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Dark Coronary Toxidrome - "A Case of Methemoglobinemia Presenting as Acute Coronary Syndrome in a Patient with Polysubstance Abuse"

Firas Al sammarrai, Devendra Patel and Nidal Arnous

Polysubstance abuse is common worldwide, with noticeable tendency of users to mix different types of drugs to reach desirable effects/pleasure. This group of population, present often to ED with acute toxicity with manifestations, that are atypical for the known classic drug abuse syndromes, because of mixing more than one substance. This case describes a previously healthy young Asian female presented to ED with her boyfriend after she developed sudden sever central chest pain, with SOB and pallor. In ED, patient was found hypotensive, tachycardic and lethargic. EKG showed nonspecific ST changes and troponins were elevated. Emergent referral for cardiac cath center was done, and Cardiac cath showed patent coronaries. On further questioning of the patient and her boyfriend, patient had taken a lot of alcohol, with Poppers (amyl nitrate), cocaine and Sildenafil, when she was celebrating with her boyfriend. Her methemoglobin (Met Hb) level was 52%. Patient was diagnosed of cocaine induced coronary vasospasm, and Popper (amylnitrate) and adulterants induced methemoglobinemia. Patient's methomoglobulinemia was treated successfully with one dose of methylene blue (as per poison control center guidelines). Cocaine itself and its metabolites are not recognized to cause methemoglobinaemia. Adulterants, pharmacologically active substances added to recreational drugs, added to cocaine are associated with methemoglobinaemia. Drug dealers add these substances to increase the weight of the expensive powder (which will increase their profit margin), and to give a false impression of purity to the user. Street cocaine in North America commonly contains both phenacetin and local anaesthetics (benzocaine, prilocaine and cetacaine) as adulterants. Poly-drug use is common in recreational drug users and the use of two or more agents may increase the risk of developing methemoglobinaemia. Clinicians managing patients with acute recreational drug toxicity should be aware of the potential for methemoglobinaemia in these patients.