Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
Medical Image of the Week: Blue-Green Urine and the Serotonin Syndrome
Figure 1. Panel A: blue-green urine a few hours after parathyroid surgery. Panel B: normal urine color 72 hours post-surgery.
A 56-year-old woman was electively admitted for parathyroidectomy for primary hyperparathyroidism with osteoporosis. Five hours post operatively, she developed acute change in mental status. The neurological exam showed inducible clonus, agitation, diaphoresis, ocular clonus, rigidity and hyperreflexia. The patient met Hunter criteria for the diagnosis of serotonin syndrome by being on citalopram and tramadol with the neurological exam findings (1). The patient had been on the same doses of these medications for years with no recent change in kidney or liver functions. The blue-green urine color was strikingly strange. Reviewing the operation room event records showed that she received a high dose of methylene blue to help identify the parathyroid glands.
Serotonin syndrome has been reported with concomitant administration of methylene blue and serotonin reuptake inhibitors (e.g., SSRIs, SNRIs, tricyclic antidepressants). It is recommended to avoid concomitant use and allow a washout period of at least 4-5 half-lives of the serotonin reuptake inhibitor prior to intravenous methylene blue use (2). Within 72 hours of holding tramadol and citalopram the patient recovered completely.
Huthayfa Ateeli, MBBS and Laila Abu Zaid, MD.
Department of Medicine, University of Arizona, Tucson, AZ USA
References
- Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20. [CrossRef] [PubMed]
- Ng BK, Cameron AJ. The role of methylene blue in serotonin syndrome: a systematic review. Psychosomatics. 2010 May-Jun;51(3):194-200. [CrossRef] [PubMed]
Cite as: Ateeli H, Azid LA. Medical image of the week: blue-green urine and the serotonin syndrome. Southwest J Pulm Crit Care. 2018;16(2):90. doi http://doi.org/10.13175/swjpcc024-18 PDF