12 “Blue Brain”: Unexpected Brain Discoloration at Autopsy Secondary to Use of Methylene Blue. Case Presentation and Review of the Literature

Abstract

Objectives: To share an unusual, beautiful, and potentially confounding gross pathology finding of a blue brain found during an autopsy of a 32-year-old man who presented in septic shock and disseminated intravascular coagulation (DIC), and review the clinical cause/uses of methylene blue. Methods: Complete autopsy including brain cutting after 2 weeks of formalin fixation. Results: On autopsy, the heart had a mild blue-green discoloration on the epicardial surface and the brain had a marked “Smurf blue” staining on both the leptomeninges and parenchyma. A thorough chart review revealed the patient underwent a massive transfusion protocol, and methylene blue was administered to treat the patient's hypotension during resuscitation efforts. The fresh frozen plasma administered to the patient was found to not have been treated with methylene blue. Conclusion: Although not commonly used in the US, the administration of fresh frozen plasma fixed with methylene blue was also considered as a possible cause for these findings. We believe the blue discoloration of the brain was secondary to methylene blue administration during resuscitative efforts. Methylene blue should be considered in any case of blue discoloration of brain parenchyma.