Methemoglobinaemia in Diabetic Ketoacidosis Patient

Magdy      Mohamed; Nadem      Javed

doi:10.2174/03666211227181618

Abstract

Background: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common X-linked genetic disorder.

Case Presentation: In this paper, we report a case of a 41-years-old male patient with non-insulin-dependent diabetes and a family history of G6PD deficiency never known to have any previous hemolytic episodes, presented as a case of diabetic ketoacidosis with features of hemolytic anemia due to G6PD deficiency manifesting as methemoglobinemia and anemia.

Conclusion: Our patient successfully managed with ascorbic acid and red blood cell transfusion. Clinicians should, therefore, be aware of the possibility of this uncommon association between diabetic ketoacidosis, G6PD deficiency, and methemoglobinemia which may be present in patients with G6PD deficiency and severe hemolysis.

Keywords: Case report, G6PD deficiency, Hemolysis, Methemoglobinemia, Diabetic ketoacidosis, Methylene blue, Vitamin C.

[1] 
El-Hazmi MA, Warsy AS. Glucose 6-Phosphate dehydrogenase deficiency genetic, pathophysiological and therapeutic aspects. Ann Saudi Med  1985; 5(4): 213-23.
[http://dx.doi.org/10.5144/0256-4947.1985.213] [PMID: 21164249] 
[2] 
Alzaki AA, Alalawi NH. Diabetic Ketoacidosis Revealing Severe Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD-D) Deficiency with Methemoglobinemia: A Case Report. Am J Case Rep  2019; 20: 726-9.
[http://dx.doi.org/10.12659/AJCR.915007] [PMID: 31113928] 
[3] 
Cappellini MD, Fiorelli G. Glucose-6-phosphate dehydrogenase deficiency. Lancet  2008; 371(9606): 64-74.
[http://dx.doi.org/10.1016/S0140-6736(08)60073-2] [PMID: 18177777] 
[4] 
Efferth T, Schwarzl SM, Smith J, Osieka R. Role of glucose-6-phosphate dehydrogenase for oxidative stress and apoptosis. Cell Death Differ  2006; 13(3): 527-8.
[http://dx.doi.org/10.1038/sj.cdd.4401807] [PMID: 16311511] 
[5] 
Palmer K, Dick J, French W, Floro L, Ford M. Methemoglobinemia in patient with G6PD deficiency and SARS-CoV-2 infection. Emerg Infect Dis  2020; 26(9): 2279-81.
[http://dx.doi.org/10.3201/eid2609.202353] [PMID: 32579876] 
[6] 
Standardization of procedure for the study of glucose-6-phosphate dehydrogenase. Report of a WHO Scientific Group. WHO Tech Rep Ser  1967; 366: 5-29.
[7] 
Skold A, Cosco DL, Klein R. Methemoglobinemia: pathogenesis, diagnosis, and management. South Med J  2011; 104(11): 757-61.
[http://dx.doi.org/10.1097/SMJ.0b013e318232139f] [PMID: 22024786] 
[8] 
Hassan KS, Al-Riyami AZ, Al-Huneini M, Al-Farsi K, Al-Khabori M. Methemoglobinemia in an elderly patient with glucose-6-phosphate dehydrogenase deficiency: a case report. Oman Med J  2014; 29(2): 135-7.
[http://dx.doi.org/10.5001/omj.2014.33] [PMID: 24715943] 
[9] 
Agarwal A, Nayak M D, Patil A, Manohar C. Glucose 6 phosphate dehydrogenase deficiency unmasked by diabetic ketoacidosis: an underrated phenomenon. J Clin Diagn Res  2013; 7(12): 3012-3.
[http://dx.doi.org/10.7860/JCDR/2013/6159.3892] [PMID: 24551713] 
[10] 
Shalev O, Wollner A, Menczel J. Diabetic ketoacidosis does not precipitate haemolysis in patients with the Mediterranean variant of glucose-6-phosphate dehydrogenase deficiency. Br Med J (Clin Res Ed)  1984; 288(6412): 179-80.
[http://dx.doi.org/10.1136/bmj.288.6412.179] [PMID: 6419846] 
[11] 
Silvestri F. Glucose-6-phosphate dehydrogenase deficiency unmasked by hyperglycemia. J Clin Diagn Res  2013; 7(12): 3012-3.
[PMID: 24551713] 
[12] 
Araujo T, Katiyar V, Gonzales Zamora JA. Acute retroviral syndrome presenting with hemolytic anemia induced by G6PD deficiency. Trop Med Infect Dis  2018; 4(1): 6.
[http://dx.doi.org/10.3390/tropicalmed4010006] [PMID: 30591622] 
[13] 
Packer CD, Hornick TR, Augustine SA. Fatal hemolytic anemia associated with metformin: a case report. J Med Case Reports  2008; 2: 300.
[http://dx.doi.org/10.1186/1752-1947-2-300] [PMID: 18783609] 
[14] 
Rehman A, Shehadeh M, Khirfan D, Jones A. Severe acute haemolytic anaemia associated with severe methemoglobinemia in a G6PD-deficient man. BMJ Case Rep  2018; 2018: bcr2017223369.
[http://dx.doi.org/10.1136/bcr-2017-223369] 
[15] 
Umbreit J. Methemoglobin--it’s not just blue: a concise review. Am J Hematol  2007; 82(2): 134-44.
[http://dx.doi.org/10.1002/ajh.20738] [PMID: 16986127] 
[16] 
Rosen PJ, Johnson C, McGehee WG, Beutler E. Failure of methylene blue treatment in toxic methemoglobinemia. Association with glucose-6-phosphate dehydrogenase deficiency. Ann Intern Med  1971; 75(1): 83-6.
[http://dx.doi.org/10.7326/0003-4819-75-1-83] [PMID: 5091568] 