Saturday night blue--a case of near fatal poisoning from the abuse of amyl nitrite

Seizures and severe methaemoglobinaemia following accidental ingestion of amyl nitrite

We present a case of a man in his late 40s presenting with generalised tonic-clonic seizures and profound methaemoglobinaemia shortly after inadvertent ingestion of amyl nitrite. Arterial blood gas analysis demonstrated methaemoglobin levels exceeding the upper detection threshold of our analyser, accompanied with profound cyanosis despite apparent oxygen saturations of 94%. Prompt administration of intravenous methylene blue led to a rapid and complete recovery. This case highlights the importance of swift recognition and treatment of methaemoglobinaemia particularly when the precipitating factor may be unknown at the time of presentation. This case also demonstrates the potential limitations of bedside blood gas analysers in diagnosis.

Nitrites: An Old Poison or a Current Hazard? Epidemiology of Intoxications Covering the Last 100 Years and Evaluation of Analytical Methods

In recent times, there has been a concerning and noteworthy rise in the global use of sodium nitrite for suicidal purposes. This is facilitated either through the employment of specialized "suicide kits" or by acquiring sodium nitrite through alternative means. Additionally, another occurrence contributing to nitrite poisoning is the recreational utilization of nitrites in the form of volatile aliphatic esters of nitrous acid, commonly referred to as "poppers". Based on current available papers and reports on the subject of nitrates, nitrites, and poppers intoxications, an epidemiological analysis and evaluation of analytical methods were performed. A total of 128 papers, documenting a collective count of 492 intoxication cases, were identified. Additionally, in order to complete the epidemiological profile of nitrite poisoning, the authors briefly examined six cases of nitrite intoxication that were under investigation in our laboratory. Furthermore, a review of nitrite poisoning cases over the past 100 years shows that the old poison is still in use and poses a substantial risk to society.

Methaemoglobinaemia due to alkyl nitrites in a patient with suspected traumatic injuries

A man in his 60s with no relevant previous medical history presented to an urban, major trauma centre by ambulance after being found with a head injury in a nightclub. The paramedics reported he was hypoxic, hypotensive and tachycardic with altered mental status. At the emergency department, he had oxygen saturations of 85% despite high-flow oxygen and was hypotensive at 88/43mmHg. We were concerned the patient was haemorrhaging given the lack of response to oxygen therapy and their hypotension. However, an arterial blood gas (ABG) established a diagnosis of methemoglobinaemia. Methylthioninium chloride was promptly administered, and the patient's condition improved. He later reported using recreational drugs, including alkyl nitrites ('poppers'). He was monitored until his fraction of methaemoglobin returned to normal baseline levels with serial ABGs. He was discharged 24 hours later. It was suspected that his use of alkyl nitrites was the most likely cause of methaemoglobinaemia.

A Rare Case of Fatal Self-Poisoning With Sodium Nitrite: Autopsy and Toxicological Findings

ABSTRACT

Fatal sodium nitrite poisonings are unusual in the forensic setting. Suicide by poisoning includes drug overdose, the inhalation of toxic gasses, and poisoning from pesticides and chemical substances. Sodium nitrite is an inorganic compound usually seen as a crystalline powder that is very water soluble. Sodium nitrite is used mostly in the food industry (as a preservative) and in medical field (as an antidote to cyanide poisoning), and if ingested in large enough amounts, it can be fatal.The ingestion of sodium nitrite can cause severe methemoglobinemia, which is a metabolic disorder characterized by an inability of hemoglobin (which gets oxidized into methemoglobin) to bind (and therefore carry) oxygen. Severe cases of this condition, if not treated, can be fatal.We describe a case of fatal self-poisoning with sodium nitrite; in particular, the article focuses on the autoptic and toxicological investigations that enabled the correct diagnosis to be established.

