When methylene blue fails: a case of methemoglobinemia induced by azoxystrobin and propiconazole managed by exchange transfusion

This report presents likely the first documented case of fatal methemoglobinemia due to ingestion of azoxystrobin and propiconazole-a combination fungicide widely used in agriculture. The case highlights the limitations of standard therapies like methylene blue in severe poisoning and underscores the need for early consideration of exchange transfusion. With the increasing use of such agents in rural communities, clinicians must maintain vigilance for unusual toxicities and ensure timely escalation in refractory cases.