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Demaret T, Bédard K, Soucy JF, Watkins D, Allard P, Levtova A, O'Brien A, Brunel-Guitton C, Rosenblatt DS, Mitchell GA. The MMACHC variant c.158T>C: Mild clinical and biochemical phenotypes and marked hydroxocobalamin response in cblC patients. Mol Genet Metab 2024; 142:108345. [PMID: 38387306 DOI: 10.1016/j.ymgme.2024.108345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024]
Abstract
Mutations in MMACHC cause cobalamin C disease (cblC, OMIM 277400), the commonest inborn error of vitamin B12 metabolism. In cblC, deficient activation of cobalamin results in methylcobalamin and adenosylcobalamin deficiency, elevating methylmalonic acid (MMA) and total plasma homocysteine (tHcy). We retrospectively reviewed the medical files of seven cblC patients: three compound heterozygotes for the MMACHC (NM_015506.3) missense variant c.158T>C p.(Leu53Pro) in trans with the common pathogenic mutation c.271dupA (p.(Arg91Lysfs*14), "compounds"), and four c.271dupA homozygotes ("homozygotes"). Compounds receiving hydroxocobalamin intramuscular injection monotherapy had age-appropriate psychomotor performance and normal ophthalmological examinations. In contrast, c.271dupA homozygotes showed marked psychomotor retardation, retinopathy and feeding problems despite penta-therapy (hydroxocobalamin, betaine, folinic acid, l-carnitine and acetylsalicylic acid). Pretreatment levels of plasma and urine MMA and tHcy were higher in c.271dupA homozygotes than in compounds. Under treatment, levels of the compounds approached or entered the reference range but not those of c.271dupA homozygotes (tHcy: compounds 9.8-32.9 μM, homozygotes 41.6-106.8 (normal (N) < 14); plasma MMA: compounds 0.14-0.81 μM, homozygotes, 10.4-61 (N < 0.4); urine MMA: compounds 1.75-48 mmol/mol creatinine, homozygotes 143-493 (N < 10)). Patient skin fibroblasts all had low cobalamin uptake, but this was milder in compound cells. Also, the distribution pattern of cobalamin species was qualitatively different between cells from compounds and from homozygotes. Compared to the classic cblC phenotype presented by c.271dupA homozygous patients, c.[158T>C];[271dupA] compounds had mild clinical and biochemical phenotypes and responded strikingly to hydroxocobalamin monotherapy.
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Affiliation(s)
- Tanguy Demaret
- Medical Genetics Division, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada; Centre de Génétique Humaine, Institut de Pathologie et Génétique, Gosselies, Belgium
| | - Karine Bédard
- Medical Genetics Division, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada; Laboratoire de Diagnostic Moléculaire, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Département de Pathologie et Biologie Cellulaire, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Jean-François Soucy
- Medical Genetics Division, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - David Watkins
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada; Department of Medical Genetics, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pierre Allard
- Medical Genetics Division, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada; Department of Biochemistry, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Alina Levtova
- Service de Médecine Génique, Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Alan O'Brien
- Service de Médecine Génique, Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Catherine Brunel-Guitton
- Medical Genetics Division, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada; Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - David S Rosenblatt
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada; Department of Medical Genetics, McGill University Health Centre, Montreal, Quebec, Canada
| | - Grant A Mitchell
- Medical Genetics Division, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada.
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Goodman D, Davidson C. Veinous Staining and Chromaturia associated with Hydroxocobalamin Infusion. BMJ Case Rep 2024; 17:e259749. [PMID: 38649239 PMCID: PMC11043731 DOI: 10.1136/bcr-2024-259749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Affiliation(s)
- Dáire Goodman
- Plastic & Reconstructive Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Plastic & Reconstructive Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Claire Davidson
- Plastic & Reconstructive Surgery, St Vincent's University Hospital, Dublin, Ireland
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Wedemire C, Samavat H, Newkirk M, Parker A. Treatment of refractory shock with vitamin B 12 : A narrative review. Nutr Clin Pract 2024; 39:356-365. [PMID: 38030578 DOI: 10.1002/ncp.11095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
High-dose vitamin B12 is a potential treatment for patients with vasodilatory shock that is refractory to other therapies. Vasodilatory shock is characterized by low blood pressure and low systemic vascular resistance. Nitric oxide and hydrogen sulfide, two potential targets of high-dose vitamin B12 given as hydroxocobalamin, facilitate this syndrome. This review explores the relationship between high-dose vitamin B12 and hemodynamic outcomes in adults with vasodilatory shock and provides an update on the literature since a 2019 review on this topic. A literature search of studies published in the past 5 years was conducted in the CINAHL, PubMed, Cochrane, and EMBASE databases in May 2023. After assessing for eligibility, eight studies met this review's inclusion criteria. Seven of the eight studies reported decreased vasopressor requirements for part or all of the study samples after receiving a hydroxocobalamin infusion. However, not all patients responded to hydroxocobalamin. These findings are limited by patient selection and differences in the timing of vasopressor requirement and blood pressure outcome assessments. The current evidence is promising as to whether vitamin B12 , given as a hydroxocobalamin infusion, may improve hemodynamic outcomes in vasodilatory shock, but the evidence is of low quality. The use of hydroxocobalamin to treat refractory, vasodilatory shock remains investigative. Larger randomized controlled trials are required to elucidate the role of vitamin B12 in treating refractory, vasodilatory shock, including in conjunction with other alternative therapies such as methylene blue and corticosteroids.
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Affiliation(s)
- Courtney Wedemire
- Department of Dietitian Services, Abbotsford Regional Hospital, Abbotsford, British Columbia, Canada
| | - Hamed Samavat
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
| | - Melanie Newkirk
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
| | - Anna Parker
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
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Pai SL, Torp KD, Insignares VC, DeMaria S, Giordano CR, Logvinov II, Li Z, Chadha R, Aniskevich S. Use of hydroxocobalamin to treat intraoperative vasoplegic syndrome refractory to vasopressors and methylene blue during liver transplantation. Clin Transplant 2024; 38:e15271. [PMID: 38485687 DOI: 10.1111/ctr.15271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/16/2024] [Accepted: 02/11/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION For patients with catecholamine-resistant vasoplegic syndrome (VS) during liver transplantation (LT), treatment with methylene blue (MB) and/or hydroxocobalamin (B12) has been an acceptable therapy. However, data on the effectiveness of B12 is limited to case reports and case series. METHODS We retrospectively reviewed records of patients undergoing LT from January 2016 through March 2022. We identified patients with VS treated with vasopressors and MB, and abstracted hemodynamic parameters, vasopressor requirements, and B12 administration from the records. The primary aim was to describe the treatment efficacy of B12 for VS refractory to vasopressors and MB, measured as no vasopressor requirement at the conclusion of the surgery. RESULTS One hundred one patients received intraoperative VS treatment. For the 35 (34.7%) patients with successful VS treatment, 14 received MB only and 21 received both MB and B12. Of the 21 patients with VS resolution after receiving both MB and B12, 17 (89.5%) showed immediate, but transient, hemodynamic improvements at the time of MB administration and later showed sustained response to B12. CONCLUSION Immediate but transient hemodynamic response to MB in VS patients during LT supports the diagnosis of VS and should prompt B12 administration for sustained treatment response.
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Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Klaus D Torp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Vianca C Insignares
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Chris R Giordano
- Department of Anesthesiology, University of Florida Health, Gainesville, Florida, USA
| | - Ilana I Logvinov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Zhuo Li
- Department of Quantitative Health Science, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Stephen Aniskevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Hardin J, Galust H, Clark RF, Ly B, Suhandynata RT. Spectrophotometric analysis of purple urine secondary to methylene blue and hydroxocobalamin co-administration. J Nephrol 2024; 37:491-494. [PMID: 37644365 PMCID: PMC11043099 DOI: 10.1007/s40620-023-01769-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The development of purple urine after methylene blue (methylthioninium chloride) and hydroxocobalamin co-administration is a rare clinical entity that has not been fully elucidated. A 47-year-old male presented to the emergency department with hypotension, cyanosis, and depressed mental status. The patient was noted to have profound peripheral and central cyanosis, as well as chocolate-colored arterial blood. He was treated with both methylene blue and hydroxocobalamin and developed purple urine for approximately 1 week. METHODS Color chromatography was performed by placing the patient's urine directly onto absorbent filter paper. Urine spectrophotometry was performed utilizing the NanoDrop One/One C UV-Vis Spectrophotometer. RESULTS Color chromatography of the urine was demonstrated clear separation of distinct red and blue phases. Urine spectrophotometry demonstrated near perfect overlap between the methylene blue + hydroxocobalamin absorbance spectrum and the patient's purple urine absorbance spectrum. CONCLUSION Purple urine secondary to methylene blue and hydroxocobalamin co-administration is due to combined urinary excretion of methylene blue (blue) and hydroxocobalamin (red), and not a novel purple metabolite. We anticipate that this is going to be an increasingly common clinical entity as the roles of both hydroxocobalamin and methylene blue expand from toxicologic antidotes to adjunct therapies for vasoplegia, poor cardiac output, and sepsis.
