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
Medical Image of the Week: Methemoglobinemia
Figure 1. A: cyanotic lips and tongue. B: restoration of reddish color after methylene blue infusion.
Figure 2. Patient’s blood showing a chocolate brown color.
A 62-year-old man with a sternal infection post-coronary artery bypass grafting was transferred because of increasing oxygen requirements, decreased mental status and Candida paralopsis fungemia. He had been treated with multiple antibiotics including sulfonamides and had eventually undergone a tracheostomy. Cetacaine was used for complaints of a sore throat. Physical examination showed cyanotic lips and tongue (Figure 1A). Blood drawn was a chocolate brown color (Figure 2). His SpO2 was 88%, however, arterial blood gases showed his SaO2 was 100% and his PaO2 453 mmHg. Co-oximetry showed 26% methemoglobin. He was administered 0.2mL/kg of 1% solution of methylene blue and his cyanosis rapidly cleared (Figure 1B).
Methemoglobinemia is a condition characterized by increased quantities of hemoglobin with iron oxidized to the ferric (Fe3+) form (1). Methemoglobin is useless as an oxygen carrier and thus causes a varying degree of cyanosis and hypoxia. It can be genetic but is usually caused by exposure to drugs or toxins. Symptoms are proportional to the fraction of methemoglobin. A normal methemoglobin fraction is about 1%. Symptoms associated with higher levels of methemoglobin are: 3-15% - cyanosis; 25-50% - headache, dyspnea; 50-70% - cardiac arrhythmias, altered mental status, delirium, seizures, coma; >70% - death. Drugs most commonly associated with methemoglobinemia include topical and injected local anesthetics (benzocaine, lidocaine, cetacaine), sulfonamides (dapsone), and nitrates (nitroprusside).
Intravenous methylene blue, a reducing agent, is the traditional antidotal agent (1). Exchange transfusion and hyperbaric oxygen treatment are second-line options for patients with severe methemoglobinemia who do not respond to methylene blue or who cannot be treated with methylene blue (e.g., those with glucose-6-phosphate dehydrogenase [G6PD] deficiency).
Robert A. Raschke, MD, MS
University of Arizona College of Medicine-Phoenix and Banner University Medical Center
Phoenix, AZ USA
Reference
- Denshaw-Burke M. Methemoglobinemia. Medscape. Nov 14, 2017. Available at: https://emedicine.medscape.com/article/204178-overview (accessed 1/11/18).
Cite as: Raschke RA. Medical image of the week: methemoglobinemia. Southwest J Pulm Crit Care. 2018;16(1):49-50. doi: https://doi.org/10.13175/swjpcc007-18 PDF