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SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a genetic disorder caused by red blood cell (RBC) enzymatic defects that leads to hemolytic anemia with sufficient oxidative stress G6PD deficiency affects approximately 400 million people, mainly African populations Methemoglobinemia is a condition in which oxidative stress converts the ferrous ion in hemoglobin into a ferric ion with higher binding affinity to oxygen leading to the inability to release O2 to tissue Both conditions can be precipitated by medications such as hydroxychloroquine (HCQ), which has seen widespread use to treat the novel coronavirus (COVID-19) CASE PRESENTATION: A 39 year old African American male presenting with weakness was found to have acute kidney failure and liver injury He was recently diagnosed with COVID-19 pneumonia and received HCQ as outpatient HCQ was stopped upon admission but the patient's mental status worsened and his hemoglobin fell from 12 2 g/dL to 6 3 g/dL with evidence of hemolylsis- LDH 1758 U/L Total bilirubin peaked at 25 4 mg/dL without evidence of biliary obstruction and an undetectable haptoglobin The patient required multiple RBC transfusions He also had significantly elevated methemoglobin levels, which peaked at 14 8% These findings along with his ethnic background prompted a G6PD assay to be sent which showed decreased enzyme activity Due to his G6PD deficiency, the patient received ascorbic acid to treat the methemoglobin His methemoglobin level remained elevated for 7 days and severe hemolysis persisted for 10 days before resolving He also experienced severe delirium, renal failure requiring hemodialysis and hypoxic respiratory failure requiring 100% O2 high flow nasal cannula He was eventually discharged home on room air DISCUSSION: In this case, HCQ along with COVID-19 infection caused enough oxidative stress to cause methemoglobinemia and also trigger a separate hemolytic anemia due to G6PD deficiency A 2018 study of Duke rheumatology patients prescribed HCQ found that in 275 patients, 4% had G6PD deficiency Of those, only 2 patients experienced hemolytic anemia but during severe lupus flares while they were not taking HCQ The authors recommended to not screen for G6PD deficiency, as HCQ use alone was not enough to trigger hemolytic anemia CONCLUSIONS: With the widespread use of HCQ as an off-label treatment for COVID-19, it is important to monitor for potential complications G6PD deficiency hemolytic anemia should be monitored for especially in patient populations at risk for the condition Methemoglobinemia happening simultaneously is exceedingly rare but should be watched for as well in patients with COVID-19 due to the severe systemic inflammation There is currently only one case report in the literature of both conditions occurring with the use of HCQ, however, these disorders can potentially worsen oxygenation in already critically ill COVID-19 patients Reference #1: Kuipers MT, van Zwieten R, Heijmans J, et al G6PD deficiency-associated hemolysis and methemoglobinemia in a COVID-19 patient treated with chloroquine [published online ahead of print, 2020 May 10] Am J Hematol 2020;10 1002/ajh 25862 doi:10 1002/ajh 25862 Reference #2: Mohammad S, Clowse MEB, Eudy AM, Criscione-Schreiber LG Examination of Hydroxychloroquine Use and Hemolytic Anemia in G6PDH-Deficient Patients Arthritis Care Res (Hoboken) 2018;70(3):481-485 doi:10 1002/acr 23296 Reference #3: Beauverd, Y, Adam, Y, Assouline, B, Samii, K COVID-19 infection and treatment with hydroxychloroquine cause severe haemolysis crisis in a patient with glucose-6-phosphate dehydrogenase deficiency Eur J Haematol 2020;00: 1– 3 https://doi org/10 1111/ejh 13432 DISCLOSURES: No relevant relationships by Karishma Bhatia, source=Web Response No relevant relationships by Young Lee, source=Web Response No relevant relationships by Steven Lim, source=Web Response
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