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Affiliation(s)
- Jeremy Hardin
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA.
- VA San Diego Healthcare System, San Diego, CA, USA.
- San Diego Division, California Poison Control System, San Diego, CA, USA.
| | - Henrik Galust
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- San Diego Division, California Poison Control System, San Diego, CA, USA
| | - Richard Franklin Clark
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA
- San Diego Division, California Poison Control System, San Diego, CA, USA
| | - Binh Ly
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA
| | - Raymond Theodore Suhandynata
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego Health, San Diego, CA, USA
- Department of Pathology, UC San Diego Health, San Diego, CA, USA
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Kamta J, Maynard K, Schult RF, Bell DE, Jones CMC, Acquisto NM. Evaluation of hydroxocobalamin use for the treatment of suspected cyanide toxicity secondary to smoke inhalation. Burns 2024; 50:157-166. [PMID: 37777459 DOI: 10.1016/j.burns.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 07/21/2023] [Accepted: 08/29/2023] [Indexed: 10/02/2023]
Abstract
Hydroxocobalamin is used for cyanide toxicity after smoke inhalation, but diagnosis is challenging. Retrospective studies have associated hydroxocobalamin with acute kidney injury (AKI). This is a retrospective analysis of patients receiving hydroxocobalamin for suspected cyanide toxicity. The primary outcome was the proportion of patients meeting predefined appropriate use criteria defined as ≥1 of the following: serum lactate ≥8 mmol/L, systolic blood pressure (SBP) <90 mmHg, new-onset seizure, cardiac arrest, or respiratory arrest. Secondary outcomes included incidence of AKI, pneumonia, resolution of initial neurologic symptoms, and in-hospital mortality. Forty-six patients were included; 35 (76%) met the primary outcome. All met appropriate use criteria due to respiratory arrest, 15 (43%) for lactate, 14 (40%) for SBP, 12 (34%) for cardiac arrest. AKI, pneumonia, and resolution of neurologic symptoms occurred in 30%, 21%, and 49% of patients, respectively. In-hospital mortality was higher in patients meeting criteria, 49% vs. 9% (95% CI 0.16, 0.64). When appropriate use criteria were modified to exclude respiratory arrest in a post-hoc analysis, differences were maintained, suggesting respiratory arrest alone is not a critical component to determine hydroxocobalamin administration. Predefined appropriate use criteria identify severely ill smoke inhalation victims and provides hydroxocobalamin treatment guidance.
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Affiliation(s)
- Jeff Kamta
- (Attribution) University of Rochester Medical Center, Department of Pharmacy, 601 Elmwood Ave, Box 638, Rochester, NY 14642, USA.
| | - Kaylee Maynard
- (Attribution) University of Rochester Medical Center, Department of Pharmacy, 601 Elmwood Ave, Box 638, Rochester, NY 14642, USA
| | - Rachel F Schult
- (Attribution) University of Rochester Medical Center, Department of Pharmacy, 601 Elmwood Ave, Box 638, Rochester, NY 14642, USA; University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Ave, Box 655, Rochester, NY 14642, USA
| | - Derek E Bell
- UR Medicine Plastic Surgery, 160 Sawgrass Dr., Suite 120, Rochester, NY 14620, USA
| | - Courtney M C Jones
- University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Ave, Box 655, Rochester, NY 14642, USA
| | - Nicole M Acquisto
- (Attribution) University of Rochester Medical Center, Department of Pharmacy, 601 Elmwood Ave, Box 638, Rochester, NY 14642, USA; University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Ave, Box 655, Rochester, NY 14642, USA
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7
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Pearce LL, Garrett KK, Bae Y, Frawley KL, Totoni SC, Peterson J. A Potential Antidote for Both Azide and Cyanide Poisonings. J Pharmacol Exp Ther 2024; 388:596-604. [PMID: 38182416 PMCID: PMC10801750 DOI: 10.1124/jpet.123.001719] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 01/07/2024] Open
Abstract
There do not appear to be any established therapeutics for treating azide poisoning at this time, and presently available antidotes to cyanide poisoning are far from ideal, being particularly impractical for use if multiple victims present. The cobalt (II/III) complex of the Schiff-base ligand trans-[14]-diene (5,7,7,12,14,14-hexamethyl-1,4,8,11-tetraazacyclotetradeca-4,11-diene (CoN4[14]) is shown to act as an effective antidote to both azide and cyanide toxicity in mice. Groups of animals challenged with an LD40 dose of NaCN (100 µmol/kg i.p.) exhibited significantly faster recovery from knockdown and fewer (zero) deaths if given CoN4[14] (50 μmol/kg i.p.) 2 minutes after the toxicant. Groups of animals challenged with an essentially lethal dose of NaCN (1.5 x LD50 = 150 µmol/kg i.p.) all survived if given the CoN4[14] (75 μmol/kg i.p.) 5 minutes before the toxicant dose. These data represent improved antidotal capability over the Food and Drug Administration-approved cobalt-based cyanide antidote hydroxocobalamin. Recovery of animals challenged sublethally with NaN3 (415 μmol/kg i.p.) was assessed employing a modified pole-climbing test. Mice given the CoN4[14] antidote (70 μg/kg i.p.) 5 minutes after the toxicant dose recovered twice as fast as the controls given no antidote. The interactions of cyanide and azide with CoN4[14] in vitro (buffered aqueous solutions) have been further investigated by a combination of spectroscopic approaches. The Co(II) form of the complex is able to bind two CN- anions while only binding a single N3 -, providing a reasonable explanation for the difference between their therapeutic abilities. SIGNIFICANCE STATEMENT: The Schiff-base complex CoN4[14] is shown to be an effective antidote to cyanide in mice, with improved therapeutic capabilities compared to the Food and Drug Administration-approved cobalt-containing hydroxocobalamin. CoN4[14] is also antidotal in mice toward azide poisoning, for which there is seemingly no approved therapy currently available. The activity toward cyanide involves a "redox-switching" mechanism that could be a common, but largely unrecognized, feature of all cobalt-based cyanide antidotes in use and under development.
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Affiliation(s)
- Linda L Pearce
- Department of Environmental and Occupational Health, Graduate School of Public Health, The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kimberly K Garrett
- Department of Environmental and Occupational Health, Graduate School of Public Health, The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yookyung Bae
- Department of Environmental and Occupational Health, Graduate School of Public Health, The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristin L Frawley
- Department of Environmental and Occupational Health, Graduate School of Public Health, The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samantha Carpenter Totoni
- Department of Environmental and Occupational Health, Graduate School of Public Health, The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jim Peterson
- Department of Environmental and Occupational Health, Graduate School of Public Health, The University of Pittsburgh, Pittsburgh, Pennsylvania
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Dyrud M, Niu J, Kohler L. Elevated methemoglobin levels in patients treated with high-dose hydroxocobalamin. Lab Med 2024; 55:50-55. [PMID: 37226975 DOI: 10.1093/labmed/lmad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess the impact of hydroxocobalamin (OHCbl) infusion on arterial blood gas and oximetry values in patients with vasoplegic syndrome. METHODS Blood samples collected from 95 patients receiving OHCbl infusion were assayed using the ABL90 FLEX Plus blood gas analyzer for the concentration of methemoglobin (MetHb), total hemoglobin (tHb), carboxyhemoglobin (COHb), arterial oxygen saturation (SaO2), arterial oxygen partial pressure (PaO2), and arterial carbon dioxide partial pressure (PaCO2). Interference of OHCbl on these variables was evaluated using the measured difference between the preinfusion and postinfusion samples. RESULTS Blood MetHb (%) measured after the infusion of OHCbl (5g) were significantly higher than the baseline levels, with a median of 4.8 (IQR, 3.0-6.5) versus 1.0 (IQR, 1.0-1.2) (P < .001). Blood COHb (%) increased from a median of 1.3 (IQR, 1.0-1.8) to 1.7 (IQR, 1.3-2.2) (P < .001) following the OHCbl infusion. No differences were seen in median levels of tHb, PaO2, PaCO2, and SaO2 between pre- and post-OHCbl treatment. CONCLUSION The presence of OHCbl in blood clearly interfered with the oximetry measurements of the hemoglobin component fractions by falsely increasing the levels of MetHb and COHb. Blood levels of MetHb and COHb cannot be reliably determined by the co-oximetry when OHCbl is known or suspected.
