A novel stoploss mutation CYB5R3 c.906A>G(p.*302Trpext*42) involved in the pathogenesis of hereditary methemoglobinemia.

Recessive congenital methemoglobinemia (RCM) is a hereditary autosomal disorder with an extremely low incidence rate. Here, we report a case of methemoglobinemia type I in a patient with congenital persistent cyanosis. The condition was attributed to a novel compound heterozygous mutation in CYB5R3, characterized by elevated methemoglobin levels (13.4 % of total hemoglobin) and undetectable NADH cytochrome b5 reductase (CYB5R3) activity. Whole-exome sequencing (WES) revealed two heterozygous mutations in CYB5R3: a previously reported pathogenic missense mutation c.611G>A(p.Cys204Tyr) inherited from the father, and a novel stop codon mutation c.906A>G(p.*302Trpext*42) from the mother, the latter mutation assessed as likely pathogenic according to ACMG guidelines. In cells overexpressing the CYB5R3 c.906A>G mutant construct, the CYB5R3 mRNA level was significantly lower than in cells overexpressing the wild-type (WT) CYB5R3 construct. However, there was no significant difference in protein expression levels between the mutant and WT constructs. Notably, an additional protein band of approximately 55 kDa was detected in the mutant cells. Immunofluorescence localization showed that, compared to wild-type CYB5R3, the subcellular localization of the CYB5R3 p.*302Trpext*42 mutant protein did not show significant changes and remained distributed in the endoplasmic reticulum and mitochondria. However, the c.906A>G(p.*302Trpext*42) mutation resulted in increased intracellular reactive oxygen species (ROS) levels and decreased NAD+/NADH ratio, suggesting impaired CYB5R3 function and implicating this novel mutation as likely pathogenic.

Deadly shades of green: A cautionary tale of an organic biopesticide poisoning.

Introduction: Methemoglobinemia is a potentially life-threatening condition characterized by the reduced oxygen-carrying capacity of hemoglobin. With the increasing popularity of natural and herbal biopesticides, there is a growing risk of exposure to substances that can induce this dyshemoglobinemia. This case report highlights the importance of recognizing and promptly treating methemoglobinemia in the context of biopesticide exposure, a concern relevant to various healthcare professionals. Case description: A 70-year-old male presented to the emergency department (ED) in an unresponsive state following suspected ingestion of an unknown quantity of an organic biopesticide labeled "Bull Fight". Initial management included fluid resuscitation, endotracheal intubation and mechanical ventilation. The patient developed significant hypoxia and hypotension. Abnormal blood color and a saturation gap raised suspicion of methemoglobinemia, which was confirmed by co-oximetry (68.7 % MetHb). Treatment with methylene blue was initiated, leading to initial improvement. However, the patient experienced rebound methemoglobinemia, requiring additional doses of methylene blue. Despite treatment, the patient ultimately succumbed to pneumonia. Discussion: This case underscores the potential dangers of organic biopesticides and the importance of considering methemoglobinemia in patients with unexplained cyanosis, saturation gap, and abnormal blood color. The increasing use of natural and herbal products in agriculture may expose individuals to undisclosed ingredients capable of inducing methemoglobinemia. Healthcare professionals across various specialities, including emergency medicine, critical care, toxicology, and primary care, must remain vigilant and maintain a high index of suspicion for this condition, especially in cases of biopesticide exposure. Conclusion: Awareness of methemoglobinemia and its association with biopesticide exposure is crucial for all healthcare providers who may encounter such cases. Prompt recognition and treatment can be lifesaving. As natural biopesticide use increases, clinicians should be prepared to diagnose and manage methemoglobinemia effectively. Careful monitoring is crucial to detect and prevent rebound methemoglobinemia. Ongoing education and preparedness are essential to address risks associated with emerging agricultural practices and products.

[One case of methemoglobinemia and hemolytic anemia caused by acute nitrogen trifluoride poisoning].

