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IN NEWS Irish in the blood
Although often misdiagnosed, an ancient blood disease is still making its presence known in those of Irish extraction.
by Colleen Dougher
Sandra Thomas loves a good St. Paddyís Day party.
Itís not the great Irish music and dance, the corned beef and cabbage, or even the abundant supply of Guinness. Itís just that having all those people of Celtic heritage gathered in one place makes her mission so much easier.
For 16 years, Thomas, who runs American Hemochromatosis Society out of her Delray Beach home, has been using St. Paddyís Day as a way to tell people about what she calls 'The Celtic Curse,' a disease that deposits iron in the heart, joints, liver, pancreas and pituitary gland, and eventually 'rusts' the insides of bodies.
Her group does everything from distributing literature at Irish festivals to placing fliers in Palm Beach County Irish pubs and using the opportunity to contact the media about this common, yet little-known genetic disorder.
While no one is immune to hemochromatosis, those with Irish, Scottish or British heritage have a significantly higher chance of carrying the gene mutation that may cause them to develop the potentially deadly disorder.
Some researchers believe that hemochromatosis originated more than 40,000 years ago in the area we now know as Ireland with a single person whose genes mutated so that he or she could over-absorb iron to compensate for an iron-poor diet.
Today, with iron-enriched foods, iron supplements and plenty of red meat, thereís no need to pull in extra iron, yet many still carry the ancient mutated genes that cause their bodies to do so, at toxic levels.
Left untreated, hemochromatosis can lead to everything from early menopause and infertility to diabetes, heart failure, cirrhosis, primary liver cancer and even death. But if caught before damage is done, hemochromatosis patients can be saved, and their health restored through a process called bloodletting, or phlebotomies.
Initially, a patient may be required to have a pint of blood drawn once or twice a week, until excess iron is depleted. Each time blood is drawn, the brain tells the red blood cells they need iron, so the blood taps the iron stored in organs and tissues. Eventually, and sometimes this takes a few years, the stores of iron are depleted. Afterward, a patient will be required to have phlebotomies maybe three or four times a year to keep iron from accumulating.
Despite the simple cure, many hemochromatosis patients remain untreated and die from diseases caused by iron overload. Even though many exhibit symptoms and simple, relatively inexpensive tests are available, theyíre often not administered.
The Centers for Disease Control now calls hemochromatosis the most common genetic disorder in the United States, one that affects 33.5 million Americans. An estimated 32 million are silent carriers, meaning they exhibit no symptoms, while 1.5 million have a double gene mutation because both parents carried the mutant gene, which puts them at high risk. Yet many doctors still believe what they were taught in medical school ó that hemochromatosis is a rare disorder that only strikes middle-aged or elderly white men.
'They want to see someone whoís at deathís door before they can actually consider hemochromatosis,' Thomas says. 'And thatís the old training, this middle-aged man coming in with a swollen belly, enlarged liver, cirrhosis of the liver, jaundice, diabetes, heart bad. Thatís hemochromatosis.'
But since the genes that cause hemochromatosis were discovered in 1996, several studies have been done that revealed that women, once thought to be spared from the disease because they lose excess iron when they menstruate each month, are not immune from the disease. Nor are African-Americans, Hispanics, or children. In fact, no one is immune, and people in their 30s ó and some even younger ó are already dying by the time theyíre diagnosed.
Yet experts also have discovered that if treated early, damage to organs and tissues is completely preventable. Ask a doctor about being tested for the disease, however, and thereís a chance youíll be laughed out of the office.
Teach your doctor well
But Thomas, whose mother died of liver cancer caused by iron overload, isnít laughing. Nor are others who struggled for years to find out what was wrong with them, only to be diagnosed too late.
Sixteen years into her awareness campaign, Thomas, a silent carrier of the disease, still finds herself talking to people whose doctors know they have high iron levels and wonít treat them because they donít have what they believe to be the classic symptoms (i.e., theyíre not at deathís door).
In 1997, a year after researchers isolated the mutated genes that cause hemochromatosis, a genetic mail-order test was developed that allows people to be screened for the disease. Those who test positive for the gene can keep their iron levels in check, and prevent iron from ever invading their organs and destroying their lives.
