Glucose 6 Phosphate

Dehydrogenase
Deficiency
Section A2
Group 5:
Capacio, Diane Chloe
Cardeno, Sheree Anne Rachille
Casem, Princess Joy P.
Castaneda, Felix
Castro, John Michael
Ceneta, Raymond
After the discussion, the class will be able to:
• Explain the Hexose Monophosphate Shunt

• Discuss the importance of G6PD as to the reaction it catalyzes, and its role in the
HMP shunt

• Define the classes of mutations involved in G6PD, the characteristics of each

class, and to what class of mutation case 1 and case 2 belong

• Determine the role of Glutathione in the development of hemolytic anemia in

G6PD deficiency

• Enumerate the drugs that can precipitate hemolytic anemia among patients with
G6PD deficiency

• Know the reason why patients who have G6PD have a lesser tendency in
contracting malaria

• Define what DNA analysis is best for identification of carriers and patient diagnosis
CASE 1
J.R., a 26 y/o black male had been in a good condition until 1 wk before he was
admitted he developed signs of Respiratory infection and low grade fever. Self
medication with over the counter cold preparation did not alleviate his Sx. 1 day
before admission, he experienced chills and hacking cough.
P.E.:
-Icterus -T: 40 C
-Bronchial breathing with rales -PR: 120bpm
-Dyspneic

Lab Findings includes:

-Hgb: 8.4 g/dL WBC:
18,000/µL
-Leukocyte & Bilirubin: 3.2 mg/dL Reticulocyte: 1.2%
-Gram positive diplococcic in sputum

DX: Pneumococcus Pneumonia

TX: PENICILLIN
Lab findings after treatment:
(+) Pneumoccoci in sputum and blood
-Less pronounced dyspnea
-afebrile
-Hgb: 13.8 g/dL
-Reticulocyte count: 12%

The doctor advised him never to take aspirin and a long list of
drugs that should be avoided. The patient experienced no further
hemolytic episode.
 D.M. at 1 1 day of After Family 6 y/o: After 1 14 y/o:
year: Ultraviolet several Hx: year:
light tx: days:

-Bilirubin: 14 -Bilirubin: 17 -Hgb: fell 13 -Brother: -Dark urine -Splenectomy -RBC is

mg/dL mg/dL g/dL anemia and during was done bec. profoundly
darkening of respiratory of deficient in
Tx: ultraviolet -Bilirubin: the urine infection spherocytosis G6PD.
light lower readings during RTI and -Hgb 5.4 g/dL -Hgb: no -During infxn
UTI change D.M.
sometimes
exp. Hemolytic
episodes.

-Reticulocyte -Maternal -Transfusion of -Blood

count: 5-10% uncle: 1 U packed contained
intermittent RBC nucleated red
jaundice and cells and red
anemia -Hgb: rose to cells with
his usual level nuclear
fragments
(heinz bodies)

-Platelet count:
700 x 10^9/L
OVERVIEW:
 G6PD catalyzes the oxidation of Glucose 6 Phosphate to
6 Phosphogluconolactone, while reducing Nicotinamide
adenine dinucleotide phosphate (NADP) to reduced form
(NADPH)

 Most common enzymatic disorder of RBC in humans. (Cpt

Ali R. Elyassi etal., 2009)

 Its activity is profoundly regulated by NADP/NADPH ratio.

 NADPH then reduces oxidized glutathione into reduced

glutathione which in turn counteracts the toxic hydrogen
peroxide(H2O2).
1st Reporter: Casem, Princess Joy P.
 THE HEXOSE MONOPHOSPHATE SHUNT

• Also known as the Pentose Phosphate Pathway (PPP)

• Has 2 major functions:

a) Generates Nicotinamide Adenine Diphosphate
(NADP) for reductive synthesis – Fatty acid and
Steroid biosynthesis; reduction of glutathione
b) Synthesis of Ribose for nucleotide and nucleic
acid formation.
•2 Phases:
a)Oxidative phase
b)Nonoxidative phase
 Glucose 6-Phosphate

