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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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2
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Lebherz K, Chau N, Grugan BM, Cates AL. Diagnosis on sight: Chocolate blood. J Am Coll Emerg Physicians Open 2023; 4:e13021. [PMID: 37554296 PMCID: PMC10405146 DOI: 10.1002/emp2.13021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Karly Lebherz
- Department of Emergency MedicineOchsner Medical CenterNew OrleansLouisianaUSA
| | - Nhat Chau
- Department of Emergency MedicineOchsner Medical CenterNew OrleansLouisianaUSA
| | - Benjamin M. Grugan
- Department of Emergency MedicineOchsner Medical CenterNew OrleansLouisianaUSA
| | - Alexis L. Cates
- Ochsner Medical CenterThe University of Queensland & Ochsner Clinical SchoolNew OrleansLouisianaUSA
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Hammami MB, Qasim A, Thakur R, Vegivinti CTR, Patton CD, Vikash S, Kumar A. Rasburicase-induced hemolytic anemia and methemoglobinemia: a systematic review of current reports. Ann Hematol 2023:10.1007/s00277-023-05364-6. [PMID: 37468669 DOI: 10.1007/s00277-023-05364-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/09/2023] [Indexed: 07/21/2023]
Abstract
Since the FDA's approval of rasburicase use for treatment of tumor lysis syndrome (TLS), multiple cases of rasburicase-induced methemoglobinemia and hemolytic anemia have been reported among patients with G6PD deficiency. This study aims to provide a systematic review of cases reporting such adverse reactions to rasburicase. A literature review of published cases in PubMed, Embase, Cochrane, and Web of Science was conducted. Descriptive studies reporting cases of rasburicase-induced methemoglobinemia and/or hemolytic anemia in English were analyzed and summarized in this study. Forty-three cases, including a case from our institution, were included in this study. Most cases (60.5%) received rasburicase for TLS treatment. Almost all patients (93.8%) were tested for G6PD after rasburicase administration. The median time to symptom onset was 24 h. The median methemoglobin level was 10%, peaking after a median of 24 h. The median hemoglobin nadir was 6.1 g/dL, and most patients (n = 32) required blood transfusion. Out of 39 cases with reported outcomes, 35 patients (89.7%) recovered, while four patients (three females and one male) died. The median time to recovery was 4.5 days while the median time to death was 8 days. Screening for G6PD deficiency among high-risk patients is important but not practical in acutely severe settings. When prior screening for G6PD deficiency is not feasible, close monitoring for methemoglobinemia and hemolytic anemia is recommended. Exchange transfusion is increasingly reported as a potentially successful therapeutic modality. Ascorbic acid may provide limited benefits. Methylene blue should be avoided as it may exacerbate hemolysis among these patients.
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Affiliation(s)
- M Bakri Hammami
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Asma Qasim
- Department of Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Rahul Thakur
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY, USA
| | - Charan Thej Reddy Vegivinti
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY, USA
- Department of Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Sindhu Vikash
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY, USA
| | - Abhishek Kumar
- Department of Hematology and Medical Oncology, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
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Anand V, Venkatesan DK, T P, Naseem M, Rathia SK. Methemoglobinemia Secondary to a Traditional Healing Practice Using Mothballs: A Need of Pediatric Vigilance. Cureus 2023; 15:e41192. [PMID: 37525810 PMCID: PMC10387263 DOI: 10.7759/cureus.41192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/02/2023] Open
Abstract
