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Kazmi S, Farooqi H, Nawaz A, Afzal Z, Idress A, Yousafzai MO, Khan MU. Rapid-onset methemoglobinemia from traditional-medicine-induced potassium nitrate poisoning: successful treatment with methylene blue-a case report. J Med Case Rep 2024; 18:439. [PMID: 39256769 PMCID: PMC11389590 DOI: 10.1186/s13256-024-04702-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/30/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Potassium nitrate poisoning is a rare but potentially serious condition that can result in methemoglobinemia and subsequent cyanosis. This case report presents a unique instance of rapid-onset methemoglobinemia resulting from the ingestion of a traditional medicine preparation containing potassium nitrate, known as "kalmi shora." CASE PRESENTATION A 14-year-old Pakistani boy reported to the emergency department with a history of sudden-onset headache, drowsiness agitation, irritability, and generalized cyanosis. Pulse oximetry showed a concerning oxygen saturation level of 58%, whereas arterial blood gas analysis revealed a normal partial pressure of oxygen (90 mmHg). The profile of abrupt onset of symptoms, generalized cyanosis, and the discrepancy between the partial pressure of oxygen and oxygen saturation readings necessitated a comprehensive assessment including inquiries into potential toxins. The peculiar appearance of the blood, resembling chocolate in color, further indicated the possibility of methemoglobinemia. The patient was successfully treated with methylene blue, leading to a prompt resolution of symptoms. CONCLUSION This case highlights the significance of considering toxin exposures, such as traditional-medicine-induced poisoning, in emergency settings. The report contributes to the medical literature by highlighting the potential risks associated with traditional remedies and emphasizes the critical role of prompt diagnosis and intervention in optimizing patient outcomes. Recognition of the specific etiology of methemoglobinemia, in this case, traditional medicine ingestion, is essential for effective management in emergency medicine.
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Affiliation(s)
- Salman Kazmi
- Medicine Department, King Edward Medical University & Mayo Hospital, Lahore, 54000, Pakistan
| | - Humaira Farooqi
- Medicine Department, King Edward Medical University & Mayo Hospital, Lahore, 54000, Pakistan
| | - Ahmad Nawaz
- Medicine Department, King Edward Medical University & Mayo Hospital, Lahore, 54000, Pakistan.
| | - Zubia Afzal
- Medicine Department, King Edward Medical University & Mayo Hospital, Lahore, 54000, Pakistan
| | - Aiman Idress
- Medicine Department, King Edward Medical University & Mayo Hospital, Lahore, 54000, Pakistan
| | - Mohammad Omar Yousafzai
- Medicine Department, King Edward Medical University & Mayo Hospital, Lahore, 54000, Pakistan
| | - Muhammad Usman Khan
- Medicine Department, King Edward Medical University & Mayo Hospital, Lahore, 54000, Pakistan
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2
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Tisack A, Mohammad TF. Drug-Induced Pigmentation: A Review. Drugs 2024; 84:1071-1091. [PMID: 39085684 DOI: 10.1007/s40265-024-02062-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 08/02/2024]
Abstract
Drug-induced pigmentation (DIP) is estimated to account for 20% of all cases of acquired hyperpigmentation. Over 50 agents have been implicated, including antibiotics, antimalarials, antiretrovirals, antipsychotics, prostaglandin analogs, heavy metals, and chemotherapeutic agents. The skin, mucosal surfaces, nails, and hair can all be affected, with the color, distribution, onset, and duration of pigmentation varying between offending agents. Both a thorough physical examination and medication history are necessary to determine the offending agent. In terms of mechanism, DIP occurs most frequently through the accumulation of melanin within the dermis but also by drug accumulation, pigment synthesis, and iron deposition. Photoprotection, including applying a broad-spectrum sunscreen, wearing photoprotective clothing, and seeking shade, plays an important role in the prevention of exacerbation of DIP. Multiple lasers, including the picosecond alexandrite, Q-switched Nd:YAG, Q-switched alexandrite, and Q-switched ruby lasers, have been successful in obtaining clearance of DIP. In this review, we examine the unique characteristics of each of the inciting agents in terms of incidence, clinical presentation, time to onset and resolution, and pathogenesis.
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Affiliation(s)
- Aaron Tisack
- Department of Dermatology, Henry Ford Health, 3031 W Grand Blvd, Detroit, MI, 48202, USA
| | - Tasneem F Mohammad
- Department of Dermatology, Henry Ford Health, 3031 W Grand Blvd, Detroit, MI, 48202, USA.
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3
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Alkhateeb W, Luthra G, Almatroud L, Saleh A, Landa E. From Poppers to Peril: Recreational Nitrite-Induced Methemoglobinemia. Cureus 2024; 16:e67435. [PMID: 39310584 PMCID: PMC11415308 DOI: 10.7759/cureus.67435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
Inhaled amyl nitrites, once used to alleviate chest pain, are more commonly now being used for their euphoric effects. The recreational use of inhaled nitrites can lead to methemoglobinemia, a life-threatening condition that hinders the utilization of oxygen in the body. In 2021, 2.2 million people aged 12 or older used inhalants in the past year. Methemoglobinemia has favorable outcomes with treatment. We present the case of a 43-year-old man, with a medical history of type 2 diabetes mellitus and hypertension presenting with bluish discoloration of the fingers that progressed to his tongue and lips. He disclosed using a recreational inhalant called "Rush" before coming in. Vital signs showed low oxygen saturation on room air, and further investigation revealed elevated methemoglobin levels on the venous blood gas. Methylene blue was used for treatment, with complete resolution of the patient's symptoms and the only side effect of green urine. The patient was later discharged home in a stable condition. History taking is a crucial part of managing methemoglobinemia, as presentation to the clinical setting could vary. Our case presents the milder version of the disease with quick complete recovery after appropriate treatment. It demonstrates inhalant abuse in a less common age group. The case also demonstrates a common side effect of methylene blue that is often forgotten.
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Affiliation(s)
- Wasef Alkhateeb
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Gaurav Luthra
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Lanah Almatroud
- College of Human Medicine, Michigan State University, East Lansing, USA
| | - Alyaa Saleh
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Elise Landa
- Critical Care Medicine, Ascension Providence Hospital, Southfield, USA
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Wani MJ, Arif A, Salman KA, Mahmood R. Glycated LDL generates reactive species that damage cell components, oxidize hemoglobin and alter surface morphology in human erythrocytes. Int J Biol Macromol 2024; 269:132257. [PMID: 38729492 DOI: 10.1016/j.ijbiomac.2024.132257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/12/2024]
Abstract
Low-density lipoprotein (LDL) transports cholesterol to various tissues via the blood. Glycation of LDL occurs during hyperglycemic condition which is characterised by persistently high blood glucose level. Circulating erythrocytes can come in direct contact with glycated LDL (G-LDL). The objective of this study was to investigate the effect of G-LDL on human erythrocytes, specifically on hemoglobin, intracellular generation of reactive species and the antioxidant defence system. Isolated erythrocytes were incubated with G-LDL (3 and 6 mg/ml) and native LDL (6 mg/ml) at 37 °C for 24 h. Native LDL and G-LDL untreated erythrocytes were similarly incubated at 37 °C and served as control. G-LDL treatment increased hemolysis compared to control and native LDL-treated erythrocytes. Incubation of erythrocytes with G-LDL led to an increase in protein oxidation and lipid peroxidation while greatly decreasing the total sulfhydryl content. It also significantly enhanced hemoglobin oxidation, heme degradation, and the release of free iron moiety. Treatment with G-LDL led to an appreciable increase in the production of reactive oxygen and nitrogen species. The antioxidant power and activities of major antioxidant enzymes were drastically reduced, while critical membrane-bound enzymes were inhibited. The surface morphology of G-LDL-treated erythrocytes was altered leading to the formation of echinocytes. Importantly, treatment of erythrocytes with native LDL did not significantly affect the above-mentioned parameters and values were similar to the corresponding controls. Thus, G-LDL is cytotoxic to human erythrocytes and causes oxidative damage to cell components. This can reduce the oxygen-transporting ability of blood and also result in red cell senescence and anemia.
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Affiliation(s)
- Mohd Junaid Wani
- Department of Biochemistry, Faculty of Medicine, J.N.M.C., Aligarh Muslim University, Aligarh 202002, U.P., India
| | - Amin Arif
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh 202002, U.P., India
| | - Khushtar Anwar Salman
- Department of Biochemistry, Faculty of Medicine, J.N.M.C., Aligarh Muslim University, Aligarh 202002, U.P., India
| | - Riaz Mahmood
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh 202002, U.P., India.
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5
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Batton R, Villard S, Popoff B. [Methemoglobinemia]. Rev Med Interne 2024:S0248-8663(24)00563-0. [PMID: 38777656 DOI: 10.1016/j.revmed.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 03/12/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024]
Abstract
Methemoglobinemia (MetHb) refers to the state of oxidation of the iron ion "ferrous" (Fe2+) to iron "ferric" (Fe3+) within the heme molecule that makes up hemoglobin (Hb). This state is physiological if its level remains controlled. The ferrous state of the heme molecule occurs in the event of significant oxidative stress. The pathophysiology of MetHb involves NADH, NADPH and glucose cycle enzymes such as cytochrome-b5-reductase. MetHb can be acquired or more rarely, congenital. Acquired causes include drug-induced effects such as topical anesthetics, or toxic effects such as nitrites. Primary causes are linked to enzyme deficiencies or constitutional Hb abnormalities. Excessively high MetHb causes symptoms of varying intensity, depending on the level of MetHb and associated comorbidities. Clinical signs are dominated by cyanosis, indicative of tissue hypoxia, which can be complicated by severe metabolic disorders leading to death. Diagnosis can be complex, as the resulting biological abnormalities may go undetected. Treatment is mainly based on identifying the etiology and restoring the heme molecule to its physiological state. Methylene blue is the main antidote in cases of elevated MetHb, but precautions must be taken in its use, and its physico-chemical effects must be understood. We provide an update on methemoglobinemia, summarizing its pathophysiology and clinical presentations, complementary tests and therapeutic principles.
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Affiliation(s)
- R Batton
- Faculté de médecine Rouen, Université de Rouen Normandie, 37, boulevard Gambetta, 76000 Rouen, France.
| | - S Villard
- Faculté de médecine, Sorbonne Universités, Paris, France
| | - B Popoff
- Service de réanimation chirurgicale, CHU de Rouen, 76000 Rouen, France
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6
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Mobarak A, C. Thambiah S, Masiman AD, Samsudin IN, Lai YY. Refractory hypoxia and saturation gap in a COVID-19 patient. Pract Lab Med 2024; 40:e00395. [PMID: 38707259 PMCID: PMC11068595 DOI: 10.1016/j.plabm.2024.e00395] [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: 12/13/2023] [Revised: 02/02/2024] [Accepted: 04/17/2024] [Indexed: 05/07/2024] Open
Abstract
Acquired methemoglobinemia, predominantly due to oxidizing medications occurs when heme iron in hemoglobin is oxidized from ferrous to ferric ion and binds oxygen irreversibly leading to functional anemia, cyanosis, and tissue hypoxia. We report a case of a 60-year-old man with multiple comorbidities who was diagnosed with coronavirus disease 2019 (COVID-19) and developed methemoglobinemia after consumption of prescribed supplements. He presented with dyspnea and cyanosis. An oxygen saturation gap with characteristic chocolate-brown arterial blood indicated methemoglobinemia. Outsourced methemoglobin (MetHb) was increased at 9.0%. Despite aggressive intervention, he succumbed to his illness. In this case, we discuss the pathophysiology of why some individuals, especially the elderly with COVID-19 are more susceptible to develop methemoglobinemia after possibly being exposed to oxidizing agents. Laboratory methods for assessing oxygen saturation, including pulse oximetry, arterial blood gas and co-oximetry are examined in relation to this case. The importance of considering a diagnosis of methemoglobinemia based on clinical and biochemical findings although MetHb assay or co-oximetry are not readily available is also emphasized.
