Hosur Ravikumar R, Nath S, Quadri JA, Bhattacharjee S. Methylene blue for treating toxic encephalopathy due to acute nickel poisoning: A case report. World J Crit Care Med 2026; 15(3): 120702 [DOI: 10.5492/wjccm.120702]
Corresponding Author of This Article
Rajathadri Hosur Ravikumar, Assistant Professor, Department of Critical Care Medicine, Ramaiah Medical College, M S Ramaiah Nagar, Mathikere, Bengaluru, Bangalore 560054, Karnātaka, India. drrajathadri@gmail.com
Research Domain of This Article
Critical Care Medicine
Article-Type of This Article
case-report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
Share the Article
Hosur Ravikumar R, Nath S, Quadri JA, Bhattacharjee S. Methylene blue for treating toxic encephalopathy due to acute nickel poisoning: A case report. World J Crit Care Med 2026; 15(3): 120702 [DOI: 10.5492/wjccm.120702]
Rajathadri Hosur Ravikumar, Department of Critical Care Medicine, Ramaiah Medical College, Bangalore 560054, Karnātaka, India
Sayan Nath, Department of Critical Care Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge 698797, Cambridgeshire, United Kingdom
Javed Ahsan Quadri, Department of Anatomy, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
Sulagna Bhattacharjee, Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
Author contributions: Hosur Ravikumar R, Nath S, and Bhattacharjee S designed the research study, performed the literature search and drafted the manuscript; Quadri JA edited the manuscript and performed the literature search; all authors have read and approved the final manuscript.
AI contribution statement: The authors used the AI model Gemini (Google) for the purpose of language editing and grammatical refinement to ensure the clarity and professional tone of the manuscript. The AI tool was also utilized to help structure the chronological timeline and reorganize clinical data into a systematic narrative format. All clinical observations, diagnostic logic, toxicological data analysis, and the resulting clinical hypotheses were independently developed by the authors. The authors have reviewed, verified, and assume full responsibility and accountability for the integrity, accuracy, originality, and scientific validity of the final manuscript and all submitted materials.
Informed consent statement: Written informed consent was obtained from the patient’s husband (legal next-of-kin) for the publication of this case report and any accompanying images, as the patient was initially unable to provide consent due to her clinical condition.
Conflict-of-interest statement: The authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Rajathadri Hosur Ravikumar, Assistant Professor, Department of Critical Care Medicine, Ramaiah Medical College, M S Ramaiah Nagar, Mathikere, Bengaluru, Bangalore 560054, Karnātaka, India. drrajathadri@gmail.com
Received: March 6, 2026 Revised: May 24, 2026 Accepted: June 23, 2026 Published online: September 9, 2026 Processing time: 168 Days and 21 Hours
Abstract
BACKGROUND
Acute nickel poisoning is a rare clinical entity with no established management guidelines. Diagnosis is often delayed by non-specific clinical presentations that can mimic other common toxidromes, such as organophosphate poisoning.
CASE SUMMARY
A female in her late twenties presented with a Glasgow Coma Scale of 3, profound hypotension, miosis, and hypersalivation following intentional ingestion of an unlabeled toilet cleaner. Initial management for suspected cholinergic toxidrome and corrosive ingestion failed to achieve clinical stability. The patient developed refractory vasoplegic shock and went into a deep coma. Magnetic resonance imaging revealed cytotoxic lesions of the corpus callosum, suggesting toxic encephalopathy. Comprehensive toxicological screening by inductively coupled plasma mass spectrometry confirmed severe nickel toxicity with significantly elevated levels in the blood, urine, and cerebrospinal fluid (55.5 μg/L). Methylene blue, initially administered as a rescue therapy for vasoplegic shock, was associated with a paradoxical spike in urinary nickel excretion (from 8.8 μg/L to 51.9 μg/L) and a rapid decline in serum levels. This biochemical “washout” coincided with dramatic neurological recovery from Glasgow Coma Scale of 3 to 15 within 72 hours.
CONCLUSION
Early comprehensive toxicological screening is essential in patients with suspected poisoning by unknown substances. In this case, nickel toxicity was confirmed by prompt screening. In the absence of standard treatment protocols in rare poisoning cases, treatment is largely supportive. The apparent clinical benefit of methylene blue-mediated nickel clearance in this case remains speculative.
Core Tip: Standard therapies failed to treat atypical cholinergic toxidrome and refractory vasoplegic shock caused by the ingestion of routine toilet cleaner. An exhaustive toxicology screen revealed acute nickel poisoning, accompanied by central nervous system metal sequestration and a unique cytotoxic lesion of the corpus callosum revealed by brain magnetic resonance imaging. Remarkably, rescue therapy with methylene blue for the shock correlated with a paradoxical spike in urinary nickel excretion and rapid clinical recovery. While the biochemical washout mechanism remains hypothetical, this case offers a crucial clinical framework for managing rare heavy metal toxicity when standard chelators are unavailable.
