|Year : 2019 | Volume
| Issue : 2 | Page : 109-113
High hemolytic markers in G6PD-deficient compared to G6PD-normal male leprosy patients
Ibrahim Musa Idris, Aisha Kuliya-Gwarzo, SG Ahmed
Department of Haematology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||27-Aug-2018|
|Date of Decision||03-Jan-2019|
|Date of Acceptance||01-Feb-2019|
|Date of Web Publication||19-Nov-2019|
Dr. Ibrahim Musa Idris
Department of Haematology, Aminu Kano Teaching Hospital, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
Introduction: Glucose-6-phosphate dehydrogenase (G6PD) deficiency (Gd−) is the most common enzymopathy, which is inherited as an X-linked recessive disorder. Individuals with Gd− are prone to hemolysis upon exposure to oxidant stress. Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae. Both leprosy and Gd− are common in Nigeria, and treatment of leprosy with dapsone can precipitate hemolysis in Gd−. Aims: The aims of this study were to determine the prevalence of Gd−, and compare the hematological and biochemical indices of Gd− with G6PD-replete (Gd+) male leprosy patients in Kano, Nigeria. Settings and Design: This was a cross-sectional study. A total of 198 male participants with leprosy were recruited at the Yadakunya leprosarium in Kano, Nigeria. Materials and Methods: Relevant data were obtained through questionnaires and case notes review. Venous blood was collected for analysis. Statistical Analysis: Unpaired t test and Chi square test were used for comparison of variables. Results: The prevalence of G6PD deficiency was 9% in male leprosy patients. Mean Hb of Gd−(10.56 ± 2.82 g/dl) was lower than Gd+(12.9 ± 2.31 g/dl), P value < 0.001. Platelet (293.52 × ±3.19 × 109/l vs. 176.31 ± 2.83 × 109/l; P value < 0.001), reticulocytes (4.49 ± 2.72% vs. 2.01 ± 1.07%, P value < 0.001), bilirubin [1.04 ± 0.22 mg/dl vs. 0.46 ± 0.27 mg/dl; P value < 0.001], and lactate dehydrogenase (LDH) [269.82 ± 58.54 mg/dl vs. 130.26 ± 51.83 mg/dl; P value <0.001] were higher in Gd− than Gd+. Conclusion: Lower Hb and higher hemolytic markers in Gd− indicate ongoing hemolysis, which can be precipitated by dapsone.
Keywords: Anemia, G6PD deficiency, hemolysis, leprosy
|How to cite this article:|
Idris IM, Kuliya-Gwarzo A, Ahmed S G. High hemolytic markers in G6PD-deficient compared to G6PD-normal male leprosy patients. Niger J Basic Clin Sci 2019;16:109-13
|How to cite this URL:|
Idris IM, Kuliya-Gwarzo A, Ahmed S G. High hemolytic markers in G6PD-deficient compared to G6PD-normal male leprosy patients. Niger J Basic Clin Sci [serial online] 2019 [cited 2020 Apr 6];16:109-13. Available from: http://www.njbcs.net/text.asp?2019/16/2/109/270999
| Introduction|| |
Glucose-6-phosphate dehydrogenase (G6PD) is a cytosolic enzyme produced in the Embden-Meyerhof pathway. The main function of G6PD is the reduction of oxidized nicotinamide adenine dinucleotide phosphate (NADP+) to NADPH, which in turn reduces oxidized glutathione (GSSG) to GSH. Red cells being oxygen carriers are prone to damage by the reactive oxygen species. Therefore, GSH serves as a potent antioxidant that helps combat free radicals to protect the cells from damage. Red cells being enucleated cannot resynthesize the enzyme, hence are more prone to damage when exposed to oxidant stress.,
Globally, G6PD deficiency is the most common enzymopathy affecting no less than 400 million people. In Nigeria, the prevalence is about 15–26% of the entire Nigerian population, with G6PD A−, which is classified as class III (enzyme activity of 10–60%) being the most prevalent.,, G6PD deficiency is inherited as an X-linked recessive disease. It is thought that G6PD deficiency in heterozygote state confers resistance to malaria infection in tandem with convergence evolution.
Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae. World Health Organization (WHO) recommends treatment of leprosy with multidrug therapy (MDT) comprising of dapsone, clofazimine, and rifampicin., More than 14 million patients have been treated using the WHO guideline. However, dapsone has been associated with precipitating hemolysis particularly in G6PD deficiency.,, It was recommended by the WHO expert committee that G6PD testing should be done prior to commencing treatment with dapsone., For safety purpose, hemoglobin level of <7.0 g/dl was considered a relative contraindication for dapsone because of the increased risk of life-threatening events when hemoglobin drops by >4 g/dl in severely anemic patients. Earlier report had shown that there was a high incidence of G6PD deficiency among leprosy patients in India, unlike the low prevalence of only 1.5% among leprosy patients in Singapore.
Considering the epidemiology of both leprosy (detection rate of 5.9/100,000) and G6PD deficiency (15–26%) in Nigeria,,, there is a likelihood of the two diseases co-existing, thus predisposing the affected individuals to adverse effect during treatment. G6PD-deficient (Gd−) individuals are prone to both extravascular and intravascular hemolysis when challenged., From our literature search, there is no study from Nigeria that has looked at the prevalence of G6PD deficiency among leprosy patients. Hence, there is paucity of data regarding the hematological parameters of Gd− leprosy patients. Therefore, the objectives of this study were to determine the prevalence of G6PD deficiency in leprosy patients and to assess the hematological and biochemical parameters of Gd− and G6PD-replete (Gd+) leprosy patients.
| Materials and Methods|| |
The study was a cross-sectional study. Because of the uniqueness of G6PD deficiency as an X-link recessive disorder, only male participants were recruited for this study. A total number of 198-male participants who have been diagnosed with leprosy and started on MDT consisting of dapsone, clofazimine, and rifampicin were recruited. Their age range for inclusion in this study was 18 to 65 years. The study was carried out at the Yadakunya leprosarium and eight other field clinics where direct observed therapy of MDT is given free of charge within Kano state, Nigeria. The study period lasted from February 2014 to August 2014. The Ethics and Research Committee of Kano State Ministry of Health approved the study protocol on 4th July 2013.
A structured questionnaire was used to obtained participants' demographic characteristics, and the clinical history was extracted from the patients' case notes.
Venous blood samples were collected, in the appropriately anticoagulated bottles, from each participant. The full blood count was done using Mindray auto analyzer (BC 2800), erythrocyte sedimentation rate (ESR) using Westergren technique, and cresyl violet supravital stain was used to prepare slides for calculating reticulocytes count. G6PD enzyme kinetic was measured using spectrophotometer (model VIS721) at 340 nm absorbance with Gesan reagent, Lactate dehydrogenase (LDH) using UV method with RANDOX test kit (lot number: 298334), and bilirubin using colorimetric method. G6PD deficiency was defined as the enzyme activity <8.8 U/g according to the manufacturer's reference limit.
Continuous variables were summarized as means and standard deviations, whereas categorical variables were summarized as frequencies and percentages. The variables were compared between Gd− and Gd+ groups using unpaired t test and Pearson Chi square test. Test statistics with P value <0.05 were considered significant. An analysis was done using STATA version 13 (Stata Corps. College Station).
| Results|| |
We investigated the biochemical and hematological parameters of 198-male leprosy patients. The prevalence of G6PD deficiency was 9% (n = 17) as shown in [Figure 1]. The average age of the Gd− group (30.47 ± 14.37 years) was less than the Gd+ group (37.76 ± 14.13 years), P value 0.04. However, other demographic and medical histories such as ethnic identity, type of leprosy, Body Mass Index (BMI), and duration of treatment were not significantly different in the two groups as shown in [Table 1].
