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ACEP Now: Vol 41 – No 05 – May 2022

Photo 3: Post methylene green urine.

The mainstay therapy for treating methemoglobinemia is methylene blue, which is converted to leucomethylene blue in the presence of NADPH and NADPH methemoglobinemia reductase.⁵ The leucomethylene facilitates the reduction of ferric to ferrous iron state through the NADPH reductase pathway.⁵ Methylene blue is administered at one to two mg/kg of body weight intravenously over five minutes. It is important to note that methylene blue will display a spurious pulse oximeter reading owing to its blue color absorbance at 660 nm.⁶ Cautious use of methylene blue in patients with G6PD deficiency should be noted as the treatment can lead to hemolysis. Alternative or adjunctive treatments include ascorbic acid and exchange transfusion.

Conclusion

Oral ingestion of isobutyl nitrite leads to life-threatening hemodynamic instability and methemoglobinemia due to its vasodilatory and oxidizing effects, respectively. Methylene blue is the mainstay treatment of symptomatic methemoglobinemia. 

References

1. Nitrite “poppers.” FDA. https://www.fda.gov/consumers/consumer-updates/nitrite-poppers.
2. Elgendy F, Del Rio-Pertuz G, Nguyen D, et al. “Popper” induced methemoglobinemia [published online Feb. 2, 2022]. Proc (Bayl Univ Med Cent).
3. Romanelli F, Smith KM, Thornton AC, et al. Poppers: epidemiology and clinical management of inhaled nitrite abuse. Pharmacotherapy. 2004;24(1):69-78.
4. Vaccher SJ, Hammoud MA, Bourne A, et al. Prevalence, frequency, and motivations for alkyl nitrite use among gay, bisexual and other men who have sex with men in Australia. Int J Drug Policy.2020;76:102659.
5. 5. Taylor GM, Avera RS, Strachan CC, et al. Severe methemoglobinemia secondary to isobutyl nitrite toxicity: the case of the ‘Gold Rush.’ Oxf Med Case Reports. 2021;2021(2):omaa136.
6. Kirlangitis JJ, Middaugh RE, Zablocki A, et al. False indication of arterial oxygen desaturation and methemoglobinemia following injection of methylene blue in urological surgery. Mil Med. 1990;155(6):260-262.

Dr. Shaker is medical toxicology fellow at the University of Texas Southwestern Medical Center in Dallas. Dr. Onisko and Dr. Sharma are both medical toxicologists and assistant professors also in the department