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Blood, 15 December 2000, Vol. 96, No. 13, pp. 4363-4365
BRIEF REPORT
Familial-skewed X-chromosome inactivation as a predisposing
factor for late-onset X-linked sideroblastic anemia in
carrier females
Mario Cazzola,
Alison May,
Gaetano Bergamaschi,
Paola Cerani,
Vittorio Rosti, and
David F. Bishop
From the Department of Hematology and the
Department of Internal Medicine and Medical Therapy, University of
Pavia Medical School, and Instituto di Ricovero e Cura a Carattere
Scientifico (IRCCS) Policlinico S. Matteo, Pavia, Italy; the Department
of Haematology, University of Wales College of Medicine, Cardiff,
Wales; and the Department of Human Genetics, Mount Sinai School of
Medicine, New York, NY.
X-linked sideroblastic anemia (XLSA) is caused by mutations in the
erythroid-specific 5-aminolevulinic acid synthase
(ALAS2) gene. An elderly woman who
presented with an acquired sideroblastic anemia is studied. Molecular
analysis revealed that she was heterozygous for a missense mutation in
the ALAS2 gene, but she expressed only the mutated gene in
reticulocytes. Her 2 daughters and a granddaughter were heterozygous
for this mutation, had normal hemoglobin levels, and expressed the
normal ALAS2 gene in reticulocytes. A grandson with a
previous diagnosis of thalassemia intermedia was found to be hemizygous
for the ALAS2 mutation. Treatment with pyridoxine completely corrected the anemia both in the proband and her grandson. All women who were analyzed in this family showed skewed X-chromosome inactivation in leukocytes, which indicated a hereditary condition associated with unbalanced lyonization. Because the preferentially active X chromosome carried the mutant ALAS2 allele,
acquired skewing in the elderly likely worsened the genetic condition
and abolished the normal ALAS2 allele expression in the proband.

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