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Affiliation(s)
- Martinus Dyrud
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
| | - Jianli Niu
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
| | - Lisa Kohler
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
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Kumar N, Falkson SR, Lu SY, Dalia AA. Hydroxocobalamin Versus Methylene Blue: Still Unanswered and Needing a Change in Approach. J Cardiothorac Vasc Anesth 2024; 38:340-341. [PMID: 37973505 DOI: 10.1053/j.jvca.2023.08.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Nicolas Kumar
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Samuel R Falkson
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shu Yang Lu
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Khandekar DA, Seelhammer TG, Mara KC, Stephens EH, Wittwer ED, Wieruszewski PM. Intraoperative Versus Postoperative Hydroxocobalamin for Vasoplegic Shock in Cardiothoracic Surgery. J Cardiothorac Vasc Anesth 2023; 37:2538-2545. [PMID: 37723020 DOI: 10.1053/j.jvca.2023.08.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVES Hydroxocobalamin inhibits nitric oxide pathways contributing to vasoplegic shock in patients undergoing cardiopulmonary bypass (CPB). The objective of this study was to evaluate the effect of intraoperative versus postoperative application of hydroxocobalamin for vasoplegic shock in patients undergoing CPB. DESIGN This was a historic cohort study. SETTING The study was conducted at a quaternary academic cardiovascular surgery program. PARTICIPANTS Adults undergoing cardiac surgery using CPB were participants in the study. INTERVENTIONS Hydroxocobalamin (5 g) intravenously over 15 minutes. MEASUREMENTS AND MAIN RESULTS The treatment groups were assigned based on the receipt location of hydroxocobalamin (ie, intensive care unit [ICU] versus operating room [OR]). The primary outcome was vasopressor-free days in the first 14 days after CPB. Of the 112 patients included, 37 patients received hydroxocobalamin in the OR and 75 in the ICU. Patients in the OR group were younger than those in the ICU group (57.5 v 63.9 years, p = 0.007), with statistically similar American Society of Anesthesiologists scores. The mean CPB duration was 3.4 hours in the OR group and 2.9 hours in the ICU group (p = 0.09). In both groups, the norepinephrine-equivalent dose of vasopressors at hydroxocobalamin was 0.27 µg/kg/min. Days alive and free of vasopressors were not different between the OR and ICU groups (estimated difference 0.48 [95% CI -1.76-2.72], p = 0.67). The odds of postoperative renal failure, mesenteric ischemia, ICU, hospital length of stay, and in-hospital mortality were also similar between groups. CONCLUSIONS A difference in vasopressor-free days after CPB was not found between patients who received hydroxocobalamin intraoperatively versus postoperatively for vasoplegic shock.
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Affiliation(s)
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
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Scalais E, Geron C, Pierron C, Cardillo S, Schlesser V, Mataigne F, Borde P, Regal L. Would, early, versus late hydroxocobalamin dose intensification treatment, prevent cognitive decline, macular degeneration and ocular disease, in 5 patients with early-onset cblC deficiency? Mol Genet Metab 2023; 140:107681. [PMID: 37604084 DOI: 10.1016/j.ymgme.2023.107681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023]
Abstract
In early-onset (EO) cblC deficiency (MMACHC), hydroxocobalamin dose-intensification (OHCBL-DI) improved biochemical and clinical outcome. In mammals, Cobalamin is reduced, in a reaction mediated by MMACHC. Pathogenic variants in MMACHC disrupt the synthesis pathway of methyl-cobalamin (MetCbl) and 5'-deoxy-adenosyl-cobalamin (AdoCbl), cofactors for both methionine synthase (MS) and methyl-malonyl-CoA mutase (MCM) enzymes. In 5 patients (pts.), with EO cblC deficiency, biochemical and clinical responses were studied following OHCbl-DI (mean ± SD 6,5 ± 3,3 mg/kg/day), given early, before age 5 months (pts. 1, 2, 3 and 4) or lately, at age 5 years (pt. 5). In all pts., total homocysteine (tHcy), methyl-malonic acid (MMA) and Cob(III)alamin levels were measured. Follow-up was performed during 74/12 years (pts. 1, 2, 3), 33/12 years (pt. 4) and 34/12 years (pt. 5). OHCbl was delivered intravenously or subcutaneously. Mean ± SD serum Cob(III)alamin levels were 42,2 × 106 ± 28, 0 × 106 pg/ml (normal: 200-900 pg/ml). In all pts., biomarkers were well controlled. All pts., except pt. 5, who had poor vision, had central vision, mild to moderate nystagmus, and with peri-foveolar irregularity in pts. 1, 2 and 4, yet none had the classic bulls' eye maculopathy and retinal degeneration characteristic of pts. with EO cblC deficiency. Only pt. 5, had severe cognitive deficiency. Both visual and cognitive functions were better preserved with early than with late OHCBL-DI. OHCBL-DI is suggested to bypass MMACHC, subsequently to be rescued by methionine synthase reductase (MSR) and adenosyl-transferase (ATR) to obtain Cob(I)alamin resulting in improved cognitive and retinal function in pts. with EO cblC deficiency.
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Affiliation(s)
- Emmanuel Scalais
- Department of Pediatrics, Division of Pediatric Neurology, Centre Hospitalier de Luxembourg, Luxembourg.
| | - Christine Geron
- Department of Pediatrics, Neonatal Center, Pediatric Intensive Care, Centre Hospitalier de Luxembourg, Luxembourg
| | - Charlotte Pierron
- Department of Pediatrics, Neonatal Center, Pediatric Intensive Care, Centre Hospitalier de Luxembourg, Luxembourg
| | - Sandra Cardillo
- Service d'Ophtalmologie, Centre Hospitalier de Luxembourg, Luxembourg
| | - Vincent Schlesser
- Laboratoire de Chimie et Hématologie, Centre Hospitalier de Luxembourg, Luxembourg
| | - Frédéric Mataigne
- Service de Neuroradiologie, Centre Hospitalier de Luxembourg, Luxembourg
| | - Patricia Borde
- Service de Biochimie, Laboratoire National de Santé, Dudelange, Luxembourg
| | - Luc Regal
- Pediatric Neurology and Metabolism, UZ, VUB, Vrije Universiteit Brussels, Brussels, Belgium
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Christel H, Aubry SC, Florence T, Nora EB, Lisa W, Tomislav P, Frédéric L. Optimization of intravenous administration of hydroxocobalamin in pediatric emergencies - HYDROX-OPTIMIS study. Int Emerg Nurs 2023; 71:101353. [PMID: 37871551 DOI: 10.1016/j.ienj.2023.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/28/2023] [Accepted: 09/10/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Procedures to prepare and infuse intravenous drugs are poorly documented. OBJECTIVE To determinate the optimal mode of hydroxocobalamin administration in children in emergency care. METHODS We identified three modes of administration: (1) connect infusion tubing to the vial, start the infusion and interrupt it when the desired dose has been delivered; (2) remove from the vial the volume corresponding to the excessive dose and connect infusion tubing and (3) extract from the vial the required volume to be delivered and infuse directly. EXPERIMENTAL STUDY 25 nurses performed each of these three procedures for children weighting 15 and 30 kg. Speed and precision were primary end-points; ease, safety and drug economy were secondary end-points. RESULTS Mode 3 was the fastest (42[37-61] sec) followed by modes 1 and 2 (p < 0.05). Mode 3 was the most precise (100[100-100]%) followed by modes 1 and 2 (p = 0.001). Mode 3 was the easiest (10.0[9.0-10.0]) followed by modes 2 and 3 (p = 0.001). Modes 1 and 3 allowed administration of a second dose whereas mode 2 did not. CONCLUSION Taking the required volume from the vial and infuse directly was the fastest, the most precise, the easiest and most economical mode of administration. It should be recommended.
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Affiliation(s)
- Hilaire Christel
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Saint-Cast Aubry
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | | | - El Barrak Nora
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Weisslinger Lisa
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Petrovic Tomislav
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Lapostolle Frédéric
- SAMU 93 - UF Research-Teaching-Quality University Paris 13, Sorbonne Paris Cité, Inserm U942 Avicenne Hospital, 125, rue de Stalingrad, 93009 Bobigny, France.
