Brief Reports Open access

Methemoglobinemia and acute hemolysis induced by high intravenous doses of vitamin C in a COVID-19 patient with unrecognized glucose-6- phosphate-dehydrogenase deficiency

Authors

Published
25 July 2022
Section
Brief Reports
DOI
10.4081/gc.2022.10286

Abstract

In glucose-6-phosphate-dehydrogenase deficiency (favism), exposure to oxidant agents can trigger hemolytic crises. The intravenous administration of very high doses of vitamin C was proposed as a treatment for severe coronavirus disease 2019 (COVID-19) pneumonia. Unlike low vitamin C doses, very high doses (>6 gr daily) can promote H2O2 formation, oxidation of hemoglobin to methemoglobin and, eventually, hemolytic anemia in patients with favism. We here describe the case of a 77-year old man hospitalized for severe COVID-19 pneumonia and treated with a mean daily dose of 9.5 gr of intravenous vitamin C during the first 6 days. He developed methemoglobinemia and hemolytic anemia, which improved after interruption of vitamin C treatment. Previously unrecognized glucose- 6-phophate-dehydrogenase deficiency was diagnosed. This first case of vitamin Cinduced hemolytic anemia in a COVID-19 patient indicates the need of a screening for glucose-6-phosphate-dehydrogenase deficiency before treatment with very high vitamin C doses or for long period.

Keywords

References

  1. References
  2. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81. doi:10.1016/S2213-2600(20)30079-5. Erratum in: Lancet Respir Med 2020;8:e26. DOI: https://doi.org/10.1016/S2213-2600(20)30079-5
  3. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines [Internet]. Bethesda (MD): National Institutes of Health (US); 2021 Apr 21-2021 Nov 9.
  4. Fowler AA 3rd, Truwit JD, Hite RD, et al. Effect of vitamin C infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the CITRIS-ALI randomized clinical trial. JAMA 2019;322:1261-70. doi:10.1001/jama.2019.11825. Erratum in: JAMA 2020;323:379. DOI: https://doi.org/10.1001/jama.2019.11825
  5. Fatima A, Khan MUA, Najeeb M, et al. Role of high dose IV vitamin C and zinc in coronavirus. Geriatric Care 2021;7:9338. DOI: https://doi.org/10.4081/gc.2021.9338
  6. Milani GP, Macchi M, Guz-Mark A. Vitamin C in the Treatment of COVID-19. Nutrients 2021;13:1172. DOI: https://doi.org/10.3390/nu13041172
  7. Zhang J, Rao X, Li Y, et al. Pilot trial of high-dose vitamin C in critically ill COVID-19 patients. Ann Intensive Care 2021;1:5. DOI: https://doi.org/10.1186/s13613-020-00792-3
  8. Said EA, Al-Reesi I, Al-Shizawi N, et al. Defining IL-6 levels in healthy individuals: a meta-analysis. J Med Virol 2021;93:3915-24. DOI: https://doi.org/10.1002/jmv.26654
  9. Luzzatto L, Ally M, Notaro R. Glucose-6-phosphate dehydrogenase deficiency. Blood 2020;136:1225-40. DOI: https://doi.org/10.1182/blood.2019000944
  10. Rehman A, Shehadeh M, Khirfan D, Jones A. Severe acute hemolytic anaemia associated with severe methemoglobinemia in a G6PD-deficient man. BMJ Case Rep 2018;2018:bcr2017223369. DOI: https://doi.org/10.1136/bcr-2017-223369
  11. Lo YH, Mok KL. High dose vitamin C induced methemoglobinemia and hemolytic anemia in glucose-6-phosphate dehydrogenase deficiency. Am J Emerg Med 2020;38:2488.e3-2488.e5. DOI: https://doi.org/10.1016/j.ajem.2020.05.099
  12. Ibrahim IH, Sallam SM, Omar H, Rizk M. Oxidative hemolysis of erythrocytes induced by various vitamins. Int J Biomed Sci 2006;2:295-8.
  13. Levine M, Padayatty SJ, Espey MG. Vitamin C: a concentration-function approach yields pharmacology and therapeutic discoveries. Adv Nutr 2011;2:78-88. DOI: https://doi.org/10.3945/an.110.000109
  14. Lopes DV, Lazar Neto F, Marques LC, et al. Methemoglobinemia and hemolytic anemia after COVID-19 infection without identifiable eliciting drug: a case-report. IDCases 2021;23:e01013. DOI: https://doi.org/10.1016/j.idcr.2020.e01013
  15. Onori ME, Ricciardi Tenore C, Urbani A, Minucci A. Glucose-6-phosphate dehydrogenase deficiency and hydroxychloroquine in the COVID-19 era: a mini review. Mol Biol Rep 2021;48:2973-8. DOI: https://doi.org/10.1007/s11033-021-06234-y
  16. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45. DOI: https://doi.org/10.1038/clpt.1981.154

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