Methemoglobinemia is a rare, life-threatening condition that occurs when the body is exposed to oxidative stress. We present the case of a 72-year-old female with a past medical history of hypertension, obesity, dyslipidemia, and heart failure who was admitted to the emergency department with altered mental status and respiratory failure. After admission, we also identified an atrioventricular block 2:1, anemia, and skin discoloration. We performed endotracheal intubation and started mechanical ventilation due to respiratory failure; however, the patient retained an oxygen "saturation gap" despite adequate ventilation. In the initial laboratory evaluation, methemoglobinemia was found to be 13%, reaching a maximum level of 16%. An electroencephalogram revealed status epilepticus after her admission to the intensive care unit. Despite all efforts and supportive care, methylene blue therapy was never attempted, and the patient died. Our case emphasizes the importance of a high index of suspicion for methemoglobinemia, especially in the presence of an oxygen "saturation gap," and that despite relatively low levels of methemoglobinemia, it can have a more severe clinical presentation in patients with comorbidities. In these patients, a reduced threshold for administering methylene blue should be taken into account.
Keywords: altered mental status; comorbidities; methemoglobinemia; respiratory failure; status epilecticus.
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