THE CONTROL OF METHEMOGLOBINEMIA WITH METHYLENE BLUE William B. Wendel J Clin Invest. 1939;18(2):179-185. https://doi.org/10.1172/JCI101033. Research Article Find the latest version: https://jci.me/101033/pdf THE CONTROL OF METHEMOGLOBINEMIA WITH METHYLENE BLUE"12 By WILLIAM B. WENDEL (From the Department of Internal Medicine, Washington University School of Medicine, St. Louis; and the Department of Chemistry, University of Tennessee, College of Medicine, Memphis) (Received for publication October 13, 1938) The cyanosis seen in a high percentage of pa- the concentration of methemoglobin from levels tients receiving sulfanilamide and related drugs as high as 25 to 40 per cent of the total pigment has been attributed variously to methemoglo- to less than 4 per cent in 30 to 40 minutes. binemia (1, 2), sulfhemoglobinemia (1), an un- In one case of sulfhemoglobinemia methylene usual degree of unsaturation of the venous blood blue was without effect upon the abnormal (3), and to the presence of aniline black (4) and pigment. other colored derivatives of sulfanilamide (5) ANIMAL OBSERVATIONS in the red blood corpuscles. Marshall and Walzl Since, in our experience, sulfanilamide does not (4) and Chesley (6) consider methemoglobin to produce methemoglobin in dogs, rabbits, rats, and be of no importance except perhaps in an occa- mice, nitrite was used to produce experimental sional patient. methemoglobinemia. Figure 1 illustrates the The present paper summarizes the results of course of blood pigment changes in seven control determinations of methemoglobin in the blood of dogs which received intravenous injections of 30 more than one hundred patients who were receiv- mgm. of sodium nitrite per kilogram of body ing sulfanilamide and showing cyanosis. Methe- weight. Following injection of nitrite, methemo- moglobin was found, at least in traces, in over 90 globin 8 rapidly accumulates and after 60 to 100 per cent of these. In thirty-five cases the blood minutes reaches a maximum concentration corre- contained methemoglobin to the extent of 15 per sponding to a loss of 60 to 70 per cent of the cent or more of the total pigment. In one in- normal oxygen capacity. It then progressively stance 40 per cent of the total blood pigment was decreases, due to reconversion to hemoglobin, and in the form of methemoglobin after 8 to 9 hours has entirely disappeared. The Animal experiments are described which con- average maximum rate of regeneration of hemo- firm and extend the observations of Williams and globin from methemoglobin (indicated in Figure Challis (7), Steele and Spink (8), and Hauschild 1 by a broken line) in these seven animals was (9) that methylene blue hastens disappearance of 0.03 volumes per cent per minute. This is essen- methemoglobin from the blood. Clinical applica- tially the same rate as observed when blood con- tion of these experiments to patients showing taining methemoglobin from these animals is in- cyanosis from sulfanilamide has shown that intra- cubated at body temperature in zitro, and may be venous injection of 0.1 to 0.2 cc. of one per cent looked upon as the rate at which the enzyme methylene blue per kilogram body weight reduces systems in the erythrocytes are able to reduce methemoglobin (10). 1 A preliminary report of this work was given before the Middle Section of the American Laryngological, 8 Methemoglobin concentration is expressed in this Rhinological, and Otological Society, St. Louis, January paper in two ways, as per cent of the total pigment and 26, 1938, and the American Society of Biological Chem- as volumes per cent, one volume per cent of methemo- ists, Baltimore, March 30, 1938 (J. Biol. Chem., 1938, globin being that concentration which results from loss 123, cxxiv), and was contained in a letter to the Editor of one volume per cent oxygen capacity. of the J. A. M. A., 1937, 109, 1216. In most experiments methemoglobin was determined 2This work was supported at both schools by grants by a spectroscopic method which will appear in a forth- from the Upjohn Company, Kalamazoo, Michigan. The coming number of the J. Lab. and Clin. Med. Occa- Upjohn Company has supplied the writer with 10 cc. sionally, methemoglobin was determined also by differ- ampoules of methylene blue which were used in the ence between total pigment and oxygen capacity. The clinical studies. two methods usually gave identical results. 