Identification of N-Hydroxy-para-aminobenzoic acid in a cyanotic child after benzocaine exposure.

CONTEXT: Methemoglobinemia (MetHb) after exposure to benzocaine (BZC) has been reported for more than 50 years, however the pathophysiologic mechanism has not been previously established. Direct administration of BZC to blood does not produce MetHb. After topical use, due to the lipophilicity and rapid acetylation in the tissue, little BZC reaches the liver for hepatic biotransformation. However, isolated human livers have been shown to produce MetHb forming N-hydroxyl metabolites from BZC. We report a case of BZC-induced MetHb with the first identification and quantification of the reactive metabolite responsible for the oxidative stress: N-Hydroxy-Para-amino benzoic acid (N-OH-PABA). CASE DETAILS: An 8 year old male was admitted to a hospital for an appendectomy. Several applications of BZC spray were used during multiple attempts at nasogastric tube placement. In various attempts to achieve local anesthesia, benzocaine spray was used in both nares and through the mouth aimed at the posterior oropharynx. The patient subsequently became cyanotic with an initial MetHb level of 32.9 %. Methylene blue was administered and the patient promptly responded with resolution of cyanosis. Blood taken within 20 min of the initial symptoms contained benzocaine (5.2ug/mL), bupivacaine (740ng/mL), lidocaine (530ng/mL), acetaminophen (12ug/mL), midazolam (60ng/mL), PABA and N-OH-PABA (35ng/mL). Serum was analyzed using Liquid Chromatography- Quadrupole Time-of-Flight Mass Spectrometry. Mass spectrometry was done using an electrospray ionization source run in negative and positive polarities. A reference standard for N-OH-PABA was synthesized for confirmation and quantification. DISCUSSION: The rare and idiopathic nature of methemoglobinemia after benzocaine use has made study of the pathophysiologic mechanism in humans difficult. Lack of understanding has brought calls for restriction of use of the widely used medication that may not be based on evidence. Our case presents several unique features: 1) benzocaine absorption after topical administration was documented with serum concentrations 2) confirmation of an in vivo formation of MetHb-forming n-hydroxyl-metabolite after benzocaine use and 3) the documentation of N-OH-PABA in humans within 20 min of MetHb post-benzocaine administration.

Electronic structure of high-spin iron(III)-alkylperoxo complexes and its relation to low-spin analogues: reaction coordinate of O-O bond homolysis.

The spectroscopic properties of the high-spin Fe(III)-alkylperoxo model complex [Fe(6-Me(3)TPA)(OH(x))(OO(t)Bu)](x)(+) (1; TPA = tris(2-pyridylmethyl)amine, (t)Bu = tert-butyl, x = 1 or 2) are defined and related to density functional calculations of corresponding models in order to determine the electronic structure and reactivity of this system. The Raman spectra of 1 show four peaks at 876, 842, 637, and 469 cm(-1) that are assigned with the help of normal coordinate analysis, and corresponding force constants have been determined to be 3.55 mdyn/A for the O-O and 2.87 mdyn/A for the Fe-O bond. Complex 1 has a broad absorption feature around 560 nm that is assigned to a charge-transfer (CT) transition from the alkylperoxo to a t(2g) d orbital of Fe(III) with the help of resonance Raman profiles and MCD spectroscopy. An additional contribution to the Fe-O bond arises from a sigma interaction between and an e(g) d orbital of iron. The electronic structure of 1 is compared to the related low-spin model complex [Fe(TPA)(OH(x))(OO(t)Bu)](x)(+) and the reaction coordinate for O-O homolysis is explored for both the low-spin and the high-spin Fe(III)-alkylperoxo systems. Importantly, there is a barrier for homolytic cleavage of the O-O bond on the high-spin potential energy surface that is not present for the low-spin complex, which is therefore nicely set up for O-O homolysis. This is reflected by the electronic structure of the low-spin complex having a strong Fe-O and a weak O-O bond due to a strong Fe-O sigma interaction. In addition, the reaction coordinate of the Fe-O homolysis has been investigated, which is a possible decay pathway for the high-spin system, but which is thermodynamically unfavorable for the low-spin complex.

Spectroscopic properties and electronic structure of low-spin Fe(III)-alkylperoxo complexes: homolytic cleavage of the O-O bond.