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Paredes RM, Castaneda M, Mireles AA, Rodriguez D, Maddry J. Comparison of hydroxocobalamin with other resuscitative fluids in volume-controlled and uncontrolled hemorrhage models in swine ( Sus-scrofa ). J Trauma Acute Care Surg 2023; 95:S120-S128. [PMID: 37199527 PMCID: PMC10389457 DOI: 10.1097/ta.0000000000004049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Traumatic hemorrhage is the leading cause of preventable death in military environments. Treatment with resuscitative fluids and blood components is based on availability, thus, frequently unavailable in the prehospital setting, due to lack of resources and costs. Hydroxocobalamin (HOC), increases blood pressure via nitric oxide scavenging. We evaluated HOC as a resuscitation fluid, in two swine hemorrhage models. Our objectives were to (1) evaluate whether HOC treatment following hemorrhagic shock improves hemodynamic parameters and (2) determine whether those effects are comparable to whole blood (WB) and lactated ringers (LR). METHODS Yorkshire swine (S us scrofa ) (n = 72) were used in models of controlled hemorrhage (CH) (n = 36) and uncontrolled hemorrhage (UH) (n = 36). Randomized animals received treatment with 500 mL of either WB, LR, HOC (150 mg/kg), followed by a six-hour observation (n = 6 each group). Survival, hemodynamics, blood gases (ABGs) and chemistries were collected. Data reported as mean ± standard error of the mean and statistical analysis by ANOVA ( p < 0.05). RESULTS Blood loss for CH was 41% ± 0.02 versus 33% ± 0.07 for UH. For CH, HOC treatment maintained higher systolic blood pressure (sBP, mm Hg) compared with WB and LR (72 ± 1.1; 60 ± 0.8; 58 ± 1.6; respectively). Heart rate (HR), cardiac output (CO), Sp o2 and vascular resistance were comparable with WB and LR. The ABG values were comparable between HOC and WB. For UH, HOC treatment maintained sBP levels comparable to WB and higher than LR (70 ± 0.9; 73 ± 0.5; 56 ± 1.2). HR, CO, Sp o2 , and systemic vascular resistance were comparable between HOC and WB. Survival, hemodynamics, blood gases were comparable between HOC and WB. No survival differences were found between cohorts. CONCLUSION Hydroxocobalamin treatment improved hemodynamic parameters and Ca 2+ levels compared with LR and equivalent to WB, in both models. Hydroxocobalamin may be a viable alternative when WB is not available.
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Peñasco Martín Y, Fernández Rodríguez A, González Castro A. Red urine after hydroxycobalamin administration. Med Intensiva 2022; 46:234. [PMID: 35221236 DOI: 10.1016/j.medine.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Y Peñasco Martín
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain.
| | - A Fernández Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - A González Castro
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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Affiliation(s)
- Muhajir Mohamed
- Department of Medicine, Launceston General Hospital, Australia
- University of Tasmania, Launceston Clinical School, Launceston, Australia
| | - Joel Thio
- Department of Medicine, Launceston General Hospital, Australia
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Abstract
An 18-year-old female patient presented to the emergency department with non-specific neurological and gastrointestinal symptoms and was found to be pancytopenic. Her vitamin B12 level was low with a normal mean corpuscular volume and her full blood count 2 months previously had been within normal range. She reported heavy use of nitrous oxide over the previous 2 weeks and other investigations revealed no cause for her pancytopenia. Her pancytopenia resolved with discontinuation of nitrous oxide and vitamin B12 treatment. Heavy use of nitrous oxide should be considered as a cause of pancytopenia.
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Bebarta VS, Garrett N, Boudreau S, Castaneda M. Intravenous Hydroxocobalamin Versus Hextend Versus Control for Class III Hemorrhage Resuscitation in a Prehospital Swine Model. Mil Med 2018; 183:e721-e729. [PMID: 30500921 DOI: 10.1093/milmed/usy173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Indexed: 01/26/2023] Open
Abstract
Background Hydroxyethyl starch (Hextend) has been used for hemorrhagic shock resuscitation, however, hydroxyethyl starch may be associated with adverse outcomes. Objective To compare systolic blood pressure (sBP) in animals that had 30% of their blood volume removed and treated with intravenous hydroxocobalamin, hydroxyethyl starch, or no fluid. Methods Twenty-eight swine (45-55 kg) were anesthetized and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged 20 mL/kg over 20 minutes and then administered 150 mg/kg IV hydroxocobalamin in 180 mL saline, 500 mL hydroxyethyl starch, or no fluid and monitored for 60 minutes. Data were modeled using repeated measures multivariate analysis of variance. Results There were no significant differences before treatment. At 20 minutes after hemorrhage, there was no significant difference in mean sBP between treated groups, however, control animals displayed significantly lower mean sBP (p < 0.001). Mean arterial pressure and heart rate improved in the treated groups but not in the control group (p < 0.02). Prothrombin time was longer and platelet counts were lower in the Hextend group (p < 0.05). Moreover, thromboelastography analysis showed longer clotting (K) times (p < 0.05) for the hydroxyethyl starch-treated group. Conclusion Hydroxocobalamin restored blood pressure more effectively than no treatment and as effectively as hydroxyethyl starch but did not adversely affect coagulation.
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Affiliation(s)
- Vikhyat S Bebarta
- Department of Pharmacology, University of Colorado Denver, 12605 E. 16th Ave, Aurora, CO
| | - Normalynn Garrett
- CREST Research Program, Department of Emergency Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX
| | - Susan Boudreau
- CREST Research Program, Department of Emergency Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX
| | - Maria Castaneda
- CREST Research Program, Department of Emergency Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX
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Almannai M, Marom R, Divin K, Scaglia F, Sutton VR, Craigen WJ, Lee B, Burrage LC, Graham BH. Milder clinical and biochemical phenotypes associated with the c.482G>A (p.Arg161Gln) pathogenic variant in cobalamin C disease: Implications for management and screening. Mol Genet Metab 2017; 122:60-66. [PMID: 28693988 PMCID: PMC5612879 DOI: 10.1016/j.ymgme.2017.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/24/2017] [Accepted: 06/25/2017] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Cobalamin C disease is a multisystemic disease with variable manifestations and age of onset. Genotype-phenotype correlations are well-recognized in this disorder. Here, we present a large cohort of individuals with cobalamin C disease, several of whom are heterozygous for the c.482G>A pathogenic variant (p.Arg161Gln). We compared clinical characteristics of individuals with this pathogenic variant to those who do not have this variant. To our knowledge, this study represents the largest single cohort of individuals with the c.482G>A (p.Arg161Gln) pathogenic variant. METHODS A retrospective chart review of 27 individuals from 21 families with cobalamin C disease who are followed at our facility was conducted. RESULTS 13 individuals (48%) are compound heterozygous with the c.482G>A (p.Arg161Gln) on one allele and a second pathogenic variant on the other allele. Individuals with the c.482G>A (p.Arg161Gln) pathogenic variant had later onset of symptoms and easier metabolic control. Moreover, they had milder biochemical abnormalities at presentation which likely contributed to the observation that 4 individuals (31%) in this group were missed by newborn screening. CONCLUSION The c.482G>A (p.Arg161Gln) pathogenic variant is associated with milder disease. These individuals may not receive a timely diagnosis as they may not be identified on newborn screening or because of unrecognized, late onset symptoms. Despite the milder presentation, significant complications can occur, especially if treatment is delayed.
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Affiliation(s)
- Mohammed Almannai
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Ronit Marom
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Kristian Divin
- Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - William J Craigen
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA.
| | - Brett H Graham
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA.
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Versteeg JA, van der Nat GAM. [A woman with pink urine and a pink skin]. Ned Tijdschr Geneeskd 2017; 161:D1223. [PMID: 28421977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A 48-year-old woman with fire-related inhalation injury had pink urine and a pink skin. This was caused by hydroxocobalamin, which was used to treat cyanide poisoning.
