Severe Methemoglobinemia due to Sodium Nitrite Poisoning

亞硝酸鈉中毒引起的嚴(yán)重血紅蛋白血癥

Academic Editor: Ritesh Agarwal

Received19 Mar 2016

Revised04 Jul 2016

Accepted25 Jul 2016

Published03 Aug 2016

學(xué)術(shù)編輯： Ritesh Agarwal

收到 19 三月 2016

修訂 04 七月 2016

接受 25 七月 2016

發(fā)布 03 八月 2016

Abstract 摘要

Case. We report a case of severe methemoglobinemia due to sodium nitrite poisoning.

我們報告一例因亞硝酸鈉中毒引起的嚴(yán)重高鐵血紅蛋白血癥。

A 28-year-old man was brought to our emergency department because of transient loss of consciousness and cyanosis. He was immediately intubated and ventilated with 100% oxygen.

一名28歲的男子被帶到我們的急診科，因為短暫的意識喪失和發(fā)紺。他立即被插管，用100%氧氣通氣。

A blood test revealed a methemoglobin level of 92.5%. Outcome. We treated the patient with gastric lavage, activated charcoal, and methylene blue (2 mg/kg) administered intravenously.

血液測試顯示高鐵血紅蛋白水平為92.5%。結(jié)局。我們通過洗胃、活性炭和靜脈注射亞甲藍(2毫克/千克)來治療患者。

Soon after receiving methylene blue, his cyanosis resolved and the methemoglobin level began to decrease.

接受亞甲藍治療后不久，他的紫紺消失，高鐵血紅蛋白水平開始下降。

After relocation to the intensive care unit, his consciousness improved and he could recall ingesting approximately 15 g sodium nitrite about 1 hour before he was brought to our hospital.

在被轉(zhuǎn)移到重癥監(jiān)護室后，他的意識得到了改善，他記得在被帶到我們醫(yī)院的大約1小時前攝入了大約15克亞硝酸鈉。

The patient was discharged on day 7 without neurologic impairment.

患者在第7天出院，無神經(jīng)損傷。

Conclusion. Severe methemoglobinemia may be fatal.

結(jié)論。嚴(yán)重的高鐵血紅蛋白血癥可能是致命的。

Therefore, accurate diagnosis of methemoglobinemia is very important so that treatment can be started as soon as possible.

因此，準(zhǔn)確診斷高鐵血紅蛋白血癥非常重要，以便盡快開始治療。

1. Introduction 引言

Although methemoglobin levels of >70% are generally fatal, patients with methemoglobin levels of up to 94% have survived [1].

雖然高鐵血紅蛋白水平超過70%通常是致命的，但高鐵血紅蛋白水平高達94%的患者存活了下來[1]。

Sodium nitrite intoxication is a common cause of severe methemoglobinemia;

亞硝酸鈉中毒是嚴(yán)重高鐵血紅蛋白血癥的常見原因；

?however, only one suicidal case has been reported [2].

然而，只有一例自殺病例被報道[2]。

?The concentration of methemoglobin does not exceed 1%-2% in the normal physiological state [3] and levels of 10%–20% generally cause cyanosis.

正常生理狀態(tài)下高鐵血紅蛋白的濃度不超過1%-2%[3]，10%-20%的水平通常會導(dǎo)致發(fā)紺。

On the other hand, methemoglobin levels of 20%–50% may cause symptoms such as respiratory distress, dizziness, headache, and fatigue.

另一方面，20%-50%的高鐵血紅蛋白水平可能會導(dǎo)致呼吸窘迫、頭暈、頭痛和疲勞等癥狀。

Furthermore, loss of consciousness and death can occur at methemoglobin levels of 50%–70% [4].

此外，高鐵血紅蛋白水平在50%-70%時會導(dǎo)致意識喪失和死亡[4]。

Methylene blue is the first choice for treating acute methemoglobinemia. It functions along with natural reduction systems to convert methemoglobin to normal hemoglobin.

亞甲藍是治療急性高鐵血紅蛋白血癥的首選。它與自然還原系統(tǒng)一起將高鐵血紅蛋白轉(zhuǎn)化為正常血紅蛋白。

It is typically administered at doses of 1-2?mg/kg body weight intravenously over 5?min, with symptom improvement expected immediately after the administration.

它通常以1-2毫克/千克體重的劑量靜脈給藥，持續(xù)5分鐘，給藥后癥狀有望立即改善。

In this report, we describe the successful treatment of a case of severe methemoglobinemia due to sodium nitrite poisoning.