This paper analyzes the pathogenesis, clinical characteristics, treatment measures and prognosis of a case of methemoglobin and hemolytic anemia caused by acute nitrogen trifluoride poisoning. The patient with occupational exposure to nitrogen trifluoride was treated immediately after the onset of illness, methemoglobin was monitored and a comprehensive examination was conducted. After comprehensive analysis, it was considered that acute nitrogen trifluoride poisoning could cause methemoglobinemia, hemolytic anemia and liver injury. The patient was disengaged and given symptomatic treatment such as oxygen therapy, methylene blue, low-dose methylpredrone, vitamin C and reduced glutathione. The prognosis of the patient is good, which provides a reference for the clinical treatment and occupational health examination of nitrogen trifluoride poisoning.

Management of Congenital Methemoglobinemia in the Perioperative Setting: A Case Report and Review of Current Literature.

Background: Methemoglobin is an altered state of hemoglobin where iron in hemoglobin is oxidized and incapable of binding oxygen; leading to complications such as cyanosis, dyspnea, headache, and heart failure. Methemoglobinemia can be congenital or acquired. Congenital methemoglobinemia is a rare disease and its worldwide incidence is unclear. We recently encountered the first documented case of congenital methemoglobinemia at our institution, necessitating perioperative care. Case Presentation: In the present case, a 22-year-old man with congenital methemoglobinemia underwent general anesthesia for dental extraction. The surgeon was informed to avoid local anesthetics and oxygenation was performed with FiO2 of 1.0. Arterial blood gas analysis showed a PH of 7.337, PaO2 of 302 mm Hg, PaCO2 of 44 mm Hg, oxyhemoglobin level of 63.4%, and methemoglobin level of 37.8%. The patient had a stable course. No methylene blue therapy was required, although cyanosis was observed during surgery. Conclusion: In summary, though rare, congenital methemoglobinemia poses fatal risks during surgery. Its management involves preoperative recognition and optimization, oxygenation status, multidisciplinary care, avoiding precipitating or oxidizing agents, discussing treatment options, maintaining cardiopulmonary stability, and ensuring perioperative safety measures with the medical team.

Rapid-onset methemoglobinemia from traditional-medicine-induced potassium nitrate poisoning: successful treatment with methylene blue-a case report.

BACKGROUND: Potassium nitrate poisoning is a rare but potentially serious condition that can result in methemoglobinemia and subsequent cyanosis. This case report presents a unique instance of rapid-onset methemoglobinemia resulting from the ingestion of a traditional medicine preparation containing potassium nitrate, known as "kalmi shora." CASE PRESENTATION: A 14-year-old Pakistani boy reported to the emergency department with a history of sudden-onset headache, drowsiness agitation, irritability, and generalized cyanosis. Pulse oximetry showed a concerning oxygen saturation level of 58%, whereas arterial blood gas analysis revealed a normal partial pressure of oxygen (90 mmHg). The profile of abrupt onset of symptoms, generalized cyanosis, and the discrepancy between the partial pressure of oxygen and oxygen saturation readings necessitated a comprehensive assessment including inquiries into potential toxins. The peculiar appearance of the blood, resembling chocolate in color, further indicated the possibility of methemoglobinemia. The patient was successfully treated with methylene blue, leading to a prompt resolution of symptoms. CONCLUSION: This case highlights the significance of considering toxin exposures, such as traditional-medicine-induced poisoning, in emergency settings. The report contributes to the medical literature by highlighting the potential risks associated with traditional remedies and emphasizes the critical role of prompt diagnosis and intervention in optimizing patient outcomes. Recognition of the specific etiology of methemoglobinemia, in this case, traditional medicine ingestion, is essential for effective management in emergency medicine.

From Poppers to Peril: Recreational Nitrite-Induced Methemoglobinemia.

