Methemoglobinemia and hemolytic anemia after phenazopyridine hydrochloride (Pyridium) administration in end-stage renal disease

Phenazopyridine is a commonly used urinary tract analgesic. As illustrated by the case we have reported, its use may be complicated by the development of methemoglobinemia and hemolytic anemia, especially in patients with renal insufficiency.     

Acute Dapsone Intoxication: A Case Treated with Continuous Infusion of Methylene Blue,Forced Diuresis and Plasma Exchange

Abstract

A case of massive dapsone poisoning (15?g) in a 26 year old man is reported. The patient exhibited high plasma dapsone concentration, marked methemoglobinemia, and signs of hemolysis. He recovered completely after intensive treatment with methylene blue, activated charcoal, forced diuresis, and plasma exchange. In order to avoid overdosage of methylene blue it is concluded that this substance should be given by continuous intravenous infusion in cases with severe methemoglobinemia. This way of administration caused a steady decrease in the methemoglobin concentration compared to intermittent administration. Plasma exchange was of minor benefit, probably due to the large distribution volume of dapsone.     

Hemolysis and methemoglobinemia secondary to rasburicase administration

OBJECTIVE: To report a case of hemolytic anemia and methemoglobinemia developing after rasburicase administration to a patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency. CASE SUMMARY: A 50-year-old African American man was hospitalized with new onset seizure, diabetic ketoacidosis, respiratory failure, and acute renal failure. Serum uric acid concentrations were elevated, and the patient was treated with one dose of intravenous rasburicase 22.5 mg for acute renal failure secondary to hyperuricemia. Routine arterial blood gas analyses performed after rasburicase was administered revealed elevated methemoglobin concentrations, which peaked at 14.7%. Hemolytic anemia developed as evidenced by a fall in blood hemoglobin from 14.8 to 5.3 g/dL. The patient made a full recovery following aggressive fluid therapy, blood transfusions, and respiratory support. G6PD deficiency was subsequently confirmed. The Naranjo probability scale indicated that rasburicase was a probable cause of hemolytic anemia and methemoglobinemia. DISCUSSION: Rasburicase is contraindicated in patients with G6PD deficiency as it may cause hemolytic anemia and methemoglobinemia. As of September 26, 2005, simultaneous occurrence of hemolytic anemia and methemoglobinemia has not been reported in patients receiving rasburicase. CONCLUSIONS: As of September 26, 2005, screening for G6PD deficiency should be performed whenever possible prior to chemotherapy administration in patients at risk of developing tumor lysis syndrome.     

Celecoxib-induced methemoglobinemia

OBJECTIVE: To report a case of acute methemoglobinemia in a patient treated with celecoxib for osteoarthritis. CASE SUMMARY: A 72-year-old African American man developed an acute confusional state (ACS) one month after receiving celecoxib for osteoarthritis of his knee joints. There was no other identifiable cause of ACS such as any recognized cause of metabolic encephalopathy, meningoencephalitis, cerebrovascular accident, or drug intoxication. He was found to have severe methemoglobinemia (serum methemoglobin fraction 9%; reference range 0-0.2). His symptoms improved substantially, and serum methemoglobin levels decreased to 0.7% after the initiation of methylene blue therapy. He was discharged on oral riboflavin and ascorbic acid and was advised not to restart celecoxib therapy. He had not shown any recurrence of the symptoms at a follow-up visit 2 months after the withdrawal of celecoxib. DISCUSSION: Celecoxib is a nonsteroidal antiinflammatory drug that selectively inhibits cyclooxygenase-2. Acute methemoglobinemia can present as a syndrome of nonspecific symptoms such as headache, nausea, fatigue, dyspnea, and lethargy; these may progress to respiratory depression, coma, shock, seizures, and death. Although acute methemoglobinemia has been reported with the use of several drugs, including sulfonamides, as of August 13, 2004, this is the first case report of severe methemoglobinemia manifesting as ACS with celecoxib therapy. Use of the Naranjo probability scale indicated a probable relationship between the clinical manifestations of methemoglobinemia and celecoxib therapy in this patient. CONCLUSIONS: Celecoxib can be associated with acute methemoglobinemia. Prompt diagnosis of this condition, withdrawal of celecoxib, and treatment with the antagonists (methylene blue, ascorbic acid, riboflavin) can reverse this potentially serious condition.     

