Case Report
Journal of Veterinary Emergency and Critical Care 23(6) 2013, pp 648–651 doi: 10.1111/vec.12113
Hemolytic anemia after ingestion of the natural hair dye Lawsonia inermis (henna) in a dog Daniel J. Jardes, DVM; Linda A. Ross, DVM, DACVIM and Jessica E. Markovich, DVM, DACVIM
Abstract
Objectives – To describe the clinical presentation and case management of a dog that developed hemolytic anemia and evidence of renal tubular dysfunction after ingestion of a natural hair dye containing Lawsonia inermis (henna). To review cases of henna toxicity reported in the human literature. Case Summary – An 8-year-old female spayed Border Collie was presented 5 days after ingestion of a box of natural hair dye. The dog was showing signs of lethargy, vomiting, diarrhea, and weakness. A serum biochemistry profile, complete blood count, and urinalysis demonstrated evidence of renal tubular dysfunction and a regenerative anemia without spherocytosis. The dog was treated with a transfusion of packed RBCs and IV fluids, resulting in significant clinical improvement. Repeat diagnostics showed resolution of the anemia and no lasting evidence of tubular dysfunction. New or Unique Information Provided – To the authors’ knowledge, this is the first reported case in the veterinary literature of toxicity following ingestion of Lawsonia inermis (henna). Henna ingestion was associated with the development of hemolytic anemia and acute kidney injury. (J Vet Emerg Crit Care 2013; 23(6): 648–651) doi: 10.1111/vec.12113 Keywords: acute kidney injury, glucosephosphate dehydrogenase deficiency, lawsonia plant, Lawsone, paraphenylenediamine.
Introduction Lawsonia inermis (henna) is a flowering plant that is used around the world as a cosmetic dye to color both the hair and skin.1 Henna has also been used medically for its analgesic and anti-inflammatory properties. The ingestion or topical application of the active ingredient Lawsone (2-hydroxy-1,4 naphthoquinone) has been shown to cause a severe hemolytic anemia and acute kidney injury in both rats and people.2, 3 Henna’s widespread use has resulted in multiple case reports of toxicity in people.3–5 The following is the first report of this toxicity in a dog and a brief review of henna toxicity reported in the human literature.
Case Summary An 8-year-old, 20 kg, female spayed Border Collie was presented to the emergency service for evaluation of progressive lethargy of 4 days duration. Five days before From the Department of Clinical Sciences, Tufts University Cummings School of Veterinary Medicine, North Grafton, MA 01536. The authors report no conflicts of interests. Address correspondence and reprint requests to Dr. Linda Ross, Tufts University Cummings School of Veterinary Medicine, 200 Westboro Road, North Grafton, MA 01536. Email: [email protected] Submitted September 16, 2012; Accepted September 30, 2013.
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Abbreviations
G6PD PCV PPD
glucose-6-phosphate dehydrogenase packed cell volume paraphenylenediamine
presentation the dog ingested a large amount of a green powder. At the time of presentation the dog’s owners were unaware of the powder’s origin or composition. The day after ingestion the dog vomited once and had diarrhea; both the vomitus and feces were green in color. Over the next few days the dog became progressively more lethargic and anorexic. The dog had a past history of dietary indiscretion that typically resulted in vomiting and diarrhea for several days that resolved without medical intervention. There were no other significant past medical problems. On presentation the dog was noted to have a dull mentation, a heart rate of 135/min, and pale pink mucous membranes. Due to the aggressive nature of the dog and need for a muzzle, assessment of capillary refill time, and a full oral exam could not be completed. Dark green feces were noted in the perianal region, and the hair on the front paws was a green-blue color. The rest of the physical exam was unremarkable. A combination of butorphanola (0.2 mg/kg), acepromazineb C Veterinary Emergency and Critical Care Society 2013
Hemolytic anemia following henna ingestion in a dog
(0.025 mg/kg), and glycopyrrolatec (0.01 mg/kg) was administered IM for sedation prior to phlebotomy and cystocentesis. Initial laboratory tests performed on an emergency basis showed mild hyponatremia (138.0 mmol/L, reference interval 140.0–154.0 mmol/L), hypokalemia (2.8 mmol/L, reference interval 3.6–4.8 mmol/L), hyperchloremia (123 mmol/L, reference interval 109–120 mmol/L), ionized hypermagnesemia (0.6 mmol/L, reference interval 0.1–0.4 mmol/L), and mild hyperlactatemia (2.6 mmol/L, reference range 0.0–2.0 mmol/L). The dog was anemic with a packed cell volume (PCV) of 16% (reference range, 39–55%) and total plasma protein of 64 g/L (6.4 g/dL), with icteric serum. A blood smear was performed and showed anisocytosis, polychromasia, eccentrocytes, codocytes, nucleated RBCs, and Howell-Jolly