Thomas is on a mission to make people aware of the $125 test, as well as simple blood tests (serum iron, total iron binding capacity and serum ferritin) that doctors seem so reluctant to give.
Itís not that thereís a conspiracy against patients with iron overload. Itís just that many doctors havenít been educated about the latest facts regarding the disease.
And since people arenít routinely tested for iron overload, doctors must be able to recognize warning signs. Unfortunately, the symptoms of hemochromatosis are often serious diseases themselves, and doctors wind up treating the heart trouble, the diabetes or the liver cancer without looking for an underlying cause.
In other cases, symptoms are all over the map, ranging from elevated liver enzymes, cirrhosis, tender swollen joints, heart problems, changes in skin pigmentation (turning bronze without going to the beach), depression, increase in blood glucose levels, a swollen stomach or a heavy feeling (mostly on the right side of the belly), redness in the palms of the hands, an enlarged spleen, chronic fatigue and, believe it or not, anemia.
While it may seem unlikely that someone with anemia, which weíve been trained to think of as iron deficiency, could suffer from iron overload, they can. One may be anemic (meaning the blood has a deficiency of red blood cells) and still have loads of iron stored in their organs. Yet, many think nothing of popping iron supplements without knowing their iron storage levels, and some do so on the advice of their physicians.
Roberta Crawford, who heads the Iron Over Diseases Association in North Palm Beach, nearly killed herself with iron pills prescribed by doctors. While they diagnosed her with anemia, they never tested her iron storage levels. Years later, she would learn that her body was storing too much iron, not in her blood but in her vital organs, and the iron pills added to the problem.
And it wasnít just one misguided physician who prescribed the supplements, she says. It was several doctors across five states.
Finally, in 1978, she was diagnosed with hemochromatosis. As is often the case, her diagnosis came by accident. Her liver was enlarged, and since she didnít drink, her doctor ordered a biopsy to look for cancer. What they found instead was a liver loaded with iron.
Thatís when her doctor told her she had a 'rare and interesting disease, hemochromatosis.'
She would soon learn, however, that, fascinating as the disease is ó sheís still researching it more than two decades later ó itís not rare. 'Whatís rare,' she says, 'is getting diagnosed.'
Equally rare is finding a doctor who understands that prescribing iron supplements to people whose iron levels havenít been properly tested could be like giving a bottle of Jack Danielís to someone with cirrhosis of the liver.
The supplements become particularly risky if they are taken by people who have family histories of heart trouble, diabetes and liver problems, or their liver enzymes are elevated.
One could try explaining this to oneís doctor, but Thomas recommends that people choose their words carefully. Many doctors donít take kindly to patients who want to educate them.
Itís what she likes to call the 'Me-Tarzan-You-Jane Syndrome.'
And those of Irish heritage, who are among the most likely to have this disorder, have even more to overcome when they try to convince a doctor that they may have hemochromatosis.
The disease tends to assault the liver. So does alcohol. And whether the reputation is earned or not, the Irish have long been known for their love of drinking. When a doctor looks at a report that reveals elevated liver enzymes ó the sign of a distressed liver ó iron overload isnít always the first thought that comes to mind.
Consider the story, posted on the Internet, of Patrick, an Illinois man who was sent for an ultrasound when his doctor discovered high iron levels and an enlarged liver. The results showed a fatty infusion in his liver and the doctor advised Patrick, who only drank socially, to stop drinking, which he did. After months of abstaining, he was retested, but his liver still hadnít returned to normal.
When tests for hepatitis came back negative, his doctor insisted he was still drinking. Each year, he returned for a checkup, only to find his liver enzymes still elevated.
When Patrick asked if a genetic problem could be affecting his liver, the doctor laughed. The doctor continued to insist Patrick was lying about the amount he drank and urged him to get help for alcoholism.
Meanwhile, Patrick had read a story about a guy called 'Iron Man' who was diagnosed with hemochromatosis after setting off metal detectors at airports because of the high level of iron stored in his body. Patrick asked his doctor if he could have this and his doctor reluctantly agreed to send him to a specialist who took one look at his lab reports and said, 'You have hemochromatosis.'
It took eight years for his doctor to refer him to the specialist. Later, the specialist told Patrick how lucky he was that his doctor recognized his symptoms.