Inhaled amyl nitrites, once used to alleviate chest pain, are more commonly now being used for their euphoric effects. The recreational use of inhaled nitrites can lead to methemoglobinemia, a life-threatening condition that hinders the utilization of oxygen in the body. In 2021, 2.2 million people aged 12 or older used inhalants in the past year. Methemoglobinemia has favorable outcomes with treatment. We present the case of a 43-year-old man, with a medical history of type 2 diabetes mellitus and hypertension presenting with bluish discoloration of the fingers that progressed to his tongue and lips. He disclosed using a recreational inhalant called "Rush" before coming in. Vital signs showed low oxygen saturation on room air, and further investigation revealed elevated methemoglobin levels on the venous blood gas. Methylene blue was used for treatment, with complete resolution of the patient's symptoms and the only side effect of green urine. The patient was later discharged home in a stable condition. History taking is a crucial part of managing methemoglobinemia, as presentation to the clinical setting could vary. Our case presents the milder version of the disease with quick complete recovery after appropriate treatment. It demonstrates inhalant abuse in a less common age group. The case also demonstrates a common side effect of methylene blue that is often forgotten.

When Pain Relief Turns Perilous: Uncovering the Hidden Dangers and Advanced Management of Benzocaine-Induced Methemoglobinemia.

Benzocaine-induced methemoglobinemia is a rare complication associated with benzocaine, a local anesthetic known for its rapid pain relief. Acquired methemoglobinemia occurs when hemoglobin is oxidized to a ferric state, impairing oxygen binding. This condition can lead to respiratory distress and potentially fatal outcomes if not promptly diagnosed and treated. We present the case of a 61-year-old Caucasian female admitted with respiratory distress after lumbar stenosis surgery. She developed acute hypoxemic respiratory failure due to pneumonia. Although initially responsive to antibiotics and oxygen, her condition worsened overnight despite non-invasive bilevel-positive airway pressure (BiPAP) therapy. The use of benzocaine spray for throat pain led to suspected methemoglobinemia. She was treated with high-dose vitamin C and methylene blue, resulting in significant improvement. This case report aims to raise awareness among healthcare workers and emphasizes that timely recognition and management are crucial for better outcomes.

De Novo Occurrence of Hb Chile [ß28(B10) Leu→Met] in a Korean Boy with Methemoglobinemia.

Hemoglobin (Hb) Chile, a variant of Hb M, is produced by a point mutation of CTG→ATG on codon 29 (legacy codon 28) of the Hb ß locus gene, which results in an amino acid substitution of Leu→Met. It has been identified in two families worldwide and is inherited in an autosomal dominant manner. Here, we report a case of Hb Chile in which a de novo mutation was detected in the proband. A 17-year-old male presented to the outpatient clinic with a pale appearance. There was cyanosis on his lips and fingers. Blood tests indicated the existence of hemolysis, but complete blood counts revealed no anemia. Peripheral arterial oxygen saturation on pulse oximetry was 80% on room air and did not improve with oxygen supplementation. The level of methemoglobin was 15.4%. Targeted next-generation sequencing identified a heterozygous NM_000518.4(HBB):c.85C > A mutation, indicating Hb Chile. The Hb Chile mutation, on the other hand, was not discovered in his parents, implying that it arose as a result of a de novo mutation. This case highlights the necessity of suspecting Hb gene mutations in patients with unexplained chronic methemoglobinemia, even if there is no family history.

A Multi-Center Retrospective Database Evaluation of Pediatric Subjects Diagnosed With Methemoglobinemia.

Background: Methemoglobinemia requires early identification and treatment, but limited knowledge exists regarding the current therapeutic approach taken by clinicians as well as the outcomes that occur in children. Objectives: To determine the current prevalence of this rare disease in the pediatric population, evaluate the impact of methemoglobin and functional hemoglobin levels, and assess how this disease is approached by clinicians. We hypothesize that methemoglobinemia prevalence is low and more methylene blue use would be observed in subjects with functional hemoglobin levels less than 7 g/dL. Design: This was a retrospective observational cohort study utilizing deidentified TriNetX® electronic health record (EHR) data. Methods: Using a multicenter EHR database, we evaluated subjective characteristics, diagnostic, laboratory results, medication, and procedural codes. Results: Ninety-eight children (mean age 5.3 ± 5.3 years) from 53 healthcare organizations were included. Methemoglobinemia prevalence was 0.0015% with an overall 30-day mortality of 6.1%. Subjects with methemoglobin percentages greater than 20% had a higher frequency of methylene blue administration (70.6% versus 24.7%, P = .0005). Critical care service requirements and methylene blue administration were similar in the subjects with functional hemoglobin less than 7 g/dL and more than 7 g/dL groups. Overall, 13 (13.2%) subjects underwent glucose-6-phosphate dehydrogenase deficiency (G6PD) testing. Conclusion: In our study, we found methemoglobinemia prevalence in children is low, there is a low frequency of G6PD testing despite methylene blue hemolysis risk, and subjects appeared to be treated similarly despite a low functional hemoglobin. These findings highlight the continued critical nature of this disease and may highlight opportunities for education aimed at improving care in children diagnosed with methemoglobinemia, particularly related to G6PD testing.