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Affiliation(s)
- Abidah Mobarak
- Department of Pathology, Hospital Melaka, Ministry of Health Malaysia, Malaysia
- Department of Pathology, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Subashini C. Thambiah
- Department of Pathology, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Ana Daliela Masiman
- Department of Pathology, Hospital Melaka, Ministry of Health Malaysia, Malaysia
| | - Intan Nureslyna Samsudin
- Department of Pathology, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Yin Ye Lai
- Department of Pathology, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Malaysia
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Ullah R, Muhammad S, Ali W, Amin S, Khan S, Rasool A, Hesham AEL, Umar M, Ali S, Iqbal S, Ahmad A. Evaluation of irrigation, drinking, and risk indices for water quality parameters of alpine lakes. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2024; 46:175. [PMID: 38619636 DOI: 10.1007/s10653-024-01950-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/07/2024] [Indexed: 04/16/2024]
Abstract
Alpine lakes are aquatic ecosystems that maintain and regulate water supply for the downstream streams, rivers, and other reservoirs. This study examined the water characteristics of various alpine lakes in Gilgit-Baltistan, Northern Pakistan. For this purpose, water was sampled and investigated for basic parameters, anions, and cations using the multi-parameter analyzers and atomic absorption spectrophotometer. Physicochemical parameters of alpine lakes were noted under the World Health Organization water guidelines, except for fluoride (F-) and turbidity in 4.3% and 36% of samples, respectively. Water quality index (WQI) classified samples (93%) as excellent and good quality (7%). Results showed maximum chronic daily intake values (0.14 ± 0.01 mg/kg-day) for nitrate (NO3-) and hazard quotient (0.80 ± 0.24) for F- in children via water intake from Upper Kachura and Shausar Lakes, respectively. Statistical analyses of Piper and Gibbs's plots revealed that the water quality is mainly characterized by bedrock geology.
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Affiliation(s)
- Rizwan Ullah
- National Centre of Excellence in Geology, University of Peshawar, Peshawar, 25130, Pakistan
- Department of River Ecology, Helmholtz Centre for Environmental Research-UFZ, Brückstra.3a, 39114, Magdeburg, Germany
| | - Said Muhammad
- National Centre of Excellence in Geology, University of Peshawar, Peshawar, 25130, Pakistan.
| | - Wajid Ali
- National Centre of Excellence in Geology, University of Peshawar, Peshawar, 25130, Pakistan
| | - Sehrish Amin
- Department of Environmental Sciences, University of Peshawar, Peshawar, 25120, Pakistan
| | - Sardar Khan
- Department of Environmental Sciences, University of Peshawar, Peshawar, 25120, Pakistan
| | - Atta Rasool
- Faculty of Science and Engineering, Southern Cross University, Lismore, NSW, 2480, Australia
| | - Abd El-Latif Hesham
- Genetics Department, Faculty of Agriculture, Beni-Suef University, Beni-Suef, 62511, Egypt
| | - Muhammad Umar
- Department of Geology Sciences, University of Haripur, Haripur, 21120, Pakistan
| | - Shaukat Ali
- Department of Environmental Sciences, Karakoram International University, Gilgit, 15100, Pakistan
| | - Shahid Iqbal
- Centre for Planning and Disaster Management, University of Peshawar, Peshawar, 25120, Pakistan
| | - Ashfaq Ahmad
- Department of Chemistry, College of Science, King Saud University, P.O. Box, 2455, Riyadh - 11451, Saudi Arabia
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8
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Rathod BD, Kamble N, Awadhiya O, Narang U, Khot RS, Kumbhalkar S. Shades of Blue: A Case Series of Acquired Methemoglobinemia. Cureus 2024; 16:e58312. [PMID: 38752026 PMCID: PMC11095280 DOI: 10.7759/cureus.58312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Acquired methemoglobinemia (MetHb) is a rare but potentially life-threatening condition that has varied etiology, usually toxin- or drug-induced. We had five cases of acquired methemoglobinemia during six months. Their presentation varied from an asymptomatic state to respiratory distress. The presence of cyanosis and low oxygen saturation (SpO2), despite normal partial pressure of oxygen (PaO2) and chocolate brown-colored blood, were diagnostic clues present in all cases. A high level of methemoglobinemia was detected on arterial blood gas (ABG), confirming the diagnosis. Methylene blue was used as an antidote along with supportive care in symptomatic cases. All these cases of methemoglobinemia recovered completely. A high index of suspicion for methemoglobinemia should be maintained in cases presenting with persistent hypoxia or cyanosis despite normal PaO2.
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Affiliation(s)
| | - Nilesh Kamble
- General Medicine, All India Institute of Medical Sciences, Nagpur, IND
| | - Onkar Awadhiya
- General Medicine, All India Institute of Medical Sciences, Nagpur, IND
| | - Udit Narang
- General Medicine, All India Institute of Medical Sciences, Nagpur, IND
| | - Rajashree S Khot
- General Medicine, All India Institute of Medical Sciences, Nagpur, IND
| | - Sunita Kumbhalkar
- General Medicine, All India Institute of Medical Sciences, Nagpur, IND
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9
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Egbujor MC, Tucci P, Buttari B, Nwobodo DC, Marini P, Saso L. Phenothiazines: Nrf2 activation and antioxidant effects. J Biochem Mol Toxicol 2024; 38:e23661. [PMID: 38369721 DOI: 10.1002/jbt.23661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/20/2024]
Abstract
Phenothiazines (PTZs) are an emerging group of molecules showing effectiveness toward redox signaling and reduction of oxidative injury to cells, via the activation on Kelch-like ECH-associated protein 1/nuclear factor erythroid 2-related factor 2 (Nrf2). Although several electrophilic and indirect Nrf2 activators have been reported, the risk of "off-target" effect due to the complexity of their molecular mechanisms of action, has aroused research interest toward non-electrophilic and direct modulators of Nrf2 pathway, such as PTZs. This review represents the first overview on the roles of PTZs as non-electrophilic Nrf2 activator and free radical scavengers, as well as on their potential therapeutic effects in oxidative stress-mediated diseases. Here, we provide a collective and comprehensive information on the PTZs ability to scavenge free radicals and activate the Nrf2 signaling pathway, with the aim to broaden the knowledge of their therapeutic potentials and to stimulate innovative research ideas.
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Affiliation(s)
| | - Paolo Tucci
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Brigitta Buttari
- Department of Cardiovascular and Endocrine-metabolic Diseases, and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - David C Nwobodo
- Department of Microbiology, Renaissance University Ugbawka, Ugbawka, Nigeria
| | - Pietro Marini
- Institute of Education in Healthcare and Medical Sciences, Foresterhill Campus, University of Aberdeen, Aberdeen, UK
| | - Luciano Saso
- Department of Physiology and Pharmacology Vittorio Erspamer, Sapienza University of Rome, Rome, Italy
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10
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Kotepui M, Mahittikorn A, Wilairatana P, Masangkay FR, Wangdi K, Kotepui KU. Methemoglobin levels in malaria: a systematic review and meta-analysis of its association with Plasmodium falciparum and Plasmodium vivax infections and disease severity. Sci Rep 2024; 14:3276. [PMID: 38332023 PMCID: PMC10853561 DOI: 10.1038/s41598-024-53741-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/04/2024] [Indexed: 02/10/2024] Open
Abstract
Reports indicate that Plasmodium infections influence methemoglobin levels. However, findings have been inconclusive or have varied across different geographic and demographic contexts. This systematic review and meta-analysis aimed to consolidate existing data regarding the association between Plasmodium infections and alterations in methemoglobin levels related to the severity of the infection. A comprehensive literature search of several databases, including Ovid, ProQuest, Embase, Scopus, MEDLINE, and PubMed, was conducted to identify relevant studies that examined methemoglobin levels in patients with malaria. Qualitative synthesis and meta-analysis of the pooled standardized mean difference were conducted to synthesize the differences in methemoglobin levels between: (1) patients with malaria and those without malaria and (2) patients with severe malaria and those with uncomplicated malaria based on various themes including publication year, study design, study area, Plasmodium species, age group, symptomatic status, severity status, and method of malaria detection. Of the 1846 studies that were initially identified from the main databases and additional searches on Google Scholar, 10 studies met the eligibility criteria and were selected for this review. The systematic review distinctly highlighted an association between malaria and elevated methemoglobin levels, an observation consistent across diverse geographical regions and various Plasmodium species. Furthermore, the meta-analysis confirmed this by demonstrating increased methemoglobin levels in patients with malaria compared to those without malaria (P < 0.001, Hedges' g 2.32, 95% CI 1.36-3.29, I2 97.27, 8 studies). Moreover, the meta-analysis found elevated methemoglobin levels in patients with severe malaria compared to those with uncomplicated malaria (P < 0.001, Hedges' g 2.20, 95% CI 0.82-3.58, I2 96.20, 5 studies). This systematic review and meta-analysis revealed increased methemoglobin levels in patients with P. falciparum and P. vivax infections, with a notable association between elevated methemoglobin levels and severe malaria. Future research should focus on elucidating the specific mechanisms by which changes in methemoglobin levels are related to infections by P. falciparum and P. vivax, particularly in terms of severity, and how these alterations could potentially impact patient management and treatment outcomes.
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Affiliation(s)
- Manas Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Thasala, Nakhon Si Thammarat, 80160, Thailand.
| | - Aongart Mahittikorn
- Department of Protozoology, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | | | - Kinley Wangdi
- QIMR Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | - Kwuntida Uthaisar Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Thasala, Nakhon Si Thammarat, 80160, Thailand
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11
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Hageman G, van Broekhuizen P, Nihom J. The role of carbon monoxide in aerotoxic syndrome. Neurotoxicology 2024; 100:107-116. [PMID: 38135191 DOI: 10.1016/j.neuro.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
Chronic low-level exposure to toxic compounds in airplane cabin air may result in Aerotoxic Syndrome (AS). Aetiologic agents are organophosphates and numerous volatile organic hydrocarbons originating from leaks of engine oil and hydraulic fluids. Despite a documented history spanning decades, the role of carbon monoxide remains controversial. What evidence exists that carbon monoxide (CO), present in the cocktail of toxic compounds in bleed air, contributes to the AS? We selected 22 publications encompassing 888 flights with 18 different aircraft types. In one study of 100 flights, fume events were confirmed in 38. Four studies were initialized after air quality incidents. The cabin CO concentrations could be categorized in three levels, 1) low (<5 ppm), without health implications, 2) moderate (5-10 ppm) with probably health implications in case of chronic exposure, and 3) high > 10 ppm, with health effects in case of acute and chronic exposure. These levels were recorded in 12, 6 and 4 studies respectively. In the six studies in category 2, max CO concentrations ranged from 5.8-9.4 ppm. The four studies with CO > 10 ppm comprised 376 of the 888 flights (42%) with six aircraft types. Toxic CO levels ranging between 13-60 ppm were identified in at least 129 of 888 (14.5%) flights. In one study with high CO levels four flight attendants were diagnosed with CO poisoning with elevated HbCO levels. Max CO levels in aviation are either the same or higher than current occupational exposure limits (OEL) for ground-based workplace exposures or levels for urban street transport environments. Specific aspects of aviation should be taken into consideration: the effect of low(er) air pressure at high altitudes increasing the toxicity of CO, and the binding of CO to CYP enzymes, leading to impaired organophosphate detoxification. We conclude that CO must be considered an important factor in the lubrication derived cocktail of airborne toxic compounds causing AS. In line with the WHO advice, a reduction of the OEL to 5 ppm over 8 hr time weighted average (TWA) for aircrew is strongly recommended. And we advocate continuous monitoring during all phases of flight and installation of CO detectors in the air supply ducts to the aircraft cabin.