Acute-onset unexplained hypoxemia persisting despite 100% oxygen has a limited differential diagnosis but poses a challenging diagnostic dilemma. Methemoglobinemia, a hemolytic condition, may lead to significant complications if it goes undiagnosed during the critical golden hour of an emergency department (ED) presentation. This case report presents the clinical details of a 30-month-old child with acute intravascular hemolysis evident by severe pallor and hemoglobinuria and severe hypoxia documented on pulse oximetry. During the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) of the primary survey, "exposure" revealed the parent's deliberate fastening of a mothball around the waist of the baby on the advice of a traditional healer, which was identified as the source of naphthalene toxicity. The swift intervention was undertaken for hypoxic respiratory compromise with 100% oxygen just after triage, and the naphthalene ball with the tied cloth was removed. Arterial blood gas and co-oximetry analysis confirmed the diagnosis of methemoglobinemia, and other laboratory tests suggested severe hemolytic anaemia as well as hemoglobinuria favouring intravascular hemolysis. With the exclusion of other common differentials for hemolytic anaemia, including sickle cell crisis, autoimmune hemolytic anaemia, hemolytic uremic syndrome, and G6PD deficiency, naphthalene exposure was considered the culprit for both hemolysis and methemoglobinemia. After obtaining the history of another similar episode of anaemia six months ago requiring blood transfusion, we retrospected on similar mothball exposure, but parents denied that, saying they were using the mothball only for the last 10 days on the advice of a local healer with intent to get rid of some evil power and sickness in their child. After analyzing the old records of prior hospitalization and getting assured of a normal report of G6PD level, intravenous methylene blue was administered. But in view of an inadequate response, a single blood volume exchange transfusion was performed during the ED stay only, which resulted in a notable reduction in subsequent methemoglobin levels and an improvement of the child's clinical condition by the second day. The child was discharged by the third day with no distress and no further episodes of hemoglobinuria, with detailed parental counselling and follow-up advice. This case underscores the imperative need for timely recognition and effective management of methemoglobinemia in the paediatric population while emphasizing the potential hazards associated with naphthalene exposure. Further comprehensive investigations are warranted to elucidate optimal treatment strategies and explore long-term outcomes in similar clinical scenarios.
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Affiliation(s)
- Varun Anand
- Trauma and Emergency/Pediatric Emergency Medicine, All India Institute of Medical Sciences Raipur, Raipur, IND
| | - Dilip K Venkatesan
- Pediatric Emergency Medicine, All India Institute of Medical Sciences Raipur, Raipur, IND
| | - Pugazhenthan T
- Pharmacology and Therapeutics, All India Institute of Medical Sciences Raipur, Raipur, IND
| | - Md Naseem
- Pediatric Emergency Medicine, All India Institute of Medical Sciences Raipur, Raipur, IND
| | - Santosh K Rathia
- Trauma and Emergency/Pediatric Emergency Medicine, All India Institute of Medical Sciences Raipur, Raipur, IND
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Muacevic A, Adler JR, Acharya S, K S. Toxin-Induced Methemoglobinemia With Kidney Injury and Hypoxic Brain Injury in a Case of Pesticide Poisoning: A Case Report. Cureus 2022; 14:e32516. [PMID: 36654552 PMCID: PMC9838593 DOI: 10.7759/cureus.32516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/14/2022] [Indexed: 12/15/2022] Open
Abstract
In many developing nations like India, the majority of the labor force comprises farmers. Therefore, there is a raised frequency of farmer suicides using pesticides. Toxin-induced methemoglobinemia is otherwise called toxic methemoglobinemia. It is a hematologic disorder attributed to exposure to toxic oxidizing agents and is most commonly seen in cases of poisoning. Methemoglobinemia is a condition in which there is an altered state of hemoglobin, resulting in reduced oxygen delivery to tissues. This case report represents a case of methemoglobinemia with acute kidney injury and hypoxic brain injury seen in a 23-year-old male patient. He was a farmer by occupation and was admitted due to ingestion of a pesticide named HUNT with suicidal intentions. He has had no previous history of psychiatric or neurologic disorders. The patient initially presented with a pulse rate of 110/min and room air saturation of 98% when he was brought to the casualty out patient department (OPD). Unfortunately, it worsened over the next 24 h, after which there was a sudden drop in SpO2 to 78% with oxygen support. Upon further examination and assessment, he was diagnosed with methemoglobinemia, leading to complications such as acute kidney failure and cerebral edema. He was then treated with hemodialysis, methylene blue, and ascorbic acid with viable improvement. This led to his complete recovery after eight days of treatment and support.
