A Case Report of Cyanosis With Refractory Hypoxemia: Is It Methemoglobinemia?

Dapsone is used in the treatment of a variety of dermatological conditions and prophylaxis of opportunistic infections. However, if consumed at a dose of more than 200 mg/day, it can cause methemoglobinemia, a condition characterized by elevated methemoglobin levels in the blood; methemoglobin is an abnormal form of hemoglobin, containing iron in the ferric state (Fe(3)(+)) rather than the reduced ferrous form (Fe(2)(+)) found in hemoglobin. A small amount of it is produced in the body due to oxidant damage to the red blood cells. Methemoglobinemia can cause varied clinical manifestations involving the cardio-respiratory and nervous systems depending upon the level of methemoglobin. While it could be congenital, it is commonly caused by exposure to drugs that cause oxidation of hemoglobin, such as benzocaine, dapsone, and nitrates. We report a case of dapsone-induced methemoglobinemia in a previously healthy young female who had consumed 15 tablets of dapsone 100 mg with suicidal intent. She presented with central cyanosis, breathlessness, and altered sensorium after five days of consumption. While the pulse-oximeter showed oxygen saturation (SaO(2)) of 84%, arterial blood gas (ABG) analysis showed partial pressure of oxygen (PaO(2)) of 427 mmHg and SaO(2) of 98%. This "saturation gap" occurred due to the presence of the abnormal hemoglobin variant. Her cyanosis did not improve despite giving 100% supplemental oxygen. There was no cardiac or respiratory cause to account for her cyanosis. Her methemoglobin level was 45.8%. She was successfully treated with specific antidote methylene blue, mechanical ventilation, and other symptomatic measures. The purpose of this presentation is to help clinicians recognize this condition early, because, if left untreated, it might prove fatal. The diagnostic clues include refractory hypoxemia, central cyanosis in the absence of cardiac and respiratory causes, saturation gap, and chocolate-colored blood.