|Table 1: Demographic characteristics and medical history of the Gd− and Gd+ study participants|
Click here to view
[Table 2] shows the haematological and biochemical parameters of Gd- and Gd+. The average hemoglobin (Hb) in the Gd− group (10.56 ± 2.82 g/dl) was lower than the Gd+ group (12.9 ± 2.31 g/dl), P value < 0.001, similarly, for packed cell volume [31.63 ± 8.04% vs. 39.95 ± 8.11%], P value <0.001. However, there were no statistically significant differences in the mean corpuscular hemoglobin concentration (MCHC) [32.39 ± 1.51 vs. 31.99 ± 1.13; P value 0.18], mean corpuscular hemoglobin (MCH) [30.36 ± 3.29 vs. 29.57 ± 2.49; P value 0.23], mean corpuscular volume [93.67 fl ± 10.36 vs. 92.17 fl ± 6.32; P value 0.38], and red cell distribution width [18.82 ± 2.91 vs. 17.66 ± 7.2; P value 0.14]. The platelet count was significantly higher in the Gd− group (293.52 ± 3.19 × 109/l vs. 176.31 ± 2.83 × 109/l; P value < 0.001). Similarly, the total white blood cell count (WBC) was significantly higher in the Gd− group (9.45 ± 4.15 × 109/l vs. 7.2 ± 2.83 × 109/l, P value <0.001). Similar trend was also observed for reticulocytes count (4.49 ± 2.72% vs. 2.01 ± 1.07%, P value < 0.001). However, although the ESR was higher in the Gd− group (38.7 ± 34.77 mm/h vs. 26.09 ± 24.92 mm/h), the difference was not significant (P-value 0.05).
|Table 2: Hematological and biochemical parameters of Gd− and Gd+ participants|
Click here to view
The serum bilirubin [1.04 ± 0.22 mg/dl vs. 0.46 ± 0.27 mg/dl; P value <0.001] and LDH [269.82 ± 58.54 mg/dl vs. 130.26 ± 51.83 mg/dl; P value <0.001] were all significantly higher in the Gd− group. Expectedly, the G6PD enzyme activity was significantly lower in the Gd− group (7.25 ± 0. 89 vs. 12.6 ± 2.71; P value <0.001).
| Discussion|| |
In this study, we documented a lower prevalence of G6PD deficiency (9%) in male leprosy patients than the 15–26% expected for the Nigerian population. Our finding is lower than the 20% prevalence of G6PD in apparently normal blood donors in Jos, north-central Nigeria, and 25.5% reported in the southwestern part of Nigeria. In addition, the prevalence is lower than the 22% earlier reported in leprosy patients in India. However, it is higher than the prevalence of 1.5% reported among leprosy patients in Singapore. Perhaps, our finding under represents the expected prevalence, considering that G6PD A− has 10–60% activity and nearly 100% activity in the reticulocytes., May et al. have shown a trimodal pattern of G6PD A− activity in southwestern Nigeria, where 4.5% of those with G6PD A− have almost normal activity. However, there is no local study among leprosy patients from Nigeria to compare the findings of our study.
The average Hb level in the Gd− group was lower than the 11.5 g/dl considered as the reference limit for mild anemia in Nigerian males. In the Gd+ group (Gd+), the average Hb was just at the upper limit of the WHO reference limit for mild anemia. Many studies have demonstrated low Hb level in leprosy patients but none had compared it between the Gd− and Gd+.,, Both MCH and MCHC were essentially within normal range, which is in agreement with what was found in another study in Saudi Arabia. However, the Saudi Arabian study was longitudinal with 12 months follow-up period. Hence, it was able to further demonstrate the temporal decrease in MCH and MCHC from 30.6 and 32.4 to 28.1 and 30.5, at the time of diagnosis and 12 months after starting MDT, respectively.
The result of this study shows that Gd− has relatively higher platelet count, higher WBC, and higher reticulocyte count. These findings generally confirm the hemolytic nature of G6PD deficiency. Higher platelet can be an indicator of hemolysis induced erythropoietin response; a hormone with cross-reactivity to thrombopoietin. Rebound leucocytosis is another feature of stress hemopoesis associated with hemolysis. Several studies have demonstrated reticulocytosis in both Gd− associated hemolysis and dapsone related hemolysis in leprosy patients.,, Kim et al. attributed 3.9% of the causes of anemia in their study participants to hemolysis. In contrast, another study demonstrated decreased level of platelet count in leprosy patients treated with 100 mg of dapsone, but no similar inference was made among those placed on 50 mg. It is difficult to draw similar parallel with this study because the investigators did not screen for G6PD deficiency.
