Chair’s Rounds:
G6PD
Elliot Stieglitz
1/23/13
Peds H/O Fellow
Sunday, September 29, 13
Outline
Sunday, September 29, 13
Outline
• G6PD Background
Sunday, September 29, 13
Outline
• G6PD Background
• Hemolysis
Sunday, September 29, 13
Outline
• G6PD Background
• Hemolysis
• Clinical manifestations
Sunday, September 29, 13
Outline
• G6PD Background
• Hemolysis
• Clinical manifestations
• Diagnosis andTreatment
Sunday, September 29, 13
Outline
• G6PD Background
• Hemolysis
• Clinical manifestations
• Diagnosis andTreatment
• Follow up of our patient
Sunday...
Outline
• G6PD Background
• Hemolysis
• Clinical manifestations
• Diagnosis andTreatment
• Follow up of our patient
Sunday...
Outline
• G6PD Background
• Hemolysis
• Clinical manifestations
• Diagnosis andTreatment
• Follow up of our patient
Sunday...
Outline
• G6PD Background
• Hemolysis
• Clinical manifestations
• Diagnosis andTreatment
• Follow up of our patient
Sunday...
Background
Sunday, September 29, 13
Background
Sunday, September 29, 13
Background
Sunday, September 29, 13
Background
• Function of G6PD is to protect red cells from oxidative damage
Sunday, September 29, 13
Background
• Function of G6PD is to protect red cells from oxidative damage
• Most common enzymopathy affecting red blood ...
Background
• Function of G6PD is to protect red cells from oxidative damage
• Most common enzymopathy affecting red blood ...
Background
• Function of G6PD is to protect red cells from oxidative damage
• Most common enzymopathy affecting red blood ...
Background
• Function of G6PD is to protect red cells from oxidative damage
• Most common enzymopathy affecting red blood ...
Background
Sunday, September 29, 13
Background
J. Mol. Biol. (1970) 52, 483490
Amino AcidjSubstitution (Histidine to Tyrosine) in a
Glucose+Phosphate Dehydrog...
Background
J. Mol. Biol. (1970) 52, 483490
Amino AcidjSubstitution (Histidine to Tyrosine) in a
Glucose+Phosphate Dehydrog...
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
• 50% reduction in severe malaria in African children
Sunday, September 29, 13
Epidemiology and Malaria
• 50% reduction in severe malaria in African children
• In female heterozygotes there are more ma...
Epidemiology and Malaria
• 50% reduction in severe malaria in African children
• In female heterozygotes there are more ma...
Epidemiology and Malaria
• 50% reduction in severe malaria in African children
• In female heterozygotes there are more ma...
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
X-Linked G6PD Deficiency Protects
Hemizygous Males but Not Heterozygous
Females against Severe Ma...
Epidemiology and Malaria
X-Linked G6PD Deficiency Protects
Hemizygous Males but Not Heterozygous
Females against Severe Ma...
Epidemiology and Malaria
X-Linked G6PD Deficiency Protects
Hemizygous Males but Not Heterozygous
Females against Severe Ma...
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Epidemiology and Malaria
Sunday, September 29, 13
Hemolysis
Sunday, September 29, 13
Hemolysis
John Lazarchick, ASH Image Bank 2011; 2011-4027
Blister cell - 1.
Sunday, September 29, 13
Hemolysis
Sunday, September 29, 13
Hemolysis
John Lazarchick, ASH Image Bank 2011; 2011-3820
Bite cell - 1.
Sunday, September 29, 13
Hemolysis
Sunday, September 29, 13
Copyright © 2011 American Society of Hematology. Copyright restrictions may apply.
Peter Maslak, ASH Image Bank 2011; 2011...
Hemolysis
Sunday, September 29, 13
Hemolysis
Sunday, September 29, 13
Hemolysis
http://www.fracp.bigpondhosting.com/examquestions/2003/2003papertwo31to40.htm
Sunday, September 29, 13
Hemolysis
Sunday, September 29, 13
Hemolysis
Sunday, September 29, 13
Clinical Manifestations
Sunday, September 29, 13
• Neonatal Jaundice
Clinical Manifestations
Sunday, September 29, 13
• Neonatal Jaundice
• Acute vs Chronic hemolysis
Clinical Manifestations
Sunday, September 29, 13
• Neonatal Jaundice
• Acute vs Chronic hemolysis
• Infection, oxidant drugs, chemical agents, fava beans
Clinical Manifest...
• Neonatal Jaundice
• Acute vs Chronic hemolysis
• Infection, oxidant drugs, chemical agents, fava beans
• Keep in mind ot...
• Neonatal Jaundice
• Acute vs Chronic hemolysis
• Infection, oxidant drugs, chemical agents, fava beans
• Keep in mind ot...
Clinical Manifestations
Sunday, September 29, 13
Clinical Manifestations
1982 59: 428-434
FJ Zuazu
JL Vives Corrons, E Feliu, MA Pujades, F Cardellach, C Rozman, A Carrera...
Clinical Manifestations
1982 59: 428-434
FJ Zuazu
JL Vives Corrons, E Feliu, MA Pujades, F Cardellach, C Rozman, A Carrera...
Clinical Manifestations
1982 59: 428-434
FJ Zuazu
JL Vives Corrons, E Feliu, MA Pujades, F Cardellach, C Rozman, A Carrera...
