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Kosasih A, James R, Chau NH, Karman MM, Panggalo LV, Wini L, Thanh NV, Obadia T, Satyagraha AW, Asih PBS, Syafruddin D, Taylor WRJ, Mueller I, Sutanto I, Karunajeewa H, Pasaribu AP, Baird JK. Case Series of Primaquine-Induced Haemolytic Events in Controlled Trials with G6PD Screening. Pathogens 2023; 12:1176. [PMID: 37764985 PMCID: PMC10537757 DOI: 10.3390/pathogens12091176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Primaquine for radical cure of Plasmodium vivax malaria poses a potentially life-threatening risk of haemolysis in G6PD-deficient patients. Herein, we review five events of acute haemolytic anaemia following the administration of primaquine in four malaria trials from Indonesia, the Solomon Islands, and Vietnam. Five males aged 9 to 48 years were improperly classified as G6PD-normal by various screening procedures and included as subjects in trials of anti-relapse therapy with daily primaquine. Routine safety monitoring by physical examination, urine inspection, and blood haemoglobin (Hb) assessment were performed in all those trials. Early signs of acute haemolysis, i.e., dark urine and haemoglobin drop >20%, occurred only after day 3 and as late as day 8 of primaquine dosing. All patients were hospitalized and fully recovered, all but one following blood transfusion rescue. Hb nadir was 4.7 to 7.9 g/dL. Hospitalization was for 1 to 7 days. Hb levels returned to baseline values 3 to 10 days after transfusion. Failed G6PD screening procedures in these trials led G6PD-deficient patients to suffer harmful exposures to primaquine. The safe application of primaquine anti-relapse therapy requires G6PD screening and anticipation of its failure with a means of prompt detection and rescue from the typically abrupt haemolytic crisis.
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Affiliation(s)
- Ayleen Kosasih
- Oxford University Clinical Research Unit Indonesia, Jakarta 10430, Indonesia; (A.K.); (M.M.K.); (J.K.B.)
| | - Robert James
- Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC 3052, Australia; (R.J.); (I.M.)
- Department of Medical Biology, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Nguyen Hoang Chau
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City 749000, Vietnam; (N.H.C.); (N.V.T.)
| | - Michelle M. Karman
- Oxford University Clinical Research Unit Indonesia, Jakarta 10430, Indonesia; (A.K.); (M.M.K.); (J.K.B.)
| | | | - Lyndes Wini
- Vector-Borne Disease Control (VBDC) Division, Solomon Islands Ministry of Health and Medical Services, Honiara P.O. Box R113, Solomon Islands;
| | - Ngo Viet Thanh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, District 5, Ho Chi Minh City 749000, Vietnam; (N.H.C.); (N.V.T.)
| | - Thomas Obadia
- Institut Pasteur, Université Paris Cité, Bioinformatics and Biostatistics Hub, F-75015 Paris, France;
- Institut Pasteur, Université Paris Cité, G5 Infectious Diseases Epidemiology and Analytics, F-75015 Paris, France
| | - Ari Winasti Satyagraha
- Exeins Health Initiative, Jakarta 12870, Indonesia; (L.V.P.); (A.W.S.)
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong 16911, Indonesia; (P.B.S.A.); (D.S.)
| | - Puji Budi Setia Asih
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong 16911, Indonesia; (P.B.S.A.); (D.S.)
| | - Din Syafruddin
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency, Cibinong 16911, Indonesia; (P.B.S.A.); (D.S.)
- Department of Parasitology, Faculty of Medicine, Hasanuddin University, Makassar 90245, Indonesia
- Hasanuddin University Medical Research Center, Makassar 90245, Indonesia
| | - Walter R. J. Taylor
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand;
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC 3052, Australia; (R.J.); (I.M.)
| | - Inge Sutanto
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta 10430, Indonesia;
| | - Harin Karunajeewa
- Department of Medicine, Western Health, The University of Melbourne, Melbourne, VIC 3010, Australia;
| | | | - J. Kevin Baird
- Oxford University Clinical Research Unit Indonesia, Jakarta 10430, Indonesia; (A.K.); (M.M.K.); (J.K.B.)