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Affiliation(s)
- G Hageman
- Department of Neurology, Medisch Spectrum Twente, hospital Enschede, Koningsplein 1, 7500 KA Enschede, the Netherlands.
| | - P van Broekhuizen
- University of Amsterdam, Spui 21, 1012 WX Amsterdam, the Netherlands
| | - J Nihom
- Department of Neurology, Medisch Spectrum Twente, hospital Enschede, Koningsplein 1, 7500 KA Enschede, the Netherlands
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12
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Abu Zahra M, Jaber DZ, Badran EF. A rare case of methemoglobinemia in a preterm newborn with unclear etiology. J Neonatal Perinatal Med 2024; 17:261-264. [PMID: 38640175 DOI: 10.3233/npm-230163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Cyanosis is a bluish discoloration of the tissues due to increased levels of deoxygenated hemoglobin in capillaries. It is a common finding in newborn infants that can be caused by different diseases, including pulmonary, cardiac, infectious, and hematological disorders. Methemoglobinemia is a rare cause of cyanosis, in which hemoglobin is oxidized, changing its heme iron configuration from the ferrous (Fe2 +) to the ferric (Fe3 +) state, creating methemoglobin (Met-Hb), a form that does not bind oxygen, leading to decreased oxygen delivery to the tissues and cyanosis. We report a rare case of a preterm newborn, who developed cyanosis and worsening hypoxemia on day ten of life, she was found to have elevated Met-Hb percentage in blood gas analysis that required treatment with intravenous methylene blue. Her symptoms resolved after a period of maintenance treatment with oral methylene blue and ascorbic acid, and the etiology of her disease remains unclear.
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Affiliation(s)
- M Abu Zahra
- Division of Pediatric Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dunia Z Jaber
- School of Medicine, The University of Jordan, Amman, Jordan
| | - Eman F Badran
- Department of Pediatrics, Division of Neonatology, School of Medicine, The University of Jordan, Amman, Jordan
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13
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Alhusari L, Pigliacampi M, Alshawabkeh Y, Hamdani T, Bsiso T, Mustafa B, Dial L. Dapsone-Induced Methemoglobinemia Presenting Concomitantly With COVID-19 Pneumonia and Pulmonary Embolism: A Case Report. Cureus 2024; 16:e51830. [PMID: 38327942 PMCID: PMC10847900 DOI: 10.7759/cureus.51830] [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: 01/07/2024] [Indexed: 02/09/2024] Open
Abstract
Acquired methemoglobinemia is a treatable condition that is often clinically subtle and can be missed on routine clinical assessment. We present a 73-year-old male who was evaluated in the emergency department with worsening respiratory symptoms requiring oxygen. He tested COVID-19 positive and had new pulmonary emboli evident on his CT chest. The patient was on dapsone therapy as a treatment for bullous pemphigoid. The discrepancy between his oxygen levels on the pulse oximeter and blood gas was noted and was treated with 3% methylene blue for dapsone-induced methemoglobinemia. The patient received treatment for COVID-19 pneumonia and pulmonary emboli. Our case demonstrates that dapsone-induced methemoglobinemia can present concomitantly with other more common causes of acute hypoxic respiratory failure. It is noteworthy for physicians to maintain a high index of suspicion for oxygen level discrepancy in hypoxic patients and consider the possibility of acquired methemoglobinemia. Hence, earlier detection and treatment of the etiology of tissue hypoxia.
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Affiliation(s)
- Leena Alhusari
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Marlena Pigliacampi
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Yara Alshawabkeh
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Teseir Hamdani
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Taysir Bsiso
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Bisher Mustafa
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Larry Dial
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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14
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Alhamoud NA, AlZugaibi RA, Aldoohan WM. Recurrent Acute Methemoglobinemia in an Infant With Persistent Gastroenteritis: A Case Report. Cureus 2024; 16:e51909. [PMID: 38196991 PMCID: PMC10775891 DOI: 10.7759/cureus.51909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/11/2024] Open
Abstract
Acute toxic methemoglobinemia is a rare and fatal condition with increased levels of oxidized hemoglobin. The clinical presentation of methemoglobinemia varies primarily based on total methemoglobin levels in the blood. Patients sometimes have significant cardiopulmonary compromise, but the majority are asymptomatic, with only cyanosis as the most prevalent sign. We report the case of a 41-day-old male who developed methemoglobinemia and persistent gastroenteritis after consumption of well water. In this case, we believe that the recurrence of acute methemoglobinemia episodes resulted from multifactorial reasons such as age at presentation, infection with nitrate-producing organisms, and consumption of nitrite-containing well water. The rationale for prophylactic therapy was implemented, aiming to prevent further episodes. This case report demonstrates the potential of prophylactic therapy as part of the management of infants with recurrent acute methemoglobinemia episodes.
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Affiliation(s)
- Nawarah A Alhamoud
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Ryan A AlZugaibi
- Pediatric Hematology Oncology, King Abdullah Specialized Children's Hospital, Riyadh, SAU
- Hematology, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Waad M Aldoohan
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
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15
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Scirè A, Casari G, Romaldi B, de Bari L, Antognelli C, Armeni T. Glutathionyl Hemoglobin and Its Emerging Role as a Clinical Biomarker of Chronic Oxidative Stress. Antioxidants (Basel) 2023; 12:1976. [PMID: 38001829 PMCID: PMC10669486 DOI: 10.3390/antiox12111976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/26/2023] Open
Abstract
Hemoglobin is one of the proteins that are more susceptible to S-glutathionylation and the levels of its modified form, glutathionyl hemoglobin (HbSSG), increase in several human pathological conditions. The scope of the present review is to provide knowledge about how hemoglobin is subjected to S-glutathionylation and how this modification affects its functionality. The different diseases that showed increased levels of HbSSG and the methods used for its quantification in clinical investigations will be also outlined. Since there is a growing need for precise and reliable methods for markers of oxidative stress in human blood, this review highlights how HbSSG is emerging more and more as a good indicator of severe oxidative stress but also as a key pathogenic factor in several diseases.
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Affiliation(s)
- Andrea Scirè
- Department of Life and Environmental Sciences (Di.S.V.A.), Università Politecnica delle Marche, 60131 Ancona, Italy
| | - Giulia Casari
- Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, 60131 Ancona, Italy; (G.C.); (B.R.); (T.A.)
| | - Brenda Romaldi
- Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, 60131 Ancona, Italy; (G.C.); (B.R.); (T.A.)
| | - Lidia de Bari
- Institute of Biomembranes, Bioenergetics and Molecular Biotechnologies (IBIOM), National Research Council (CNR), 70126 Bari, Italy;
| | - Cinzia Antognelli
- Department of Medicine and Surgery, Università Degli Studi di Perugia, 06129 Perugia, Italy;
| | - Tatiana Armeni
- Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, 60131 Ancona, Italy; (G.C.); (B.R.); (T.A.)
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16
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Kolosionek TJ, Amaducci AM, Fikse DJ, Katz KD. Combined Ethylene Glycol Poisoning with Methemoglobinemia Due to Antifreeze Ingestion. J Emerg Med 2023; 65:e438-e440. [PMID: 37734990 DOI: 10.1016/j.jemermed.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/26/2023] [Accepted: 06/13/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Antifreeze poisoning is potentially life-threatening and often requires multiple antidotal therapies and hemodialysis. Ethylene or propylene glycol toxicity is commonly caused by antifreeze ingestion. However, ingestion of antifreeze is typically not associated with methemoglobinemia. Currently, only one other case of antifreeze ingestion causing combined ethylene glycol poisoning and methemoglobinemia has been reported. CASE REPORT A 56-year-old man presented after a witnessed, intentional, large-volume antifreeze ingestion. Evaluation revealed dark brown blood and significantly elevated methemoglobin and ethylene glycol levels. He was successfully treated with methylene blue, fomepizole, and hemodialysis. No other potential cause for methemoglobinemia was elucidated, and further research indicated that minor components of the specific antifreeze product served as an oxidizing agent. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the impact of minor, unreported product components that may significantly contribute to clinical toxicity, as well as the need to remain vigilant when reviewing product information and potential limitations therein.
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Affiliation(s)
- Timothy J Kolosionek
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Alexandra M Amaducci
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Derek J Fikse
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Kenneth D Katz
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
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17
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Malik MJ, Pasha MN, Liu L, Nalbandyan M. Methemoglobinemia: A Case Report. Cureus 2023; 15:e47752. [PMID: 38021620 PMCID: PMC10676284 DOI: 10.7759/cureus.47752] [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: 07/24/2023] [Indexed: 12/01/2023] Open
Abstract
Methemoglobinemia is a potentially life-threatening condition in which there is diminution of the oxygen-carrying capacity of circulating hemoglobin. It can result from either congenital or acquired processes. Methemoglobin forms when hemoglobin is oxidized to contain iron in the ferric (Fe3+) rather than the normal ferrous (Fe2+) state. Methemoglobinemia is a clinical diagnosis and is suspected in the presence of hypoxemia refractory to supplemental oxygen and the presence of chocolate-colored blood. Symptoms are usually dependent on methemoglobin levels; at levels higher than 35%, systemic symptoms from tissue hypoxia may be fatal. A high index of suspicion is required in patients with refractory hypoxia or cyanosis when treated with oxygen. Treatment options involve the removal of the inciting agent and treatment with the antidote methylene blue. Here we present a case of methemoglobinemia in a young patient who attended a college rave party.
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Affiliation(s)
- Mona J Malik
- Internal Medicine, University of California Riverside, Riverside, USA
| | | | - Louisa Liu
- Internal Medicine, University of California Riverside, Riverside, USA
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18
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Arastoo M, Mazanetz MP, Miller S, Shiells H, Hull C, Robinson K, Storey JMD, Harrington CR, Wischik CM. Exploring the Anti-Hypoxaemia Effect of Hydromethylthionine: A Prospective Study of Phase 3 Clinical Trial Participants. Int J Mol Sci 2023; 24:13747. [PMID: 37762050 PMCID: PMC10531415 DOI: 10.3390/ijms241813747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023] Open
Abstract
Methylthioninium chloride (MTC) is a standard treatment for methaemoglobinaemia. A preparation of reduced MTC has been reported to increase blood oxygen saturation (SpO2) and lower respiratory rates in patients with severe COVID-19. We have developed a stable form of reduced methylthionine (hydromethylthionine-mesylate, HMTM) having a benign safety profile in two Phase 3 trials in Alzheimer's disease. The aim of this prospective study was to determine the effects of oral HMTM on SpO2 and methaemoglobin (metHb) levels in a cohort of patients with mild hypoxaemia not due to COVID-19. Eighteen participants randomised to a single dose of 4, 75, 100 or 125 mg doses of HMTM had SpO2 levels below 94% at baseline. Patients were routinely monitored by pulse oximetry after 4 h, and after 2 and 6 weeks of twice daily dosing. Significant ~3% increases in SpO2 occurred within 4 h and were sustained over 2 and 6 weeks with no dose differences. There were small dose-dependent increases (0.060-0.162%) in metHb levels over 2 to 6 weeks. Minimum-energy computational chemistry revealed that HMT can bind within 2.10 Å of heme iron by donating a pair of electrons from the central nitrogen of HMT to d orbitals of heme iron, but with lower affinity than oxygen. In conclusion, HMTM can increase SpO2 without reducing metHb by acting as a strong displaceable field ligand for heme iron. We hypothesise that this facilitates a transition from the low oxygen affinity T-state of heme to the higher affinity R-state. HMTM has potential as an adjunctive treatment for hypoxaemia.
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Affiliation(s)
- Mohammad Arastoo
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZP, UK; (M.A.); (C.R.H.)