Interestingly, both bilirubin and LDH were also higher in Gd−. In support of this finding, a study had documented evidence of hyperbilirubinaemia in Gd− patients treated with dapsone containing antimalarial. In addition, a temporal rise in bilirubin from 0.81 mg/dl (at the point of diagnosis) to 1.0 mg/dl (at the 12th month of treatment) was reported by Al-Sieni et al. LDH, like bilirubin and reticulocytes, is an indirect marker of hemolysis. Therefore, our findings of anemia and raised indirect hemolytic markers are suggestive of ongoing hemolysis in the Gd−.
The strengths of this study are in being one of a few that have reported the prevalence of G6PD deficiency in the patients with leprosy and its likely effect on hematological and biochemical parameters. Our study design is easy to replicate and has minimal risk of attrition because everything was taken as a snapshot.
The study is limited by failure to screen for more direct markers of hemolysis such as plasma free Hb. We did not also screen for malaria and other common causes of anemia such as iron and folate deficiencies. Moreover, the cross-sectional nature of the design would not allow for follow-up, as such temporality cannot be established by this study design.
| Conclusion|| |
This study has shown that the prevalence of G6PD deficiency in male leprosy patients is lower than in the general population. It has also demonstrated a comparatively lower Hb and increased indirect hemolytic markers in leprosy patients with G6PD deficiency. A further longitudinal study is recommended to look at the effect of dosage on blood parameters of both Gd− and Gd+ leprosy patients. Proper screening for G6PD activity should be encouraged in the national protocol for leprosy control program. More research is needed to develop new and safer drugs for the treatment of this neglected tropical disease to save patients from avoidable adverse effects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
LuzzattoL, Poggi V. Glucose-6-phosphate dehydrogenase deficiency. In: Stuart H, Nathan DG, Ginsburg D, Thomas A, Samuel E, editors. Nathan and Oski'sHaematology of Infancy. 7th
ed. Philadelphia: Saunders Elsevier; 2009. p. 883-900.
Luzzatto L. Glucose 6-phosphate dehydrogenase deficiency: From genotype to phenotype. Haematologica 2006;91:1303-6.
Zanella A, Edward CG. Disorders of red cell metabolism. In: Hoffbrand AV, Catovsky D, Tuddenham EGD, Green AR, editors. Postgraduate Haematology. 6th
ed. India: Wiley-Blackwell; 2005. p. 140-56.
Van Solinge WW, Van Wijk R. Disorders of red cells resulting from enzyme abnormalities. Williams Hematology. 8th
ed. New York: McGraw-Hill Medical Publishing; 2010. p. 647-74.
Bertil G. Hereditary Hemolytic Anemias Due to Red Cell Enzyme Disorders. In: Greer JP, Foerster J, Rodgers GM, Paraskevas F, Gladder B, Arber DA, et al
, editors. Wintrobe's Clinical Hematology. 12th
ed. Philadelphia: Wolters Kluwer/Lippincott; 2009. p. 933-49.
Pamba A, Richardson ND, Carter N, Duparc S, Premji Z, Tiono AB, et al
. Clinical spectrum and severity of hemolytic anemia in glucose 6-phosphate dehydrogenase–deficient children receiving dapsone. Blood 2012;120:4123-33.
Ruth L, Diana L. Leprosy. In: ParryE, Godfrey R, Mabey D, Gill G, editors. PrinciplesofMedicineinAfrica. 3rd
ed. New York: Cambridge University Press; 2004.p. 575-90.
Sofola O. Leprosy elimination campaign: The Nigerian experience. LeprRev 1999;70:465-71.
Bennett BH, Parker DL, Robson M. Leprosy: Steps along the journey of eradication. Public Health Rep 2008;123:198-205.
