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Old 10-09-2012
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Question HIV Patient with Chocloate Brown Blood

A 45 yr old known HIV pt. with CD4 180 mg/dl has been diagnosed with PCP 2weeks ago and was started on trimethoprim and sulphamethaxazole....2 days back the pt. complaints with dyspnea, headache, fatigue, altered mental status and found dead the next day morning..his blood was chocolate brown colored during examination....what could have avoided the pt. condition if the physician has prescribed adjunct to his current therapy..?

a) dapsone
b) ondansetron
c) cimetidine
d) oxygen supplement
e) pencillin derivatives
f) heparin
g) rifampin
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Dapsone=methhemoglobinemia
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Quote:
what could have avoided the pt. condition if the physician has prescribed adjunct to his current therapy..?
c) cimetidine
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Chocolate brown blood.
MethHb increase
Rx- dapsone
But how tmp-SMX caused conversion of ferrous to ferric?
So not sure about answer
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Default EE/

E...pentamidine?
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Quote:
Originally Posted by venky2600 View Post
Q) a 45 yr old known HIV pt. with CD4 180 mg/dl has been diagnosed with PCP 2weeks ago and was started on trimethoprim and sulphamethaxazole....2 days back the pt. complaints with dyspnea,headache ,fatigue,altered mentalstatus and found dead the next day morning..his blood was chocolate brown colored during examination....which of the following physician could've been given to this pt. to overcome this condition...?

a) dapsone
b) ondansetron
c) cimetidine
d) oxygen supplement
e) pencillin derivatives
f) heparin
g) rifampin

sorry guys...the question was wrongly framed with no answer in it.......
by changing the last phrase can lead to the answer.....:sorry:...i'll post the answer soon
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d) oxygen supplement
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g) rifampin
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I think the author tried to say that some condition was treated with dapsone and pt ended up with methemoglobinemia and the rx would be IV methylene blue + vit c
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to clear the confusion about this topic adding another question...

2Q)A 56 yr old known HIV pt. with CD4 140 mg/dl has been diagnosed with PCP 3weeks ago and was started on dapsone medical therapy....2 days back the pt. complaints with dyspnea, headache, fatigue, altered mental status and found dead the next day morning..his blood was chocolate brown colored during examination....what could have avoided the pt. condition if the physician has prescribed adjunct to his current therapy..?

a) pentamidine
b) ondansetron
c) cimetidine
d) oxygen supplement
e) pencillin derivatives
f) heparin
g) rifampin
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Quote:
Originally Posted by venky2600 View Post
sorry guys...the question was wrongly framed with no answer in it.......
by changing the last phrase can lead to the answer.....:sorry:...i'll post the answer soon
Would go with D
The standard R for methemoglobinemia is 100% O2 and methylene blue
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Quote:
Originally Posted by Anders View Post
Would go with D
The standard R for methemoglobinemia is 100% O2 and methylene blue
and for 2nd question???
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again im going with rifampin
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Quote:
Originally Posted by venky2600 View Post
and for 2nd question???
Would choose A
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Post 3 questions.....all gets clear of methemoglobinemia

1Q) a 45 yr old known HIV pt. with CD4 180 mg/dl has been diagnosed with PCP 2weeks ago and was started on trimethoprim and sulphamethaxazole....2 days back the pt. complaints with dyspnea,headache ,fatigue,altered mentalstatus and found dead the next day morning..his blood was chocolate brown colored during examination....which of the following physician could've been given to this pt. to overcome this condition...?

a) dapsone
b) ondansetron
c) cimetidine
d) oxygen supplement
e) pencillin derivatives
f) heparin
g) rifampin

2Q)A 56 yr old known HIV pt. with CD4 140 mg/dl has been diagnosed with PCP 3weeks ago and was started on dapsone medical therapy....2 days back the pt. complaints with dyspnea, headache, fatigue, altered mental status and found dead the next day morning..his blood was chocolate brown colored during examination....what could have avoided the pt. condition if the physician has prescribed adjunct to his current therapy..?

a) pentamidine
b) ondansetron
c) cimetidine
d) oxygen supplement
e) pencillin derivatives
f) heparin
g) rifampin

3 Q) A 45 yr old known HIV pt. with CD4 140 mg/dl has been diagnosed with PCP 3weeks ago and was started on dapsone medical therapy....2 days back the pt. complaints with dyspnea, headache, fatigue, altered mental status and found dead the next day morning..his blood was chocolate brown colored and also contain denatured Hb inclusions in RBC during examination......what treatment could have benefit this pt?

a) trimethoprim
b) ondansetron
c) methylene blue
d) vitamin C
e) pencillin derivatives
f) heparin
g) rifampin
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Now should be C
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we are salivating for correct option
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1- a) dapsone
2- d) oxygen supplement
3- g) rifampin