- Scottish Biologics Facility, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZP, UK
| | - Michael P. Mazanetz
- NovaData Solutions Ltd., 15 Monreith Rd, Newlands, Glasgow G43 2NX, UK;
- Department of Chemistry, University of Aberdeen, Aberdeen AB24 3UE, UK;
| | - Sonya Miller
- TauRx Therapeutics Ltd., 395 King Street, Aberdeen AB24 3FX, UK; (S.M.); (H.S.); (C.H.)
| | - Helen Shiells
- TauRx Therapeutics Ltd., 395 King Street, Aberdeen AB24 3FX, UK; (S.M.); (H.S.); (C.H.)
| | - Claire Hull
- TauRx Therapeutics Ltd., 395 King Street, Aberdeen AB24 3FX, UK; (S.M.); (H.S.); (C.H.)
| | | | - John M. D. Storey
- Department of Chemistry, University of Aberdeen, Aberdeen AB24 3UE, UK;
- TauRx Therapeutics Ltd., 395 King Street, Aberdeen AB24 3FX, UK; (S.M.); (H.S.); (C.H.)
| | - Charles R. Harrington
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZP, UK; (M.A.); (C.R.H.)
- TauRx Therapeutics Ltd., 395 King Street, Aberdeen AB24 3FX, UK; (S.M.); (H.S.); (C.H.)
| | - Claude M. Wischik
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZP, UK; (M.A.); (C.R.H.)
- TauRx Therapeutics Ltd., 395 King Street, Aberdeen AB24 3FX, UK; (S.M.); (H.S.); (C.H.)
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19
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Brunori L, Elias Santo-Domingo N, Donnelly E, Bassolino S, Lewis D. Emergency treatment with intravenous infusion of methylene blue followed by oral administration in a cat presented with severe recurrent methemoglobinemia. J Vet Emerg Crit Care (San Antonio) 2023; 33:460-466. [PMID: 37120710 DOI: 10.1111/vec.13298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/14/2022] [Accepted: 05/07/2022] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To describe the use of IV infusion followed by oral administration of methylene blue (MB) to successfully treat recurrent methemoglobinemia (MetHb) in a young cat. CASE SUMMARY A 6-month-old male Ragdoll cat presented with recurrent episodes of severe MetHb and was successfully managed with IV infusion of MB followed by a course of oral MB. Although the definitive cause of the patient's MetHb remains unknown, the cat made a full recovery following treatment without developing any significant side effects secondary to therapy and at the time of writing not had any further recurrences. Follow-up at 6 months found the patient in good health and without any long-term consequences. NEW INFORMATION PROVIDED To the authors' knowledge, this is the first report of a cat presented with severe MetHb quantitatively assessed via co-oximetry and successfully treated with both IV and oral administration of MB.
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Affiliation(s)
- Lara Brunori
- Emergency & Critical Care Specialist Service, VetsNow 24/7 Pet Emergency & Specialty Hospital, Glasgow, UK
| | - Neus Elias Santo-Domingo
- Emergency & Critical Care Specialist Service, VetsNow 24/7 Pet Emergency & Specialty Hospital, Glasgow, UK
| | - Emma Donnelly
- Emergency & Critical Care Specialist Service, VetsNow 24/7 Pet Emergency & Specialty Hospital, Glasgow, UK
| | - Serena Bassolino
- Emergency & Critical Care Specialist Service, VetsNow 24/7 Pet Emergency & Specialty Hospital, Glasgow, UK
| | - Daniel Lewis
- Emergency & Critical Care Specialist Service, VetsNow 24/7 Pet Emergency & Specialty Hospital, Glasgow, UK
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20
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Schweitzer-Chaput A, Callot D, Bouazza N, Lesage F, Oualha M, Paret N, Boyer-Gervoise M, Treluyer JM, Chouchana L. Local anesthetics systemic toxicity in children: analysis of the French pharmacovigilance database. BMC Pediatr 2023; 23:321. [PMID: 37355586 PMCID: PMC10290397 DOI: 10.1186/s12887-023-04126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/11/2023] [Indexed: 06/26/2023] Open
Abstract
PURPOSE To characterize clinical profile of pediatric local anesthetic (LA) systemic toxicity (LAST) and to identify determinants of life-threatening outcomes. METHODS Spontaneous reports notified to the French Pharmacovigilance Network were retrieved and followed by a case-by-case review, according to the following criteria: LA as suspected drug, age < 18 years, adverse drug reactions related to nervous system, cardiac, respiratory, psychiatric or general disorders. Multivariate logistic regression analysis was performed to identify factors leading to life-threatening reaction (i.e. continuous seizures or cardiorespiratory arrest). RESULTS Among 512 cases retrieved, 64 LAST cases were included (neonates 11%, infants 30%, children 36%, adolescents 23%) mainly involving lidocaine (47%), lidocaine + prilocaine (22%) and ropivacaine (14%). Toxicity profiles were neurological (58%), cardiac (11%) or mixed (20%) and 7 patients (11%) developed methemoglobinemia. LAST was life-threatening for 23 patients (36%) and 2 patients died. Doses were above recommendations in 26 patients (41%) and were not different between life-threatening and non-life-threatening cases. The context of use (general and orthopedic surgery, p = 0.006) and the type of LA agent (lidocaine, p = 0.016) were independently associated with a life-threatening outcome. CONCLUSION In this national retrospective analysis, LAST in children appear to be a rare event. Neurological and cardiac signs were the most frequently reported reactions. LAST in children can be life-threatening, even at therapeutic doses. Although a fatal outcome may anecdotally occur, the vast majority of patients recovered after appropriate medical care.
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Affiliation(s)
- Arnaud Schweitzer-Chaput
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France
| | - Delphine Callot
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France
| | - Naim Bouazza
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France
- Unité de Recherche Clinique Paris Descartes Necker Cochin, AP-HP, Paris, France
| | - Fabrice Lesage
- Service de Réanimation Pédiatrique, Hôpital Necker, Paris, France
| | - Mehdi Oualha
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France
- Service de Réanimation Pédiatrique, Hôpital Necker, Paris, France
| | - Nathalie Paret
- Centre Antipoison, Hospices Civils De Lyon, Lyon, France
| | - Marie Boyer-Gervoise
- Centre Régional de Pharmacovigilance, Service de Pharmacologie Clinique, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Jean-Marc Treluyer
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France
- Unité de Recherche Clinique Paris Descartes Necker Cochin, AP-HP, Paris, France
| | - Laurent Chouchana
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France.
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France.
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21
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Idries IY, Khristoforov V, Duddala S, Duong YV, Zaman M. Out of the Blue: Methemoglobinemia Associated With the Use of Amyl Nitrite in Rush Poppers for Erectile Stimulation. Cureus 2023; 15:e41201. [PMID: 37525797 PMCID: PMC10387288 DOI: 10.7759/cureus.41201] [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: 06/29/2023] [Indexed: 08/02/2023] Open
Abstract
We report a clinical scenario involving a 51-year-old male patient with a history of prediabetes and gastritis who exhibited altered mental status following the consumption of poppers, a supplement containing nitrites, which is used for erectile stimulation. Shortly after the ingestion, the patient experienced convulsions, foaming at the mouth, and subsequently developed altered mental status and severe respiratory distress. The diagnosis of methemoglobinemia was confirmed based on elevated methemoglobin levels on venous blood gas analysis. Notably, the patient's blood had a chocolate-colored appearance upon admission, which is a characteristic finding in methemoglobinemia. Prompt recognition and management, including the administration of methylene blue, led to the resolution of symptoms. This case highlights the potential complications associated with the consumption of poppers and emphasizes the importance of early intervention.
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Affiliation(s)
- Iyad Y Idries
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | | | - Sushant Duddala
- Research, Prathima Institute of Medical Sciences, Nagunur, IND
| | - Y V Duong
- Research, University of Debrecen Medical School, Debrecen, HUN
| | - Mohammad Zaman
- Critical Care Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
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22
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Egbueri JC. A multi-model study for understanding the contamination mechanisms, toxicity and health risks of hardness, sulfate, and nitrate in natural water resources. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023; 30:61626-61658. [PMID: 36928703 DOI: 10.1007/s11356-023-26396-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/07/2023] [Indexed: 05/10/2023]
Abstract
Several water quality contaminants have attracted the attention of numerous researchers globally, in recent times. Although the toxicity and health risk assessments of sulfate and water hardness have not received obvious attention, nitrate contamination has gained peculiar research interest globally. In the present paper, multiple data-driven indexical, graphical, and soft computational models were integrated for a detailed assessment and predictive modeling of the contamination mechanisms, toxicity, and human health risks of natural waters in Southeast Nigeria. Majority of the tested physicochemical parameters were within their satisfactory limits for drinking and other purposes. However, total hardness (TH), SO4, and NO3 were above stipulated limits in some locations. A nitrate health risk assessment revealed that certain areas present a chronic health risk to children, females, and males due to water intake. However, the dermal absorption route was found to have negligible health risks. SO4 in some locations was above the 100 mg/L Nigerian limit; thus, heightening the potential health effects due to intake of the contaminated water resources. Most samples had low TH values, which exposes users to health defects. There are mixed contamination mechanisms in the area, according to graphical plots, R-mode hierarchical dendrogram, factor analysis, and stoichiometry. However, geogenic mechanisms predominate over human-related mechanisms. Based on the results, a composite diagrammatic model was developed. Furthermore, predictive radial basis function (RBF) and multiple linear regression (MLR) models accurately predicted the TH, SO4, and NO3, with the RBF outperforming the MLR models. Insights from the RBF and MLR models were useful in validating the results of the hierarchical dendrogram, factor, stoichiometric, and graphical analyses.
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Affiliation(s)
- Johnbosco C Egbueri
- Department of Geology, Chukwuemeka Odumegwu Ojukwu University, Uli, Anambra State, Nigeria.
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23
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Cai Z, Shao Y, Wu Y. Middle ear cholesteatoma resection under general anesthesia in patients with congenital methemoglobinemia: A case report. Medicine (Baltimore) 2023; 102:e33561. [PMID: 37058021 PMCID: PMC10101292 DOI: 10.1097/md.0000000000033561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/29/2023] [Indexed: 04/15/2023] Open
Abstract
RATIONALE Congenital methemoglobinemia is a rare cyanosis cause that can be manifested in affected individuals. We report a case of congenital methemoglobinemia after middle ear cholesteatoma resection under general anesthesia. PATIENT CONCERNS The primary concern of the patient is to safely perform cholesteatoma resection of the middle ear to reduce the pain associated with years of surgery and to survive the perioperative period. DIAGNOSES Congenital methemoglobinemia type 1. INTERVENTIONS The patient underwent general anesthesia and cholesteatoma resection of the middle ear. OUTCOMES The patient successfully underwent cholesteatoma resection in the middle ear under general anesthesia and went through the perioperative period smoothly, and successfully returned to society. LESSONS For patients requiring general anesthesia complicated with rare methemoglobinemia, we improve the awareness of crisis and make comprehensive preparation and monitoring, learn the pathophysiological mechanism related to the disease, so as to protect the operation of methemoglobin patients under general anesthesia.
