A 38-year-old man presents to the emergency department with a complaint of dark urine, weakness, and back pain for 2 days. Prior to onset of symptoms, the patient was seen by his primary care physician for a rash with associated sensory loss. He was prescribed medication that he has been taking for the past 4 days. He denies headache, fever, chills, or nausea. Past medical history is noncontributory. Vital signs are temperature 36° C (98.° F), blood pressure 122/76 mmHg, pulse 68 beats/min, and respirations 18/min. Body mass index (BMI) is 25 kg/m2. Physical examination reveals conjunctival pallor. The rest of his exam is unremarkable.
Lab values are as follows:
Hemoglobin (blood): 7.9 g/dL
Hematocrit: 24%
Reticulocyte count: 5%
Platelet count: 140,000/mm^3
Leukocyte count: 10,900/mm^3
Which of the following is the next best step in management of this patient?
The correct answer is:
C) Discontinue the new medication
This patient is undergoing an acute hemolytic episode secondary to G6PD deficiency. His primary care physician most likely prescribed dapsone for newly diagnosed leprosy given his rash and sensory loss. G6PD deficiency is a genetic disorder characterized by increased vulnerability of red blood cells to oxidative injury due to decreased NADPH production. Dapsone is one of the medications that precipitates hemolysis in G6PD-deficient patients. Common symptoms include anemia, jaundice, pallor, back pain, and dark urine. Discontinuation of the trigger (in this case, dapsone) should resolve the episode.
Answer choice A: Admit to hospital for observation, is incorrect. Appropriate treatment of this case would be removal of the medication that caused the hemolytic episode. Pediatric patients with severe anemia may need to be admitted, but not this patient.
Answer choice B: CT scan of the abdomen and pelvis, is incorrect. Imaging is not typically required for acute hemolytic anemia in the setting of G6PD.
Answer choice D: Emergent transfusion with packed red blood cells, is incorrect. Emergent transfusions are usually reserved for when the hemoglobin concentration drops below 7.0 g/dL or if patients are severely symptomatic.
Answer choice E: Prescribe broad-spectrum antibiotics, is incorrect. This patient would not benefit from antibiotics since the cause of the acute hemolytic episode is not infectious in nature.
Key Learning Point
G6PD deficiency is an inherited condition in which red blood cells are more susceptible to oxidative injury. Medications such as dapsone predispose patients with this condition to acute hemolytic episodes.
