Glucose-6-phosphate dehydrogenase deficiency (G6PDD), also known as favism, is the most common enzyme deficiency anemia worldwide. It is an inborn error of metabolism that predisposes to red blood cell breakdown. Most of the time, those who are affected have no symptoms. Following a specific trigger, symptoms such as yellowish skin, dark urine, shortness of breath, and feeling tired may develop. Complications can include anemia and newborn jaundice. Some people never have symptoms.
It is an X-linked recessive disorder that results in defective glucose-6-phosphate dehydrogenase enzyme. Glucose-6-phosphate dehydrogenase is an enzyme that protects red blood cells, which carry oxygen from the lungs to tissues throughout the body, from reactive oxygen species. An enzyme defect results in the premature breakdown of red blood cells. This destruction of red blood cells is called hemolysis. Red blood cell breakdown may be triggered by infections, certain medication, stress, or foods such as fava beans. Depending on the specific mutation the severity of the condition may vary. Diagnosis is based on symptoms and supported by blood tests and genetic testing.
Affected persons must avoid dietary triggers, notably fava beans. This can be difficult, as fava beans may be called "broad beans" and are used in many foods, whole or as flour. Falafel is probably the best known, but fava beans are often used as filler in meatballs and other foods.
Treatment of acute episodes may include medications for infection, stopping the offending medication, or blood transfusions. Jaundice in newborns may be treated with bili lights. It is recommended that people be tested for G6PDD before certain medications, such as primaquine, are taken.
About 400 million people have the condition globally. It is particularly common in certain parts of Africa, Asia, the Mediterranean, and the Middle East. Males are affected more often than females. In 2015, it is believed to have resulted in 33,000 deaths.
Signs and symptoms Most individuals with G6PD deficiency are asymptomatic. When it induces hemolysis, the effect is usually short-lived.
Most people who develop symptoms are male, due to the X-linked pattern of inheritance, but female carriers can be affected due to unfavorable lyonization or skewed X-inactivation, where random inactivation of an X chromosome in certain cells creates a population of G6PD-deficient red blood cells coexisting with unaffected red blood cells. A female with one affected X chromosome will show the deficiency in approximately half of her red blood cells. However, in some cases, including double X-deficiency, the ratio can be much more than half, making the individual almost as sensitive as males.
Red blood cell breakdown (also known as hemolysis) in G6PD deficiency can manifest in many ways, including the following: Prolonged neonatal jaundice, possibly leading to kernicterus (arguably the most serious complication of G6PD deficiency) Hemolytic crises in response to: Illness (especially infections) Certain drugs (see below) Certain foods, most notably broad beans, from which the word favism derives Certain chemicals Diabetic ketoacidosis Hemoglobinuria (red or brown urine) Very severe crisis can cause acute kidney injury
Favism is a hemolytic response to the consumption of fava beans, also known as broad beans. Though all individuals with favism show G6PD deficiency, not all individuals with G6PD deficiency show favism. The condition is more prevalent in infants and children, and the G6PD genetic variant can influence chemical sensitivity.Luzzatto, L. "GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENCY." Advanced Medicine-Twelve: Proceedings of a Conference Held at the Royal College of Physicians of London, 11–14 February 1985. Vol. 21. Churchill Livingstone, 1986. Other than this, the specifics of the chemical relationship between favism and G6PD are not well understood.
Cause G6PD deficiency results from mutations in the G6PD gene. The G6PD gene contributes to the production of glucose-6-phosphate dehydrogenase. Chemical reactions involving glucose-6-phosphate dehydrogenase produce compounds that prevent reactive oxygen species from building up to toxic levels within red blood cells. If a reduction in the amount of glucose-6-phosphate dehydrogenase or alteration of structure occurs due to G6PD gene mutations, the enzyme loses its protective role, leading to the accumulation of reactive oxygen species and thus damaging red blood cells.
Triggers Carriers of the underlying mutation do not show any symptoms unless their red blood cells are exposed to certain triggers, which can be of four main types: Foods (fava beans is the hallmark trigger for G6PD mutation carriers) Certain medicines including rasburicase, primaquine and other antimalarials[PMID 36049896] Moth balls (naphthalene) Stress from a bacterial or viral infection
Drugs Many substances are potentially harmful to people with G6PD deficiency. Variation in response to these substances makes individual predictions difficult. Antimalarial drugs that can cause acute hemolysis in people with G6PD deficiency include primaquine and tafenoquine. Dapsone, methylene blue, pegloticase, rasburicase, and toluidine should also be avoided by people with G6PD deficiency.(CPIC guideline G6PD ) Henna has been linked to hemolytic crisis in G6PD-deficient infants. Rasburicase is contraindicated in G6PD deficiency. Over 40 medications, including ascorbic acid at high doses and sulfonamides, have been hypothesized to be linked to hemolysis in G6PD-deficient individuals, but the evidence supporting most of these medications is lacking.Clinical Pharmacogenetics Implementation Consortium;
Genetics Two variants (G6PD A− and G6PD Mediterranean) are the most common in human populations. G6PD A− has an occurrence of 10% of Africans and African-Americans, while G6PD Mediterranean is prevalent in the Middle East. The known distribution of the mutated allele is largely limited to people of Mediterranean origins (Spaniards, Italians, Greeks, Armenians, Sephardi Jews, and other Semitic peoples). Both variants are believed to stem from a strongly protective effect against Plasmodium falciparum and Plasmodium vivax malaria.Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009-05-28). Robbins and Cotran Pathologic Basis of Disease, Professional Edition: Expert Consult - Online (Robbins Pathology) (Kindle Locations 33351-33354). Elsevier Health. Kindle Edition. It is particularly frequent in the Kurdish Jewish population, wherein approximately 1 in 2 males have the condition, and the same rate of females are carriers. It is also common in African American, Saudi Arabian, Sardinian males, some African populations, and Asian groups.Glucose-6-Phosphate Dehydogenase Deficiency (G6PD) on The Jewish Genetic Disease Consortium (JGDC) website .