bodies. A saline agglutination test was performed and was negative. The dog was blood typed and was dog erythrocyte antigen 1.1 negative. A CBC with reticulocyte count and serum biochemistry profile was submitted. Urine was collected via cystocentesis and submitted for urinalysis. An abbreviated abdominal ultrasound exam was performed to rule out intra-abdominal hemorrhage. This involved focused ultrasonographic assessment for the presence of fluid in four regions in the abdomen: between liver lobes and the diaphragm, at the apex of the bladder, and around each kidney. No free fluid was visualized. A lateral abdominal radiograph was taken to look for evidence of metal ingestion. No metallic foreign material or other abnormalities were noted. Evaluation of zinc levels was not performed. A transfusion of 1 unit of dog erythrocyte antigen 1.1 negative packed RBCs was administered over 4 hours. Due to the dog’s aggressive temperament, it was monitored by cardiac telemetry for changes in heart rate that might reflect a transfusion reaction. The dog was tachycardic with a heart rate of 164/min at the start of the transfusion. The heart rate returned to normal (90/min) by completion of the transfusion. Intravenous fluids were initiated (lactated Ringer’s solutiond supplemented with 40 mEq of potassium chloridee per liter administered at a rate of 60 mL/kg/day), and famotidinef (0.5 mg/kg IV q 12 hr) was administered after completion of the transfusion. Three hours after presentation the dog was still depressed. The mucous membranes were now pink and the heart rate was 80/min Recheck blood work on completion of the transfusion showed improvement in the dog’s anemia (PCV 28%, total plasma protein 64 g/L [6.4 g/dL]). Telemetry was discontinued. The results from the diagnostic tests submitted on presentation were reported. The serum was again noted to be icteric. The CBC revealed mild leukocytosis C Veterinary Emergency and Critical Care Society 2013, doi: 10.1111/vec.12113
(18.1 × 109 cells/L, reference interval, 4.9–16.9 × 109 cells/L [18.1 × 103 cells/L, reference interval 4.9– 16.9 × 103 cells/L]). The differential count showed neutrophila (16.0 × 109 cells/L, reference interval, 2.8– 11.5 × 109 cells/L [16.0 × 103 cells/L, reference interval 2.8–11.5 × 103 cells/L]) and lymphopenia (0.7 × 109 cells/L, reference interval, 1.0–4.8 × 109 cells/L [0.7 × 103 cells/L, reference interval 1.0–4.8 × 103 cells/L]). There were 14 nucleated RBCs per 100 WBCs. The HCT confirmed the previously documented anemia (15%, reference interval 39–55%). Occasional eccentrocytes, codocytes, and Howell-Jolly bodies were noted on microscopic exam of the blood smear. There was also 1+ anisocytosis and polychromasia (scale, none – 3+). The absolute reticulocyte count showed regenerative anemia (160 × 109 cells/L, reference interval, 0–60 × 109 cells/L [160 × 103 cells/L, reference interval 0–60 × 103 cells/L]). There were no other significant abnormalities on the CBC. These results were consistent with regenerative hemolytic anemia and a stress leukogram. A Coombs test was performed and the results were negative. Serum biochemistry results showed mild hypocalcemia (9.3 mg/dL, reference interval 9.4–11.9 mg/dL [2.3 mmol/L, reference interval 2.4–3.0 mmol/L]), hypokalemia (3.1 mmol/L, reference interval 3.7–5.4 mmol/L) and hyperbilirubinemia (total bilirubin 0.6 mg/dL, reference interval 0.10–0.30 mg/dL [10.3 mol/L, reference interval 1.7–5.1 mol/L]). Tick-borne diseases were of concern due to the dog’s clinical signs and exposure potential. An ELISA testg for Dirofilaria immitis, Anaplasma phagocytophilum, Ehrlichia canis, and Borrelia burgdorferi was performed. The results of these tests were negative. The urinalysis showed moderately concentrated urine (specific gravity [USG] of 1.025). There was trace proteinuria (reference scale: none, trace, 1–3+), 3+ (500 mg/dL, [5 g/L]) glucosuria (reference scale: none, trace, 1–3+), 2+ bilirubinuria (reference scale: none, trace, 1–3+), and 2+ hemoglobinuria (reference scale: none, trace, 1–3+). The color of the urine was yellow and the turbidity was noted as being slightly hazy. Given the severity of the anemia and lack of hemoglobin color change to the serum and urine, primarily extravascular hemolysis was suspected. Renal tubular damage was suspected due to the dog’s glucosuria without concurrent hyperglycemia. Urine spot fractional excretions were measured for calcium, potassium, sodium, chloride, and phosphorus on the serum and urine collected at the time of presentation. These results were all within the normal range. A urine protein/creatinine ratio was also performed on this urine sample, and found to be slightly increased (0.6, reference interval, 0.0–0.5). 649
