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From the Department of Surgery, Middlemore Hospital, Auckland, New Zealand.
Address correspondence to: Dr. Bradley Ng, P.O. BOX 25–109, St Heliers, Auckland, New Zealand. Phone: +64–9–521–8071; E-mail: bkwng{at}hotmail.com
Purpose: To report a case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy; to advance the argument for a diagnosis of serotonin syndrome; and to consider this diagnosis in previous, unexplained reports of adverse reactions amongst patients undergoing parathyroidectomy using methylene blue.
Clinical features: Methylene blue was administered to a 58-yr-old woman undergoing a parathyroidectomy under general anesthesia. The patient had a background of obsessive compulsive disorder treated with paroxetine. Postoperatively, she demonstrated symptoms and signs of serotonin syndrome; specifically tachycardia, agitation, dystonia and abnormal eye movements. These clinical findings spontaneously resolved themselves over the subsequent 48 hr.
Conclusion: An interaction between methylene blue and serotonergic agents may give rise to the serotonin syndrome. Consideration should be given to avoiding methylene blue in patients taking serotonergic agents. The diagnosis should be considered in patients with autonomic, neuromuscular or neurological changes and should be managed accordingly.
1 Martindale SJ, Stedeford JC. Neurological sequelae following methylene blue injection for parathyroidectomy. Anaesthesia 2003; 58: 1041–2.[Medline]
2 Bach KK, Lindsay FW, Berg LS, Howard RS. Prolonged postoperative disorientation after methylene blue infusion during parathyroidectomy. Anesth Analg 2004; 99: 1573–4.
3 Majithia A, Stearns MP. Methylene blue toxicity following infusion to localize parathyroid adenoma. J Laryngol Otol 2006; 120: 138–40.[Medline]
4 Mathew S, Linhartova L, Raghuraman G. Hyperpyrexia and prolonged postoperative disorientation following methylene blue infusion during parathyroidectomy. Anaesthesia 2006; 61: 580–3.[Medline]
5 Patel AS, Singh-Ranger D, Lowery KA, Crinnion JN. Letter to the editor. Head Neck 2006; 28: 567–8.[Medline]
6 Mihai R, Mitchell EW, Warwick J. Dose-response and postoperative confusion following methylene blue infusion during parathyroidectomy. Can J Anesth 2007; 54: 79–81.
7 Khan MA, North AP, Chadwick DR. Prolonged postoperative altered mental status after methylene blue infusion during parathyroidectomy: a case report and review of the literature. Ann R Coll Surg Engl 2007; 89: W9–11.[Medline]
8 Szabadi E, Bradshaw CM. Affective disorders: 1. Antidepressants. In: King DJ (Ed.). Seminars In Clinical Psychopharmacology, 2nd ed. London: Gaskell; 2004: 178–243.
9 Shen WW. A history of antipsychotic drug development. Compr Psychiatry 1999; 40: 407–14.[Medline]
10 Wheeler MH, Wade JS. Intraoperative identification of parathyroid glands: appraisal of methylene blue staining. Am J Surg 1982; 143: 713–6.[Medline]
11 Gillman PK. Methylene blue implicated in potentially fatal serotonin toxicity. Anaesthesia 2006; 61: 1013–4.[Medline]
12 Robenshtok E, Luria S, Tashma Z, Hourvitz A. Adverse reaction to atropine and the treatment of organophosphate intoxication. Isr Med Assoc J 2002; 4: 535–9.[Medline]
13 Cooper JO. The relative costs of anesthesia drugs in New Zealand versus the United States. Anesth Analg 1995; 80: 850–1.[Medline]
14 Nadler JE, Green H, Rosenbaum A. Intravenous injection of methylene blue in man with reference to its toxic symptoms and effect on electrocardiogram. Am J Med Sci 1934; 188: 15–21.
15 Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352: 1112–20.
16 Sternbach H. The serotonin syndrome. Am J Psychiatry 1991; 148: 705–13.
17 Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter serotonin toxicity criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM 2003; 96: 635–42.
18 Wegener G, Volke V, Rosenberg R. Endogenous nitric oxide decreases hippocampal levels of serotonin and dopamine in vivo. Br J Pharmacol 2000; 130: 575–80.[Medline]
19 Naylor GJ, Smith AH, Connelly P. A controlled trial of methylene blue in severe depressive illness. Biol Psychiatry 1987; 22: 657–9.[Medline]
20 Dijkstra B, Healy C, Kelly LM, McDermott EW, Hill AD, O’Higgins N. Parathyroid localisation-current practice. J R Coll Surg Edinb 2002; 47: 599–607.[Medline]
21 Sinha SN, Subramaniam P. Initial parathyroid exploration: current trends in Australia. Aust N Z J Surg 1996; 66: 279–81.[Medline]
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  J. L. Parlow and J. M. van Vlymen The methylene blues: anticipating adverse reactions to non-anesthetic drugs/Le blues du methylene : prevenir les reactions indesirables aux medicaments non anesthesiques Can J Anesth, January 1, 2008; 55(1): 1 - 5. [Full Text] [PDF]
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