Acalypha indica (kuppaimeni) leaf extract is an herbal remedy, widely used locally for treatment of minor ailments. A 5-years-old boy presented to the emergency room with acute onset of passage of red colored urine and yellowish discoloration of eyes for a day. He was given ~50 mL of kuppaimeni leaves concoction for an upper respiratory infection 6-8 hours before the onset of symptoms. There was no significant past history or family history. Child was pale and icteric at admission, SpO2 in room air was 80%, which did not improve with supplementary oxygen. Sensorium was normal, and examination of other systems were normal.

Laboratory workup showed anemia (hemoglobin, 4.5g/dL), reticulocytosis (10%), hyperbilirubinemia (indirect bilirubin, 7.1 mg/dL), high aspartate transaminase (277 U/L), normal alanine transaminase (33 U/L), high lactate dehydrogenase (7253 U/L) and hemoglobinuria suggesting acute intravascular hemolysis. Serum creatinine was normal. Peripheral smear showed blister and bite cells with polychromasia. Direct Coomb test was negative. Glucose-6-Phosphate-Dehydrogenase assay showed low level of 133 IU per million RBC (normal value, 202–522 IU). Co-oximetry was done, which showed elevated methemoglobin (10.5%).

He was managed with high flow oxygen, packed red cell transfusion, hyper-hydration and diuresis. Methylene blue for treatment of methemoglobinemia was considered but deferred in view of low G6PD levels. Child started improving on next day, and was discharged home on the fourth day. On follow-up, repeat G6PD level was low (100 IU per million RBC), confirming G6PD deficiency.

Hemolysis after use of A. indica has been reported previously [1]. In a systematic review, it has been categorized as a possible cause of hemolysis [2]. There are reports of symptomatic methemoglobinemia accompanying hemolytic crisis in G6PD-deficient individuals [3]. G6PD deficiency results in diminished production of NADPH through pentose phosphate pathway. NADPH deficiency leads to deficient glutathione production which is useful to protect hemoglobin from oxidative damage. This finally culminates in methemoglobinemia during oxidative stress induced G6PD deficiency hemolytic crisis [3].

We report this case to increase awareness regarding A. indica-induced hemolysis, in association with methemoglobinemia in G6PD deficiency.

1. Ehelepola NDB, Abayagunawardana AN, Sudusinghe TNA. Vegetable-induced hemolytic crisis in a G6PD deficient person: A case report. BMC Res Notes. 2018;11:179.

2. Lee SWH, Lai NM, Chaiyakunapruk N, Chong DWK. Adverse effects of herbal or dietary supplements in G6PD deficiency: A systematic review. Br J Clin Pharmacol. 2017;83:172-9.

3. Schuurman M, Waardenburg DV, Costa JD, Niemarkt H, Leroy P. Severe hemolysis and methemoglobinemia following fava beans ingestion in glucose-6-phosphatase dehydrogenase deficiency - Case report and literature review. Eur J Pediatr. 2009;168:779-82.