在本報告中，我們描述了一例因亞硝酸鈉中毒導(dǎo)致的嚴(yán)重高鐵血紅蛋白血癥的成功治療。

2. Case Presentation案例演示

A 28-year-old man was brought to our emergency department because of transient loss of consciousness and cyanosis.

一名28歲的男子被帶到我們的急診科，因為短暫的意識喪失和發(fā)紺。

He was immediately intubated without concomitant drug administration and ventilated with 100% oxygen.

他立即被插管，沒有同時給藥，并用100%氧氣通氣。

Heart rate was 72?beats/min and blood pressure was 82/50?mmHg;

心率72次/分，血壓82/50 mmHg；

?oxygen saturation was undetectable on pulse oximetry.

脈搏血氧飽和度檢測不到。

His Glasgow Coma Scale score was 3 and he had blue-gray discoloration of the skin, particularly of the face and nail beds (Figure 1).

他的格拉斯哥昏迷評分為3分，皮膚呈藍灰色變色，尤其是面部和甲床(圖1)。

Figure 1?

His face, lips, and toes were deeply cyanosed on admission.

入院時，他的臉、嘴唇和腳趾都嚴(yán)重發(fā)紫。

He was initially treated with 100% oxygen, gastric lavage, and activated charcoal administration.

他最初接受了100%氧氣、洗胃和活性炭治療。

Arterial blood gas analysis and blood tests revealed the following: pH, 7.31; PaCO2, 31.4?mmHg; PaO2, 564?mmHg; base excess, ?10.2?mmol/L; sodium, 137?mmol/L; potassium, 3.2?mmol/L; lactate, 12.1?mmol/L; and methemoglobin, 92.5%.

動脈血氣分析和血液化驗顯示:pH，7.31；二氧化碳，31.4mmHg；PaO2，564mmHg；堿剩余，-10.2mmol/升；鈉，137mmol/升；鉀，3.2mmol/升；乳酸鹽，12.1mmol/升；高鐵血紅蛋白，92.5%。

The patient was immediately given 150?mg methylene blue (2?mg/kg body weight) intravenously over 5?min only at one time.

患者在大于5分鐘一次性靜脈注射150毫克亞甲藍(2毫克/千克體重)。

?He regained consciousness, and cyanosis resolved within minutes after methylene blue injection;

他恢復(fù)了知覺，注射亞甲藍后，發(fā)紺在幾分鐘內(nèi)消失；

?methemoglobin concentration decreased to 19% after 60?min.

60分鐘后，高鐵血紅蛋白濃度降至19%。

On the second day of admission, the patient was extubated.

入院第二天，患者拔管。

He then recalled intentionally ingesting approximately 15?g sodium nitrite about 1 hour before ambulance call.

隨后，他回憶說，在打電話叫救護車前約1小時，他故意攝入了約15克亞硝酸鈉。

Methemoglobin level was again determined along with serum concentration of sodium nitrite.

高鐵血紅蛋白水平與血清亞硝酸鈉濃度一起再次測定。

?Methemoglobinemia resolved soon after injection of methylene blue;

注射亞甲藍后，高鐵血紅蛋白血癥很快消失；

however, the serum concentration of sodium nitrite decreased gradually (Figure 2).

然而，亞硝酸鈉的血清濃度逐漸降低(圖2)。

And there was no rebound methemoglobin formation given the persistence of sodium nitrite in the patient.

盡管患者體內(nèi)持續(xù)存在亞硝酸鈉，卻沒有出現(xiàn)反彈性高鐵血紅蛋白形成。

Cranial T2-weighted magnetic resonance imaging (MRI) demonstrated bilateral and symmetrical hyperintense lesions in the globus pallidus (Figure 3).

頭顱T2加權(quán)磁共振成像顯示蒼白球雙側(cè)對稱高信號病變(圖3)。

The patient was transferred to the general ward and was subsequently discharged on day 7 without neurologic impairment.

患者被轉(zhuǎn)移到普通病房，隨后在第7天出院，無神經(jīng)損傷。

3. Discussion 討論

Sodium nitrite is generally used as a coloring agent or preservative in food and as an antimicrobial agent in meat products.

亞硝酸鈉通常在食品中用作著色劑或防腐劑，在肉制品中用作抗菌劑。

The estimated lethal dose of sodium nitrite in adults is approximately 2.6?g [5]; however, a case of a patient surviving after ingesting 6?g sodium nitrite has been reported [6]. Severe methemoglobinemia with fatal outcomes following ingestion of sodium nitrite and intentional self-poisoning have been reported [3, 7].