Dx and Rx
Sunday, September 29, 13
Dx and Rx
• Dx
Sunday, September 29, 13
Dx and Rx
• Dx
• Signs and symptoms of hemolysis
Sunday, September 29, 13
Dx and Rx
• Dx
• Signs and symptoms of hemolysis
• G6PD assay
Sunday, September 29, 13
Dx and Rx
• Dx
• Signs and symptoms of hemolysis
• G6PD assay
• Heinz body preparation
Sunday, September 29, 13
Dx and Rx
• Dx
• Signs and symptoms of hemolysis
• G6PD assay
• Heinz body preparation
• Rx
Sunday, September 29, 13
Dx and Rx
• Dx
• Signs and symptoms of hemolysis
• G6PD assay
• Heinz body preparation
• Rx
• Supportive care
Sunday, Sept...
Dx and Rx
• Dx
• Signs and symptoms of hemolysis
• G6PD assay
• Heinz body preparation
• Rx
• Supportive care
• Transfusio...
Dx and Rx
• Dx
• Signs and symptoms of hemolysis
• G6PD assay
• Heinz body preparation
• Rx
• Supportive care
• Transfusio...
Dx and Rx
Sunday, September 29, 13
Dx and RxDRUGS TO AVOID IN G6PD DEFICIENCY
DEFINITE RISK OF HAEMOLYSIS POSSIBLE RISK OF HAEMOLYSIS
Pharmacological
Class
D...
Dx and Rx
Sunday, September 29, 13
Dx and Rx
Sunday, September 29, 13
Dx and Rx
Sunday, September 29, 13
Follow up visit
Sunday, September 29, 13
Follow up visit
Sunday, September 29, 13
Follow up visit
Sunday, September 29, 13
Follow up visit
Sunday, September 29, 13
Follow up visit
Sunday, September 29, 13
Follow up visit
Sunday, September 29, 13
Take Home Points
Sunday, September 29, 13
Take Home Points
• G6PD is relatively common in certain populations
Sunday, September 29, 13
Take Home Points
• G6PD is relatively common in certain populations
• There are different categories of severity
Sunday, S...
Take Home Points
• G6PD is relatively common in certain populations
• There are different categories of severity
• Possibl...
Take Home Points
• G6PD is relatively common in certain populations
• There are different categories of severity
• Possibl...
Take Home Points
• G6PD is relatively common in certain populations
• There are different categories of severity
• Possibl...
References
• Arese P, De Flora A. Pathophysiology of hemolysis in glucose-6-phosphate dehydrogenase deficiency. Semin
Hema...
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Glucose 6 Phosphate Dehydrogenase Deficiency G6PD

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Case presentation followed by discussion of the disorder.

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Glucose 6 Phosphate Dehydrogenase Deficiency G6PD

  1. 1. Chair’s Rounds: G6PD Elliot Stieglitz 1/23/13 Peds H/O Fellow Sunday, September 29, 13
  2. 2. Outline Sunday, September 29, 13
  3. 3. Outline • G6PD Background Sunday, September 29, 13
  4. 4. Outline • G6PD Background • Hemolysis Sunday, September 29, 13
  5. 5. Outline • G6PD Background • Hemolysis • Clinical manifestations Sunday, September 29, 13
  6. 6. Outline • G6PD Background • Hemolysis • Clinical manifestations • Diagnosis andTreatment Sunday, September 29, 13
  7. 7. Outline • G6PD Background • Hemolysis • Clinical manifestations • Diagnosis andTreatment • Follow up of our patient Sunday, September 29, 13
  8. 8. Outline • G6PD Background • Hemolysis • Clinical manifestations • Diagnosis andTreatment • Follow up of our patient Sunday, September 29, 13
  9. 9. Outline • G6PD Background • Hemolysis • Clinical manifestations • Diagnosis andTreatment • Follow up of our patient Sunday, September 29, 13
  10. 10. Outline • G6PD Background • Hemolysis • Clinical manifestations • Diagnosis andTreatment • Follow up of our patient Sunday, September 29, 13
  11. 11. Background Sunday, September 29, 13
  12. 12. Background Sunday, September 29, 13
  13. 13. Background Sunday, September 29, 13
  14. 14. Background • Function of G6PD is to protect red cells from oxidative damage Sunday, September 29, 13
  15. 15. Background • Function of G6PD is to protect red cells from oxidative damage • Most common enzymopathy affecting red blood cells (200-400 million people worldwide) Sunday, September 29, 13
  16. 16. Background • Function of G6PD is to protect red cells from oxidative damage • Most common enzymopathy affecting red blood cells (200-400 million people worldwide) • Classification schema: Sunday, September 29, 13
  17. 17. Background • Function of G6PD is to protect red cells from oxidative damage • Most common enzymopathy affecting red blood cells (200-400 million people worldwide) • Classification schema: • Clinical class Sunday, September 29, 13
  18. 18. Background • Function of G6PD is to protect red cells from oxidative damage • Most common enzymopathy affecting red blood cells (200-400 million people worldwide) • Classification schema: • Clinical class • Enzyme variants Sunday, September 29, 13
  19. 19. Background Sunday, September 29, 13
