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• W4387268322 abstract "SESSION TITLE: Lung Physiology Challenges SESSION TYPE: Case Reports PRESENTED ON: 10/10/2023 08:30 am - 09:30 am INTRODUCTION: Hypoxemia is very common due to pathology of the heart or lungs. However, while very uncommonly seen, hemoglobinopathies can be induced in the adult patient and can lead to significant hypoxemia, posing a diagnostic challenge. Sulfhemoglobinemia (SH) occurs when hemoglobin iron is oxidized to the ferric (3+) form (same as methemoglobinemia), but also sulfur is added to the porphyrin ring creating an irreversible change in the hemoglobin molecule. CASE PRESENTATION: The patient is a 46-year-old female with a history of recurrent cystitis and bipolar disorder who chronically took phenazopyridine on and off for dysuria relief. She presented to the emergency department with two weeks of worsening fatigue, dyspnea, and a change in skin color. She was found to have pulse oximetry of 80% on room air with otherwise normal vitals. She notably had clear lungs, perioral cyanosis, and cyanosis of the digits. CT chest pulmonary embolism protocol was without any abnormalities. Blood drawn by the nurse was noted to be black. Her hemoglobin was 12.2, and arterial blood gas (ABG) showed a pH of 7.39, pCO2 of 36.0, pO2 of 78, and SpO2 of 83 on room air. Not reported by the electronic medical record (EMR) in any manner, the ABG sample was noted by the co-oximeter that the presence of SH altered all results. Methemoglobin level was 2.3%. Initially, SH was not measured, but after suspicion, a sample was sent to a specialized lab and, several days later, resulted at 4.9% (normal 0-0.4). Echocardiogram was normal without a shunt, and she had no tissue injury, as evidenced by normal troponin, lactate, liver function tests, and creatinine. She was watched in the hospital for four days with oxygen saturation of around 80% and was released in stable condition to home. DISCUSSION: Dyshemoglobinemias, such as methemoglobinemia and SH, are not commonly encountered and may not be often represented in the differential diagnosis of some providers when faced with a patient with cyanosis. There is no reversal agent for sulfhemoglobin, unlike methemoglobin. Resolution depends on removing the offending agent and patience for RBC turnover, after which the patient should normalize their hemoglobin structure and physiology. Transfusion or exchange transfusion can be considered in cases where there is tissue injury, but in most patients, the disease will be self-limited, and care will be supportive. The presence of sulfhemoglobin will right-shift the hemoglobin oxygen curve, promoting offloading of oxygen from the normal hemoglobin CONCLUSIONS: The report highlights SH as a significant entity that can cause cyanosis. More importantly, this may be difficult to diagnose as some co-oximeters will not measure it, though it may recognize its presence has altered the results. As in our case and another report, this abnormality was not sent to the EMR and was a near-miss event. This highlights dependence on technology which is not yet designed to relay information gathered in the testing (even though it may have been discovered), offering an opportunity for process improvement. REFERENCE #1: Morales A, Walsh R, Brown W, Checinski P, Williams SR. Case Report: Phenazopyridine-Induced Sulfhemoglobinemia in an 83-Year-Old Presenting with Dyspnea. J Emerg Med. 2021 Aug;61(2):147-150. REFERENCE #2: Flexman AM, Del Vicario G, Schwarz SK. Dark green blood in the operating theatre. Lancet. 2007 Jun 9;369(9577):1972. REFERENCE #3: Steinberg, M. H., Benz, E. J., & Adewoye, A. H. (2018). Chapter 33 Pathobiology of the Human Erythrocyte and Its Hemoglobins. In Hematology (7th ed., pp. 447–457). Elsevier. DISCLOSURES: No relevant relationships by Augusto Amaral Neto No relevant relationships by Isabela Azevedo Ferreira de Souza No relevant relationships by Joel Barnett No relevant relationships by Katherine Dobrovolny" @default.
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• W4387268322 date "2023-10-01" @default.
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• W4387268322 title "A RARE INTRIGUING CASE OF COMBINED DYSURIA AND DYSPNEA" @default.
• W4387268322 doi "https://doi.org/10.1016/j.chest.2023.07.3746" @default.
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