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Vidhyashree BH, Zuber M, Taj S, Venkataraman R, Sathish Kumar BP, Jabeen N. Rasburicase induced methemoglobinemia: A systematic review of descriptive studies. J Oncol Pharm Pract 2022:10781552221075239. [PMID: 35119341 DOI: 10.1177/10781552221075239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE There is an increased number of reports being published on rasburicase-induced methemoglobinemia recently. We aimed to identify and critically evaluate all the descriptive studies that described the rasburicase-induced methemoglobinemia, its treatment approach, and their outcomes. METHODOLOGY PubMed, Scopus and grey literature databases were searched from inception to January 2022 using search terms "rasburicase" and "methemoglobinemia" without any language and date restriction. A bibliographic search was also done to find additional studies. Only descriptive studies on Rasburicase-induced methemoglobinemia were included for our review. Two contributors worked independently on study selection, data abstraction, and quality assessment, and any disagreements were resolved by consensus or discussion with a third reviewer. RESULT A total of 24 reports including 27 patients (23 male, 3 female patients, and 1 study did not specify the gender of the patient) aged from 5 to 75 years were included in the review. Immediate withdrawal of the drug and administering methylene blue, ascorbic acid, blood transfusion, and supportive oxygen therapy are the cornerstone in the management of rasburicase-induced methemoglobinemia. CONCLUSION Rasburicase administration should be followed by careful monitoring of patients for any severe complication and treat it as early as possible appropriately. In a patient who presents with rasburicase-induced haemolysis or methemoglobinemia, it is often important to expect a diagnosis of G6PD deficiency unless otherwise confirmed and to avoid administering methylene blue, even though the patient is from a low-risk ethnicity for G6PDD.
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Affiliation(s)
- B H Vidhyashree
- Department of Pharmacy Practice, 75972Sri Adichunchanagiri College of Pharmacy, Adichunchanagiri University, BG Nagara, Nagamangala, Karnataka, India
| | - Mohammed Zuber
- Department of Pharmacy Practice, 75972Sri Adichunchanagiri College of Pharmacy, Adichunchanagiri University, BG Nagara, Nagamangala, Karnataka, India
| | - Shifa Taj
- Department of Pharmacy Practice, 77379Sarada Vilas College of Pharmacy, Mysore, Karnataka, India
| | - Rajesh Venkataraman
- Department of Pharmacy Practice, 75972Sri Adichunchanagiri College of Pharmacy, Adichunchanagiri University, BG Nagara, Nagamangala, Karnataka, India
| | - B P Sathish Kumar
- Department of Pharmacy Practice, 75972Sri Adichunchanagiri College of Pharmacy, Adichunchanagiri University, BG Nagara, Nagamangala, Karnataka, India
| | - Nihala Jabeen
- Markaz Unani Medical College and Hospital, Markaz Knowledge City, Kaithapoyil, Thamarassery, Kerala, India
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Pirrone I, Farruggia P, Cacciatore F, Giambona A, Guarina A, Marcello AP, Mosa C, Scalzo S, D'Angelo P. Rasburicase-induced Methemoglobinemia: A Case Report and Literature Review. J Pediatr Hematol Oncol 2021; 43:e886-e890. [PMID: 33122582 DOI: 10.1097/mph.0000000000001979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 09/17/2020] [Indexed: 11/25/2022]
Abstract
Rasburicase is a recombinant urate oxidase enzyme indicated for tumor lysis syndrome, a potential life-threatening oncologic emergency that occurs most commonly during initial chemotherapy for hematological malignancies. As a result of the defects in the physiological antioxidant pathway, erythrocytes of patients with glucose-6-phosphate dehydrogenase deficiency are not protected against the oxidizing stress exerted by hydrogen peroxide generated with the administration of rasburicase. The authors report a 14-year-old patient, diagnosed with T-cell acute lymphoblastic leukemia, who developed methemoglobinemia and hemolytic anemia with low oxygen saturation after starting steroids, hyperhydratation, and rasburicase administration. The complications resolved with supportive therapy only.
