eMedicine Specialties > Hematology > Red Blood Cells and Disorders

Methemoglobinemia: Follow-up

Author: Mary Denshaw-Burke, MD, FACP, Assistant Clinical Professor, Institute for Medical Research, Program Director of Hematology/Oncology Fellowship, Education Coordinator for Oncology, Lankenau Hospital; Consulting Staff, Roxborough Memorial Hospital
Coauthor(s): Deric C Savior, MD, Fellow in Hematology/Oncology, Lankenau Hospital; John Schoffstall, MD, Associate Professor, Department of Emergency Medicine, Medical College of Pennsylvania
Contributor Information and Disclosures

Updated: Oct 4, 2009

Follow-up

Further Inpatient Care

  • Patients with methemoglobinemia with asymptomatic cyanosis from a known substance ingestion are the only patients who should be considered for discharge. Discharge these patients after a 6-hour observation period only if the implicated cause has been eliminated and is not known to cause rebound methemoglobinemia.
  • Patients with methemoglobinemia who are symptomatic or who have a significantly elevated methemoglobin level should be admitted to the hospital. A lower threshold for hospital admission should occur for patients with complicating factors, such as underlying anemia, chronic cardiopulmonary disease, or peripheral vascular disease. These patients should be admitted. Symptomatology determines the level of care that is needed.
  • Exchange transfusion and hyperbaric oxygen treatment are second-line treatment options for patients with severe methemoglobinemia whose condition does not respond to intravenous methylene blue or who cannot be treated with methylene blue (eg, G6PD deficient patients). Exchange transfusion basically replaces the abnormal hemoglobin in the red blood cells with normal hemoglobin. Hyperbaric oxygen treatments permit tissue oxygenation to occur through oxygen dissolved in plasma, rather than through hemoglobin-bound oxygen.

Further Outpatient Care

  • Good outpatient follow-up care is required in patients treated for methemoglobinemia. Discharged patients should be reevaluated by a physician within 24 hours for any signs or symptoms of recurring disease. Patients should also be provided with strict discharge instructions detailing symptoms that should prompt immediate medical reevaluation, such as shortness of breath, increasing fatigue, or chest pain.

Inpatient & Outpatient Medications

  • Inpatient medication for methemoglobinemia is primarily intravenous methylene blue (see Medical Care and Medication).
  • Outpatient medications for the treatment of cyanosis that is associated with chronic mild methemoglobinemia include oral methylene blue, ascorbic acid, and riboflavin.

Transfer

  • Patient transfer should occur when life-threatening methemoglobinemia that is refractory to treatment occurs in a facility that cannot provide the appropriate critical care.

Deterrence/Prevention

  • Individuals who ingest well water in heavily agricultural areas should have their well water checked periodically for the presence of inorganic nitrates and other chemicals.
  • Individuals with known G6PD deficiency or methemoglobin reductase enzyme deficiencies should use great care with the ingestion of medication and minimize or prevent toxin exposure.

Complications

  • Patients can die from acute acquired methemoglobinemia, especially if the clinical entity is not recognized.

Prognosis

  • Congenital methemoglobinemia patients are usually asymptomatic except for the presence of chronic cyanosis.
  • Patients with acquired methemoglobinemia due to toxin exposure can be severely ill when diagnosed. However, with prompt diagnosis and appropriate treatment, a full recovery is possible.

Patient Education

  • Patients with inherited methemoglobinemia should be counseled regarding the avoidance of toxins, chemicals, and certain drugs (eg, dapsone).

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider methemoglobinemia in the patient with cyanosis that is unresponsive to oxygen therapy
  • Failure to evaluate for hemolysis in patients with methemoglobinemia
  • Treating patients who are G6PD deficient with methylene blue
  • Treating patients with asymptomatic cyanosis with IV methylene blue
  • Administering additional IV methylene blue to patients with successful initial treatment but who have methylene blue – induced skin discoloration
  • Failure to consider the possibility of rebound methemoglobinemia
  • Failure to admit to the appropriate level of care
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Matthew Bouchard, MD, to the development and writing of this article.



More on Methemoglobinemia

Overview: Methemoglobinemia
Differential Diagnoses & Workup: Methemoglobinemia
Treatment & Medication: Methemoglobinemia
Follow-up: Methemoglobinemia
References
Further Reading
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Further Reading

Related eMedicine Topics

Clinical Trial
 Clinical Guideline

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Keywords

methemoglobinemia, cyanosis, methemoglobin, metHb, hemoglobin M, Hb M, NADH-metHb reductase deficiencies, acquired methemoglobinemia, enterogenous methemoglobinemia, secondary methemoglobinemia, congenital methemoglobinemia, hereditary methemoglobinemia, hereditary methemoglobinemic cyanosis, primary methemoglobinemia, cytochrome b5 reductase deficiency, cyt b5R

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Contributor Information and Disclosures

Author

Mary Denshaw-Burke, MD, FACP, Assistant Clinical Professor, Institute for Medical Research, Program Director of Hematology/Oncology Fellowship, Education Coordinator for Oncology, Lankenau Hospital; Consulting Staff, Roxborough Memorial Hospital
Mary Denshaw-Burke, MD, FACP is a member of the following medical societies: American College of Physicians and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Deric C Savior, MD, Fellow in Hematology/Oncology, Lankenau Hospital
Disclosure: Nothing to disclose.

John Schoffstall, MD, Associate Professor, Department of Emergency Medicine, Medical College of Pennsylvania
John Schoffstall, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Paul Schick, MD, Emeritus Professor, Department of Internal Medicine, Thomas Jefferson University Medical College; Research Professor, Department of Internal Medicine, Drexel University College of Medicine; Adjunct Professor of Medicine, Lankenau Hospital, Wynnewood, PA
Paul Schick, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Hematology, International Society on Thrombosis and Haemostasis, and New York Academy of Sciences
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Marcel E Conrad, MD, (Retired) Distinguished Professor of Medicine, University of South Alabama
Marcel E Conrad, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Blood Banks, American Chemical Society, American College of Physicians, American Physiological Society, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Association of Military Surgeons of the US, International Society of Hematology, Society for Experimental Biology and Medicine, and Southwest Oncology Group
Disclosure: No financial interests None None

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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