Von Pelt ED, den Hollander JC, de Vries HJ, van Beek Y, Melles DC, van der Meijden WI, et al.
Atropical disease characterized by rapidly progressive skin lesions and haemolyticanaemia. Neith J Med 2011;69:400,404.
Kher M, Grover S. Glucose-6-phosphate-dehydrogenase deficiency in leprosy. Lancet 1969;293:1318-9.
Saha N, Wong HB, Baneerje B, Wong MO. Distribution of ABO blood groups, G6PD deficiency, and abnormal haemoglobinsin leprosy. J Med Genet 1971;8:315-6.
Carol B, Barbara JB. Basic haematological techniques. In: Barbara JB, Imelda B, Mike AL, Lewis SM, editors. Practical Haematology. 11th
ed. Edinburgh: Churcilllivingstone; 2012. p. 33-6.
Egesie OJ, Joseph DE, Isiguzoro I, Egesie UG. Glucose-6-phosphate dehydrogenase (G6PD) activity and deficiency in a population of Nigerian males resident in Jos. Niger J of Physiol Sci 2008;23:1-2.
Omisakin CT, Esan AJ, Ogunleye AA, Ojo-Bola O, Owoseni MF, Omoniyi DP. Glucose-6-phosphate dehydrogenase (G6PD) deficiency and sickle cell trait among blood donors in Nigeria. Am JPubl Health Res 2014;2:51-5.
May J, Meyer CG, Großterlinden L, Ademowo OG, Mockenhaupt FP, Olumese PE, et al
. Red cell glucose-6-phosphate dehydrogenase status and pyruvate kinase activity in a Nigerian population. Trop MedInt Health 2000;5:119-23.
Okpala I. Normal haempoiesis and bone marrow failure. In: Okpala I, Johnson C, editors. Synopsis of HaematologyIncluding Blood Diseases in the Tropics. 1st
ed. South Carolina: Createspace Publishers; 2010. p. 1-15.
Halim NK, Ogbeide E. Haematological alteration in leprosy patients treated with dapsone. East Afr Med J 2002;79:100-2.
Kim JP, Kim YS, Lee RH. The study of anemia in persons affected leprosy. Korean Lepr Bull 2011;44:53-61.
Deps P, Guerra P, Nasser S, Simon M. Hemolytic anemia in patients receiving daily dapsone for the treatment of leprosy. LeprRev 2012;83:305-7.
Al-Sieni AI, Al-Layati WZ, Al-Abbasi FA. Temporal adverse effects in leprosy Saudi patients receiving multidrug therapy. Clin Exp Pharmacol 2013;4:1-4.
Kenneth K. Reactive thrombocytosis. In: Marshal A, Kenneth K, Thomas J, Josef T, Marcel M, editors. Williams Hematology. 8th
ed. New York: McGraw-Hill Medical Publishing; 2010.p. 1929-31.
David C. Neutropenia and neutrophilia. In: Marshal A, Kenneth K, Thomas J, Josef T, Marcel M, editors. Williams Hematology. 8th
ed. New York: McGraw-Hill Medical Publishing; 2010.p. 939-49.
Donà G, Ragazzi E, Clari G, Bordin L. Hemolysis and anemia induced by dapsone hydroxylamine. INTECH Open Access Publisher; 2012. Available from: http://cdn.intechopen.com/pdfs/30561.pdf
. [Last accessed on 2013Jan 10].
Dupnik KM, Cardoso FJ, De Macêdo AL, De Sousa IL, Leite RC, Jerônimo SM, et al
. Intolerance to leprosy multi-drug therapy: More common in women. Lepr Rev 2013;84:209-18.
Kato GJ, McGowan V, Machado RF, Little JA, Taylor J, Morris CR, et al
. Lactate dehydrogenase as a biomarker of hemolysis-associated nitric oxide resistance, priapism, leg ulceration, pulmonary hypertension, and death in patients with sickle cell disease. Blood 2006;107:2279-85.
[Table 1], [Table 2]