179 180 WILLIAM B. WENDEL atD z -J 0x 0;0 Li IN- Lhi 200 300 MINUTES AFTER NITRITE INJECTION FIG. 1. AccumuLMAoN AND DISAPPEARANCE OF METHEMOGLO}IN IN THE BLOOD OF DOGS FOLLOWING THE INTRAVENOUS INJECTION OF SODIUm NimTE (30 MGM. PER KILOGRAM OF BODY WEIGHT) Having determined the physiological rate of obtained with a number of dogs, shows that in- hemoglobin regeneration from methemoglobin jection of 2 mgm. of methylene blue (in the form various substances were tested for possible accel- of a one per cent aqueous solution) per kilogram erating action upon this process. Sodium formal- of body weight increases the rate of disappearance dehyde sulfoxylate, which reduces methemoglobin of methemoglobin 'from the blood four or five- in aqueous solution, was found to be without ef- fold. Table I summarizes the results of a series fect in trvo. Sodium formaldehyde sulfoxylate, of similar experiments in which the effect of vari- however, reduces methylene blue and since re- ous quantities of wnethylene blue upon the rate of duced (leuco) methylene blue converts methe- disappearance of methemoglobin from the blood moglobin to hemoglobin very rapidly, it seemed was determined. A measurable effect is evident possible that simultaneous injection of these two even with the smallest amount of dye injected, substances might accelerate conversion of methe- namely, 0.1 mgm. per kilogram of body weight. moglobin to hemoglobin. A cycle between sul- Oxygen capacity figures in Table I indicate that foxylate in the plasma and methemoglobin in the the methemoglobin which disappears rapidly fol- red cells mediated by methylene blue was pictured. lowing injection of methylene blue is converted When tested it was found that simultaneous intra- to functionally active hemoglobin. The duration venous injection of methylene blue and sulfoxy- of the anti-methemoglobin action of 5 mgm. of late caused methemoglobin to disappear from the methylene blue per kilogram in dogs is at most blood very rapidly. Control experiments, how- about 2 hours. ever, showed that methylene blue alone was equally Methylene blue accelerates the disappearance of effective. Figure 2, which illustrates the results methemoglobin also from the blood of rabbits. METHEMOGLOBINEMIA AND METHYLENE BLUE 181 Methylene blue is effective as an anti-methemo- DOG 22 globin agent also when given by mouth. As com- HbO2, INITIAL, 16.4 VOL.X N AFTER 95 MIN. 6.3 VOL L.X pared with intravenous injection the response to o t 155 15.4 administration by mouth is slow, and more of the 10- 2 MG. MB./KG. dye is required. Observations to date indicate that SLOPE 0.2 VOL- /MIN. accumulation of methemoglobin can be prevented in adults by oral administration of 0.5 to 1.0 gram i-j of methylene blue per day even when the patient is receiving large doses of sulfanilamide. z Before methylene blue was injected into pa- 0 -i tients receiving sulfanilamide, compatibility of 0 these two substances was tested in dogs and rab- Lai s bits. Several times as much methylene blue was Lai injected into experimental animals as is required in humans. Also the dye was injected at a time when the animals were severely toxic from large MB doses of sulfanilamide (1 gram per kilogram per I I No increase in was evident follow- 0 100 200 300 day). toxicity MINUTES AFTER NITRITE I NJECTION ing intravenous injection of the dye. In order to elicit cumulative effects of administra- FIG. 2. EmFCr OF INTRAVENOUS INJECTION OF [ETHY- possible LENE BLUE, 2 MGM. PER KILOGRLAM OF BODY WEIG:ET ON tion of the combination of drugs one dog was RATE OF CONVERSION OF METHEMOGLOBIN TO HEMO*GLOBIN given 0.6 gram sulfanilamide per kilogram per IN THE DoG day and 0.27 gram of methylene blue per day HbO, means oxygen capacity. MB over arrovv mdi- by mouth for 4 weeks. No outward evidence of cates injection of methylene blue. toxicity or abnormal blood rhanges was observed. Preliminary experiments with Dr. Anna Dula- CLINICAL APPLICATION ney of the University of Tennessee Medical In collaboration with Dr. Alexis F. Harn tmann School on mice injected with highly virulent of Washington University Medical School, where strains of beta hemolytic streptococci indicate that the writer began and completed an importanit part of this work, these observations receivedI first TABLE I clinical application in the summer of 1937. Since Effect of various amounts of methykne blue on rate of these early observations many others have been conversion of methemoglobin to hemoglobin in dogs made with the cooperation of physicians c n the staff of the University of Tennessee Mledical Amount of Rate of OXYen capacity Dog methylene disappear- School. In summary, intravenous injection of number blue ance of After After icted methemoglobin Before 0.1 to 0.2 cc. per kilogram of body weighit of a nitrite i methlee bluet Mm. per otumes per cent soluma otusm solume one per cent aqueous solution of methylene blue kilegram per minute per cent per cet per cent converts in the course of about 45 minutes all of 14 10 0.77 17.3 (50 minutes) 14 10 0.33t 12.8 4.4 13.2 (30 minutes) in the ocytes 21 10 0.31t the methemoglobin circulating erythr 16 5 0.19 functionally active hemoglobin, even when 18 5 0.25 17.7 7.3 17.0 (65 minutes) into 17 2 0.23 the concentration representss initi- 22 2 0.20 16.4 6.3 15.4 (60 minutes) methemoglobin 19 1 0.076 12.7 5.5 10.6 (95 minutes) as much as 25 to 40 per cent of the totsal pig- 20 1 0.14 ally 6 0.5 0.12 ment.