https://doi.org/10.4081/ecj.2024.12034
Eating vegetables is not always a good advice. A case report and literature review of acquired methemoglobinemia
Submitted: 27 October 2023
Accepted: 12 January 2024
Published: 26 January 2024
Accepted: 12 January 2024
Abstract Views: 1333
PDF: 426
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Methemoglobinemia (MET) is a life-threatening condition resulting from the development of methemoglobin (MetHb), which binds oxygen irreversibly, causing refractory hypoxia and so-called “functional anemia”. MET can be caused by hereditary or acquired processes. Acquired forms are the most common. Symptoms correlate with the MetHb level and range from cyanosis and dyspnea to dysrhythmias, metabolic acidosis, coma, and cardiac arrest. MetHb levels above 70% are fatal. Methylene blue (MB) is the specific antidote. In all cases, supportive treatment, including intravenous hydration, glucose correction, and oxygen supplementation, must be started immediately. Exchange transfusion has been used successfully to treat MET and may be appropriate in patients for whom MB is ineffective. We report the case of a 54-year-old woman who presented to our emergency department for the acute and sudden development of chest pain, shortness of breath, and severe cyanosis after drinking a significant amount of boiled courgette water. Arterial blood gas analysis revealed a MetHb level of 26%. She was treated immediately with MB, oxygen supplementation, and hydration with normalization of her MetHb in 12 hours. Our recommendation is to always investigate MET in patients with unexplained cyanosis and refractory hypoxia.
Savino F, Maccario S, Guidi C, et al. Methemoglobinemia caused by the ingestion of courgette soup given in order to resolve constipation in two formula-fed infants. Ann Nutr Metab 2006;50:368-71.
DOI: https://doi.org/10.1159/000094301
Prchal J. Chapter 51: Methemoglobinemia and Other Dyshemoglobinemias. 10th ed. McGraw Hill; 2021.
Mansouri A, Lurie AA. Concise review: methemoglobinemia. Am J Hematol 1993;42:7-12.
DOI: https://doi.org/10.1002/ajh.2830420104
Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: etiology, pharmacology, and clinical management. Ann Emerg Med 1999;34:646-56.
DOI: https://doi.org/10.1016/S0196-0644(99)70167-8
Ludlow JT, Wilkerson RG, Nappe TM. Methemoglobinemia. StatPearls Publishing; 2021.
Iolascon A, Bianchi P, Andolfo I, et al. SWG of red cell and iron of EHA and EuroBloodNet. Recommendations for diagnosis and treatment of methemoglobinemia. Am J Hematol 2021;96:1666-78.
DOI: https://doi.org/10.1002/ajh.26340
Percy MJ, Lappin TR. Recessive congenital methaemoglobinaemia: cytochrome b(5) reductase deficiency. Br J Haematol 2008;141:298-308.
DOI: https://doi.org/10.1111/j.1365-2141.2008.07017.x
Dekker J, Eppink MH, van Zwieten R, et al. Seven new mutations in the nicotinamide adenine dinucleotide reduced-cytochrome b(5) reductase gene leading to methemoglobinemia type I. Blood 2001;97:1106-14.
DOI: https://doi.org/10.1182/blood.V97.4.1106
Nicolas-Jilwan M. Recessive congenital methemoglobinemia type II: Hypoplastic basal ganglia in two siblings with a novel mutation of the cytochrome b5 reductase gene. Neuroradiol J 2019;32:143-7.
DOI: https://doi.org/10.1177/1971400918822153
Ash-Bernal R, Wise R, Wright SM. Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals. Medicine (Baltimore) 2004;83:265-73.
DOI: https://doi.org/10.1097/01.md.0000141096.00377.3f
Ward KE, McCarthy MW. Dapsone-induced methemoglobinemia. Ann Pharmacother 1998;32:549-53.
DOI: https://doi.org/10.1345/aph.17003
Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg 2009;108:837-45.
DOI: https://doi.org/10.1213/ane.0b013e318187c4b1
McGuigan MA. Benzocaine-induced methemoglobinemia. Can Med Assoc J 1981;125:816.
Kane GC, Hoehn SM, Behrenbeck TR, Mulvagh SL. Benzocaine-induced methemoglobinemia based on the Mayo Clinic experience from 28 478 transesophageal echocardiograms: incidence, outcomes, and predisposing factors. Arch Intern Med 2007;167:1977-82.
DOI: https://doi.org/10.1001/archinte.167.18.1977
O'Donohue WJ Jr, Moss LM, Angelillo VA. Acute methemoglobinemia induced by topical benzocaine and lidocaine. Arch Intern Med 1980;140:1508-9.
