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Introduction
Red blood cells have several protective mechanisms to prevent oxidative stress. One such mechanism is the Glucose 6 phosphate dehydrogenase enzyme (G6PD).Deficiency of this enzyme is widely prevalent. Usually most patients remain asymptomatic .When subjected to oxidative stress which can happen due to numerous triggers; these patients undergo intravascular hemolysis which can range in severity. Many of the triggers have been identified and have been reported. We present a case report of a patient with underlying G6PD deficiency who developed intravascular hemolysis and methemoglobinemia triggered by the consumption of a liquid preparation of a herbal medicine  [Acalypha indica] which is used widely used in India in a branch of alternative medicine called Ayurveda. There have been only two reports of this in the past both from Srilanka in the nineties. We present this case because of its rarity and interesting features and also to reconfirm that this particular herbal remedy needs to be used with caution in those patients whose G6PD status remains unknown.
Case report
A 54 year old male patient, a known diabetic was admitted with complaints of headache and vomiting for three days, yellowish discoloration of eyes for two days, dark colored urine, fever and fatigue for two days. Patient had consumed a liquid preparation of an herbal extract called kuppameni (Botanical name - Acalypha indica). Examination of patient revealed presence of pallor and icterus. His systemic examination was normal. His urine was dark brown in appearance and room air oxygen saturation (SaO2) was 74 %.SaO2 remained at 74% in spite of 10 litres of oxygen supplementation. Complete blood count (CBC) revealed hemoglobin of 8.6 grams/dl, WBC count was elevated (40900 cells/ mm3) and platelet count was normal (2.44 lakhs/mm3). Peripheral smear showed presence of anisopoikilocytosis and fragmented cells. Supra vital stains showed a uncorrected reticulocyte count of 7.8% (corrected reticulocyte count � 4.44%) and presence of Heinz bodies with neutrophilic leucocytosis and normal platelet morphology. Urine examination showed presence of albuminuria and hemoglobinuria. Liver function tests revealed a total bilirubin level of 6.5 mg/dl with predominant indirect hyperbilirubinemia (6.3mg/dl).Serum electrolytes, serum creatinine, blood urea, alkaline phosphatase, aminotransferases (SGPT, SGOT) were all within normal limits.  Arterial blood gas analysis (ABG) revealed a partial pressure of oxygen of (PaO2) of 70 mm hg with saturation (SaO2) of 97% with normal partial pressure of carbon dioxide (PCO2) and pH. Serology for Human immunodeficiency virus; hepatitis B and hepatitis C were negative. Since room air saturation was low and it was not corrected with oxygen supplementation blood methemoglobin levels were done and was found to be high (19.2%).Thus our patient had anemia, hemoglobinuria, indirect hyperbilirubinemia and methemoglobinemia.
     Work up for hemolytic anemia was done. Serum lactate dehydrogenase was found to be 1995 U/dl, direct Coomb�s test was negative, and serum Glucose 6 Phosphate Dehydrogenase enzyme (G6PD) level was 9U/gm Hb (normal range 7-20.4U/gm Hb). Ultrasound abdomen and echocardiogram were within normal limits. Serial methemoglobin and indirect bilirubin levels showed a decreasing trend with the methemoglobin level at the time of discharge being 1.2%. During the course of hospital stay patient developed transient renal dysfunction with creatinine reaching a value of 2.3mg/dl on third day of hospital stay and reducing to 1.8 mg/dl at time of discharge. Patient was treated with 3 units of packed cell transfusions, IV fluids and supportive measures. At time of discharge SaO2 was 100% in room air. G6PD level done 5 months after discharge showed a value of 6.4 U/gm Hb confirming the deficiency.
Discussion
G6PD is an enzyme present in red blood cells (RBC's) preventing oxidative injury [1]. Deficiency of G6PD can lead on to hemolytic anemia because of oxidative damage. Glutathione is a chemical present in RBC�s that has free radical scavenging and neuromodulatory function. Glutathione is present in both the oxidized and reduced forms. Free radicals convert reduced glutathione to the oxidized form and in turn it is regenerated with the help of the enzyme glutathione reductase which has NADPH as a cofactor. G6PD is needed for the generation of NADPH. Hence G6PD deficiency can lead to accumulation of glutathione in the oxidized form thus leading to oxidative damage [2].
G6PD deficiency is the most common enzyme deficiency in the world [2].  7.5% of the world�s population has either one or two gene mutation for G6PD deficiency[3]. The two main abnormal variants of the G6PD enzyme are the A- variant and the Mediterranean variant. The Mediterranean variant is common in India and Middle East whereas the A- variant is common in Africa and Southern Europe .The gene for the enzyme is located on the X chromosome in the long arm. So males are generally heterozygous and women can have any pattern from normal to heterozygous to homozygous.
Patients with G6PD deficiency are asymptomatic and are not anemic. The clinical features of G6PD deficiency include acute hemolytic anemia, neonatal jaundice and chronic non spherocytic hemolytic anemia. The acute hemolytic anemia in G6PD deficiency can be commonly triggered by infection, drugs like primaquine, dapsone & nitrofurantoin, fava beans, henna, tea and naphthalene. The duration of the hemolysis depends on the type of variant of whether it is A- or Mediterranean variant with hemolysis being more severe in the Mediterranean variant. Usually hemolysis is self limited.
G6PD levels can be measured qualitatively or quantitatively. Quantitative tests may be falsely negative immediately after a hemolytic episode because there is a reticulocytosis immediately after the hemolytic episode and the younger RBC's contain higher G6PD levels compared to older cells [1].The offending agent has to be discontinued if hemolysis occurs, and in case of severe anemia, packed cell transfusions can be given. The patient has to be counseled about avoidance of known triggers of hemolysis.
Acalypha indica is a medicinal herb used frequently in India. It is used in Ayurveda. [4] It belongs to the family Euphorbiaceae. It grows in deciduous and monsoon forests. It is said to have multiple medicinal properties like liver protective effect, anti inflammatory, antimicrobial and antitussive effects. Various parts of the plants have been used such as the roots, leaves, seeds and flowers. It is used in various formulations such as powder, decoction, liquid extract and juice. It has been used in a variety of conditions such as scabies, rheumatism, to relieve constipation and also for bed sores.
Our patient who was a middle aged male patient with history of consuming kuppameni which is an herbal preparation of Acalypha indica presented with features of intravascular hemolysis and methemoglobinemia. He also had underlying G6PD deficiency. G6PD levels done during hemolytic episode was normal which can be explained by the preponderance of RBC precursors which has greater G6PD activity compared to older RBCs. There was serial increase in serum creatinine levels secondary to hemolysis which subsequently resolved. The acute hemolytic episode in this patient with underlying G6PD deficiency was triggered by the herbal preparation kuppameni (acalypha indica).There are only two publications in the literature prior to this from Srilanka [5,6]. We present this case report because it is rare and interesting and also to advice caution regarding use of this particular preparation especially if the G6PD status of the person is unknown [4].