Not sure... but make sense to me....
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The correct answer is cimetidine.
Rx of methemoglobinemia(oxidized form of Hb- Fe3+ that does not bind oxygen as readily, hence chocolate colored blood & cyanosis) is...
1.methylene blue( converts Fe3+ back to Fe2+)
2.vitamin c
3.Cimetidine-Cimetidine is used in dapsone-induced methemoglobinemia to prevent further formation of its metabolite which is also responsive as an oxidizing agent.
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Quote:
Originally Posted by merci12 View Post
The correct answer is cimetidine.
Rx of methemoglobinemia(oxidized form of Hb- Fe3+ that does not bind oxygen as readily, hence chocolate colored blood & cyanosis) is...
1.methylene blue( converts Fe3+ back to Fe2+)
2.vitamin c
3.Cimetidine-Cimetidine is used in dapsone-induced methemoglobinemia to prevent further formation of its metabolite which is also responsive as an oxidizing agent.
Please note When I wrote the Rx of methemoglobinemia as 1,2,3 I didnt mean as those are the answers for q1,q2,q3.
they are merely the 3 Rx options in methemoglobiemia.

so if I were to answer the above 3 qs, they would be----1) c 2)c & 3) since cimetidine is not in the options, I would go with methylene blue ??
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Dapsone itself is metabolized by CYP microsomial system to toxic metabolites and everything that induces CYP system will increase the methemoglobin formation capacity of dapsone. that's why cimetidine is used in dapsone induced methemoglobinemia to inhibit it's metabolism and decrease the risk.
in theory itself TMP-SMX ( as inhibitor of CYP ) should decrease dapsone action, but it doesn't:

http://www.ncbi.nlm.nih.gov/pubmed/1352810

"N-Acetylcysteine, cimetidine, and ketoconazole are experimental therapies in the treatment of methemoglobinemia that have shown some promising results."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071541/

"The most prominent adverse effects seen during treatment with dapsone, an antibacterial and antiprotozoal agent, are hemolysis and methemoglobinemia. An in vitro microsomal/cytochrome P(450) (CYP)-linked assay, which allows reactive metabolites generated in situ to react with the co-incubated human erythrocytes, was employed to profile CYP isoforms responsible for hemotoxicity of dapsone. Dapsone caused a robust generation of methemoglobin in human erythrocytes in the presence of human/mouse liver microsomes, which indicates contribution of CYP-mediated metabolism for hemotoxicity. The highest methemoglobin formation with dapsone was observed with CYP2C19, with minor contributions from CYP2B6, CYP2D6 and CYP3A4. Cimetidine and chloramphenicol completely abrogated methemoglobin generation by dapsone " - i think that giving rifampin will increase the dapsone induced methemoglobinemia risk.


http://www.ncbi.nlm.nih.gov/pubmed/19998329

this issue was discussed here:

Dapsone Related Methemoglobinemia
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Default methaemoglobinaemia

please give the correct answer with explanations !
Quote:
Originally Posted by venky2600 View Post
1Q) a 45 yr old known HIV pt. with CD4 180 mg/dl has been diagnosed with PCP 2weeks ago and was started on trimethoprim and sulphamethaxazole....2 days back the pt. complaints with dyspnea,headache ,fatigue,altered mentalstatus and found dead the next day morning..his blood was chocolate brown colored during examination....which of the following physician could've been given to this pt. to overcome this condition...?

a) dapsone
b) ondansetron
c) cimetidine
d) oxygen supplement
e) pencillin derivatives
f) heparin
g) rifampin

2Q)A 56 yr old known HIV pt. with CD4 140 mg/dl has been diagnosed with PCP 3weeks ago and was started on dapsone medical therapy....2 days back the pt. complaints with dyspnea, headache, fatigue, altered mental status and found dead the next day morning..his blood was chocolate brown colored during examination....what could have avoided the pt. condition if the physician has prescribed adjunct to his current therapy..?

a) pentamidine
b) ondansetron
c) cimetidine
d) oxygen supplement
e) pencillin derivatives
f) heparin
g) rifampin

3 Q) A 45 yr old known HIV pt. with CD4 140 mg/dl has been diagnosed with PCP 3weeks ago and was started on dapsone medical therapy....2 days back the pt. complaints with dyspnea, headache, fatigue, altered mental status and found dead the next day morning..his blood was chocolate brown colored and also contain denatured Hb inclusions in RBC during examination......what treatment could have benefit this pt?

a) trimethoprim
b) ondansetron
c) methylene blue
d) vitamin C
e) pencillin derivatives
f) heparin
g) rifampin
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Correct Answer 1-d ,2-c, 3-d

sorry guys for delayed reply......these questions are just for understanding abt the methemoglobinemia well..

methemoglobinemia is a fatl condition with iron turning into oxidized form ,ferric form(fe3+) from ferrous form(fe2+)...so oxidized Hb has decreased affinity for oxygen leading to cyanosis ,headache,fatigue,altered mental status,chocolate brown colored blood....
it is caused by various causes ,most commonly acquired by various oxidizing drugs like dapsone,nitrates and antibiotics like trimethoprim,sulphonamides etc and also metoclopropamide...

treatment----1)methylene blue is the mainstay treatment----it acts via reduction of met.Hb by NADPH-metHb reductase system......
2) vit.c----only can reduce acquired methemoglobinemia
3) 100% oxygen therapy----as last resort ,if nothing works

1Q)D----- methemoglobinemia is dangerous side effect ,when prescribing TMP-SMX combo....,so it can be prevented by giving methylene blue or vit.c or 100% oxygen therapy-----as the first 2 are not provide in options oxygen supplement is the appropriate one

2Q)C--------dapsone induced methemoglobinemia is also a fatal condition..it is prevented priorly by starting along with cimetidine(cimetidine inhibit the metabolite formation of dapsone and prevents methemoglobinemia)....