But even after Patrick was diagnosed, his regular doctor only sent him for a phlebotomy four times. Fortunately, Patrick sought the help of an experienced hematologist who explained that he would need at least 40 treatments.
With those treatments, his liver enzymes finally returned to normal.
One of many tales
It seems that behind every story of diagnosis, thereís a much longer story of the struggle for answers. And the story of Thomasí mother, Josephine Bogie Thomas, is no different.
In 1981, when her mom started feeling tired and began limping, her doctor told her she probably had osteoporosis, and that her aches and fatigue were common for a woman in her early 60s.
He suggested that she might one day need a hip replacement and ran some tests, which picked up on her elevated liver enzymes, a common indicator for hemochromatosis. But her doctor, never suspecting 'a rare disease that only affects men,' couldnít figure out why her liver enzymes were elevated, and Josephine Thomas spent the next few years bouncing from one doctor to the next seeking answers.
Then, in 1983, she was diagnosed with advanced ovarian cancer and her doctors ordered a CAT scan of her liver. According to Thomas, the radiologist noted in the accompanying report that her liver was dense with iron, but never mentioned it, perhaps because he didnít expect her to beat the cancer.
But after two surgeries and eight grueling months of chemotherapy, she did. Later Thomas, while sifting through her momís medical records, discovered the radiologistís note, investigated it and got the diagnosis that would explain her consistently elevated liver enzymes: hereditary hemochromatosis.
By this time, Josephine Thomasí body was loaded with iron and she had developed cirrhosis.
The 103 pints of blood she gave during regular phlebotomies returned her iron levels to normal and she lived 14 more years. But eventually the damaged cells in her liver turned malignant, and last May she died of advanced primary liver cancer.
But not before educating everyone within earshot about the disease. Even while in the hospital for tests and treatments, she distributed literature about the disease to nurses, doctors, medical students, visitors, janitors, anyone who would listen.
Thomas and her father were devastated when she died, but found comfort in knowing that there would be no more needles stuck in her abdomen, no more CAT scans, ultrasounds, biopsies or staring at a fax machine waiting for lab results. No more jaundice, nausea or looking like she was eight months pregnant, and no more helplessness, worry or pain.
'Her dying wish,' Sandra says, 'was that everyone would get tested for hereditary hemochromatosis/iron overload, so they wouldnít have to go through what she was going through.'
Warnings fall on deaf ears
Sandra Thomas continues to spread the word, but unfortunately, her warnings, like her motherís, sometimes fall on deaf ears.
Even the nurses who cared for her mother ó people who consistently see patients dying of liver cancer brought on by iron overload ó turned down her offers for free genetic testing.
Not that the test kit is complicated, time-consuming or particularly expensive. It costs about $125 and consists of two long swabs that you rub several times on the inside of each cheek. Afterward, the swabs are mailed to a lab. Within a week, the results are mailed to your doctor.
If it were up to Thomas, genetic testing would be done at birth. But not all of the organizations struggling to make people aware of hemochromatosis support genetic testing.
Crawford makes it clear on the Iron Overload Disease Associationís Web site that her group does not recommend DNA testing. While labs can test for gene mutations, not all the genes have been discovered yet, so the test could miss people who have iron overload, she says. And a negative result, could make it harder for people to convince their doctors that they may be suffering from the disease.
Crawford, author of The Iron Elephant, which has become a bible for many hemochromatosis patients, recently heard from an internist who referred a patient with hyptertension, cirrhosis and blood tests indicative of high iron storage levels to a San Francisco clinic for bloodletting. When a genetic test turned up negative, the internist told her, the clinic concluded it was not primary hemochromatosis and recommended against phlebotomy.
Crawford says this story is typical. At least once a week, she says, she gets a call from someone whose doctor refuses to treat dangerously high iron levels because of a negative DNA test result.
The way Thomas sees it, however, this is not so much an argument against genetic testing as it is an argument for finding a doctor who knows about iron overload, or is willing to learn.
Thomas was national director of public education for Crawfordís organization for 10 years, but in 1998 started her own organization, where she takes a more active role in promoting genetic testing.
And while sheíll be the first to admit that the genetic test should be done along with blood tests, she says getting a doctorís attention is often difficult.
