Greenish-blue discoloration of the brain and heart after treatment with methylene blue

Abstract

Greenish-blue discoloration of the brain and heart was observed during the autopsy of a 63-year-old woman who had been treated with methylene blue for septic shock following a traffic accident. This “pistachio” or “avatar” discoloration occurs when the colorless metabolite leucomethylene blue is oxidized to methylene blue upon exposure to atmospheric oxygen. Other clinically documented adverse effects of methylene blue include greenish-blue urine and bluish discoloration of the skin and mucosa. In medicine, methylene blue is an inhibitor of nitric oxide synthase and guanylate cyclase with different clinical applications, namely, rapid reversal of circulatory shock that is refractory to fluid administration, inotropic agents, and vasoconstrictors. Postmortem differential diagnosis with putrefaction and hydrogen sulfide poisoning should be made, and forensic pathologists should be aware of methylene blue-related greenish-blue discoloration to avoid unnecessary workup and investigations.

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The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, and royalties.

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Correspondence to Ricardo Jorge Dinis-Oliveira.

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Durão, C., Pedrosa, F. & Dinis-Oliveira, R.J. Greenish-blue discoloration of the brain and heart after treatment with methylene blue. Forensic Sci Med Pathol (2020). https://doi.org/10.1007/s12024-020-00316-2

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Keywords

  • Methylene blue
  • Greenish-blue discoloration
  • Heart
  • Brain
  • Forensic autopsy