Methemoglobinemia Workup

Updated: Jun 28, 2023
  • Author: Khaled F Abouelezz, MBChB; Chief Editor: Emmanuel C Besa, MD  more...
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Laboratory Studies

Investigations to rule out hemolysis (complete blood count [CBC], reticulocyte count, peripheral smear review, lactate dehydrogenase [LDH], bilirubin, haptoglobin and Heinz body preparation) and end-organ dysfunction or failure (liver function tests, electrolytes, renal function tests) should be included in the workup. Urine pregnancy tests should be performed in females of childbearing age.

Investigations to evaluate a hereditary cause for methemoglobinemia should be ordered when appropriate. Hemoglobin electrophoresis and DNA sequencing of the globin chain gene can be used to identify hemoglobin M.

Specific enzyme assays (nicotinamide adenine dinucleotide [NADH]–dependent reductase, cytochrome b5 reductase) may be determined, often in multiple cell lines (ie, platelets, granulocytes, and fibroblasts), to diagnose inherited cases. A quick and easy bedside test for determining whether dark blood is due to methemoglobinemia is to bubble 100% oxygen in a tube that contains the dark blood. If the blood remains dark, that is likely because of the presence of methemoglobin.

Another simple test (and one that is less likely to splash potentially infectious blood) is to place 1-2 drops of blood on white filter paper, then evaluate for color change upon exposure to oxygen. (This test can be accelerated by gently blowing supplemental oxygen onto the filter paper.) Deoxygenated hemoglobin changes from dark red or violet to bright red, whereas methemoglobin remains brown.

Serum levels of nitrites or other offending drugs may be determined. Often, these results are not immediately available, and treatment may have to be started empirically if the index of suspicion is high.


Arterial Blood Gas Determination

The presence of methemoglobin can falsely elevate the calculated oxygen saturation when arterial blood gases (ABGs) are obtained. One possible clue to the diagnosis of methemoglobinemia is the presence of a “saturation gap.” This occurs when there is a difference between the oxygen saturation measured on pulse oximetry and the oxygen saturation calculated on the basis of ABG results.

The partial pressure of oxygen (PO2) value of the ABG measurement reflects plasma oxygen content and does not correspond to the oxygen-carrying capacity of hemoglobin. It should be within the reference range in patients with methemoglobinemia.




Co-oximetry should be performed if available. The co-oximeter is an accurate device for measuring methemoglobin and is the key to diagnosing methemoglobinemia. It is a simplified spectrophotometer that can measure the relative absorbance of 4 different wavelengths of light and thus is capable of differentiating methemoglobin from carboxyhemoglobin, oxyhemoglobin, and deoxyhemoglobin. Newer co-oximeters can also measure sulfhemoglobin, which can be confused with methemoglobin by older devices.

Availability of appropriate equipment may be a problem. Lipemic specimens may result in a falsely elevated methemoglobin level. In addition, the presence of methylene blue interferes with the accurate measurement of methemoglobin by co-oximetry, hence this method cannot be used to monitor methemoglobin levels after treatment with methylene blue is initiated. Blood substitutes can cause co-oximetry to yield unreliable results.

Pulse oximetry

Pulse oximetry is used extensively in the evaluation of patients with cyanosis and respiratory distress. However, findings of bedside pulse oximetry in the presence of methemoglobinemia may be misleading. Pulse oximetry measurements with low-levels of methemoglobinemia often result in falsely low values for oxygen saturation and are often falsely high in those with high-level methemoglobinemia. The reason for these inaccuracies is as follows.

The pulse oximeter only measures the relative absorbance of 2 wavelengths of light (660 nm and 940 nm) to differentiate oxyhemoglobin from deoxyhemoglobin. The ratio of absorption of light at each of these wavelengths is converted into oxygen saturation by using calibration curves. Methemoglobin increases absorption of light at both wavelengths (more at 940 nm) and therefore offers optical interference to pulse oximetry by falsely absorbing light.

As a result, oxygen saturations by pulse oximetry in methemoglobinemia plateau at about 85%; therefore, a patient with a methemoglobin level of 5% and a patient with a level of 40% have approximately the same saturation values on pulse oximetry (~85%). The severity of the cyanosis does not correspond to the pulse oximetry reading: a patient may appear extremely cyanotic but still have a pulse oximetry reading in the high 80s.

However, newer multiwavelength pulse oximeters have been developed that can detect methemoglobinemia with an accuracy comparable to that achievable with co-oximeters.


Other Studies

Potassium cyanide test

This test can distinguish between methemoglobin and sulfhemoglobin. Methemoglobin reacts with cyanide to form cyanomethemoglobin, which has a bright red color. Sulfhemoglobin does not react with cyanide and therefore does not change to a bright red color.

Diagnostic imaging

Imaging studies of the chest and echocardiography may be helpful to exclude pulmonary or cardiac disease.