DOI: https://doi.org/10.1001/archinte.140.11.1508
Avery AA. Infantile methemoglobinemia: reexamining the role of drinking water nitrates. Environ Health Perspect 1999;107:583-6.
DOI: https://doi.org/10.1289/ehp.99107583
Johnson CJ, Kross BC. Continuing importance of nitrate contamination of groundwater and wells in rural areas. Am J Ind Med 1990;18:449-56.
DOI: https://doi.org/10.1002/ajim.4700180416
Sanchez-Echaniz J, Benito-Fernández J, Mintegui-Raso S. Methemoglobinemia and consumption of vegetables in infants. Pediatrics 2001;107:1024-8.
DOI: https://doi.org/10.1542/peds.107.5.1024
Cannata G, Abate L, Scarabello C, et al. The Dose Makes the Poison: A Case Report of Acquired Methemoglobinemia. Int J Environ Res Public Health 2020;17:1845.
DOI: https://doi.org/10.3390/ijerph17061845
Chow CK, Hong CB. Dietary vitamin E and selenium and toxicity of nitrite and nitrate. Toxicology 2002;180:195-207.
DOI: https://doi.org/10.1016/S0300-483X(02)00391-8
Freeman L, Wolford RW. Methemoglobinemia secondary to cleaning solution ingestion. J Emerg Med 1996;14:599-601.
DOI: https://doi.org/10.1016/S0736-4679(96)00139-4
Fossen Johnson S. Methemoglobinemia: Infants at risk. Curr Probl Pediatr Adolesc Health Care 2019;49:57-67.
DOI: https://doi.org/10.1016/j.cppeds.2019.03.002
Jajoo V, Masavkar S, Ahmed Zaki S, Pawar P. Acquired methaemoglobinaemia in infancy associated with acute diarrhoea: A case series. Trop Doct 2023. doi: 10.1177/00494755231205632. Epub ahead of print.
DOI: https://doi.org/10.1177/00494755231205632
Wilkerson RG. Getting the blues at a rock concert: a case of severe methaemoglobinaemia. Emerg Med Australas 2010;22:466-9.
DOI: https://doi.org/10.1111/j.1742-6723.2010.01336.x
Reisinger A, Vogt S, Essl A, et al. Lessons of the month 3: Intravenous poppers abuse: case report, management and possible complications. Clin Med (Lond) 2020;20:221-23.
DOI: https://doi.org/10.7861/clinmed.2019-0469
Barrangou-Poueys-Darlas M, Gerardin M, Deheul S, et al. Poppers Use and High Methaemoglobinaemia: 'Dangerous Liaisons'. Pharmaceuticals (Basel) 2021;14:1061.
DOI: https://doi.org/10.3390/ph14101061
Hunter L, Gordge L, Dargan PI, Wood DM. Methaemoglobinaemia associated with the use of cocaine and volatile nitrites as recreational drugs: a review. Br J Clin Pharmacol 2011;72:18-26.
DOI: https://doi.org/10.1111/j.1365-2125.2011.03950.x
Houghton L, Jones Q, Wathen C. An unusual complication of cocaine toxicity. Acute Med 2013;12:96-7.
DOI: https://doi.org/10.52964/AMJA.0295
Koubaissi SA, Al Assaad RG, Itani Z, Bouakl I. Black Urine and Methemoglobinemia in the Setting of Sepsis Due to Clostridium Perfringens. Clin Med Insights Case Rep 2020;13:1179547620981894.
DOI: https://doi.org/10.1177/1179547620981894
Allen A, Fisher C, Premawardhena A, et al. Methemoglobinemia and ascorbate deficiency in hemoglobin E β thalassemia: metabolic and clinical implications. Blood 2012;120:2939-44.
DOI: https://doi.org/10.1182/blood-2012-06-435875
Haymond S, Cariappa R, Eby CS, Scott MG. Laboratory assessment of oxygenation in methemoglobinemia. Clin Chem 2005;51:434-44.
DOI: https://doi.org/10.1373/clinchem.2004.035154
Skold A, Cosco DL, Klein R. Methemoglobinemia: pathogenesis, diagnosis, and management. South Med J 2011;104:757-61
DOI: https://doi.org/10.1097/SMJ.0b013e318232139f
Gupta A, Jain N, Agrawal A, et al. A fatal case of severe methaemoglobinemia due to nitrobenzene poisoning. BMJ Case Rep 2011;2011:bcr0720114431.
DOI: https://doi.org/10.1136/bcr.07.2011.4431
Harvey M, Cave G, Chanwai G. Fatal methaemoglobinaemia induced by self-poisoning with sodium nitrite. Emerg Med Australas 2010;22:463–5.
