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Indian Pediatr 2017;54: 473-475 |
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Acquired
Methemoglobinemia – A Sporadic Holi Disaster
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Sanjeevani Satish Masavkar, Anupama Mauskar, Gaurav
Patwardhan, Vasudeva Bhat and Mamta V Manglani
From Department of Pediatrics, Lokmanya Tilak
Municipal Medical College and General Hospital, Sion, Mumbai, India.
Correspondence to: Dr Sanjeevani Satish Masavkar,
Associate Professor, 242/9458, Kannamwar Nagar 2, Vikhroli E, Mumbai 400
083, India.
Email:
[email protected]
Received: July 08, 2016;
Initial review: October 20, 2016;
Accepted: March 03, 2017.
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Objective: To study clinical profile and outcome in patients with
methemoglobinemia following exposure to toxic colors during Holi
festival. Methods: This retrospective study included 112 children
(5 to 12 years) admitted with methemoglobinemia after playing Holi.
Clinical and treatment details were reviewed. Results: The common
symptoms were giddiness, vomiting and headache. Treatment included
thorough skin wash, intravenous fluid and methylene blue in 111
children. Age 7-9 and > 11 years, vomiting, giddiness, cyanosis, PaO2 <
80 mm Hg and oxygen saturation < 95% were associated with higher need
for methylene blue. All children had a good outcome. Conclusion:
Timely diagnosis and management of acquired methemoglobinemia can save
lives.
Keywords: Exposure, Management, Methylene blue, Toxic colors.
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A cquired methemoglobinemia occurs with
contaminated colors (aniline dyes) [1]. Holi, a popular Indian festival,
is celebrated using powdered or water-based colors in India. It marks
the beginning of spring [2]. With the use of modern synthetic colors,
which may be contaminated, the risk of methemoglobinemia has aggravated
[3]. Toxic methemo-globinemia is also known after exposure to oxidant
drugs, local anesthetic agents, high-nitrate food and aniline dyes,
coloring compounds or cleaning solutions [4-9]. Though rare, it can be
life threatening if not recognized and treated promptly. Though there
are anecdotal reports and case series in literature, there are no large
studies published so far [1,2,4-10]. We report 112 children with
acquired methemoglobinemia during celebration of Holi in March 2012 with
the objectives of studying their clinical profile, association of the
requirement of methylene blue with clinical parameters as well as
methemoglobin level, PaO2
and oxygen saturation and outcome.
Methods
This is a retrospective analysis of records of all
children below 12 years with acquired methemoglobinemia due to
contaminated colors. History and clinical findings were reviewed from
their charts for analysis with special reference to methemoglobinemia
and its central nervous system consequences. Approval from Institutional
ethics committee was obtained for publishing these data. Methylene blue
was administered intravenously in the dose of 2 mg/kg/dose and repeated
after one hour if cyanosis persisted. The number of doses of methylene
blue required was noted.
Methemoglobinemia was defined as methemoglobin level
>3% [6]. Children were grouped based on methemoglobin level and symptoms
into 3 to 15%, 16 to 30%, and >30% for association with methlylene blue
requirement [6,11]. Odds ratio and 95% CI were calculated as a measure
of association. Statistical analysis was done using Stata 11.
Results
A total of 112 children (87 boys) with a mean (SD)
age of 9.6 (1.88) years, who came to our hospital within 3 to 4 hours’
time, were included. Seventeen children were aged between 5 to 7 years,
26 in the 7-9 year age group, 50 in 9-11 years, and 19 above 11 years.
The common presenting features were giddiness (52, 46.4%), vomiting (50,
44.6%), headache (47, 42%), abdominal pain (16, 14.3%), and altered
sensorium (15, 13.4%). Seizures were present in two children and
breathlessness in three children.
On examination, 69 (61.6%) children had bluish
discolouration of mucous membranes, 15 (13.4 %) were drowsy, and 2
(1.8%) had tachycardia. Glasgow Coma Scale in 15 children with altered
sensorium was 5 to 10 in one and >10 in 14. Arterial blood gas analysis
revealed acidosis in 47 (42%) children. On co-oxymetry, 70 (62.5%)
children had PaO 2 less than
80 mm Hg and 83 (74.1%) had SaO2
less than 95%. The level of methemoglobin varied from 3% to 74%, with 3
to 15% in 71 (63.4%), 16 to 30% in 25 (22.3%) and >30% in 16 (14.3%)
children.
Of the 80 children who required single dose of
methylene blue, 66 had methemoglobin levels between 3 to 15% and 14 had
levels 15 to 74%. Among the 22 who required two doses of
methylene blue, 14 had 15-74% levels of methemoglobin, and all 9
children who required three does had high (>15%) methemoglobin level. It
was found that age group of 7 to 9 years and more than 11 years;
presence of giddiness, vomiting and cyanosis; level of methemoglobin;
oxygen saturation less than 95%; and PO 2
less than 80 mmHg were significant determinants of higher need for
methylene blue (Table I).
