Greenish-blue discoloration of the brain and heart after treatment with methylene blue
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Greenish-blue discoloration of the brain and heart after treatment with methylene blue Carlos Durão 1,2 & Frederico Pedrosa 1 & Ricardo Jorge Dinis-Oliveira 3,4,5 Accepted: 9 September 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Greenish-blue discoloration of the brain and heart was observed during the autopsy of a 63-year-old woman who had been treated with methylene blue for septic shock following a traffic accident. This “pistachio” or “avatar” discoloration occurs when the colorless metabolite leucomethylene blue is oxidized to methylene blue upon exposure to atmospheric oxygen. Other clinically documented adverse effects of methylene blue include greenish-blue urine and bluish discoloration of the skin and mucosa. In medicine, methylene blue is an inhibitor of nitric oxide synthase and guanylate cyclase with different clinical applications, namely, rapid reversal of circulatory shock that is refractory to fluid administration, inotropic agents, and vasoconstrictors. Postmortem differential diagnosis with putrefaction and hydrogen sulfide poisoning should be made, and forensic pathologists should be aware of methylene blue-related greenish-blue discoloration to avoid unnecessary workup and investigations. Keywords Methylene blue . Greenish-blue discoloration . Heart . Brain . Forensic autopsy
Case report A 63-year-old woman was admitted to the emergency department following a right-side impact car accident and incarceration. At the accident site, the Glasgow score recorded was less than 10, and the patient was endotracheally intubated and treated with tranexamic acid. Although she remained hemodynamically stable during transport, cardiorespiratory arrest in asystole was registered on hospital admission. During her stay in the emergency department, the victim was always in
* Ricardo Jorge Dinis-Oliveira [email protected]; [email protected] 1
Portuguese National Institute of Legal Medicine and Forensic Sciences, Lisbon, Portugal
2
Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
3
Department of Sciences, IINFACTS - Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal
4
Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
5
UCIBIO-REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
refractory hypovolemic and cardiogenic shock, justifying vasopressor support with noradrenaline, dobutamine, and adrenaline, and reinforcement with intravenous fluids and blood derivatives. Her hospital course was complicated by a persistent altered mental status, respiratory failure, acute kidney injury with acid-base imbalance that justified supplementation with bicarbonate, and hypotension. The hypotension became refractory to catecholamines, requiring the use of methylene blue to m
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