Case No.

4: GLOCOSE 6 Phosphate Deficiency

JD, a 21 year old male, working as a tour guide, was admitted at Chong Hua Hospital because of
severe jaundice which was noted a day prior to admission. History revealed that when he knew that his
new assignment is in Palawan, he then took a prophylactic measure, an antimalarial, Primaquine, to
protect himself. The day after intake of Primaquine he noticed yellowish discoloration of the face
progressing down to the lower extremities. This prompted him to seek admission for proper
management.
Past history revealed a previous admission when he was 12 years old for the same complaint, when
he was given Sulfonamides for Urinary Tract Infection.
Laboratory examinations done revealed low hemoglobin and hematocrit, there was saturation of
haptoglobin, RBC’s showed Heinz bodies, (+) anisopoikilocytosis and (+) reticulocytosis.

1. State the diagnosis of the case and discuss its bases

 Diagnosis: Glucose 6-Phosphate Dehydrogenase Deficiency
 Is a hereditary condition in which red blood cells break down when the body is exposed to certain
drugs or the stress of infection

Sx: History: Laboratory Examination:

 Severe jaundice prior to
admission
 Yellowish discoloration of
the face progressing down
to the lower extremities
after taking antimalarial
drug (Primaquine)
 Similar jaundice condition
after taking antibiotic
(Sulfonamide) at 12 y.o.
 Low hgb and hematocrit
levels
 Saturation of haptoglobin
 RBCs show Heinz bodies
 (+) anisopoikilocytosis
 (+) reticulocytosis

2. List and discuss the 3 differential diagnosis

SIMILAR SX WITH THE G6PD HEREDITARY HEMOLYTIC GILBERT’S

CONDITIONS: DEFICIENCY SPHEROCYTOSIS ANEMIA SYNDROME
Oxidant drugs:
antimalarial drugs
(primaquine),
antibiotics
(sulfonamide)
Yellowish discoloration
of the face progressing
/ / /
down to the lower
extremities
Low hb level (<10%)
(normal: 5.5 - 20.5 / /
units/g)
Low hematocrit level / /
Saturation of
decreased
haptoglobin
 RBCs show Heinz
none /
bodies
(+) anisopoikilocytosis / /
(+) reticulocytosis / / Normal count

a. HEREDITARY SPHEROCYTOSIS
- Disorder of RBC membrane. It causes your red blood cells to be shaped like spheres instead of
flattened discs that curve inward. The spherical cells are less flexible than normal red blood cells.

b. HEMOLYTIC ANEMIA
- blood disorder that occurs when RBCs are destroyed faster than they can be replaced

c. GILBERT’S SYNDROME
- relatively mild condition characterized by periods of elevated levels of a toxic substance called
bilirubin in the blood (hyperbilirubinemia). Bilirubin is produced by the breakdown of red blood cells.
Primary symptom is jaundice.

3. Discuss the molecular genetics of G6PD deficiency. Discuss the epidemiology of G6PD deficiency.
 G6PD deficiency is caused by an alteration (mutation) in the G6PD gene. The genetic defect that
causes G6PD deficiency has been identified mostly as single base missense mutation The G6PD gene
is located on the long arm (q) of the X chromosome (Xq28), which contains instructions for encoding
an enzyme glucose-6-phosphate dehydrogenase (catalyzes the coenzyme NADPH, which protects
cells from oxidative damage). A mutation in the G6PD gene results in low levels of functional
glucose-6-phosphate dehydrogenase, which in turn leads to low levels of NADPH and a depletion of
an antioxidant known as glutathione, necessary to protect the cell’s hemoglobin and its cell
membrane from highly reactive oxygen radicals. This reduction in NADPH makes red blood cells
more susceptible to destruction from oxidative stress than other cells, resulting in their premature
breakdown when in the presence of triggering factors.
 G6PD deficiency is the most common human enzymopathy and affects >400 million individuals
worldwide and has the highest prevalence in persons of African, Asian, and Mediterranean descent.
It is inherited as an X-linked recessive disorder, and thus most often affects males. The severe form
of the disorders occurs more often in the Mediterranean population. Several studies have indicated
that G6PD deficiency is malaria protective which is linked to the inability of malaria to grow
efficiently in G6PD-deficient cells.

4. Describe the biochemical defect among patients with G6PD deficiency & discuss the Pentose
Phosphate Pathway in relation to G6PD deficiency.
 Diminished G6PD activity impairs the ability of the cell to form the NADPH that is essential for
the maintenance of the G-SH pool. This results in a decrease in the detoxification of free radicals
and peroxides formed within the cell. G-SH also helps maintain the reduced states of sulfhydryl
groups in proteins, including hemoglobin. Oxidation of those sulfhydryl groups leads to the
formation of denatured proteins that form insoluble masses (called Heinz bodies) that attach to
RBC membranes. Although G6PD deficiency occurs in all cells of the affected individual, it is
most severe in RBC, where the pentose phosphate pathway provides the only means of
generating NADPH.
  G6PD is the key enzyme in the oxidative pentose phosphate pathway. The first step of the
pentose phosphate is catalyzed by G6PD. In this step, NADP+ is reduced to NADPH, and ribulose
– 5- phosphate, a precursor of DNA, RNA, and ATP, emerge from G6P. The most important
reducing agent in the cytoplasm of cells is NADPH. The second enzymatic step in this pathway is
NADPH production as a consequence of reactions that reduce oxidized glutathione. The only
defense oxidant stress in the RBC is GDH production. In unstressed, normal erythrocytes, the
G6PD activity is only about 2% of total capacity. The pentose phosphate pathway’s main
function is the generation of reducing capacity through the production of NADPH and ultimately,
GSH. This is essential for cell survival and is available in the erythrocyte for generating reducing
capacity.

