H.A. (1989) Normal erythrocyte osmotic fra-
anaemia. British Journal of Haematology, 12, 44–53. gility in hereditary spherocytosis. Journal of Pediatrics, 114, 264–266.
Lefrere, J.J., Courouce, A.M., Girot, R., Bertrand, Y. & Soulier, J.P. Parpart, A.K., Lorenz, P.B., Parpart, E.R., Gregg, J.R. & Chase, A.M.
(1986) Six cases of hereditary spherocytosis revealed by human (1947) The osmotic resistance (fragility) of human red cells. Journal
parvovirus infection. British Journal of Haematology, 62, 653–658. of Clinical Investigation, 26, 636–640.
Lindenbaum, J. & Klipstein, F.A. (1963) Folic acid deficiency in sickle- Pati, A.R., Patton, W.N. & Harris, R.I. (1989) The use of the technicon
cell anemia. New England Journal of Medicine, 269, 875–882. H1 in the diagnosis of hereditary spherocytosis. Clinical and
Mackenzie, F., Elliot, D., Eastcott, H., Hughes-Jones, N., Barkhan, P. & Laboratory Haematology, 11, 27–30.
Mollinson, P. (1962) Relapse in hereditary spherocytosis with pro- Pedersen, F.K. (1983) Postsplenectomy infections in Danish children
ven splenunculus. Lancet, 1, 1102–1104. splenectomized 1969–1978. Acta Paediatrica Scandinavica, 72, 589–
Marchetti, M., Quaglini, S. & Barosi, G. (1998) Prophylactic sple- 595.
nectomy and cholecystectomy in mild hereditary spherocytosis: Petit, J.J. & Estany, C. (1987) Mediastinal extramedullary erythropoi-
analyzing the decision in different clinical scenarios. Journal of esis in hereditary spherocytosis. Clinical and Laboratory Haemato-
Internal Medicine, 244, 217–226. logy, 9, 327–332.
McLane, N.J., Grizzard, W.S., Kousseff, B.G., Hartmann, R.C. & Sever, Pilar Ricard, M. & Gilanz, F. (1996) Assessment of the severity of
R.J. (1984) Angioid streaks associated with hereditary spherocytosis. hereditary spherocytosis using routine haematological data obtained
American Journal of Ophthalmology, 97, 444–449. with dual angle laser scattering cytometry. Clinical and Laboratory
Michaels, L.A., Cohen, A.R., Zhao, H., Raphael, R.I. & Manno, C.S. Haematology, 18, 75–78.
(1997) Screening for hereditary spherocytosis by use of automated Pinto, L., Iolascon, A., Miraglia del Giudice, E., Matarese, S.M.R.,
erythrocyte indexes. Journal of Pediatrics, 130, 957–960. Nobili, B. & Perrotta, S. (1995) The Italian survey on hereditary
Miraglia del Giudice, E., Iolascon, A., Pinto, L., Nobili, B. & Perrotta, S. spherocytosis. International Journal of Pediatric Hematology and
(1994) Erythrocyte membrane protein alterations underlying clinical Oncology, 2, 43–47.
heterogeneity in hereditary spherocytosis. British Journal of Hae- Pulsoni, A., Ferrazza, G., Malagnino, F., Maurillo, L., Pescarmona, E.,
matology, 88, 52–55. Picardi, A., Rendina, E.A. & Amadori, S. (1992) Mediastinal extra-
Miraglia del Giudice, E., Lombardi, C., Francese, M., Nobili, B., medullary hematopoiesis as first manifestation of hereditary spher-
Conte, M.L., Amendola, G., Cutillo, S., Iolascon, A. & Perrotta, S. ocytosis. Annals of Hematology, 65, 196–198.
