I have come across an unusual hospital presentation of “blue limbs” three times in my years of practice, though the incidence in the population is likely to be high.
As a surgical house officer, I encountered the condition twice within a couple of weeks. On the first occasion I was covering the wards when I was bleeped regarding a patient who had developed blue hands. A rare problem, I thought, and a number of possible medical and severe scenarios ran through my head. As I approached the ward, I expected to find a case of either Raynaud's syndrome or a rather ill patient, perhaps cyanosed or with superior vena cava obstruction!
To my surprise, I found a man sitting comfortably on the bed. Puzzled, I inquired diligently about respiratory, circulatory, and neurological symptoms. He was perfectly well with no abnormal symptoms or signs apart from the blue colour of his hands. It was after the examination turned out to be normal that I took greater note of his purple, paisley print pyjamas. I discovered these were new and, on touching the material, found that the colour rubbed off easily.
The second case of blue hands occurred on the same ward a few weeks later. On account of my recent experience, the scenario I anticipated was less dramatic (that is, “common things are common”) and approached the ward confidently. Alas, on this occasion the patient had no purple pyjamas. I added an extra feature to the examination routine—try rubbing the colour off the hands—and was delighted when it worked. We were a little stuck for clues, but, looking around, we came across his newspaper and found the sports page he'd been holding had a large dark blue picture background.
The third and most challenging case occurred many years later when, as senior surgical house officer covering vascular referrals, I was bleeped by the paediatric registrar. He was puzzled by a teenage girl who had developed blue legs. His examination had revealed normal pulses and no other abnormalities. I assured him that I had some experience in “similar cases.”
The white girl was accompanied by her concerned mother and seemed slightly embarrassed. She was well built for her age and had no abnormal symptoms. Her legs, from hip downwards, were a faint blue-grey colour not dissimilar to that found in vascular insufficiency, but all other signs, including warmth and pulses, were normal. However, the previous examination had been incomplete—her socks had not been removed. Beneath the white socks was the clue to the mystery: the feet and ankles were of normal colour sharply demarcated from the blue above the sock line.
The girl only then revealed that she had just bought a pair of grey jeans and had worn them that day for the first time. She later noticed her legs had changed colour, but, in spite of her efforts and a warm bath, the colour remained.
We now had the full story, yet the final proof and treatment were still missing. After hopelessly rubbing and wiping the legs with water, I found, at the bottom of my white coat pocket, the solution—the faithful alcohol swab.
It is therefore important to remember in cases when all conventional knowledge fails—take a full history, make a thorough examination, and use a little imagination.