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We read with great interest the recent article by Saxena et al on methemoglobinemia.1 We appreciate the diligent workup by Saxena et al that led to the timely diagnosis of the methemoglobinemia.

Patient reported by Saxena et al had a hemoglobin value of 10.3gm/dl. The anemia in the index subject was probably multifactorial-nutritional deficiency, anemia of chronic disease or secondary to bone marrow depression due to methotrexate use. Methemoglobinemia can also be associated with intravascular hemolysis, which is another common cause of anemia. The same was ruled out in the index case by confirming a negative hemolytic work up (normal values for unconjugated bilirubin, haptoglobin, lactic acid dehydrogenase and glucose-6-phosphate dehydrogenase). Using methylene blue (MB), the antidote for methemoglobinemia has two major hurdles; first, it is not universally available; and second, caution while using in patients with known or suspected G6PD deficiency. Knowing about the local disease burden of G6PD deficiency is important as it is the most common human enzyme defect, affecting approximately 400 million population globally. A recent meta-analysis (72 studies, sample size of 38,565) on the Indian population showed the overall magnitude of approximately 8.5% (varied from 0–27% depending on regional and ethnic background).2 As G6PD is a X-linked disease, males usually show full-blown disease while the majority of females remain unaffected carriers. Other known contraindications to use MB are hypersensitivity to MB, cyanide poisoning-related methemoglobinemia and severe renal impairment.

Saturation gap of 8% in index case was well above the value of 5%, which is considered as a threshold of significant gap.3 In small centres where Evelyn-Malloy method of methemoglobin is difficult to detect, a more handy way to quantify methemoglobin is Rad-57 pulse oximeter, which uses eight-light wavelengths of light instead of the usual two.

Pneumocystis pneumonia (PCP) is a very challenging disease, especially in immunocompromised individuals. We recently addressed the cost-benefit analysis of using dapsone as PCP prophylaxis in transplant patients that also has a potential to cause methemoglobinemia.4 As mentioned by Saxena et al, MB is the only FDA-approved antidote of choice for methemoglobinemia. Ascorbic acid, cimetidine and riboflavin are few other drugs that can be used as adjunctive therapy with variable outcomes.5 Hyperbaric oxygen therapy and red blood cell exchange can be considered in refractory cases or when conventional therapy is contraindicated.6,7

In conclusion, the index case illustrates the therapeutic and diagnostic challenge while approaching a suspected case of methemoglobinemia. Early recognition, timely removal of the inciting drug, and treatment can avert the fatality related to methemoglobinemia.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Kamal Kant Sahu, Medicine, Saint Vincent Hospital, Worcester, United States; Ajay Kumar Mishra, Medicine, Saint Vincent Hospital, Worcester, United States; Amos Lal, Medicine, Mayo Clinic, United States; Ahmad Daniyal Siddiqui, Medicine, Saint Vincent Hospital, United States; Susan V George, Medicine, Saint Vincent Hospital, United States.

Acknowledgements

Correspondence

Dr Kamal Kant Sahu, MD Medicine, Saint Vincent Hospital, Worcester, United States.

Correspondence Email

kamalkant.sahu@stvincenthospital.com

Competing Interests

Nil.

1. Saxena P, Muthu V, Dhooria S, Sehgal IS, Prasad KT, Agarwal R. Murphy’s law in force: sequential adverse events encountered during the treatment of Pneumocystis pneumonia (cotrimoxazole-induced acute peripheral neuropathy and primaquine-induced methemoglobinemia). N Z Med J. 2020 Jan 17; 133(1508):123–126.

2. Kumar P, Yadav U, Rai V. Prevalence of glucose-6-phosphate dehydrogenase deficiency in India: an updated meta-analysis. Egypt J Med Hum Genet. 2016; 17:295–302.

3. Akhtar J, Johnston BD, Krenzelok EP. Mind the gap. J Emerg Med. 2007 Aug; 33(2):131–2.

4. Sahu KK, Lal A, Mishra AK, George SV. Methemoglobinemia in Transplant Recipient Patients: Future of Dapsone as Pneumocystis carinii Pneumonia Prophylaxis. Prog Transplant. 2020 Jan 2:1526924819893316.

5. Sahu KK, Mishra AK. Role of ascorbic acid in dapsone induced methemoglobinemia. Clin Exp Emerg Med. 2019 Mar; 6(1):91–92.

6. Sehgal IS, et al. Therapeutic whole blood exchange in the management of methaemoglobinemia: Case series and systematic review of literature. Transfus Med. 2020.Al-Qahtani S, Abusham S, Alhelali I. Severe Methemoglobinemia Secondary to Ferula asafoetida Ingestion in an Infant: A Case Report. Saudi J Med Med Sci. 2020 Jan–Apr; 8(1):56–59.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

We read with great interest the recent article by Saxena et al on methemoglobinemia.1 We appreciate the diligent workup by Saxena et al that led to the timely diagnosis of the methemoglobinemia.