(1998) Frequent de novo monoallelic expression of beta-spectrin Reid, M.M. (1994) Splenectomy, sepsis, immunisation, and guidelines.
gene (SPTB) in children with hereditary spherocytosis and iso- Lancet, 344, 970–971.
lated spectrin deficiency. British Journal of Haematology, 101, Reinhart, W.H., Wyss, E.J., Arnold, D. & Ott, P. (1994) Hereditary
251–254. spherocytosis associated with protein band 3 defect in a Swiss kin-
Miraglia del Giudice, E., Perrotta, S., Nobili, B., Specchia, C., d’Urzo, dred. British Journal of Haematology, 86, 147–155.
G. & Iolascon, A. (1999) Coinheritance of Gilbert syndrome Reliene, R., Mariani, M., Zanella, A., Reinhart, W.H., Ribeiro, M.L., del
increases the risk for developing gallstones in patients with heredi- Giudice, E.M., Perrotta, S., Iolascon, A., Eber, S. & Lutz, H.U. (2002)
tary spherocytosis. Blood, 94, 2259–2262. Splenectomy prolongs in vivo survival of erythrocytes differently in
Miraglia del Giudice, E., Nobili, B., Francese, M., D’Urso, L., Iolascon, spectrin/ankyrin- and band 3-deficient hereditary spherocytosis.
A., Eber, S. & Perrotta, S. (2001) Clinical and molecular evaluation Blood, 100, 2208–2215.
of non-dominant hereditary spherocytosis. British Journal of Hae- Rescorla, F.J. & Grosfeld, J.L. (1992) Cholecystitis and cholelithiasis in
matology, 112, 42–47. children. Seminars of Pediatric Surgery, 1, 98–106.
Mohandas, N., Clark, M.R., Jacobs, M.S. & Shohet, S.B. (1980) Ana- Rescorla, F.J., Engum, S.A., West, K.W., Tres Scherer, L.R., III, Rouse,
lysis of factors regulating erythrocyte deformability. Journal of T.M. & Grosfeld, J.L. (2002) Laparoscopic splenectomy has become
Clinical Investigation, 66, 563–573. the gold standard in children. American Surgery, 68, 297–301; dis-
Mohandas, N., Kim, Y.R., Tycko, D.H., Orlik, J., Wyatt, J. & Groner, W. cussion 301–302.
(1986) Accurate and independent measurement of volume and he- Rice, H.E., Oldham, K.T., Hillery, C.A., Skinner, M.A., O’Hara, S.M. &
moglobin concentration of individual red cells by laser light scat- Ware, R.E. (2003) Clinical and hematologic benefits of partial
tering. Blood, 68, 506–513. splenectomy for congenital hemolytic anemias in children. Annals of
Morton, N., MacKinney, A., Kosowe, N., Schilling, R. & Gray, M. Surgery, 237, 281–288.
(1962) Genetics of spherocytosis. American Journal of Human Ge- Robertson, J.F., Carachi, R., Sweet, E.M. & Raine, P.A. (1988) Chole-
netics, 14, 170–184. lithiasis in childhood: a follow-up study. Journal of Pediatric Surgery,
Mulder, H., Schlangen, J.T. & van Voorthuisen, A.E. (1975) Extra- 23, 246–249.
medullary hematopoiesis in the posterior mediastinum. Radiology Rosenblatt, D.S. & Hoffbrand, A.V. (1999) Megaloblastic anemia and
Clinics (Basel), 44, 550–556. disorders of cobalamin and folate metabolism. In: Pediatric Hema-
Nikol, S., Huehns, T.Y., Kiefmann, R. & Hofling, B. (1997) Excessive tology (ed. by J.S. Lilleyman, I.M. Hann & V.S. Blanchette), pp. 167–
arterial thrombus in spherocytosis. A case report. Angiology, 48, 184. Churchill Livingstone, London.
