Hemoglobin C Disease: Overview, Clinical Presentation, Laboratory Studies (2025)

Hemoglobin C (Hb C) is a common structural hemoglobin variant. Persons with hemoglobin C trait (Hb AC) are phenotypically normal, with no clinically evident symptoms, while those with hemoglobin C disease (Hb CC) may have a mild degree of hemolytic anemiaand sequelae of hemolysis including jaundice, gallstones, or splenomegaly. Although the clinical complications of hemoglobin C disease are not severe, inheritance with other hemoglobinopathies such as hemoglobin S may have significant consequences. Given this, genetic counseling and anticipatory guidance play an important role in providing care for these patients.

Pathophysiology

Hemoglobin C (Hb C) is a structural variant of normal hemoglobin A (Hb A) caused by an amino acid substitution of lysine for glutamic acid at position six of the beta hemoglobin chain. Hb C is less soluble than Hb A in red cells, likely from electrostatic interactions between positively charged β6-lysyl groups and negatively charged groups on adjacent molecules. Crystal formation (classically, hexagonal-shaped crystals on peripheral blood smear) may result, which can lead to increased blood viscosity and cellular rigidity and shortened erythrocyte survival.

Unlike sickle cell disease (SCD), Hb C does not cause linear intracellular polymerization of red cells that encounter intravascular areas of low oxygen tension. ^[1] Thus, while there is evidence for reduced erythrocyte deformability associated with the Hb C variant (see below), vaso-occlusion does not occur. Both the heterozygous and homozygous states may induce erythrocyte dehydration (xerocytosis) and an elevated mean corpuscular hemoglobin concentration (MCHC) may be noted on a complete blood count.

A number of studies suggest that Hb C protects against malaria, providing a selective evolutionary advantage in regions where malaria is endemic. A large case-control study in Burkina Faso found a strong association between resistance to clinical malaria and presence of the Hb C variant in both the heterozygous and the homozygous state. ^[2] In a similar though somewhat contradictory manner, a separate study carried out in 4 rural villages of Burkina Faso foundno evidence of protection for Hb C in the heterozygous state (odds ratio [OR] for Hb AC vs Hb AA, 1.49, P = 0.31), but did find protection higher than even that observed with Hb S in the homozygous and double heterozygous states (odds ratio for Hb CC and Hb SC vs Hb AA, 0.04; P = 0.002). ^[3]

Smaller case-control and cross-sectional studies have reported no association between Hb C and reduced incidence of malaria parasitemia; however, one longitudinal study using family-based association analysis found a strong relationship between Hb C and protection against mild malaria, as well as a negative association between Hb C and parasitemia. ^{[2, 4, 5]}

In vitro studies have shown lower parasite multiplication rates in Hb CC than in Hb AA erythrocytesand it has been proposed that the inhibitory effect of Hb C on parasitemia may partially explain the protective effect against malaria. ^[5] Thus, it has been proposed that the Hb C variant has been evolutionarily selected for in regions across the globe where malaria is endemic, as is the case for the Hb S variant.

Epidemiology

Given the proposed survival advantage conferred by Hb C against malaria, it is not surprising that Hb C appears to have originated on the west coast of Africa. Hb C is found in diverse populations in Africa, southern Europe, and South and Central America, though its exact allelic distribution across these varied populations remains unclear.

In a global database of population surveys, Hb C was found to reach its highest predicted frequency in the western part of Burkina Faso, with an allele frequency of 24%. ^{[6, 7]} In the United States, 2-3% of African Americans are heterozygotes for Hb C, and approximately 1 in 5000 are homozygotes. ^[8] Hb C has also been identified in individuals with no known African ancestry. ^[9]

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Hemoglobin C trait (Hb AC) is clinically silent. Hemoglobin C disease (Hb CC) is a mild disorder that generally does not cause any symptoms and is associated with a normal life expectancy. ^[10] Affected individuals exhibit normal growth and development and typically tolerate surgery and pregnancy without issues. ^{[11, 12]}

Some patients may experience mild hemolytic anemia, though under stress conditions the hemolysis may become more pronounced and come to clinical attention. Affected patients may have splenomegaly.Case reports exist of spontaneous splenic rupture, but the overall splenic function is usually unaffected. ^[13] As with other diseases causing chronic hemolytic anemia, cholelithiasis from pigmented gallstones occurs with increased frequency (see gallstones).

