Hepatitis A-associated oxidative haemolysis in a patient with glucose-6-phosphate dehydrogenase deficiency with co-inherited sickle cell trait.

An adult male patient in his late teens presented with pruritus, nausea and progressive jaundice after travel to West Africa. He did not get a pre-travel hepatitis A vaccination or malaria chemoprophylaxis. Laboratory testing demonstrated hepatocellular injury with alanine aminotransferase (ALT) 4002 U/L (reference <60), marked hyperbilirubinaemia (total bilirubin 632 µmol/L, reference <20) and a mildly prolonged international normalised ratio (INR). Concurrently, he developed non-immune haemolysis with undetectable haptoglobin, elevated lactate dehydrogenase and reticulocytosis, as well as bite and blister cells on blood film with a negative direct antiglobulin test. Acute hepatitis A virus infection was confirmed and enzymatic testing showed glucose-6-phosphate dehydrogenase deficiency. Haemoglobin electrophoresis also identified sickle cell trait. He improved with supportive care, avoidance of oxidant medications and close monitoring without renal injury or need for transfusion. This case illustrates an approach to jaundice in a returning traveller, the recognition of oxidative haemolysis at the bedside and preventive opportunities.