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Affiliation(s)
- Ilaria Pirrone
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Pediatric Postgraduate School, University of Palermo
| | - Piero Farruggia
- Pediatric Hematology and Oncology Unit, Pediatric Department, ARNAS Civico, Di Cristina and Benfratelli Hospitals
| | - Francesca Cacciatore
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Pediatric Postgraduate School, University of Palermo
| | - Antonino Giambona
- Laboratory for Molecular Diagnosis of Rare Diseases, Department of Hematology for Rare Diseases of Blood and Blood-Forming Organs, Villa Sofia-Cervello Hospital, Palermo
| | - Angela Guarina
- Pediatric Hematology and Oncology Unit, Pediatric Department, ARNAS Civico, Di Cristina and Benfratelli Hospitals
| | - Anna Paola Marcello
- Oncoematology Unit, Physiopathology of Anemia Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Clara Mosa
- Pediatric Hematology and Oncology Unit, Pediatric Department, ARNAS Civico, Di Cristina and Benfratelli Hospitals
| | - Simona Scalzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Pediatric Postgraduate School, University of Palermo
| | - Paolo D'Angelo
- Pediatric Hematology and Oncology Unit, Pediatric Department, ARNAS Civico, Di Cristina and Benfratelli Hospitals
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8
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Gupta P, Verma PK. A Rare Cause of Methemoglobinemia: How Safe are So-called Biopesticide? Indian J Crit Care Med 2020; 24:208-209. [PMID: 32435103 PMCID: PMC7225755 DOI: 10.5005/jp-journals-10071-23373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
With increasing awareness of "greener" environment, market is flooded with biopesticide. Natural insecticides can be chemical, mineral, or biological. We report an unusual case of methemoglobinemia after deliberate ingestion of an insecticide containing extract of pine oil and azadirachtin oil, Ti oil, and kerosene. On literature search, no such case report has been documented so far. How to cite this article: Gupta P, Verma PK. A Rare Cause of Methemoglobinemia: How Safe are So-called Biopesticide? Indian J Crit Care Med 2020;24(3):208-209.
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Affiliation(s)
- Poonam Gupta
- Department of Anesthesia and Intensive Care, Safdarjang Hospital and Vardhman Mahavir Medical College, New Delhi, India
| | - Pradeep K Verma
- Department of Anesthesia and Intensive Care, Safdarjang Hospital and Vardhman Mahavir Medical College, New Delhi, India
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9
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Lin DMH, Becker J, Wu Y, Cooling L. How do I perform whole blood exchange? Transfusion 2020; 60:449-453. [PMID: 31909491 DOI: 10.1111/trf.15660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 11/02/2019] [Accepted: 11/03/2019] [Indexed: 01/19/2023]
Affiliation(s)
| | - Joanne Becker
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
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10
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Singh P, Rakesh K, Agarwal R, Tripathi PP, Dhooria S, Sehgal IS, Prasad KT, Hans R, Sharma R, Sharma N, Lad D, Aggarwal AN, Muthu V. Therapeutic whole blood exchange in the management of methaemoglobinemia: Case series and systematic review of literature. Transfus Med 2020; 30:231-239. [DOI: 10.1111/tme.12666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 01/07/2020] [Accepted: 01/16/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Pawan Singh
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Kodati Rakesh
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Ritesh Agarwal
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Paramatma P. Tripathi
- Department of Transfusion medicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Sahajal Dhooria
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Inderpaul S. Sehgal
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Kuruswamy T. Prasad
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Rekha Hans
- Department of Transfusion medicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Rattiram Sharma
- Department of Transfusion medicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Navneet Sharma
- Department of Internal MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Deepesh Lad
- Department of HematologyPostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Ashutosh N. Aggarwal
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Valliappan Muthu
- Department of Pulmonary MedicinePostgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
