“Blue Angel. ”  Still image by Paul Goldfinger from the movie Marco Polo.

By Paul Goldfinger, MD, FACC

Cyanosis: a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

The patient was a middle aged woman who worked in the bank on Blackwell Street in Dover,  New Jersey, where I had recently opened my practice.   People began to notice a change in her appearance: she had developed a bluish discoloration of her skin. Each day it became worse and worse until her friends and family became alarmed. Everyone was amazed that she had no symptoms other than the striking blue face which was looking at her in the mirror. Finally she called her family physician.

I got a call about the case from her doctor, a kindly older man who smoked cigarettes in his office and dropped ashes on his vest. “Paul” he said, “I want you to see this lady who’s turning blue.”

I was shocked by the call. Middle aged females don’t just turn blue out of the blue. I could see why he might want a cardiologist, but how could his patient have a heart condition when she felt fine?

She came to the ER at Dover General Hospital where I met her. She was indeed cyanotic, but the cause was not obvious. I admitted her to the hospital where it became clear that she had neither heart disease or lung disease—the two leading causes of cyanosis. Those were the days when you could admit a patient to the hospital “for tests.”

All the tests were negative, so I decided to go back to basics—an old fashioned approach: a meticulous detailed history was required.

As I was going over all the particulars again, she mentioned something that she hadn’t disclosed when I first met her: she was being treated for a urinary tract infection. When I looked up her medication, I discovered that her pyridium could cause a change in her blood hemoglobin to produce a compound called methemoglobin. So instead of red blood, her blood was turning blue.

Eureka! The lab ran a methemoglobin level on her blood , and we had the diagnosis: methemoglobinemia—the first and last case I ever saw.

We stopped that medication and we kept her in the hospital, and each day, when I made rounds, I became more and more relieved—she was turning light blue: lighter and lighter each day.

Finally I became confident enough to tell her that she was cured; and I sang her a few bars of the chorus to this song: (performed here by Ethel Waters in 1929)

ETHEL WATERS.  “Am I Blue?”