A case of false hematuria and an unexpected diagnosis

Waterpipe tobacco smoking is becoming frequent worldwide with the prevalence increasing among youth. Glucose-6-phosphate dehydrogenase deficiency is the most common enzymatic disorder of red blood cells, predisposing patients to decreased resistance to oxidative stress, when exposed to certain toxic substances. The authors present a case of a 17-year-old male patient, with no relevant past medical history, who presents to the pediatric emergency department complaining of “hematuria”. Icteric sclera was identified on physical examination. Hemolytic anemia due to glucose6-phosphate dehydrogenase deficiency was found and a false hematuria was identified. The present case report is intended as an alert to the waterpipe smoking as a possible cause of false hematuria. Given its prevalence, the diagnosis of G6PD deficiency should be considered in the presence of non-immune hemolytic anemia. Introduction Adolescence is defined by World Health Organization (WHO) as people between 10 and 19 years and can now be understood as a dynamic period of brain development, with the remodeling of the brain reward system taking part in this period. Psychologically it is characterized by low resistance to peer influences and low risk perception, leading to an increase in risk taking behavior, including smoking, drugs, and alcohol consumption.1 Waterpipe tobacco smoking (WTS) is becoming prevalent worldwide and its prevalence is increasing dramatically among youth. In the past decade WTS has been associated with many chronic health effects such as lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, and asthma. Waterpipe smoke contain toxic chemicals such as carbon monoxide, polycyclic aromatic hydrocarbons, volatile aldehydes, and addictive chemical nicotine.2 Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymatic disorder of red blood cells (RBC), caused by a genetic defect in the G6PD enzyme, which generates NADPH and protects RBCs from oxidative injury.3 Consequently, G6PD deficiency patients have decreased resistance to oxidative stress, when exposed to certain toxic substances.3 The authors present a case of acute hemolysis in a 17-year-old male, without previous history of anemia or jaundice, who presents to the pediatric emergency department complaining of “hematuria”. Case Report A 17-year-old male patient, with no relevant past medical or family history, presented to the pediatric emergency department complaining of hematuria the past 12 hours. He denied dysuria, urgency, frequent urination, fever, or recent history of respiratory or gastrointestinal infections. A history of waterpipe smoking with red pigmentation tobacco (figure 1), the day before, was reported. He denied any other toxic consumptions. Physical examination revealed icteric sclera and was otherwise unremarkable. The urine analysis showed a red-orange pigmentation (figure 2), with no leukocytes, erythrocytes, nitrites, or bilirubin detection. Urine toxic screening and culture was also negative. The laboratory evaluation carried out showed hemoglobin 10.5 g/dL [11.5-18.0], hematocrit 0.306 L/L [0.370-0.540], VGM/MCV 98.1 fL [76.0-96.0], HGM/MCH 33.6 pg [27.0-32-0], reticulocyte count 2.2% [0.5-1.5%], platelets 284,000 cells/μL [130400], leukocytes 5,0 x 109 cells/μL [4,0-11,0] with 48,7% neutrophils [40-74], total serum bilirubin 5.8 mg/dL [<1.2], conjugated bilirubin 0.52 mg/dL [<0.3], lactate dehydrogenase 358 IU/L [100-250], aspartate aminotransferase 19 IU/L [<40], alanine aminotransferase 19 IU/L [<50], C-reactive protein 1.98 mg/dL [<0.2], serum haptoglobin concentration 17.00 mg/dL [30.00-200.00], glucose 6 phosphate dehydrogenase 3.1 IU/gHb [7.90-16.30]. The direct and indirect coombs test were negative. Red blood cell morphology included rare spherocytes and polychromatophilic macrocytes. Hemolytic anemia due to a glucose 6 phosphate dehydrogenase deficiency diagnosis was suspected and confirmed after a low value of the enzyme repeated one month later after the hemolytic crisis (glucose 6 phosphate dehydrogenase 2.7 UI/gHb) . At this point the clinical history was reviewed and the consumption of fava-beans was identified two days before the onset of symptoms. In the absence of Address for Correspondance: Rita de Oliveira Sousa, Department of Pediatrics, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267 Almada, Portugal Email: rita.mcosousa@gmail.com ©2021 Pediatric Oncall ARTICLE HISTORY Received 5 September 2021 Accepted 20 November 2021