Identification of sulfhemoglobinemia after surgical polypectomy

Abstract

Sulfhemoglobinemia (SHb) is an uncommon cause of cyanosis that is predominantly drug-induced in adults. We report an unusual case of sodium sulfate-induced sulfhemoglobinemia in a 61-year-old woman after surgical polypectomy. Fractional hemoglobin derivates were assayed by spectrophotometry and high-performance liquid chromatography. The SHb ratio was 8.6% in the first sample and 3.77% a month later measured by spectrophotometry. In the blood hemolysate, a new peak was identified as SHb with high-performance liquid chromatography (HPLC). HPLC showed the presence of 9.37% SHb in the first sample and 4.88% a month later. After removing the suspected toxic agent the cyanosis decreased significantly. The findings underline the importance of routine SHb detection in cyanosis of unknown origin especially in emergency cases.

Hydrogen sulfide activation in hemeproteins: The sulfheme scenario

“…High levels of sulfHb and sulfMb can be poisonous since they alter the protein O 2 transport or storage functionalities, causing a cyanosis known as sulfhemoglobinemia [14]. Possible symptoms are chocolate brown arterial blood, fatigue, chest pain and tightness, dizziness, pallor, livid discoloration of the skin and lips, bluish stain on finger tips, foul urine and breath, and tremor of the upper and lower extremities [37–39]. It is very common for sulfhemoglobinemia to be initially misdiagnosed as methemoglobinemia [37, 38, 40].…”

“…Possible symptoms are chocolate brown arterial blood, fatigue, chest pain and tightness, dizziness, pallor, livid discoloration of the skin and lips, bluish stain on finger tips, foul urine and breath, and tremor of the upper and lower extremities [37–39]. It is very common for sulfhemoglobinemia to be initially misdiagnosed as methemoglobinemia [37, 38, 40]. A helpful note for its diagnostic is the lack of respiratory distress for the degree of cyanosis, [37] and near normal O 2 tension [41].…”

“…It is very common for sulfhemoglobinemia to be initially misdiagnosed as methemoglobinemia [37, 38, 40]. A helpful note for its diagnostic is the lack of respiratory distress for the degree of cyanosis, [37] and near normal O 2 tension [41]. It can lead to end-organ damage and death when high sulfHb levels are reached (approximately 60%) [40].…”

“…It can lead to end-organ damage and death when high sulfHb levels are reached (approximately 60%) [40]. In order to be clinically detectable the sulfHb concentration should be more than 5 g/L (approximately 80 μM) [37, 38] while normal concentrations are below 0.37 g/L (approximately 5.8 μM) [38]. Its identification is usually performed by spectrophotometry, co-oximetry, gas chromatography or HPLC [37, 40].…”

“…In order to be clinically detectable the sulfHb concentration should be more than 5 g/L (approximately 80 μM) [37, 38] while normal concentrations are below 0.37 g/L (approximately 5.8 μM) [38]. Its identification is usually performed by spectrophotometry, co-oximetry, gas chromatography or HPLC [37, 40]. Treatment involves suspected chemical agent suspension, external O 2 supply [37] and in severe cases, blood transfusion [40].…”