A palette of patients

Some patients feel blue. Some see red. Some are in the black. They can be green with envy, or if scared, plain old yellow. But what do you do when your patients really are green or orange or gray?

Time to break out the deerstalker and the magnifying glass and get your Sherlock on.

BLUE MAN GROUP: We're talking not about the modern cerulean performance troupe, but 11 homeless men in New York in September 1944. Symptoms included altered mental status and abdominal cramps but, most noticeably, sky-blue lips and fingers. It wasn't cyanosis. Could it be carbon monoxide poisoning? That was the quandary for the staff of Beekman Downtown Hospital.

In the end, the patients were all methemoglobin-positive. All 11 had eaten at the same cafeteria. It was discovered that both the oatmeal and one salt shaker had been mistakenly filled with sodium nitrite instead of nitrate. When your non-hypoxic patients are feeling blue, you might also consider amiodarone or hydroxychloroquine (or other anti-malarials), which can give the skin a bluish tinge.

Not just the grass is blue in Kentucky; there are also the Blue Fugates, a family descended from an 1820 immigrant to that state, Martin Fugate, who had familial congenital methemoglobinemia. Blue sclera can be a sign of osteogenesis imperfect, pseudoxanthoma elasticum, and other disorders.

SEEING RED: So many things can make a patient red, from eczema and psoriasis to drug reactions, with a textbook in between. If a patient is in the hospital for MRSA pneumonia and turns bright red, likely it's red man syndrome from the vancomycin. If a patient presents with diffuse erythroderma and lymphadenopathy, better check a peripheral smear. It might be DRESS syndrome with eosinophilia and systemic symptoms, but you might also find Sézary cells, a sign of cutaneous lymphoma.

FADE TO BLACK: A patient has had many years of rosacea, but presents now with diffuse dark blue-black discoloration of the legs and face. Is it ochronosis (alcaptonuria, not related to okra) or maybe just terra firma dermatosis? In this case, the clue is the rosacea, for which the patient has been on long-term minocycline, leading to the skin discoloration. If only the tongue is black, it might be black hairy tongue; time to get out the tongue scraper.

JUST TWO SHADES OF GRAY: In the eighteenth century, a patient suffering from gonorrhea was treated with large doses of gold (and lead and mercury to cap it off). Three hundred years later, a patient with HIV was looking for an alternative to antivirals. He downloaded instructions for making colloidal silver and began self-administration. Both patients turned a slate-gray color. Argyria (silver) and chrysiasis (gold) are diseases caused by metal deposition in the skin and are irreversible. A patient with gray-black skin might have diffuse melanosis cutis, a sign of metastatic melanoma, and indubitably a very bad finding.

GREEN WITH ENVY: You're a club-footed medical student, and she is a prostitute, but you can't help loving her. You are also a painter and note her green-tinged skin. (This tale comes from “Of Human Bondage” by W. Somerset Maugham, written in 1915.) Most certainly this is chlorosis; the green skin is a sign of iron-deficiency anemia. Too bad she will die of syphilis anyway. If you are not The Hulk, a Martian or other fantasy figure, you might also get green skin from FD&C Blue Dye No. 1, found in feeding tube solutions, which can cause discoloration of the skin in patients with multiple organ failure in the ICU.

JUST PLAIN YELLOW: It takes a bilirubin of 2.5 to produce the changes of jaundice, but anyone who has seen a patient with a bilirubin of 20 has no problem identifying the specter of icterus. If it's just the nails, it might be yellow nail syndrome, characterized by yellow nails, lymphedema and pleural effusions with bronchiectasis.

RHYMES WITH ORANGE: The patient was a vegan, and had been on a binge of tomatoes, carrots and sweet potatoes. When her mother arrived for a visit, she was horrified to find her daughter looking distinctly citrus-colored. Xanthemia, or carotenosis, is the presence of excess carotene in the bloodstream. Carotenoids are passively absorbed by the gastrointestinal tract and metabolized to vitamin A. They are excreted in sweat, sebaceous glands and urine. Sometimes this condition is induced on purpose, such as with the treatment of erythropoietic protoporphyria with beta carotene, and sometimes for show, as in canthaxanthin used to induce a tan (not FDA approved!). If you are crying orange tears, maybe it's just rifampin (named after a French crime novel, “Rififi”).

BROWN-NOSING: The patient in question was a heavy drinker, which might have explained his abnormal liver function tests, but not the cardiomyopathy, diabetes, and brownish-bronze skin hue. The diagnosis: bronze diabetes or hemochromatosis. If you are a young presidential candidate with an unearned tan, it might be Addison's disease as part of an autoimmune polyendocrine syndrome. Adrenocortico-tropic hormone (ACTH) and melanocyte-stimulating hormone (MSH) have the same precursor molecule: pro-opiomelanocortin. The anterior pituitary's effort to stimulate the dysfunctional adrenal gland leads to hyperpigmentation. But hey—you still look better on television than Richard Nixon.