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Throughout the day of presentation the dog maintained a PCV of 28%. The dog’s appetite returned and there were no episodes of vomiting or diarrhea. After further investigation by the owner it was discovered that the green powder the dog had ingested was 113 grams of a natural hair-coloring agent.h According to the product label, the dye contained a combination of 3 plants: Lawsonia inermis (henna), Indigofera tinctoria (indigo), and Senna auriculata (formerly Cassia auriculata). The ingestion had occurred the night before clinical signs developed and 5 days before presentation. The American Society for the Prevention of Cruelty to Animals Animal Poison Control Center was called for information about reported intoxications in small animals. The toxicologists stated that henna toxicity had not been reported in veterinary medicine. The dog was monitored for the next 24 hours for signs of continued hemolysis. Treatment included continued IV fluids and famotidine. The next day electrolytes were within normal limits. Blood urea nitrogen was mildly decreased (7 mg/dL, reference interval 10–26 mg/dL [2.5 mmol/L, reference interval 3.6–9.3 mmol/L]). The dog remained mildly anemic (PCV 30%). A blood sample was collected later in the day and submitted for lead level testing. Blood lead levels were not increased (1.0 g/dL, reference interval < 10 g/dL [0.05 mol/L, reference interval < 0.48 mol/L]). A voided sample of urine was collected and submitted for urinalysis. USG was 1.014 and there was trace heme protein. All other values were within reference intervals. The dog’s energy level continued to improve and she was discharged that evening. Thirty days after discharge, the owners reported that the dog was doing well and returned to a normal activity level. A CBC performed by the referring veterinarian a year after discharge showed a normal HCT (37.3%, reference interval 37–55%). A biochemistry at this time showed normal kidney values. Because a urinalysis was not performed at this time, it is unknown if there is evidence of chronic kidney disease following the acute tubular injury.
Discussion Lawsonia inermis (henna) is a flowering plant native to tropical and subtropical regions of Africa as well as Southern and Southeast Asia. It has been used cosmetically for centuries as a red-brown dye for skin, hair, and clothing.1 It is used for ceremonial purposes in some cultures and is even applied to children at birth. Henna has also been reported to have medical uses. Antiinflammatory, antipyretic, and analgesic properties have been reported.1 Currently henna is used as a cosmetic agent worldwide. The product in this case is marketed
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as a safe and natural alternative to traditional chemical hair dyes.6 Lawsone (2-hydroxy-1,4 naphthoquinone) is the active ingredient found in the crushed leaves of the henna plant. Studies have shown that lawsone causes oxidative damage to erythrocytes leading to hemolysis and Heinz body anemia when administered orally to rats.7 These rats also were found to have increased plasma levels of urea and creatinine, as well as histologically identified renal tubular necrosis.7 The mechanism of nephrotoxicity of lawsone is currently unknown.8 Other studies have shown that in vitro lawsone is only a weak oxidative agent against rat erythrocytes9, 10 It is proposed that an unknown mechanism, not related to oxidative stress, results in the degree of hemolysis seen clinically with henna ingestion in rats and people.8–10 Glucose-6-phosphate dehydrogenase (G6PD) deficiency is one documented mechanism for increased susceptibility to the hemolytic activity of henna, both in vivo and in vitro.10 G6PD deficiency is an X-linked enzyme deficiency of the pentose phosphate pathway that affects over 200 million people worldwide.4 This deficiency reduces the ability of erythrocytes to survive oxidative damage. It is currently unknown if G6PD deficiency increases susceptibility to the nephrotoxic effects of henna. G6PD deficiency is reported to be rare in dogs. One study tested 3,300 dogs and found only one dog to have a mild deficiency.11 The dog in this case has not been tested for this deficiency due to the lack of a commercially available test. However, henna has shown to also be toxic in rats without G6PD deficiency. At this time it is unknown what role G6PD deficiency plays in henna toxicity in other nonhuman species. Multiple case reports of henna toxicity in G6PD deficient human patients support the vulnerability of this group to henna’s oxidative damage.3–5 These reported cases outline the progression of toxicity seen in people and reflect the signs of toxicity seen in this dog. Seven children with G6PD deficiency had topical applications of henna, resulting in lethargy and jaundice. Vomiting was reported as an early sign in 5 of the 7 cases. In all cases initial laboratory tests showed a regenerative anemia without spherocytosis and hyperbilirubinemia. Four of the patients made full recoveries following blood transfusions and 48 hours of supportive care. Three patients presented with oliguria, rapidly became anuric, and died before dialysis was initiated.3–5 Patients that presented with azotemia had a rapid progression to anuric renal failure.3–5 Only one of these patients had a urinalysis reported. The results showed isosthenuria with 1+ proteinuria. The dog in this case presented with clinical signs and clinicopathologic abnormalities similar to the