Siblings with pediatric sodium chlorite toxicity causing methemoglobinemia,renal failure and hemolytic anemia

Introduction: Over the past decade, Miracle Mineral Solution (sodium chlorite) has been promoted as a cure-all for many conditions. Case Report: A 9-year-old boy presented with his brother after they accidentally ingested a small amount of undiluted 22.4% sodium chlorite. Symptoms included nausea, vomiting, diarrhea, and dyspnea. Oxygen saturation remained 71% despite supplemental oxygen (15L/min). The patient was noted to have dark chocolate-appearing blood, minimal urine output, diffuse pallor and cyanosis. He developed methemoglobinemia, renal failure requiring renal replacement therapy and hemolysis requiring blood transfusion. Discussion: These are the 7^th and 8^th reported cases of sodium chlorite toxicity by ingestion and the second and third in children. Takeaway for Physicians: Miracle Mineral Solution is a commonly purchased potentially lethal compound that can cause methemoglobinemia with respiratory failure, hemolytic anemia requiring transfusion and renal failure requiring dialysis.     

Acquired methemoglobinemia from phenazopyridine use

Background

Phenazopyridine-induced methemoglobinemia is relatively rare with fewer than ten cases reported over the past 35 years. We describe a case of phenazopyridine-induced methemoglobinemia that is unique in the way the patient presented and how initial workup was completed.

Case presentation

The patient presented with lethargy, diarrhea, light-headedness, and headaches, with past medical history of breast cancer, seizures, and recent dysuria for which she had been taking phenazopyridine. She was noted to have a persistent hypoxemia despite supplemental oxygen delivery and a shunting process was considered, with pulmonary embolus and methemoglobinemia due to phenazopyridine use being of chief concern. She was stabilized, and confirmation of original diagnosis was made at the main ED and treatment successfully rendered with good effect.

Conclusions

Methemoglobinemia, while rare, can be associated with use of over-the-counter medicines and should be considered as part of a broad differential. This case serves to emphasize the importance of a thorough history and physical—tools especially helpful when at a satellite facility with relatively limited resources.

     

Therapeutic apheresis for babesiosis

Infection with the tick-borne protozoa Babesia is becoming more common. Babesiosis is usually successfully treated with antibiotics but, in some cases, apheresis may also be indicated. We report two patients with babesiosis and hemolysis treated by apheresis and antibiotics. One case had traditional indications for red blood cell (RBC) exchange, and a second patient was treated with RBC exchange, and plasmapheresis for hemolysis, probably secondary to Babesia parasitemia. Case 1 involved a 44-year-old man with chronic relapsing pancreatitis who had become infected with Babesia from a unit of RBCs transfused during surgery. At 5 weeks after surgery, fever and severe hemolysis developed, along with a hemoglobin of 69 g/L; 30% of his RBCs were found to be infected with Babesia. This patient had several postoperative complications; the babesiosis was treated with clindamycin, quinine, and three RBC exchanges. Parasitemia fell to less then 1% of RBCs, but the patient died of pancreatitis. Case 2 was a 47-year-old man with a renal transplant who had been receiving immunosuppressive therapy for 8 years. He had a history of tick bites, fever, and hemolytic anemia. Analysis of a peripheral blood smear detected Babesia. He was initially treated with antibiotic therapy and two RBC exchanges. Hemolysis improved transiently but worsening parasitemia developed later, as well as an IgG RBC autoantibody. He was then treated by plasmapheresis and RBC exchange. Although his condition improved, he had a third hemolytic episode, which was treated with plasmapheresis and RBC exchange before the parasitemia and autoimmune hemolytic anemia disappeared. In conclusion, immunosuppressed or severely ill people who become infected with Babesia may benefit from RBC exchange or plasmapheresis, or both. J. Clin. Apheresis 13:32–36, 1998. © 1998 Wiley-Liss, Inc.     

High dose vitamin C induced methemoglobinemia and hemolytic anemia in glucose-6-phosphate dehydrogenase deficiency

Investigational use of intravenous vitamin C has been on the rise, but its side effects may be underreported. A 75-year-old woman presented with acute onset of jaundice, dark urine and shortness of breath after receiving 30 g of vitamin C infusion as an unconventional therapy for her hemifacial spasm. Diagnosis of methemoglobinemia and hemolytic anemia was made clinically and confirmed on laboratory tests. She recovered with supportive treatment and packed cell transfusion. Her previously unrecognised underlying condition of glucose-6-phosphate dehydrogenase (G6PD) deficiency was confirmed months after the initial presentation. This is the first reported case of methemoglobinemia and hemolytic anemia induced by high dose vitamin C in a female patient with G6PD deficiency. The dosage of vitamin C administered was also relatively low compared with previous adult reports. When administered at physiological dose, vitamin C can be used as an alternative to methylene blue in treatment of methemoglobinemia in patients with G6PD deficiency. However at supraphysiological dose vitamin C can paradoxically lead to hemolytic anemia in the same group of patients. Physicians should be alert of these potential complications of high dose vitamin C.     