Fatal methemoglobinemia: A case series highlighting a new trend in intentional sodium nitrite or sodium nitrate ingestion as a method of suicide

Unintentional exposure to nitrite- or nitrate-containing toxic salts is a recognized cause of acquired methemoglobinemia (MetHb). This systemic alteration of the blood can be fatal if not recognized and treated promptly. The intentional ingestion of sodium nitrite (NaNO₂) or sodium nitrate (NaNO₃), causing MetHb, is an uncommon and recently identified method of suicide, with the first reported case in the literature occurring in New Zealand in 2010. In this case series we present 28 cases of sudden death of individuals with evidence of MetHb and/or toxic salt ingestion, occurring in the Province of Ontario, Canada, between the years 1980 and 2020, inclusive. Of the 28 deaths in our case series, 25 showed evidence of intentional ingestion of sodium nitrite or sodium nitrate salts. Our year-over-year data demonstrated this is an increasingly used method of suicide in our provincial population, with the majority of cases occurring in the final two years of our study. Postmortem detection of MetHb is typically established via screening techniques such as scene evidence suggesting fatal consumption of a toxic salt in addition to the characteristic grey-purple lividity observed upon the body. The diagnosis can be established via postmortem blood testing demonstrating elevated methemoglobin saturation. Additionally, we have confirmed that postmortem MRI in cases of MetHb demonstrates a T1-bright (hyperintense) signal of the blood; both within intracardiac blood on chest MRIs and postmortem blood samples in tubes.

Plasmapheresis in severe methemoglobinemia following occupational exposure

Ferrous iron can be converted to ferric iron by oxidative stress which results in the formation of methemoglobin. Consequently, the oxygen dissociation curve is shifted to the left, which leads to tissue hypoxia and ultimately may cause death. Acquired methemoglobinemia can be due to a host of offending agents and chemicals including nitrites, local anesthetics, aniline and antimalarial drugs. There are several approaches to the management of methemoglobinemia. The first step is to stop the offending agent and initiate supportive measures. Methylene blue can be used successfully provided the patient has no evidence of glucose 6 phosphate deficiency. Hyperbaric oxygen and intravenous ascorbic acid are other treatment options. We present a case of unusually severe methemoglobinemia (82% methemoglobin) secondary to occupational exposure that failed to respond to several lines of management including methylene blue, red cell exchange, intravenous ascorbic acid, and hyperbaric oxygen. However, the patient responded swiftly to plasmapheresis started upon suspicion of concomitant thrombotic thrombocytopenic purpura, and he subsequently recovered completely. Thus, plasmapheresis may have a role in severe methemoglonbinemia unresponsive to standard treatment options.

Severe Methemoglobinemia due to Sodium Nitrite Poisoning

Case. We report a case of severe methemoglobinemia due to sodium nitrite poisoning. A 28-year-old man was brought to our emergency department because of transient loss of consciousness and cyanosis. He was immediately intubated and ventilated with 100% oxygen. A blood test revealed a methemoglobin level of 92.5%. Outcome. We treated the patient with gastric lavage, activated charcoal, and methylene blue (2 mg/kg) administered intravenously. Soon after receiving methylene blue, his cyanosis resolved and the methemoglobin level began to decrease. After relocation to the intensive care unit, his consciousness improved and he could recall ingesting approximately 15 g sodium nitrite about 1 hour before he was brought to our hospital. The patient was discharged on day 7 without neurologic impairment. Conclusion. Severe methemoglobinemia may be fatal. Therefore, accurate diagnosis of methemoglobinemia is very important so that treatment can be started as soon as possible.

Pop goes the O2: a case of popper-induced methaemoglobinamia

A 39-year-old man presented to the emergency department after falling downstairs after he consumed a large quantity of alcohol. On examination, he had altered mental state (GCS 14), central cyanosis and low oxygen saturation of 86%, despite 100% oxygen being administered. His arterial blood gas confirmed diagnosis of methaemoglobinaemia with a methaemoglobin percentage of 14.08. He was treated successfully with methylthioninium chloride. The patient later admitted to use of recreational poppers (amyl nitrates) the previous evening. The emergency physician is challenged by the presentation of a patient with altered mental state and unexplained low oxygen saturation with concurrent alcohol intoxication but must have a high index of suspicion for methaemoglobinaemia particularly with a history of recreational drug ingestion.

Teenage toxins: recreational poisoning in the adolescent

Adolescents are experimenting with recreational drugs on a regular basis, particularly at social gatherings such as parties, raves and mass events. A combination of reduced fluid intake, physical activity and drug-induced hyperthermia leads to complications such as heat stroke, delirium and potentially death. The clinician needs to be aware of the variety of pharmacologically active substances available in the recreational marketplace in order to diagnose and manage these patients. Recreational misadventure, because of incorrect dosage or mixing multiple substances, is a common reason for teenagers presenting to hospital with toxidromes. Death from club drug overdose is more likely to be associated with suicidal intent, related risky behaviour and trauma, as well as the inherent toxicity of the drug itself. Although many teenagers are concerned about 'drink spiking' with club drugs, the most common agent causing drink spiking incidents is ethanol.

