Case report: Acute Hepatitis E Infection with Co‐Existent Glucose‐6‐Phosphate Dehydrogenase Deficiency

Abstract

Hepatitis E virus is one of the leading causes of acute viral hepatitis in India but usually manifests as a mild self-limiting illness. Viral hepatitis in the presence of glucose-6-phosphate dehydrogenase (G6PD) deficiency may be associated with complications such as severe anemia, hemolysis, renal failure, hepatic encephalopathy and even death. The incidence of G6PD deficiency in the general population of northern India is reported to be between 2.2% and 14%. Despite both hepatitis E infection and G6PD deficiency being common, their impact on patient illness has only recently been reported. The present study reports a case of severe hemolysis in a patient with G6PD deficiency and hepatitis E infection.Key words: Glucose-6-phosphate dehydrogenase; G6PD; Hemolysis; Hepatitis E Exposé de cas : Hépatite E aiguë en présence d'un déficit en glucose-6-phosphate-déshy-drogénase Le virus de l'hépatite E est l'une des principales causes d'hépatite aiguë en Inde, mais il s'agit en général d'une maladie bénigne, spontanément résolutive. Par contre, une hépatite virale en présence d'un déficit en glucose-6-phosphate-déshydrogénase (G6PD) peut donner lieu à des complications comme une anémie grave, l'hémolyse, l'insuffisance rénale, une encéphalopathie porto-cave et même la mort. L'incidence du déficit en G6PD dans la population en général dans le Nord de l'Inde varie entre 2,2 et 14 %. Même si l'hépatite E et le déficit en G6PD sont deux affections fréquentes, on ne fait état de leur influence sur l'évolution de la maladie que depuis peu. Voici un cas d'hémolyse grave chez un patient atteint à la fois d'un déficit en G6PD et d'une hépatite E.H epatitis E is an enterically transmitted virus and is one of the most common causes of acute viral hepatitis in India (1). Glucose-6-phosphate dehydrogenase (G6PD) deficiency is found in 2.2% to 14% of the general population in North India (2). The coexistence of viral hepatitis and G6PD deficiency has been reported to be associated with severe jaundice and other complications (3,4). Hepatitis E infection with G6PD deficiency has been associated with more severe illness in only one previous report (5). We report an additional case. CASE REPORTA 35-year-old man with no history of alcoholism or liver disease presented with low grade fever, upper abdominal pain, fatigue and loss of appetite for eight to 10 days. He had noticed a yellow discolouration of the eyes for three days and dark coloured urine for five to six days. On examination, he was deeply icteric. Abdominal examination revealed a soft, tender liver, palpable 4 cm below the costal margin. There was no splenomegaly and the remainder of the physical examination was normal.Laboratory investigations revealed a hemoglobin mass concentration of 126 g/L, a total leucocyte count of 12.2x10 9 /L, and a total serum bilirubin of 198 µmol/L with a conjugated fraction of 141 µmol/L. The serum aspartate aminotransferase (AST) concentration was 376 U/L and the alanine aminotransferase (ALT) concentration was 270 U/L. The prothrombin time wa...

Massive Hemolysis Causing Renal Failure in Acute Hepatitis E Infection

“…G6PD deficiency reportedly affects 2.2–14% of the north Indian population, and co-existence of both illnesses, though rare, has been documented 2,3. Acute viral hepatitis and HEV per se can lead to mild hemolysis; however, cases of severe hemolysis with markedly raised bilirubin with acute kidney injury, as in our patient, are very rare 3,4. Our patient had severe intravascular hemolysis, as evidenced by the rapid fall in hemoglobin, marked elevation in mixed hyperbilirubinemia, hemoglobinuria, and markedly raised plasma LDH.…”

“…Abid et al3 were the first to describe this rare life-threatening association in a series of five cases, four of which experienced renal failure leading to a long, protracted course of illness. Occasional reports have also suggested that HEV can cause massive hemolysis and renal injury in patients with G6PD deficiency 4,5…”

Phylogeny and Origin of Glucose-6-Phosphate Dehydrogenase (G6PD) Defi ciency Mutations in Indonesia

“…A similar relationship exists between malaria and sickle-cell disease. This is because the cells infected with the Plasmodium parasite are cleared more rapidly by the spleen (Monga et al,2003). This phenomenon might give G6PDH deficiency carriers an evolutionary advantage by increasing their fi tness in malarial endemic environments.…”

Viral Hepatitis with Acute Hemoglobinuria

“…8 Likewise, hepatitis D superinfection in a chronic HBSAg carrier with G6PD deficiency has been associated with acute hemoglobinuria. 9 Severe anemia without major blood loss is an unusual feature of hepatitis A infection.…”

“…Despite acute hemoglobinuria, this patient did not develop acute renal failure, contrary to previous reports. 7,8 G6PD catalyses the initial step in the hexose monophosphate shunt, oxidizing glucose-6-phosphate to 6-phosphogluconolactone, and reducing NADP to NADPH. The hexose monophosphate shunt pathway of glucose metabolism is the only red cell source of NADPH.…”