Possible fenugreek induced haemolysis in a patient with previously unknown G6PD deficiency

Abstract

Glucose 6 phosphate dehydrogenase (G6PD) deficiency is the most common disease producing enzymopathy. People with G6PD deficiency cannot cope with oxidative stressors. These patients are asymptomatic until they develop a haemolytic crisis which presents as anaemia and jaundice. The agents known to cause haemolysis in these patients are: oxidant drugs, (primaquine, chloroquine and other anti-malarials), antibiotics, (chloramphenicol, nitrofurantoin, sulphonamides, and all quinolone antibiotics). Chemicals to be avoided are moth balls (napththalene), aniline dyes, and some Chinese herbal medicine (San Chi, Chuan Lian). The classic presentation of exposure to Fava beans (legumes), causing oxidative haemolysis, has led G6PD deficiency to be also known as Favism. The patient we present here had no exposure to any of the known causes of oxidative haemolysis. Instead his precipitating cause strongly suggests raw fenugreek (T foenum-graecum L), a legume used as a herbal treatment for diabetes and previously not known to be a precipitant of haemolysis in G6PD deficiency.

BACKGROUND

Fenugreek has not been known to cause haemolysis in individuals with glucose 6 phosphate dehydrogenase (G6PD) deficiency and it is believed that this is the first documented case. It is important that awareness of this precipitant causing haemolysis be documented as well as follow-up studies be performed.

CASE PRESENTATION

In January 2008, a 16-year-old Asian Indian man was admitted to our hospital with a 4 day history of feeling unwell and progressively worsening yellow skin and eyes. His other medical problems included an 8 month history of poorly controlled insulin dependent diabetes. He was prescribed long acting insulin (Novorapid, Levemir), and was also taking Karela (bitter melon) for his diabetes. He smokes and drinks occasionally. The patient denied any pain or pruritus and complained of no other symptoms. He had no history of recent travel, change in diet, abdominal pain, or nausea and vomiting, and had received no blood transfusions. His stool was not pale and his urine was dark coloured and contained 4+ sugar. He had no previous diagnosis of any blood disorders or specifically G6PD deficiency. On physical examination, he had pronounced jaundice of the sclera and skin. He was apyrexial. There was no organomegaly and no abdominal findings.

He had started to take fenugreek seeds a week before his admission. He was told by someone knowledgeable in herbal medicine to take 2–3 raw fenugreek seeds twice a day to help with diabetic control. He instead took a teaspoonful of seeds once a day (approximately 30–40 seeds). Further research at G6PDDeficiency.org revealed that fenugreek is a legume and the statement, “people may react less severely to other legumes besides fava beans” is made on the website.¹ It was concluded in the absence of any other known precipitant that fenugreek triggered this episode of haemolysis.

INVESTIGATIONS

His laboratory values of note on admission (29 January 2008) were:

• Full blood count: haemoglobin 12.7 g/dl (normal 13–17; whereas in September 07 it was 14.9 and subsequently on February 27 it was 16.4), red cell count 4.26×10¹²/l (normal 4.4–5.8), packed cell volume (PCV) 0.37 l/l (normal 0.37–0.5), mean cell volume (MCV) 87.8 fl (normal 80–99), mean corpuscular haemoglobin (MCH) 29.8 pg (normal 26–33.5), mean corpuscular haemoglobin concentration (MCHC) 34.0 g/dl (normal 30–35), red cell distribution width (RDW) 12.7% (normal 11.5–15), white cells 6.2×10⁹/l (normal 3–10), neutrophils 64.4%, 4.0×10⁹/l (normal 2–7.5), lymphocytes 28.3%, 1.8×10⁹/l (normal 1.5–4), monocytes 5.0%, 0.3×10⁹/l (normal 0.2–1), eosinophils 1.8%, 0.1×10⁹/l (normal 0–0.4), basophils 0.5%, 0.0×10⁹/l (normal 0–0.1).

• Coagulation screen: prothrombin time 9.8 s (normal 11.1–13.5), activated partial thromboplastin time (APTT, PTTK) 30.9 s (normal 22–41), APTT ratio 1.11, fibrinogen 1.93 g/l (normal 1.5–4), international normalised ratio (INR) 0.90.

• Renal profile: sodium 134 mmol/l (normal 135–145), potassium 4.4 mmol/l (normal 3.5–5.1), urea 4.2 mmol/l (normal 1.7–8.3), creatinine (sample icteric—unsuitable for analysis).

