Unexpected Intravascular Hemolysis and Methemoglobinemia during Treatment for Lymphoma

James O. Ballard^1, , Edward J. Wyluda¹, Hong Zheng¹ and Michael H. Creer¹

¹Penn State Hershey Medical Center, Hershey, PA, U.S.A.

Cite this paper

James O. Ballard, Edward J. Wyluda, Hong Zheng and Michael H. Creer. Unexpected Intravascular Hemolysis and Methemoglobinemia during Treatment for Lymphoma. American Journal of Medical Case Reports. 2016; 4(4):144-147. doi: 10.12691/AJMCR-4-4-9

Abstract

A patient undergoing chemotherapy for relapsed non Hodgkin lymphoma developed tumor lysis syndrome, hypoxia and the abrupt onset of intravascular hemolysis. A past history of unexplained anemia and the finding of blister cells on peripheral smear led to the suspicion of congenital glucose phosphate dehydrogenase (G6PD) deficiency with intravascular hemolysis induced by the drug rasburicase. G6PD deficiency was confirmed by quantitative G6PD assay one month after the episode. Retrospective review of arterial blood gas data confirmed the transient presence of methemoglobinemia accompanying the hemolytic event. Health care providers should be aware of the potential for patients with previously undiagnosed G6PD deficiency to develop hemolysis and methemoglobinemia when oxidant drugs such as rasburicase are administered.

Keywords

hemolytic anemia, non-Hodgkin lymphoma, rasburicase, methemoglobinemia

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Beutler, E., “G6PD deficiency,” Blood, 84 (11), 3613-3636, 1994.
[2]	Burka, E.R., Weaver, Z., Marks, P.A., “Clinical spectrum of hemolytic anemia associated with glucose-6-phosphatase dehydrogenase deficiency,” Annals of Internal Medicine, 64, 817-825, 1966.
[3]	Beutler, E., “Disorders of red cells resulting from enzyme abnormalities,” in Williams Hematology, edited by M.A. Lichtman, E. Beutler, T.J. Kipps, et al., 7th edition, McGraw-Hill Medical, New York, 2006, 612-617.
[4]	Coiffier, G., Mounier, N., Bologna, S., et al., “Efficacy and safety of rasburicase (recombinant urate oxidase) for the prevention and treatment of hyperuricemia during induction chemotherapy of aggressive non-Hodgkin’s lymphoma: Results of the GRAAL1 (Groupe d’Etude des Lymphomes de l/Adulte Trial on Rasburicase Activity in Adult Lymphoma) Study,” Journal of Clinical Oncology, 21, 4402-4406, 2003.
[5]	Cheah, C.Y., Lew, T.E., Seymour J.F., et al., “Rasburicase causing severe oxidative hemolysis and methemoglobinemia in a patient with previously unrecognized glucose-6-phosphate dehydrogenase deficiency,” Acta Haematologica, 130, 254-259. 2013.
[6]	Sonbol, M.B., Yadav, H., Vaidya, R., et al., “Methemoglobinemia and hemolysis in a patient with G6PD deficiency treated with rasburicase,” American Journal of Hematology, 88, 152-154, 2013.
[7]	Roberts, D.A., Freed, J.A., “Rasburicase-induced methemoglobinemia in two African-American female patients: an under-recognized and continued problem,” European Journal of Haematology, 2015. 94: 83-85.
[8]	Youngster, I., Arcavi, L., Schechmaster, R., et al., “Medications and glucose-6-phosphate dehydrogenase deficiency: an evidence- based review,” Drug Safety, 33 (9), 713-26, 2010.