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discrepancy between arterial oxygen saturation and pulse oximetry.1 Methemoglobinemia commonly results from exposure to oxidizing agents (Table).2 Normal levels of MHb are maintained by cytochromeb5-MHb reductase responsible for converting MHb to hemoglobin.3 Long-standing dapsone use probably caused elevated MHb levels preoperatively. Lidocaine likely added further oxidative stress causing the cytochrome-b5-MHb reductase system to be overwhelmed. Pulse oximetry measures the ratio of absorbance of oxyhemoglobin and deoxyhemoglobin at wavelengths of 660 nm and 940 nm. Because MHb absorbs light equally at both wavelengths, the light absorbance ratio of 1.0 correlates with a saturation of 85%. Co-oximetry measures light absorbance at four different wavelengths and is able to distinguish MHb from other hemoglobins.4 A high index of suspicion is required when decreased SpO2 follows the administration of recognized oxidative agents. Patients on multiple medications are particularly prone to have their medications overlooked. Reassuringly, methemoglobinemia once diagnosed can be promptly treated.

A malignant hyperthermia-like reaction in a six-month-old female with a 5q chromosomal deletion