Patient reported by Saxena et al had a hemoglobin value of 10.3gm/dl. The anemia in the index subject was probably multifactorial-nutritional deficiency, anemia of chronic disease or secondary to bone marrow depression due to methotrexate use. Methemoglobinemia can also be associated with intravascular hemolysis, which is another common cause of anemia. The same was ruled out in the index case by confirming a negative hemolytic work up (normal values for unconjugated bilirubin, haptoglobin, lactic acid dehydrogenase and glucose-6-phosphate dehydrogenase). Using methylene blue (MB), the antidote for methemoglobinemia has two major hurdles; first, it is not universally available; and second, caution while using in patients with known or suspected G6PD deficiency. Knowing about the local disease burden of G6PD deficiency is important as it is the most common human enzyme defect, affecting approximately 400 million population globally. A recent meta-analysis (72 studies, sample size of 38,565) on the Indian population showed the overall magnitude of approximately 8.5% (varied from 0–27% depending on regional and ethnic background).2 As G6PD is a X-linked disease, males usually show full-blown disease while the majority of females remain unaffected carriers. Other known contraindications to use MB are hypersensitivity to MB, cyanide poisoning-related methemoglobinemia and severe renal impairment.

Saturation gap of 8% in index case was well above the value of 5%, which is considered as a threshold of significant gap.3 In small centres where Evelyn-Malloy method of methemoglobin is difficult to detect, a more handy way to quantify methemoglobin is Rad-57 pulse oximeter, which uses eight-light wavelengths of light instead of the usual two.

Pneumocystis pneumonia (PCP) is a very challenging disease, especially in immunocompromised individuals. We recently addressed the cost-benefit analysis of using dapsone as PCP prophylaxis in transplant patients that also has a potential to cause methemoglobinemia.4 As mentioned by Saxena et al, MB is the only FDA-approved antidote of choice for methemoglobinemia. Ascorbic acid, cimetidine and riboflavin are few other drugs that can be used as adjunctive therapy with variable outcomes.5 Hyperbaric oxygen therapy and red blood cell exchange can be considered in refractory cases or when conventional therapy is contraindicated.6,7

In conclusion, the index case illustrates the therapeutic and diagnostic challenge while approaching a suspected case of methemoglobinemia. Early recognition, timely removal of the inciting drug, and treatment can avert the fatality related to methemoglobinemia.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Kamal Kant Sahu, Medicine, Saint Vincent Hospital, Worcester, United States; Ajay Kumar Mishra, Medicine, Saint Vincent Hospital, Worcester, United States; Amos Lal, Medicine, Mayo Clinic, United States; Ahmad Daniyal Siddiqui, Medicine, Saint Vincent Hospital, United States; Susan V George, Medicine, Saint Vincent Hospital, United States.

Acknowledgements

Correspondence

Dr Kamal Kant Sahu, MD Medicine, Saint Vincent Hospital, Worcester, United States.

Correspondence Email

kamalkant.sahu@stvincenthospital.com

Competing Interests

Nil.

1. Saxena P, Muthu V, Dhooria S, Sehgal IS, Prasad KT, Agarwal R. Murphy’s law in force: sequential adverse events encountered during the treatment of Pneumocystis pneumonia (cotrimoxazole-induced acute peripheral neuropathy and primaquine-induced methemoglobinemia). N Z Med J. 2020 Jan 17; 133(1508):123–126.

2. Kumar P, Yadav U, Rai V. Prevalence of glucose-6-phosphate dehydrogenase deficiency in India: an updated meta-analysis. Egypt J Med Hum Genet. 2016; 17:295–302.

3. Akhtar J, Johnston BD, Krenzelok EP. Mind the gap. J Emerg Med. 2007 Aug; 33(2):131–2.

4. Sahu KK, Lal A, Mishra AK, George SV. Methemoglobinemia in Transplant Recipient Patients: Future of Dapsone as Pneumocystis carinii Pneumonia Prophylaxis. Prog Transplant. 2020 Jan 2:1526924819893316.

5. Sahu KK, Mishra AK. Role of ascorbic acid in dapsone induced methemoglobinemia. Clin Exp Emerg Med. 2019 Mar; 6(1):91–92.

6. Sehgal IS, et al. Therapeutic whole blood exchange in the management of methaemoglobinemia: Case series and systematic review of literature. Transfus Med. 2020.Al-Qahtani S, Abusham S, Alhelali I. Severe Methemoglobinemia Secondary to Ferula asafoetida Ingestion in an Infant: A Case Report. Saudi J Med Med Sci. 2020 Jan–Apr; 8(1):56–59.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

We read with great interest the recent article by Saxena et al on methemoglobinemia.1 We appreciate the diligent workup by Saxena et al that led to the timely diagnosis of the methemoglobinemia.