Octreotide-induced acute life-threatening gallstones after vicarious contrast medium excretion: A case report

BACKGROUNDOctreotide is widely used for the treatment of acromegaly, neuroendocrine tumors, and secretory diarrhea. However, long-term octreotide treatment can increase the incidence of gallstones. Vicarious contrast medium excretion (VCME) through the hepatobiliary system is well known. However, few studies have reported octreotide-induced acute gallstones following VCME.CASE SUMMARYA 69-year-old man presented with left lower back pain and hematuria caused by a fall. The patient had a history of polycystic kidney disease. VCME occurred following renal artery embolization for a ruptured polycystic kidney. After 5 d of treatment with octreotide, the patient developed acute gallstones and intrahepatic cholestasis which further induced pancreatitis and cholangitis. He was discharged after hemodialysis, antibiotics, and supportive treatments.CONCLUSIONFor patients with a high-risk of VCME, octreotide should be cautiously administered and carefully monitored.     

Phenazopyridine-induced sulfhemoglobinemia

OBJECTIVE: To report a case of sulfhemoglobinemia in a patient receiving phenazopyridine for a urinary tract infection. CASE SUMMARY: A 63-year-old white woman presented to the emergency department with complaints of fatigue and bluish discoloration of her body that had gradually progressed over the previous 6-8 weeks. About 4 months prior to presenting to the emergency department, she had started taking phenazopyridine, an over-the-counter medication for symptoms of dysuria. Because the cyanosis did not improve after the patient received oxygen and methylene blue, sulfhemoglobinemia was suspected and confirmed by spectrophotometer analysis. DISCUSSION: Sulfhemoglobin is a green-pigmented molecule containing a sulfur atom in one or more of the porphyrin rings. It is a rare cause of cyanosis, which is usually drug induced. Sulfhemoglobinemia is suspected when a cyanotic patient has normal to near-normal oxygen tension, laboratory reports of elevated methemoglobin, and does not respond to methylene blue therapy. Sulfhemoglobinemia is relatively rare, despite the widespread use of drugs that have been reported to cause it. Predisposing factors, such as chronic constipation, present in our patient, have been suggested as a source of hydrogen sulfide. CONCLUSIONS: This case of sulfhemoglobinemia, which occurred after the patient took phenazopyridine, is considered a probable adverse event according to the Naranjo probability scale.     

Methemoglobinemia and acute hemolysis after tetracaine lozenge use

Acquired methemoglobinemia is a rare but severe condition associated with oxidizing stressors, most notably medications. Although the symptoms can be life threatening, they usually respond promptly to exposure cessation and methylene blue injection. We describe the first case of methemoglobinemia associated with tetracaine lozenge use. A previously healthy 33-year-old man was admitted with fever, respiratory distress, cyanosis, and acute hemolysis. Physical findings and chest radiograph were normal. Low pulse oximetry readings contrasted with normal partial pressure of oxygen and calculated oxygen saturation. The methemoglobin level was 10.8%. The patient recovered with methylene blue injection and blood transfusions. He reported recent self-medication with tetracaine lozenges for a sore throat during a flu-like illness. No other cause of methemoglobinemia was found.     

Methemoglobinemia in a Case of Paint Thinner Intoxication,Treated Successfully with Vitamin C

Background

Methemoglobin (MetHb) is an oxidized form of hemoglobin. It is a poor transporter of oxygen and is unable to deliver oxygen to the tissue. Globally, drug & toxin induced methemoglobinemia is more common as compared with the congenital form. Methemoglobinemia caused by paint thinner intoxication is rare. Methylene blue is well established as the first-line therapy for severe methemoglobinemia.

Small bowel ulcer bleeding due to suspected clopidogrel use in a patient with clopidogrel resistance: A case report

BACKGROUNDClopidogrel is a platelet aggregation inhibitor used for the management of cardiovascular disease. While antiplatelet therapy decreases cardiovascular events after successful coronary drug-eluting stenting, it increases the risk of gastrointestinal (GI) bleeding. About 20% of the patients who take clopidogrel exhibit resistance to the drug.CASE SUMMARYWe report the first case of a small bowel bleeding ulcer in an 86-year-old man with clopidogrel resistance. He had a history of taking clopidogrel due to unstable angina. There was no evidence of bleeding in the stomach, duodenum, or colon through upper and lower GI endoscopies. The abdominal computed tomography showed the extravasation of radiocontrast media at the ileum. Because of unstable vital signs, emergency surgery was performed. Multiple ulcers with inflammation were found in the ileum. The pathologic findings revealed simple inflammation. The VerifyNow P2Y12 test showed clopidogrel resistance. One year after changing to aspirin, capsule endoscopy was performed and the small bowel ulcers were improved.CONCLUSIONSmall bowel ulcers and bleeding due to clopidogrel are not very common, but the prevalence is expected to increase in older age patients with risk factors despite clopidogrel resistance.     

