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When the 25-year-old woman arrived at the emergency room, she was weak, dizzy and breathless. But his doctors immediately targeted a much more disturbing symptom.
"She looked physically blue," Otis Warren, an emergency physician who had treated the woman last year in Rhode Island, told The Washington Post.
The woman's skin and nails had taken on a bluish tinge – a common sign that the body was not getting enough oxygen – and her blood had also become unusually dark, according to a report published Thursday in the New England Journal of Medicine.
Fortunately, the doctors knew exactly what was wrong.
The symptoms involved a rare and potentially fatal condition called acquired methemoglobinemia, in which exposure to certain chemicals or drugs altered the shape of a person's hemoglobin molecules, thus preventing their blood from releasing from oxygen in the surrounding tissues, Warren said. As a result, the tissues become blue and the blood that now "selfishly holds on to oxygen" shifts from "brilliant bright red color" to "chocolate brown," he said. Methemoglobinemia can also be transmitted by families, although this form is much rarer.
In this case, the doctors stated that the woman's condition was caused by a reaction to a topical analgesic that she used to relieve a toothache. The drug contained benzocaine, the active ingredient in several over-the-counter anesthetic ointments. Benzocaine is also often used by doctors and nurses to numb the nose and throat of patients during procedures. According to the Food and Drug Administration, more than 400 cases of methemoglobinemia associated with benzocaine have been reported.
The next morning, after applying the medication, the woman, who was not listed in the report, told the doctors that she was waking up breathless, Warren said.
Then she saw herself in the mirror, became "very worried" and rushed to the hospital, he said.
"I'm blue," the woman told the medical staff on her arrival, according to Warren. His blood samples also showed revealing discoloration, he said. Warren pointed out that the woman's blood was brown, not dark blue, as reported by other media.
Throughout his career, Warren said, he has only seen another patient with the disorder, but remembers these signs very well.
"It's the kind of thing you care about," he said.
Once the doctors learned about the existence of benzocaine, they quickly connected the dots and administered the well-named antidote, methylene blue, Warren said. Methylene blue brings the modified hemoglobin back to its normal form, thus restoring the blood's ability to deliver oxygen.
The laboratory results then confirmed the diagnosis, revealing that 44% of the hemoglobin in the woman's body had been affected, according to the case report. Patients with levels of more than 50% may be at risk for heart failure, coma or even death, Warren said.
"She was on this precipice, of course," he said.
In a 2018 announcement about the danger of benzocaine products and methemoglobinemia, the FDA reported identifying 119 cases reported in the past decade, most of which were serious and required treatment. Of these cases, four people, including one infant, died. The federal agency warned that oral drugs containing benzocaine should not be used to treat infants and children under 2 years of age, a demographic group particularly sensitive to blood disorders, Warren said.
"These products carry serious risks and provide little or no benefit for the treatment of oral pain, including painful gums in infants due to teething," the FDA wrote.
It is unclear how much benzocaine was used by the woman, but Warren said even small amounts could be dangerous depending on the person.
"It is a commonly used drug without any problems, all the time," he said. "Some people have this idiosyncratic reaction and you will not know it until it happens."
The woman received two doses of methylene blue administered intravenously and responded well to the treatment, Warren said. She spent a night in the hospital before her symptoms disappeared and she was released with a recommendation from the dentist.
Warren said he and another doctor had decided to release the details of the woman's experience Thursday because of her scarcity, adding that it was "a physiological case" very interesting".
"I could work another 20 years and never see anything like it again," he said.
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