  20. 20. Background J. Mol. Biol. (1970) 52, 483490 Amino AcidjSubstitution (Histidine to Tyrosine) in a Glucose+Phosphate Dehydrogenase Variant (G6PD Hektoen) Associated with Over-production AKIRA YOSHIDA Division of Medical Genetics, Department of Medicine University of Washington, Seattle, Wash. 98105, U.X.A. (Received 21 November 1969, and in revised form 3 April 1970) The structural difference between the normal human glucose-6-phosphate dehydrogensse and the Hektoen variant associated with fourfold increased enzyme concentration was elucidated by peptide mapping of their tryptic and chymo- tryptic peptides. A single ammo acid substitution, from histidine in the normal enzyme to tyrosine in the variant enzyme, was found. These furdings indicate that a single-step base change in a structural gene resulting in an amino acid substitution may also increase production of the variant protein. 1. Introduction Genetic alterations of human glucose-6-phosphate dehydrogenase (n-glucose-6- phosphate: NADP oxidoreductase, EC 1.1.1.49) are the most prevalent and hetero- geneous of the known mammalian enzyme abnormalities. More than 50 types of GGPD,? which are distinguishable by electrophoretic mobility, or by enzymic character- istics, or by both methods, have been reported (Motulsky & Yoshida, 1969;Beutler, 1969). The genetic determinant of GGPD is located on the X-chromosome in man (Kirkman t Hendrickson, 1963). Therefore, males (XY) are always hemizygotes and females (XX) are homozygotes or heterozygotes. Genetic and biochemical evidence indicates that the GGPD gene in man is not duplicated (Yoshida, 1968a). Since no autosomally-controlled structural mutations have been discovered, it can be inferred that all GGPD variants are alleles at this single X-linked locus. Among them, so far only one variant is associated with markedly increased enzyme activity of red cells and leukocytes. This variant, designated as GGPD Hektoen, at first could not be distinguished from the normal enzyme, by kinetic properties or by electrophoretic mobility on starch gel, and was assumed to be structurally identical to the normal enzyme (Dern, 1966). Consequently, the increase in enzyme activity in tissues was attributed to a possible regulatory mutation. Later studies in this laboratory revealed that G6PD Hektoen could be distinguished from the normal enzyme by starch gel electrophoresis under certain conditions and that its enzymic properties were slightly different from those of normal G6PD (Yoshida, 1968b; Dern, McCurdy & Yoshida, Sunday, September 29, 13
  21. 21. Background J. Mol. Biol. (1970) 52, 483490 Amino AcidjSubstitution (Histidine to Tyrosine) in a Glucose+Phosphate Dehydrogenase Variant (G6PD Hektoen) Associated with Over-production AKIRA YOSHIDA Division of Medical Genetics, Department of Medicine University of Washington, Seattle, Wash. 98105, U.X.A. (Received 21 November 1969, and in revised form 3 April 1970) The structural difference between the normal human glucose-6-phosphate dehydrogensse and the Hektoen variant associated with fourfold increased enzyme concentration was elucidated by peptide mapping of their tryptic and chymo- tryptic peptides. A single ammo acid substitution, from histidine in the normal enzyme to tyrosine in the variant enzyme, was found. These furdings indicate that a single-step base change in a structural gene resulting in an amino acid substitution may also increase production of the variant protein. 1. Introduction Genetic alterations of human glucose-6-phosphate dehydrogenase (n-glucose-6- phosphate: NADP oxidoreductase, EC 1.1.1.49) are the most prevalent and hetero- geneous of the known mammalian enzyme abnormalities. More than 50 types of GGPD,? which are distinguishable by electrophoretic mobility, or by enzymic character- istics, or by both methods, have been reported (Motulsky & Yoshida, 1969;Beutler, 1969). The genetic determinant of GGPD is located on the X-chromosome in man (Kirkman t Hendrickson, 1963). Therefore, males (XY) are always hemizygotes and females (XX) are homozygotes or heterozygotes. Genetic and biochemical evidence indicates that the GGPD gene in man is not duplicated (Yoshida, 1968a). Since no autosomally-controlled structural mutations have been discovered, it can be inferred that all GGPD variants are alleles at this single X-linked locus. Among them, so far only one variant is associated with markedly increased enzyme activity of red cells and leukocytes. This variant, designated as GGPD Hektoen, at first could not be distinguished from the normal enzyme, by kinetic properties or by electrophoretic mobility on starch gel, and was assumed to be structurally identical to the normal enzyme (Dern, 1966). Consequently, the increase in enzyme activity in tissues was attributed to a possible regulatory mutation. Later studies in this laboratory revealed that G6PD Hektoen could be distinguished from the normal enzyme by starch gel electrophoresis under certain conditions and that its enzymic properties were slightly different from those of normal G6PD (Yoshida, 1968b; Dern, McCurdy & Yoshida, enaso in the centrifuge at 50,740 rev./min 32 min after reaching final speed at 2OY ion of the protein was about 0.3% in 0.05 nr-acetate buffw (pH 6.0) contnininq 1 mn~-8.mercaptoethanol, and 0.02 mwNADP. (4 (b) E II. Starch gel electrophoretic patterns of GBPD. Gel buffer was 5 mnr-phosphate. ctrode buffer was 0.05 >r-phosphate, pH 6.5. Elcctrophoresis at 6 v/cm for 6 hr at 4Sunday, September 29, 13
  22. 22. Epidemiology and Malaria Sunday, September 29, 13
  23. 23. Epidemiology and Malaria Sunday, September 29, 13
  24. 24. Epidemiology and Malaria Sunday, September 29, 13
  25. 25. Epidemiology and Malaria • 50% reduction in severe malaria in African children Sunday, September 29, 13
  26. 26. Epidemiology and Malaria • 50% reduction in severe malaria in African children • In female heterozygotes there are more malarial parasites in G6PD replete cells compared to deficient Sunday, September 29, 13
