Celal Devecioğlu

Clinical and Cranial Magnetic Resonance Imaging (MRI) Findings of 21 Patients With Serious Hyperbilirubinemia

This study aims to compare neurological examination and cranial magnetic resonance imaging (MRI) findings in patients with serious hyperbilirubinemia. Twenty-one serious hyperbiluribinemic term neonates (6 girls, 15 boys) who underwent exchange transfusions were included in the study. Neurological examination findings, body weight, age at admission, blood culture, urine culture, urine analysis, C-reactive protein, thyroxine, thyroid-stimulating hormone, total and indirect bilirubin levels, causes of hyperbilirubinemia (blood group typing, glucose-6-phosphate dehydrogenase, blood smear, tandem mass), treatment and duration of follow-up, auditory test results, and cranial MRI findings were evaluated. All patients were term neonates with an average body weight of 2943 ± 533 g. The mean age at admission was 4.47 ± 2.22 days, and the mean bilirubin level was 35.0 ± 10.8 mg/dL. Exchange transfusion was performed once in all, except 4 patients who needed 2 transfusions. Kernicterus findings were found in 76% of patients on neurological examination, and cranial MRI detected a pathological finding in 71% of patients. In 2 patients, cranial MRI showed kernicterus findings, despite normal neurological examination. In contrast, in 3 patients, despite kernicterus findings in neurological examination, cranial MRI was normal. Although cranial MRI has an important place in the diagnosis of kernicterus, it does not always correlate with clinical findings. We believe that studies with larger series are warranted.

Henna causes life‐threatening hyperbilirubinaemia in glucose‐6‐phosphate dehydrogenase deficiency

The crushed leaves of henna are used as a cosmetic agent all over the world, particularly in the Middle East. Following its application, it causes a red-brown colouration of the skin. Lawsone (2-hydroxy-1,4 naphthoquinone) is a chemical present in henna. Percutaneous application of henna is known to cause haemolysis in blood cells deficient in glucose-6-phosphate dehydrogenase (G6PD). We report a case of a child who developed hyperbilirubinaemia after application of henna. A 7-day-old boy, who had been previously well, was admitted to our hospital with a 29-hour history of mild pallor and jaundice. Henna had been applied topically for prevention of nappy rash and for traditional cosmetic purposes. Jaundice, lethargy and mild pallor had developed within 29 h following henna application. The patient had been born at 38 weeks of gestation in hospital, and had cried immediately after birth. He had been breastfed, and no vaccines had been administered. On admission, findings were as follows: weight 3280 g, length 520 mm, head circumference 36 cm (50th percentile), axillary temperature 36.7 C, blood pressure 57 ⁄ 35 mmHg and heart rate 148 beats ⁄ min. General appearance was poor. He was hypoactive and very icteric. Approximately 50% of the skin surface had the red-brown colour typical of henna application, including both lower extremities and the plantar areas of the feet (Fig. 1). Abnormal relevant laboratory investigations were haemoglobin 12 g ⁄ dL [normal range (NR) 13–20], platelets 490 · 10/L (NR 150–450), total bilirubin 62.7 lmol/L (NR > 20.5) and indirect bilirubin 58.5 lmol/L (NR > 20.5). On peripheral smear, the proportion of normoblasts was 13% and reticulocytes 7%. Anisocytosis and fragmented erythrocytes were present. A sickling test was negative. Screening revealed G6PD deficiency. Urine analysis was positive for protein, bilirubin and haemoglobin. Both the patient’s and the mother’s blood group was A Rh+, and direct Coombs’ test was negative. Because of the patient’s high serum indirect bilirubin level, exchange transfusion was performed immediately, and intensive phototherapy was then administered. Despite an initial decrease, serum bilirubin level (SBL) again increased to 33 mg ⁄ dL after 12 h, thus a second exchange transfusion was performed. After 36 h of phototherapy, SBL reduced to 8 mg ⁄ dL. Follow-up examinations did not reveal any residual jaundice or any sign of kernicterus. G6PD is required for the generation of the reduced form of nicotinamide adenine dinucleotide phosphate (NADPH), which maintains glutathione in the reduced form to counteract the day-to-day oxidant stresses on PD