Successful intervention in a child with toxic methemoglobinemia due to nail polish remover poisoning

Abstract

Children are most susceptible to accidental exposure of common household substances and one of the common household substances is nail polish remover. We are presenting a case of accidental ingestion of nail polish remover with lethal methemoglobinemia (serum methemoglobin level-72%). This patient was treated successfully with injection methylene blue. However, even small amounts can be dangerous to children, so it is important to keep this and all household chemicals in a safe place

INTRODUCTION

Nail polishes and nail polish removers may contain a variety of hydrocarbon-based solvents, while nail adhesives usually contain various acrylic ester monomers. The chemical N,N-dimethyl-p-toluidine is a chemical commonly found in artificial fingernail solutions.[1] Its oxidation metabolite phenyl hydroxylamine is presumably one of the most potent chemical producers of methemoglobin. Accidentally drinking small amounts of acetone/nail polish remover is unlikely to harm in an adult.[2] Although there are so many reported case of nail polish removal poisoning in the western literature,[1,2] but so far no such case reported in Asia.

CASE REPORT

A 13-month-old male child presented to us with history of ingestion of small volume of nail polish remover 2 h back and followed by he has started vomiting and gradually becoming lethargic. After admission, the child was kept under observation and we observed that gradually he became cyanosed, restless, and more lethargic. He had no other significant history. On general physical examination, at the beginning though he had no cyanosis or any significant observation. But, after about 1 h he found to have cyanosis. On systemic examination, he had only lethargy and irritability without any sign of respiratory distress. Otherwise, no abnormality was found on systemic examination. We investigated the child and he had all the hematological and biochemical parameters within normal limit. But, he had low oxygen saturation (85-87%) in pulse oxymeter and simultaneously taken arterial blood gas showing pO₂: 157 mm of Hg with mildly increased lactate (1.9 mmol/lit) and the pH and other parameter was within normal limit. As there was low SpO₂ with increased pO₂, so we suspected that he must be having methemoglobinemia and further investigated for serum methemoglobin level and serum G6PD level. The serum methemoglobin level came out to be 72% and G6PD found to be in the normal range. So we managed the child with oxygen, intravenous fluids, and inj. Methylene blue (2 mg/kg), single dose. The child responded promptly with the treatment. The cyanosis was resolved and child was active and accepted orally also. The repeat serum methemoglobin was 2%. The child was discharged after 1 day with the final diagnosis of toxic methemoglobinemia due to nail polish remover poisoning.

DISCUSSION

When an infant presents severe cyanosis which is not associated with respiratory distress, methemoglobinemia should always be suspected. Children affected with methemoglobinemia have a peculiar lavender color. Blood from the heel sticks is chocolate-brown and does not become pink when exposed to room air.[1] In the absence of cyanide level determinations, lethargy, vomiting, seizures, and the lack of normal venous blood hemoglobin desaturation are clues to cyanide toxicity.[3] Diagnosis can be confirmed by excluding other causes of cyanosis and by spectrophotometric analysis of blood for methemoglobin. When methemoglobin levels reach 70% or more, the patient will collapse and become comatose and may die.[4] Therapy with methylene blue results in prompt relief. Treatment with methylene blue can be complicated by the presence of underlying enzyme deficiencies, including glucose-6-phosphate dehydrogenase deficiency. Health care providers should not confuse the potentially highly toxic acetonitrile-containing cosmetics, particularly false-fingernail removers, with less-toxic acetone-containing fingernail-polish removers.[5] This potential confusion between acetone and acetonitrile poisoning is compounded by the initial similarity of their early features, including vomiting, lethargy, slurred speech, ataxia, stupor, coma, and respiratory depression. Delayed vomiting, although not typically a major clinical indicator of most cases of cyanide poisoning, may be important in alerting health care providers to acetonitrile toxicity in exposed children.[5] However, vomiting is common from many causes and is not sufficient by itself to dictate the administration of a cyanide antidote in the absence of other supporting evidence of cyanide toxicity from history and clinical laboratory studies. Sudden death is possible in some nail polish poisoning cases.[6] The health care provider will measure and monitor the patient's vital signs, including temperature, pulse, breathing rate, and blood pressure. The patient may receive activated charcoal if the patient arrives immediately after swallowing the poison, gastric lavage, oxygen, if needed.[6] The person survives past 48 h; the chances for recovery are good.[6]

We wish to draw attention to the potential toxicity of acetone containing nail polish removers and the need for appropriate labeling of product packaging. Since alternative products are available, these products should be removed from the market. Pediatrician should be well versed with this clinical situation.