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IN THE NAME OF GOD. Shafiepour ,m MD . Kerman university of medical sciences. A patient with human immunodeficiency virus had a rash in association with trimethoprim sulfamethoxazole used as prophylaxis for Pneumocystis carinii pneumonia. An alternative

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shafiepour m md kerman university of medical sciences

IN THE NAME OF GOD

Shafiepour,m MD.

Kerman university of medical sciences

slide2

A patient with human immunodeficiency virus had a rash in association with trimethoprim

sulfamethoxazoleused as prophylaxis for Pneumocystiscarinii pneumonia. An alternative

medication was used, but the patient took 3 times the normal dose by mistake. He became dyspneic, and headache, nausea and vomiting, and the skin discoloration shown here developed

(a normal hand is shown for contrast on the right).

slide4

1. What was the alternative medication?

1a. Pentamidine

1b. Pyrimethamine-sulfonamide

1c. Atovaquone

1d. Dapsone

1e. Clindamycin-primaquine

slide5

2. In addition to supplemental oxygen, which one of the following would be the most appropriate antidote?

2a. N-Acetylcysteine

2b. Amyl nitrite

2c. Methylene blue

2d. Deferoxamine

2e. 4-Methylpyrazole

slide6

Methemoglobinemia Due to Dapsone Overdose

• Methemoglobin is the ferric form of hemoglobin (HbFe3+) that cannot bind

oxygen

• Although sometimes inherited, it is more often formed by oxidative stress

• Among drugs, nitrites are commonly associated with this condition

• Chocolate-brown or slate-blue cyanosis unrelieved with oxygen suggests the diagnosis

slide7

• Arterial blood gas studies will show normal arterial oxygen pressure but low oxygen saturation.

Pulse oximetryresults will be inappropriately increased (the pulse oximeterresult will be higher than the actual oxygen saturation, although the absolute value may still be below normal)

slide8

• Methylene blue is the antidote for patients with severe hypoxia, unless they have glucose-6 phosphate dehydrogenase deficiency, in which case it may worsen the clinical condition. If the patient has this deficiency, ascorbic acid can be used to reduce the methemoglobin

slide9

The characteristic muddy appearance of freshly drawn blood can be a critical clue. The best diagnostic test is methemoglobin assay, which is usually available on an emergency basis.

Methemoglobinemia often causes symptoms of cerebral ischemia at levels >15%; levels >60% are usually lethal. Intravenous injection of 1 mg/kg of methylene blue is effective emergency therapy. Milder cases and follow-up of severe cases can be treated orally with methylene blue (60 mg three to four times each day) or ascorbic acid (300–600 mg/d).