5. Describe how diagnosis of G6PD deficiency is established.

a. Complete Blood Count
- active G6PD shows the presence of Heinz bodies (protein aggregates) within red blood cells.
b. Liver Function Test
- determine other causes of liver damage and jaundice - serum albumin, blood bilirubin,
prothrombin time, blood liver enzymes (alanine amino transferase (ALT), aspartate
aminotransferase (AST), gamma glutanyl transferase (ggt), alkaline phosphate (ALP).
c. Other Lab Test
- Coomb’s test, checks for the presence of direct antiglobulin, result should be ideally negative
as RBC breakdown is not an autoimmune condition.
- Beutler Fluorescent Spot test, result are reduced in RBC breakdown (hemolysis).

6. List and describe the classes of G6PD enzyme variants in the order of their severity.

Class I Severe enzyme deficiency, chronic nonspherocytic hemolysis

Class II Severe enzyme deficiency (1-10% residual activity), intermittent acute
Class III Moderate enzyme deficiency (10-60% residual activity), intermittent
Class IV No enzyme deficiency (60-150% activity)
Class V Increased enzyme activity (>150%)

7. Discuss the pathophysiology of G6PD deficiency. To include the following:

a. State and discuss factors that can trigger hemolysis of RBC among patients with G6PD
deficiency.
 Most individuals who have inherited one of the many G6PD mutations are asymptomatic.
However, some patients with G6PD deficiency develop haemolytic anemia if they are
treated with an oxidant drug, ingest fava beans, or contract a severe infection.

1. Oxidant drugs: Commonly used drugs that produce hemolytic anemia in patients with
G6PD deficiency are best remembered from the mnemonic AAA—Antibiotics
(sulfamethoxazole and chloramphenicol), Antimalarials (primaquine but not quinine),
and Antipyretics (acetanilide but not acetaminophen).
 2. Favism: Some forms of G6PD deficiency, for example the Mediterranean variant, are
particularly susceptible to the hemolytic effect of the fava (broad) bean, a dietary staple
in the Mediterranean region. Favism, the hemolytic effect of ingesting fava beans, is not
observed in all individuals with G6PD deficiency, but all patients with favism have G6PD
deficiency.

3. Infection: Most common precipitating factor of hemolysis in G6PD deficiency. The

inflammatory response to infection results in the generation of free radicals in
macrophages, which can diffuse into the red blood cells and cause oxidative damage.

b. Describe the manifestations of RBC hemolysis in G6PD deficiency.

 Diminished G6PD activity impairs the ability of the cell to form the NADPH that is essential
for the maintenance of the reduced glutathione pool. This results in:
1. a decrease in the cellular detoxification of free radicals and peroxides formed within the
cell.
2. Glutathione also helps maintain the reduced states of sulfhydryl groups in proteins,
including hemoglobin. Oxidation of those sulfhydryl groups leads to the formation of
denatured proteins that form insoluble masses (called Heinz bodies) that attach to the
red cell membranes.
3. Additional oxidation of membrane proteins causes the red cells to be rigid (less
deformable), and they are removed from the circulation by macrophages in the spleen
and liver. Although G6PD deficiency occurs in all cells of the affected individual, it is
most severe in erythrocytes, where the pentose phosphate pathway provides the only
means of generating NADPH. Other tissues have alternative sources for NADPH
production (such as NADP+-dependent malate dehydrogenases) that can keep
glutathione reduced.
4. The erythrocyte has no nucleus or ribosomes and cannot renew its supply of the
enzyme. Thus, red blood cells are particularly vulnerable to enzyme variants with
diminished stability.

8. Discuss the management and prognosis.

 Most affected individuals do not require treatment and is often best managed by preventative
measures. In individuals who are G6PD-deficient, exposure from fava beans should be avoided to
prevent hemolytic anemia. If an episode of hemolytic anemia is due to the use of a certain
medication, the causative drug should be discontinued under a physician’s supervision. If such an
episode is due to an underlying infection, steps should be taken to treat the infection.
 Some adults may need short-term treatment with fluids to prevent hemodynamic shock or in severe
cases where the rate of hemolysis is very rapid, blood transfusions are more likely to be indicated.
 Neonatal jaundice is treated by placing the infant under special lights that alleviate the jaundice. In
more severe cases, an exchange transfusion may be necessary. Genetic counseling may be of benefit
for patients and their families.
 The life span of individuals with a severe form of G6PD deficiency may be somewhat shortened as a
result of complications arising from chronic hemolysis. This negative effect of G6PD deficiency has
been balanced by an increased resistance to Plasmodium falciparum malaria. Most acute episodes
of hemolytic anemia are self-limited, and only the most severe cases require a transfusion or an
exchange transfusion.