Glucose 6 Phosphate Dehydrogenase Deficiency G6PD

Chair’s Rounds:
G6PD
Elliot Stieglitz
1/23/13
Peds H/O Fellow
Sunday, September 29, 13

Outline

Outline
• G6PD Background

Outline
• G6PD Background
• Hemolysis

Outline
• G6PD Background
• Hemolysis
• Clinical manifestations

Outline
• G6PD Background
• Hemolysis
• Diagnosis andTreatment

Outline
• G6PD Background
• Hemolysis
• Diagnosis andTreatment
• Follow up of our patient

Background

Background
• Function of G6PD is to protect red cells from oxidative damage

Background
• Most common enzymopathy affecting red blood cells (200-400
million people worldwide)

Background
• Classiﬁcation schema:

Background
• Clinical class

Background
• Clinical class
• Enzyme variants

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,

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

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

• 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

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

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

Hemolysis

Hemolysis
John Lazarchick, ASH Image Bank 2011; 2011-4027
Blister cell - 1.

Hemolysis
John Lazarchick, ASH Image Bank 2011; 2011-3820
Bite cell - 1.

Copyright © 2011 American Society of Hematology. Copyright restrictions may apply.
Peter Maslak, ASH Image Bank 2011; 2011-4044
Schistocyte - 1.
Hemolysis

Hemolysis
http://www.fracp.bigpondhosting.com/examquestions/2003/2003papertwo31to40.htm

Clinical Manifestations

• Neonatal Jaundice

• Acute vs Chronic hemolysis

• Infection, oxidant drugs, chemical agents, fava beans

• Keep in mind other blood cells require G6PD as well

• Keep in mind other blood cells require G6PD as well
• Phagocytosis could be impaired

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
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For personal use only.at UCSF LIBRARY & CKM on January 21, 2013.bloodjournal.hematologylibrary.orgFrom

1982 59: 428-434
FJ Zuazu
Barcelona)
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.

1982 59: 428-434
FJ Zuazu
Barcelona)
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.

Dx and Rx

Dx and Rx
• Dx

Dx and Rx
• Dx
• Signs and symptoms of hemolysis

Dx and Rx
• Dx
• G6PD assay

Dx and Rx
• Dx
• G6PD assay
• Heinz body preparation

Dx and Rx
• Dx
• G6PD assay
• Rx

Dx and Rx
• Dx
• G6PD assay
• Rx
• Supportive care

Dx and Rx
• Dx
• G6PD assay
• Rx
• Supportive care
• Transfusions (Keep in mind donor source!)

Dx and Rx
• Dx
• G6PD assay
• Rx
• Supportive care
• Transfusions (Keep in mind donor source!)
• Guidance on what to avoid

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

Follow up visit

Take Home Points

Take Home Points
• G6PD is relatively common in certain populations

Take Home Points
• There are different categories of severity

Take Home Points
• Possibly protects against P. falciparum

Take Home Points
• All cells need G6PD

Take Home Points
• All cells need G6PD
• No need to test for G6PD during acute hemolysis

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/

Glucose 6 Phosphate Dehydrogenase Deficiency G6PD

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