Rapidly progressive fatal pneumococcal sepsis in adults: a report of two cases

We report two cases of a rapidly progressive fatal overwhelming pneumococcal infection. Patient 1 was a 67-year-old man with a 24-h history of fever and malaise and was transferred to our department. He was severely ill, tachypneic, and felt a chill. A purpuric discoloration with ecchymosis of the skin was noted over the body. The chest X-ray findings demonstrated thickening of the bronchovascular bundle in the right lower lung field, which later revealed the presence of bronchopneumonia. Laboratory studies revealed the presence of metabolic acidosis and disseminated intravascular coagulation. After presentation, rapid deterioration occurred followed by cardiopulmonary arrest. Despite cardiopulmonary resuscitation, the patient died only 3 h after presentation. The isolates from the patient's blood revealed penicillin-susceptible Streptococcus pneumoniae, serotype 4. Patient 2 was a 30-year-old woman with a prior history of uneventful pregnancies was transferred to our department with a 2-day history of fever, nausea, headache, and malaise. Although she was in the 19th week of pregnancy at the time, she suffered a miscarriage just prior to admission. Upon presentation to our department, she demonstrated unstable vital signs, diminished consciousness, anuria, and icterus. Purpuric discoloration with ecchymosis of the skin was noted in over most of her body, including the distal extremities. The chest X-ray findings were close to normal. Initial laboratory studies revealed the presence of severe metabolic acidosis and disseminated intravascular coagulation with multiple organ failure. Despite aggressive cardiopulmonary support, normal neurological responses disappeared on the 2nd day following admission and the patient died on the 16th day after admission. The patient's isolates from blood and vaginal swabs both later revealed penicillin-susceptible Streptococcus pneumoniae, serotype 12F. The presentation of rapidly progressive septic shock should raise the treating physician's suspicion of overwhelming pneumococcal infection, which has limited management options.     

The Morel-Lavallée lesionLavalleeLavelle

BackgroundTrauma patients present to the emergency department with various injuries. Few injuries can be easily missed during the evaluation of polytrauma patients. We report one such rare injury in a trauma patient.Case ReportWe report the case of a 67-year-old man who presented to the emergency department with an alleged history of trauma. He reported severe pain in the lower abdomen, right hip, and right thigh. An x-ray study did not reveal any bony injury, and an extended focused assessment with sonography in trauma was also negative. Point-of-care ultrasound of his right thigh revealed the presence of a Morel-Lavallée lesion.Why Should an Emergency Physician Be Aware of This?Morel-Lavallée lesions are post-traumatic, closed, degloving injuries that go unnoticed in many polytrauma patients. Emergency physicians should be mindful of this lesion because delay in diagnosis can result in significant complications.     

An over-the-counter omission

Despite the widespread use of over-the-counter (OTC) medications, their utilization is rarely ascertained at hospital admission. Presented here is an interesting case of acute renal failure and hemolytic anemia attributable to a commonly utilized OTC medication. The chronic use of phenazopyridine accounted for all of these findings. Upon discontinuation, everything normalized within one month. Although the differential diagnosis for renal failure and hemolytic anemia is extensive, scleral icterus, normal bilirubin, and orange-colored urine raised the suspicion of phenazopyridine use. This case report highlights overuse of common OTC medications, as well as a lack of knowledge of potential adverse reactions. With history-taking vigilance and patient education, adverse events from OTC medications can be minimized.     

