“Mystery of Blue boy” Methemoglobinemia poisoning: Challenging in identification and treatment

Kalaivani1, Sneka2, Jothimeena3, Veeralakshmi. M4, Angel Roselin S5

Department of Nursing – ER, Kauvery Hospital, Tirunelveli, Tamil Nadu

Introduction

Poisoning occurs after dermal, respiratory or oral exposure to either organophosphate pesticide (E.g. Chlorpyrifos, Dimethoate, Malathion, Parathion) or nerve agents causing intubation of acetylcholinesterase at nerve synapses.

Background

National data in India estimates that people die from poisoning at the rate of 2.4 per 1,00,000 populations.

Mechanism of Toxicity

Methemoglobin inducers act by oxidizing ferrous (Fe2+) to Ferric (Fe3+) hemoglobin. This abnormal hemoglobin is incapable of carrying oxygen, inducing a functional anemia. In addition, the shape of the oxygen hemoglobin dissociation curves is altered, aggravating cellular hypoxia.

Case Presentation

A 14 years aged male patient was admitted with the history of poisoning, with compound [Profenofos 40% + cypermethrin 45%], history not clear, plus consumption of around 10-15 tablets of camphor as a whole, as told by the parents. After initial treatment with non-invasive oxygen, given at local hospital, he was referred to our hospital for further management.

Brought to casualty in an altered state of consciousness, desaturation (with NIV support, SPo2 – 82%). Patient was in state of acute grief following death of his uncle for almost 2 weeks.

Clinical Presentation

On examination, the patient had altered state of consciousness, pallor present, peripheral cyanosis present, pulse rate 130/bpm, BP – 130/80 mmhg and NIV support [ High flow Position], SpO2 – 82%, intubated ‘7’ size tube ‘21 ‘fixation, bilateral air entry present, connected to ventilator SpO2 – 78% in FiO2 – 100%. The abdomen was soft and bowel sounds were normal. Respiratory system had abnormality.

Management

A 12 year aged male, H/O poisoning? While receiving, vitals were SpO2 – 80%, HR – 160/min, BP – 110/60 mmHg, RR – 40 /bpm, with dilated pupil 3mm. Patient‘s poor prognosis was explained to patient attender. Patient was intubated on 13.07.2024.

He had pallor, peripheral cyanosis and started on IV antibiotics, and Inj. Pralidoxime 500 mg.  Patient was given 2 units PRBC transfusion on 14/7/2024. Peripheral smear study showed normocytic normochromic blood picture with neutrophilic leukocytosis.

In view of peripheral hypoxia and increased cyanosis. Inj. IV Methylene Blue 100 mg in 100 ML NS over 10 min given. After 20 min, patient vitals improved SpO2 97%, HR-90/min. Patient condition was explained to his mother and treatment continued after getting consent.

On 15/7/2024 after getting history of blossom liquid + camphor consumption, he was diagnosed with microglobuliemia, and Inj. Pralidoxime was stopped (14/7/2024).

Patient had good response to Inj. Methylene Blue, hence extubation done on 16/7/2024. Post extubation vitals were stable, ryles tube removed, started on oral liquid.

17/7/2024 patient shifted to room, in view of sudden intention (psychiatrist) crisis opinion obtained and orders followed. Patient was discharge on 18/10/2024.

CBC

CBC14/7/202415/7/202416/7/202417/7/202418/7/2024
HB7.5/14.514.113.812.912.6
PCV44.9 / 46.445.547.543642.3
TC6480/16376132201171093608350
PLT170000/265002300002490002400002450000
NEUT95.7 / 84.777.678.4-51.5
L4.0 / 5.912.511.824.234.8
E0.3 / 0.10.20.42.24.8
M0.0/9.29.69.210.38.6

14/7/2024 – ESR = 72

RFT

RFT14/7/202415/7/2024
Urea15.4731.99
Creatinine0.300.99

Antidotes

Methylene blue is the primary antidote for acquired methemoglobinemia. When methylene blue is not available, alternative treatment such as ascorbic acid and hyperbaric oxygen can be useful.

Inj. Methylene blue should be administered intravenously as a 1 – 2 mg/kg dose over 3–5 min. Methylene blue is the most effective treatment for acquired methemogloblinemia condition that occur when hemoglobin loses its ability to carry oxygen.

Other Treatment

  • Ascorbic acid – can be used to reduce methemoglobin levels.
  • Hyperbaric oxygen – can be used if methylene blue is ineffective or contraindicated.
  • Exchange Transfusion – can be used in severe cases.
  • Cimetidine – can be used in dispone induced methemoglobinemia

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