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Raru Y, Abouzid M, Parsons J, Zeid F. Rasburicase induced severe hemolysis and methemoglobinemia in a Caucasian patient complicated by acute renal failure and ARDS. Respir Med Case Rep 2018; 26:142-145. [PMID: 30603605 PMCID: PMC6307101 DOI: 10.1016/j.rmcr.2018.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/18/2018] [Accepted: 12/18/2018] [Indexed: 11/19/2022] Open
Abstract
Rasburicase is a recombinant urate-oxidase enzyme and is a very important medication for tumor lysis syndrome. Methemoglobinemia and hemolysis are known side effects of rasburicase that result from oxidative stress caused by hydrogen peroxide, a byproduct generated during the breakdown of uric acid to allantoin. Patients with G6PD deficiency have a decreased tolerance to oxidative stress and are therefore at a greater risk of hemolysis and methemoglobinemia with rasburicase. Our patient is a 56-year-old Caucasian male with a recent diagnosis of grade 2-3a non-Hodgkin's lymphoma who presented to our emergency department with shortness of breath and dark discoloration of urine. Patient was discharged 36 hours ago from our hospital after he was given a first course of R-CHOP regimen and a dose of rasburicase. On further evaluation, patient was found to have severe anemia with hemolytic picture, hyperkalemia and acute kidney injury. He also had a discrepancy of the transcutaneous saturation (75%) and the saturation in an arterial blood gas value (99%). His methemoglobin level was found to be 11.9%. We were aware that methylene blue is a contraindication in patients with G6PD deficiency but considering patient being Caucasian and low risk for it and his deteriorating respiratory condition, it was decided to offer the treatment and patient received 1 dose of methylene blue which failed to improve his methemoglobinemia. He was also given vitamin C and 8 units of packed red blood cell throughout his stay in the hospital. Patient's hospital course was complicated by ARDS needed to be on mechanical ventilation support for 4 days and acute renal failure secondary to pigment nephropathy and acute tubular necrosis which required a hemodialysis support. Even if rasburicase induced methemoglobinemia and hemolysis are not very common complications, clinicians who prescribe and follow patients should detect this serious complication early and manage it accordingly. Our case can be used as a reminder that patients should be followed closely and given the right instructions on discharge to treat these complications which are associated with severe consequences. It is also vital to assume a diagnosis of G6PD deficiency until proven otherwise in a patient who presents with rasburicase induced hemolysis and avoid administration of methylene blue even if the patient is from a low risk ethnicity for G6PD as in our patient.
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Affiliation(s)
- Yonas Raru
- Internal Medicine Resident, Marshall University School of Medicine, Huntington, WV, USA
- Corresponding author.
| | - Mahmoud Abouzid
- Internal Medicine Resident, Marshall University School of Medicine, Huntington, WV, USA
| | - Julia Parsons
- Internal Medicine Resident, Marshall University School of Medicine, Huntington, WV, USA
| | - Fuad Zeid
- Pulmonary and Critical Care Medicine, Marshall University School of Medicine, Huntington, WV, USA
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12
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Rehman A, Shehadeh M, Khirfan D, Jones A. Severe acute haemolytic anaemia associated with severe methaemoglobinaemia in a G6PD-deficient man. BMJ Case Rep 2018; 2018:bcr-2017-223369. [PMID: 29592989 DOI: 10.1136/bcr-2017-223369] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Methaemoglobin is a form of haemoglobin in which the ferrous (Fe2+) ion contained in the iron-porphyrin complex of haem is oxidised to its ferric (Fe3+) state. Methaemoglobinaemia, the presence of methaemoglobin in the blood, is most commonly treated with methylene blue. However, methylene blue cannot be used in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency as it is ineffective in such patients and it can worsen G6PD deficiency haemolysis. We report the case of a 30-year-old man who presented with clinical features of G6PD deficiency-associated haemolysis and was found to have severe methaemoglobinaemia (35%). He was administered blood transfusions and intravenous ascorbic acid. His methaemoglobinaemia resolved within 24 hours. This case demonstrates the successful management of a patient with severe methaemoglobinaemia in the setting of G6PD deficiency haemolysis. Emergency physicians should be aware of the possible co-occurrence of severe methaemoglobinaemia in a patient with G6PD deficiency haemolysis.