A negative test may not necessarily mean that a person doesnít have iron overload, she says, but a positive result helps identify those at high risk for developing it. It also sounds a warning bell for family members who, in turn, get tested. And having that positive result, she says, makes it easier to persuade a doctor that they should get a blood test.
'If you say ĎWell, look at this result. I have the mutation,í 99 percent of the doctors are going to back down on that one,' she says.
The reality is that many people are too intimidated to confront their doctors. Without confirmation from the genetic test that theyíre at high risk, many wonít push their doctors to look further to find out conclusively that they have hemochromatosis.
'If you did a survey of practicing physicians, you would probably find that 95 percent of them still think itís a rare disease,' says Geoffrey Block, a liver and genetic disease specialist at the Hemochromatosis Center at University of Pittsburgh Medical Center, where Thomasí mother was treated.
And that misconception is costing people their lives.
The CDC, Block says, has done a number of studies on how long it takes people with the classic symptoms to be diagnosed.
'On average,' he says, 'it took seven years and 10 physicians. And this [study] was on people who were aggressive enough about their personal health care to not take ĎItís all in your headí as an answer.'
Meanwhile, Blockís clinic is full of the people who didnít get that answer soon enough. He is now treating 75 to 80 patients who have cirrhosis and another seven who have cancer, and all tested positive on the genetic screen.
And while he also has patients who have iron overload for other reasons, he says, he has no doubt that genetic testing early in life would help a huge number of people who have an 80 to 90 percent chance of developing iron overload.
As people continue to be diagnosed, doctors will be trained to recognize the disease, Block says. Eventually, there will be routine blood screening.
But it could take 10 to 15 years, he says, and in the interim people will die.
Fortunately, Block says, many will learn about this disease through grass-roots groups like American Hemochromatosis Society and Iron Overload Diseases Association, the two Palm Beach County organizations with decidedly different views on genetic testing.
'They may disagree and squabble about whatís important and whatís not,' Block says. 'But theyíre both part of trying to promote awareness, and to tell people that if you have a suspicion, you need to follow it up and pursue it.'
Med Klin (Munich). 2009 Dec 15;104(12):931-46. [Hereditary hemochromatosis]. [Article in German] Niederau C. Source Katholische Kliniken Oberhausen gGmbH, St Josef-Hospital, Klinik fŁr Innere Medizin, Akademisches Lehrkrankenhaus der Universitšt Duisburg-Essen, Duisburg-Essen. claus.niederau @st-josef.de
Abstract Genetic hemochromatosis is classified into four subtypes of which only type 1 is of clinical importance in Caucasians. Type 1 is due to an autosomal recessive inborn error of metabolism; the homozygous C282Y mutation of the HFE gene on chromosome 6 accounts for more than 90% of the clinical phenotype in populations of Celtic origin. The mutation leads to an inadequately high intestinal iron absorption which may finally cause iron overload in and damage to various organs. Type 2 is the juvenile form of iron overload which leads to a severe phenotype prior to age 30 with cardiomyopathy and hypogonadism. The corresponding mutations are located in the hemojuveline and hepcidin genes. Typ 3 has mainly been described in Italian families and refers to mutations in transferrin receptor 2 gene. Histopathologic and clinical consequences of type 3 hemochromatosis are similar to those seen in type 1. Types 2 and 3 are autosomal recessive traits. Type 4 hemochromatosis follows an autosomal dominant trait; the corresponding mutation affects the basolateral iron carrier ferroportin 1. Diagnosis of hemochromatosis is based on determinations of serum ferritin and transferrin saturation with the latter being more sensitive and specific. In case of a homozygous C282Y gene test, liver biopsy is not required for diagnosis. Liver biopsy is, however, recommended in C282Y homozygotes at ferritin values > 1,000 ng/ml because of an increased risk for liver fibrosis. Phlebotomy treatment is the standard care to remove iron in genetic hemochromatosis. Patients treated in the early noncirrhotic stage have a normal life expectancy. Thus, future efforts should aim at early diagnosis. Iron removal also improves the outcome in cirrhotic patients. Liver carcinoma may develop in cirrhotic patients despite iron depletion. Liver cancers without cirrhosis are so rare that screening is only recommended in cirrhotic patients.
PMID: 20039160 [PubMed - indexed for MEDLINE]
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