Abstract Introduction Amyl nitrites (“poppers”) are inhalants used recreationally for their vasodilatory and euphoric effects. They are potent oxidizing agents capable of inducing methemoglobinemia and, in susceptible individuals, hemolytic anemia—particularly in those with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Case A 55-year-old man with treated neurosyphilis, psoriasis, and long-term popper use (every other day for ∼30 years) presented to the emergency department for progressive fatigue, jaundice, and dark urine. On presentation, he was hypoxic (SpO2 84% on room air) without respiratory distress with stable vitals including blood pressure and heart rate. On physical examination, there was conjunctival pallor but no hepatosplenomegaly or petechiae noted. Laboratory evaluation revealed acute macrocytic hemolytic anemia (hemoglobin 8.7 g/dL from baseline 13.2 g/dL, MCV 110 fL, reticulocyte index 10%, haptoglobin 10 mg/dL, LDH 1867 U/L, indirect bilirubin 3.5 mg/dL), negative direct antiglobulin test, and peripheral smear showing acanthocytes, spherocytes, and basophilic stippling. Iron studies showed elevated serum iron and transferrin saturation. Vitamin b12 levels were noted to be 290 pg/mL and his intrinsic factor antibodies were positive. Arterial blood gas demonstrated PaO2 62.7 mmHg, methemoglobin 3.0%, and carboxyhemoglobin 4.1%. He did have some degree of SpO2-PaO2 dissociation as noted on his vitals and blood gas.Given the hemolysis secondary to oxidant injury, methylene blue was withheld due to concern for potential G6PD deficiency. There were also concerns of pernicious anemia contributing to his anemia. He was treated with high-dose ascorbic acid, vitamin B12 repletion, and supportive care with supplemental oxygen which was weaned off quickly from HFNC to room air. G6PD level was obtained but recognized as potentially unreliable in the acute setting. The patient improved clinically and was discharged with hematology follow-up for further evaluation. Discussion Chronic popper use can cause oxidative stress leading to both methemoglobinemia and hemolysis, even at mild methemoglobin levels in susceptible patients. In patients presenting with hypoxia and hemolytic anemia after nitrite exposure, G6PD deficiency should be suspected, and methylene blue should be avoided until excluded. There should be an evaluation for nutritional anemias either due to diet-related issues or autoimmune etiologies like pernicious anemia. This abstract is funded by: none
Joseph et al. (Fri,) studied this question.