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Never seen this before:

18 yr old female arrives via ems with blue skin and normal sao2 with otherwise stable vs. has had a uri for last week.

questions? workup/dx/tx?

this is a weird one. open to everyone. 

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Given any Rx or taking anything OTC for URI? PMHx? Recent travel? Any known exposure to chemical fumes, inhalants, etc? Is she short of breath or did she just call the ambulance because of the skin color changes? Any pain? 

Edited by karebear12892

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no to all of above. teacher at school called 911 because she was acting very tired and had a blue face and arms. good questions. 

more hx, exam, labs, ddx, tx? 

dx was actually clinched by something Resp therapy told me before labs came back. 

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Hmmm ok. I was thinking methemoglobinemia but outside of medication use and chemical exposure, I'm not sure what else might cause that. I'll put that DDx on the back burner for now. 

I'll let someone else chime in on history.....

PE: particularly interested in sclera color and pupil size/reactivity, any odor to her breath (has she been exposed to toxic levels of something without realizing it?), cardiac murmurs, adventitious lung sounds, respiratory rate/effort, blanching vs. non-blanching cyanosis (honestly not entirely sure why I'm checking for that but I have a gut feeling that is important), capillary refill, volume status, fingernails (clubbing?), skin temperature, GCS/look for focal neuro deficits

Initial labs....CBC, reticulocyte count, peripheral blood smear, CMP, ABG, UA, +/- CXR and/or echo depending on cardiopulmonary exam...also debating whether arterial or venous blood sample would be more informative for gross examination, but definitely want to take a look at one of those before it goes off to the lab. 

Not quite sure what I'm treating and she doesn't seem very symptomatic, so I'd say just keep her on a cardiac monitor until labs come back. 

Might think of more later!

Edited by karebear12892
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all exam features negative aside from blue skin on face/hands/forearms. ABG and methemoglobin level done and nl. cxr initially ordered then cancelled. ekg nl. 

when you check for blanching vs non-blanching on the forearms your fingers come away blue(and no, this isn't about new blue clothes, sheets, etc). 

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don't feel bad. major zebra:

https://www.ejcrim.com/index.php/EJCRIM/article/view/84/174

pseudochromhydrosis. basically sweat mixes with bacteria present on the skin , causing a discoloration. can be lots of different colors depending on the bacteria involved.  treatment is topical antibacterial preparations like hibiclens/chlorhexidine. 

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Wow, that's a zebra all right! What was the clue provided by RT? 

"May cause psychological stress and social embarrassment." I'd say so.

Cool case 😎 thanks for sharing! 

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They showed me the alcohol swab used prior to the abg. (it was blue). no new blue clothes, etc. 

2 minutes of googling and a negative ED workup resulted in the dx. 

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Was she incredibly short?  Did you ask if her house was a toadstool, or if she lived in a village surrounded by lots of other blue people?  Ever been attacked by a wizard named Gargamel?

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I know you have already solved this, and it was a fascinating case, but no one mentioned argyria, possibly from silver supplements. You know Oregon is world headquarters for crazy supplement use. Never heard of pseudochromhydrosis before.

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Similar to my last ride along w/ Dallas Fire. First pt called out as an “unconscious person”, so Rescue/Engine dispatch. Get there and there’s a guy in a shower chair in the tub with a Foley back with bluish/purple discoloration inside the bag. EMS didn’t inquire but I asked family about it and there were no home meds or recent contrast studies that would explain same. Never got an answer. He was a no transport.

 

 

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