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Roghani SH, Arif MA, Niazi R, Mansoor S. Naphthalene or Mothball Poisoning Manifesting as Acute Intravascular Hemolysis and Acquired Methemoglobinemia. Cureus 2024; 16:e64325. [PMID: 39131009 PMCID: PMC11316454 DOI: 10.7759/cureus.64325] [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: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
Naphthalene is a major component of mothballs. Domestically, people use mothballs as an insect repellent. Its deliberate or accidental ingestion leading to toxicity has rarely been reported in the medical literature, despite its widespread use in Southeast Asia. Naphthalene, or mothball poisoning, is a rare but serious condition that can have detrimental effects on human health. This case report presents the clinical course of a 22-year-old male who ingested six naphthalene balls, resulting in severe symptoms including fever, abdominal pain, vomiting, jaundice, and dark-colored urine. Laboratory investigations were suggestive of acute intravascular hemolysis and methemoglobinemia. The patient was promptly admitted to the hospital, where he received supportive care along with specific treatment in the form of red blood cell transfusions, intravenous methylene blue, ascorbic acid, and N-acetyl cysteine. Through this report, the importance of raising awareness about the dangers of naphthalene poisoning and the specific treatment options available is highlighted.
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Affiliation(s)
| | - Mohammad Ali Arif
- Internal Medicine, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Rauf Niazi
- Internal Medicine, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Sadia Mansoor
- Internal Medicine, Pakistan Institute of Medical Sciences, Islamabad, PAK
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2
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Karaçoban G, Gurbanov A, Özen H, Gün E, Çakmaklı HF, Kendirli T. Successful Treatment with Ascorbic Acid in a Case of Methemoglobinemia Due to Glucose-6-Phosphate Dehydrogenase Deficiency. Turk Arch Pediatr 2024; 59:112-113. [PMID: 38454269 PMCID: PMC10837515 DOI: 10.5152/turkarchpediatr.2024.23112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/12/2023] [Indexed: 03/09/2024]
Abstract
Cite this article as: Karaçoban G, Gurbanov A, Özen H, Gün E, Çakmaklı HF, Kendirli T. Successful treatment with ascorbic acid in a case of methemoglobinemia due to glucose-6-phosphate dehydrogenase deficiency. Turk Arch Pediatr. 2024;59(1):112-113.
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Affiliation(s)
- Gülçin Karaçoban
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Anar Gurbanov
- Department of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hasan Özen
- Department of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emrah Gün
- Department of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hasan Fatih Çakmaklı
- Department of Pediatric Hematology and Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Department of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
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3
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Discenza LN, Balog A, Huang C, Moore R, Ranasinghe A, Lin TA, D'Arienzo C, Olah TV. Quantification of Linrodostat and its metabolites: Overcoming bioanalytical challenges in support of a discovery Indoleamine 2,3 dioxygenase program. J Chromatogr B Analyt Technol Biomed Life Sci 2022; 1207:123305. [PMID: 35839627 DOI: 10.1016/j.jchromb.2022.123305] [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: 12/14/2021] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
BMS-986205 (Linrodostat) is a small molecule inhibitor of Indoleamine 2, 3 dioxygenase (IDO) that is currently being evaluated in clinical trials for the oral treatment of advanced cancer. Initially, there were concerns regarding possible toxicity following administration, since BMS-986205 undergoes metabolism to form 4-chloroaniline. However, it was later determined that the downstream metabolites of 4-chloroaniline might be a greater concern. To evaluate the potential toxicity of these metabolites, a sensitive LC-MS/MS analytical method was needed to quantify both the parent compound and multiple metabolites. This presented a challenge since the method required the analysis of multiple analytes while still retaining the analytical sensitivity required to support studies. By utilizing a multi-function analytical method, we were able to quantify the necessary analytes using a complex LC-MS/MS-based method including the application of both negative and positive electrospray ionization.
