{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T23:41:56Z","timestamp":1775691716514,"version":"3.50.1"},"reference-count":16,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2020,3,12]],"date-time":"2020-03-12T00:00:00Z","timestamp":1583971200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100012352","name":"Universit\u00e0 degli Studi di Milano","doi-asserted-by":"publisher","award":["PED-2020-01"],"award-info":[{"award-number":["PED-2020-01"]}],"id":[{"id":"10.13039\/100012352","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Background: Methemoglobinemia (MET) should be suspected in cases where cyanosis is not associated with signs and symptoms of lung and\/or heart disease, or in a cyanotic child exhibiting discrepancies in the partial pressure of oxygen in the arterial blood, the blood oxygen saturation, and the clinical assessment. Case presentation: A 10-month-old girl was taken to the Pediatric Emergency Department for the acute, sudden development of significant peroral cyanosis associated with gray pigmentation of the skin. The problem was evidenced approximately one hour after she ingested a homemade puree of mixed vegetables, mainly composed of potatoes and chards that had been prepared three days before and had been kept in the refrigerator since then. Physical examination revealed that the child was very pale, conscious, and without respiratory distress. Oxygen saturation of hemoglobin in the arterial blood (SpO2) was 94%. Respiratory, cardiovascular, and abdominal evaluations did not reveal any signs of disease. A venous blood sample showed chocolate-colored blood with a pH of 7.404, a partial pressure of CO2 (pCO2) of 40.6 mmHg, a partial pressure of oxygen (pO2) of 21.3 mmHg, a bicarbonate level of 24 mmol\/L, and an oxygen saturation (SO2%) of 47.7%. CO-oximetry carried out simultaneously identified a methemoglobin level of 22%. MET was suspected, and oxygen via nasal cannula at a rate of 4 L\/min was given with only a slight increase in oxygen saturation (96%). Slow intravenous injection of methylene blue 1 mg\/kg over a period of 5 min was initiated. The peripheral oxygen saturation (SpO2) gradually improved to 100% over the next 20 min. Forty minutes later, venous blood gas analysis showed a methemoglobin level of 0.9% with a complete resolution of cyanosis; supplemental oxygen via nasal cannula was therefore discontinued. During the next 36 h, the patient remained hemodynamically stable with good oxygenation on room air. Conclusions: This case report shows that recognition of acquired MET in a child with sudden cyanosis onset requires a high index of suspicion. In daily activities, there is a need to pay particular attention when homemade vegetable soups for child alimentation are prepared. The consumption of vegetable soups must occur immediately after preparation. Storage in a refrigerator must last no more than 24 h and if longer storage is needed, vegetable soups should be frozen.<\/jats:p>","DOI":"10.3390\/ijerph17061845","type":"journal-article","created":{"date-parts":[[2020,3,12]],"date-time":"2020-03-12T12:22:51Z","timestamp":1584015771000},"page":"1845","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["The Dose Makes the Poison: A Case Report of Acquired Methemoglobinemia"],"prefix":"10.3390","volume":"17","author":[{"given":"Giulia","family":"Cannata","sequence":"first","affiliation":[{"name":"Pediatric Clinic, Pietro Barilla Children\u2019s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Luciana","family":"Abate","sequence":"additional","affiliation":[{"name":"Pediatric Clinic, Pietro Barilla Children\u2019s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chiara","family":"Scarabello","sequence":"additional","affiliation":[{"name":"Pediatric Clinic, Pietro Barilla Children\u2019s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Monica","family":"Rubini","sequence":"additional","affiliation":[{"name":"Pediatric Clinic, Pietro Barilla Children\u2019s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alessandra","family":"Giacometti","sequence":"additional","affiliation":[{"name":"Pediatric Clinic, Pietro Barilla Children\u2019s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicola","family":"Principi","sequence":"additional","affiliation":[{"name":"Universit\u00e0 degli Studi di Milano, 20122 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4103-2837","authenticated-orcid":false,"given":"Susanna","family":"Esposito","sequence":"additional","affiliation":[{"name":"Pediatric Clinic, Pietro Barilla Children\u2019s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Icilio","family":"Dodi","sequence":"additional","affiliation":[{"name":"Pediatric Clinic, Pietro Barilla Children\u2019s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2020,3,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"76","DOI":"10.3928\/00904481-20150203-12","article-title":"Diagnostic considerations in infants and children with cyanosis","volume":"44","author":"Hiremath","year":"2015","journal-title":"Pediatr. Ann."