Page 15 - Journal of Special Operations Medicine - Fall 2015

many of which share the common denominator of poor Disclosures
uptake, transport, and/or delivery of oxygen. Currently, The authors have nothing to disclose.
G6PD deficiency is not included. 11

References
Conclusion
1. Youngster L, Arcavi L, Schechmaster R, et al. Medications and
Many risk factors were present and likely working syn- glucose-6-phosphate dehydrogenase deficiency: an evidence-
ergistically at the time this patient developed frostbite based review. Drug Saf. 2010;33:713–726.
(Figure 3). G6PD deficiency is not currently recognized 2. Minucci A, Moradkhani K, Hwang MJ, et al. Glucose-6-
in medical literature as being a risk factor for frostbite. phosphate dehydrogenase (G6PD) mutations database: review
11
This case proposes the mechanism that oxidative stress, of the ‘old’ and update of the new mutations. Blood Cells Mol
Dis. 2012;48:154–165.
from one of many possible causes, can cause AHA in 3. Zubieta-Calleja GR, Paulev PE, Zubieta-Calleja L, Zubieta-
those with G6PD deficiency, and this anemia can potenti- Castillo G. Altitude adaptation through hematocrit changes. J
ate frostbite indirectly via microvascular injury (Figure 3). Physiol Pharmacol. 2007;58(Suppl 5; Pt 2):811–818.
4. Cappellini MD, Fiorelli G. Glucose-6-phosphate dehydroge-
Figure 3 Proposed mechanism for the factors affecting the nase deficiency. Lancet. 2008;371:64–74.
indirect cellular injury involved in frostbite specific to this case. 5. Tizianello A, Pannaciulli I, Ajmar F, Salvidio E. Sites of de-
struction of red cells in G-6-PD deficient Caucasians and in
phenylhydrazine treated patients. Scand J Haematol. 1968;5:
116–128.
6. Luzzatto L, Seneca E. G6PD deficiency: a classic example of
pharmacogenetics with on-going clinical implications. Br J
Haematol. 2014;164:469–480.
7. Kattamis CA, Kyriazakou M, Chaidas S. Favism: clinical and
biochemical data. J Med Genet. 1969;6:34–41.
8. Bakonyi T, Radak Z. High altitude and free radicals. J Sports
Sci Med. 2004;3:64–69.
9. Metin B, Erat M. Investigation of the effects of some sulfon-
amide derivatives on the activities of glucose-6-phosphate
dehydrogenase, 6-phosphogluconate dehydrogenase and glu-
tathione reductase from human erythrocytes. J Enzyme Inhib
Med Chem. 2008;23:418–423.
10. Laemmle T. Acetazolamide (Diamox) may cause frostbite at
extreme altitude. Wilderness Environ Med. 2001;12:290.
11. Imray C, Freer J. Frostbite. In: Auerbach P, editor. Wilderness
medicine. 6th ed. Philadelphia, PA: Elsevier Mosby; 2012:
More research needs to be done to determine if acetazol- 181–201.
amide truly has the potential to protect against or induce
AHA in individuals with G6PD deficiency. 1,6,9 The di-
uretic effects of acetazolamide increase the risk of frost-
bite by directly contributing to dehydration (Figure 3). Dr Bowles is program director and instructor of the Mountain
10
Medicine and Cold Weather Medicine Courses at the Marine
Independent of the specific mechanisms discussed here, Corp Mountain Warfare Training Center; assistant professor at
the Uniformed Services University of Health Services; and grad-
this case has identified the possibility of G6PD deficiency uate of the Marine Corp’s Mountain Leader Course and the
as a serious risk to the wilderness expeditioner. The list of Nepalese Army High Altitude and Mountain Warfare School.
causes of AHA in those with G6PD deficiency is lengthy
and includes a wide variety of drugs, viruses, foods, Dr Joas is the AIRTEVRON NINE flight surgeon and Senior

herbs, and environments. 2,4,6–8 AHA can be directly life Regional Flight Surgeon at Naval Air Weapons Station China
threatening; however, in austere and hazardous environ- Lake. A graduate of Uniformed Services University of Health
ments, it also has the potential to increase morbidity and Sciences, he completed his residency in Family Medicine at
mortality via second-order effects. Many of the illnesses Naval Hospital Pensacola. He was previously the Combined
Joint Special Operations Air Component Surgeon General.
and injuries common to the wilderness environment are
caused by hypoxia, worsened by hypoxia, and/or treated Mr Head practiced and taught as a Paramedic for 10 years.
by supplemental oxygen. Thus, any of these will be made He is information systems manager at Naval Hospital Napals
more severe by anemia. Due to this potential, G6PD defi- and is the recipient of two naval Commendation medals. He
ciency needs to be recognized in medicine literature as a was previously an instructor with the National Search and
serious comorbidity that should lead to caution for these Rescue Association.
individuals during certain wilderness and high-altitude
activities. Conversely, frostbite must be considered as a
novel presentation of G6PD deficiency.

Frostbite: G6PD Deficiency? 3