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Affiliation(s)
- Zenghua Cai
- Department of Anesthesiology, Bethune International Peace Hospital, Shijiazhuang, China
| | - Yu Shao
- Department of Anesthesiology, Bethune International Peace Hospital, Shijiazhuang, China
| | - Yu Wu
- Department of Anesthesiology, Bethune International Peace Hospital, Shijiazhuang, China
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24
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Azeez Z, Vallabhaneni P. It is all blue! Arch Dis Child Educ Pract Ed 2023; 108:150-151. [PMID: 35772941 DOI: 10.1136/archdischild-2021-323520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 06/21/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Zak Azeez
- Child Health, Swansea Bay University Health Board, Port Talbot, UK
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25
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Arif A, Quds R, Salam S, Mahmood R. Esculin protects human blood cells from bioallethrin-induced toxicity: An ex vivo study. PESTICIDE BIOCHEMISTRY AND PHYSIOLOGY 2023; 191:105375. [PMID: 36963944 DOI: 10.1016/j.pestbp.2023.105375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
Bioallethrin, a household insecticide, is a member of the pyrethroid family and is known for its adverse effects on human health. Human exposure to pyrethroids is unavoidable due to their widespread use in controlling several fatal vector-borne diseases, mostly in developing nations. Bioallethrin is known to induce oxidative stress in target cells, including erythrocytes. Here we have studied the protective effect of dietary antioxidant esculin on bioallethrin-induced damage in isolated human erythrocytes. The cells were incubated with 200 μM bioallethrin, without or with different concentrations of esculin (200, 400 and 600 μM), and the results compared to the untreated control samples. Bioallethrin-treated erythrocytes showed a significant increase in oxidative stress markers, like protein and lipid oxidation, accompanied by decrease in free amino groups and ratio of reduced to oxidized glutathione. There was enhanced generation of reactive oxygen and nitrogen species with changes in plasma membrane integrity. Bioallethrin oxidized hemoglobin to methemoglobin, which cannot transport oxygen. It altered the activities of antioxidant enzymes and lowered the electron donating and free radical quenching ability of erythrocytes. The cell morphology and redox system of erythrocyte membrane were also altered by bioallethrin. Treatment with esculin, prior to incubation with bioallethrin, led to significant restoration in all these parameters in an esculin concentration-dependent manner. Thus esculin attenuated the biolletherin-induced oxidative damage to erythrocytes. Esculin can, therefore, be an effective chemoprotectant against xenobiotic-induced toxicity in human erythrocytes.
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Affiliation(s)
- Amin Arif
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh 202002, U.P., India
| | - Ruhul Quds
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh 202002, U.P., India
| | - Samreen Salam
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh 202002, U.P., India
| | - Riaz Mahmood
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh 202002, U.P., India.
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26
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Kosenko E, Tikhonova L, Alilova G, Montoliu C. Erythrocytes Functionality in SARS-CoV-2 Infection: Potential Link with Alzheimer's Disease. Int J Mol Sci 2023; 24:5739. [PMID: 36982809 PMCID: PMC10051442 DOI: 10.3390/ijms24065739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a rapidly spreading acute respiratory infection caused by SARS-CoV-2. The pathogenesis of the disease remains unclear. Recently, several hypotheses have emerged to explain the mechanism of interaction between SARS-CoV-2 and erythrocytes, and its negative effect on the oxygen-transport function that depends on erythrocyte metabolism, which is responsible for hemoglobin-oxygen affinity (Hb-O2 affinity). In clinical settings, the modulators of the Hb-O2 affinity are not currently measured to assess tissue oxygenation, thereby providing inadequate evaluation of erythrocyte dysfunction in the integrated oxygen-transport system. To discover more about hypoxemia/hypoxia in COVID-19 patients, this review highlights the need for further investigation of the relationship between biochemical aberrations in erythrocytes and oxygen-transport efficiency. Furthermore, patients with severe COVID-19 experience symptoms similar to Alzheimer's, suggesting that their brains have been altered in ways that increase the likelihood of Alzheimer's. Mindful of the partly assessed role of structural, metabolic abnormalities that underlie erythrocyte dysfunction in the pathophysiology of Alzheimer's disease (AD), we further summarize the available data showing that COVID-19 neurocognitive impairments most probably share similar patterns with known mechanisms of brain dysfunctions in AD. Identification of parameters responsible for erythrocyte function that vary under SARS-CoV-2 may contribute to the search for additional components of progressive and irreversible failure in the integrated oxygen-transport system leading to tissue hypoperfusion. This is particularly relevant for the older generation who experience age-related disorders of erythrocyte metabolism and are prone to AD, and provide an opportunity for new personalized therapies to control this deadly infection.
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Affiliation(s)
- Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia
| | - Lyudmila Tikhonova
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia
| | - Gubidat Alilova
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia
| | - Carmina Montoliu
- Hospital Clinico Research Foundation, INCLIVA Health Research Institute, 46010 Valencia, Spain
- Pathology Department, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
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27
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Alotaibi S, Mously A, Alnujaimy Z, Alotaibi A, Alharthi A. Trimethoprim/sulfamethoxazole-induced methemoglobinemia in pediatric patient: A case report. Clin Case Rep 2023; 11:e7124. [PMID: 36950667 PMCID: PMC10025246 DOI: 10.1002/ccr3.7124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/20/2023] [Accepted: 03/04/2023] [Indexed: 03/22/2023] Open
Abstract
In this report, a case of high dose of sulfamethoxazole/trimethoprim-induced methemoglobinemia and is reported in a young boy with ventilator-associated pneumonia and was treated successfully with methylene blue and cessation of the offending agent.
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Affiliation(s)
- Sultan Alotaibi
- Pharmaceutical Care ServicesKing Abdulaziz Medical CityJeddahSaudi Arabia
| | - Alaa Mously
- Department of Pharmaceutical ServicesPrince Sultan Military Medical CityRiyadhSaudi Arabia
| | - Zainab Alnujaimy
- Department of PediatricsPrince Sultan Military Medical CityRiyadhSaudi Arabia
| | - Abdulansir Alotaibi
- Pediatric Infectious Diseases DepartmentWomen and Children's Health Institute, John Hopkins Aramco HealthcareDhahranSaudi Arabia
| | - Abdullah Alharthi
- Pharmacy Services AdministrationKing Saud Medical City, Riyadh First Cluster, MOHRiyadhSaudi Arabia
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28
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Al-Abdulmalek A, Al-Sulaiman R, Abu-Tineh M, Yassin MA. Congenital Methemoglobinemia: First Confirmed Case in the Arab Population with a Novel Variant in the CYB5R Gene in the State of Qatar: A Case Report. J Blood Med 2023; 14:247-251. [PMID: 37025988 PMCID: PMC10072335 DOI: 10.2147/jbm.s395865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/21/2023] [Indexed: 04/01/2023] Open
Abstract
Methemoglobinemia (MetHb) is a rare hematological condition characterized by high methemoglobin levels in the blood. It happens when hemoglobin is oxidized, resulting in hypoxia and cyanosis, which may occur in inherited or acquired forms. Inherited or congenital methemoglobinemia is a rare autosomal recessive condition and has never been reported in the Arab population. Here we report a case of a 22-year-old Arab man with a positive family history who presented with bluish discoloration of the fingers and lips and was found to have methemoglobinemia. Genetic study on the patient and his family revealed compound heterozygous variants in the CYB5R3 Exon 5 c.431G>A p.Gly144Asp likely pathogenic variant and CYB5R3 Exon 9 c.871G>A p.Val291Met variant of unknown significance. We suggest that the novel c.871G>A p.Val291Met variant could be causative for methemoglobinemia.
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Affiliation(s)
| | - Reem Al-Sulaiman
- Department of Medical Oncology/Hematology, National Center for Cancer Care and Research, Doha, Qatar
| | - Mohammad Abu-Tineh
- Department of Medical Oncology/Hematology, National Center for Cancer Care and Research, Doha, Qatar
- Correspondence: Mohammad Abu-Tineh, Department of Oncology/Hematology and BMT, National Center for Cancer Care and Research, Hamad Medical Corporation, Alrayan Road, Doha, Qatar, Tel +97455003969, Email
| | - Mohamed A Yassin
- Department of Medical Oncology/Hematology, National Center for Cancer Care and Research, Doha, Qatar
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29
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Tiel Groenestege WM, Wijnen EJ, Janssen MJW. Abdominal Pain and Cola-Colored Serum. Clin Chem 2023; 69:207-208. [PMID: 36724483 DOI: 10.1093/clinchem/hvac193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/17/2022] [Indexed: 02/03/2023]
Affiliation(s)
| | - Ella J Wijnen
- Department of Obstetrics and Gynecology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Marcel J W Janssen
- Laboratory of Clinical Chemistry and Haematology, VieCuri Medical Centre, Venlo, The Netherlands
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30
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Methemoglobinemia Secondary to Inhalation of Automobile Emissions with Suicide Motivations. J Clin Med 2023; 12:jcm12030734. [PMID: 36769383 PMCID: PMC9917999 DOI: 10.3390/jcm12030734] [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: 12/23/2022] [Revised: 12/30/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Methemoglobinemia (MetHb) is a rare and potentially severe dyshemoglobinemia that can be induced by exposure to oxidizing agents, decreasing the functional capacity of the hemoglobin molecule to transport and release oxygen into the tissues. MetHb can originate from gases with oxidizing capacity generated by internal combustion engines, although since the universalization of catalyst converters in automobiles, a tiny proportion of MetHb poisoning is due to exposure to engine gases and fumes. Within this group, only two cases due to suicidal motivations have been reported in the last 30 years. CASE PRESENTATION Here, we expose the case of a patient with MetHb levels of 25.2% (normal 0-1.5%) who with suicidal motivations had attached and locked a hose to the exhaust pipe of her vehicle with electrical tape, becoming exposed to a sustained concentration of the vehicle's exhaust. Upon her arrival at the emergency department, the presence of generalized greyish cyanosis with alterations of the sensorium, dissociation between saturation measured by arterial blood gas analysis and pulse oximetry (98% vs. 85%), no response to high-flow oxygen therapy, and an excellent response to intravenous methylene blue treatment were highlighted. CONCLUSIONS This report illustrates an original case of acute toxic acquired MetHb due to inhalation of oxidizing substances originating from the bad ignition of an internal combustion engine. When evaluating a patient with suspected gas intoxication, we usually consider poisoning by the most common toxins, such as carbon monoxide or cyanide. In this context, we propose an algorithm to assist in the suspicion of this entity in patients with cyanosis in the emergency department. MetHb poisoning should be suspected, and urgent co-oximetry should be requested when there is no congruence between cyanosis intensity and oxygen saturation measured by pulse oximetry, if there is discordance between the results of oxygen saturation measured by arterial blood gas and pulse oximeter, and if there is no response to oxygen treatment. This algorithm could be useful to not delay diagnosis, improve prognosis, and limit potential sequelae.
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31
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Möller M, Orrico F, Villar S, López AC, Silva N, Donzé M, Thomson L, Denicola A. Oxidants and Antioxidants in the Redox Biochemistry of Human Red Blood Cells. ACS OMEGA 2023; 8:147-168. [PMID: 36643550 PMCID: PMC9835686 DOI: 10.1021/acsomega.2c06768] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/09/2022] [Indexed: 06/01/2023]
Abstract
Red blood cells (RBCs) are exposed to both external and internal sources of oxidants that challenge their integrity and compromise their physiological function and supply of oxygen to tissues. Autoxidation of oxyhemoglobin is the main source of endogenous RBC oxidant production, yielding superoxide radical and then hydrogen peroxide. In addition, potent oxidants from other blood cells and the surrounding endothelium can reach the RBCs. Abundant and efficient enzymatic systems and low molecular weight antioxidants prevent most of the damage to the RBCs and also position the RBCs as a sink of vascular oxidants that allow the body to maintain a healthy circulatory system. Among the antioxidant enzymes, the thiol-dependent peroxidase peroxiredoxin 2, highly abundant in RBCs, is essential to keep the redox balance. A great part of the RBC antioxidant activity is supported by an active glucose metabolism that provides reducing power in the form of NADPH via the pentose phosphate pathway. There are several RBC defects and situations that generate oxidative stress conditions where the defense mechanisms are overwhelmed, and these include glucose-6-phosphate dehydrogenase deficiencies (favism), hemoglobinopathies like sickle cell disease and thalassemia, as well as packed RBCs for transfusion that suffer from storage lesions. These oxidative stress-associated pathologies of the RBCs underline the relevance of redox balance in these anucleated cells that lack a mechanism of DNA-inducible antioxidant response and rely on a complex and robust network of antioxidant systems.
