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The Formation of Methemoglobin and Sulfhemoglobin During Sulfanilamide Therapy

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The Formation of Methemoglobin and Sulfhemoglobin During Sulfanilamide Therapy THE FORMATION OF METHEMOGLOBIN AND SULFHEMOGLOBIN DURING SULFANILAMIDE THERAPY J. S. Harris, H. O. Michel J Clin Invest. 1939;18(5):507-519. https://doi.org/10.1172/JCI101064. Research Article Find the latest version: https://jci.me/101064/pdf THE FORMATION OF METHEMOGLOBIN AND SULFHEMOGLOBIN DURING SULFANILAMIDE THERAPY By J. S. HARRIS AND H. 0. MICHEL (From the Departments of Pediatrics and Biochemistry, Duke University School of Medicine, Durham) (Received for publication April 8, 1939) Cyanosis almost invariably follows the admin- during the administration of sulfanilamide. Wen- istration of therapeutic amounts of sulfanilamide del (10) found spectroscopic evidence of met- (1). This cyanosis is associated with and is due hemoglobin in every blood sample containing over to a change in the color of the blood. The dark- 4 mgm. per cent sulfanilamide. Evelyn and Mal- ening of the blood is present only in the red cells loy (11) have found that all patients receiving and therefore must be ascribed to one of two sulfanilamide show methemoglobinemia, although causes, a change in the hemoglobin itself or a the intensity is usually very slight. Finally Hart- staining of the red cells with some product formed mann, Perley, and Barnett (12) found cyanosis during the metabolism of sulfanilamide. It is the associated with methemoglobinemia in almost ev- purpose of this paper to assay quantitatively the ery patient receiving over 0.1 gram sulfanilamide effect of sulfanilamide upon the first of these fac- per kilogram of body weight per day. They be- tors-that is, upon the formation of abnormal lieved that the intensity of the methemoglobinemia heme pigments. depended to a slight extent upon the blood sulf- A resume of the literature reveals conflicting anilamide concentration but more upon the peculi- data on the state of the hemoglobin after sulfanil- arities of the patients. They also noted that the amide administration. Many observers have not tendency to methemoglobin formation was appar- been able to demonstrate sulfhemoglobin or met- ently enhanced by the presence of acute inflamma- hemoglobin in any of their cases (2). Mull and tory processes and a toxic state of the patient. Smith (3) reported evidence of inactive hemo- In common with other observers, they found that globin as judged by the difference between oxygen methemoglobinemia usually disappears within 24 capacity and total heme pigment but were unable to 72 hours after the administration of the drug to find the characteristic spectral bands of either is discontinued. methemoglobin or sulfhemoglobin. Marshall and The tendency of sulfanilamide and its deriva- Walzl (4) found that two of seven cyanotic pa- tives to produce sulfhemoglobinemia has been tients showed slight methemoglobinemia. In the noted for some time. Colebrook and Kenny (13) remaining five patients, the oxygen capacity was found that 3 of 38 patients treated with " Pron- equivalent to the total iron content of the blood. in the absence tosil Soluble" developed sulfhemoglobinemia. These bloods appeared dark spite of Instances of sulfhemoglobinemia after the admin- abnormal heme and the writers con- of pigments of cluded that some other substance, probably an istration sulfanilamide have been reported by oxidation product of sulfanilamide, had stained the Paton and Eaton (6) (5 cases), Archer and Dis- red cells. Their conclusion received very indirect combe (8) (5 cases) and Evelyn and Malloy (11) support from the work of Ottenberg and Fox (5) (4 positive blood examinations). Colebrook and who showed that a bluish pigment was formed Purdie (14) noted cyanosis in 58 of 106 patients from sulfanilamide in aqueous solutions by the receiving sulfanilamide. Spectroscopic examina- action of ultraviolet light. tion of the bloods in 53 of these cases showed Occasional cases of methemoglobinemia of methemoglobin in 24, sulfhemoglobin in 13, both varying intensity have been reported by Paton sulfhemoglobin and methemoglobin in 8, and ab- and Eaton (6), Posner, Guthrie, and Mattice (7), sence of abnormal heme pigments in only 8. Archer and Discombe (8), and Bensley and Ross Frost (15) has found sulfhemoglobinemia post- (9). Recently, several reports have demonstrated mortem in a case treated with prontosil and benzyl- that methemoglobin formation is the usual event sulfanilamide. 