NA
NAD Glucose 6-Phosphate
DP dehydrogenase
P+
H

6-Phosphogluconolactone

Gluconolactone
hydrolase

6-Phosphogluconate

6-Phosphogluconate
NADP+ NADPH
dehydrogenase

Ribulose 5-Phosphate
Importance of G6PD
• Enzyme that catalyzes G6P to 6 Phosphogluconolactone

• 1st enzyme in the PPP

•Rate limiting enzyme of the PPP

• Requires NADP as hydrogen acceptor thereby reducing NADP

to NADPH

•The PPP produces NADPH in the RBC membrane

G6PD deficiency in Hemolytic Anemia

 - Most common red cell enzymopathy associated

with hemolysis.
 - G6PD enzyme is necessary for subsequent
production of NADPH and glutathione through
HMP shunt pathway.
 -Reduced Glutathione protects enzymes and
hemoglobin against oxidation by reducing
hydrogen peroxide and free radicals.
 - Heme is liberated from globin and globin
denatures forming Heinz bodies.
2nd Reporter: Castaneda, Felix II
Heinz bodies
 - consist of denatured hemoglobin
 -best identified by staining with basic
dyes such as cresyl violet.
 - Occurs in individuals with a deficiency
of G6PD
 - causes of Heinz bodies formation:
Oxidative stress results from fava beans
and primaquine consumption
 leads to the formation of “Bite cell”
Heinz bodies
Bite cells
 When RBC with heinz bodies passes
the spleen, the spleenic macrophages
will attack the hb removing along with it
a part of RBC membrane while leaving
the red cell intact. (pitting)
Bite cell
 Mutation into the gene for G6PD

Activity of G6PD

Levels of NADPH

Regeneration of GSH (Reduced Glutathione) from

GSSG (Oxidized) by Glutathione Reductase (which
uses NADPH)

Oxidation due to decreased level of GSH and Increase

level of Intracellular oxidants (e.g H2O2) of SH groups of
Hb
(forming heinz bodies) , and of membrane proteins, altering
membrane structure and increasing susceptibility to
ingestion by macrophages.

Hemolysis
 5 Classes of G6PD:
Class 1—enzyme deficiency with chronic hemolytic anemia
(<10% of normal activity)

Class 2—Class II variants also have severe enzyme

deficiency, but there is usually only intermittent
hemolysis.

Class 3—Class III variants have moderate enzyme

deficiency (10 to 60% of normal) with intermittent hemolysis,
usually associated with infection or drugs.

Class 4—have no enzyme deficiency nor hemolysis

Class 5—increased enzyme activity

Fortunately, only a small number of people fall into Class 1

Classes IV and V are of no clinical significance.

 Drugs that can precipitate hemolytic anemia
in patients with G6PD

3rd Reporter: Capacio, Diane Chloe

 Definite Risk of Hemolysis Possible Risk of Hemolysis
Class Drugs Class Drugs
Antihelmintic Niridazole Analgesic Acetanilide
Aspirin
Antibiotic Nitrofurantoin Antibiotic Furazolidone
Nalidixic acid
Sulfamethoxazole
Sulfacetamide
Antimalarial Primaquine Dx. Agent for Toluidine Blue
CA detection
Antimethemog Methylene Blue Others Naphthalene
lobinemic Trinitrotoluene
Urate Oxide
Antimycobacte Thiazosulfone
rium
Genitourinary Phenazipyridine
analgesic
 This drugs may induce hemolysis in G6PD
deficiency (Koda-Kimble, 1978)
 In G6PD deficient individuals, oxidative
stress may result in the denaturation, or
unfolding, of the hemoglobin molecule, the
principal oxygen carrying molecule inside the
red blood cells.
 This results in the loss of biological function
with respect to hemoglobin and leads to the
inability of the red blood cell to effectively
transport oxygen throughout the body
(Yoshida & Beutler, 1986). 
 Overview about Malaria
 Malaria is a febrile illness caused by sporozoa
of genus Plasmodium, with four species which
infects humans: P. falciparum, P. vivax, P.
ovale, and P. malariae

 Undergo developmental stages in the female

Anopheles, which is a vector.
 G6PD have lesser tendency to contact
malaria

 a deficiency in G6PD has been shown to

sometimes confer a resistance to the
malaria-causing parasite, Plasmodium
falciparum  (Scriver et al., 1995).