DOI: https://doi.org/10.1111/j.1742-6723.2010.01335.x
Kreutz RW, Kinni ME. Life-threatening toxic methemoglobinemia induced by prilocaine. Oral Surg Oral Med Oral Pathol 1983;56:480–2.
DOI: https://doi.org/10.1016/0030-4220(83)90092-0
Margulies DR, Manookian CM. Methemoglobinemia as a cause of respiratory failure. J Trauma 2002;52:796–7.
DOI: https://doi.org/10.1097/00005373-200204000-00037
Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023;148:e149-84.
DOI: https://doi.org/10.1161/CIR.0000000000001161
Pushparajah Mak RS, Liebelt EL. Methylene Blue: An Antidote for Methemoglobinemia and Beyond. Pediatr Emerg Care 2021;37:474-7.
DOI: https://doi.org/10.1097/PEC.0000000000002526
Zuschlag ZD, Warren MW, K Schultz S. Serotonin Toxicity and Urinary Analgesics: A Case Report and Systematic Literature Review of Methylene Blue-Induced Serotonin Syndrome. Psychosomatics 2018;59:539-46.
DOI: https://doi.org/10.1016/j.psym.2018.06.012
Liao YP, Hung DZ, Yang DY. Hemolytic anemia after methylene blue therapy for aniline-induced methemoglobinemia. Vet Hum Toxicol 2002;44:19-21.
Rosen PJ, Johnson C, McGehee WG, Beutler E. Failure of methylene blue treatment in toxic methemoglobinemia. Association with glucose-6-phosphate dehydrogenase deficiency. Ann Intern Med 1971;75:83-6.
DOI: https://doi.org/10.7326/0003-4819-75-1-83
Rehman A, Shehadeh M, Khirfan D, Jones A. Severe acute haemolytic anaemia associated with severe methaemoglobinaemia in a G6PD deficient man. BMJ Case Rep 2018;2018:bcr2017223369.
DOI: https://doi.org/10.1136/bcr-2017-223369
Rino PB, Scolnik D, Fustiñana A, Mitelpunkt A, Glatstein M. Ascorbic acid for the treatment of methemoglobinemia: the experience of a large tertiary care pediatric hospital. Am J Ther 2014;21:240-3.
DOI: https://doi.org/10.1097/MJT.0000000000000028
Park EJ, Lee M, Min YG. Successful treatment of NO-induced methemoglobinemia with low-dose vitamin C. Clin Toxicol (Phila) 2017;55:686.
DOI: https://doi.org/10.1080/15563650.2017.1315126
Park SY, Lee KW, Kang TS. High-dose vitamin C management in dapsone-induced methemoglobinemia. Am J Emerg Med 2014;32:684.e1–684.e3.
DOI: https://doi.org/10.1016/j.ajem.2013.11.036
Lee KW, Park SY. High-dose vitamin C as treatment of methemoglobinemia. Am J Emerg Med 2014;32:936.
DOI: https://doi.org/10.1016/j.ajem.2014.05.030
Tanen DA, LoVecchio F, Curry SC. Failure of intravenous N-acetylcysteine to reduce methemoglobin produced by sodium nitrite in human volunteers: a randomized controlled trial. Ann Emerg Med 2000;35:369–373.
DOI: https://doi.org/10.1016/S0196-0644(00)70056-4
Williams LA 3rd, Adamski J, Kinard TN, et al. The first reported use of red blood cell exchange to treat hemoglobin Evans with secondary methemoglobinemia. J Clin Apher 2023;38:755-9.
DOI: https://doi.org/10.1002/jca.22086
Lindenmann J, Matzi V, Kaufmann P, et al. Hyperbaric oxygenation in the treatment of life-threatening isobutyl nitrite-induced methemoglobinemia: a case report. Inhal Toxicol 2006;18:1047–9.
DOI: https://doi.org/10.1080/08958370600904629
Cho Y, Park SW, Han SK, et al. A case of methemoglobinemia successfully treated with hyperbaric oxygenation monotherapy. J Emerg Med 2017;53:685–7.
DOI: https://doi.org/10.1016/j.jemermed.2017.04.036
Altintop I, Sanri E, Tatli M, et al. Methemoglobinemia treated with hyperbaric oxygen therapy: a case report. Turk J Emerg Med 2018;18:176–8.
DOI: https://doi.org/10.1016/j.tjem.2018.03.005
How to Cite
Vercelli, A., Nasone, I., Pagani, L., Dacrema, A., Veneziani, A., Agosti, A., & Poggiali, E. (2024). Eating vegetables is not always a good advice. A case report and literature review of acquired methemoglobinemia. Emergency Care Journal, 20(1). https://doi.org/10.4081/ecj.2024.12034
Copyright (c) 2024 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