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Affiliation(s)
- Lorell N Discenza
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA.
| | - Aaron Balog
- Discovery Oncology, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA
| | - Christine Huang
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA
| | - Robin Moore
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA
| | - Asoka Ranasinghe
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA
| | - Tai-An Lin
- Discovery Oncology, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA
| | - Celia D'Arienzo
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA
| | - Timothy V Olah
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb Company, Route 206 & Provinceline Road, Princeton, NJ 08543, USA
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4
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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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5
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Laslett N, Hibbs J, Hallett M, Ghaneie A, Zemba-Palko V. Glucose-6-Phosphate Dehydrogenase Deficiency-Associated Hemolytic Anemia and Methemoglobinemia in a Patient Treated With Hydroxychloroquine in the Era of COVID-19. Cureus 2021; 13:e15232. [PMID: 34178542 PMCID: PMC8223605 DOI: 10.7759/cureus.15232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/13/2022] Open
Abstract
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymatic disorder of red blood cells worldwide. The severity of hemolytic anemia varies among individuals with G6PD deficiency, depending on the genetic variant in the G6PD gene; this makes the diagnosis of the condition more challenging in some cases. In this report, we present a case of severe hemolytic anemia and methemoglobinemia in a patient with G6PD deficiency who had been exposed to hydroxychloroquine prescribed for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. To the best of our knowledge and based on a literature search, this is one of the first case reports in the literature about hemolytic crisis and methemoglobinemia in a patient with critical illness due to severe coronavirus disease 2019 (COVID-19) who was exposed to hydroxychloroquine. It is critical for physicians and caregivers to recognize the effects of oxidative stressors such as hydroxychloroquine, particularly in this era of the COVID-19 pandemic and in regions with a high prevalence of G6PD deficiency, for the appropriate management of this unique subset of patients.
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Affiliation(s)
- Nicole Laslett
- Hematology/Oncology , Lankenau Medical Center, Wynnewood, USA
| | - Julianne Hibbs
- Hematology and Medical Oncology, Alliance Cancer Specialists, Langhorne, USA
| | - Max Hallett
- Internal Medicine, Catholic Medical Center, Manchester, USA
| | - Arezoo Ghaneie
- Hematology and Medical Oncology, Lankenau Medical Center, Wynnewood, USA
| | - Vlasta Zemba-Palko
- Pathology and Laboratory Medicine, Lankenau Medical Center, Wynnewood, USA
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Palmer K, Dick J, French W, Floro L, Ford M. Methemoglobinemia in Patient with G6PD Deficiency and SARS-CoV-2 Infection. Emerg Infect Dis 2020; 26. [PMID: 32579876 PMCID: PMC7454064 DOI: 10.3201/eid2609.202353] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We report a case of intravascular hemolysis and methemoglobinemia, precipitated by severe acute respiratory syndrome coronavirus 2 infection, in a patient with undiagnosed glucose-6-phosphate dehydrogenase deficiency. Clinicians should be aware of this complication of coronavirus disease as a cause of error in pulse oximetry and a potential risk for drug-induced hemolysis.
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7
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Alzaki AA, Alalawi NH. Diabetic Ketoacidosis Revealing Severe Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD-D) Deficiency with Methemoglobinemia: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:726-729. [PMID: 31113928 PMCID: PMC6543950 DOI: 10.12659/ajcr.915007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Patient: Male, 17 Final Diagnosis: Diabetic ketoacidosis revealing severe G6PD deficiency with methemoglobinemia Symptoms: Jaundice Medication: — Clinical Procedure: None Specialty: Hematology
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Affiliation(s)
- Alaa A Alzaki
- Department of Internal Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Noor H Alalawi
- Department of Internal Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Wan Azman WN, Omar J, Koon TS, Tuan Ismail TS. Hemolyzed Specimens: Major Challenge for Identifying and Rejecting Specimens in Clinical Laboratories. Oman Med J 2019; 34:94-98. [PMID: 30918601 PMCID: PMC6425048 DOI: 10.5001/omj.2019.19] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pre-analytical quality in clinical chemistry testing is as important as analytical and post-analytical quality. The most prevalent pre-analytical interference and a major source of error producing unreliable laboratory test results is hemolysis of blood samples. In vitro hemolysis may be due to the blood withdrawal technique or sample handling whereas in vivo hemolysis can originate from acquired, hereditary, or iatrogenic conditions and is not technique dependent. Interpreting in vivo or in vitro hemolysis requires clinicians to supply reliable clinical history and findings. Even then, to reject or release the result with interpretation is still under debate. Thus, hemolyzed specimens are a serious pre-analytical problem calling for well-designed and strictly implemented laboratory guidelines. The aim of this non-systematic review (addressed to healthcare professionals) was to highlight the challenges in identifying and rejecting hemolysis specimens.
