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Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymopathy in humans affecting about 400 million people worldwide (1,2). It is an X-linked recessive inborn error of metabolism which can result in haemolysis on exposure to a number of triggers, such as some infections, and certain medicines and foods. The Mediterranean mutation is the most common variant of the enzyme deficiency and is often associated with favism (3). Severe haemolytic episodes may result after contact with oxidants (4). Henna, obtained from the crushed leaves of Lawsonia alba, has been used for centuries to dye the skin, hair and nails in many countries in south-east Asia and the Middle East (5). The application of henna has resulted in life-threatening episodes of haemolytic anaemia in individuals with a genetic deficiency in G6PD activity (6,7). We report on a 6-year-old boy, previously undiagnosed with G6PD deficiency, who developed life-threatening haemolysis after application of henna to his skin. This is the first report of henna-induced haemolytic anaemia in Sudan. Written informed consent was obtained from the father of the child for publication of this case report and any accompanying images. A 6-year-old boy was brought by his parents to Soba University Hospital on 26 March 2015 with a two-day history of shortness of breath, headache and yellow discolouration of the sclera. There had been a change in his urine colour which was tea-like. This child was previously very well, however, his mother reported that henna had been applied to his hands and feet as part of a kindergarten graduation ceremony 3 days prior to admission. Similar symptoms had developed at the age of 2 years when henna was applied to his skin on the occasion of his circumcision but they did not seek any medical advice at the time. Apart from this, his past history was uneventful. There was no past history of blood transfusion or drug ingestion and no family history of a similar condition. Physical examination revealed an extremely pale child with henna applied to his hands and feet (Figures 1 and 2). He was irritable with slight jaundice. His pulse rate was 125 beats/min., respiratory rate 30 breaths/min., temperature 37.3°C, oxygen saturation 99% in room air and blood pressure normal (100/70 mmHg). Clinical examination also revealed gallop rhythm and a short systolic murmur (haemic) on the left sternal border. All these symptoms and signs were suggestive of an acute haemolytic process. Laboratory investigations showed haemoglobin of 4 g/dL, haematocrit of 13.1%, reticulocyte count of 5.1%, white cell count of 18.2 × 109/L and platelet count of 359 2 × 109/L Peripheral smear showed mild hypochromia with anisocytosis and nucleated red blood cells. Blood film for malaria was negative and direct Coomb test was negative. Urine microscopy showed few pus cells, no red blood cells and bilirubin (++). A urine test for haemoglobin was not done as it was not available in our laboratory. Liver function test revealed a total serum bilirubin of 51.3 Umol/L and direct bilirubin of 5.13 Umol/L; the rest of the liver function tests were normal. Renal function tests showed no derangement with serum urea of 12.5 mmol/L, creatinine 44.21 Umol/L sodium 136 mmol/L and potassium of 4.2 mmol/L. A presumptive diagnosis of acute haemolysis due to G6PD deficiency was made and the child received 1 blood transfusion and folic acid after which he recovered fully. Six weeks later a blood sample was sent abroad to Jordan for G6PD assay by kinetic determination. It showed a low level of G6PD of 3.1 U/g (normal range 4.50–13.50 U/g), confirming his G6PD deficiency. The child was discharged home in good health after having been counselled regarding the condition and given a list of drugs and food items to avoid including nitrofurantoin, nalidixic acid, sulfamethoxazole and fava beans.

Liefe-threatening haemolysis induced by henna in a Sudanese child with glucose-6-phosphate dehydrogenase deficiency