  27. 27. Epidemiology and Malaria • 50% reduction in severe malaria in African children • In female heterozygotes there are more malarial parasites in G6PD replete cells compared to deficient • Invasion appears to be similar but growth is retarded in G6PD cells Sunday, September 29, 13
  28. 28. Epidemiology and Malaria • 50% reduction in severe malaria in African children • In female heterozygotes there are more malarial parasites in G6PD replete cells compared to deficient • Invasion appears to be similar but growth is retarded in G6PD cells • Possible mechanism is oxidant stress leading to cell death or membrane damage leading to phagocytosis Sunday, September 29, 13
  29. 29. Epidemiology and Malaria Sunday, September 29, 13
  30. 30. Epidemiology and Malaria Sunday, September 29, 13
  31. 31. Epidemiology and Malaria Sunday, September 29, 13
  32. 32. Epidemiology and Malaria Sunday, September 29, 13
  33. 33. Epidemiology and Malaria Sunday, September 29, 13
  34. 34. Epidemiology and Malaria Sunday, September 29, 13
  35. 35. Epidemiology and Malaria X-Linked G6PD Deficiency Protects Hemizygous Males but Not Heterozygous Females against Severe Malaria Aldiouma Guindo1,2[ , Rick M. Fairhurst2[ , Ogobara K. Doumbo1 , Thomas E. Wellems2* , Dapa A. Diallo1 1 Malaria Research and Training Center, Faculty of Medicine, Pharmacy, and Odontostomatology, University of Bamako, Mali, 2 Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America Funding: This work was supported by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Academic Editor: Sanjeev Krishna, University of London, United Kingdom Citation: Guindo A, Fairhurst RM, Doumbo OK, Wellems TE, Diallo DA (2007) X-linked G6PD deficiency protects hemizygous males but not heterozygous females against severe malaria. PLoS Med 4(3): e66. doi:10. 1371/journal.pmed.0040066 A B S T R A C T Background Glucose-6-phosphate dehydrogenase (G6PD) is important in the control of oxidant stress in erythrocytes, the host cells for Plasmodium falciparum. Mutations in this enzyme produce X- linked deficiency states associated with protection against malaria, notably in Africa where the AÀ form of G6PD deficiency is widespread. Some reports have proposed that heterozygous females with mosaic populations of normal and deficient erythrocytes (due to random X chromosome inactivation) have malaria resistance similar to or greater than hemizygous males with populations of uniformly deficient erythrocytes. These proposals are paradoxical, and they are not consistent with currently hypothesized mechanisms of protection. Methods and Findings We conducted large case-control studies of the AÀform of G6PD deficiency in cases of severe or uncomplicated malaria among two ethnic populations of rural Mali, West Africa, where malaria is hyperendemic. Our results indicate that the uniform state of G6PD deficiency in hemizygous male children conferred significant protection against severe, life-threatening PLoSMEDICINE Sunday, September 29, 13
  36. 36. Epidemiology and Malaria X-Linked G6PD Deficiency Protects Hemizygous Males but Not Heterozygous Females against Severe Malaria Aldiouma Guindo1,2[ , Rick M. Fairhurst2[ , Ogobara K. Doumbo1 , Thomas E. Wellems2* , Dapa A. Diallo1 1 Malaria Research and Training Center, Faculty of Medicine, Pharmacy, and Odontostomatology, University of Bamako, Mali, 2 Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America Funding: This work was supported by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Academic Editor: Sanjeev Krishna, University of London, United Kingdom Citation: Guindo A, Fairhurst RM, Doumbo OK, Wellems TE, Diallo DA (2007) X-linked G6PD deficiency protects hemizygous males but not heterozygous females against severe malaria. PLoS Med 4(3): e66. doi:10. 1371/journal.pmed.0040066 A B S T R A C T Background Glucose-6-phosphate dehydrogenase (G6PD) is important in the control of oxidant stress in erythrocytes, the host cells for Plasmodium falciparum. Mutations in this enzyme produce X- linked deficiency states associated with protection against malaria, notably in Africa where the AÀ form of G6PD deficiency is widespread. Some reports have proposed that heterozygous females with mosaic populations of normal and deficient erythrocytes (due to random X chromosome inactivation) have malaria resistance similar to or greater than hemizygous males with populations of uniformly deficient erythrocytes. These proposals are paradoxical, and they are not consistent with currently hypothesized mechanisms of protection. Methods and Findings We conducted large case-control studies of the AÀform of G6PD deficiency in cases of severe or uncomplicated malaria among two ethnic populations of rural Mali, West Africa, where malaria is hyperendemic. Our results indicate that the uniform state of G6PD deficiency in hemizygous male children conferred significant protection against severe, life-threatening PLoSMEDICINE http://www.cdc.gov) or by GraphPad Instat version 3.01 (GraphPad Software, http://www.graphpad.com). Exact condi- tional likelihood methods were used to calculate pooled ORs, Table 1 presents the distributions of malaria cases in the Dogon and Malinke´-predominant groups by ethnicity, sex, and