成人亞硝酸鈉的估計致死劑量約為2.6克[5]；然而，已有一例患者在攝入6克亞硝酸鈉后存活的報道[6]。據(jù)報道，嚴(yán)重的高鐵血紅蛋白血癥在攝入亞硝酸鈉和故意服毒后會導(dǎo)致致命的后果。

The initial sign of methemoglobinemia is cyanosis [8] and the diagnosis should be considered in all patients who present with cyanosis, particularly if it does not improve with supplemental oxygen.

高鐵血紅蛋白血癥的最初癥狀是發(fā)紺[8]，所有出現(xiàn)發(fā)紺的患者都應(yīng)考慮診斷，尤其是在吸氧后沒有改善的情況下。

?As the levels reach 30%–40%, symptoms such as headache, fatigue, tachycardia, weakness, and dizziness are experienced. Methemoglobin levels of 60% produce lethargy, convulsions, and coma.

當(dāng)水平達到30%-40%時，會出現(xiàn)頭痛、疲勞、心動過速、虛弱和頭暈等癥狀。高鐵血紅蛋白水平達到60%會導(dǎo)致嗜睡、抽搐和昏迷。

Methemoglobin levels of >70% are generally lethal, although survival has been reported with a level of 94% [2]. Nitrite is also a potent vasodilator and can cause coronary ischemia and stroke as a result of hypotension, tachycardia, and hypoxia.

高鐵血紅蛋白水平超過70%通常是致命的，盡管據(jù)報道存活率為94% [2]。亞硝酸鹽也是一種有效的血管擴張劑，可因低血壓、心動過速和缺氧而導(dǎo)致冠狀動脈缺血和中風(fēng)。

Methylene blue [9] is indicated as the first-line antidote therapy for patients with severe methemoglobinemia.

亞甲藍[9]是嚴(yán)重高鐵血紅蛋白血癥患者的一線解毒劑療法。

?It is recommended that patients with methemoglobin levels >30%, high risk factors such as anemia, or symptoms at any level should be treated using methylene blue at a dose of 1-2?mg/kg body weight intravenously over 5?min.

建議高鐵血紅蛋白水平> 30%的患者、貧血等高危因素或任何水平的癥狀應(yīng)使用亞甲藍進行治療，劑量為1-2毫克/千克體重，靜脈注射5分鐘以上。

?Generally, methemoglobin concentration decreases significantly within 1-2?h after a single dose; additional doses may be necessary.

一般在單次給藥后1-2 h內(nèi)高鐵血紅蛋白濃度顯著下降；可能需要額外的劑量。

In this case, we could suspect whether the patient had some poisoning because of his cyanosis and severe methemoglobinemia. So we could use methylene blue very quickly in the emergency room.

在這種情況下，因為發(fā)紺和嚴(yán)重的高鐵血紅蛋白血癥，所以我們可以懷疑病人亞硝酸鹽中毒。因此我們可以在急診室快速使用亞甲藍。

Cranial T2-weighted MRI findings 3 days after sodium nitrite ingestion were similar to those in carbon monoxide poisoning.

攝入亞硝酸鈉后3天的頭顱T2加權(quán)磁共振成像結(jié)果與一氧化碳中毒相似。

?It has been reported that the globus pallidus is most susceptible to hypoxia. Severe methemoglobinemia can cause severe tissue hypoxia similar to that in carbon monoxide poisoning; this may explain the involvement of the globus pallidus in our case.

據(jù)報道，蒼白球最容易缺氧。嚴(yán)重高鐵血紅蛋白血癥可引起與一氧化碳中毒相似的嚴(yán)重組織缺氧；這可能解釋了在我們的病例中蒼白球的參與。

In conclusion, we reported a case of severe methemoglobinemia secondary to intentional ingestion of sodium nitrite.

總之，我們報告了一例因故意攝入亞硝酸鈉導(dǎo)致的嚴(yán)重高鐵血紅蛋白血癥。

Methemoglobinemia should be considered in all cyanotic patients who are unresponsive to oxygen therapy.

所有對氧療無反應(yīng)的紫紺患者都應(yīng)考慮高鐵血紅蛋白血癥。

Rapid diagnosis and early intervention with methylene blue infusion can prevent a fatal outcome as in the present case with an initial methemoglobin level of 92.5%.

快速診斷和亞甲藍輸注早期干預(yù)可防止致命結(jié)果，如本例中初始高鐵血紅蛋白水平為92.5%。

Competing Interests

The authors declare that there are no competing interests regarding the publication of this paper.

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Copyright

Copyright ? 2016 Kenichi Katabami et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.