Histological Features of Methylene Blue–Induced Phototoxicity Administered in the Context of Parathyroid Surgery

Abstract

Methylene blue is a chromophore dye known for its photosensitizing properties. It is also administered intravenously as a tracer in parathyroid surgery to identify abnormal glands. We describe 2 cases of acute methylene blue-induced phototoxicity in patients who underwent parathyroidectomy. Both patients developed an acute vesiculopustular inflammatory rash on the anterior neck corresponding to the site exposed intraoperatively to overhanging surgical lights. One of the patients also developed a bulla on her finger at the site of attachment of the oxygen probe. Biopsies were taken from both patients at different time points. The histological findings included destruction of sebaceous glands and deposition of diastase-periodic acid-Schiff-positive hyaline material around dermal blood vessels. These features are similar to those seen in skin treated with photodynamic therapy and systemic photosensitivity disorders such as the porphyrias. The wavelengths of light emitted by the surgical lights and oxygen probe overlap with the absorption spectrum of methylene blue. This resulted in excitation of the systemically administered methylene blue at exposed sites, with resultant local tissue damage and a phototoxic reaction.

Feasibility of indocyanine green fluorescence imaging for intraoperative identification of parathyroid glands during thyroid surgery

“…After publication of this study, MB has been implemented by other surgeons . The chance of complications due to intravenous administration of MB, including neurotoxicity and acute MB‐induced phototoxicity, pain at infusion site and nausea is a major drawback of this technique . To avoid these complications due to a high dose of MB, a lower dose in combination with near‐infrared fluorescence (NIRF) imaging was investigated .…”

“…7 The chance of complications due to intravenous administration of MB, including neurotoxicity and acute MB-induced phototoxicity, pain at infusion site and nausea is a major drawback of this technique. [7][8][9][10] To avoid these complications due to a high dose of MB, a lower dose in combination with near-infrared fluorescence (NIRF) imaging was investigated. 11 However, in analogy with the use of MB for staining without NIRF imaging, this technique mainly visualizes abnormal PGs.…”

Photosensitivity Reaction From Operating Room Lights After Oral Administration of 5-Aminolevulinic Acid for Fluorescence-Guided Resection of a Malignant Glioma

“…Multiple past reports have been published detailing photosensitivity reactions that resulted from operating room light exposure, but these concerned patients who had erythropoietic protoporphyria [ 10 , 11 ] or who were preoperatively administered methylene blue [ 12 , 13 ]. Erythropoietic protoporphyria is an X-linked disorder of porphyria metabolism that leads to the accumulation of protoporphyrin IX in cells of erythroid lineage [ 14 ].…”

Undesirable Effects of Some Topical Antiseptics Chemical, pharmacological and dermatological aspects

“…MB is a common antiseptic but as a chromophore dye it is also known for its photosensitizing properties. These have been described especially during MB assisted parathyroid surgery when a Light-Emitting Diode (LED) type of lamp was used [31,32]. A rare case of hypersensitivity reaction to MB has been reported during lip reconstruction surgery with anaphylactic shock to MB [33].…”