A rare combination of methemoglobinemia and carboxyhemoglobinemia in pesticide poisoning.

Dyshemoglobinemias are disorders in which the haemoglobin is functionally altered and prevented from carrying oxygen. They include carboxyhemoglobin, methemoglobin, and sulfhemoglobin. This increase in abnormal haemoglobin has reduced oxygen binding capacity, which leads to decrease in total oxygen content in the blood causing anaemic-hypoxia. The anaemic-hypoxia which is present in these disorders are refractory to the oxygen supplementation and cause many systemic and life threatening complications.Many cases are reported in literature with either of haemoglobin. It is very rare to have two abnormal haemoglobin levels in the same patient. Here we discuss an uncommon case which presented to our tertiary care hospital after consuming pesticide with suicidal intention. The patient was very pale, had peripheral cyanosis,tachypnea and tachycardia and dizziness on presentation. The SpO2 of 85% was our clue to suspect methemoglobinemia which was confirmed along with carboxyhemoglobinemia on arterial blood gas saving result. Despite that patient being very unstable, she was successfully managed with 100% oxygen through High flow nasal cannula (HFNC), methylene blue and blood transfusion. The patient's signs and symptoms gradually reduced in a few days and got discharged after 2 weeks without any neurological and cardiorespiratory sequelae. An early suspicion and personalized emergency management was the key to success. As in all fields of Medicine, Emergency Medicine is also witnessing a change towards precision and personalized Medicine practice.