Co-inheritance

Hemoglobin C is mainly of clinical significance when inherited in combination with Hb S (Hb SC disease) or when co-inherited with β-thalassemia (hemoglobin C–β thalassemia). Little data exist regarding patients with very rare genotypes (eg, hemoglobin C–hemoglobin E compound heterozygotes). However, these patients would be expected to have few clinically evident limitations or symptoms.

Hemoglobin SC Disease

The clinical manifestations of Hb SC disease are generally similar to but less severe than those of Hb SS disease. Growth and development are normal or slightly decreased, vaso-occlusive episodes do occur but less frequently, and the median lifespan in the United States for male and female Hb SC patients is 60 and 68 years, respectively. ^{[14, 15, 16, 17, 18, 19, 20]} Importantly, two specific complications may occur more frequently in Hb SC than in Hb SS: vascular retinopathy (see Hemoglobinopathy Retinopathy) and avascular necrosis of the femoral head.

The Hb SC genotype is a well-known risk factor for proliferative sickle cell retinopathy (PSCR). ^{[21, 22]} Stages of PSCR have been described by peripheral retinal ischemia, peripheral neovascularization, intravitreal hemorrhage, and tractional or mixed retinal detachment that can lead to vision loss. A longitudinal analysis showed that Hb SC patients were significantly more likely to develop severe (stage III-IV) PSCR than Hb SS patients. ^[23]

Avascular necrosis of the femoral head has also been reported with higher frequency in Hb SC than Hb SS. This phenomenon usually occurs during the final months of pregnancy in women with Hb SC and is attributed to fat emboli after bone marrow infarction. ^[24] A longitudinal study in patients with Hb SC reported advanced retinopathy in 22.9% and osteonecrosis in 14.8%, re-emphasizing the prominence of these complications in this population. ^[10]

Hemoglobin C–β thalassemia

Individuals may be compound heterozygotes for beta-thalassemia and hemoglobin C, which can result in mild to moderate chronic hemolytic anemia. These patients are more likely to be symptomatically anemic due to alpha chain/beta chain expression imbalance, though their clinical phenotype generally resembles those with beta-thalassemia trait.

Differential diagnosis

The differential diagnosis of hemoglobin C disease includes the following conditions:

• Hemolytic Anemia

• Sickle Cell Disease

• Beta Thalassemia

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Patients can usually be evaluated in an outpatient setting. Routine screening laboratory studies are not necessary for asymptomatic patients; those with a moderate to severe clinical course should be evaluated for other hemoglobinopathies or chronic conditions.

The most commonly used method for the detection of hemoglobinopathies is hemoglobin electrophoresis or high-performance liquid chromatography (HPLC). Cellulose acetate screening will distinguish between the normal hemoglobins HbA, HbF, and HbA2, as well as the common variants, Hb S and Hb C, by charge. In the United States, newborn screening is the most common method of detecting individuals with Hb C disease. For those not diagnosed at birth, hemoglobin variant analysis by HPLC can provide the diagnosis.

Hemoglobin analysis results are as follows:

• Patients who are homozygous for Hb C show mostly Hb C; Hb A is absent and Hb F is slightly increased compared with normal individuals.

• Patients who are heterozygous for Hb C may show 30-40% Hb C, 50-60% Hb A; Hb A2 is increased slightly.

• Patients who have hemoglobin C and beta-zero thalassemia show no hemoglobin A; to distinguish these patients from homozygous C patients, the best method is to test both parents, if possible.

• Patients who have Hb C and beta⁺ thalassemia show low but present levels of hemoglobin A.

Hemoglobin variants that have the same mobility as Hb C include Hb E and Hb O-Arab. If co-migration is suspected, usually a second electrophoretic procedure is performed on citrate agar (acid electrophoresis) which is capable of distinguishing the respective variants.

In pregnancy, if prenatal screening suggests an increased risk of hemoglobinopathy, hemoglobin analysis is indicated for the mother. If maternal hemoglobin analysis shows that the mother is either homozygous or a heterozygous carrier for Hb C, paternal evaluation may be indicated to assess the fetal risk of Hb SC disease. DNA-based testing for hemoglobin C can be performed during the first trimester of pregnancy from chorionic villus sampling at 10-12 weeks gestation or by amniocentesis after 15 weeks gestation.