 P. falciparum – most severe form of malaria

 Found in warm, moist climates and distributed
over most tropical places like Africa, South
East Asia etc.

 This resistance is due to the fact that the

parasite selectively infects red blood cells.

 This renders mature erythrocytes more

vulnerable to oxidative stress and the
mechanism of protection produced by the
G6PD deficiency condition.
 In G6PD deficient red blood cells, an
essential metabolite for the survival of the
parasite is present in insufficient quantities.

 A reduction in the amount of functional

glucose-6-dehydrogenase appears to make it
more difficult for this parasite to invade red
blood cells.

 This is due to decreased activity of G6PD

within these cells which ultimately leads to the
death of the parasite (Farid, personal
interview).
Method in identifying patients and carriers
with G6PD

 Genetic analysis of DNA provides accurate

results in patients without symptoms and
those undergoing hemolysis.

Molecular techniques:
 Polymerase chain reaction amplification
 Restriction enzyme digestion
Polymerase chain reaction amplification

 is a laboratory technique for "amplifying" a

specific DNA sequence. PCR is extremely
efficient and sensitive; it can make millions
or billions of copies of any specific
sequence of DNA.
 Restriction enzyme digestion
 are enzymes isolated from bacteria that
recognize specific sequences in DNA and
then cut the DNA to produce fragments,
called restriction fragments. Restriction
enzymes play a very important role in the
construction of recombinant DNA
molecules.
 Laboratory Diagnostic Tests

 Serum Direct Bilirubin Level

 Complete blood count
 Haptoglobin Level
 Reticulocyte count
 Serum Direct Bilirubin Test
 an important part of routine newborn (neonatal)
diagnostic screening tests.

 The level of bilirubin in a newborn's blood serum is

measured to determine if the circulating level of bilirubin
is normal or abnormal.

 Case 1 Lab findings:

bilirubin test = 3.2 mg/dL

 Normal: 0.1-0.4mg/dL
Complete Blood Count (CBC)
 It is a screening test used to diagnose and
manage numerous diseases. The results
can reflect problems with fluid volume
(such as dehydration) or loss of blood.
 The test can reveal problems with red
blood cell production and destruction, or
help diagnose infection, allergies, and
problems with blood clotting.
 Case 1 Lab findings:
Hemoglobin count = 8.4 g/dL
(N= above 14 g/dL)
WBC = 18,000/uL
(N= 5,000 – 10,000/uL)

 Case 2 Lab findings:

Hemoglobin count = 13.8 g/dL
 Haptoglobin Test
 is a blood protein made by the liver. The
haptoglobin levels decrease in hemolytic
anemia. Hemolytic anemias include a
variety of conditions that result in
hemolyzed, or burst of the red blood
cells.

 Normal: 27-139mg/dL
 Reticulocyte Count
 The test is done to determine if red blood
cells are being created in the bone marrow
at an appropriate rate.
 The number of reticulocytes in the blood is
a sign of how quickly they are being
produced and released by the bone marrow.

 Normal: 1 – 2% adult
1 - 3% infant
 Case 1 Lab findings:
Reticulocyte count = 1.2%
(N= 1 – 2%)

 Case 2 Lab findings:

Reticulocyte count = 10%
NORMAL VALUES:
 RBC (varies with altitude):
Male: 4.7 to 6.1 million cells/mcL
Female: 4.2 to 5.4 million cells/mcL
 WBC: 4,500 to 10,000 cells/mcL
 Hematocrit (varies with altitude):
Male: 40.7 to 50.3 %
Female: 36.1 to 44.3 %
 Hemoglobin (varies with altitude):
Male: 13.8 to 17.2 gm/dL
Female: 12.1 to 15.1 gm/dL
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http://rialto.com/g6pd
http://themedicalbiochemistrypage.org/g6pdhdeficiency.html
http://www.answers.com/topic/polymerase-chain-reaction