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Affiliation(s)
- Wan Norlina Wan Azman
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
| | - Julia Omar
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
| | - Tan Say Koon
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
| | - Tuan Salwani Tuan Ismail
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
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9
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Late-Life Presentation of Unsuspected G6PD Deficiency. Case Rep Crit Care 2018; 2018:8198565. [PMID: 30356359 PMCID: PMC6176296 DOI: 10.1155/2018/8198565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/09/2018] [Indexed: 11/17/2022] Open
Abstract
Deficiency of glucose-6-phosphate dehydrogenase (G6PD) is the commonest enzyme deficiency in humans with a wide range of possible clinical manifestations depending on the specific genetic variant in each case. Here we present the case of an 86-year-old male of African descent who acutely developed symptoms of G6PD deficiency immediately after he received methylene blue for treating methemoglobinemia. The contrast between a low SO2 on pulse oximetry and a normal arterial gas sampling raised the possibility of methemoglobinemia. The patient was treated with packed red blood cells and folic acid, and a rapid clinical improvement followed by normalization of the red blood cell count ensued. In view of the patient's advanced age, the lack of a history of similar episodes in the past, and the normal laboratory results during the hemolytic crisis, this case remained a diagnostic challenge for over three months, when a follow-up measure of G6DP activity eventually confirmed the diagnosis. A latent deficiency of G6PD may become clinically manifest under the appropriate triggering conditions even in elderly patients and in the absence of past or current clinical and laboratory evidence of G6PD deficiency.
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10
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Volney G, Tatusov M, Yen AC, Karamyan N. Naphthalene Toxicity: Methemoglobinemia and Acute Intravascular Hemolysis. Cureus 2018; 10:e3147. [PMID: 30345203 PMCID: PMC6191007 DOI: 10.7759/cureus.3147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Naphthalene poisoning is a rare form of toxicity that may occur after ingestion, inhalation, or dermal exposure to naphthalene-containing compounds such as mothballs. Clinically, patients present with acute onset of dark brown urine, watery diarrhea, and non-bloody bilious vomiting 48-96 hours after exposure. Vital sign abnormalities include fever, tachycardia, hypotension, and persistent pulse oximetry readings of 84%-85% despite oxygen supplementation. Laboratory workup demonstrates hyperbilirubinemia with indirect predominance, hemolytic anemia, methemoglobinemia, and renal dysfunction. Treatment options include supportive care, red cell transfusion, ascorbic acid, methylene blue, and N-acetylcysteine. We present a case of naphthalene toxicity in a 20-year-old autistic male, who improved with supportive care, red blood cell transfusion, and ascorbic acid.
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Affiliation(s)
- Giselle Volney
- Internal Medicine, Ross University School of Medicine, Roseau, DMA
| | - Michael Tatusov
- Medicine/Trauma and Critical Care, University of Maryland School of Medicine, Baltimore, USA
| | - Andy C Yen
- Internal Medicine, Ross University School of Medicine, Baltimore, USA
| | - Nune Karamyan
- Internal Medicine, University of Maryland Prince George's Hospital Center, Cheverly, USA
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