Case Report ABSTRACTS

The Grey Man
Shuaib Ahmed Quraishi
Surrey and Sussex NHS Trust
Jay Chiew
Haseeb Yusuf Quraishi
Deepak Jayaram
The Grey Man
A 45-year-old gentleman presented to the Acute Medical Take with an episode of syncope. He was working
as a chef and had no significant medical history. From the records he had one episode of drug overdose in
the past.
On arrival he was severely cyanosed, tachypnoiec, tachycardic and hypotensive with a BP of 70/40. His ECG
revealed a sinus tachycardia. He was confused and had a GCS of 13/15. His whole torso was grey in colour.
He had admitted to have taken vodka on the same day.
Initial blood tests revealed normal CRP, WCC and a raised ALT at 89. An arterial blood gas revealed a
metabolic acidosis (pH 7.32, pCO2 3.3, p02 49 lac11, BE -11, HCO3 12.9, Sa02 69% and a methaemoglobin
of 69%. A chest radiograph was normal. A focused echo scan revealed normal biventricular function.
Drug overdose or poisoning was suspected. The case was discussed with the local poisons unit and they
advised to treat with methylene blue. As he was profoundly hypotensive intensive care was involved to
provide inotropic support. 2mg/kg IV Methylene blue was administered. After one hour of administration
the patient’s complexion turned from grey to pink in complexion. Blood pressure improved, acidosis
improved and the methaemoglobin levels reduced in level slowly on intensive care and he was discharged
a few days later. The case was reported to public health in order to investigate the composition of the
vodka.
This case was important as it dealt with a rare and unfamiliar presentation where it is known that severely
raised methaemoglobin above 70% can lead to seizures and death itself. Prompt recognition by the acute
physician and treatment with methylene blue was vital in managing this condition.