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1016\/j.pcl.2004.03.010","article-title":"An approach to diagnosis and management of cyanosis and tachypnea in term infants","volume":"51","author":"Sasidharan","year":"2004","journal-title":"Pediatr. Clin. North Am."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1097\/SMJ.0b013e318232139f","article-title":"Methemoglobinemia: Pathogenesis, diagnosis, and management","volume":"104","author":"Skold","year":"2011","journal-title":"South Med J."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1111\/j.1365-2125.2011.03950.x","article-title":"Methaemoglobinemia associated with the use of cocaine and volatile nitrites as recreational drugs: A review","volume":"72","author":"Hunter","year":"2011","journal-title":"Br. J. Clin. Pharm."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"13","DOI":"10.2165\/00139709-200322010-00003","article-title":"Occupational Methaemoglobinaemia: Mechanisms of Production, Features, Diagnosis and Management Including the Use of Methylene Blue","volume":"22","author":"Bradberry","year":"2003","journal-title":"Toxicol. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1016\/S0196-0644(99)70167-8","article-title":"Methemoglobinemia: Etiology, Pharmacology, and Clinical Management","volume":"34","author":"Wright","year":"1999","journal-title":"Ann. Emerg. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1590\/S0034-70942008000600011","article-title":"Methemoglobinemia: From diagnosis to treatment","volume":"58","author":"Nascimento","year":"2008","journal-title":"Rev. Bras. Anestesiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1016\/j.toxlet.2010.11.002","article-title":"Vegetable-borne nitrate and nitrite and the risk of methaemoglobinaemia","volume":"200","author":"Chan","year":"2011","journal-title":"Toxicol. Lett."},{"key":"ref_9","unstructured":"American Academy of Pediatrics, Committee on Nutrition (1970). Infant methemoglobinemia: The role of dietary nitrate. Pediatrics, 46, 475\u2013478."},{"key":"ref_10","first-page":"183","article-title":"Methemoglobinemia: Nitrate toxicity in rural America","volume":"46","author":"Kross","year":"1992","journal-title":"Am. Fam. Physician"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1001\/archpedi.1994.02170050048009","article-title":"Nitrate in baby foods: Adding to the nitrate mosaic","volume":"148","author":"Dusdieker","year":"1994","journal-title":"Arch. Pediatr. Adolesc. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1159\/000336287","article-title":"Timing of introduction of complementary food: Short- and long-term health consequences","volume":"60","author":"Przyrembel","year":"2012","journal-title":"Ann. Nutr. Metab."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1024","DOI":"10.1542\/peds.107.5.1024","article-title":"Methemoglobinemia and consumption of vegetables in infants","volume":"107","year":"2001","journal-title":"Pediatrics"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1056\/NEJM197304192881606","article-title":"Infantile methemoglobinemia caused by carrot juice","volume":"288","author":"Keating","year":"1973","journal-title":"N. Engl. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Baroni, L., Goggi, S., Battaglino, R., Berveglieri, M., Fasan, I., Filippin, D., Griffith, P., Rizzo, G., Tomasini, C., and Tosatti, M.A. (2018). Vegan Nutrition for Mothers and Children: Practical Tools for Healthcare Providers. Nutrients, 11.","DOI":"10.3390\/nu11010005"},{"key":"ref_16","first-page":"e116","article-title":"A 5-Month-Old Infant with Diffuse Cyanosis and No Other Symptoms","volume":"45","author":"Cavarzere","year":"2016","journal-title":"Pediatr. Ann."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/6\/1845\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:06:27Z","timestamp":1760173587000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/6\/1845"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,3,12]]},"references-count":16,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2020,3]]}},"alternative-id":["ijerph17061845"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17061845","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,3,12]]}}}