Central European Journal of Medicine A Case of Almagel-induced Methemoglobinemia after Pancreatoduodenal Resection * E-mail: jurate.gudaityte@kaunoklinikos.lt Received 10 April 2011; Accepted 13 July 2011 Abstract: We are reporting the case of severe methemoglobinemia resulting from Almagel which was given for treatment of gastrointestinal ul- cers after pancreatoduodenal resection. A 64 year old man was treated with Almagel A postoperatively. One day after treatment began, the patient reported what appeared to be cyanotic discolorations of his lips and fngers. (SpO 2 80%, normal pO 2 ). Two days later, the patient was diagnosed with methemoglobinemia via co-oximetry and treated with methylene blue. The causes of methemoglobinemia remained unclear, and Almagel A was reinitiated until the second episode of methemoglobinemia, was diagnosed and treated promptly. The dose of benzocaine in Almagel A (100 mg/5 ml) was suffcient enough to cause methemoglobinemia, confrmed using multiwave- length co-oximeter and successfully treated with methylene blue. © Versita Sp. z o.o. Keywords: Adverse drug reactions • Almagel • Methemoglobinemia • Benzocaine 1 Department of Anaesthesiology, Medical Academy, Lithuanian University of Health Sciences, LT 50009 Kaunas, Lithuania 2 Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, LT 50009 Kaunas, Lithuania Jurate Gudaityte 1 *, Jurgita Borodiciene 1 , Ricardas Zalys 1 , Danguole Ceslava Rugyte 1 , Andrius Macas 1 , Tadas Latkauskas 2 Case Report 1. Introduction Methemoglobin is an altered state of hemoglobin where- by the ferrous form of iron (Fe 2+ ) is oxidized to the fer- ric state (Fe 3+ ), making the heme moiety incapable of carrying oxygen [1]. Normally accounting for about 1% of all circulating hemoglobin, methemoglobin is then re- duced back to hemoglobin, mainly by the activity of the cytochrome-b5-methemoglobinemia (MHb) reductase system [2]. Besides congenital forms, methemoglobinemia develops in the presence of oxidizing agents, such as benzocaine-containing topical anaesthetic sprays, and it is characterized by cyanosis. If untreated, methemo- globinemia may prove lethal [3]. Here we report a case of severe acquired methe- moglobinemia complicating treatment with Almagel after pancreatoduodenal resection. Almagel is an ant- acid medication in combination with a local anaesthes- tic (benzocaine) preferentially used in Eastern Europe for the prophylaxis and treatment of peptic ulcers and meteorism. The standard single dose 5 ml of Almagel suspension contains Aluminium hydroxide gel 300 mg, Magnesium hydroxide gel 100 mg, Benzocaine 100 mg and Sorbitol 800 mg (Actavis Nordic A/S, Denmark) [4]. The single dose for an adult can be increased to 2 and even 3 measuring spoonfuls in the presence of pain giv- en 1-2 hours after meal and at bedtime. Due to the risk of methemoglobinemia the duration of treatment should not exceed 3 days. After the pain has passed treatment should be continued with Almagel which does not con- tain benzocaine. By bringing the attention of other clinicians to the knowledge of potential side-effects of all prescribed medication and their constituting parts, we presume that this report will result in improved recognition and prompt treatment. Cent. Eur. J. Med. • 6(6) • 2011 • 773-777 DOI: 10.2478/s11536-011-0100-7 773 Unauthenticated Download Date | 2/26/20 10:11 PM