SHM Converge Scientific Abstract ePoster Gallery-Rasburicase-Induced Methemoglobinemia Treated With Ascorbic Acid in a Female With Uterine Carcinosarcoma and Acute Kidney Injury

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A 65-year-old woman with recurrent uterine carcinosarcoma presented with massive ascites, dyspnea, fatigue, acute kidney injury, and progressive carcinomatosis with possible liver metastases. She had stopped cancer treatment four months earlier because of declining functional status. On admission, she was oliguric with creatinine 6.6 mg/dL and uric acid 14.5 mg/dL. Because of concern for spontaneous tumor lysis syndrome, nephrology administered rasburicase after a therapeutic paracentesis removed 4.5 liters of fluid.<br /><br />Four hours later, she developed apparent severe hypoxia with SpO2 79% despite 100% oxygen, but arterial blood gas showed a PaO2 of 500 mmHg and normal oxygen saturation, creating a classic saturation gap. Methemoglobin was elevated at 19.6%, confirming rasburicase-induced methemoglobinemia. Chest imaging and bedside cardiac evaluation were unrevealing. Hematology recommended treatment with intravenous ascorbic acid rather than methylene blue because of concern for possible glucose-6-phosphate dehydrogenase (G6PD) deficiency, which can predispose patients to worsening hemolysis and methemoglobinemia with methylene blue. Her G6PD level later returned low-normal, but false-normal results can occur in acute hemolysis or milder deficiency.<br /><br />She received one unit of packed red blood cells and intravenous ascorbic acid 5 g every 12 hours for five doses, adjusted for renal dysfunction. Her methemoglobin level and hypoxia improved. However, her mental status, kidney failure, and overall prognosis remained poor. After goals-of-care discussions, treatment was transitioned to comfort measures, and she died on hospital day 7 while awaiting hospice placement.<br /><br />This case highlights the importance of recognizing methemoglobinemia when pulse oximetry and arterial oxygenation are discordant, considering G6PD deficiency even in females, and using intravenous ascorbic acid as a potential alternative when methylene blue is contraindicated.

Asset Subtitle

Laura Tarantino Lang

Meta Tag

Author List Benjamin Greenberg, Katharine McNiel, Laura Tarantino Lang, Pavel Aksionav, Renas Zibari, Rohit Raina

Category Clinical Vignettes

Concept Rasburicase

Concept Methemoglobinemia

Concept Saturation gap

Concept Glucose-6-Phosphate Dehydrogenase Deficiency

Concept Methylene Blue

Distinguished Non-Finalist

Presenter Organization Department of Internal Medicine & Pediatrics, University of Tennessee Health Science Center – Memphis

Presenting Author Laura Tarantino Lang

Track Adult

Keywords

uterine carcinosarcoma

rasburicase

methemoglobinemia

saturation gap

acute kidney injury

spontaneous tumor lysis syndrome

G6PD deficiency

ascorbic acid

pulse oximetry discordance

carcinomatosis

Rasburicase

Methemoglobinemia

Saturation gap

Glucose-6-Phosphate Dehydrogenase Deficiency

Methylene Blue