Acquired methemoglobinemia in a third trimester puerpera and her premature infant with sodium nitrite poisoning: A case report.

BACKGROUND: The common cause of sodium nitrite poisoning has shifted from previous accidental intoxication by exposure or ingestion of contaminated water and food to recent alarming intentional intoxication as an employed method of suicide/exit. The subsequent formation of methemoglobin (MetHb) restricts oxygen transport and utilization in the body, resulting in functional hypoxia at the tissue level. In clinical practice, a mismatch of cyanotic appearance and oxygen partial pressure usually contributes to the identification of methemoglobinemia. Prompt recognition of characteristic mismatch and accurate diagnosis of sodium nitrite poisoning are prerequisites for the implementation of standardized systemic interventions. CASE SUMMARY: A pregnant woman was admitted to the Department of Critical Care Medicine at the First Affiliated Hospital of Harbin Medical University due to consciousness disorders and drowsiness 2 h before admission. Subsequently, she developed vomiting and cyanotic skin. The woman underwent orotracheal intubation, invasive mechanical ventilation (IMV), and correction of internal environment disturbance in the ICU. Her premature infant was born with a higher-than-normal MetHb level of 3.3%, and received detoxification with methylene blue and vitamin C, supplemental vitamin K1, an infusion of fresh frozen plasma, as well as respiratory support via orotracheal intubation and IMV. On day 3 after admission, the puerpera regained consciousness, evacuated the IMV, and resumed enteral nutrition. She was then transferred to the maternity ward 24 h later. On day 7 after admission, the woman recovered and was discharged without any sequelae. CONCLUSION: MetHb can cross through the placental barrier. Level of MetHb both reflects severity of the sodium nitrite poisoning and serves as feedback on therapeutic effectiveness.

Naphthalene or Mothball Poisoning Manifesting as Acute Intravascular Hemolysis and Acquired Methemoglobinemia.

Naphthalene is a major component of mothballs. Domestically, people use mothballs as an insect repellent. Its deliberate or accidental ingestion leading to toxicity has rarely been reported in the medical literature, despite its widespread use in Southeast Asia. Naphthalene, or mothball poisoning, is a rare but serious condition that can have detrimental effects on human health. This case report presents the clinical course of a 22-year-old male who ingested six naphthalene balls, resulting in severe symptoms including fever, abdominal pain, vomiting, jaundice, and dark-colored urine. Laboratory investigations were suggestive of acute intravascular hemolysis and methemoglobinemia. The patient was promptly admitted to the hospital, where he received supportive care along with specific treatment in the form of red blood cell transfusions, intravenous methylene blue, ascorbic acid, and N-acetyl cysteine. Through this report, the importance of raising awareness about the dangers of naphthalene poisoning and the specific treatment options available is highlighted.

A Rare Case of Familial Methemoglobinemia with Congenital Heart Disease.

Methemoglobinemia is a rare dyshemoglobin disorder which can either be congenital or acquired. Dyshemoglobin disorders can be asymptomatic or symptomatic. We narrate the case of a 12-year-old girl who presented with a fever, cough, and oxygen saturation of 85%. She was diagnosed with COVID-19, along with a large atrial septal defect and pulmonary arterial hypertension. Arterial blood gas analysis revealed normal partial pressure of oxygen and on 100% exposure to oxygen, blood color turned chocolate brown. After the resolution of COVID-19 in 10 days, the patient was treated with oral ascorbic acid and successful atrial septal defect repair. It is important to suspect dyshemoglobin disorder in a patient who presents with hypoxia/hypoxemia.