C Veterinary Emergency and Critical Care Society 2013, doi: 10.1111/vec.12113
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nonoliguric children. The time to onset of clinical signs was also similar between these cases, with initial signs seen within 24–48 hours of exposure to henna. Both this dog and the reported children had a regenerative anemia without spherocytosis and were Coombs test negative. These results suggest that henna toxicity in both dogs and children causes a non-immune mediated hemolytic anemia. The presence of eccentrocytes is supportive of oxidative damage in canine hematology.12 The significance of the occasional codocytes seen in this case is unknown and their presence is not reported in the cases of human toxicity. It is unknown at this time if the nephrotoxicity of henna demonstrated in rats and humans occurs in other veterinary species. The dog in this case had evidence of renal tubular dysfunction as evidenced by transient glucosuria and proteinuria. The other plants present in the dye ingested by this dog were Indigofera tinctoria (indigo) and Senna auriculata (formerly Cassia auriculata). Both of these plants have been investigated experimentally in rats for their antioxidant properties, without evidence of toxicity.13–15 Indigofera tinctoria has been recently shown to cause cardiac and neurologic toxicity in a 3-year-old child resulting in death.16 Neither of these plants have been reported to cause hemolysis or acute kidney injury in any species. A chemical commonly used in combination with Lawsonia inermis is paraphenylenediamine (PPD). This combination is sometimes known as “black henna.” The addition of PPD to henna produces a darker, more intense red color and accelerates the dyeing process.17 PPD is reported to have much more significant toxicity in people than henna alone, including severe oropharyngeal angioedema, encephalopathy, seizures, intravascular hemolysis, rhabdomyolysis, and acute renal failure.17–19 The product website for the dye ingested in this case claims the product contain no PPD, chemicals or other contaminants such as heavy metals or pesticides.6 There was no product available for testing of these substances as part of this case. Like henna, PPD toxicity has not been directly reported in any veterinary species. However, one case report describes a young boy ingesting a fatal amount of PPD and in the description there is mention of the boy’s dog also ingesting PPD and dying hours later.20 The case reported in this paper demonstrates that henna ingestion is toxic to dogs. The dog in this report presented with gastrointestinal signs, hemolytic anemia, and evidence of renal tubular dysfunction 5 days after ingestion. Cases of henna ingestion described in the human literature suggest that the severity of toxicity is variable. In mild cases, a favorable response is seen with transfusions and supportive care. Conversely, in cases in which patients presented with oliguria, it is suggested C Veterinary Emergency and Critical Care Society 2013, doi: 10.1111/vec.12113
that dialysis could prevent the progression of acute kidney injury and death.
Footnotes a b c d e f g h
Torbugesic, Fort Dodge Animal Health, Fort Dodge, IA. Aceproject, Vetus, Butler Schein Animal Health, Dublin, OH. Glycopyrrolate, American Regent Inc, Shirley, NY. Lactated Ringer’s solution, Baxter Healthcare Corporation, Deerfield, IL. Potassium chloride, Hospira Inc, Lake Forest, IL. Famotidine, West-ward Pharmaceutical Corp, Eatontown, NJ. Idexx Laboratories SNAP 4Dx Test, Westbrook, ME. Light Mountain Natural Hair Color, Lotus Brands Inc, Twin Lakes, WI.
References 1. Ali BH, Bashir AK, Tanira MO. Anti-inflammatory, antipyretic, and analgesic effects of Lawsonia inermis L. (henna) in rats. Pharmacology 1995; 51(6):356–363. 2. Munday R, Smith BL, Fowke EA. Haemolytic activity and nephrotoxicity of 2-hydroxy-1,4-naphthoquinone in rats. J Appl Toxicol 1991; 11(2):85–90. 3. Devecioglu ˘ C, Katar S, Dogru ˘ O, et al. Henna-induced hemolytic anemia and acute renal failure. Turk J Pediatr 2001; 43(1):65–66. ¨ AN, Ertekin MV, Ertekin V, et al. Henna (Lawsonia inermis 4. Kok Linn.) induced haemolytic anaemia in siblings. Int J Clin Pract 2004; 58(5):530–532. 5. Raupp P, Hassan JA, Varughese M, et al. Henna causes life threatening haemolysis in glucose-6-phosphate dehydrogenase deficiency. Arch Dis Child 2001; 85(5):411–412. 6. Light Mountain Natural Hair Color and Conditioner. Available at: http://www.light-mountain-hair-color.com/. Accessed October 26, 2011. 7. Munday R, Smith BL, Fowke EA. Haemolytic activity and nephrotoxicity of 2-hydroxy-1,4-naphthoquinone in rats. J Appl Toxicol 1991; 11(2):85–90. 