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Affiliation(s)
- J A Versteeg
- Elisabeth-TweeSteden Ziekenhuis, afd. Intensive Care, Tilburg
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20
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Nguyen L, Afshari A, Kahn SA, McGrane S, Summitt B. Utility and outcomes of hydroxocobalamin use in smoke inhalation patients. Burns 2016; 43:107-113. [PMID: 27554631 DOI: 10.1016/j.burns.2016.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/22/2016] [Accepted: 07/31/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hydroxocobalamin has been available for use for suspected cyanide toxicity in smoke inhalation patients in the United States since 2006. Our study compares outcomes of patients who received hydroxocobalamin to historical controls who did not. METHODS In this retrospective review, patients administered hydroxocobalamin (2008-2014) were compared to historical controls (2002-2008). Patients <18 years, patients who received an alternate antidote, and patients without suspicion of smoke inhalation injury were excluded. Mortality was the primary outcome. Secondary outcomes evaluated were 7-day change in creatinine, culture-proven pneumonia, days on mechanical ventilation, ventilator- free days (VFD), ICU length of stay (ICU LOS), and hospital length of stay (HLOS). RESULTS A total of 138 patients in the hydroxocobalamin group and 135 in the control group were identified. Mortality rate was similar between both groups (29% vs. 28%, p=0.90). Hydroxocobalamin was associated with lower pneumonia rate (23% vs. 49%, p<0.01), less ventilator days (4 days vs. 7 days, p<0.01), and increased VFD (20 days vs. 11 days, p=0.01) compared to controls. Shorter ICU LOS (6 days vs. 10 days, p=0.03) and a trend toward lower HLOS (7 day vs. 11 days, p=0.06) were also found in patients who received hydroxocobalamin. CONCLUSIONS Routine administration was associated with lower rate of pneumonia, faster liberation from the ventilator, and reductions in intensive care unit stay. Burn centers should consider its empiric use in suspected smoke inhalation patients.
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Affiliation(s)
- Lyly Nguyen
- Vanderbilt University Medical Center, Department of Plastic Surgery, 1161 21st Avenue S, S2221, Nashville, TN 37232, United States; Morristown Medical Center, Department of Surgery, 100 Madison Ave, Morristown, NJ 07960, United States.
| | - Ashkan Afshari
- Vanderbilt University Medical Center, Department of Plastic Surgery, 1161 21st Avenue S, S2221, Nashville, TN 37232, United States; Unversity of South Carolina, Department of Surgery, 2 Medical Park Suite 306, Columbia, SC 29203, United States.
| | - Steven A Kahn
- University of South Alabama, Department of Surgery, Division of Trauma/Critical Care, 2451 Fillingim St., Mobile, AL 36617, United States.
| | - Stuart McGrane
- Vanderbilt University Medical Center, Department of Anesthesiology, Division of Critical Care, 1211 21st Ave S, 526 MAB, Nashville, TN 37212, United States.
| | - Blair Summitt
- Vanderbilt University Medical Center, Department of Plastic Surgery, 1161 21st Avenue S, S2221, Nashville, TN 37232, United States.
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Öztürk Z, Arhan E, Aydin K, Hirfanoğlu T, Tümer L, Okur I, Serdaroğlu A, Akbaş Y, Karaoğlu B. COBALAMIN C DEFICIENCY WITH INFANTILE SPASM AND CUTANEOUS FINDINGS: A UNIQUE CASE. Genet Couns 2016; 27:399-403. [PMID: 30204970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Cobalamin C (CbIC) deficiency is a rare disorder of vitamin B12 metabolism which results from impaired conversion of both its active forms methylcobalamin and adenosylcobalamin. Early onset cblC typically presents in the first year of life with hypotonia, lethargy, seizures, microcephaly, hydrocephalus, developmental delay and other multisystem involvement including hematologic, ocular, renal, hepatic and cardiac symptoms. We report a case of a female infant with cblC deficiency who presented with seizures, developmental delay and hypopigmented cutaneous lesions. To our knowledge, the patient is the first diagnosed with cblC deficiency who had skin hypopigmentation.
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Gurkas E, Kartal A, Aydin K, Kucukçongar A, Dilber C, Ceylaner S. REVERSIBLE CLINICAL AND MAGNETIC RESONANCE IMAGING FINDINGS IN LATE-ONSET COBALAMIN C DEFECT. Genet Couns 2015; 26:425-430. [PMID: 26852513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Cobalamin C (Cbl C) disease is an inborn error of intracellular cobalamin metabolism. Two distinct clinical types are defined according to the age of onset. We describe an 8 year old girl with late-onset Cbl C disease presenting with neuropsychiatric symptoms. Mutation analysis revealed homozygous c.394C>T (p.R132X) mutation in the MMACHC gene. Serial magnetic resonance imaging (MRI) before and after the treatment are provided. MRI of the brain before treatment showed bilateral patchy focal hyperintensities in the white matter and cortical atrophy. After treatment with intramuscular hydroxycobalamin, oral folinic acid, oral betaine, normalization of MRI findings can be achieved in addition to clinical improvement. We present this case to draw attention to the reversibility of clinical and MRI findings in the late onset Cbl C disease after treatment.
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Trakadis YJ, Alfares A, Bodamer OA, Buyukavci M, Christodoulou J, Connor P, Glamuzina E, Gonzalez-Fernandez F, Bibi H, Echenne B, Manoli I, Mitchell J, Nordwall M, Prasad C, Scaglia F, Schiff M, Schrewe B, Touati G, Tchan MC, Varet B, Venditti CP, Zafeiriou D, Rupar CA, Rosenblatt DS, Watkins D, Braverman N. Update on transcobalamin deficiency: clinical presentation, treatment and outcome. J Inherit Metab Dis 2014; 37:461-73. [PMID: 24305960 DOI: 10.1007/s10545-013-9664-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 11/13/2013] [Accepted: 11/14/2013] [Indexed: 10/25/2022]
Abstract
Transcobalamin (TC) transports cobalamin from blood into cells. TC deficiency is a rare autosomal recessive disorder usually presenting in early infancy with failure to thrive, weakness, diarrhoea, pallor, anemia, and pancytopenia or agammaglobulinemia. It can sometimes resemble neonatal leukemia or severe combined immunodeficiency disease. Diagnosis of TC deficiency is suspected based on megaloblastic anemia, elevation of total plasma homocysteine, and blood or urine methylmalonic acid. It is confirmed by studying the synthesis of TC in cultured fibroblasts, or by molecular analysis of the TCN2 gene. TC deficiency is treatable with supplemental cobalamin, but the optimal type, route and frequency of cobalamin administration and long term patient outcomes are unknown. Here we present a series of 30 patients with TC deficiency, including an update on multiple previously published patients, in order to evaluate the different treatment strategies and provide information about long term outcome. Based on the data presented, current practice appears to favour treatment of individuals with TC deficiency by intramuscular injections of hydroxy- or cyanocobalamin. In most cases presented, at least weekly injections (1 mg IM) were necessary to ensure optimal treatment. Most centres adjusted the treatment regimen based on monitoring CBC, total plasma homocysteine, plasma and urine methylmalonic acid, as well as, clinical status. Finally, continuing IM treatment into adulthood appears to be beneficial.
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Affiliation(s)
- Y J Trakadis
- Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada,
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Cisse FA, Bah H, Konate F, Camara N, Camara MI, Conde K, Kassory IFB, Sanogo A, Diakhate I, Cisse A. [Neurological disorders related to vitamin B12 deficiency in prisons in Guinea: a 22-case study]. Bull Soc Pathol Exot 2013; 106:156-159. [PMID: 23793871 DOI: 10.1007/s13149-013-0296-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 04/30/2013] [Indexed: 06/02/2023]
Abstract
Neurological disorders related to vitamin B12 deficiency are common in prisons of tropical Africa. We collected 22 cases (20 men and 2 women). They all showed vitamin B12 deficiency associated with neurological signs that were represented by sclerosis combined with bone marrow (n = 9), peripheral neuropathy (n = 6), cerebellar syndrome (n = 2), a pyramidal syndrome of the lower limbs (n = 4) and optic neuropathy (n = 1). Laboratory tests showed a mean hemoglobin concentration of 7.2 ± 1.5 g/dl, mean 104 ± 28 fl, macrocytic anemia in 10 patients. Biermer's disease was identified in 9 patients, 3 patients showed the syndrome of non dissociation of vitamin B12, a gastrectomy in 2 patients and no etiology was identified in 8 patients.
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Affiliation(s)
- F A Cisse
- Service de neurologie, CHU Conakry, Conakry, République de Guinée
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De La Calzada-Jeanlouie M, Coombs J, Shaukat N, Olsen D. Utility of sodium thiosulfate in acute cyanide toxicity. Ann Emerg Med 2013; 61:124-5. [PMID: 23260693 DOI: 10.1016/j.annemergmed.2012.07.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 07/13/2012] [Accepted: 07/13/2012] [Indexed: 11/18/2022]
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26
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Liu YP, Yang YL. [Advances in the clinical and laboratory studies on methylmalonic aciduria combined with homocysteinemia type cblC]. Zhonghua Er Ke Za Zhi 2013; 51:313-316. [PMID: 23927810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Affiliation(s)
- Neal Larkman
- Harrogate District General Hospital, Radiology, Harrogate HG2 7SX, UK.