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Affiliation(s)
- Abdul Rehman
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan.,Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Diala Khirfan
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Akhnuwhkh Jones
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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13
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Cooling L. Brisk clinical response to erythrocytapheresis in a G6PD-deficient patient with rasburicase-induced methemoglobinemia. J Clin Apher 2017; 32:599-600. [PMID: 28370399 DOI: 10.1002/jca.21540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 03/17/2017] [Accepted: 03/18/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Laura Cooling
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
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14
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Ibrahim U, Saqib A, Mohammad F, Atallah JP, Odaimi M. Rasburicase-induced methemoglobinemia: The eyes do not see what the mind does not know. J Oncol Pharm Pract 2017; 24:309-313. [PMID: 28345492 DOI: 10.1177/1078155217701295] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rasburicase is indicated for the prevention and treatment of tumor lysis syndrome which can be a potentially life-threatening emergency. The drug has oxidizing potential and as an adverse effect, it can convert the ferrous form of iron in erythrocytes to its ferric form resulting in the formation of methemoglobin which makes the heme component incapable of carrying oxygen. Patients with glucose-6-phosphate dehydrogenase enzyme deficiency are at high risk of methemoglobinemia from oxidizing agents. Symptoms of methemoglobinemia range from none to life-threatening hypoxemia, cyanosis and respiratory compromise. Treatment is indicated at levels above 20% and at lower levels if the patient is significantly anemic. We present a case of a 60-year-old male with diffuse large B cell lymphoma at high risk of tumor lysis syndrome. Rasburicase was administered to prevent renal failure and further rise in uric acid. Twenty-four hours later, a bedside pulse oximetry showed an oxygen saturation ranging from 60 to 65% with minimal cyanosis. Co-oximetry revealed a methemoglobin level of 9.8%. Methylene blue was administered and the methemoglobin level decreased to 2.6%. However, the patient developed hemolysis several hours later, likely secondary to rasburicase and methylene blue, requiring transfusion support. We discuss this potentially fatal and initially asymptomatic adverse effect of rasburicase along with diagnostic and treatment considerations, and review the cases described in the current literature.
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Affiliation(s)
- Uroosa Ibrahim
- 1 Department of Hematology/Oncology, Staten Island University Hospital, Staten Island, NY, USA
| | - Amina Saqib
- 2 Department of Pulmonary/Critical Care, Staten Island University Hospital, Staten Island, NY, USA
| | - Farhan Mohammad
- 2 Department of Pulmonary/Critical Care, Staten Island University Hospital, Staten Island, NY, USA
| | - Jean Paul Atallah
- 2 Department of Pulmonary/Critical Care, Staten Island University Hospital, Staten Island, NY, USA
| | - Marcel Odaimi
- 2 Department of Pulmonary/Critical Care, Staten Island University Hospital, Staten Island, NY, USA
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15
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Allister LM, Torres C, Schnall J, Bhatia K, Miller ES. Jaundice, Anemia, and Hypoxemia. J Emerg Med 2017; 52:93-97. [DOI: 10.1016/j.jemermed.2016.07.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 10/20/2022]
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16
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Reeves DJ, Saum LM, Birhiray R. I.V. ascorbic acid for treatment of apparent rasburicase-induced methemoglobinemia in a patient with acute kidney injury and assumed glucose-6-phosphate dehydrogenase deficiency. Am J Health Syst Pharm 2016; 73:e238-42. [DOI: 10.2146/ajhp150591] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- David J. Reeves
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN, and Department of Pharmacy, St. Vincent Hospital, Indianapolis, IN
| | - Lindsay M. Saum
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN, and Department of Pharmacy, St. Vincent Hospital, Indianapolis, IN
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17
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Montgomery KW, Booth GS. A perfect storm: Tumor lysis syndrome with rasburicase-induced methemoglobinemia in a G6PD deficient adult. J Clin Apher 2016; 32:62-63. [DOI: 10.1002/jca.21462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Kathleen W. Montgomery
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center; Nashville Tennessee
| | - Garrett S. Booth
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center; Nashville Tennessee
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18
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Sherwood GB, Paschal RD, Adamski J. Rasburicase-induced methemoglobinemia: case report, literature review, and proposed treatment algorithm. Clin Case Rep 2016; 4:315-9. [PMID: 27099716 PMCID: PMC4831372 DOI: 10.1002/ccr3.495] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/22/2015] [Accepted: 12/25/2015] [Indexed: 11/11/2022] Open
Abstract
Rasburicase for the treatment of tumor lysis syndrome has been associated with hemolytic anemia and methemoglobinemia, usually in patients with G6PD deficiency. Risks and benefits should be considered prior to use of rasburicase in at‐risk patients. Methylene blue will worsen the hemolytic anemia in G6PD deficiency and should be avoided.