8. Munday R, Smith BL, Munday CM. Structure-activity relationships in the haemolytic activity and nephrotoxicity of derivatives of 1,2and 1,4-naphthoquinone. J Appl Toxicol 2007;27 (3):262–269. 9. Kruger-Zeitzer E, Sullivan SG, Stern A, et al. Effects of 1,4naphthoquinone derivatives on red blood cell metabolism. J Appl Toxicol 1990; 10(2):129–133. 10. McMillan DC, Sarvate SD, Oatis JE, et al. Role of oxidant stress in lawsone-induced hemolytic anemia. Toxicol Sci 2004; 82(2):647–655. 11. Smith JE, Ryer K, Wallace L. Glucose-6-phosphate dehydrogenase deficiency in a dog. Enzyme 1976; 21(4):379–382. 12. Caldin M, Carli E, Furlanello T, et al. A retrospective study of 60 cases of eccentrocytosis in the dog. Vet Clin Pathol 2005; 34(3):224– 231. 13. Thabrew I, Munasinghe J, Chackrewarthi S, et al. The effects of Cassia auriculata and Cardiospermum halicacabum teas on the steady state blood level and toxicity of carbamazepine. J Ethnopharmacol 2004; 90(1):145–150. 14. Annie S, Rajagopal PL, Malini S. Effect of Cassia auriculata Linn. root extract on cisplatin and gentamicin-induced renal injury. Phytomedicine 2005; 12(8):555–560. 15. Chitra M, Muthusudha N, Sasikala R. Bioefficiency of indigogera tinctoria linn. on isoniazid induced hepatotoxicity in albino rats. Anc Sci Life 2003; 23(2):79–89. 16. Labib S, Berdai M-A, Bendadi A, et al. Fatal poisoning due to Indigofera. Arch Pediatr 2012; 19(1):59–61. 17. Anuradha S, Arora S, Mehrotra S, et al. Acute renal failure following para-phenylenediamine (PPD) poisoning: a case report and review. Ren Fail 2004; 26(3):329–332. 18. Ashraf W, Dawling S, Farrow LJ. Systemic paraphenylenediamine (PPD) poisoning: a case report and review. Hum Exp Toxicol 1994; 13(3):167–170. 19. Sahay M, Vani R, Vali S. Hair dye ingestion–an uncommon cause of acute kidney injury. J Assoc Physicians India 2009; 57:743–744. 20. Lifshits M, Yagupsky P, Sofer S. Fatal paraphenylenediamine (hair dye) intoxication in a child resembling Ludwig’s angina. J Toxicol Clin Toxicol 1993; 31(4):653–656.
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Journal of Veterinary Emergency and Critical Care 23(6) 2013, pp 648–651 doi: 10.1111/vec.12113
Hemolytic anemia after ingestion of the natural hair dye Lawsonia inermis (henna) in a dog Daniel J. Jardes, DVM; Linda A. Ross, DVM, DACVIM and Jessica E. Markovich, DVM, DACVIM
Abstract
Objectives – To describe the clinical presentation and case management of a dog that developed hemolytic anemia and evidence of renal tubular dysfunction after ingestion of a natural hair dye containing Lawsonia inermis (henna). To review cases of henna toxicity reported in the human literature. Case Summary – An 8-year-old female spayed Border Collie was presented 5 days after ingestion of a box of natural hair dye. The dog was showing signs of lethargy, vomiting, diarrhea, and weakness. A serum biochemistry profile, complete blood count, and urinalysis demonstrated evidence of renal tubular dysfunction and a regenerative anemia without spherocytosis. The dog was treated with a transfusion of packed RBCs and IV fluids, resulting in significant clinical improvement. Repeat diagnostics showed resolution of the anemia and no lasting evidence of tubular dysfunction. New or Unique Information Provided – To the authors’ knowledge, this is the first reported case in the veterinary literature of toxicity following ingestion of Lawsonia inermis (henna). Henna ingestion was associated with the development of hemolytic anemia and acute kidney injury. (J Vet Emerg Crit Care 2013; 23(6): 648–651) doi: 10.1111/vec.12113 Keywords: acute kidney injury, glucosephosphate dehydrogenase deficiency, lawsonia plant, Lawsone, paraphenylenediamine.
Introduction Lawsonia inermis (henna) is a flowering plant that is used around the world as a cosmetic dye to color both the hair and skin.1 Henna has also been used medically for its analgesic and anti-inflammatory properties. The ingestion or topical application of the active ingredient Lawsone (2-hydroxy-1,4 naphthoquinone) has been shown to cause a severe hemolytic anemia and acute kidney injury in both rats and people.2, 3 Henna’s widespread use has resulted in multiple case reports of toxicity in people.3–5 The following is the first report of this toxicity in a dog and a brief review of henna toxicity reported in the human literature.
Case Summary An 8-year-old, 20 kg, female spayed Border Collie was presented to the emergency service for evaluation of progressive lethargy of 4 days duration. Five days before From the Department of Clinical Sciences, Tufts University Cummings School of Veterinary Medicine, North Grafton, MA 01536. The authors report no conflicts of interests. Address correspondence and reprint requests to Dr. Linda Ross, Tufts University Cummings School of Veterinary Medicine, 200 Westboro Road, North Grafton, MA 01536. Email: [email protected] Submitted September 16, 2012; Accepted September 30, 2013.