TABLE I Factors Associated With Higher Requirement of Methylene Blue in Children
Variables |
OR (95% CI) |
P value |
Age (y) |
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7.1 to 9 |
10.0 (1.1-87.5) |
0.037 |
9.1 to 11 |
5.2 (0.6 - 43.3) |
0.128 |
>11 |
11.6 (1.3-106.7) |
0.030 |
Vomiting |
3.9 (1.6-9.4) |
0.002 |
Giddiness |
4.1 (1.7-10) |
0.002 |
Cyanosis |
2.6 (1-6.6) |
0.054 |
PO2 <80 mmHg |
0.2 (0.1-0.6) |
0.005 |
SaO2 (%) <95 |
0.2 (0.1-0.8) |
0.021 |
Level of methemoglobin >15% 31.8 (9.6-105.4) <0.001
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Sixteen children with higher initial concentration
(>30%) of methemoglobin showed gradual (in 24 h) reduction in
methemoglobin levels with treatment. None of them required ventilator or
inotropes, and were discharged within 36 (109 children) and 48 hours (3
children).
Discussion
Chemical dyes in colors used during Holi festivals
can harm humans and the environment [3,6,10]. High
levels of methemoglobin following exposure to contaminated colors can
lead to cyanosis, dyspnea, headache, giddiness, metabolic acidosis, CNS
depression, seizure, coma and death [1-3]. In the present study too,
children with methemoglobin between 3 to 15% had giddiness, vomiting,
dyspnea, headache, fatigue and abdominal pain, with altered sensorium in
those with level >15%; those with level >30% had altered sensorium,
cyanosis and seizures in addition. Clinical presentation varied with the
level of methemoglobin.
Arterial blood gases (PaO 2
and SaO2) provide the level
of decompensation, while co-oxymetry differen-tiates various states of
hemoglobin, giving the level of methemoglobin [12].
The study has a limitation of being a retrospective
analysis, and hence, lacks planned investigations such as a complete
blood count and G6PD levels. There was no time to find out the
contaminant as it was a mass casualty with 112 children within 3 to 4
hours. However, on follow up, the toxic substance was identified as
aniline dye, used in leather industries in the locality. Fortunately,
because of this, action was taken and this kind of disaster did not
recur in subsequent years during the festival of Holi.
We conclude that colors used by children during Holi
festival should be standardized and monitored for quality. Also,
physicians should be aware of this rare cause of acquired
methemoglobinemia for timely diagnosis and prompt treatment.
Acknowledgments: We thank our former Dean, Dr.
Sandhya Kamath and present Dean, Dr. Suleman Merchant for permission to
publish this manuscript.
Contributors: SSM: conceived and designed the
study, collected data, analyzed the study, and prepared manuscript; GP,
VB: helped in management of patients and collection of the data; AVM:
reviewed the manuscript and carried out critical revision; MVM: guided
in management of patients, preparing the manuscript and finalization of
the manuscript. The final version of manuscript was approved by all
authors.
Funding: None; Competing interests: None
stated.
What This Study Adds?
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Toxic contamination of Holi
colors can lead to acquired methemoglobinemia, which should be
promptly diagnosed and treated to save lives.
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References
1. Mauskar A, Karande S, Kulkarni M. Acquired
methemoglobinemia due to contaminated colours: A preventable disaster. J
Trop Pediatr. 2009;55:139-40.
2. Zaki SA, Jadhav A, Chandane P. Methaemoglobinaemia
during Holi festival. Ann Trop Paediatr. 2009;29:221-3.
3. Microsoft Word - Factsheet 8 Holi.doc -
microsoft-word-Factsheet-8-Holi.pdf. Available from:
http://e-oexist.com/products/Holi/microsoft-word-factsheet-8-Holi.pdf.
Accessed February 26, 2016.
4. Hadjiliadis D, Govert JA. Methemoglobinemia after
infusion of ifosfamide chemotherapy: First report of a potentially
serious adverse reaction related to ifosfamide. Chest. 2000;118:1208-10.
5. Dahshan A, Donovan GK. Severe methemoglobinemia
complicating topical benzocaine use during endoscopy in a toddler: a
case report and review of the literature. Pediatrics. 2006;117:e806-9.
6. Ashurst J, Wasson M. Methemoglobinemia: A
systematic review of the pathophysiology, detection, and treatment.
Delaware Med J. 2011;83:203-8.
7. Singh R, Vinayagam S, Vajifdar H.
Methemoglobinemia as a result of accidental lacquer thinner poisoning.
Indian J Crit Care Med. 2012;16:44-7.
8. Ash-Bernal R, Wise R, Wright SM. Acquired
methemo-globinemia: A retrospective series of 138 cases at 2 teaching
hospitals. Medicine (Baltimore). 2004;83:265-73.
9. Venkateswari R, Ganesh R, Deenadayalan M, Mahender
E, Ramachandran B, Janakiraman L. Transient methemoglobinemia in an
infant. Indian J Pediatr. 2007;74:1037-8.
10. Velpandian T, Saha K, Ravi AK, Kumari SS, Biswas
NR, Ghose S. Ocular hazards of the colours used during the festival-of-colours
(Holi) in India— malachite green toxicity. J Hazard Mater.
2007;139;:204-8.
11. Prasad R, Singh R, Mishra OP. Dapsone induced
methemoglobinemia: Intermittent vs continuous intravenous methylene blue
therapy. Indian J Pediatr. 2008;75:245-7.
12. Mack E. Focus on diagnosis: co-oximetry. Pediatr
Rev. 2007;28:73-4.
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