3Q)D--------G6PD deficiency vignette------pt. has G6PD deficiency(denatured Hb inclusion in RBC----heinz bodies)-----methylene blue acts via NADPH-metHb reductase system-----so, methylene blue is ineffective in G6PD patients,so vit.c(though effectively less) or 100% oxygen are used instead..

other options

rifampin-----it is used along with dapsone to decrease the resistance ..

pentamidine-----it is used an alternative to PCP, but it can't be used adjunct to it or it do not show any effect for methemoglobinemia too..

ondansetron,pencillin derivatives and heparin---are not used for methemoglobinemia
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Default methaemoglobinaemia

What is the reaction when methylene blue is used for the treatment?how does it act by the G6PD -met Hb pathway?
Quote:
Originally Posted by venky2600 View Post
sorry guys for delayed reply......these questions are just for understanding abt the methemoglobinemia well..

methemoglobinemia is a fatl condition with iron turning into oxidized form ,ferric form(fe3+) from ferrous form(fe2+)...so oxidized Hb has decreased affinity for oxygen leading to cyanosis ,headache,fatigue,altered mental status,chocolate brown colored blood....
it is caused by various causes ,most commonly acquired by various oxidizing drugs like dapsone,nitrates and antibiotics like trimethoprim,sulphonamides etc and also metoclopropamide...

treatment----1)methylene blue is the mainstay treatment----it acts via reduction of met.Hb by NADPH-metHb reductase system......
2) vit.c----only can reduce acquired methemoglobinemia
3) 100% oxygen therapy----as last resort ,if nothing works

1Q)D----- methemoglobinemia is dangerous side effect ,when prescribing TMP-SMX combo....,so it can be prevented by giving methylene blue or vit.c or 100% oxygen therapy-----as the first 2 are not provide in options oxygen supplement is the appropriate one

2Q)C--------dapsone induced methemoglobinemia is also a fatal condition..it is prevented priorly by starting along with cimetidine(cimetidine inhibit the metabolite formation of dapsone and prevents methemoglobinemia)....

3Q)D--------G6PD deficiency vignette------pt. has G6PD deficiency(denatured Hb inclusion in RBC----heinz bodies)-----methylene blue acts via NADPH-metHb reductase system-----so, methylene blue is ineffective in G6PD patients,so vit.c(though effectively less) or 100% oxygen are used instead..

other options

rifampin-----it is used along with dapsone to decrease the resistance ..

pentamidine-----it is used an alternative to PCP, but it can't be used adjunct to it or it do not show any effect for methemoglobinemia too..

ondansetron,pencillin derivatives and heparin---are not used for methemoglobinemia
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Originally Posted by preeti617 View Post
What is the reaction when methylene blue is used for the treatment?how does it act by the G6PD -met Hb pathway?
according to kaplan biochem videos

normally, around 1-3 % daily Hb(in ferrous form) converts to met.Hb(ferric form) and release oxygen radicals.....------our body reverts it(forming back into ferrous iron----not forming oxygen radicals)-----by met.Hb reductase, NADPH comes from HMP shunt
in G6PD ,no such reaction occurs due to NADPH is needed for that enzyme to work-- methylene blue acts via met.Hb reductase inhibition ...so, in this vignette methylene blue can't show any effect to the pt...so only 100% oxygen and vitamin c are the treatment options
hope it understands....thanks

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Help HIV patient with chocolat brown blood

Met Hb acs by acting aas an artificial electron carrier to met HB from the NADPH from HMP shunt not as an inhibitor of met HB reductase!Please elaborate am confused
Quote:
Originally Posted by venky2600 View Post
according to kaplan biochem videos

normally, around 1-3 % daily Hb(in ferrous form) converts to met.Hb(ferric form) and release oxygen radicals.....------our body reverts it(forming back into ferrous iron----not forming oxygen radicals)-----by met.Hb reductase, NADPH comes from HMP shunt
in G6PD ,no such reaction occurs due to NADPH is needed for that enzyme to work-- methylene blue acts via met.Hb reductase inhibition ...so, in this vignette methylene blue can't show any effect to the pt...so only 100% oxygen and vitamin c are the treatment options
hope it understands....thanks

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Quote:
Originally Posted by preeti617 View Post
Met Hb acs by acting aas an artificial electron carrier to met HB from the NADPH from HMP shunt not as an inhibitor of met HB reductase!Please elaborate am confused
yes ,you're right it acts by the NADPH dependant met.Hb reductase(not by inhibition as i posted earlier)....but the carrier thing i don't know abt it
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