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Affiliation(s)
- Matias
N. Möller
- Laboratorio
de Fisicoquímica Biológica, Instituto de Química
Biológica, Facultad de Ciencias,
Universidad de la República, Montevideo 11400, Uruguay
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
| | - Florencia Orrico
- Laboratorio
de Fisicoquímica Biológica, Instituto de Química
Biológica, Facultad de Ciencias,
Universidad de la República, Montevideo 11400, Uruguay
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
- Laboratorio
de Enzimología, Instituto de Química Biológica,
Facultad de Ciencias, Universidad de la
República, Montevideo 11400, Uruguay
| | - Sebastián
F. Villar
- Laboratorio
de Fisicoquímica Biológica, Instituto de Química
Biológica, Facultad de Ciencias,
Universidad de la República, Montevideo 11400, Uruguay
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
| | - Ana C. López
- Laboratorio
de Fisicoquímica Biológica, Instituto de Química
Biológica, Facultad de Ciencias,
Universidad de la República, Montevideo 11400, Uruguay
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
- Laboratorio
de Enzimología, Instituto de Química Biológica,
Facultad de Ciencias, Universidad de la
República, Montevideo 11400, Uruguay
| | - Nicolás Silva
- Laboratorio
de Fisicoquímica Biológica, Instituto de Química
Biológica, Facultad de Ciencias,
Universidad de la República, Montevideo 11400, Uruguay
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
- Laboratorio
de Enzimología, Instituto de Química Biológica,
Facultad de Ciencias, Universidad de la
República, Montevideo 11400, Uruguay
- Departamento
de Medicina Transfusional, Hospital de Clínicas, Facultad de
Medicina, Universidad de la República, Montevideo 11600, Uruguay
| | - Marcel Donzé
- Laboratorio
de Fisicoquímica Biológica, Instituto de Química
Biológica, Facultad de Ciencias,
Universidad de la República, Montevideo 11400, Uruguay
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
| | - Leonor Thomson
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
- Laboratorio
de Enzimología, Instituto de Química Biológica,
Facultad de Ciencias, Universidad de la
República, Montevideo 11400, Uruguay
| | - Ana Denicola
- Laboratorio
de Fisicoquímica Biológica, Instituto de Química
Biológica, Facultad de Ciencias,
Universidad de la República, Montevideo 11400, Uruguay
- Centro
de Investigaciones Biomédicas (CEINBIO), Universidad de la República, Montevideo 11800, Uruguay
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Muacevic A, Adler JR, Pathak PR, Penot AR. Phenazopyridine-Induced Methemoglobinemia: A Case Report. Cureus 2023; 15:e33715. [PMID: 36788851 PMCID: PMC9922166 DOI: 10.7759/cureus.33715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Methemoglobinemia is a condition caused by increased methemoglobin, a reduced form of hemoglobin, in the blood. This causes the molecules to bind oxygen more tightly and decreases their ability to release that oxygen to tissue. Most cases of methemoglobinemia are acquired and occur either in pediatric populations or in individuals with predisposing conditions. This report illustrates a case of an otherwise healthy 31-year-old patient presenting to the emergency department with cyanosis of the hands and mouth and an O2 saturation of 78% after taking increased doses of the over-the-counter medication phenazopyridine. A "chocolate-brown" color of her arterial blood, and increased methemoglobin levels of 20.2%, confirmed the diagnosis of methemoglobinemia. She was treated with both methylene blue and ascorbic acid, and her oxygen saturation and serum chemistry returned to normal levels within a few hours. The case highlights the importance of discussing the dosage of all over-the-counter medications with patients and recognizing the signs and symptoms of methemoglobinemia.
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33
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Muacevic A, Adler JR, Agudo M, Rodrigues M, Santos F. The Serious Impact of Comorbidities on Methemoglobinemia: A Case Report. Cureus 2023; 15:e33923. [PMID: 36687290 PMCID: PMC9851850 DOI: 10.7759/cureus.33923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/19/2023] Open
Abstract
Methemoglobinemia is a rare, life-threatening condition that occurs when the body is exposed to oxidative stress. We present the case of a 72-year-old female with a past medical history of hypertension, obesity, dyslipidemia, and heart failure who was admitted to the emergency department with altered mental status and respiratory failure. After admission, we also identified an atrioventricular block 2:1, anemia, and skin discoloration. We performed endotracheal intubation and started mechanical ventilation due to respiratory failure; however, the patient retained an oxygen "saturation gap" despite adequate ventilation. In the initial laboratory evaluation, methemoglobinemia was found to be 13%, reaching a maximum level of 16%. An electroencephalogram revealed status epilepticus after her admission to the intensive care unit. Despite all efforts and supportive care, methylene blue therapy was never attempted, and the patient died. Our case emphasizes the importance of a high index of suspicion for methemoglobinemia, especially in the presence of an oxygen "saturation gap," and that despite relatively low levels of methemoglobinemia, it can have a more severe clinical presentation in patients with comorbidities. In these patients, a reduced threshold for administering methylene blue should be taken into account.
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Muacevic A, Adler JR, Atogwe ID, Bhandari S, Balasubramanian P, Ronderos DM. Nail Polish Remover Induced Methemoglobinemia: An Uncommon Occurrence. Cureus 2022; 14:e32107. [PMID: 36601139 PMCID: PMC9805361 DOI: 10.7759/cureus.32107] [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: 11/29/2022] [Indexed: 12/04/2022] Open
Abstract
Methemoglobinemia, defined as hemoglobin's impaired oxygen-carrying capacity due to oxidation from the ferrous (Fe2+) state to the ferric (Fe3+) state, has many well-documented etiologies. One example of an uncommon cause of acquired methemoglobinemia is the ingestion of nail polish remover, which can contain methemoglobin generators such as nitroethane, N,N-dimethyl-p-toluidine, and isobutyl nitrite. We present a case of methemoglobinemia in an 81-year-old male following accidental ingestion of isobutyl nitrite-containing nail polish remover, commonly used as a recreational inhalant. Furthermore, we review potentially toxic substances found in commercially available nail products. This case was designed to identify and efficiently treat a rather uncommon cause of methemoglobinemia induced in this case by a common household item, nail polish remover.
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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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36
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Sehlaoui H, Hassikou R, Dakak H, Zouahri A, El Hasini S, Iaaich H, Ghanimi A, Douaik A. Nitrate contamination and associated health risks of the Benslimane groundwater, Morocco. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2022; 44:4343-4358. [PMID: 35032290 DOI: 10.1007/s10653-021-01186-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/17/2021] [Indexed: 06/14/2023]
Abstract
Consumption of polluted water has harmful impacts on human health. This study examined the quality of groundwater in the Benslimane area for drinking purposes based on the Water quality index (WQI), Nitrate pollution index (NPI), and Total risk quotient (THQ) for different age groups. A total of 120 groundwater samples were collected for physicochemical analyses. The results showed WQI values ranging from 157.7 to 472.7 and an average of 279.4, with a total absence of water of excellent or good quality, and about 62.5% of the groundwater samples were of very poor quality for consumption. Nitrate concentrations ranged from 1 to 270 mg/L with an average of 64 mg/L, and 56.7% had values above the World Health Organization safety level of 50 mg/L. The NPI showed that 78.3% of the sampled sites showed very high pollution as a result of intense anthropogenic activities. High contamination is observed in the north and east of the region for arboriculture, grapes, maize, and vegetables as opposed to cereals. The health risk associated with nitrates, based on oral exposure, was much higher than dermal contact. The total risk quotient for both pathways was 0.02 to 6.58, 0.02 to 6.12, 0.06 to 17.06, and 0.05 to 13.35 for women, men, children, and infants, respectively. A total of 65, 63.3, 82.0, and 78.3% of groundwater samples presented a non-cancer health risk for women, men, children, and infants, respectively. Therefore, this study can help identify contaminated areas in order to track corrective safety measures to control groundwater quality in the region and improve sanitary conditions.
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Affiliation(s)
- Habiba Sehlaoui
- Microbiology and Molecular Biology Team, Center of Plant and Microbial Biotechnology, Biodiversity and Environment, Faculty of Sciences, Mohammed V University of Rabat, 4 Avenue Ibn Battouta, P. O. Box 1014, Rabat, Morocco.
- National Institute of Agricultural Research, Regional Center of Rabat, Research Unit On the Environment and Conservation of Natural Resources, P. O. Box 6356 - Institutes, 10101, Rabat, Morocco.
| | - Rachida Hassikou
- Microbiology and Molecular Biology Team, Center of Plant and Microbial Biotechnology, Biodiversity and Environment, Faculty of Sciences, Mohammed V University of Rabat, 4 Avenue Ibn Battouta, P. O. Box 1014, Rabat, Morocco
| | - Houria Dakak
- National Institute of Agricultural Research, Regional Center of Rabat, Research Unit On the Environment and Conservation of Natural Resources, P. O. Box 6356 - Institutes, 10101, Rabat, Morocco
| | - Abdelmjid Zouahri
- National Institute of Agricultural Research, Regional Center of Rabat, Research Unit On the Environment and Conservation of Natural Resources, P. O. Box 6356 - Institutes, 10101, Rabat, Morocco
| | - Soukaina El Hasini
- National Institute of Agricultural Research, Regional Center of Rabat, Research Unit On the Environment and Conservation of Natural Resources, P. O. Box 6356 - Institutes, 10101, Rabat, Morocco
- Department of Chemistry, Faculty of Sciences, Mohammed V University of Rabat, 4 Avenue Ibn Battouta, P. O. Box 1014, Rabat, Morocco
| | - Hamza Iaaich
- National Institute of Agricultural Research, Regional Center of Rabat, Research Unit On the Environment and Conservation of Natural Resources, P. O. Box 6356 - Institutes, 10101, Rabat, Morocco
| | - Ahmed Ghanimi
- Department of Chemistry, Faculty of Sciences, Mohammed V University of Rabat, 4 Avenue Ibn Battouta, P. O. Box 1014, Rabat, Morocco
| | - Ahmed Douaik
- National Institute of Agricultural Research, Regional Center of Rabat, Research Unit On the Environment and Conservation of Natural Resources, P. O. Box 6356 - Institutes, 10101, Rabat, Morocco
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37
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Hypoxia in A Patient with Anti-p200 Pemphigoid under Combined Dapsone and Pantoprazole Treatment. Biomedicines 2022; 10:biomedicines10112837. [DOI: 10.3390/biomedicines10112837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
A 70-year-old male patient was admitted to our dermatology outpatient clinic with newly developed personality changes and signs of hypoxemia. His anti-p200 Pemphigoid was treated with Dapsone for a few weeks. Due to generalized tonic-clonic seizure with a subsequent Glasgow Coma Scale of 5 points and a peripheral oxygen saturation not exceeding 88% under conditions of high-flow nasal cannula, he was intubated by the emergency team and transferred to the intensive care unit. Comprehensive tests were performed, but Dapsone-induced methemoglobinemia remained the exclusive explanation for the observed scenario, although arterial MetHb analysis showed a peak value of only 6%. The patient recovered shortly after repeated infusions of Methylene blue and Ascorbate, and cessation of Dapsone. We provide an overview of the pathophysiology, diagnostic procedures, and possible explanations for this case of Dapsone-induced methaemoglobinaemia. In conclusion, our case report provides evidence that even mild chronic methemglobinemia can induce severe clinical symptoms.