Needle Embolization: Suspecting Needle Migration in Intravenous Drug Abusers

BackgroundThirteen million people inject drugs globally, making intravenous drug abuse a substantial concern worldwide. While intravenous drug users occasionally report the breaking of a needle into the skin or subcutaneous tissue, central needle migration remains a rare but potentially devastating complication.Case ReportA 27-year-old man with a history of intravenous drug abuse presented to the emergency department with the sudden onset of left-sided neck pain, chills, and subjective fever with a history of needle breaking in his left neck 3 weeks earlier while using heroin. A computed tomography scan of his chest revealed a needle lodged in the right ventricle with associated mediastinitis and mass effect on the left brachiocephalic vein, and a left internal jugular thrombus. Broad-spectrum antibiotics were initiated. This patient was managed nonsurgically for several reasons and was discharged on hospital day 12 with oral antibiotics.Why Should an Emergency Physician Be Aware of This?Intravenous drug abusers commonly use cervical veins when their peripheral vasculature has become sclerosed. This puts intravenous drug users at increased risk for intravascular embolization. Due to varied symptomology—chest pain, dyspnea, fever, or asymptomatic—and timelines—days, weeks, or months—after reported needle fragmentation, this remains a complex and likely underdiagnosed condition. Case reports describe serious complications of intracardiac needle embolization, such as cardiac perforation, constrictive pericarditis, septic endocarditis, dysrhythmias, granulomas, venous thrombosis, empyema, acute or delayed spontaneous pneumothorax, osteomyelitis, and valvular damage. In this complicated patient population, clinicians should consider needle retention and relocation in patients who report needle breaking or in those who present with chest pain, dyspnea, or fever among other complaints.     

Acute coronary syndrome with severe atherosclerotic and hyperthyroidism: A case report

BACKGROUNDAcute coronary syndrome (ACS) encompasses a spectrum of cardiovascular emergencies arising from the obstruction of coronary artery blood flow and acute myocardial ischemia. Recent studies have revealed that thyroid function is closely related to ACS. However, only a few reports of thyrotoxicosis-induced ACS with severe atherosclerosis have been reported.CASE SUMMARYA 33-year-old man, who had a history of hyperthyroidism without taking any antithyroid drugs and no history of coronary heart disease, experienced neck pain with occasional heart palpitations starting 3 mo prior that were aggravated after an activity. As the symptoms worsened at 21 d prior, he went to a hospital for treatment. The electrocardiogram examination showed a multilead ST segment elevation and pathological Q waves. Based on these findings and his symptoms, the patient was diagnosed with a suspected myocardial infarction and transferred to our hospital on July 2, 2020. He was diagnosed with a rare case of ACS due to coronary artery atherosclerosis in the anterior descending artery complicated by hyperthyroidism. A paclitaxel-coated drug balloon was used for treatment to avoid the use of metal stents, thus reducing the time of antiplatelet therapy and facilitating the continued treatment of hyperthyroidism. The 9-mo follow-up showed favorable results.CONCLUSIONThis case highlights that atherosclerosis is a cause of ACS that cannot be ignored even in a patient with hyperthyroidism.     

A Rare Presentation of Epstein–Barr Virus Infection

BackgroundEpstein–Barr virus (EBV) is a herpesvirus spread by intimate contact. It is known to cause infectious mononucleosis. Complications, including hematologic pathology and splenic rupture, are uncommon. This report is a case of EBV-induced autoimmune hemolytic anemia and biliary stasis.Case ReportAn 18-year-old man presented to the emergency department with abdominal pain, nausea, vomiting, and jaundice. He did not have risk factors for liver injury or hepatitis. His vital signs were notable for a fever. On examination, he was obviously jaundiced, but not in distress. Laboratory evaluation showed hemolytic anemia and biliary stasis. Ultimately, his inpatient workup yielded positive EBV serology and a positive direct agglutinin test with cold agglutinins. He made a full recovery with supportive care.Why Should an Emergency Physician Be Aware of This?EBV is a widely disseminated herpesvirus. Infectious mononucleosis is a common presentation of acute infection, and treatment of EBV-related diseases are largely supportive. Complications, such as splenic rupture and hematologic pathology, are uncommon. Biliary stasis and autoimmune hemolytic anemia in the form of cold agglutinin disease secondary to EBV is rare, and typically resolves with supportive care and cold avoidance. More advanced treatment methods are available in the setting of severe hemolysis. Elevated transaminases, direct hyperbilirubinemia, or evidence of hemolytic anemia in the setting of a nonspecific viral syndrome should raise suspicion for EBV infection. Rapid recognition can lead to more prompt prevention and treatment of other EBV-related complications.     

Intravenous Imferon masquerading as an acute hemolytic transfusion reaction

The case of a 74-year-old woman with a history of chronic iron deficiency anemia requiring transfusion is reported. Shortly after receiving intravenous iron-dextran, the patient was transfused with two units of crossmatch compatible packed red blood cells and subsequently experienced severe racking chills associated with mild elevation of temperature. In the evaluation of this febrile reaction, her serum exhibited a distinct red-brown discoloration which was interpreted as free hemoglobin. Laboratory studies performed to evaluate the possibility of acute intravascular hemolysis were all within normal limits. Subsequent investigation revealed that the color of the recipients serum was due to iron-dextran. Caution is urged in the evaluation of patients for hemolytic transfusion reactions who have been administered intravenous iron-dextran, since the drug imparts a red-brown tinge to the plasma which may be misinterpreted as free hemoglobin.