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Vilibić M, Jukić V, Vidović A, Brecić P. Cobalamin deficiency manifested with seizures, mood oscillations, psychotic features and reversible dementia in the absence of typical neurologic and hematologic signs and symptoms: a case report. Coll Antropol 2013; 37:317-319. [PMID: 23697293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Cobalamin deficiency is associated with a wide spectrum of hematologic, neurologic, gastroenterologic and psychiatric disorders or symptoms. We report a case of a 50-year-old man with complex partial seizures with secondary generalization, mood oscillations and psychotic symptoms alternating with confusion and reversible dementia secondary to cobalamin deficiency in the absence of typical neurologic and/or hematologic symptoms and signs. Exclusion of epilepsy, acute, atrophic or expansive lesion of central nervous system and usual etiology associated with reversible dementia (infectious diseases, an endocrine etiology and deficiency of vitamins other than cobalamin); finding of cobalamin deficiency only and complete neuropsychiatric recovery after substitution, confirmed etiology. Typical and atypical psychiatric manifestations due to cobalamin deficiency that precede neurologic and/or hematologic signs and symptoms can recover completely after adequate replacement therapy.
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Affiliation(s)
- Maja Vilibić
- University of Zagreb, "Vrapce" University Psychiatric Hospital, Department of Biological Psychiatry and Psychogeriatry, Zagreb, Croatia.
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Huang Z, Han LS, Ye J, Qiu WJ, Zhang HW, Gao XL, Wang Y, Ji WJ, Li XY, Gu XF. [Outcomes of patients with combined methylmalonic acidemia and homocystinuria after treatment]. Zhonghua Er Ke Za Zhi 2013; 51:194-198. [PMID: 23751581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Combined methylmalonic acidemia with homocystinuria is a common form of methylmalonic acidemia in China. Patients with this disease can progress to death without timely and effective treatment. This study aimed to analyze the treatment outcomes of patients with combined methylmalonic acidemia and homocystinuria. METHOD From September 2004 to April 2012, 58 patients with combined methylmalonic acidemia and homocystinuria (34 males and 24 females) were diagnosed and treated in our hospital. Fifty cases were from clinical patients including 42 early-onset cases and 8 late-onset cases. Their age when they were diagnosed ranged from 18 days to 30.8 years. The other 8 cases were from newborn screening. All the patients were treated with vitamin B12, betaine, folic acid, vitamin B6, and L-carnitine. The physical and neuropsychological development, general laboratory tests, the levels of amino acids, acylcarnitines, and homocysteine in blood, and organic acids in urine were followed up. RESULT The follow-up period ranged from 1 month to 7.1 years. Three cases died (all were early-onset cases). In the other patients after treatment, the symptoms such as recurrent vomiting, seizures, lethargy, and poor feeding disappeared, muscle strength and muscle tension were improved, and general biochemical abnormalities such as anemia and metabolic acidosis were corrected. Among the surviving 55 cases, 49 had neurological impairments such as developmental delay and mental retardation. The median levels of blood propionylcarnitine and its ratio with acetylcarnitine, serum homocysteine, and urine methylmalonic acid were significantly decreased (P < 0.01), from 7.73 µmol/L (ranged from 1.5 to 18.61 µmol/L), 0.74 (ranged from 0.29 to 2.06), 97.3 µmol/L (ranged from 25.1 to 250 µmol/L) and 168.55 (ranged from 3.66 to 1032.82) before treatment to 2.74 µmol/L (ranged from 0.47 to 12.09 µmol/L), 0.16 (ranged from 0.03 to 0.62), 43.8 µmol/L (ranged from 17 to 97.8 µmol/L) and 6.81 (ranged from 0 to 95.43) after treatment, respectively. CONCLUSION Patients with combined methylmalonic acidemia and homocystinuria respond to a combined treatment consisting of supplementation of hydroxycobalamin, betaine, folic acid, vitamin B6 and L-carnitine with clinical and biochemical improvement. But the long-term outcomes are unsatisfactory, with neurological sequelae in most patients.
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Affiliation(s)
- Zhuo Huang
- Department of Pediatric Endocrinologic, Genetic and Metabolic Diseases, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
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Akıl M, Kaya A, Ustyol L, Aktar F, Akbayram S. Acute cyanide intoxication due to apricot seed ingestion. J Emerg Med 2012; 44:e285-6. [PMID: 23158573 DOI: 10.1016/j.jemermed.2012.05.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 02/03/2012] [Accepted: 05/08/2012] [Indexed: 11/18/2022]
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Abourazzak S, Chaouki S, Boubou M, Amrani M, Atmani S, Hida M. [Involuntary movements in infantile cobalamin deficiency appearing during treatment]. Presse Med 2012; 42:479-82. [PMID: 22922060 DOI: 10.1016/j.lpm.2012.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 06/03/2012] [Accepted: 06/07/2012] [Indexed: 11/19/2022] Open
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Bebarta VS, Pitotti RL, Dixon PS, Valtier S, Esquivel L, Bush A, Little CM. Hydroxocobalamin and epinephrine both improve survival in a swine model of cyanide-induced cardiac arrest. Ann Emerg Med 2012; 60:415-22. [PMID: 22424656 DOI: 10.1016/j.annemergmed.2012.02.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/19/2012] [Accepted: 02/01/2012] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To determine whether hydroxocobalamin will improve survival compared with epinephrine and saline solution controls in a model of cyanide-induced cardiac arrest. METHODS Forty-five swine (38 to 42 kg) were tracheally intubated, anesthetized, and central venous and arterial continuous cardiovascular monitoring catheters were inserted. Potassium cyanide was infused until cardiac arrest developed, defined as mean arterial pressure less than 30 mm Hg. Animals were treated with standardized mechanical chest compressions and were randomly assigned to receive one of 3 intravenous bolus therapies: hydroxocobalamin, epinephrine, or saline solution (control). All animals were monitored for 60 minutes after cardiac arrest. Additional epinephrine infusions were used in all arms of the study after return of spontaneous circulation for systolic blood pressure less than 90 mm Hg. A sample size of 15 animals per group was determined according to a power of 80%, a survival difference of 0.5, and an α of 0.05. Repeated-measure ANOVA was used to determine statistically significant changes between groups over time. RESULTS Baseline weight, time to arrest, and cyanide dose at cardiac arrest were similar in the 3 groups. Coronary perfusion pressures with chest compressions were greater than 15 mm Hg in both treatment groups indicating sufficient compression depth. Zero of 15 (95% confidence interval [CI] 0% to 25%) animals in the control group, 11 of 15 (73%; 95% CI 48% to 90%) in the hydroxocobalamin group, and 11 of 15 (73%; 95% CI 48% to 90%) in the epinephrine group survived to the conclusion of the study (P<.001). The proportion of animals with return of spontaneous circulation at 5 minutes was 4 of 15 (27%; 95% CI 10% to 52%), and that of return of spontaneous circulation at 10 minutes was 11 of 15 (73%; 95% CI 48% to 90%) in the 2 treatment groups. Additional epinephrine infusion after return of spontaneous circulation was administered for hypotension in 2 of 11 (18%; 95% CI 4% to 48%) hydroxocobalamin animals and in 11 of 11 (100%; 95% CI 70% to 100%) of the epinephrine animals (P<.001). At 60 minutes, serum lactate was significantly lower in the hydroxocobalamin group compared with the epinephrine group (4.9 [SD 2.2] versus 12.3 [SD 2.2] mmol/L), and the pH was significantly higher (7.34 [SD 0.03] versus 7.15 [SD 0.07]). Serial blood cyanide levels in the hydroxocobalamin group were also lower than that of the epinephrine group from cardiac arrest through the conclusion of the study. CONCLUSION Intravenous hydroxocobalamin and epinephrine both independently improved survival compared with saline solution control in our swine model of cyanide-induced cardiac arrest. Hydroxocobalamin improved mean arterial pressure and pH, decreased blood lactate and cyanide levels, and decreased the use of rescue epinephrine therapy compared with that in the epinephrine group.