743–748. Rutkow, I.M. (1981) Twenty years of splenectomy for hereditary
Pajor, A., Lehoczky, D. & Szakacs, Z. (1993) Pregnancy and hereditary spherocytosis. Archives of Surgery, 116, 306–308.
spherocytosis. Report of 8 patients and a review. Archives of Gyne- Rybicki, A.C., Schwartz, R.S., Hustedt, E.J. & Cobb, C.E. (1996) In-
cology and Obstetrics, 253, 37–42. creased rotational mobility and extractability of band 3 from protein
Palek, J. & Sahr, K.E. (1992) Mutations of the red blood cell membrane 4.2-deficient erythrocyte membranes: evidence of a role for protein
proteins: from clinical evaluation to detection of the underlying 4.2 in strengthening the band 3-cytoskeleton linkage. Blood, 88,
genetic defect. Blood, 80, 308–330. 2745–2753.
472 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474
Guideline
Sandler, A., Winkel, G., Kimura, K. & Soper, R. (1999) The role of lowing neonatal treatment with normal hematopoietic cells. Blood,
prophylactic cholecystectomy during splenectomy in children with 97, 3972–3975.
hereditary spherocytosis. Journal of Pediatric Surgery, 34, 1077– Whitfield, C.F., Follweiler, J.B., Lopresti-Morrow, L. & Miller, B.A.
1078. (1991) Deficiency of alpha-spectrin synthesis in burst-forming
Schroter, W. & Kahsnitz, E. (1983) Diagnosis of hereditary spher- units-erythroid in lethal hereditary spherocytosis. Blood, 78, 3043–
ocytosis in newborn infants. Journal of Pediatrics, 103, 460–463. 3051.
Smith, B.M., Schropp, K.P., Lobe, T.E., Rogers, D.A., Presbury, G.J., Wichterle, H., Hanspal, M., Palek, J. & Jarolim, P. (1996) Combination
Wilimas, J.A. & Wong, W.C. (1994) Laparoscopic splenectomy in of two mutant alpha spectrin alleles underlies a severe spherocytic
childhood. Journal of Pediatric Surgery, 29, 975–977. hemolytic anemia. Journal of Clinical Investigation, 98, 2300–2307.
Spickett, G.P., Bullimore, J., Wallis, J., Smith, S. & Saunders, P. (1999) Wolfe, L.C., John, K.M., Falcone, J.C., Byrne, A.M. & Lux, S.E. (1982)
Northern Region asplenia register – analysis of first two years. A genetic defect in the binding of protein 4.1 to spectrin in a kindred
Journal of Clinical Pathology, 52, 424–429. with hereditary spherocytosis. New England Journal of Medicine, 307,
Stenson, P.D., Ball, E.V., Mort, M., Phillips, A.D., Shiel, J.A., Thomas, 1367–1374.
N.S., Abeysinghe, S., Krawczak, M. & Cooper, D.N. (2003) Human Xiros, N., Economopoulos, T., Papageorgiou, E., Mantzios, G. &
Gene Mutation Database (HGMD): 2003 update. Human Mutation, Raptis, S. (2001) Massive hemothorax due to intrathoracic extra-
21, 577–581. medullary hematopoiesis in a patient with hereditary spherocytosis.
Stewart, G.W. & Turner, E.J. (1999) The hereditary stomatocytoses and Annals of Hematology, 80, 38–40.
allied disorders: congenital disorders of erythrocyte membrane Yawata, Y., Kanzaki, A., Inoue, T., Ata, K., Wada, H., Okamoto, N.,
permeability to Na and K. Baillieres Best Practice and Research Higo, I., Yawata, A., Sugihara, T. & Yamada, O. (1994) Red cell
Clinical Haematology, 12, 707–727. membrane disorders in the Japanese population: clinical, biochem-
Stewart, G.W., Amess, J.A., Eber, S.W., Kingswood, C., Lane, P.A., ical, electron microscopic, and genetic studies. International Journal
Smith, B.D. & Mentzer, W.C. (1996) Thrombo-embolic disease after of Hematology, 60, 23–38.
splenectomy for hereditary stomatocytosis. British Journal of Zanella, A., Izzo, C., Rebulla, P., Zanuso, F., Perroni, L. & Sirchia, G.
