SALVADOR Patricia P.

To

discuss the different genetic aberrations leading to G6PD deficiency To discuss the relationship of Malaria resistance with having G6PD deficiency

I.
II. III. IV.

Brief History Mutations involving G6PD deficiency Clinical and Laboratory findings G6PD resistance in relation to having Malaria

 Pythagoras

danger of eating FAVA

BEANS
Hemolytic

effect of anti- malarial drug

PRIMAQUINE

Sensitive individuals had low levels of G6PD activity in their RBC

 G6PD

deficiency one of the most common inherited disorders. and in vitro studies advantageous during Plasmodium falciparum infection individuals are asymptomatic

Epidemiological

Affected

Possess risk of acute hemolysis

Glucose 6-phosphte dehydrogenase (G6PD)

Mutations in gene for G6PD

Enzyme Activity

Production of NADPH

Reduced Glutathione

Reactive Oxygen Intermediates

Damage to RBC

Hemolysis

Hemolytic Anemia

located on the long (q) arm of the X chromosome at position 28 Hemophilia A, color vision Fragile X and dyskeratosis congenita

 X-linked

recessive

Male

Normal Hemizygote (XY) Deficient Hemizygote

(XaY) with variant gene Affected

 Female

Normal Homozygote (XX) Carrier Heterozygote(XaX)

Female carriers can also be affected by the disease if: Two copies of the gene in the genome is defective

Five

(5) classes by World Health Organization (WHO)

Residual

enzyme activity Severity of hemolysis

 Severe

clinical symptoms Chronic hereditary non-sperocytic hemolytic anemia Has < 20% G6PD activity Hemolysis in the absence of stressor

 Mild

clinical expression with intermittent hemolysis Most common <10% G6PD activity Stress is present

 Mild

clinical expression with intermittent hemolysis Associated with infections or drugs With 10% - 60% G6PD activity

 Not

deficient at all 100% G6PD activity Has no clinical manifestation

 Greater

than 100% activity Has increased activity than normal

located

on the long (q) arm of the X chromosome at position 28 Generally in males Females can also be affected provided both X gene is variant

Classes Class I

Enzyme deficiency Severe (less than 10% of normal activity)

Hemolysis Chronic hemolytic anemia even in the absence of stress

Important details Results in hereditary nonspherocytic hemolytic anemia

Class II

Severe (1-10% of normal activity)

Stress required for hemolysis to be precipitated

Class III

Moderate (10-60% Intermittent of normal activity) hemolysis asssociated with infection or drugs No enzyme deficiency (60150%) N/A Great interest as genetic markers

Class IV

Class V

No enzyme deficiency (>150%)

N/A

No clinical significance

Asymptomatic
Triggered by:
bacterial and viral infections painkillers and feverreducing drugs antibiotics (especially those that have "sulf" in their names) antimalarial drugs (especially those that have "quine" in their names)

Symptomatic
Hemolytic anemia
paleness extreme tiredness rapid heartbeat rapid breathing or shortness of breath jaundice, or yellowing of the skin and eyes, particularly in newborns an enlarged spleen dark, tea-colored urine

Complete blood count

Hematocrit Hemoglobin RBC count

Reticulocyte count
Heinz bodies in PBS

Lactate dehydrogenase Haptoglobin Indirect bilirubin Urinalysis Hemogloburia

Beutler fluorescent spot test

Inexpensive test Identifies NADPH produced by G6PD under UV light

Beutler fluorescent spot test

Principle: Reduction of oxidized pyridine nucleotide (NADP NADPH)

(+) : Blood spot do NOT fluoresce False (+): Active hemolysis Performed several weeks after hemolytic episode

Ascorbate Cyanide test Specimen: EDTA or Heparin Test the ability of normal cells to detoxify H202 when incubated with ascorbate. Cyanide: catalase inhibitor Specifically measures the Glutathione peroxidase system (+): brown color ( - ): color unchanged

Plasmodium falciparum Blood conditions that may affect malaria ineffectivity

Sickle cell anemia PABA deficiency Duffy factor

Glucose-6-Phosphate

dehydrogenase deficiency

Malaria is transmitted to humans by infected mosquitoes where it incubates in the liver.

The malaria parasites are then released into the blood stream where they infect red blood cells.

The parasites then grow and replicate in the red blood cell for 10 to 14 days until the RBC bursts.

Several poisons are released into the blood stream which causes the high fever, chills and sweats.