All mutations that cause G6PD deficiency are found on the long arm of the X chromosome, on band Xq28. The G6PD gene spans some 18.5 kilobases. The following variants and mutations are well-known and described: +Descriptive mutations Mutation Gene ProteinDesignationShort nameIsoformG6PD-ProteinOMIM-CodeTypeSubtypePositionPositionStructure changeFunction changeG6PD-A(+)Gd-A(+)G6PD A+305900.0001Polymorphism nucleotideA→G376(Exon 5)126Asparagine→Aspartic acid (ASN126ASP)No enzyme defect (variant)G6PD-A(-)Gd-A(-)G6PD A+305900.0002Substitution nucleotideG→A376(Exon 5)and20268and126Valine→Methionine (VAL68MET)Asparagine→Aspartic acid (ASN126ASP)G6PD-MediterraneanGd-MedG6PD B+305900.0006Substitution nucleotideC→T563(Exon 6)188Serine→Phenylalanine (SER188PHE)Class IIG6PD-CantonGd-CantonG6PD B+305900.0021Substitution nucleotideG→T1376459Arginine→Leucine (ARG459LEU)Class IIG6PD-ChathamGd-ChathamG6PD+305900.0003Substitution nucleotideG→A1003335Alanine→Threonine (ALA335THR)Class IIG6PD-CosenzaGd-CosenzaG6PD B+305900.0059Substitution nucleotideG→C1376459Arginine→Proline (ARG459PRO)G6PD-activity <10%, thus high portion of patients.G6PD-MahidolGd-MahidolG6PD+305900.0005Substitution nucleotideG→A487(Exon 6)163Glycine→Serine (GLY163SER)Class IIIG6PD-OrissaGd-OrissaG6PD+305900.0047Substitution nucleotideC→G13144Alanine→Glycine (ALA44GLY)NADP-binding place affected. Higher stability than other variants.G6PD-AsahiGd-AsahiG6PD A-+305900.0054Substitution nucleotide (several)A→G±G→A376(Exon 5)20212668Asparagine→Aspartic acid (ASN126ASP)Valine→Methionine (VAL68MET)Class III.
Pathophysiology
Glucose-6-phosphate dehydrogenase (G6PD) is an enzyme in the pentose phosphate pathway (see image, also known as the HMP shunt pathway). G6PD converts glucose-6-phosphate into 6-phosphoglucono-δ-lactone. It is the rate-limiting enzyme of this metabolic pathway that supplies reducing energy to cells by maintaining the level of the reduced form of the co-enzyme nicotinamide adenine dinucleotide phosphate (NADPH). The NADPH maintains the supply of reduced glutathione in the cells that are used to mop up free radicals that cause oxidative damage. The pathway also stimulates catalase, an antioxidant enzyme.
The G6PD / NADPH pathway is the only source of reduced glutathione in red blood cells (erythrocytes). The role of red cells as oxygen carriers puts them at substantial risk of damage from oxidizing free radicals except for the protective effect of G6PD/NADPH/glutathione.
People with G6PD deficiency are therefore at risk of hemolytic anemia in states of oxidative stress. Oxidative stress can result from infection and from chemical exposure to medication and certain foods. Broad beans, e.g., fava beans, contain high levels of vicine, divicine, convicine, and isouramil, all of which create oxidants.
When all remaining reduced glutathione is consumed, enzymes and other proteins (including hemoglobin) are subsequently damaged by the oxidants, leading to cross-bonding and protein deposition in the red cell membranes. Damaged red cells are phagocytosed and sequestered (taken out of circulation) in the spleen. The hemoglobin is metabolized to bilirubin (causing jaundice at high concentrations). The red cells rarely disintegrate in the circulation, so hemoglobin is rarely excreted directly by the kidney, but this can occur in severe cases, causing acute kidney injury.
Deficiency of G6PD in the alternative pathway causes the buildup of glucose, and thus an increase of advanced glycation endproducts (AGE). The deficiency also reduces the amount of NADPH, which is required for nitric oxide (NO) synthesis. The high prevalence of diabetes mellitus type 2 and hypertension in Afro-Caribbeans in the West could be directly related to the incidence of G6PD deficiency in those populations.
Although female carriers can have a mild form of G6PD deficiency (dependent on the degree of inactivation of the unaffected X chromosome – see Skewed X-inactivation), homozygous females have been described; in these females, there is co-incidence of a rare immune disorder termed chronic granulomatous disease (CGD).
Diagnosis The diagnosis is generally suspected when patients from certain ethnic groups (see epidemiology) develop anemia, jaundice, and symptoms of hemolysis after challenges from any of the above causes, especially when there is a positive family history.
Generally, tests will include: Complete blood count and reticulocyte count; in active G6PD deficiency, Heinz bodies can be seen in red blood cells on a blood film; Liver enzymes (to exclude other causes of jaundice); Lactate dehydrogenase (elevated in hemolysis and a marker of hemolytic severity) Haptoglobin (decreased in hemolysis); A "direct antiglobulin test" (Coombs' test) – this should be negative, as hemolysis in G6PD is not immune-mediated;