G6PD genotype. These distributions show similar Table 1. Distribution of Severe and Uncomplicated Malaria in Recruited Children According to Ethnicity, Sex, and G6PD Genotype Group Illness All Male Female Deficient Normal Hemizygous Normal Heterozygous Homozygous Normal Dogon Severe malaria 5 (7.5) 62 (92.5) 0 (0) 37 (100) 5 (16.7) 0 (0) 25 (83.3) Uncomplicated malaria 81 (16.6) 407 (83.4) 34 (13.8) 213 (86.2) 46 (19.1) 1 (0.4) 194 (80.5) Malinke´ predominant Severe malaria 40 (11.0) 325 (89.0) 15 (7.7) 180 (92.3) 22 (12.9) 3 (1.8) 145 (85.3) Uncomplicated malaria 340 (14.9) 1,937 (85.1) 152 (14.1) 926 (85.9) 148 (12.4) 40 (3.3) 1,011 (84.3) Stratified analysis Pooled OR (95% CI) 0.42 (0.23–0.73) 1.00 (0.62–1.55) 0.51 (0.10–1.63) p-Value ,0.001 .0.999 0.35 Data shown as number of cases (%) by sex and G6PD genotype. doi:10.1371/journal.pmed.0040066.t001 G6PD Deficiency and Malaria Protection Sunday, September 29, 13
  37. 37. Epidemiology and Malaria X-Linked G6PD Deficiency Protects Hemizygous Males but Not Heterozygous Females against Severe Malaria Aldiouma Guindo1,2[ , Rick M. Fairhurst2[ , Ogobara K. Doumbo1 , Thomas E. Wellems2* , Dapa A. Diallo1 1 Malaria Research and Training Center, Faculty of Medicine, Pharmacy, and Odontostomatology, University of Bamako, Mali, 2 Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America Funding: This work was supported by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Academic Editor: Sanjeev Krishna, University of London, United Kingdom Citation: Guindo A, Fairhurst RM, Doumbo OK, Wellems TE, Diallo DA (2007) X-linked G6PD deficiency protects hemizygous males but not heterozygous females against severe malaria. PLoS Med 4(3): e66. doi:10. 1371/journal.pmed.0040066 A B S T R A C T Background Glucose-6-phosphate dehydrogenase (G6PD) is important in the control of oxidant stress in erythrocytes, the host cells for Plasmodium falciparum. Mutations in this enzyme produce X- linked deficiency states associated with protection against malaria, notably in Africa where the AÀ form of G6PD deficiency is widespread. Some reports have proposed that heterozygous females with mosaic populations of normal and deficient erythrocytes (due to random X chromosome inactivation) have malaria resistance similar to or greater than hemizygous males with populations of uniformly deficient erythrocytes. These proposals are paradoxical, and they are not consistent with currently hypothesized mechanisms of protection. Methods and Findings We conducted large case-control studies of the AÀform of G6PD deficiency in cases of severe or uncomplicated malaria among two ethnic populations of rural Mali, West Africa, where malaria is hyperendemic. Our results indicate that the uniform state of G6PD deficiency in hemizygous male children conferred significant protection against severe, life-threatening PLoSMEDICINE Sunday, September 29, 13
  38. 38. Epidemiology and Malaria Sunday, September 29, 13
  39. 39. Epidemiology and Malaria Sunday, September 29, 13
  40. 40. Epidemiology and Malaria Sunday, September 29, 13
  41. 41. Epidemiology and Malaria Sunday, September 29, 13
  42. 42. Hemolysis Sunday, September 29, 13
  43. 43. Hemolysis John Lazarchick, ASH Image Bank 2011; 2011-4027 Blister cell - 1. Sunday, September 29, 13
  44. 44. Hemolysis Sunday, September 29, 13
  45. 45. Hemolysis John Lazarchick, ASH Image Bank 2011; 2011-3820 Bite cell - 1. Sunday, September 29, 13
  46. 46. Hemolysis Sunday, September 29, 13
  47. 47. Copyright © 2011 American Society of Hematology. Copyright restrictions may apply. Peter Maslak, ASH Image Bank 2011; 2011-4044 Schistocyte - 1. Hemolysis Sunday, September 29, 13
  48. 48. Hemolysis Sunday, September 29, 13
  49. 49. Hemolysis Sunday, September 29, 13
  50. 50. Hemolysis http://www.fracp.bigpondhosting.com/examquestions/2003/2003papertwo31to40.htm Sunday, September 29, 13
  51. 51. Hemolysis Sunday, September 29, 13
  52. 52. Hemolysis Sunday, September 29, 13
  53. 53. Clinical Manifestations Sunday, September 29, 13
  54. 54. • Neonatal Jaundice Clinical Manifestations Sunday, September 29, 13
  55. 55. • Neonatal Jaundice • Acute vs Chronic hemolysis Clinical Manifestations Sunday, September 29, 13
  56. 56. • Neonatal Jaundice • Acute vs Chronic hemolysis • Infection, oxidant drugs, chemical agents, fava beans Clinical Manifestations Sunday, September 29, 13
  57. 57. • Neonatal Jaundice • Acute vs Chronic hemolysis • Infection, oxidant drugs, chemical agents, fava beans • Keep in mind other blood cells require G6PD as well Clinical Manifestations Sunday, September 29, 13
  58. 58. • Neonatal Jaundice • Acute vs Chronic hemolysis • Infection, oxidant drugs, chemical agents, fava beans • Keep in mind other blood cells require G6PD as well • Phagocytosis could be impaired Clinical Manifestations Sunday, September 29, 13
  59. 59. Clinical Manifestations Sunday, September 29, 13
