Rasburicase Causing Severe Oxidative Hemolysis and Methemoglobinemia in a Patient with Previously Unrecognized Glucose-6-Phosphate Dehydrogenase Deficiency

Abstract

Rasburicase is frequently used in tumor lysis syndrome (TLS). Although it is very well tolerated, it can cause severe oxidative hemolytic anemia and methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. We report another case of rasburicase-induced methemoglobinemia in a patient with previously unrecognized G6PD deficiency and review the cases of methemoglobinemia and oxidative hemolysis reported in the literature to date. Patients from ethnicities in which G6PD deficiency is prevalent at high risk of TLS should be screened for G6PD deficiency prior to administration of rasburicase where practical. Asymptomatic decrease in oxygen saturation by oximetry and cyanosis are signs of methemoglobinemia; patients recover with conservative measures including supplemental oxygen and packed red cell transfusion.

Low-dose Rasburicase in Hematologic Malignancies

“…Rasburicase is a safe drug, and only rarely it causes any serious side effects such as anaphylaxis [17]; or methhemoglobinemia and hemolytic anemia in G6PD deficient patients [18,19]. None of the index 41 patients developed any of these side effects.…”

“…Median age, 9 y (range, 0. [9][10][11][12][13][14][15][16][17][18][19]. Underlying diagnoses were as follows: T-cell ALL, 19; Pre-B ALL, 17; T-NHL, 2; B-NHL, 2; AML, 1.…”

A perfect storm: Tumor lysis syndrome with rasburicase‐induced methemoglobinemia in a G6PD deficient adult

“…Of the reported cases of rasburicase-induced methemoglobinemia, 11 of the 15 patients tested for G6PD were found deficient (73%) [8][9][10][11][12][13][14]; however, this may be an underestimate, as some patients were only tested for the condition in the acute phase of illness. G6PD deficiency is a relative contraindication for methylene blue therapy; like rasburicase, it may exacerbate methemoglobinemia and cause hemolysis [15].…”

Rasburicase‐induced methemoglobinemia: case report, literature review, and proposed treatment algorithm

“…Since the use of rasburicase began, we are aware of 15 reported cases of methemoglobinemia with or without associated hemolysis (Table 3) [2][3][4][5][6][7][8][9][10][11][12][13][14]. It was first reported in patients with G6PD deficiency [2], but has also been seen in patients without G6PD deficiency [5,8].…”