The father of a healthy 15-year-old girl brings her to the emergency department (ED) for evaluation of blue hands.
Her father reported to the ED staff that his daughter had called him in the middle of a meeting right after she had given a stressful oral presentation. She said that her hands were blue and she couldn’t breathe. The father instructed his daughter to go directly to the nurse’s office to seek help. When he arrived at her school to pick her up, he found his daughter tearful, but not out of breath. Her lips were pink but her hands were dusky and blue. That’s when he rushed her to the pediatric ED.
In the ED, the girl was immediately connected to a pulse oximeter that showed oxygen saturation levels of 99%. She was alert and oriented, but tearful when she looked at her hands again. She was afebrile; blood pressure was 105/68 mm Hg. Her physical exam showed moist mucous membranes and no perioral cyanosis. She had no murmurs and her lung exam was normal without wheezing, tachypnea, or increased work of breathing. Her abdominal exam was normal with no organomegaly.
The rest of her exam, including a neuromuscular exam, also was normal with the exception of her hands that had a dusky-blue color especially concentrated on the dorsum of her hands (Figure). The astute ED resident asked if she had touched anything blue that day or if she was wearing any new clothing that was blue. Her answer was neither. She recounted that the only thing that was different about this day was that she had been nervous about her oral presentation just prior to her hands turning blue and her trouble breathing.
Laboratory tests and EKG
Her laboratory tests were completely normal and included a complete blood count with normal differential; a normal comprehensive metabolic panel; a negative antinuclear antibody test (ANA; <1:40); a normal erythrocyte sedimentation rate (ESR) of 14; normal thyroid stimulating hormone (TSH) and free thyroxin (free T4); and normal urinalysis.
An electrocardiogram (EKG) was done and demonstrated a normal sinus rhythm with no abnormalities.
The ED physician looked over the labs, and then looked at her blue hands and shook his head. The discharge diagnosis was acrocyanosis, but she would have to follow up with both Cardiology and Rheumatology for a more definitive cause.