  60. 60. Clinical Manifestations 1982 59: 428-434 FJ Zuazu JL Vives Corrons, E Feliu, MA Pujades, F Cardellach, C Rozman, A Carreras, JM Jou, MT Vallespi and Barcelona) susceptibility to infections: description of a new molecular variant (G6PD with chronic hemolytic anemia, granulocyte dysfunction, and increased Severe-glucose-6-phosphate dehydrogenase (G6PD) deficiency associated http://bloodjournal.hematologylibrary.org/site/misc/rights.xhtml#repub_requests Information about reproducing this article in parts or in its entirety may be found online at: http://bloodjournal.hematologylibrary.org/site/misc/rights.xhtml#reprints Information about ordering reprints may be found online at: http://bloodjournal.hematologylibrary.org/site/subscriptions/index.xhtml Information about subscriptions and ASH membership may be found online at: For personal use only.at UCSF LIBRARY & CKM on January 21, 2013.bloodjournal.hematologylibrary.orgFrom Sunday, September 29, 13
  61. 61. Clinical Manifestations 1982 59: 428-434 FJ Zuazu JL Vives Corrons, E Feliu, MA Pujades, F Cardellach, C Rozman, A Carreras, JM Jou, MT Vallespi and Barcelona) susceptibility to infections: description of a new molecular variant (G6PD with chronic hemolytic anemia, granulocyte dysfunction, and increased Severe-glucose-6-phosphate dehydrogenase (G6PD) deficiency associated http://bloodjournal.hematologylibrary.org/site/misc/rights.xhtml#repub_requests Information about reproducing this article in parts or in its entirety may be found online at: http://bloodjournal.hematologylibrary.org/site/misc/rights.xhtml#reprints Information about ordering reprints may be found online at: http://bloodjournal.hematologylibrary.org/site/subscriptions/index.xhtml Information about subscriptions and ASH membership may be found online at: For personal use only.at UCSF LIBRARY & CKM on January 21, 2013.bloodjournal.hematologylibrary.orgFrom 100 100 53.5 ± 6.5 7.69 ± 1.61 105 100 40 6 5 60 Normal 68 111 ± 2 114 ± 2 55.5 ± 7.5 8±1 2.61 ± 0.7 50 ± 8 Normal 62 ± 9.370.5 ± 7.8 CNSHA None Favism f 0 0 Electrophoretic mobility (% of normal B enzyme) Tris-EDTA-borate, pH 8.0 Phosphate EDTA, pH 7.0 KmG6P (atM) KmNADP (aiM) Substrate analogues utilization 2dG6P (% of G6P rate) Deamino NAD- (% of NADP rate) Optimum pH Heat stability at 46#{176}C(residual activity after 60 mm of in- cubation) (%) Clinical manifestations 2.32 ± 0.51 51.5 ± 6.5 Inflexion at pH 8.5 by the patient’s granulocytes was normal, whereas the cytochemical NBT reduction test was severely decreased. The spectrophotometric assay of zymosan- stimulated NBT reduction confirmed the results obtained with the cytochemical test. Accordingly, superoxide radical (02) production measured through the ferricytochrome-c reduction and iodination test were strongly decreased in the patient’s granulocytes. On the other hand, MPO index, LAP score, chemotax- is, and random migration of patient’s PMN were within normal limits and ultrastructural studies provided no evidence for abnormalities either in size or in number of granules in the patient’s granulocytes (Table 4). DISCUSSION G6PD deficiency can be divided into four classes on the basis of erythrocyte enzyme activity and asso- + ciated clinical manifestations:3’ class 1 deficiency is characterized by severely reduced activity of G6PD and chronic nonspherocytic hemolytic anemia (CNSHA); class 2 consists in a severe deficiency of G6PD usually not associated with hemolytic anemia; class 3 corresponds to moderate to mild G6PD defi- ciency; and class 4 refers to very mild or unapparent enzyme deficiency. The enzyme variants within each class can be divided further on the basis of their electrophoretic mobility, kinetic characteristics, pH optima, and utili- zation of substrate analogues. In general, G6PD- deficient patients who suffer from CNSHA (class I) have inherited an uncommon variant characterized by decreased G6PD activity in leukocytes and plate- lets’4’53233 together with severe erythrocyte G6PD + BARCELONA Fig. 1 . Starch-gel electrophoresis at pH 8.0 of partially pun- fled G6PD from the patient and two controls. Electrophoretic mobility of G6PD Barcelona is intermediate between normal B enzyme and the fast Gd( + )A black variant. Arrow indicates sample origin (0). x iO’31U Fig. 2. Electroimmunodiffusion of normal B enzyme and deficient G6PD Barcelona obtained from freshly prepared leuko- cytes. In normal B enzyme. the activity of the first leukolyzate dilution applied to the gel is indicated. The other dilutions were in the ratio 1 :2, 1 :4, and 1 :8. In deficient G6PD Barcelona, the activity of the first immunoprecipitat. peak was obtained with an undi- luted leukocyte extract containing 220 x 10 d white blood cells. Sunday, September 29, 13
  62. 62. Clinical Manifestations 1982 59: 428-434 FJ Zuazu JL Vives Corrons, E Feliu, MA Pujades, F Cardellach, C Rozman, A Carreras, JM Jou, MT Vallespi and Barcelona) susceptibility to infections: description of a new molecular variant (G6PD with chronic hemolytic anemia, granulocyte dysfunction, and increased Severe-glucose-6-phosphate dehydrogenase (G6PD) deficiency associated http://bloodjournal.hematologylibrary.org/site/misc/rights.xhtml#repub_requests Information about reproducing this article in parts or in its entirety may be found online at: http://bloodjournal.hematologylibrary.org/site/misc/rights.xhtml#reprints Information about ordering reprints may be found online at: http://bloodjournal.hematologylibrary.org/site/subscriptions/index.xhtml Information about subscriptions and ASH membership may be found online at: For personal use only.at UCSF LIBRARY & CKM on January 21, 2013.bloodjournal.hematologylibrary.orgFrom 432 Table 3. Results of Granuloc yte Functi on Tests Normal Controls Patient (Mean ± SD) Cytochemical test Latex ingestion (%)‘ 100 98.44 ± 2.26 NBT reduction (%)t 10 90.6 ± 9.2 Quantitative NBT-reduction OD x 2.5 min/ 1oc cells Spontaneous 0.035 0. 