Exploring the Possible Link Between Diabetic Ketoacidosis, Glucose-6-Phosphate Dehydrogenase Deficiency, and Methemoglobinemia.

One of the most widespread enzymopathies affecting human beings is glucose-6-phosphate dehydrogenase (G6PD) deficiency, which is brought on by inherited mutations in the X-linked gene. Red blood cells (RBCs) with a G6PD deficiency are more sensitive to oxidative assault and consequently to hemolysis. There are more than 200 known G6PD mutations, of which around half are polymorphic and thus prevalent in a variety of populations. We present a case of diabetic ketoacidosis (DKA), with severe hemolytic anemia and methemoglobinemia. The patient was admitted to the intensive care unit, treated for DKA, and received a blood transfusion. In addition, the patient presented with high methemoglobin levels and features of severe hemolytic anemia from the onset, which made the diagnostic consideration of G6PD highly likely. Accordingly, the patient was treated with several doses of ascorbic acid instead of methylene blue. In a nutshell, a patient with DKA who has hemolytic anemia has to have it properly evaluated and controlled. The link between methemoglobinemia, G6PD deficiency, and DKA should be recognized by medical professionals, particularly when oxygen saturation gaps are found.

Dapsone-Induced Methemoglobinemia in a Woman With Multiple Myeloma Without Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency.

Methemoglobinemia is a condition characterized by the presence of abnormal hemoglobin, known as methemoglobin, in the blood, which impairs the ability of red blood cells to carry oxygen effectively. Symptoms include cyanosis, shortness of breath, fatigue, and in severe cases, organ damage or death. We presented a case of a 49-year-old female with multiple myeloma who developed drug-induced methemoglobinemia while on dapsone prophylaxis for Pneumocystis carinii pneumonia (PCP). Despite normal glucose-6-phosphate dehydrogenase (G6PD) levels, the patient exhibited cyanosis and shortness of breath. The case underscores the importance of considering methemoglobinemia in patients with unexplained hypoxemia, especially when associated with medication use. Diagnosis relies on clinical assessment, arterial or venous blood gas analysis with co-oximetry, and a thorough medication history. Methemoglobinemia poses a diagnostic challenge due to its varied presentations and requires a high index of suspicion, particularly in patients with multiple myeloma receiving potentially causative medications such as dapsone. Thorough evaluation, interdisciplinary collaboration, and prompt treatment are essential for favorable outcomes in these complex cases.

Novel hypothesis for infant methemoglobinemia: Survival and metabolism of nitrite-producers from vegetables under gastrointestinal stress and intestinal adhesion.

Infants have digestive environments that are more favorable for microbial proliferation and subsequent endogenous nitrite production than those of adults, but direct evidence of this has been lacking. In this study, we propose a novel epidemiology of infant methemoglobinemia by demonstrating the risk posed by nitrite-producers in the gastrointestinal tract. Nitrite-producers from vegetables (n = 323) were exposed to stress factors of the gastrointestinal environment (gastric pH, intestinal bile salts, anaerobic atmosphere) reflecting 4 different postnatal age periods (Neonate, ≤1 month; Infant A, 1-3 months; Infant B, 3-6 months; Infant C, 6-12 months). "High-risk" strains with a nitrate-to-nitrite conversion rate of ≥1.3 %, the minimum rate corresponding to nitrite overproduction, under the Neonate stress condition were analyzed for intestinal adhesion. Among all the phyla, Pseudomonadota achieved the highest survival (P < 0.05; survival rate of 51.3-71.8 %). Possible cross-protection against bile resistance due to acid shock was observed for all the phyla. All the high-risk strains exhibited moderate autoaggregation (14.0-36.4 %), whereas only a few exhibited satisfactory surface hydrophobicity (>40 %). The Pantoea agglomerans strain strongly adhered to Caco-2 cells (7.4 ± 1.1 %). This study showed the ability of the Pantoea, Enterobacter, and Klebsiella strains to survive under gastrointestinal stress for ≤12 months, to excessively produce nitrite under neonatal stress conditions, and to settle in the human intestine. To our knowledge, this is the first study to reveal the role of the natural flora of vegetables in the epidemiology of infant methemoglobinemia through a multilateral approach.