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Affiliation(s)
- Garrett B Sherwood
- Internal Medicine Resident University of Alabama at Birmingham Birmingham Alabama
| | - Rita D Paschal
- Department of Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Jill Adamski
- Department of Laboratory Medicine and Pathology Mayo Clinic Scottsdale Arizona
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19
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20
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Bontant T, Le Garrec S, Avran D, Dauger S. Methaemoglobinaemia in a G6PD-deficient child treated with rasburicase. BMJ Case Rep 2014; 2014:bcr-2014-204706. [PMID: 25115783 DOI: 10.1136/bcr-2014-204706] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 5-year-old boy from the Congo, was admitted for hyperleucocytic acute lymphoblastic leukaemia, with a high risk of tumour lysis syndrome (TLS). He had splenomegaly and mediastinal lymphadenopathy on chest X-ray. We started steroids and hyperhydration with rasburicase to prevent TLS. Respiratory failure with mediastinal enlargement developed rapidly. A few hours after intensive care unit (ICU) admission, he was started on mechanical ventilation. Chemotherapy was started immediately given the strong suspicion of mediastinal compression. Low oxygen saturation with high partial arterial oxygen pressure persisted. Blood tests confirmed 20% methaemoglobinaemia and glucose-6-phosphate dehydrogenase (G6PD) deficiency. Allopurinol was substituted for rasburicase. The methaemoglobinaemia disappeared rapidly and he was discharged from the ICU after 72 h. In case of rasburicase use, a close clinical monitoring is mandatory, especially in populations where G6PD deficiency is highly prevalent. Methaemoglobinaemia must be suspected in case of low oxygen saturation when all other potential causes have been ruled out.
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Affiliation(s)
- Thomas Bontant
- PICU, Hopital Robert Debré, AP-HP and Paris Diderot, Paris 7 University, Paris, France
| | - Sophie Le Garrec
- PICU, Hopital Robert Debré, AP-HP and Paris Diderot, Paris 7 University, Paris, France
| | - David Avran
- PICU, Hopital Robert Debré, AP-HP and Paris Diderot, Paris 7 University, Paris, France
| | - Stephane Dauger
- PICU, Hopital Robert Debré, AP-HP and Paris Diderot, Paris 7 University, Paris, France
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21
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George T, Shaikh AI, Thomas L, Kundavaram AP. Severe methemoglobinemia due to insecticide poisoning. Indian J Crit Care Med 2014; 18:113-4. [PMID: 24678157 PMCID: PMC3943119 DOI: 10.4103/0972-5229.126087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Methemoglobinemia is an altered state of hemoglobin resulting in impaired oxygen delivery to the tissues. Deliberate ingestion of certain insecticides and pesticides may result in this condition. We report a case of severe methemoglobinemia after deliberate ingestion of an insecticide marketed to be safe and containing only biological extracts and fillers. Methemoglobinemia should be suspected with low oxygen saturation on pulse oxymetry and the presence of chocolate colored blood. The methemoglobin level of 91% in our patient is the highest level reported among methemoglobinemia survivors.
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Affiliation(s)
- Tarun George
- Department of Medicine 4, Christian Medical College, Vellore, Tamil Nadu, India
| | - Atif I Shaikh
- Department of Medicine 4, Christian Medical College, Vellore, Tamil Nadu, India
| | - Lovely Thomas
- Department of Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
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22
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Pavo García MR, Núñez-Ramos R, Peralta Salas JE, Vivanco Martínez JL. [Rasburicase-induced methemoglobinemia in a patient with leukemia recurrence]. An Pediatr (Barc) 2014; 81:e38-9. [PMID: 24588957 DOI: 10.1016/j.anpedi.2014.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 12/26/2013] [Accepted: 01/03/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- M R Pavo García
- Unidad de Hemato-Oncología Pediátrica, Hospital 12 de Octubre, Madrid, España
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23
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24
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Bucklin MH, Groth CM. Mortality Following Rasburicase-Induced Methemoglobinemia. Ann Pharmacother 2013; 47:1353-8. [DOI: 10.1177/1060028013501996] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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25
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Bauters T, Mondelaers V, Robays H, De Wilde H, Benoit Y, De Moerloose B. Methemoglobinemia and hemolytic anemia after rasburicase administration in a child with leukemia. Int J Clin Pharm 2013; 35:303-5. [DOI: 10.1007/s11096-010-9447-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 10/11/2010] [Indexed: 11/30/2022]
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26