100 ± 0.060 Stimulated by Zymosan 0.044 0.400 ± 0.120 o;-stimulated production (nmole/ 10’ 0.29 3.62 ± 1 . 1 1 cells) lodination (nmole/hr/ 10’ cells) 3.2 1 1 . 14 ± 3.81 Random migration (x i0 .tm) 0.25 0.38 ± 0.13 Chemotaxis ( x i0 Mm) Autologous serum (AS) 0.82 1 .37 ± 0.24 zymosan-activated As 1 .02 1 .52 ± 0.30 Supernatant of Klebsiella cul- 0.75 0.9 1 ± 0.30 tune Klebsiella-activated AS 0.55 1 . 13 ± 0.35 ‘Percentage of mature wanulocytes that ingested latex particles. tPercenta e of mature granulocytes containing blue-black formazan deposits; this percentage is calculated from the number of latex- containing mature granulocytes. OD, optical density (absorbance). Table 4. Ultrastructural Parameters Score Granulocytes and in Granulocytes of 20 N Patient (Mean ± SD) Cellular area (sq IL) 37.54 ± 5.07 Nuclear area (sq iz) 7.46 ± 2.68 Cytoplasmic area (sq l ) 30.08 ± 4. 1 9 Nuclear/cytoplasmic ratio 0.25 ± 0.09 Numberof -anulespercell 150.25 ± 31.09 When sufficiently severe, leukocyte ciency gives rise to metabolic and bact of granulocytes and in some instances festations that resemble those of patient granulomatous disease (CGD).7’8 These usually differ, however, with respect appearance of infection and the presenc anemia. 8 Thus, none of the 50 d of G6PD deficiency associated with CN to increased susceptibility to b tions,”2’45’532’33 and only 6 patients w ciency, including the present case, are CNSHA was associated with infections respiratory tract or urinary tract.78 T For persat UCSF LIBRARY & CKM on January 21, 2013.bloodjournal.hematologylibrary.orgFrom 100 100 53.5 ± 6.5 7.69 ± 1.61 105 100 40 6 5 60 Normal 68 111 ± 2 114 ± 2 55.5 ± 7.5 8±1 2.61 ± 0.7 50 ± 8 Normal 62 ± 9.370.5 ± 7.8 CNSHA None Favism f 0 0 Electrophoretic mobility (% of normal B enzyme) Tris-EDTA-borate, pH 8.0 Phosphate EDTA, pH 7.0 KmG6P (atM) KmNADP (aiM) Substrate analogues utilization 2dG6P (% of G6P rate) Deamino NAD- (% of NADP rate) Optimum pH Heat stability at 46#{176}C(residual activity after 60 mm of in- cubation) (%) Clinical manifestations 2.32 ± 0.51 51.5 ± 6.5 Inflexion at pH 8.5 by the patient’s granulocytes was normal, whereas the cytochemical NBT reduction test was severely decreased. The spectrophotometric assay of zymosan- stimulated NBT reduction confirmed the results obtained with the cytochemical test. Accordingly, superoxide radical (02) production measured through the ferricytochrome-c reduction and iodination test were strongly decreased in the patient’s granulocytes. On the other hand, MPO index, LAP score, chemotax- is, and random migration of patient’s PMN were within normal limits and ultrastructural studies provided no evidence for abnormalities either in size or in number of granules in the patient’s granulocytes (Table 4). DISCUSSION G6PD deficiency can be divided into four classes on the basis of erythrocyte enzyme activity and asso- + ciated clinical manifestations:3’ class 1 deficiency is characterized by severely reduced activity of G6PD and chronic nonspherocytic hemolytic anemia (CNSHA); class 2 consists in a severe deficiency of G6PD usually not associated with hemolytic anemia; class 3 corresponds to moderate to mild G6PD defi- ciency; and class 4 refers to very mild or unapparent enzyme deficiency. The enzyme variants within each class can be divided further on the basis of their electrophoretic mobility, kinetic characteristics, pH optima, and utili- zation of substrate analogues. In general, G6PD- deficient patients who suffer from CNSHA (class I) have inherited an uncommon variant characterized by decreased G6PD activity in leukocytes and plate- lets’4’53233 together with severe erythrocyte G6PD + BARCELONA Fig. 1 . Starch-gel electrophoresis at pH 8.0 of partially pun- fled G6PD from the patient and two controls. Electrophoretic mobility of G6PD Barcelona is intermediate between normal B enzyme and the fast Gd( + )A black variant. Arrow indicates sample origin (0). x iO’31U Fig. 2. Electroimmunodiffusion of normal B enzyme and deficient G6PD Barcelona obtained from freshly prepared leuko- cytes. In normal B enzyme. the activity of the first leukolyzate dilution applied to the gel is indicated. The other dilutions were in the ratio 1 :2, 1 :4, and 1 :8. In deficient G6PD Barcelona, the activity of the first immunoprecipitat. peak was obtained with an undi- luted leukocyte extract containing 220 x 10 d white blood cells. Sunday, September 29, 13
  63. 63. Dx and Rx Sunday, September 29, 13
  64. 64. Dx and Rx • Dx Sunday, September 29, 13
  65. 65. Dx and Rx • Dx • Signs and symptoms of hemolysis Sunday, September 29, 13
  66. 66. Dx and Rx • Dx • Signs and symptoms of hemolysis • G6PD assay Sunday, September 29, 13
  67. 67. Dx and Rx • Dx • Signs and symptoms of hemolysis • G6PD assay • Heinz body preparation Sunday, September 29, 13
  68. 68. Dx and Rx • Dx • Signs and symptoms of hemolysis • G6PD assay • Heinz body preparation • Rx Sunday, September 29, 13
  69. 69. Dx and Rx • Dx • Signs and symptoms of hemolysis • G6PD assay • Heinz body preparation • Rx • Supportive care Sunday, September 29, 13