Refractory hypoxia and saturation gap in a COVID-19 patient.

Acquired methemoglobinemia, predominantly due to oxidizing medications occurs when heme iron in hemoglobin is oxidized from ferrous to ferric ion and binds oxygen irreversibly leading to functional anemia, cyanosis, and tissue hypoxia. We report a case of a 60-year-old man with multiple comorbidities who was diagnosed with coronavirus disease 2019 (COVID-19) and developed methemoglobinemia after consumption of prescribed supplements. He presented with dyspnea and cyanosis. An oxygen saturation gap with characteristic chocolate-brown arterial blood indicated methemoglobinemia. Outsourced methemoglobin (MetHb) was increased at 9.0%. Despite aggressive intervention, he succumbed to his illness. In this case, we discuss the pathophysiology of why some individuals, especially the elderly with COVID-19 are more susceptible to develop methemoglobinemia after possibly being exposed to oxidizing agents. Laboratory methods for assessing oxygen saturation, including pulse oximetry, arterial blood gas and co-oximetry are examined in relation to this case. The importance of considering a diagnosis of methemoglobinemia based on clinical and biochemical findings although MetHb assay or co-oximetry are not readily available is also emphasized.

Methemoglobinemia Following Indoxacarb Ingestion: A Unique Toxicological Presentation.

Indoxacarb, an oxadiazine insecticide, is known for its selective lethality by blocking neuronal voltage-dependent sodium channels. While primarily developed to target insect populations resistant to other pesticides, its toxicity in humans remains poorly understood. We present a case of methemoglobinemia resulting from indoxacarb ingestion, a rare manifestation of its toxic effects. A 38-year-old farmer attempted suicide by ingesting the insecticide, leading to cyanosis, hypoxemia, and characteristic arterial blood gas findings indicative of methemoglobinemia. Prompt diagnosis was challenging due to the absence of specific tests, necessitating clinical suspicion. Treatment with methylene blue and supportive therapy resulted in significant clinical improvement, highlighting the importance of early intervention in managing indoxacarb poisoning. This case underscores the need for increased awareness among healthcare providers regarding the potential toxic effects of indoxacarb. It emphasizes the importance of prompt recognition and treatment of methemoglobinemia in pesticide-related poisonings. Further research is warranted to elucidate the mechanisms underlying indoxacarb toxicity in humans and to optimize treatment strategies for affected individuals.

Acquired methemoglobinemia induced by indoxacarb poisoning: a case report.

Indoxacarb, a large-spectrum non-organophosphorus oxadiazine insecticide, is broadly used in farming whose mechanism of action is the blockage of voltage-gated sodium channels of insects. There is restricted data on human poisoning. We report a case of an 18-year-old male patient without comorbidities presented with unconsciousness and cyanosis after the intentional ingestion of indoxacarb in a suicide attempt. Methemoglobinemia was clinically suspected and was successfully treated after methylene blue injection, associated with supportive and symptomatic management. This case emphasizes the importance of considering methemoglobinemia after indoxacarb ingestion in addition to its early recognition and timely injection of methylene blue which led to complete recovery without sequelae.

Shades of Blue: A Case Series of Acquired Methemoglobinemia.

Acquired methemoglobinemia (MetHb) is a rare but potentially life-threatening condition that has varied etiology, usually toxin- or drug-induced. We had five cases of acquired methemoglobinemia during six months. Their presentation varied from an asymptomatic state to respiratory distress. The presence of cyanosis and low oxygen saturation (SpO2), despite normal partial pressure of oxygen (PaO2) and chocolate brown-colored blood, were diagnostic clues present in all cases. A high level of methemoglobinemia was detected on arterial blood gas (ABG), confirming the diagnosis. Methylene blue was used as an antidote along with supportive care in symptomatic cases. All these cases of methemoglobinemia recovered completely. A high index of suspicion for methemoglobinemia should be maintained in cases presenting with persistent hypoxia or cyanosis despite normal PaO2.