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(A) Destruction of myocardial fibers by an inflammatory infiltrate mainly consisting of lymphocytes and histiocytes. Lymphocytes were predominantly T cells with CD3, CD4 and CD8 (inset) positivity. (B) Skeletal muscle fibers infiltrated by identical inflammatory population, including T lymphocytes and CD68 (inset) positive macrophages (inset). (A and B, haematoxylin and eosin stain; insets A and B, immunohistochemistry for CD8 and CD68 respectively; original magnification, 400×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Teba González-Ferrero, Kelly Vargas-Osorio, José Ramón González-Juanatey" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Teba" "apellidos" => "González-Ferrero" ] 1 => array:2 [ "nombre" => "Kelly" "apellidos" => "Vargas-Osorio" ] 2 => array:2 [ "nombre" => "José Ramón" "apellidos" => "González-Juanatey" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622000195?idApp=UINPBA00004N" "url" => "/23870206/0000015800000003/v1_202202040749/S2387020622000195/v1_202202040749/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Methemoglobinemia secondary to consumption of poppers" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "142" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Elena Díez Urdiales, Ana Esteban Molina, Naiara Gargallo Gasca" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Elena" "apellidos" => "Díez Urdiales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Ana" "apellidos" => "Esteban Molina" "email" => array:1 [ 0 => "a.estebanmolina@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Naiara" "apellidos" => "Gargallo Gasca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metahemoglobinemia secundaria al consumo de poppers" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Oxidation of the iron molecule in haemoglobin (Hb) leads to methaemoglobinaemia. This reaction prevents the transport of oxygen (O<span class="elsevierStyleInf">2</span>), generating tissue hypoxia. The most common cause is that acquired by exogenous agents.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 53-year-old man with a history of HIV infection and treated syphilis. Following the use of methamphetamine and inhaled poppers, he developed syncopal symptoms and facial cyanosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On initial assessment by the outpatient medical service, the patient presented with visual hallucinations, preserved speech with moderate tachypnoea, bilateral normoventilation and marked facial cyanosis. Pulse oximetry showed O<span class="elsevierStyleInf">2</span> saturation (SatO<span class="elsevierStyleInf">2</span>) 70%, sinus tachycardia 130 beats per minute, systolic blood pressure 130 mmHg. Treatment with oxygen therapy was initiated using a reservoir mask.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Upon arrival at the Emergency Department, the patient remained tachypnoeic, cyanotic with SatO<span class="elsevierStyleInf">2</span> 80%. An arterial blood gas analysis was performed, showing a blood sample with a dark red appearance: pH: 7.36; pO<span class="elsevierStyleInf">2</span> 219; arterial SatO<span class="elsevierStyleInf">2</span> 88%; pCO<span class="elsevierStyleInf">2</span> 31; HCO<span class="elsevierStyleInf">3</span> 17 mmol/l; lactate 5.7 mmol/l. Co-oxymetry: methaemoglobin (MetHb) 67%, oxyhaemoglobin 31%.</p><p id="par0025" class="elsevierStylePara elsevierViewall">With the diagnostic impression of symptomatic methaemoglobinaemia secondary to the consumption of inhaled nitrites, methylene blue was administered at a dose of 1 mg/kg.</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was admitted to the Intensive Care Unit, with progressive improvement in respiratory mechanics, skin and mucous coloration, as well as a decrease in the level of methaemoglobinaemia to 10%, oxyhaemoglobin 86%, pO<span class="elsevierStyleInf">2</span> 300, arterial SatO<span class="elsevierStyleInf">2</span> 99%, lactate 1.5 mmol/l after 60 min of methylene blue administration.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was discharged from the Intensive Care Unit 24 h after admission.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Poppers, a volatile nitrite-based recreational substance. They are usually inhaled, with rapid absorption and immediate systemic effects, due to increased synthesis of intracellular cyclic guanosine monophosphate, which activates myosin phosphatase that dephosphorylates myosin, leading to relaxation of smooth muscle.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Its consumption can trigger methaemoglobinaemia, caused by the oxidation of iron in Hb, transforming its ferrous state to ferric, giving rise to MetHb, which is unable to bind O<span class="elsevierStyleInf">2</span> and therefore transport it. Pathophysiologically, the haemoglobin dissociation curve shifts to the left, increasing the affinity of haemoglobin for O<span class="elsevierStyleInf">2</span> and causing a decrease in the release of O<span class="elsevierStyleInf">2</span> into the tissues, leading to tissue hypoxia.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Under physiological conditions MetHb values should be less than 1-2% of total circulating Hb. The guiding sign of this pathology is cyanosis of the skin, mucosa and blood without hypoxemia. The conventional pulse oximeter may give a falsely normal or near-normal SatO<span class="elsevierStyleInf">2</span> because these devices confuse oxyhaemoglobin with MetHb. Pulse oximeters allow the bloodless estimation of more than 2 haemoglobin types, such as carboxyhaemoglobin and MetHb, with acceptable accuracy, which is useful in settings where laboratory equipment is not available.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The inability of haemoglobin to adequately transport O<span class="elsevierStyleInf">2</span> to tissues results in tissue hypoxia. Patients with MetHb < 20% will be cyanotic but asymptomatic, with MetHb of 20-40% signs and symptoms of general tissue hypoxia occur (nausea, instability, dyspnoea, headache, tachycardia, tachypnoea, anxiety, agitation, stupor), with MetHb of 40-60% there are signs of severe tissue hypoxia (coma, seizures, arrhythmias, hypotension, shock, metabolic acidosis) and with MetHb > 60% may lead to cardiopulmonary arrest.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The faster MetHb is established, the worse it is tolerated, patients with regular use of the toxic substance may be well adapted to high doses of MetHb.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In acquired, symptomatic, or MetHb > 20% methaemoglobinaemia, methylene blue at doses 1-2 mg/kg is indicated, if not available or contraindicated (glucose-6-phosphate dehydrogenase deficiency), treatment with ascorbic acid should be initiated.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">This article has not received any type of funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Díez Urdiales E, Esteban Molina A, Gargallo Gasca N. Metahemoglobinemia secundaria al consumo de poppers. Med Clin (Barc). 2022;158:143.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Methemoglobinemia: Etiology, pharmacology, and clinical management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.O. Wright" 1 => "W.J. Lewander" 2 => "A.D. 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Terris" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/emj.19.3.270" "Revista" => array:6 [ "tituloSerie" => "Emerg Med J" "fecha" => "2002" "volumen" => "19" "paginaInicial" => "270" "paginaFinal" => "271" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11971852" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A severe methahaemoglobinemia induced by nitrates: A case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Burrato" 1 => "M.G. Garziera" 2 => "E. Bigruglio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00063110-200312000-00017" "Revista" => array:6 [ "tituloSerie" => "Eur J Emerg Med" "fecha" => "2003" "volumen" => "10" "paginaInicial" => "326" "paginaFinal" => "330" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14676514" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015800000003/v1_202202040749/S2387020622000134/v1_202202040749/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015800000003/v1_202202040749/S2387020622000134/v1_202202040749/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622000134?idApp=UINPBA00004N" ]
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Vol. 158. Issue 3.
Pages 142 (February 2022)
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Vol. 158. Issue 3.
Pages 142 (February 2022)
Letter to the Editor
Methemoglobinemia secondary to consumption of poppers
Metahemoglobinemia secundaria al consumo de poppers
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