What is the most likely diagnosis for a 1-year-old boy with pallor, jaundice, lethargy, delayed growth, short stature, prominent forehead, and splenomegaly, with lab results showing severe anemia (low Hemoglobin (HB) levels), elevated Red Cell Distribution Width (RDW), microcytic anemia (low Mean Corpuscular Volume (MCV)), elevated reticulocyte count, and abnormal Hemoglobin (HB) electrophoresis with elevated Hb A2 and Hb F levels?

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β-Thalassemia Major

This 1-year-old boy has β-thalassemia major (homozygous β-thalassemia), as evidenced by the severely elevated HbA2 (30%) and HbF (50%) on hemoglobin electrophoresis, combined with severe microcytic anemia, splenomegaly, and characteristic skeletal changes. 1, 2

Diagnostic Reasoning

Key Laboratory Findings That Confirm β-Thalassemia

  • Hemoglobin electrophoresis is diagnostic: HbA2 at 30% (normal 2-3%) and HbF at 50% (normal 1-2%) are pathognomonic for β-thalassemia major 1, 2
  • Severe microcytic anemia: Hemoglobin of 40 g/L with MCV of 70 fL indicates profound microcytic anemia 1, 2
  • Elevated RBC count (5.8 × 10¹²/L) despite severe anemia is characteristic of thalassemia, where the bone marrow produces many small, poorly hemoglobinized red cells 1, 2
  • Elevated reticulocyte count (2.4%) reflects the bone marrow's compensatory response to chronic hemolysis 2, 3
  • Elevated RDW (14%) indicates heterogeneous red cell populations due to ineffective erythropoiesis 1, 4

Clinical Features Supporting β-Thalassemia Major

  • Growth delay and short stature are characteristic of β-thalassemia major, with weight deficits occurring early and preceding linear growth failure 5
  • Prominent forehead results from extramedullary hematopoiesis causing bone marrow expansion in the skull 6, 7
  • Splenomegaly develops from chronic hemolysis and extramedullary hematopoiesis 6, 3, 8
  • Jaundice reflects chronic hemolysis with hyperbilirubinemia 6, 3
  • Pallor and lethargy result from severe anemia 6, 3

Why Other Diagnoses Are Excluded

Iron Deficiency Anemia (Option A) - Incorrect

  • Hemoglobin electrophoresis would be normal in iron deficiency, not showing elevated HbA2 and HbF 1, 2
  • RBC count would be low, not elevated as seen here (5.8 × 10¹²/L) 1, 2
  • Ferritin would be low (<30 μg/L), and transferrin saturation would be reduced (<15-16%) 1, 2
  • Iron deficiency does not cause prominent forehead or the degree of splenomegaly seen here 1

Sickle Cell Disease (Option C) - Incorrect

  • Hemoglobin electrophoresis would show HbS, not elevated HbA2 and HbF in this pattern 9
  • Sickle cell disease typically presents with painful vaso-occlusive crises, not primarily with this constellation of findings 9
  • The MCV in sickle cell disease is typically normal or only mildly reduced, not 70 fL 9

α-Thalassemia (Option D) - Incorrect

  • Hemoglobin electrophoresis would be normal or show only HbH in α-thalassemia, not markedly elevated HbA2 and HbF 1, 2
  • Severe α-thalassemia (HbH disease or Bart's hydrops fetalis) presents differently, with Bart's hydrops causing intrauterine or neonatal death 1
  • The specific pattern of HbA2 elevation is pathognomonic for β-thalassemia, not α-thalassemia 1, 2

Clinical Implications and Management Considerations

This child will require lifelong transfusion therapy to maintain adequate hemoglobin levels and prevent complications of chronic anemia and extramedullary hematopoiesis 7, 5

Iron chelation therapy is essential to prevent iron overload from chronic transfusions, which can cause cardiac, hepatic, and endocrine complications 7

Monitor for complications including growth failure, delayed puberty, cardiac dysfunction, hepatic disease, and endocrinopathies (particularly hypogonadism and growth hormone deficiency) 7, 5

Splenectomy may be considered if hypersplenism develops with increased transfusion requirements, though this is typically delayed until after age 5-6 years due to infection risk 3, 8

Genetic counseling for the family is indicated, as both parents are obligate carriers of β-thalassemia trait 6

References

Guideline

Iron Deficiency Anemia: Diagnostic Parameters

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Anemia Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Congenital Hemolytic Anemia.

The Medical clinics of North America, 2017

Guideline

Management of Low RDW with High NRBC

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Malnutrition and growth abnormalities in children with beta thalassemia major.

The Southeast Asian journal of tropical medicine and public health, 1996

Research

Haemoglobin Lepore in a Malay family: a case report.

The Malaysian journal of pathology, 2005

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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