  70. 70. Dx and Rx • Dx • Signs and symptoms of hemolysis • G6PD assay • Heinz body preparation • Rx • Supportive care • Transfusions (Keep in mind donor source!) Sunday, September 29, 13
  71. 71. Dx and Rx • Dx • Signs and symptoms of hemolysis • G6PD assay • Heinz body preparation • Rx • Supportive care • Transfusions (Keep in mind donor source!) • Guidance on what to avoid Sunday, September 29, 13
  72. 72. Dx and Rx Sunday, September 29, 13
  73. 73. Dx and RxDRUGS TO AVOID IN G6PD DEFICIENCY DEFINITE RISK OF HAEMOLYSIS POSSIBLE RISK OF HAEMOLYSIS Pharmacological Class Drugs* Pharmacological Class Drugs* • ß-Naphthol • Niridazole • Stibophen • Nitrofurans - Nitrofurantoin - Nitrofurazone • Quinolones - Ciprofloxacin - Moxifloxacin - Nalidixic acid - Norfloxacin - Ofloxacin • Chloramphenicol • Sulfonamides - Co-trimoxazole (Sulfamethoxazole + Trimethoprim) - Sulfacetamide - Sulfadiazine - Sulfadimidine - Sulfamethoxazole - Sulfanilamide - Sulfapyridine - Sulfasalazine (Salazosulfapyridine) - Sulfisoxazole (Sulfafurazole) • Mepacrine • Pamaquine • Pentaquine • Primaquine • Methylene blue • Dapsone • Para-aminosalicylic acid • Sulfones - Aldesulfone sodium (Sulfoxone) - Glucosulfone - Thiazosulfone • Doxorubicin • Rasburicase • Phenazopyridine (Pyridium) • Acetylphenylhydrazine • Phenylhydrazine • Acetylsalicylic acid (Aspirin) • Acetanilide • Paracetamol (Acetaminophen) • Aminophenazone (Aminopyrine) • Dipyrone (Metamizole) • Phenacetin • Phenazone (Antipyrine) • Phenylbutazone • Tiaprofenic acid • Furazolidone • Streptomycin • Sulfonamides - Sulfacytine - Sulfaguanidine - Sulfamerazine - Sulfamethoxypyridazole • Phenytoin • Glibenclamide • Dimercaprol (BAL) • Antazoline (Antistine) • Diphenhydramine • Tripelennamine • Hydralazine • Methyldopa • Chloroquine & derivatives • Proguanil • Pyrimethamine • Quinidine • Quinine • Isoniazid • Trihexyphenidyl (Benzhexol) • Dopamine (L-dopa) • Procainamide • Quinidine • Toluidine blue • Colchicine • Probenecid • Mestranol • Isobutyl nitrite • Menadiol Na sulfate • Menadione • Menadione Na bisulfite • Phytomenadione • Ascorbic acid (Vit C) (rare) • Arsine • Berberine (in Coptis chinensis) • Fava beans • Naphthalene (in mothballs) • Para-aminobenzoic acid Anthelmintics Antibiotics Antimalarials Antimethemo- globinaemic Agents Antimycobacterials Antineoplastic Adjuncts Genitourinary Analgesics Others Analgesics Antibiotics Anticonvulsants Antidiabetics Antidotes Antihistamines Antihypertensives Antimalarials Antimycobacterials Antiparkinsonism Agents Cardiovascular Drugs Diagnostic Agent for Cancer Detection Gout Preparations Hormonal Contraceptives Nitrates Vitamin K Substance Vitamins Others Please refer to the Contents page for more Summary Tables. MIMS Summary Table G6PDDeficiency ver01032006 *Nomenclature based on INN (International non-proprietary name) Refer to www.g6pd.org for further information. Copyright © 2006 MIMS Sunday, September 29, 13
  74. 74. Dx and Rx Sunday, September 29, 13
  75. 75. Dx and Rx Sunday, September 29, 13
  76. 76. Dx and Rx Sunday, September 29, 13
  77. 77. Follow up visit Sunday, September 29, 13
  78. 78. Follow up visit Sunday, September 29, 13
  79. 79. Follow up visit Sunday, September 29, 13
  80. 80. Follow up visit Sunday, September 29, 13
  81. 81. Follow up visit Sunday, September 29, 13
  82. 82. Follow up visit Sunday, September 29, 13
  83. 83. Take Home Points Sunday, September 29, 13
  84. 84. Take Home Points • G6PD is relatively common in certain populations Sunday, September 29, 13
  85. 85. Take Home Points • G6PD is relatively common in certain populations • There are different categories of severity Sunday, September 29, 13
  86. 86. Take Home Points • G6PD is relatively common in certain populations • There are different categories of severity • Possibly protects against P. falciparum Sunday, September 29, 13
  87. 87. Take Home Points • G6PD is relatively common in certain populations • There are different categories of severity • Possibly protects against P. falciparum • All cells need G6PD Sunday, September 29, 13
  88. 88. Take Home Points • G6PD is relatively common in certain populations • There are different categories of severity • Possibly protects against P. falciparum • All cells need G6PD • No need to test for G6PD during acute hemolysis Sunday, September 29, 13
  89. 89. References • Arese P, De Flora A. Pathophysiology of hemolysis in glucose-6-phosphate dehydrogenase deficiency. Semin Hematol 1990; 27:1. • Brewer GJ, Zarafonetis CJ. The haemolytic effect of various regimens of primaquine with chloroquine in American Negroes with G6PD deficiency and the lack of an effect of various antimalarial suppressive agents on erythrocyte metabolism. Bull World Health Organ 1967; 36:303. • Beutler E. G6PD deficiency. Blood 1994; 84:3613. • Seidman DS, Shiloh M, Stevenson DK, et al. Role of hemolysis in neonatal jaundice associated with glucose-6 phosphate dehydrogenase deficiency. J Pediatr 1995; 127:804. • Shalev O, Manny N, Sharon R. Posttransfusional hemolysis in recipients of glucose-6-phosphate dehydrogenase- deficient erythrocytes. Vox Sang 1993; 64:94. • http://www.uptodate.com/contents/diagnosis-and-treatment-of-glucose-6-phosphate-dehydrogenase-deficiency#H1 • http://imagebank.hematology.org/ Sunday, September 29, 13

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