Acquired methemoglobinemia is a common, potentially fatal syndrome that can occur as a result of exposure to numerous xenobiotics. A case report of a 14-month-old female who developed methemoglobinemia following a dapsone ingestion. The child was treated with numerous boluses of methylene blue and ultimately required a continuous infusion of methylene blue. The common causes of methemoglobinemia, as well as the underlying pathophysiology, diagnosis, and treatment strategies are discussed.Keywords Methemoglobinemia . Methemoglobin . Dapsone . Cyanosis . Poisoning . Methylene blue Case PresentationA 14-month-old female infant presented to the emergency department (ED) with a chief complaint of cyanosis. The child had no significant past medical history and appeared normal throughout the prior day, except for some mild rhinorrhea and a single episode of non-bloody, non-bilious emesis the night prior to admission. An additional episode of emesis occurred the morning of admission. There were no other complaints, and the remainder of the review of systems was negative. The patient's mother noted cyanosis around the face and lips, prompting evaluation in the ED. The patient's room air oxygen saturation by pulse oximetry (SpO 2 ) was 87%, and a chest X-ray was negative. She was transferred to a pediatric tertiary care center for further evaluation of suspected congenital heart disease.On arrival to the referral center, the child was noted to be tachycardic, tachypneic, and cyanotic in mild respiratory distress. The pertinent abnormal vital signs were a heart rate of 212 beats per minute and a respiratory rate of 48 breaths per minute. The SpO 2 on 15 L of oxygen administered via a non-rebreather mask was 88%. The remainder of the physical examination was unremarkable. The venous blood gas (VBG) drawn on arrival revealed a pH of 7.42, a pCO 2 of 30 mmHg, a pO 2 of 43 mmHg, HCO 3 of 18.8 mmol/L, and methemoglobin, "high." The initial venous blood drawn for the laboratory testing was noted to have a brownish hue. The hemoglobin concentration was 13.0 g/dL, and the remainder of the baseline complete blood count and comprehensive metabolic profile were normal.Given the elevated methemoglobin fraction and clinical picture consistent with methemoglobinemia, the child received a 2-mg/kg IV bolus of methylene blue. The child's symptoms improved promptly and a repeat examination of the patient approximately 1 h later revealed an asymptomatic, playful child without cyanosis. A repeat VBG at this time revealed a methemoglobin fraction of 13.3%. The child was transferred to the PICU for further observation.

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The Toxicology Investigators Consortium (ToxIC) Core Registry was established by the American College of Medical Toxicology in 2010. The Core Registry collects data from participating sites with the agreement that all bedside and telehealth medical toxicology consultations will be entered. This twelfth annual report summarizes the registry’s 2021 data and activity with its additional 8552 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from January 1 to December 31, 2021. Detailed data was collected from these cases and aggregated to provide information, which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. Gender distribution included 50.4% of cases in females, 48.2% of cases in males, and 1.4% of cases in transgender or gender non-conforming individuals. Non-opioid analgesics were the most commonly reported agent class (14.9%), followed by opioids (13.1%). Acetaminophen was the most common agent reported. Fentanyl was the most common opioid reported and was responsible for the greatest number of fatalities. There were 120 fatalities, comprising 1.4% of all cases. Major trends in demographics and exposure characteristics remained similar to past years’ reports. Sub-analyses were conducted to describe new demographic characteristics, including marital status, housing status and military service, the continued COVID-19 pandemic and related toxicologic exposures, and novel substances of exposure. Supplementary Information The online version contains supplementary material available at 10.1007/s13181-022-00910-6.

The Toxicology Investigators Consortium (ToxIC) Registry was established by the American College of Medical Toxicology in 2010. The registry collects data from participating sites with the agreement that all bedside and telehealth medical toxicology consultation will be entered. This eleventh annual report summarizes the Registry's 2020 data and activity with its additional 6668 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from January 1 to December 31, 2020. Detailed data was collected from these cases and aggregated to provide information which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. Gender distribution included 50.6% cases in females, 48.4% in males, and 1.0% identifying as transgender. Non-opioid analgesics were the most commonly reported agent class, followed by opioid and antidepressant classes. Acetaminophen was once again the most common agent reported. There were 80 fatalities, comprising 1.2% of all registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe race and ethnicity demographics and exposures in the registry, telemedicine encounters, and cases related to the COVID-19 pandemic.