Plasmodium oxidizes RBC NADPH from the Pentose Phosphate pathway for its metabollism

Deficiency of RBC reduced gluthathione (GSH)

Infected RBC dies before the parasite is ready, the malarial parasite dies

High susceptibility to oxidative stress

 Plasmodium

oxidizes RBC NADPH from the Pentose Phosphate pathway for its metabollism
deffient individual may have resistance to malaria due to impaired growth the of parasite

G6PD

Case 1
JR, 26 y/o, black male
1 week before admission -signs of respiratory infection and a low-grade fever -self-medication of OTC cold preparation failed to alleviate his symptoms 1 day before admission -chills and hacking cough -at 40.6 C his mother brought him to the ER -acutely ill, dyspneic and coughing -was admitted to the hospital

 Physical Exam
-slight icterus -bronchial breathing over the left lower lung field with scattered rales; moderate degree of dyspnea -Temp - 40 C -Pulse - 120 bpm

 Lab Finding -Hemoglobin - 8.4 g/dl -WBC - 18,000/l with 80% polymorphonuclear leukocytes -Bilirubin - 3.2 mg/dL -Reticulocyte - 1.2%. -Gram positive diplococci in the sputum Penicillin therapy

 Next day -considerable improvement -cultures confirmed the presence of pneumococci in both sputum and blood -maximum temperature was 38.2 C -his dyspnea is less pronounced. Next few days -fever abated completely -hemoglobin however, fell to 7.2 g/dL -reticulocyte count rose rapidly so that 7 days after admission, it had reached 12% (normal, <1%)

 One month after the episode of pneumococcus pneumonia -hemoglobin was nearly normal at 13.8g/dL -patient fell quite well -was warned to never again to take aspirin -was supplied a long list of unfamiliar drugs and advised him never to take any of them *Observed intermittently over the next several years, the patient experienced no further hemolytic episode

CASE 1
CLASS III

PREVALENCE Found in 11% of black men

STRESS Infection Oxidizing drugs

OXIDATIVE BURST Phagocytes releases oxidants

 Case 2
Patient D.M. 1 day old -bilirubin was 14mg/dL -treated with ultraviolet light 2 day old -bilirubin climbed to 17 mg/dL -Preparations for exchange transfusion were but abandoned when it fell to 13 g/dL -reticulocyte count at 5 to 10%

made

 Family History -older brother - anemia and darkening of urine: 1. during a respiratory infection 2. when a urinary tract infection was treated with a sulfonamide of unknown type -parents - both well -maternal uncle - had intermittent jaundice & anemia

-The child developed normally -steady-state hemoglobin of 10.5 g/dL -reticulocyte of 10% At 6 years old -dark urine in the course of a respiratory infection -hemoglobin declined to 5.4g/dL -transfusion of 1 U of packed red cells -subsequently, hemoglobin rose to the usual level

 Following year
-diagnosis of hereditary spherocytosis -splenectomy was performed -no change in the steady-state hemoglobin level -nucleated red cells and red cells with Howell-Jolly bodies

-platelet count elevated to 700 x 109/L

 At 14 years old -anemia was re-evaluated -red cells were profoundly deficient in G6PD activity -has continued to get along quite well clinically -mildly jaundiced at times -during infections: -hemolytic episode -fall in hemoglobin concentration -darkening of the urine -has been cautioned to seek medical attention promptly -has dealt well with infections up to now

CASE 2
CLASS I

Severe G6PD Deficiency

Hemolysis occur even in Pathologic jaundice the absence of stress

Hereditary spherocytosis

Splenectomy

Splenomegaly

Drugs precipitating hemolytic anemia

Antimalarials
Primaquine Dapsone/Chloroproguanil Chloroquine Quinine

Sulphonamides/Sulphones
Sulphametoxazole Sulfasalazine Sulfisoxazole Sulfadimidine Sulfadiazine Dapsone Others

Drugs precipitating hemolytic anemia

Antibacterial/Antibiotics
Cotrimoxazole Ciprofloxacin Chloramphenicol Nalidixic acid Norfloxacin p-Aminosalicylic acid Nitrofurantoin Niridazole

Antipyretic/analgesics
Acetanilide Acetylsalicylic acid high dose (>3 g/d) Acetylsalicylic acid (<3 g/d) Phenazopyridine (Pyridium) Acetaminophen Phenacetin