• Liver profile: bilirubin 267 (unconjugated hyperbilirubinaemia) (as opposed to July 07 when it was 32), alkaline phosphatase 118 IU/l (normal 0–390). Reticulocyte count 2.5% (normal 0.38–2.64), lactate dehydrogenase 380 IU/l (normal 240–480), ferritin 551 ng/ml (normal 30–400), B12 559 pg/ml (normal 180–914), folate (serum) 5.7 ng/ml (normal 3.1–17.5), blood film comment—sample sent away before blood film made.

• Urine culture: white blood cells/cmm <10, red blood cells/cmm <1, epithelial cells not seen, crystals not seen, casts not seen, bacteria not seen, debris not seen, isolate no bacterial growth.

• G6PD screen deficient, G6PD quantitative assay 0.3 U/g Hb (normal 5–21), haptoglobins 0.5 g/l, Hep B surface antigen non-reactive, Hep C antibody non-reactive, α1-antitrypsin 1.09 g/l (normal 1.1–2.1), α1-antitrypsin phenotype (AAT mutations screened: PI*Z (M=wild type, Z=penetrant mutation) PI*S (M=wild type, S=mutation with low disease penetrance); result = PI*MM (patient has screened negative for both mutations. The DNA result greatly reduces the likelihood that this patient is affected with α1-antitrypsin deficiency), caeruloplasmin 0.22 g/l (normal 0.2–0.6), auto-antibody profile: smooth muscle antibodies negative, mitochondrial antibodies negative, gastric parietal cell antibodies negative, LKM (liver–kidney microsomal) antibodies negative.

On 1 February, the patient’s laboratory values were:

• Full blood count: haemoglobin 12.0 g/l, red cell count 4.00×10¹²/l, PCV 0.37 l/l, MCV 91.5 fl, MCH 30.0 pg, MCHC 32.8 g/dl, RDW 13.3%, white cells 4.7×10⁹/l, neutrophils 42.2%, 2.0×10⁹/l, lymphocytes 47.0%, 2.2×10⁹/l, monocytes 6.8% 0.3×10⁹/l, eosinophils 3.8% 0.2×10⁹/l, basophils 0.2% 0.0×10⁹/l.

• Coagulation screen: prothrombin time 10.6 s, APTT (PTTK) 34 s, APTT ratio 1.22, fibrinogen 1.89 g/l, INR 1.00.

• Renal profile: sodium 140 mmol/l, potassium 3.8 mmol/l, urea 6.7 mmol/l, creatinine (sample icteric—unsuitable for analysis).

• Liver profile: bilirubin 234, direct bilirubin (conjugated) 7 μmol/l (normal 0–5), alkaline phosphatase 110 IU/l, alanine transaminase 10 IU/l (normal 10–50), albumin 47 g/l (normal 32–45), γ-glutamyl transferase 11 IU/l (normal 9–40), calcium 2.44 mmol/l (normal 2.15–2.55), corrected calcium 2.33 mmol/l (normal 2.15–2.55), C reactive protein 1 mg/l (normal 0–5), reticulocyte count 4.5%, haptoglobin 0.8 g/l (normal 0.5–2), ferritin 481 ng/ml. Abdominal ultrasound—liver normal size and texture, spleen 10.7 cm.

On 27 February (follow-up visit with general practitioner), that patient’s laboratory values were:

• Full blood count: haemoglobin 16.4 g/l, red cell count 5.39×10¹²/l, PCV 0.49 l/l, MCV 90.2 fl, MCH 30.4 pg, MCHC 33.7 g/dl, RDW 11.5%, white cells 5.6×10⁹/l, neutrophils 37.1%, 2.0×10⁹/l, lymphocytes 51.5%, 2.2×10⁹/l, monocytes 7.2%, 0.3×10⁹/l, eosinophils 3.8%, 0.2×10⁹/l, basophils 0.4%, 0.0×10⁹/l.

• Renal profile: sodium 140 mmol/l, potassium 4.7 mmol/l, urea 5.5 mmol/l, creatinine 74 umol/l (normal 66–112).

• Liver profile: bilirubin 37, alkaline phosphatase 120 IU/l, alanine transaminase 12 IU/l (normal 10–50), albumin – 48 g/l (normal 32–45), γ-glutamyl transferase 11 IU/l (normal 9–40), calcium 2.40 mmol/l (normal 2.15–2.55), corrected calcium 2.27 mmol/l (normal 2.15–2.55).