	


References
Lucio Luzzatto. Hemolytic anemias and anemia due to acute blood loss. In: S Fauci, E. Braunwald, D.L. Kasper et al Eds. Harrison�s Principles of Internal Medicine.18th edn. New York: Mc Graw Hill, 2012: 872-887
 Elizabeth A Price, Stavroula Otis, Stanley L. Schrier. Red blood cell enzymopathies. In: Ronald Hoffman, Edward J Benz.Jr, Leslie E. Silberstein et al Eds. Hematology: Basic Principles and Practice. 6th edn. Philadelphia; Saunders 2013.
3. DD Farhud, L Yazdanpanah. Glucose 6 Phosphate dehydrogenase Deficiency. Iranian Journal of Public Health. 2008; 37; 4; 1-18
4. D.Jageteeshwari, J.Deepa et al. Acalypha indica L-an important medicinal plant; a Review of its traditional uses and pharmacological properties. International Journal of research in botany 2013; 3; 1: 19-22
5. Lamabadusuriya SP, Jayantha UK. Acalypha indica induced haemolysis in G6PD deficiency. Ceylon Med J. 1994; 39;1: 46-7.(Abstract only)
6. Sellahewa K. Acalypha indica induced haemolysis in G6PD deficiency. Ceylon Med J. 1994; 39; 3:145. (No abstract available)



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