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Primaquine overdose in a toddler

Published:November 19, 2020DOI:https://doi.org/10.1016/j.ajem.2020.10.084

      Abstract

      Antimalarial medications carry a risk of rare, but serious side effects. Primaquine in particular is known to cause methemoglobinemia and hemolytic anemia. In patients with underlying glucose-6-phosphate dehydrogenase (G6PD) deficiency, these side effects become amplified and can be life-threatening. This can complicate treatment plans as the recommended first-line management of severe methemoglobinemia, methylene blue, may cause or worsen hemolytic anemia in G6PD deficient patients. We present a case of a toddler with an accidental primaquine overdose who had undiagnosed G6PD deficiency. Over the 2 days following his ingestion he developed severe methemoglobinemia and hemolytic anemia toxicity. He was initially treated with a dose of methylene blue prior to learning of his G6PD deficiency. He was subsequently given additional doses of ascorbic acid and a blood transfusion. His condition gradually improved and he was ultimately discharged in good condition. To our knowledge, this case represents a unique presentation of mixed methemoglobinemia and hemolytic toxicity due to an accidental primaquine overdose in a G6PD deficient pediatric patient. Though cases remain relatively rare, pediatric patients represent the vast majority of known primaquine overdoses. Their diagnosis and treatment require maintaining a high index of suspicion and a good working knowledge of antimalarial toxicities and management options.

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      References

        • Poison Control: National Capital Poison Center
        Poison Statistics National Data 2018.
        (accessed July 20, 2020)
        • John G.K.
        • Douglas N.M.
        • von Seidlein L.
        • et al.
        Primaquine radical cure of Plasmodium vivax: a critical review of the literature.
        Malar J. 2012; 11: 280https://doi.org/10.1186/1475-2875-11-280
        • Recht J.
        • Ashley E.A.
        • White N.J.
        Use of primaquine and glucose-6-phosphate dehydrogenase deficiency testing: divergent policies and practices in malaria endemic countries.
        PLoS Negl Trop Dis. 2018; 12https://doi.org/10.1371/journal.pntd.0006230
        • Ashley E.A.
        • Rect J.
        • White N.J.
        Primaquine: the risks and the benefits.
        Malar J. 2014; 13: 418https://doi.org/10.1186/1475-2875-13-418
        • Carmona-Fonseca J.
        • Alvarez G.
        • Maestre A.
        Methemoglobinemia and adverse events in Plasmodium vivax malaria patients associated with high doses of primaquine treatment.
        Am J Trop Med Hyg. 2009; 80: 188-193
        • Baird J.K.
        • Fryauff D.J.
        • Hoffman S.L.
        Primaquine for prevention of malaria in travelers.
        Clin Infect Dis. 2003; 37: 1659-1667https://doi.org/10.1086/379714
        • Cappellini M.
        • Fiorelli G.
        Glucose-6-phosphate dehydrogenase deficiency.
        Lancet. 2008 Jan 5; 371: 64-74
        • Nascimento T.
        • Pereira R.
        • de Mello J.
        • Costa J.
        Methemoglobinemia: from diagnosis to treatment.
        Rev Bras Anestesiol. Nov–Dec 2008; 58: 651-664
        • Adeyinka A.
        • Samanapally H.
        • Kondamudi N.
        Cyanosis.
        StatPearls Publishing LLC, August 2020
        • Clifton J.
        • Leikin J.B.
        Methylene blue.
        Am J Ther. 2003; 10: 289-291https://doi.org/10.1097/00045391-200307000-00009
        • Sikka P.
        • Bindra V.
        • Kapoor S.
        • et al.
        Blue cures blue but be cautious.
        J Pharm Bioallied Sci. 2011 Oct; 3: 543-545
        • Rino P.B.
        • Scolnik D.
        • Fustinana A.
        • et al.
        Ascorbic acid for the treatment of methemoglobinemia: the experience of a large tertiary care pediatric hospital.
        Am J Ther. 2014; 21: 240-243https://doi.org/10.1097/MJT.0000000000000028
        • Cortazzo J.A.
        • Lichtman A.D.
        Methemoglobinemia: a review and recommendations for management.
        J Cardiothorac Vasc Anesth. 2014; 28: 1043-1047https://doi.org/10.1053/j.jvca.2013.02.005
        • Altintop I.
        • Sanri E.
        • Tatli M.
        • et al.
        Methemoglobinemia treated with hyperbaric oxygen therapy: a case report.
        Turk J Emerg Med. 2018 Apr 13; 18: 176-178
        • Jaeger A.
        • Sauder P.
        • Kopferschmitt J.
        • Flesch F.
        Clinical features and management of poisoning due to antimalarial drugs.
        Med Toxicol Adverse Drug Exp. 1987; 2: 242-273https://doi.org/10.1007/BF03259868
        • Mondal R.K.
        • Mann U.
        • Sharma M.
        Cyanotic child – can it be methaemoglobinemia?.
        Indian J Pediatr. 2002; 69: 989-990https://doi.org/10.1007/BF02726022
        • Karb R.
        One pill (or sip) can kill.
        American College of Emergency Physicians, 2020 (Accessed July 27, 2020)