Patient reported by Saxena et al had a hemoglobin value of 10.3gm/dl. The anemia in the index subject was probably multifactorial-nutritional deficiency, anemia of chronic disease or secondary to bone marrow depression due to methotrexate use. Methemoglobinemia can also be associated with intravascular hemolysis, which is another common cause of anemia. The same was ruled out in the index case by confirming a negative hemolytic work up (normal values for unconjugated bilirubin, haptoglobin, lactic acid dehydrogenase and glucose-6-phosphate dehydrogenase). Using methylene blue (MB), the antidote for methemoglobinemia has two major hurdles; first, it is not universally available; and second, caution while using in patients with known or suspected G6PD deficiency. Knowing about the local disease burden of G6PD deficiency is important as it is the most common human enzyme defect, affecting approximately 400 million population globally. A recent meta-analysis (72 studies, sample size of 38,565) on the Indian population showed the overall magnitude of approximately 8.5% (varied from 0–27% depending on regional and ethnic background).2 As G6PD is a X-linked disease, males usually show full-blown disease while the majority of females remain unaffected carriers. Other known contraindications to use MB are hypersensitivity to MB, cyanide poisoning-related methemoglobinemia and severe renal impairment.

Saturation gap of 8% in index case was well above the value of 5%, which is considered as a threshold of significant gap.3 In small centres where Evelyn-Malloy method of methemoglobin is difficult to detect, a more handy way to quantify methemoglobin is Rad-57 pulse oximeter, which uses eight-light wavelengths of light instead of the usual two.

Pneumocystis pneumonia (PCP) is a very challenging disease, especially in immunocompromised individuals. We recently addressed the cost-benefit analysis of using dapsone as PCP prophylaxis in transplant patients that also has a potential to cause methemoglobinemia.4 As mentioned by Saxena et al, MB is the only FDA-approved antidote of choice for methemoglobinemia. Ascorbic acid, cimetidine and riboflavin are few other drugs that can be used as adjunctive therapy with variable outcomes.5 Hyperbaric oxygen therapy and red blood cell exchange can be considered in refractory cases or when conventional therapy is contraindicated.6,7

In conclusion, the index case illustrates the therapeutic and diagnostic challenge while approaching a suspected case of methemoglobinemia. Early recognition, timely removal of the inciting drug, and treatment can avert the fatality related to methemoglobinemia.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Kamal Kant Sahu, Medicine, Saint Vincent Hospital, Worcester, United States; Ajay Kumar Mishra, Medicine, Saint Vincent Hospital, Worcester, United States; Amos Lal, Medicine, Mayo Clinic, United States; Ahmad Daniyal Siddiqui, Medicine, Saint Vincent Hospital, United States; Susan V George, Medicine, Saint Vincent Hospital, United States.

Acknowledgements

Correspondence

Dr Kamal Kant Sahu, MD Medicine, Saint Vincent Hospital, Worcester, United States.

Correspondence Email

kamalkant.sahu@stvincenthospital.com

Competing Interests

Nil.

1. Saxena P, Muthu V, Dhooria S, Sehgal IS, Prasad KT, Agarwal R. Murphy’s law in force: sequential adverse events encountered during the treatment of Pneumocystis pneumonia (cotrimoxazole-induced acute peripheral neuropathy and primaquine-induced methemoglobinemia). N Z Med J. 2020 Jan 17; 133(1508):123–126.

2. Kumar P, Yadav U, Rai V. Prevalence of glucose-6-phosphate dehydrogenase deficiency in India: an updated meta-analysis. Egypt J Med Hum Genet. 2016; 17:295–302.

3. Akhtar J, Johnston BD, Krenzelok EP. Mind the gap. J Emerg Med. 2007 Aug; 33(2):131–2.

4. Sahu KK, Lal A, Mishra AK, George SV. Methemoglobinemia in Transplant Recipient Patients: Future of Dapsone as Pneumocystis carinii Pneumonia Prophylaxis. Prog Transplant. 2020 Jan 2:1526924819893316.

5. Sahu KK, Mishra AK. Role of ascorbic acid in dapsone induced methemoglobinemia. Clin Exp Emerg Med. 2019 Mar; 6(1):91–92.

6. Sehgal IS, et al. Therapeutic whole blood exchange in the management of methaemoglobinemia: Case series and systematic review of literature. Transfus Med. 2020.Al-Qahtani S, Abusham S, Alhelali I. Severe Methemoglobinemia Secondary to Ferula asafoetida Ingestion in an Infant: A Case Report. Saudi J Med Med Sci. 2020 Jan–Apr; 8(1):56–59.

Contact diana@nzma.org.nz
for the PDF of this article

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