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38
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Yoshida T, Nishimura K, Murabe H, Yokota T. Dapsone-induced methaemoglobinaemia in relapsing polychondritis. BMJ Case Rep 2022; 15:e252431. [PMID: 36109093 PMCID: PMC9478832 DOI: 10.1136/bcr-2022-252431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tomohiro Yoshida
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Keisuke Nishimura
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Murabe
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshihiko Yokota
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
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39
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Arva K, Sharma A. A rare combination of methemoglobinemia and carboxyhemoglobinemia in pesticide poisoning. Am J Emerg Med 2022; 62:148.e5-148.e7. [PMID: 36163065 DOI: 10.1016/j.ajem.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Dyshemoglobinemias are disorders in which the haemoglobin is functionally altered and prevented from carrying oxygen. They include carboxyhemoglobin, methemoglobin, and sulfhemoglobin. This increase in abnormal haemoglobin has reduced oxygen binding capacity, which leads to decrease in total oxygen content in the blood causing anaemic-hypoxia. The anaemic-hypoxia which is present in these disorders are refractory to the oxygen supplementation and cause many systemic and life threatening complications.Many cases are reported in literature with either of haemoglobin. It is very rare to have two abnormal haemoglobin levels in the same patient. Here we discuss an uncommon case which presented to our tertiary care hospital after consuming pesticide with suicidal intention. The patient was very pale, had peripheral cyanosis,tachypnea and tachycardia and dizziness on presentation. The SpO2 of 85% was our clue to suspect methemoglobinemia which was confirmed along with carboxyhemoglobinemia on arterial blood gas saving result. Despite that patient being very unstable, she was successfully managed with 100% oxygen through High flow nasal cannula (HFNC), methylene blue and blood transfusion. The patient's signs and symptoms gradually reduced in a few days and got discharged after 2 weeks without any neurological and cardiorespiratory sequelae. An early suspicion and personalized emergency management was the key to success. As in all fields of Medicine, Emergency Medicine is also witnessing a change towards precision and personalized Medicine practice.
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Affiliation(s)
- Koushik Arva
- MD PGY-3 Emergency Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.
| | - Ashima Sharma
- Professor, Emergency Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Yoon JC, Kim SE. Suicide attempt using sodium nitrite ordered on the internet: Two case reports. Medicine (Baltimore) 2022; 101:e29355. [PMID: 35839015 PMCID: PMC11132383 DOI: 10.1097/md.0000000000029355] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/08/2022] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Sodium nitrite is a potent oxidizing agent that impairs oxygen transport and delivery through methemoglobin formation. Clinical manifestations are known to induce methemoglobinemia, dysrhythmia, hypotension, and even death. While accidental intoxication of sodium nitrite by contaminated water and food has previously occurred, there has been a substantial upsurge in suicide intoxication in recent years. PATIENT CONCERNS We present case reports of 2 patients who attempted suicide by sodium nitrite after ordering a "suicide powder" on the internet market. They were brought to the emergency department after attempting suicide by ingesting sodium nitrite. They experienced dyspnea, cyanosis, and mild nausea. DIAGNOSIS Based on their history and blood tests, methemoglobinemia was initially diagnosed. INTERVENTIONS AND OUTCOMES The patients received methylene blue antidotal therapy in the emergency department. The patients were discharged after neuropsychiatric evaluation and treatment for mental illness, suicidal ideation, and suicide attempts. They informed us of how simple and easy it was for them to buy sodium nitrite for suicidal purposes. LESSONS With widely shared information on the usage of sodium nitrite for suicide and the absence of proper regulation, the incidence of acute poisoning will increase. This increases physicians' chances of encountering unexplained cyanosis and methemoglobinemia. Clinical suspicion of sodium nitrite intoxication is warranted in cases of unexplained cyanosis or methemoglobinemia. We want to highlight how simple and easy it is to buy sodium nitrite for suicidal purposes.
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Affiliation(s)
- Jae Chol Yoon
- Research Institute of Clinical Medicine of Jeonbuk National University and Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju-si, Republic of Korea
- Department of Emergency Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - So Eun Kim
- Research Institute of Clinical Medicine of Jeonbuk National University and Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju-si, Republic of Korea
- Department of Emergency Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
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Rajkumar H, Naik PK, Singh G, Rishi M. Hydrogeochemical characterization, multi-exposure deterministic and probabilistic health hazard evaluation in groundwater in parts of Northern India. TOXIN REV 2022. [DOI: 10.1080/15569543.2022.2080222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Herojeet Rajkumar
- Department of Environment Studies, Post Graduate Government College, Chandigarh, India
| | - Pradeep K. Naik
- Rajiv Gandhi National Ground Water Training & Research Institute, Raipur, Chhattisgarh, India
| | | | - Madhuri Rishi
- Department of Environmental Studies, Panjab University, Chandigarh, India
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Kiernan EA, Carpenter JE, Dunkley CA, Moran TP, Rothstein LS, Silver E, Salehi M, Koch DD, Morgan BW, Murray BP. Elevated methemoglobin levels in patients treated with hydroxocobalamin: a case series and in-vitro analysis. Clin Toxicol (Phila) 2022; 60:1012-1018. [PMID: 35549585 DOI: 10.1080/15563650.2022.2072315] [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: 11/03/2022]
Abstract
BACKGROUND Historically, the first step in treating cyanide (CN-) toxicity utilized antidotes to induce methemoglobinemia. This is concerning in patients who are already hypoxemic or have elevated carboxyhemoglobin. Hydroxocobalamin (OHCbl) is now the first-line antidote for CN- toxicity and is not known to induce methemoglobinemia. We observed elevated methemoglobin (MetHb) levels in several patients treated with OHCbl and sought to investigate the incidence of MetHb formation following administration of OHCbl. METHODS Chart review: A single-center, retrospective case series of patients who received 5 or 10 g of hydroxocobalamin from 01/01/2011 through 04/30/2019. Data was analyzed using descriptive statistics. In-vitro study: Discarded blood was separated into whole blood and plasma samples. OHCbl and normal saline was added to reach 0×, 1×, 2×, and 4× peak therapeutic concentrations and analyzed at times 0, 2, and 4 h after administration. RESULTS Chart review: Twenty-seven cases of OHCbl administration were identified. The median age was 53 years (IQR 38 - 64) and 20 (74.1%) were male. Exposure to a house fire or smoke inhalation was the reason for OHCbl administration in 21 (77.8%) patients. Five (18.5%) patients received 10 g of OHCbl while the rest received 5 g. Six (22.2%) patients developed methemoglobinemia, all after 5 g OHCbl administration; four had been exposed to fire and smoke, two received the medication for severe acidosis of unknown etiology not related to fire or smoke. The median peak level was 7.1% (IQR 2.2 - 16.4%) at a median time of 11.4 h post-administration. Two patients received methylene blue (MB), neither responded. Death occurred in 17 (63%) cases. In-vitro study: We observed a dose dependent elevation in total hemoglobin but did not detect any increase in MetHb. CONCLUSION We observed a noteworthy temporal association between the formation of methemoglobinemia and the administration of hydroxocobalamin. This does not appear to be an artifact of the CO-oximeters. This could have profound implications for patients who are already hypoxemic or have impaired oxygen carrying capacity from carboxyhemoglobin.
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Affiliation(s)
| | | | | | - Tim P Moran
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Maryam Salehi
- Emory University School of Medicine, Atlanta, GA, USA
| | - David D Koch
- Emory University School of Medicine, Atlanta, GA, USA
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Groundwater Quality and Associated Human Health Risk in a Typical Basin of the Eastern Chinese Loess Plateau. WATER 2022. [DOI: 10.3390/w14091371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Groundwater is an important source for drinking, agricultural, and industrial purposes in the Linfen basin of the Eastern Chinese Loess Plateau (ECLP). To ensure the safety of drinking water, this study was carried out to assess the quality using the water quality index (WQI) and potential health risks of groundwater using the human health risk assessment model (HHRA). The WQI approach showed that 90% of the samples were suitable for drinking, and Pb, TH, F−, SO42−, and TDS were the most significant parameters affecting groundwater quality. The non-carcinogenic health risk results indicated that 20% and 80% of the samples surpassed the permissible limit for adult females and children. Additionally, all groundwater samples could present a carcinogenic health risk to males, females, and children. The pollution from F−, Pb, and Cr6+ was the most serious for non-carcinogenic health risk. Cd contributed more than Cr6+ and As to carcinogenic health risks. Residents living in the central of the study area faced higher health risks than humans in other areas. The research results can provide a decision-making basis for the scientific management of the regional groundwater environment and the protection of drinking water safety and public health.
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Raucci U, Stanco M, Roversi M, Ponticiello E, Pisani M, Rosa M, Falsaperla R, Pavone P, Bondone C, Raffaldi I, Calistri L, Masi S, Reale A, Villani A, Marano M. Acquired methemoglobinemia in children presenting to Italian pediatric emergency departments: a multicenter report. Clin Toxicol (Phila) 2022; 60:920-925. [PMID: 35416740 DOI: 10.1080/15563650.2022.2061986] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Methemoglobinemia (MetHb) is a rare inherited or acquired cause of cyanosis in children. Owing to its rarity, case reports and case series are mostly available in the current literature. This study reports data on a large sample of children with acquired MetHb. METHODS Data on patients admitted for acquired MetHb between January 2007 to December 2020 was extracted from the databases of five Italian pediatric emergency departments (EDs). Demographical and clinical characteristics was reported and discussed. RESULTS Nineteen cases of acquired MetHb were evaluated. Ten patients (52.6%) were male and 9 (47.4%) were female. The median age was 8.23 months. The median time from trigger to symptom onset was 6 hours. Mostly, the intoxication presumptively occurred by home ingestion of contaminated food, mainly badly preserved vegetable broth. All patients were cyanotic at admission, most patients also presented tachycardia and/or tachypnea, and two patients were comatose. Antidotal therapy with methylene blue was given in 14 patients (73.7%). The median hospital stay was 2 days. All patients survived. DISCUSSION As MetHb leads to the pathognomonic brown blood discoloration, blood gas analysis is mandatory immediately upon hospital arrival of a cyanotic patient. A correct medical history is crucial to identify the trigger and remove it. In our sample, the age onset was much lower than in the previous literature, and MetHb mainly due to ingestion of contaminated vegetable broth. Methylene blue led to a rapid recovery in all patients. Oxygen therapy may well lead to complete recovery when methemoglobin levels do not exceed 30% in asymptomatic and 20% in mildly symptomatic patients. CONCLUSIONS The diagnosis and management of acquired MetHb in the emergency setting requires acknowledgment of this condition as a cause of cyanosis in the weaning child. Indeed, when promptly recognized and treated, this severe condition rapidly resolves with no significant acute sequelae.