507 508 J. S. HARRIS AND H. 0. MICHEL PLAN OF STUDY RESULTS Between May 1937 and May 1938, an attempt A. Methemoglobin formation was made to obtain frequent blood specimens of There were 960 blood examinations made on all patients receiving sulfanilamide in the clinics 476 patients. Methemoglobin, in quantities de- and on the wards of Duke Hospital. The drug monstrable by the hand spectroscope, was found was generally given by mouth in equal doses four in the red cells of 277 or 58 per cent of the pa- to six times daily. The blood specimens were tients at some time during the administration of drawn, when possible, between three and five sulfanilamide. The distribution of these patients hours after the ingestion of the drug and were according to age and sex is shown in Figure 1. examined shortly thereafter. The per cent of patients developing methemoglobi- The free whole blood sulfanilamide concentra- nemia is roughly equal in the sexes, but is higher tion was determined by the method of Marshall in the very young. (16). At least two standards were used because of the slight deviations from Beer's law. The Effect of blood sulfanilamide concentration on bloods were examined qualitatively for the pres- methemoglobinemia ence of abnormal pigments (17). The absorption All blood specimens were divided into five spectra were inspected through a hand spectro- groups on the basis of their sulfanilamide con- scope for abnormal bands in the red region. The centration. In each group, the percentage of alpha methemoglobin band was confirmed by the bloods which showed methemoglobin (in sufficient usual tests (addition of cyanide in all cases, occa- quantity to be detected by the hand spectroscope) sionally supplemented by the action of alkalies was calculated. These are plotted against the and reducing agents). The alpha sulfhemoglobin sulfanilamide concentration of the group in the band was checked by its stability to these reagents. upper curve in Figure 2. In the 0 to 4 mgm. per The bands were recognized if more than 4 to 6 cent sulfanilamide group, 39 per cent of the speci- per cent of the total pigment had been converted mens were positive. This percentage increased to methemoglobin or if more than 1 per cent was with increasing sulfanilamide concentration until present as sulf hemoglobin. If the abnormal bands 100 per cent was reached in the group of bloods were detected, the bloods were subjected to quan- showing over 16 mgm. per cent sulfanilamide. titative spectrophotometric examination (17). In each sulfanilamide concentration group, the The method for methemoglobin depended either average methemoglobin value of all bloods within on the ratio of the extinctions of oxyhemoglobin that group was calculated. It can be seen in Fig- and cyanmethemoglobin at wavelengths of 575 m,u ure 2 (lower curve) that the average methemo- and 560 mu or on the specific change in absorption globin value varies directly as the sulfanilamide at a wavelength of 634 mp upon the conversion concentration of the blood. It is to be clearly un- of methemoglobin to cyanmethemoglobin. The derstood that, throughout this study, only those method for sulfhemoglobin depended upon the bloods were considered positive for methemoglobin ratio of the extinctions of sulfhemoglobin and which showed the pigment in amounts detectable oxyhemoglobin at wavelengths of 540 and 560 m,. by the hand spectroscope. Since quantitative ex- All quantitative determinations were performed amination was limited to these bloods, the average on the Bausch and Lomb Universal Spectropho- methemoglobin values herein reported are not true tometer. averages. Specimens, calculated as not contain- Normal bloods never showed any change in ing methemoglobin, may have contained up to ap- absorption at 634 m,u upon the addition of cy- proximately 0.6 gram per cent. Undoubtedly, the anide, nor did the blue product formed from sulf- number of positive bloods and the average met- anilamide by the action of ultraviolet light. Since hemoglobin levels would have been raised if speci- all quantitative determinations were preceded by mens with smaller amounts of methemoglobin had confirmatory qualitative tests, it is almost certain been subjected to quantitative determination. that the methods were specific for the pigments in Nevertheless, it is obvious that there is very di- question. rect correlation between the average methemo- METHEMOGLOBIN AFTER SULFANILAMIDE 509 z w w 5 0 z 50 6 MALES FEMALES 0-5 6-10 11-20 21-40 41-60 OVER 00 SEX AGE IN YEARS FIG. 1. THE INCIDENcE OF METHEMOGLOBINEMIA, ACCORDING TO SEX AND AGE Total height of column gives the number of patients studied in each group. The shaded portion gives the number of patients showing methemoglobinemia at some time during therapy. The numbers in the shaded areas refer to the percentage of patients in each group that showed methemoglobinemia. globin level and the concentration of sulfanilamide in the blood. At sulfanilamide concentrations in ibo PER CENT POSITIVE 2.0 excess of 16 mgm. per cent, methemoglobin was *1~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~11 invariably present in easily demonstrable quanti- ties. The maximum methemoglobinemia was 5 grams per cent; a conversion of over 40 per cent of the total hemoglobin. This occurred at a blood sulfanilamide concentration of 18 mgm. per cent. 0 Effect of age and sex upon the development of /0.- methemoglobin 0.~~~~~ ~ ~ ~ ~ ~ ~ It has already been shown that the percentage - 00..v 0N 01-44820 VERAE MH8 bC.1 1-4 1 of patients developing methemoglobinemia is BLOO2ULAVERAG IE 0.4.(G.% roughly equal in the sexes but is higher in the very young.
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