Methaemoglobinaemia associated with the use of cocaine and volatile nitrites as recreational drugs: a review

Methaemoglobinaemia can cause significant tissue hypoxia, leading to severe, potentially life-threatening clinical features and/or death. Over recent years there have been increasing reports of methaemoglobinaemia related to recreational drug use. There have been 25 articles describing methaemoglobinaemia related to recreational use of volatile nitrites (poppers) and more recently, four reports of methaemoglobinaemia in association with recreational cocaine use. In this article we discuss the mechanisms by which methaemoglobinaemia occurs in relation to the use of both volatile nitrites and cocaine, and summarize the published cases of recreational drug-related methaemoglobinaemia. The volatile nitrites can cause methaemoglobinaemia directly through their activity as oxidizing agents. However, with cocaine, methaemoglobinaemia is related to adulterants such as local anaesthetics or phenacetin, rather than to the cocaine itself. Clinicians managing patients with acute recreational drug toxicity should be aware of the potential for methaemoglobinaemia in these patients, particularly in patients with cyanosis or unexplained low oxygen saturations on pulse oximetry, and ensure that appropriate and timely management is provided, including, where appropriate, the use of methylthioninium chloride (methylene blue).

Laboratory assessment of oxygenation in methemoglobinemia

BACKGROUND

This case conference reviews laboratory methods for assessing oxygenation status: arterial blood gases, pulse oximetry, and CO-oximetry. Caveats of these measurements are discussed in the context of two methemoglobinemia cases.

CASES

Case 1 is a woman who presented with increased shortness of breath, productive cough, chest pain, nausea, fever, and cyanosis. CO-oximetry indicated a carboxyhemoglobin (COHb) fraction of 24.9%. She was unresponsive to O(2) therapy, and no source of carbon monoxide could be noted. Case 2 is a man who presented with syncope, chest tightness, and signs of cyanosis. His arterial blood was dark brown, and CO-oximetry showed a methemoglobin (MetHb) fraction of 23%.

ISSUES

Oxygen saturation (So(2)) can be measured by three approaches that are often used interchangeably, although the measured systems are quite different. Pulse oximetry is a noninvasive, spectrophotometric method to determine arterial oxygen saturation (S(a)O(2)). CO-oximetry is a more complex and reliable method that measures the concentration of hemoglobin derivatives in the blood from which various quantities such as hemoglobin derivative fractions, total hemoglobin, and saturation are calculated. Blood gas instruments calculate the estimated O(2) saturation from empirical equations using pH and Po(2) values. In most patients, the results from these methods will be virtually identical, but in cases of increased dyshemoglobin fractions, including methemoglobinemia, it is crucial that the distinctions and limitations of these methods be understood.

CONCLUSIONS

So(2) calculated from pH and Po(2) should be interpreted with caution as the algorithms used assume normal O(2) affinity, normal 2,3-diphosphoglycerate concentrations, and no dyshemoglobins or hemoglobinopathies. CO-oximeter reports should include the dyshemoglobin fractions in addition to the oxyhemoglobin fraction. In cases of increased MetHb fraction, pulse oximeter values trend toward 85%, underestimating the actual oxygen saturation. Hemoglobin M variants may yield normal MetHb and increased COHb or sulfhemoglobin fractions measured by CO-oximetry.

The origin of "Saturday night palsy"?

THE TERM Saturday night palsy has become synonymous with radial nerve compression in the arm resulting from direct pressure against a firm object. It typically follows deep sleep on the arm, often after alcohol intoxication. The commonly accepted origin of the phrase is the association of Saturday night with carousing. We offer an alternate explanation: we think that the term Saturday night palsy was introduced mistakenly as a simplification of saturnine palsy (much like the way the word palsy was shortened from paralysis). Saturnine palsy, which is a relatively common complication of lead poisoning, has the same clinical presentation of radial nerve compression, and Saturday night palsy even sounds like saturnine palsy. Moreover, Saturday, lead, carousing, and alcohol are associated with each other through their connection to Saturn, the Roman god of agriculture, which encourages the association of the two syndromes with one another.