infection in patient with G6PD deficiency

A 54-year-old Chinese male hepatitis B virus (HBV) carrier presented with jaundice, cyanosis, and confusion. Despite oxygen supplement, pulse oximetry showed persistent desaturation and investigations showed raised methemo-globin (16.8%, normal <1.5%). There was also grossly raised aspartate and alanine aminotransferase (>6,000 IU), bilirubin (763 IU), and lactate dehydrogenase (5,211 IU) and he was referred for liver failure. This was followed 2 days later by a rapid fall in hemoglobin levels (from 14.1 g/dl to 5.8 g/dl) with reactive leukocytosis. A peripheral blood film showed abundant hemighost cells (arrows, Fig. 1). Glucose-6-phosphate dehydrogenase (G6PD) deficiency was confirmed (0.83 IU/g Hb, normal 6.3–10.3). Interestingly, his HBV–DNA was negative and antibodies to hepatitis A and C viruses (HAV-IgM, HCV