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Kumthekar AA, Gidwani HV, Kumthekar AB. Metformin associated B12 deficiency. J Assoc Physicians India 2012; 60:58-60. [PMID: 22799121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
According to the ADA guidelines, metformin and lifestyle modifications are the first line therapies in the treatment of type 2 diabetes mellitus. Metformin does, however, cause vitamin B-12 malabsorption, which may increase the risk of developing vitamin B-12 deficiency--a clinically important and treatable condition. Here we report a case of 60 year old diabetic male presenting with clinical features of Vitamin B-12 deficiency on long term metformin therapy, which was confirmed on investigations. Patient showed symptomatic improvement with change in treatment.
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Brunel-Guitton C, Costa T, Mitchell GA, Lambert M. Treatment of cobalamin C (cblC) deficiency during pregnancy. J Inherit Metab Dis 2010; 33 Suppl 3:S409-12. [PMID: 20830523 DOI: 10.1007/s10545-010-9202-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 08/18/2010] [Accepted: 08/24/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the successful pregnancy of a woman with methylmalonic acidemia and hyperhomocysteinemia, cblC type [cobalamin C (cblC) deficiency] (MIM 277400). METHOD Retrospective chart review. RESULTS A 24-year-old woman presented at 14 weeks gestation with nausea, self-restricted protein diet, and weight loss. She had a past history of asymptomatic methylmalonic acidemia but had been lost to follow-up since the age of 15 years. Biochemical evaluation revealed combined methylmalonic acidemia and hyperhomocysteinemia. Complementation analysis confirmed cblC deficiency. One copy of the most common mutations in the MMACHC gene, c.271dupA, was identified. The women was treated from 15 weeks of gestation with a low protein diet (64 g/day) (1.1 g /kg of weight/day), L-carnitine (1 g per os 3 times daily to 3 g per os 3 times daily in the third trimester), aspirin (salicylic acid) 80 mg per day, folic acid 5 mg per day, and hydroxocobalamin 1 mg intramuscular every week to two times per week in the third trimester. The pregnancy was uneventful and the delivery at term. The newborn was healthy at delivery and at follow-up. CONCLUSION We report on the successful outcome of pregnancy in a treated woman with cblC disease. The pregnancy was uneventful for both fetus and mother with the delivery of a term healthy boy. There is a need for an international registry on the management and outcomes of pregnancy in women with inborn errors of metabolism.
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Affiliation(s)
- Catherine Brunel-Guitton
- Medical Genetics Division, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, Canada H3T 1C5
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Abstract
Hydroxocobalamin is a new antidote approved by the FDA for the treatment of cyanide poisoning. Our report describes a patient with cyanide poisoning who survived after treatment with hydroxocobalamin and complications we encountered with hemodialysis. A 34-year-old female presented to the emergency department after a syncopal event and seizures. Her systolic blood pressure was 75 mmHg, her QRS complex progressively widened, and pulses were lost. She was intubated and resuscitated with fluids, sodium bicarbonate for her QRS widening and vasopressors. Venous blood gas demonstrated a pH of 6.36 with an O2 saturation of 99%. Due to the acidemia with a normal pulse oximetry, simultaneous venous and arterial blood gases were obtained. Venous gas demonstrated a pH of 6.80 with a PO2 of 222 mmHg, an O2 saturation of 99%. The arterial blood gas showed a pH of 6.82, a PO2 518 mmHg, an O2 saturation of 100%. Cyanide was suspected and hydroxocobalamin and sodium thiosulfate were given. Within 40 min of hydroxocobalamin administration, vasopressors were discontinued. Initially, nephrology attempted dialysis for metabolic acidosis; however, the dialysis machine repeatedly shut down due to a “blood leak”. This was an unforeseen effect attributed to hydroxocobalamin. Cyanide level, drawn 20 min after the antidote was completed, was elevated at 22 mcg/dL. Her urinary thiocyanate level could not be analyzed due to an “interfering substance”. Hydroxocobalamin is an effective antidote. However, clinicians must be aware of its effects on hemodialysis machines which could delay the initiation of this important treatment modality in the severely acidemic patient.
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Affiliation(s)
- Mark Sutter
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.
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Hon KL, Cheung KL. Pink toes and red urine: what is this poison? Hong Kong Med J 2010; 16:411-412. [PMID: 20890011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Affiliation(s)
- K L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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Chan A, Balasubramanian M, Blackledge W, Mohammad OM, Alvarez L, Boss GR, Bigby TD. Cobinamide is superior to other treatments in a mouse model of cyanide poisoning. Clin Toxicol (Phila) 2010; 48:709-17. [PMID: 20704457 PMCID: PMC3119202 DOI: 10.3109/15563650.2010.505197] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
CONTEXT Cyanide is a rapidly acting cellular poison, primarily targeting cytochrome c oxidase, and is a common occupational and residential toxin, mostly via smoke inhalation. Cyanide is also a potential weapon of mass destruction, with recent credible threats of attacks focusing the need for better treatments, as current cyanide antidotes are limited and impractical for rapid deployment in mass casualty settings. OBJECTIVE We have used mouse models of cyanide poisoning to compare the efficacy of cobinamide (Cbi), the precursor to cobalamin (vitamin B(12)), to currently approved cyanide antidotes. Cbi has extremely high affinity for cyanide and substantial solubility in water. MATERIALS AND METHODS We studied Cbi in both an inhaled and intraperitoneal model of cyanide poisoning in mice. RESULTS We found Cbi more effective than hydroxocobalamin, sodium thiosulfate, sodium nitrite, and the combination of sodium thiosulfate-sodium nitrite in treating cyanide poisoning. Compared to hydroxocobalamin, Cbi was 3 and 11 times more potent in the intraperitoneal and inhalation models, respectively. Cobinamide sulfite (Cbi-SO(3)) was rapidly absorbed after intramuscular injection, and mice recovered from a lethal dose of cyanide even when given at a time when they had been apneic for over 2 min. In range-finding studies, Cbi-SO(3) at doses up to 2000 mg/kg exhibited no clinical toxicity. DISCUSSION AND CONCLUSION These studies demonstrate that Cbi is a highly effective cyanide antidote in mouse models, and suggest it could be used in a mass casualty setting, because it can be given rapidly as an intramuscular injection when administered as Cbi-SO(3). Based on these animal data Cbi-SO(3) appears to be an antidote worthy of further testing as a therapy for mass casualties.
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Affiliation(s)
- Adriano Chan
- Medicine Service, VA San Diego Healthcare, San Diego, CA 92161
- Department of Medicine, University of California, San Diego, CA 92093, USA
| | | | - William Blackledge
- Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Othman M. Mohammad
- Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Luis Alvarez
- Medicine Service, VA San Diego Healthcare, San Diego, CA 92161
- Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Gerry R. Boss
- Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Timothy D. Bigby
- Medicine Service, VA San Diego Healthcare, San Diego, CA 92161
- Department of Medicine, University of California, San Diego, CA 92093, USA
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Affiliation(s)
- Ben Hudson
- Department of Public Health and General Practice, University of Otago, Christchurch 8140, New Zealand.
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Torremadé Barreda J, Serrallach Orejas M, Valles-Ortega J, Franco Miranda E. [Treatment with hydroxocobalamin for cyanide poisoning: a rare cause of pseudohematuria]. Actas Urol Esp 2010; 34:124-126. [PMID: 20223147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Affiliation(s)
- Dong-Zong Hung
- Division of Toxicology, Trauma & Emergency Center, China Medical University Hospital, Taichung, Taiwan.
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Molloy A, Cawley N, Ali E, Connolly S, Tubridy N, Hutchinson M. A pernicious leucoencephalopathy. Ir Med J 2009; 102:292-294. [PMID: 19902649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Pernicious anaemia may manifest various neurological symptoms and signs ranging from the subtle to the dramatic. We describe a young man with cobalamin deficiency presenting with sensorimotor deficits, ataxia, dysarthria, mild cognitive deterioration and altered mood of insidious onset. The MRI brain findings were in keeping with a leucoencephalopathy without evidence of MRI changes in the spinal cord. This constellation of features has been reported rarely. His response to treatment as well as the marked improvement of the leucoencephalopathy on imaging suggests at least partial reversibility of the neurological deficits.
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Affiliation(s)
- A Molloy
- Department of Neurology, St Vincent's University Hospital, Elm Park, Dublin 4
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Pontes HAR, Neto NC, Ferreira KB, Fonseca FP, Vallinoto GM, Pontes FSC, Pinto DDS. Oral manifestations of vitamin B12 deficiency: a case report. J Can Dent Assoc 2009; 75:533-537. [PMID: 19744365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Megaloblastic anemias are a subgroup of macrocytic anemias, in which distinctive morphologic abnormalities occur in red cell precursors in bone marrow, namely megaloblastic erythropoiesis. Of the many causes of megaloblastic anemia, the most common are disorders resulting from cobalamin or folate deficiency. The clinical symptoms are weakness, fatigue, shortness of breath and neurologic abnormalities. The presence of oral signs and symptoms, including glossitis, angular cheilitis, recurrent oral ulcer, oral candidiasis, diffuse erythematous mucositis and pale oral mucosa offer the dentist an opportunity to participate in the diagnosis of this condition. Early diagnosis is important to prevent neurologic signs, which could be irreversible. The aim of this paper is to describe the oral changes in a patient with megaloblastic anemia caused by a dietary deficiency of cobalamin.