Haematology, 93, 303–310. (1980) Acidified glycerol lysis test: a screening test for spherocytosis.
Streichman, S. & Gescheidt, Y. (1998) Cryohemolysis for the detection British Journal of Haematology, 45, 481–486.
of hereditary spherocytosis: correlation studies with osmotic fragility
and autohemolysis. American Journal of Hematology, 58, 206–212.
Summerfield, G.P. & Wyatt, G.P. (1985) Human parvovirus infection Appendix
revealing hereditary spherocytosis. Lancet, 2, 1070. The definitions of the types of evidence and the grading
Sutton, C.D., Garcea, G., Marshall, L.J., Lloyd, T.D., De Alwis, C. &
recommendations used in this guideline originate from the US
Lewis, M.H. (2003) Pelvic extramedullary haematopoiesis associated
Agency for Health Care Policy and Research and are set out
with hereditary spherocytosis. European Journal of Haematology, 70,
326–329.
below.
Tanoue, K., Okita, K., Akahoshi, T., Konishi, K., Gotoh, N., Tsutsumi,
N., Tomikawa, M. & Hashizume, M. (2002) Laparoscopic sple- Statements of evidence
nectomy for hematologic diseases. Surgery, 131, S318–S323.
Ia Evidence obtained from the meta-analysis of randomized
Tchernia, G., Gauthier, F., Mielot, F., Dommergues, J.P., Yvart, J.,
controlled trials.
Chasis, J.A. & Mohandas, N. (1993) Initial assessment of the ben-
eficial effect of partial splenectomy in hereditary spherocytosis.
Ib Evidence obtained from at least one randomized controlled
Blood, 81, 2014–2020. trial.
Tchernia, G., Bader-Meunier, B., Berterottiere, P., Eber, S., Dommer- IIa Evidence obtained from at least one well-designed
gues, J.P. & Gauthier, F. (1997) Effectiveness of partial splenectomy controlled study without randomization.
in hereditary spherocytosis. Current Opinion in Hematology, 4, 136– IIb Evidence obtained from at least one other type of well-
141. designed quasi-experimental study.
Tchernia, G., Delhommeau, F., Perrotta, S., Cynober, T., Bader-Meu- III Evidence obtained from well-designed non-experimental
nier, B., Nobili, B., Rohrlich, P., Salomon, J.L., Sagot-Bevenot, S., del descriptive studies, such as comparative studies, correla-
Giudice, E.M., Delaunay, J., DeMattia, D., Schischmanoff, P.O., tion studies and case studies.
Mohandas, N. & Iolascon, A. (2000) Recombinant erythropoietin
IV Evidence obtained from expert committee reports or
therapy as an alternative to blood transfusions in infants with
opinions and/or clinical experiences of respected author-
hereditary spherocytosis. Hematology Journal, 1, 146–152.
Tse, W.T. & Lux, S.E. (1999) Red blood cell membrane disorders.
ities.
British Journal of Haematology, 104, 2–13.
Waghorn, D. & Mayon-White, R. (1997) A study of 42 episodes of
overwhelming post-splenectomy infection: is guidance for asplenic Grades of recommendations
individuals being followed? Journal of Infection, 35, 289–294. A Required at least one randomized controlled trial as part of
Walker, W. (1976) Splenectomy in childhood; a review in England and a body literature of overall good quality and consistency
Wales. British Journal of Surgery, 63, 36–43. addressing the specific recommendations (evidence levels
Wandersee, N.J., Lee, J.C., Deveau, S.A. & Barker, J.E. (2001) Reduced Ia, Ib).
incidence of thrombosis in mice with hereditary spherocytosis fol-
474 ª 2004 Blackwell Publishing Ltd, British Journal of Haematology, 126, 455–474