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Sonbol MB, Yadav H, Vaidya R, Rana V, Witzig TE. Methemoglobinemia and hemolysis in a patient with G6PD deficiency treated with rasburicase. Am J Hematol 2013; 88:152-4. [PMID: 22573495 DOI: 10.1002/ajh.23182] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 02/27/2012] [Indexed: 01/12/2023]
Affiliation(s)
| | - Hemang Yadav
- Division of Internal Medicine; Mayo Clinic; Rochester; Minnesota
| | - Rakhee Vaidya
- Division of Hematology; Mayo Clinic; Rochester; Minnesota
| | - Vishal Rana
- Division of Hematology; Mayo Clinic; Rochester; Minnesota
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27
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Cheah CY, Lew TE, Seymour JF, Burbury K. Rasburicase causing severe oxidative hemolysis and methemoglobinemia in a patient with previously unrecognized glucose-6-phosphate dehydrogenase deficiency. Acta Haematol 2013; 130:254-9. [PMID: 23860572 DOI: 10.1159/000351048] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 03/17/2013] [Indexed: 11/19/2022]
Abstract
Rasburicase is frequently used in tumor lysis syndrome (TLS). Although it is very well tolerated, it can cause severe oxidative hemolytic anemia and methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. We report another case of rasburicase-induced methemoglobinemia in a patient with previously unrecognized G6PD deficiency and review the cases of methemoglobinemia and oxidative hemolysis reported in the literature to date. Patients from ethnicities in which G6PD deficiency is prevalent at high risk of TLS should be screened for G6PD deficiency prior to administration of rasburicase where practical. Asymptomatic decrease in oxygen saturation by oximetry and cyanosis are signs of methemoglobinemia; patients recover with conservative measures including supplemental oxygen and packed red cell transfusion.
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Affiliation(s)
- Chan Y Cheah
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Vic., Australia
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28
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Ng JS, Edwards EM, Egelund TA. Methemoglobinemia induced by rasburicase in a pediatric patient: A case report and literature review. J Oncol Pharm Pract 2011; 18:425-31. [DOI: 10.1177/1078155211429385] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rasburicase is a recombinant urate oxidase enzyme indicated for tumor lysis syndrome (TLS), a potential life-threatening oncologic emergency that occurs most commonly during chemotherapy for hematological malignancies. As a result of the defects in the physiological antioxidant pathway, erythrocytes of patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency are not protected against the oxidating stress exerted by hydrogen peroxide generated with the administration of rasburicase. Therefore, rasburicase is contraindicated in patients with known G6PD deficiency and the manufacturer recommends screening all patients with high risk for G6PD deficiency before initiating rasburicase therapy. However, it is logistically difficult in clinical settings because of the high risk of morbidity and mortality associated with TLS if treatment is delayed and the long turnaround time of the G6PD deficiency screening. Therefore, administering rasburicase to patients developing TLS before confirming a patient’s G6PD status is practically inevitable. Methemoglobinemia, and/or hemolysis, may result from the oxidative stress. Descriptions of the clinical course should it happen are limited in the literature. There are eight reported cases of rasburicase-related methemoglobinemia, with or without hemolytic anemia, in the literature of which five are pediatric patients. Six reports (including three pediatric patients) had detailed descriptions of the event and management. The recent reports of methemoglobinemia observed in patients with probable G6PD activity further complicated the picture. We are reporting a 16-year-old patient diagnosed with Burkitt’s lymphoma who developed methemoglobinemia after receiving one dose of rasburicase. He was managed by transfusion and oxygen support. The patient recovered well and the observed methemoglobinemia was reversible.
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Affiliation(s)
- John S Ng
- Department of Pharmacy, Wolfson Children’s Hospital, Jacksonville, USA
| | - Elisa M Edwards
- Department of Pharmacy, Wolfson Children’s Hospital, Jacksonville, USA
| | - Tosha A Egelund
- Department of Pharmacy, Wolfson Children’s Hospital, Jacksonville, USA
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29
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Bauters T, Mondelaers V, Robays H, De Wilde H, Benoit Y, De Moerloose B. Methemoglobinemia and hemolytic anemia after rasburicase administration in a child with leukemia. Int J Clin Pharm 2011; 33:58-60. [DOI: 10.1007/s11096-011-9484-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 10/11/2010] [Indexed: 11/24/2022]
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