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Affiliation(s)
- Umberto Raucci
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Michela Stanco
- Department of Women, Children And General and Specialist Surgery, University of the Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Roversi
- Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, University of Rome Tor Vergata, Residency School of Pediatrics, Rome, Italy
| | | | - Mara Pisani
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Margherita Rosa
- Dipartimento di Area Critica, AORN Santobono Pausilipon, Naples, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit [NICU], AOU "Policlinico", PO "San Marco", University of Catania, Catania, Italy.,Unit of Pediatrics and Pediatric Emergency, AOU "Policlinico", PO "San Marco", University of Catania, Catania, Italy
| | - Piero Pavone
- Division of Pediatrics and Pediatric Emergency, University Hospital Policlinico "Rodolico-San Marco," Catania, Italy
| | - Claudia Bondone
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Irene Raffaldi
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Lucia Calistri
- Pediatric Emergency Unit, Anna Meyer's Children Hospital, Florence, Italy
| | - Stefano Masi
- Pediatric Emergency Unit, Anna Meyer's Children Hospital, Florence, Italy
| | - Antonino Reale
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Marano
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Paediatric Clinical Toxicology Centre, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
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Bai Y, Su J, Ali A, Chang Q, Gao Z, Wang Y, Liu Y. Insights into the mechanism of Mn(II)-based autotrophic denitrification: Performance, genomic, and metabonomics. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 810:151185. [PMID: 34699810 DOI: 10.1016/j.scitotenv.2021.151185] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 06/13/2023]
Abstract
The technologies for groundwater nitrate pollution treatment have drawn increasing global attention. As for autotrophic denitrification (AD), most researches aimed to the mixed microbial culture bioreactors, the mechanism of AD by purely cultured bacteria has not been fully investigated yet. Here, denitrification ability, bacterial activity, and dissolved organic matter evolution of Cupriavidus sp. HY129 in both AD and heterotrophic denitrification (HD) were studied. Genomic analysis and microbial metabolomic analysis were applied to explore the mechanism of AD and the difference and intrinsic factors in AD and HD. The results revealed that HD resulted in higher denitrification efficiency and biomass compared to AD and the bacteria preferred to synthesize humic-like proteins to maintain the progress of AD. Bacteria carry out Mn oxidation outside the bacteria cell and transfer electrons into the cell for AD. Cupriavidus sp. HY129 genome has critical metabolic pathways in both autotrophic and heterotrophic conditions, as well as the MCO gene for mediating the Mn oxidation. Energy metabolism pathways were the most significantly differences between AD and HD. Moreover, sphingolipid metabolism and mineral absorption metabolism were the most essential pathways in the autotrophic process to maintain the normal physiological activities and Mn transfer. The results explored the differences between AD and HD pathways in the same bacteria for the first time and provided new insight into understanding the metabolic characteristics of different denitrification, which provide useful information to the global nitrogen cycle and nitrate pollution treatment.
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Affiliation(s)
- Yihan Bai
- School of Environmental and Municipal Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China
| | - Junfeng Su
- School of Environmental and Municipal Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China; Shaanxi Key Laboratory of Environmental Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China.
| | - Amjad Ali
- School of Environmental and Municipal Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China
| | - Qiao Chang
- School of Environmental and Municipal Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China
| | - Zhihong Gao
- School of Environmental and Municipal Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China
| | - Yue Wang
- School of Environmental and Municipal Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China
| | - Yu Liu
- School of Environmental and Municipal Engineering, Xi'an University of Architecture and Technology, Xi'an 710055, China
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Jayapal A, Rosario DC, Sanchez J, Ambati S. Benzocaine-induced methaemoglobinaemia in an adolescent with sepsis. BMJ Case Rep 2022; 15:e248013. [PMID: 35228243 PMCID: PMC8886395 DOI: 10.1136/bcr-2021-248013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/04/2022] Open
Abstract
Methaemoglobinaemia is a potentially life-threatening condition characterised by hypoxaemia, cyanosis, pallor, fatigue, metabolic acidosis, headache and in severe cases, coma or death. Topical anaesthetics have been reported to cause methaemoglobinaemia. Topical benzocaine was specifically implicated in roughly 66% of anesthetic-induced methaemoglobinaemia cases in a large systematic review in adults. This complication has occurred often in adult patients with pre-existing comorbidities resulting in diminished use in children overall with only few paediatric cases reported worldwide. Additionally, there is growing evidence of a link between sepsis and methaemoglobinaemia due to increased circulating nitrous oxide from infectious pathogen metabolism. In this report, we discuss a case of a 16-year-old young boy, being evaluated for suspected endocarditis, presenting with acute methaemoglobinaemia after use of topical benzocaine spray for transesophageal echocardiogram. This case exemplifies the importance of blood gas with co-oximetry testing in all cases of refractory hypoxemia who have had procedures requiring topical anaesthetics.
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Affiliation(s)
| | | | - Javier Sanchez
- Pediatrics, Albany Medical Center, Albany, New York, USA
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Three novel mutations in CYB5R3 gene causing NADH-cytochrome b5 reductase enzyme deficiency leads to recessive congenital methaemoglobinemia. Mol Biol Rep 2022; 49:2141-2147. [PMID: 35064402 DOI: 10.1007/s11033-021-07031-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Methemoglobin is the reduced form of haemoglobin that is normally found in the blood in levels < 1%. Methemoglobinemia can occur as a congenital or acquired disease. Two types of recessive congenital methaemoglobinemia (RCM) are caused by the NADH-dependent cytochrome b5 reductase enzyme deficiency of the CYB5R3 gene. RCM-I is characterized by higher methaemoglobin levels (> 2 g/dL), causing only cyanosis, whereas RCM-II is associated with cyanosis with neurological impairment. METHODS Routine haematological investigations were done by standard method. The methaemoglobin level was evaluated by the potassium ferricyanide assay. NADH-cytochrome b5 reductase (cytb5r) enzyme activities were measured by standard methods, and molecular analysis was performed by polymerase chain reaction (PCR) followed by DNA sequencing. The interpretation of mutation effect and the molecular modeling were performed by using specific software DEEP VIEW SWISS-PDB VIEWER and Pymol molecular graphics program. RESULTS The present study discovered three novel homozygous pathogenic variants of CYB5R3 causing RCM I and II in four unrelated Indian patients. In patient-1 and patient-2 of RCM type I caused due to novel c.175C>T (p.Arg59Cys) and other reported c.469T>C (p.Phe157Ser) missense pathogenic variants respectively, whereas patient-3 and patient-4 presented with the RCM type II are related to developmental delay with cyanosis since birth due to a novel homozygous (g.25679_25679delA) splice-site deletion and novel homozygous c.824_825insC (p.Pro278ThrfsTer367) single nucleotide insertion. The CYB5R3 transcript levels were estimated by qRT-PCR in the splice-site deletion, which was 0.33fold of normal healthy control. The insertion of nucleotide C resulted in a frameshift of termination codon are associated with neurological impairment. CONCLUSIONS Molecular diagnosis of RCM can help to conduct genetic counselling for novel mutations and, subsequently, prenatal diagnosis of high-risk genetic disorders.
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Takagi S, Ando S, Kono R, Oono Y, Nagasaka H, Kohase H. Methemoglobinemia Induced by Prilocaine in a Child With Noonan Syndrome. Anesth Prog 2022; 69:25-29. [PMID: 36223191 PMCID: PMC9552618 DOI: 10.2344/anpr-69-02-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/04/2022] [Indexed: 11/06/2022] Open
Abstract
Limited information is currently available on methemoglobinemia caused by the administration of prilocaine in children undergoing dental procedures in Japan. This case report presents the development of methemoglobinemia due to prilocaine overdose. The patient was a female aged 5 years 8 months with Noonan syndrome who also had pulmonary valve stenosis and hypertrophic cardiomyopathy. She presented with severe dental caries affecting 12 total teeth and required general anesthesia due to a lack of cooperation during dental treatment. General anesthesia was performed, during which 3% prilocaine with 0.03 IU/mL felypressin was administered intraoperatively via infiltration. Her SpO2 gradually decreased after 30 minutes, and cyanosis was observed postoperatively. Several assessments including a 12-lead electrocardiogram, an anteroposterior chest radiograph, and venous blood gas analysis were performed to identify potential causes. However, there were no indications of acute respiratory or cardiovascular abnormalities. It was noted that a total of 192 mg prilocaine was administered during the procedure, and methemoglobinemia was suspected to have developed because of overdose. Further testing revealed an elevated serum methemoglobin of 6.9%, supporting methemoglobinemia as the cause of her decreased SpO2. In dental procedures that require the use of prilocaine to treat multiple teeth, particularly for pediatric patients, it is important to carefully manage prilocaine dosing, as an overdose may lead to methemoglobinemia.
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Affiliation(s)
- Saori Takagi
- Division of Dental Anesthesiology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Sakado, Japan
| | - Shinnosuke Ando
- Division of Dental Anesthesiology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Sakado, Japan
| | - Ryoko Kono
- Division of Dental Anesthesiology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Sakado, Japan
| | - Yuka Oono
- Division of Dental Anesthesiology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Sakado, Japan
| | - Hiroshi Nagasaka
- Department of Anesthesiology, Saitama Medical University, Faculty of Medicine, Saitama, Japan
| | - Hikaru Kohase
- Division of Dental Anesthesiology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Sakado, Japan
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Fadah K, Rivera M, Lingireddy A, Kalas MA, Ghafouri RS, Deoker A. A Rare Culprit of Methemoglobinemia. J Investig Med High Impact Case Rep 2022; 10:23247096221117919. [PMID: 35959982 PMCID: PMC9379961 DOI: 10.1177/23247096221117919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Methemoglobinemia is a rare cause of hypoxia and can be a diagnostic challenge
early in the disease course. The incidence of medication-induced
methemoglobinemia is more common than congenital-related methemoglobinemia. The
most common cause of methemoglobinemia is exposure to household detergents,
illicit drugs, or medications with nitrate or sulfonamide chemical groups. The 2
main medications accounting for up to 45% of medication-induced cases are
dapsone and benzocaine. We report a case of hypoxia and diarrhea with an
arterial blood gas (ABG) showing methemoglobinemia at 26%. Infectious and
autoimmune workup were negative. Methemoglobinemia level returned to normal
level within 2 weeks of hydrochlorothiazide discontinuation, suggesting
medication-induced methemoglobinemia at appropriate hypertension dosage. In this
case, there was an acute rise in methemoglobin levels following initiation of an
hydrochlorothiazide-losartan combination, which improved following the
discontinuation of hydrochlorothiazide. Extensive workup ruled out cytochrome b5
reductase (Cb5R) and Glucose-6-phosphate dehydrogenase (G6PD) deficiency, which
raised the suspicion of hydrochlorothiazide-induced methemoglobinemia, as it is
part of the sulfa drug family.
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Affiliation(s)
- Kahtan Fadah
- Texas Tech University Health Sciences Center, El Paso, USA
| | | | | | - M. Ammar Kalas
- Texas Tech University Health Sciences Center, El Paso, USA
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Maraj DC, Barak-Norris R, Dankha M. A Rare Case of Benzocaine-Induced Methemoglobinemia. Cureus 2021; 13:e19259. [PMID: 34881122 PMCID: PMC8643242 DOI: 10.7759/cureus.19259] [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] [Accepted: 11/04/2021] [Indexed: 11/07/2022] Open
Abstract
Methemoglobinemia is a severely dangerous condition that can be induced by congenital mutations or can be acquired. One of the ways to acquire methemoglobinemia is by using topical anesthetics during procedures, such as nasogastric (NG) tube placement, transesophageal echocardiogram (TEE), esophagogastroduodenoscopies (EGD), and during endoscopic retrograde cholangiopancreatography (ERCP). Herein, we present the case of a 35-year-old lady who presented to the hospital for an initial hysterectomy. However, due to topical anesthetic use during an NG tube placement, she developed methemoglobinemia. She then developed hypoxia, an altered mental status, and had elevated methemoglobinemia levels. She denied any previous episode of methemoglobinemia and had no family history of the condition as well. She was rapidly given methylene blue, which resolved her symptoms and induced normal methemoglobin levels on subsequent arterial blood gas analysis. Those who are unknowingly susceptible to developing methemoglobinemia and receive anesthetics during hospital procedures are at risk for serious adverse effects and clinical deterioration if not treated correctly. Therefore, it is important to recognize the clinical signs of methemoglobinemia as soon as they appear and have the required treatment readily available, as any delay could result in dangerous consequences for the patient.
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Affiliation(s)
- Diva C Maraj
- Allergy and Immunology, St. Joseph Mercy Oakland Hospital, Pontiac, USA
| | - Ronda Barak-Norris
- Allergy and Immunology, St. Joseph Mercy Oakland Hospital, Pontiac, USA.,Allergy and Immunology, Beaumont Hospital, Royal Oak, USA.,Allergy and Immunology, Ascension Providence Hospital, Southfield, USA
| | - Melody Dankha
- Research, St. Joseph Mercy Oakland Hospital, Pontiac, USA
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