HemeChip, aminiaturized paper-based microchip electrophoresis hemoglobintest, has a reported sensitivity of 100% and an accuracy of 98.4% for identifying hemoglobin variants. It has been proposed as a point-of-care option for screening newborns in low-resource settings. ^[25] However, the initial cost to acquire the machine and the continuous power supply needed to run the test may limit its usability. ^[26]

An alternative test that does not require instrumentation, electricity, or refrigeration, HemoTypeSC™ has also been studied for point-of-care screening in low-resource communities. This test is acompetitive lateral-flow immunoassay that uses monoclonal antibodies to detect hemoglobins A, S, and C in a 1.5-μL sample of whole blood. A global, multicenter evaluation reported an overall sensitivity of 99.5% and specificity of 99.9% across all hemoglobin phenotypes. ^[26]

Hemoglobin C Trait

Hemoglobin concentrations are usually within the normal range, but the erythrocyte mass and survival may both be decreased. ^[1] Despite decreased survival, the reticulocyte count will not typically be increased; this is thought to be secondary to the lower oxygen affinity of Hb C, which facilitates sufficient oxygen delivery to tissues despite a lowererythrocyte mass. Peripheral blood may show moderate amounts of target cells and intracellular crystals (5-30%). ^{[24, 27]}

Hemoglobin C Disease

Hemolytic anemia may be mild to moderate in severity. Markers of hemolysis include increased LDH, reticulocyte count, and direct bilirubin ^[1] . Despite the anemia, reticulocyte counts are only slightly elevated in homozygous individuals, due to the reduced oxygen affinity of this hemoglobin variant. Erythrocyte morphology is markedly abnormal, with prevalent microcytosis, target cells (>90%), spherocytes, and crystallized hemoglobin. ^{[28, 27, 29]}

The reticulocyte count in these patients may be normal despite the presence of chronic hemolytic anemia; this is proposed to be due to a reduced affinity of Hb C for oxygen. The lower affinity facilitates sufficient delivery of oxygen to tissues in the face of mild anemia.

The electrostatic interactions between the positively charged β-6 amino groups and the negatively charged groups on adjacent molecules lead to decreased solubility of deoxy-Hb C. This decreased solubility likely leads to shortened erythrocyte survival. In settings of hypertonicity or deoxygenation, Hb CC cells form intracellular crystals of hemoglobin that are classically hexagonal in shape. These crystals reduce the internal viscosity of the erythrocyte, leading to reduced deformability and a predisposition to fragmentation, spherocyte formation, and splenic sequestration. ^[29]

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Imaging studies

Dental radiographs may show infarction. If the patient has right upper quadrant pain, abdominal ultrasonography may show gallstones. Fluorescein angiography detects neovascularization present at the equatorial region of the eye, which may be missed with funduscopic examinations.

Histologic findings

In an oxygenized state, the hemoglobin C cell forms circulating intraerythrocytic crystals (tactoids) and has reduced solubility. In a deoxygenated state, virtually all hemoglobin C cells have crystalloid inclusions. Deoxygenation further reduces cell solubility and increases blood viscosity. Addition of 3% salt solution to a drop of blood will result in the appearance of the crystals, which are visible on a smear.

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As with any chronic hemolytic anemia, body stores of folic acid may be depleted rapidly from high red cell turnover, and therefore folic acid supplementation at a dosage of 1 mg/day orally is indicated. Long-term antibiotic prophylaxis is not indicated, as these patients have normal splenic function. No special diet is required and physical activities are not restricted.

Consultations that may be useful include:

• Geneticist

• Hematologist

• Ophthalmologist

Patients may benefit from genetic counseling, as it is important to discuss the possibility of co-inheritance with other hemoglobinopathies.

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Drew H Barnes, MD Fellow Physician, Hospice and Palliative Medicine, The Ohio State University Wexner Medical Center

Drew H Barnes, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Physicians, American Medical Association, American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Claudia M da Costa Dourado, MD Clinical Assistant Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Program Director, Hematology and Medical Oncology Fellowship Program, Attending Physician, Division of Hematology and Medical Oncology, Department of Medicine, Einstein Medical Center Philadelphia

Claudia M da Costa Dourado, MD is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald A Sacher, MD, FRCPC, DTM&H Professor Emeritus of Internal Medicine and Hematology/Oncology, Emeritus Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MD, FRCPC, DTM&H is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Bryan A Mitton, MD, PhD Clinical Instructor, Division of Pediatric Hematology-Oncology, Department of Pediatrics, Stanford University School of Medicine

Disclosure: Nothing to disclose.

Tabitha M Cooney, MD Pediatric Hematology/Oncology Fellow, Lucile Packard Children’s Hospital, Stanford University School of Medicine

Tabitha M Cooney, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group

Disclosure: Nothing to disclose.

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