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Case Report
Methemoglobinemia Mimics Complicated Malaria
Shruti Sarkar, Dipankar Sarkar
Department of Pediatrics, Peoples College of Medical Sciences and Research Centre, Bhanpur, Bhopal- 462010 (MP.) Abstract:
Methemoglobinemia is an uncommon condition seen in clinical practice. It is generally caused by exposure to drugs, chemicals or solvents. Many drugs are implicated in the causation of Methemoglobinemia one of which isChloroquine. We present here a case of Methemoglobinemia following Chloroquine which was given for the treatment offever. The clinical presentation resembled closely to that of complicated Malaria. This case is presented with the objectiveof increasing awareness that uncommon illnesses can sometimes resemble closely to a very commonly seen condition andhence can be missed.
Key Words: Methemoglobinemia, Complicated Malaria
Introduction:
by a local doctor before presenting to our hospital.
There was no history of exposure to other drug, condition seen in clinical practice. Whereas, malaria chemical or solvent. Our clinical impression was of in our country is one of the commonest reason for Methemoglobinemia. We also investigated him for the admission to hospital. Here, we present a case report cause of fever. He was given inhaled oxygen, packed of drug induced methemoglobinemia which resembled cell transfusion, IV Ceftriaxone, Amikacin and IV the presentation of complicated malaria so closely that fluids. Investigations showed Hb-6.1, WBC - 35,000 without the high index of suspicion, monitoring and (neutrophils- 83%) and platelets- 6.1 lacs. CRP was investigating facilities of a tertiary care center, the positive in 1:4 dilution. Blood urea and creatinine were diagnosis would not have been suspected and made.
normal. Urine had 20 to 30 pus cells/ HPF but no Incorrect diagnosis and inappropriate treatment could RBCs. Perip heral smear s howed evidence of have caused more harm to the patient. This case is hemolysis with reticulocytosis of 6%. G6PD activity reported with the objective of increasing awareness that was normal. Blood gas showed partial pressure of sometimes uncommon condition can closely resemble oxygen to be 110 mm Hg. Smear for malaria and commonly seen ones and can be missed.
malaria antigen test were negative. Our impressionwas of Methemoglobinemia and probable UTI. Due Case Report:
to financial constraints of the family Methemoglobin A 6 year old boy presented to the Department level estimation was sent on 3rd day of admission after of Pediatrics with a history of moderate grade fever for 2 units of packed cells had been transfused. It was 10 days, vomiting for 2 days with altered blood once.
found to be raised at 27.5%, confirming the diagnosis He had passed cola colored urine that morning although of Methemoglobinemia. We added oral Ascorbic acid the total urine output was normal. On examination he to the treatment. He was afebrile on 3rd day of had marked pallor, tachypnea, (30/min), pulse was 130 admission and urine became clear. He made steady / min. normovolemic, had normal blood pressure and progress from 3rd day onwards and was discharged on mild Jaundice. Oxygen saturation was 58% in room 8th day with clear written instructions regarding the air. Chest was clear, heart sounds were normal, liver drugs to be avoided. Our final diagnosis was was just palpable and he was fully conscious and Chloroquine induced Methemoglobinemia with oriented. He had received oral Chloroquine prescribed --------------------------------------------------------------------
Corresponding Author: Dr. Shruti Sarkar, Assistant Professor,
Discussion:
Department of Pediatrics, Peoples College of Medical Science and Oxidant exposure is generally the cause of Research Center, Bhopal, 462010 (MP)Ph.: 0755- 4005229, Mobile 09826433108, 09977701964 acquired Methemoglobinemia as seen in exposure to drugs, chemicals or solvents or indirectly as in People’s Journal of Scientific Research 25 Vol 1 - July 08 Methemoglobinemia Mimics Complicated Malaria --------------- S Sarkar & D Sarkar.
sepsis. (Mansourie & Lurie, 1993; Hall et al, 1986; features and management. Journal of Medical Ohashi et al, 1998; Kennedy et al, 1997). By oxidation the ferrous molecule in the hemoglobin gets oxidized 4. Kennedy N, Smith CP, Mc. Whinney P.: Faulty to ferric, the resultant molecule is Methemoglobin, sausage production causing Methemoglobinemia.
which is incapable of binding oxygen.
Archives of Disease in Childhood, 1997;76:367- Levels greater than 2 % are non physiological or abnormal. Symptoms generally appear when levels 5. Mansourie A, Lurie AA.: Concise review:methmo exceeds 15% and levels > 70 % may cause death -globinemia. American Journal of Hematology, (Rehman,2001). Spectral properties of Methemoglobin are different and it interferes with pulse oximetry 6. Ohashi K, Yukioka H, Hayashi M, Asada A.: readings which are characteristically very low. Arterial Elevated methemoglobinin patients with sepsis.
blood gas partial pressures are very high because of Acta Anaesthesiologica Scandinvica,1998;42: high flow oxygen therapy. Hemolytic anemia with intravascular hemolysis may follow drug induced 7. Rehman H U.: Methemoglobinemia. The Western Methemoglobinemia as was seen in this patient.( Hall Journal of Medicine, 2001 ; 175 : 193-196.
8. Sharma N, Varma S.: Unusual life-threatening This case illustrates an uncommon condition adverse drug effects with Chloroquine in a young i.e. Methemoglobinemia precipitated by a very girl. Journal of Postgraduate Medicine, 2003; commonly used drug that is Chloroquine. The clinical scenario described here is very much similar to that ofcomplicated malaria, the treatment on the contrary istotally different.( Bolyai et al, 1972).
Chloroquine is a very widely used drug in India especially in the periphery. Chloroquine inducedMethemoglobinemia has been reported before. (Cohenet al, 1968; Sharma & Varma, 2003). The point beingmade here is that C hloroquine inducedMethemoglobinemia with intravascular hemolysis asseen in our patient mimics the clinical picture ofcomplicated Malaria. One should have a high index ofsuspicion and low threshold for investigations wherecases are complicated. In the periphery, whereinvestigation facilities are limited and even simplemonitoring facilities like pulse oximetr y areunavailable, early referral to higher centers in the eventof complications is recommended.
Bibliography:
1. Bolyai JZ, Smith RP, Gray CT.: Ascorbic acid and chemically induced methemoglobinemias.
Toxicology & Applied Pharmacology,1972;21: 2. Cohen RJ, Sachs JR, Wicker DJ, Conrad ME.: chemoprophylaxis in Vietnam. New England Journal of Medicine, 19 68;279:1127-1131.
3. Hall AH, Kurig KW, Rumack BH.: Drug and chemical-induced methemoglobinemia. Clinical People’s Journal of Scientific Research 26 Vol 1 - July 08

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