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Methylene Blue-Associated Serotonin Syndrome: A ‘Green’ Encephalopathy After Parathyroidectomy

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Abstract

Introduction

Methylene blue (MB) infusion is frequently used to localize the parathyroid glands during parathyroidectomy and generally considered safe. Several recent reports suggest neurological toxicity and post-operative altered mental state typically after large dose infusions. The mechanism by which MB has neurotoxic effects in some patients remains uncertain.

Methods/Results

Case Report: A 67-year-old male underwent lumbar laminectomy followed by parathyroidectomy. Postoperatively, he was comatose (Glasgow Coma Scale of 7) and underwent extensive neurological evaluation. Brain computed tomography (CT) imaging and CT angiography revealed no ischemia, vessel occlusion, or hemorrhage. Electroencephalogram (EEG) showed only slowing of cerebral hemispheric activity bilaterally. Over the next 48 h, his mental status slowly improved and the patient made a full neurological recovery (Glasgow Coma Scale 15).

Conclusion

Methylene blue, when used in patients on antidepressant drugs, may be associated with a transient encephalopathic state and serotonin syndrome. Patients on antidepressants undergoing parathyroidectomy who may receive MB infusion should be considered for alternative parathyroid gland identification or discontinuation of the antidepressants before surgery. MB-associated serotonin syndrome is an increasing and under recognized (‘green’) post-operative encephalopathy that warrants education to critical care neurologists and other physicians.

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Authors and Affiliations

  1. Departments of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA

    Michael Rowley, Kevin Riutort & David Shapiro

  2. Departments of Otolaryngology, Mayo Clinic, Jacksonville, FL, USA

    John Casler

  3. Departments of Critical Care, Mayo Clinic, Jacksonville, FL, USA

    Emir Festic & William D. Freeman

  4. Departments of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA

    William D. Freeman

Authors
  1. Michael Rowley
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  2. Kevin Riutort
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  3. David Shapiro
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  4. John Casler
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  5. Emir Festic
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  6. William D. Freeman
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Corresponding author

Correspondence to William D. Freeman.

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Rowley, M., Riutort, K., Shapiro, D. et al. Methylene Blue-Associated Serotonin Syndrome: A ‘Green’ Encephalopathy After Parathyroidectomy. Neurocrit Care 11, 88–93 (2009). https://doi.org/10.1007/s12028-009-9206-z

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  • DOI: https://doi.org/10.1007/s12028-009-9206-z

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