A 61-year-old female died in hospital with multiple organ failure 4 weeks following presentation with acute kidney injury, hemolytic anemia and methemoglobinemia. At autopsy, brown to black discoloration of cartilages was observed. Histology revealed brown pigmentation of the hyaline cartilage, with focal full-thickness erosion of the articular hyaline cartilage, characteristic of alkaptonuria (ochronosis). Although alkaptonuria is rarely fatal, this case illustrates a rare acute fatal complication. Accumulation of circulating homgentisic acid secondary to acute derangement of renal function is believed to have overwhelmed the endogenous antioxidant processes, resulting in hemolysis and methemoglobinemia, which were refractory to treatment. Small numbers of cases have previously been reported in the literature in patients known to suffer with the disease, all of which were preceded by acute kidney injury. Whilst the clinical diagnosis of alkaptonuria may be challenging, the autopsy findings of this rare condition are striking and this case illustrates the utility of the autopsy, albeit retrospectively, in arriving at a diagnosis. To our knowledge this is the first reported case where previously undiagnosed alkaptonuria has presented with methemoglobinemia.
Methemoglobinemia Alkaptonuria Ochronosis Autopsy
This is a preview of subscription content, log in to check access.
We thank Miss Tasma How and the histopathology laboratory at Forensic Science SA for technical support, and Dr. Sui Yu, Mr. Kristian Brion and Mr. Tim Pyragius of SA Pathology for the genetic analysis.
Compliance with ethical standards
This article does not contain any studies with human participants performed by any of the authors. Approval to report the case was given by Forensic Science SA, Adelaide, Australia.
Conflict of interest
The authors declare that they have no conflict of interest.
Abreo K, Abreo F, Zimmerman SW, Hartman H, Gilbert EF, Katcher ML, et al. A fifty-year-old man with skin pigmentation, arthritis, chronic renal failure and methemoglobinemia. Am J Med Genet. 1983;14:97–114.CrossRefPubMedGoogle Scholar
Zaraa I, LAbbene I, Trojjet S, Mrabet D, Meddeb N, Chelly, et al. Endogenous ochronosis with a fatal outcome. J Cutan Med Surg. 2012;16:357–60.CrossRefPubMedGoogle Scholar
Davison AS, Milan AM, Gallagher JA, Ranganath LR. Acute fatal metabolic complications in alkaptonuria. J Inherit Metab Dis. 2016;39:203–10.CrossRefPubMedGoogle Scholar
Heng AE, Courbebaisse MD, Kemeny JL, Matesan R, Bonniol C, Deteix P, et al. Hemolysis in a patient with alkaptonuria and chronic kidney failure. Am J Kidney Dis. 2010;56:e1–4.CrossRefPubMedGoogle Scholar
Isa Y, Nihei S, Irifukuhama Y, Ikeda T, Matsumoto H, Nagata K, et al. A rare case of acquired methemoglobinemia associated with alkaptonuria. Intern Med. 2014;53:1797–800.CrossRefPubMedGoogle Scholar
Bataille S, Moal V, Aquaron RR, Grünfeld JP, Daniel L. Hemolysis: a fatal complication of alkaptonuria in a severe renal failure patient. Clin Nephrol. 2014;81:374–6.CrossRefPubMedGoogle Scholar
Liu W, Prayson RA. Dura mater involvement in ochronosis (Alkaptonuria). Arch Pathol Lab Med. 2001;125:961–3.PubMedGoogle Scholar
Uchiyama C, Kondoh H, Shintani H. Acute methemoglobinemia associated with ochronotic valvular heart disease: report of a case. Thorac Cardiovasc Surg. 2010;58:113–9.CrossRefGoogle Scholar
Mullan A, Cocker D, Taylor G, Millar C, Ranganath L. Fatal oxidative haemolysis and methaemoglobinaemia in a patient with alkaptonuria and acute kidney injury. Clin Kidney J. 2015;8:109–12.CrossRefPubMedGoogle Scholar
Cortazzo JA, Lichtman AD. Methemoglobinemia: a review and recommendations for management. J Cardiothoracic and Vasc Anaesthesia. 2014;28:1043–7.CrossRefGoogle Scholar