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Abbreviations
G6PD PCV PPD
glucose-6-phosphate dehydrogenase packed cell volume paraphenylenediamine
presentation the dog ingested a large amount of a green powder. At the time of presentation the dog’s owners were unaware of the powder’s origin or composition. The day after ingestion the dog vomited once and had diarrhea; both the vomitus and feces were green in color. Over the next few days the dog became progressively more lethargic and anorexic. The dog had a past history of dietary indiscretion that typically resulted in vomiting and diarrhea for several days that resolved without medical intervention. There were no other significant past medical problems. On presentation the dog was noted to have a dull mentation, a heart rate of 135/min, and pale pink mucous membranes. Due to the aggressive nature of the dog and need for a muzzle, assessment of capillary refill time, and a full oral exam could not be completed. Dark green feces were noted in the perianal region, and the hair on the front paws was a green-blue color. The rest of the physical exam was unremarkable. A combination of butorphanola (0.2 mg/kg), acepromazineb C Veterinary Emergency and Critical Care Society 2013
Hemolytic anemia following henna ingestion in a dog
(0.025 mg/kg), and glycopyrrolatec (0.01 mg/kg) was administered IM for sedation prior to phlebotomy and cystocentesis. Initial laboratory tests performed on an emergency basis showed mild hyponatremia (138.0 mmol/L, reference interval 140.0–154.0 mmol/L), hypokalemia (2.8 mmol/L, reference interval 3.6–4.8 mmol/L), hyperchloremia (123 mmol/L, reference interval 109–120 mmol/L), ionized hypermagnesemia (0.6 mmol/L, reference interval 0.1–0.4 mmol/L), and mild hyperlactatemia (2.6 mmol/L, reference range 0.0–2.0 mmol/L). The dog was anemic with a packed cell volume (PCV) of 16% (reference range, 39–55%) and total plasma protein of 64 g/L (6.4 g/dL), with icteric serum. A blood smear was performed and showed anisocytosis, polychromasia, eccentrocytes, codocytes, nucleated RBCs, and Howell-Jolly bodies. A saline agglutination test was performed and was negative. The dog was blood typed and was dog erythrocyte antigen 1.1 negative. A CBC with reticulocyte count and serum biochemistry profile was submitted. Urine was collected via cystocentesis and submitted for urinalysis. An abbreviated abdominal ultrasound exam was performed to rule out intra-abdominal hemorrhage. This involved focused ultrasonographic assessment for the presence of fluid in four regions in the abdomen: between liver lobes and the diaphragm, at the apex of the bladder, and around each kidney. No free fluid was visualized. A lateral abdominal radiograph was taken to look for evidence of metal ingestion. No metallic foreign material or other abnormalities were noted. Evaluation of zinc levels was not performed. A transfusion of 1 unit of dog erythrocyte antigen 1.1 negative packed RBCs was administered over 4 hours. Due to the dog’s aggressive temperament, it was monitored by cardiac telemetry for changes in heart rate that might reflect a transfusion reaction. The dog was tachycardic with a heart rate of 164/min at the start of the transfusion. The heart rate returned to normal (90/min) by completion of the transfusion. Intravenous fluids were initiated (lactated Ringer’s solutiond supplemented with 40 mEq of potassium chloridee per liter administered at a rate of 60 mL/kg/day), and famotidinef (0.5 mg/kg IV q 12 hr) was administered after completion of the transfusion. Three hours after presentation the dog was still depressed. The mucous membranes were now pink and the heart rate was 80/min Recheck blood work on completion of the transfusion showed improvement in the dog’s anemia (PCV 28%, total plasma protein 64 g/L [6.4 g/dL]). Telemetry was discontinued. The results from the diagnostic tests submitted on presentation were reported. The serum was again noted to be icteric. The CBC revealed mild leukocytosis C Veterinary Emergency and Critical Care Society 2013, doi: 10.1111/vec.12113
