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Hardin J, Galust H, Clark RF, Ly B, Suhandynata RT. Spectrophotometric analysis of purple urine secondary to methylene blue and hydroxocobalamin co-administration. J Nephrol 2024; 37:491-494. [PMID: 37644365 PMCID: PMC11043099 DOI: 10.1007/s40620-023-01769-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The development of purple urine after methylene blue (methylthioninium chloride) and hydroxocobalamin co-administration is a rare clinical entity that has not been fully elucidated. A 47-year-old male presented to the emergency department with hypotension, cyanosis, and depressed mental status. The patient was noted to have profound peripheral and central cyanosis, as well as chocolate-colored arterial blood. He was treated with both methylene blue and hydroxocobalamin and developed purple urine for approximately 1 week. METHODS Color chromatography was performed by placing the patient's urine directly onto absorbent filter paper. Urine spectrophotometry was performed utilizing the NanoDrop One/One C UV-Vis Spectrophotometer. RESULTS Color chromatography of the urine was demonstrated clear separation of distinct red and blue phases. Urine spectrophotometry demonstrated near perfect overlap between the methylene blue + hydroxocobalamin absorbance spectrum and the patient's purple urine absorbance spectrum. CONCLUSION Purple urine secondary to methylene blue and hydroxocobalamin co-administration is due to combined urinary excretion of methylene blue (blue) and hydroxocobalamin (red), and not a novel purple metabolite. We anticipate that this is going to be an increasingly common clinical entity as the roles of both hydroxocobalamin and methylene blue expand from toxicologic antidotes to adjunct therapies for vasoplegia, poor cardiac output, and sepsis.
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Affiliation(s)
- Jeremy Hardin
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA.
- VA San Diego Healthcare System, San Diego, CA, USA.
- San Diego Division, California Poison Control System, San Diego, CA, USA.
| | - Henrik Galust
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- San Diego Division, California Poison Control System, San Diego, CA, USA
| | - Richard Franklin Clark
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA
- San Diego Division, California Poison Control System, San Diego, CA, USA
| | - Binh Ly
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA
| | - Raymond Theodore Suhandynata
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego Health, San Diego, CA, USA
- Department of Pathology, UC San Diego Health, San Diego, CA, USA
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Hubbard JA, Hoffman MA, Ellis SE, Sobolesky PM, Smith BE, Suhandynata RT, Sones EG, Sanford SK, Umlauf A, Huestis MA, Grelotti DJ, Grant I, Marcotte TD, Fitzgerald RL. Biomarkers of Recent Cannabis Use in Blood, Oral Fluid and Breath. J Anal Toxicol 2021; 45:820-828. [PMID: 34185831 DOI: 10.1093/jat/bkab080] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 12/25/2022] Open
Abstract
Proving driving under the influence of cannabis (DUIC) is difficult. Establishing a biomarker of recent use to supplement behavioral observations may be a useful alternative strategy. We determined whether cannabinoid concentrations in blood, oral fluid (OF), or breath could identify use within 3h, likely the period of greatest impairment. In a randomized trial, 191 frequent (≥4/week) and occasional (<4/week) cannabis users smoked one cannabis (placebo [0.02%], 5.9% or 13.4% THC) cigarette ad libitum. Blood, OF and breath samples were collected prior to and up to 6h after smoking. Samples were analyzed for 10 cannabinoids in OF, 8 in blood, and THC in breath. Frequent users had more residual THC in blood and were categorized as "recently used" prior to smoking; this did not occur in OF. Per se limits ranging from undetectable to 5 ng/mL THC in blood offered limited usefulness as biomarkers of recent use. Cannabinol (CBN, cutoff=1 ng/mL) in blood offered 100% specificity but only 31.4% sensitivity, resulting in 100% PPV and 94.0% NPV at 4.3% prevalence; but CBN may vary by cannabis chemovar. A 10 ng/mL THC cutoff in OF exhibited the overall highest performance to detect use within 3h (99.7% specificity, 82.4% sensitivity, 92.5% PPV, 99.2% NPV) but was still detectable in 23.2% of participants ~4.4h post smoking limiting specificity at later time points. OF THC may be a helpful indicator of recent cannabis intake, but this does not equate to impairment. Behavioral assessment of impairment is still required to determine DUIC. This study only involved cannabis inhalation and additional research evaluating alternative routes of ingestion (i.e., oral) is needed.
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Affiliation(s)
- J A Hubbard
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - M A Hoffman
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - S E Ellis
- Department of Cognitive Science, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92092 USA.,Halıcıoğlu Data Science Institute, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92092 USA
| | - P M Sobolesky
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - B E Smith
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - R T Suhandynata
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - E G Sones
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - S K Sanford
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - A Umlauf
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - M A Huestis
- Institute for Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA 19107 USA
| | - D J Grelotti
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - I Grant
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - T D Marcotte
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - R L Fitzgerald
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
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