• Lipid profile: triglycerides 0.7 mmol/l (normal 0–2.3), cholesterol 4.0 mmol/l (normal 2.3–4.9), high density lipoprotein (HDL) 1.3 mmol/l (normal 0.9–1.5), low density lipoprotein (LDL) 2.38 mmol/l (normal 0–3).

• Glycated haemoglobin: haemoglobin A1c (DCCT aligned) 6.3% total Hb (normal 4–6).

• Blood glucose: glucose (random plasma) 17.2 mmol/l (normal 2.8–6).

DIFFERENTIAL DIAGNOSIS

• G6PD deficiency

• Antibody induced haemolysis

• Acute hepatitis

• α1 antitrypsin deficiency

TREATMENT

He was asked to abstain from fenugreek and other known oxidative stressors and information on G6PD was provided.

OUTCOME AND FOLLOW-UP

The patient was counselled about the diagnosis, told what caused this current episode and why he became jaundiced, and given a pamphlet on what foods and drugs to avoid so that it would not happen again. As G6PD deficiency is a relatively benign disease, the only treatment is abstinence and avoidance of the oxidative stressors described above. On 29 July 2008, his mother confirmed that he had immediately ceased the fenugreek after the hospital admission 6 months ago. No further acute episodes of haemolysis have occurred before or since. The patient’s bilirubin concentration decreased significantly by the time of the hospital follow-up visit. The patient continues to have a slightly elevated bilirubin value. It was not thought clinically acceptable to re-challenge the patient with fenugreek.

DISCUSSION

G6PD deficiency is the most common disease producing enzymopathy in the world. The relatively high gene frequency is accounted for because it confers protection against malaria. G6PD catalyses the oxidation of G6P → 6-phosphogluconate while concomitantly reducing NADP → NADPH. NADPH is a cofactor in many reactions, but importantly it maintains glutathione in its reduced form. Reduced glutathione is a scavenger of oxygen radicals in the cell. Reduced glutathione uses glutathione peroxidase to convert H₂O₂ → H₂O. Importantly, G6PD is the red blood cell’s lone supply of NADPH. Thus, people with G6PD deficiency cannot cope with oxidative stressors. These patients are asymptomatic for the most part and they tend to find out about their disease through a haemolytic crisis.

Fenugreek has been known to lower blood glucose concentrations and is a herbal remedy for diabetes.² Recently a study was published regarding its hypolipidaemic effects.³ Fenugreek is widely used as an ingredient in Indian curry dishes. The patient’s mother stated that she routinely uses cooked fenugreek in their curry dishes. She uses ½ teaspoon (15–20 seeds) as an ingredient in the curry, which she cooks for approximately 30 min. This curry dish then feeds four people. They usually eat the curry over a couple of days and she prepares it about once a week. This might raise the question of whether cooking alters the chemical nature of the causative agent in raw fenugreek, preventing haemolysis in G6PD deficient individuals. Another question could be brought up with regards to the amount of fenugreek causing the haemolysis. The young man had been chronically exposed to low levels of fenugreek in his mother’s curry before he began taking much larger doses of raw fenugreek as an adjunct to diabetes treatment. Fenugreek has not been known to cause haemolysis in G6PD deficient individuals and it is believed that this is the first documented case. Further studies into the substance in fenugreek that causes haemolysis are needed. Whether it is a dose dependent phenomenon or a reaction to the cooked or uncooked legume is not known; however, raw fava beans can produce a reaction in some people and cooking may prevent this reaction.⁴ The same may be true for haemolysis caused by fenugreek.

The patient developed evidence of haemolysis after taking fenugreek seeds as shown by a moderate drop in Hb and a rise in unconjugated bilirubin; haemoglobinuria and haemosiderin in the urine were not tested at the time. Although this was not conclusive evidence of a causative relationship between fenugreek seed and haemolysis, all other possible causes of haemolysis had been excluded. Although the association could be tested using in vitro methods such as showing a reduction of glutathione in the subject’s whole blood sample, no further episodes of haemolysis have occurred subsequently. Therefore, no further blood samples have been taken from this patient for the purposes of study alone, which could well have provided an answer to the question of whether cooking alters the haemolytic property of the seeds or whether it was a dose dependent effect.

LEARNING POINTS

• Fenugreek needs to be added to the list of oxidants capable of causing haemolysis in G6PD deficiency.

• More in depth studies need to be conducted to find out the exact mechanism of haemolysis.

• Studies need to be conducted to answer the questions of whether it is a matter of cooked versus uncooked fenugreek or if it is a dose dependant phenomenon that causes the haemolysis.