Authors: Doctor HMGN Senevirathna , Doctor PPDRP Maduchandra

Abstract

Background:
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common enzymatic disorder in Asia and Africa that predisposes red blood cells to oxidative injury. Acalypha indica is a widely used traditional herbal plant in South Asia and contains oxidant compounds capable of precipitating hemolysis and methemoglobinemia in susceptible individuals. Severe complications such as acute kidney injury (AKI) are rarely reported.

Case Presentation:
A 24-year-old previously healthy male presented with dark urine, exertional dyspnea, malaise, and epigastric pain one day after ingesting Acalypha indica leaves as part of a meal. On examination, he was febrile, pale, and icteric, with tachycardia and tachypnea. Oxygen saturation was 86% on room air and showed poor response to high-flow oxygen. Arterial blood gas analysis demonstrated a normal partial pressure of oxygen despite persistent hypoxia on pulse oximetry, raising suspicion of methemoglobinemia, which was supported by bedside color chart estimation.

Laboratory evaluation revealed severe anemia (hemoglobin 5 g/dL), markedly elevated lactate dehydrogenase (3,500 U/L), reticulocytosis (16%), and significant indirect hyperbilirubinemia. Peripheral blood smear showed bite and blister cells, consistent with oxidative hemolysis, and the direct Coombs test was negative. A clinical diagnosis of Acalypha indica–induced hemolytic crisis with methemoglobinemia in suspected G6PD deficiency was made.

Given the contraindication of methylene blue in G6PD deficiency, management included high-flow oxygen, intravenous ascorbic acid, and packed red cell transfusions. Despite initial stabilization, the patient developed oliguric AKI with refractory hyperkalemia and metabolic acidosis, requiring three sessions of hemodialysis. Renal function gradually recovered, and he was discharged on day 15. Quantitative testing performed three months later confirmed G6PD deficiency.

Conclusion:
This case highlights the life-threatening potential of traditional herbal remedies such as Acalypha indica in individuals with undiagnosed G6PD deficiency. Early recognition of methemoglobinemia, avoidance of methylene blue, and prompt supportive and renal replacement therapy are crucial for favorable outcomes. Increased public awareness and screening for G6PD deficiency in endemic regions are essential to prevent similar presentations.

Keywords: Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency), Acalypha indica, Acute hemolytic anemia, Methemoglobinemia, Acute kidney injury, Herbal medicine toxicity.