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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Ley B, Winasti Satyagraha A, Kibria MG, Armstrong J, Bancone G, Bei AK, Bizilj G, Brito M, Ding XC, Domingo GJ, von Fricken ME, Gornsawun G, Lam B, Menard D, Monteiro W, Ongarello S, Pal S, Panggalo LV, Parikh S, Pfeffer DA, Price RN, da Silva Orfano A, Wade M, Wojnarski M, Worachet K, Yar A, Alam MS, Howes RE. Repeatability and reproducibility of a handheld quantitative G6PD diagnostic. PLoS Negl Trop Dis 2022; 16:e0010174. [PMID: 35176015 PMCID: PMC8853557 DOI: 10.1371/journal.pntd.0010174] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/17/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The introduction of novel short course treatment regimens for the radical cure of Plasmodium vivax requires reliable point-of-care diagnosis that can identify glucose-6-phosphate dehydrogenase (G6PD) deficient individuals. While deficient males can be identified using a qualitative diagnostic test, the genetic make-up of females requires a quantitative measurement. SD Biosensor (Republic of Korea) has developed a handheld quantitative G6PD diagnostic (STANDARD G6PD test), that has approximately 90% accuracy in field studies for identifying individuals with intermediate or severe deficiency. The device can only be considered for routine care if precision of the assay is high. METHODS AND FINDINGS Commercial lyophilised controls (ACS Analytics, USA) with high, intermediate, and low G6PD activities were assessed 20 times on 10 Biosensor devices and compared to spectrophotometry (Pointe Scientific, USA). Each device was then dispatched to one of 10 different laboratories with a standard set of the controls. Each control was tested 40 times at each laboratory by a single user and compared to spectrophotometry results. When tested at one site, the mean coefficient of variation (CV) was 0.111, 0.172 and 0.260 for high, intermediate, and low controls across all devices respectively; combined G6PD Biosensor readings correlated well with spectrophotometry (rs = 0.859, p<0.001). When tested in different laboratories, correlation was lower (rs = 0.604, p<0.001) and G6PD activity determined by Biosensor for the low and intermediate controls overlapped. The use of lyophilised human blood samples rather than fresh blood may have affected these findings. Biosensor G6PD readings between sites did not differ significantly (p = 0.436), whereas spectrophotometry readings differed markedly between sites (p<0.001). CONCLUSIONS Repeatability and inter-laboratory reproducibility of the Biosensor were good; though the device did not reliably discriminate between intermediate and low G6PD activities of the lyophilized specimens. Clinical studies are now required to assess the devices performance in practice.
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Affiliation(s)
- Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | | | | | - Jillian Armstrong
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Germana Bancone
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Amy K. Bei
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Greg Bizilj
- PATH, Seattle, Washington, United States of America
| | - Marcelo Brito
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | | | | | - Gornpan Gornsawun
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Brandon Lam
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Didier Menard
- Institut Pasteur, INSERM U1201, Paris, France
- Laboratoire de Parasitologie et Mycologie Médicale, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Institut de Parasitologie et Pathologie Tropicale, UR7292 Dynamique des interactions hôte pathogène, Fédération de Médecine Translationnelle, Université de Strasbourg, Strasbourg, France
| | - Wuelton Monteiro
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | - Sampa Pal
- PATH, Seattle, Washington, United States of America
| | | | - Sunil Parikh
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Daniel A. Pfeffer
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Alessandra da Silva Orfano
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Martina Wade
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Mariusz Wojnarski
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Aqsa Yar
- Institut Pasteur, INSERM U1201, Paris, France
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Satyagraha AW, Sadhewa A, Panggalo LV, Subekti D, Elyazar I, Soebianto S, Mahpud N, Harahap AR, Baird JK. Genotypes and phenotypes of G6PD deficiency among Indonesian females across diagnostic thresholds of G6PD activity guiding safe primaquine therapy of latent malaria. PLoS Negl Trop Dis 2021; 15:e0009610. [PMID: 34270547 PMCID: PMC8318249 DOI: 10.1371/journal.pntd.0009610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/28/2021] [Accepted: 06/30/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Plasmodium vivax occurs as a latent infection of liver and a patent infection of red blood cells. Radical cure requires both blood schizontocidal and hypnozoitocidal chemotherapies. The hypnozoitocidal therapies available are primaquine and tafenoquine, 8-aminoquinoline drugs that can provoke threatening acute hemolytic anemia in patients having an X-linked G6PD-deficiency. Heterozygous females may screen as G6PD-normal prior to radical cure and go on to experience hemolytic crisis. METHODS & FINDINGS This study examined G6PD phenotypes in 1928 female subjects living in malarious Sumba Island in eastern Indonesia to ascertain the prevalence of females vulnerable to diagnostic misclassification as G6PD-normal. All 367 (19%) females having <80% G6PD normal activity were genotyped. Among those, 103 (28%) were G6PD wild type, 251 (68·4%) were heterozygous, three (0·8%) were compound heterozygotes, and ten (2·7%) were homozygous deficient. The variants Vanua Lava, Viangchan, Coimbra, Chatham, and Kaiping occurred among them. Below the 70% of normal G6PD activity threshold, just 18 (8%) were G6PD-normal and 214 (92%) were G6PD-deficient. Among the 31 females with <30% G6PD normal activity were all ten homozygotes, all three compound heterozygotes, and just 18 were heterozygotes (7% of those). CONCLUSIONS In this population, most G6PD heterozygosity in females occurred between 30% and 70% of normal (69·3%; 183/264). The prevalence of females at risk of G6PD misclassification as normal by qualitative screening was 9·5% (183/1928). Qualitative G6PD screening prior to 8-aminoquinoline therapies against P. vivax may leave one in ten females at risk of hemolytic crisis, which may be remedied by point-of-care quantitative tests.
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Affiliation(s)
| | | | | | - Decy Subekti
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Iqbal Elyazar
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Saraswati Soebianto
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Nunung Mahpud
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | | | - J. Kevin Baird
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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