(18.1 × 109 cells/L, reference interval, 4.9–16.9 × 109 cells/L [18.1 × 103 cells/L, reference interval 4.9– 16.9 × 103 cells/L]). The differential count showed neutrophila (16.0 × 109 cells/L, reference interval, 2.8– 11.5 × 109 cells/L [16.0 × 103 cells/L, reference interval 2.8–11.5 × 103 cells/L]) and lymphopenia (0.7 × 109 cells/L, reference interval, 1.0–4.8 × 109 cells/L [0.7 × 103 cells/L, reference interval 1.0–4.8 × 103 cells/L]). There were 14 nucleated RBCs per 100 WBCs. The HCT confirmed the previously documented anemia (15%, reference interval 39–55%). Occasional eccentrocytes, codocytes, and Howell-Jolly bodies were noted on microscopic exam of the blood smear. There was also 1+ anisocytosis and polychromasia (scale, none – 3+). The absolute reticulocyte count showed regenerative anemia (160 × 109 cells/L, reference interval, 0–60 × 109 cells/L [160 × 103 cells/L, reference interval 0–60 × 103 cells/L]). There were no other significant abnormalities on the CBC. These results were consistent with regenerative hemolytic anemia and a stress leukogram. A Coombs test was performed and the results were negative. Serum biochemistry results showed mild hypocalcemia (9.3 mg/dL, reference interval 9.4–11.9 mg/dL [2.3 mmol/L, reference interval 2.4–3.0 mmol/L]), hypokalemia (3.1 mmol/L, reference interval 3.7–5.4 mmol/L) and hyperbilirubinemia (total bilirubin 0.6 mg/dL, reference interval 0.10–0.30 mg/dL [10.3 mol/L, reference interval 1.7–5.1 mol/L]). Tick-borne diseases were of concern due to the dog’s clinical signs and exposure potential. An ELISA testg for Dirofilaria immitis, Anaplasma phagocytophilum, Ehrlichia canis, and Borrelia burgdorferi was performed. The results of these tests were negative. The urinalysis showed moderately concentrated urine (specific gravity [USG] of 1.025). There was trace proteinuria (reference scale: none, trace, 1–3+), 3+ (500 mg/dL, [5 g/L]) glucosuria (reference scale: none, trace, 1–3+), 2+ bilirubinuria (reference scale: none, trace, 1–3+), and 2+ hemoglobinuria (reference scale: none, trace, 1–3+). The color of the urine was yellow and the turbidity was noted as being slightly hazy. Given the severity of the anemia and lack of hemoglobin color change to the serum and urine, primarily extravascular hemolysis was suspected. Renal tubular damage was suspected due to the dog’s glucosuria without concurrent hyperglycemia. Urine spot fractional excretions were measured for calcium, potassium, sodium, chloride, and phosphorus on the serum and urine collected at the time of presentation. These results were all within the normal range. A urine protein/creatinine ratio was also performed on this urine sample, and found to be slightly increased (0.6, reference interval, 0.0–0.5). 649
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Throughout the day of presentation the dog maintained a PCV of 28%. The dog’s appetite returned and there were no episodes of vomiting or diarrhea. After further investigation by the owner it was discovered that the green powder the dog had ingested was 113 grams of a natural hair-coloring agent.h According to the product label, the dye contained a combination of 3 plants: Lawsonia inermis (henna), Indigofera tinctoria (indigo), and Senna auriculata (formerly Cassia auriculata). The ingestion had occurred the night before clinical signs developed and 5 days before presentation. The American Society for the Prevention of Cruelty to Animals Animal Poison Control Center was called for information about reported intoxications in small animals. The toxicologists stated that henna toxicity had not been reported in veterinary medicine. The dog was monitored for the next 24 hours for signs of continued hemolysis. Treatment included continued IV fluids and famotidine. The next day electrolytes were within normal limits. Blood urea nitrogen was mildly decreased (7 mg/dL, reference interval 10–26 mg/dL [2.5 mmol/L, reference interval 3.6–9.3 mmol/L]). The dog remained mildly anemic (PCV 30%). A blood sample was collected later in the day and submitted for lead level testing. Blood lead levels were not increased (1.0 g/dL, reference interval < 10 g/dL [0.05 mol/L, reference interval < 0.48 mol/L]). A voided sample of urine was collected and submitted for urinalysis. USG was 1.014 and there was trace heme protein. All other values were within reference intervals. The dog’s energy level continued to improve and she was discharged that evening. Thirty days after discharge, the owners reported that the dog was doing well and returned to a normal activity level. A CBC performed by the referring veterinarian a year after discharge showed a normal HCT (37.3%, reference interval 37–55%). A biochemistry at this time showed normal kidney values. Because a urinalysis was not performed at this time, it is unknown if there is evidence of chronic kidney disease following the acute tubular injury.