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Garcia BG, Cardoso MFP, de Faria O, Gomez RS, Mesquita RA. A case report of pernicious anemia and recurrent aphthous stomatitis. J Contemp Dent Pract 2009; 10:83-89. [PMID: 19279976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
AIM The aim of this report is to present the management of a patient with pernicious anemia afflicted with recurrent aphthous stomatitis (RAS). BACKGROUND RAS is one of the most common lesions of the oral mucosa. Although the exact etiology of RAS is still unknown different hematinic deficiencies have been proposed. CASE REPORT Painful recurrent ulcers covered with a grayish pseudomembrane surrounded by an erythematous margin were identified on the tongue and in the buccal mucosa of a 71-year-old woman. The patient also presented with depapilation of the tongue. The clinical diagnosis was RAS. Laboratory tests including a hemogram were ordered to determine existing levels of folic acid, iron, ferritin, and vitamins B2, B6, and B12. Levels of serum vitamin B12 and serum hemoglobin were low. The laboratory investigation also showed a medium corpuscular volume of 104.1 fl. A gastroduodenoscopy revealed no macroscopic abnormality. A gastric biopsy showed mucosal atrophy in the gastric corpus with evidence of intestinal metaplasia. Antibodies against an intrinsic factor were negative. The diagnosis pernicious anemia was made, with RAS caused by vitamin B12 malabsorption. Treatment consisted of the administration of 1.0 ml of hydroxocolabamin intramuscularly twice weekly over four weeks followed by 1.0 ml once weekly for four weeks. Clinical resolution was observed after two months. SUMMARY The association of RAS with vitamin B12 malabsorption is a rare event. However, along with conventional RAS clinical management, iron, folic acid, vitamin B deficiencies, and nutritional intolerance must be considered. Evaluation of the predisposing factors is imperative in treating patients with RAS including vitamin B12 malabsorption. CLINICAL SIGNIFICANCE Determination of the levels of vitamin B12 should be the basis for replacement therapy. Such therapy can be considered a benefit to the patients with RAS as its etiology remains unclear. Clinicians must be alert to the possibility this lesion could be a signal of systemic disease.
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Affiliation(s)
- Bruna Gonçalves Garcia
- Department of Oral Surgery, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
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Ellen C. Hydroxocobalamin: a better cyanide antidote. JEMS 2008; 33:14-17. [PMID: 19043885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Dart RC. Hydroxocobalamin for Acute Cyanide Poisoning: New Data from Preclinical and Clinical Studies; New Results from the Prehospital Emergency Setting. Clin Toxicol (Phila) 2008; 44 Suppl 1:1-3. [PMID: 16990188 DOI: 10.1080/15563650600811607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fortin JL, Ruttimann M, Capellier G, Bigorie A, Ferlicot S, Thervet E. Successful organ transplantation after treatment of fatal cyanide poisoning with hydroxocobalamin. Clin Toxicol (Phila) 2008; 45:468-71. [PMID: 17503248 DOI: 10.1080/15563650701338179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cyanide-poisoned patients are potential organ donors provided that organs are not damaged by the poison or by antidotal treatment. CASE STUDY A patient with third-degree burns and smoke inhalation-associated cyanide poisoning confirmed by measurements of whole blood cyanide was found in cardiac arrest and administered epinephrine and hydroxocobalamin (5 g + 5 g). Cardiac activity resumed, but the patient was declared brain dead on the third day of hospitalization when coma deteriorated to a shock state with refractory hypoxemia. Kidneys, heart, and liver were removed and transplanted into four patients. Gross pre-transplantation inspection of the donor organs and renal histology showed no evidence that hydroxocobalamin caused organ toxicity. Donor organs functioned normally through follow-up periods of several months. CONCLUSION Anoxic cardiac arrest following acute cyanide poisoning treated with hydroxocobalamin (5 g + 5 g) was not a contraindication to organ transplantation after confirmed encephalic death in this patient.
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Affiliation(s)
- J L Fortin
- Emergency Medical Service of the Paris Fire Brigade,Paris, France.
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Dueñas Laita A, Nogué Xarau S, Burillo-Putze G, Castrodeza Sanz J. [Availability of hydroxicobalamin as an antidote for patients intoxicated by fire smoke in Spanish hospitals]. Med Clin (Barc) 2008; 131:318-319. [PMID: 18803928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Zwickler T, Lindner M, Aydin HI, Baumgartner MR, Bodamer OA, Burlina AB, Das AM, DeKlerk JBC, Gökcay G, Grünewald S, Guffon N, Maier EM, Morava E, Geb S, Schwahn B, Walter JH, Wendel U, Wijburg FA, Müller E, Kölker S, Hörster F. Diagnostic work-up and management of patients with isolated methylmalonic acidurias in European metabolic centres. J Inherit Metab Dis 2008; 31:361-7. [PMID: 18563634 DOI: 10.1007/s10545-008-0804-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2007] [Revised: 03/25/2008] [Accepted: 04/02/2008] [Indexed: 10/21/2022]
Abstract
The long-term outcome of patients with methylmalonic aciduria (MMA) is still uncertain due to a high frequency of complications such as chronic renal failure and metabolic stroke. The understanding of this disease is hampered by a huge variation in the management of these patients. The major aim of this study was to evaluate the current practice in different European metabolic centres. A standardized questionnaire was sent to 20 metabolic centres asking for standard procedures for confirmation of diagnosis, testing cobalamin responsiveness, dietary treatment, pharmacotherapy, and biochemical and clinical monitoring. Sixteen of 20 metabolic centres (80%) returned questionnaires on 183 patients: 89 of the patients were classified as mut(0), 36 as mut(-), 13 as cblA, 7 as cblB, and 38 as cblA/B. (1) Confirmation of diagnosis: All centres investigate enzyme activity by propionate fixation in fibroblasts; six centres also perform mutation analysis. (2) Cobalamin response: Ten centres follow standardized protocols showing large variations. A reliable exclusion of nonspecific effects has not yet been achieved by these protocols. (3) Long-term treatment: In cobalamin-responsive patients, most centres use hydroxocobalamin (1-14 mg/week i.m. or 5-20 mg/week orally), while two centres use cyanocobalamin. All cobalamin-nonresponsive patients and most cobalamin-responsive patients are supplemented with L: -carnitine (50-100 mg/kg per day). Fourteen centres use intestinal decontamination by antibiotic therapy. Most centres follow D-A-CH (n = 6) or Dewey (n = 4) recommendations for protein requirements. Fourteen centres regularly use precursor-free amino acid supplements. Standardized monitoring protocols are available in seven centres, again showing high variability.
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Affiliation(s)
- T Zwickler
- Division of Metabolic Diseases, University Children's Hospital, Heidelberg, Germany
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Sharma AP, Greenberg CR, Prasad AN, Prasad C. Hemolytic uremic syndrome (HUS) secondary to cobalamin C (cblC) disorder. Pediatr Nephrol 2007; 22:2097-103. [PMID: 17874135 DOI: 10.1007/s00467-007-0604-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 06/17/2007] [Accepted: 07/23/2007] [Indexed: 01/28/2023]
Abstract
Diarrhea-positive hemolytic uremic syndrome (HUS) is a common cause of acute renal failure in children. Diarrhea-negative (D-), or atypical HUS, is etiologically distinct. A Medline search identified seven previously reported D- cases of HUS secondary to cobalamin C (cblC) disease presenting in infancy. An infantile presentation is reported to be associated with a high mortality rate (6/7 cases). We describe the results of a 5-year longitudinal follow-up in a child diagnosed with D- HUS secondary to cblC disease in infancy. Mutation analysis in this patient identified homozygosity for the 271 dupA mutation (c.271 dupA) in the cblC MMACHC gene. We briefly review the published experience in cblC-associated HUS to highlight the clinical characteristics of this uncommon, but potentially treatable, condition.
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Affiliation(s)
- Ajay P Sharma
- Department of Pediatrics, University of Western Ontario, London, ON, Canada.
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