The spectroscopic properties, electronic structure, and reactivity of the low-spin Fe(III)-alkylperoxo model complex [Fe(TPA)(OH(x))(OO(t)Bu)](x+) (1; TPA = tris(2-pyridylmethyl)amine, (t)Bu = tert-butyl, x = 1 or 2) are explored. The vibrational spectra of 1 show three peaks that are assigned to the O-O stretch (796 cm(-1)), the Fe-O stretch (696 cm(-)(1)), and a combined O-C-C/C-C-C bending mode (490 cm(-1)) that is mixed with upsilon(FeO). The corresponding force constants have been determined to be 2.92 mdyn/A for the O-O bond which is small and 3.53 mdyn/A for the Fe-O bond which is large. Complex 1 is characterized by a broad absorption band around 600 nm that is assigned to a charge-transfer (CT) transition from the alkylperoxo pi*(upsilon) to a t(2g) d orbital of Fe(III). This metal-ligand pi bond is probed by MCD and resonance Raman spectroscopies which show that the CT state is mixed with a ligand field state (t(2g) --> e(g)) by configuration interaction. This gives rise to two intense transitions under the broad 600 nm envelope with CT character which are manifested by a pseudo-A term in the MCD spectrum and by the shapes of the resonance Raman profiles of the 796, 696, and 490 cm(-1) vibrations. Additional contributions to the Fe-O bond arise from sigma interactions between mainly O-O bonding donor orbitals of the alkylperoxo ligand and an e(g) d orbital of Fe(III), which explains the observed O-O and Fe-O force constants. The observed homolytic cleavage of the O-O bond of 1 is explored with experimentally calibrated density functional (DFT) calculations. The O-O bond homolysis is found to be endothermic by only 15 to 20 kcal/mol due to the fact that the Fe(IV)=O species formed is highly stabilized (for spin states S = 1 and 2) by two strong pi and a strong sigma bond between Fe(IV) and the oxo ligand. This low endothermicity is compensated by the entropy gain upon splitting the O-O bond. In comparison, Cu(II)-alkylperoxo complexes studied before [Chen, P.; Fujisawa, K.; Solomon, E. I. J. Am. Chem. Soc. 2000, 122, 10177] are much less suited for O-O bond homolysis, because the resulting Cu(III)=O species is less stable. This difference in metal-oxo intermediate stability enables the O-O homolysis in the case of iron but directs the copper complex toward alternative reaction channels.

Resonance Raman studies of the iron(II)--alpha-keto acid chromophore in model and enzyme complexes.

The bidentate coordination of an alpha-keto acid to an iron(II) center via the keto group and the carboxylate gives rise to metal-to-ligand charge-transfer transitions between 400 and 600 nm in model complexes and in alpha-ketoglutarate-dependent dioxygenases. Excitation into these absorption bands of the Fe(II)TauD(alpha-KG) complex (TauD = taurine/alpha-ketoglutarate dioxygenase, alpha-KG = alpha-ketoglutarate) elicits two resonance Raman features at 460 and 1686 cm(-1), both of which are sensitive to (18)O labeling. Corresponding studies of model complexes, the six-coordinate [Fe(II)(6-Me(3)-TPA)(alpha-keto acid)](+) and the five-coordinate [Fe(II)(Tp(Ph2))(alpha-keto acid)] (6-Me(3)-TPA = tris[(6-methyl-2-pyridyl)methyl]amine, Tp(Ph2) = hydrotris(3,5-diphenylpyrazol-1-yl)borate), lead to the assignment of these two features to the Fe(II)(alpha-keto acid) chelate mode and the nu(C==O) of the keto carbonyl group, respectively. Furthermore, the chelate mode is sensitive to the coordination number of the metal center; binding of a sixth ligand to the five-coordinate [Fe(II)(Tp(Ph2))(benzoylformate)] elicits a 9--20 cm(-1) downshift. Thus, the 10 cm(-1) upshift of the chelate mode observed for Fe(II)TauD(alpha-KG) upon the addition of the substrate, taurine, is associated with the conversion of the six-coordinate metal center to a five-coordinate center, as observed for the iron center of clavaminate synthase from X-ray crystallography (Zhang, Z.; et al. Nat. Struct. Biol. 2000, 7, 127-133) and MCD studies (Zhou, J.; et al. J. Am. Chem. Soc. 1998, 120, 13539--13540). These studies provide useful insights into the initial steps of the oxygen activation mechanism of alpha-ketoglutarate-dependent dioxygenases.

Patient's acceptance of outpatient hysteroscopy.

There is a trend towards performing hysteroscopy and endometrial biopsy on an outpatient basis, as this alleviates the need for both an inpatient stay and a general anesthesia. Despite the wide acceptance by medical staff, there are few publications on how patients actually tolerate and accept these procedures. We performed a survey on 185 patients attending the outpatient hysteroscopy clinic at a teaching hospital to assess the degree of pain and their acceptance to those procedures using a visual analogue scale. All procedures were successfully performed under no anesthesia without complications. The mean age of the patients was 48 (range 24-78) and 9.4% were nulliparas. The mean pain experienced was 4.7 (SD 2.7) during hysteroscopy and 5.0 (SD 2.9) during endometrial biopsy. The overall preference scores for the procedure to be done under was 3.1 (SD 3.7). About 7% of patients expressed a preference for an overnight stay in hospital after the procedure, but the preference score was low (2.5, SD 3.6). The procedure was well accepted (8.3, SD 2.4) and highly recommended by the patients (8.4, SD 2.9). Outpatient hysteroscopy is well accepted and tolerated by patients.