Discussion Lawsonia inermis (henna) is a flowering plant native to tropical and subtropical regions of Africa as well as Southern and Southeast Asia. It has been used cosmetically for centuries as a red-brown dye for skin, hair, and clothing.1 It is used for ceremonial purposes in some cultures and is even applied to children at birth. Henna has also been reported to have medical uses. Antiinflammatory, antipyretic, and analgesic properties have been reported.1 Currently henna is used as a cosmetic agent worldwide. The product in this case is marketed
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as a safe and natural alternative to traditional chemical hair dyes.6 Lawsone (2-hydroxy-1,4 naphthoquinone) is the active ingredient found in the crushed leaves of the henna plant. Studies have shown that lawsone causes oxidative damage to erythrocytes leading to hemolysis and Heinz body anemia when administered orally to rats.7 These rats also were found to have increased plasma levels of urea and creatinine, as well as histologically identified renal tubular necrosis.7 The mechanism of nephrotoxicity of lawsone is currently unknown.8 Other studies have shown that in vitro lawsone is only a weak oxidative agent against rat erythrocytes9, 10 It is proposed that an unknown mechanism, not related to oxidative stress, results in the degree of hemolysis seen clinically with henna ingestion in rats and people.8–10 Glucose-6-phosphate dehydrogenase (G6PD) deficiency is one documented mechanism for increased susceptibility to the hemolytic activity of henna, both in vivo and in vitro.10 G6PD deficiency is an X-linked enzyme deficiency of the pentose phosphate pathway that affects over 200 million people worldwide.4 This deficiency reduces the ability of erythrocytes to survive oxidative damage. It is currently unknown if G6PD deficiency increases susceptibility to the nephrotoxic effects of henna. G6PD deficiency is reported to be rare in dogs. One study tested 3,300 dogs and found only one dog to have a mild deficiency.11 The dog in this case has not been tested for this deficiency due to the lack of a commercially available test. However, henna has shown to also be toxic in rats without G6PD deficiency. At this time it is unknown what role G6PD deficiency plays in henna toxicity in other nonhuman species. Multiple case reports of henna toxicity in G6PD deficient human patients support the vulnerability of this group to henna’s oxidative damage.3–5 These reported cases outline the progression of toxicity seen in people and reflect the signs of toxicity seen in this dog. Seven children with G6PD deficiency had topical applications of henna, resulting in lethargy and jaundice. Vomiting was reported as an early sign in 5 of the 7 cases. In all cases initial laboratory tests showed a regenerative anemia without spherocytosis and hyperbilirubinemia. Four of the patients made full recoveries following blood transfusions and 48 hours of supportive care. Three patients presented with oliguria, rapidly became anuric, and died before dialysis was initiated.3–5 Patients that presented with azotemia had a rapid progression to anuric renal failure.3–5 Only one of these patients had a urinalysis reported. The results showed isosthenuria with 1+ proteinuria. The dog in this case presented with clinical signs and clinicopathologic abnormalities similar to the
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Hemolytic anemia following henna ingestion in a dog
nonoliguric children. The time to onset of clinical signs was also similar between these cases, with initial signs seen within 24–48 hours of exposure to henna. Both this dog and the reported children had a regenerative anemia without spherocytosis and were Coombs test negative. These results suggest that henna toxicity in both dogs and children causes a non-immune mediated hemolytic anemia. The presence of eccentrocytes is supportive of oxidative damage in canine hematology.12 The significance of the occasional codocytes seen in this case is unknown and their presence is not reported in the cases of human toxicity. It is unknown at this time if the nephrotoxicity of henna demonstrated in rats and humans occurs in other veterinary species. The dog in this case had evidence of renal tubular dysfunction as evidenced by transient glucosuria and proteinuria. The other plants present in the dye ingested by this dog were Indigofera tinctoria (indigo) and Senna auriculata (formerly Cassia auriculata). Both of these plants have been investigated experimentally in rats for their antioxidant properties, without evidence of toxicity.13–15 Indigofera tinctoria has been recently shown to cause cardiac and neurologic toxicity in a 3-year-old child resulting in death.16 Neither of these plants have been reported to cause hemolysis or acute kidney injury in any species. A chemical commonly used in combination with Lawsonia inermis is paraphenylenediamine (PPD). This combination is sometimes known as “black henna.” The addition of PPD to henna produces a darker, more intense red color and accelerates the dyeing process.17 PPD is reported to have much more significant toxicity in people than henna alone, including severe oropharyngeal angioedema, encephalopathy, seizures, intravascular hemolysis, rhabdomyolysis, and acute renal failure.17–19 The product website for the dye ingested in this case claims the product contain no PPD, chemicals or other contaminants such as heavy metals or pesticides.6 There was no product available for testing of these substances as part of this case. Like henna, PPD toxicity has not been directly reported in any veterinary species. However, one case report describes a young boy ingesting a fatal amount of PPD and in the description there is mention of the boy’s dog also ingesting PPD and dying hours later.20 The case reported in this paper demonstrates that henna ingestion is toxic to dogs. The dog in this report presented with gastrointestinal signs, hemolytic anemia, and evidence of renal tubular dysfunction 5 days after ingestion. Cases of henna ingestion described in the human literature suggest that the severity of toxicity is variable. In mild cases, a favorable response is seen with transfusions and supportive care. Conversely, in cases in which patients presented with oliguria, it is suggested C Veterinary Emergency and Critical Care Society 2013, doi: 10.1111/vec.12113
that dialysis could prevent the progression of acute kidney injury and death.
Footnotes a b c d e f g h
Torbugesic, Fort Dodge Animal Health, Fort Dodge, IA. Aceproject, Vetus, Butler Schein Animal Health, Dublin, OH. Glycopyrrolate, American Regent Inc, Shirley, NY. Lactated Ringer’s solution, Baxter Healthcare Corporation, Deerfield, IL. Potassium chloride, Hospira Inc, Lake Forest, IL. Famotidine, West-ward Pharmaceutical Corp, Eatontown, NJ. Idexx Laboratories SNAP 4Dx Test, Westbrook, ME. Light Mountain Natural Hair Color, Lotus Brands Inc, Twin Lakes, WI.
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