Green Skin? Google it.

Your next patient is a 16-year-old male with a chief complaint of “turning green”. You glance at the triage note – normal vital signs and no symptoms except that the child’s skin has been turning green off and on all day and got worse this evening, so they came in. OK, you need a template. What makes a 16-year-old male turn green? Umm, not sure, actually. You decide call on Dr. Google and so you sidle up to a computer. The charge nurse, who is sitting next to you, looks up and gets curious. “So, what could make a kid’s skin turn green?” All you can remember is something about copper jewelry sometimes causing this. You confess your ignorance and convert him to the cause. You leave him to continue searching the web while you go down the hall to do a basic H&P.

The child says he has been feeling fine. But today at school, another student pointed out to him that the back of his neck was green. Looking carefully, he then noticed that he had patches where his skin was green on his arms as well. He went to the restroom and looked at the back of his neck and sure enough, there was a section that appeared greenish. An hour later, the color had faded, but for the rest of the day and into the evening, the areas that were green have intensified and then faded. He did notice that when he laid his hand on the back of his neck, the green would show up more.

He also noted, as he got ready for bed, that he had green patches on his legs as well. He denies any symptoms whatsoever, his skin doesn’t itch or burn. His fellow student pointed out the color change to him right after chemistry class, but he didn’t work with any chemicals today and all of his classmates appear to be their usual hues. He pointed out the green to his parents who are naturally concerned that something in the chemistry class has poisoned their child. He has no significant past history and does not take any medications, herbal remedies, teas, or anything else out of the ordinary.

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The physical exam is mostly unremarkable. The boy has a few, faintly green-gray patches on his arms and legs, and the back of his neck. They’re a little hard to see but definitely visible in the florescent light. The patient and his parents assure you that the color was more intense earlier tonight.

“So what is it?” the parents want to know. “Will you be running any tests?”

“I need to think through some things,” you mutter, stalling for time. Promising to get back to them you head back to the computer and the charge nurse, who has stumbled upon “The Handbook of Occupational Dermatology” on the web. It has a neat little table, which lists the different colors human skin can turn, with putative causes for each. Under green there are only two entries: copper dust and icthymol (used in topical salves).

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Back down the hall you go, this time to ask the kid if he’s been exposed to either of those entities. Funny you should ask that. The other evening, he accidentally spilled an entire box of copper BBs onto the floor of his room. He sat down and picked them up one by one and returned them to the box. Afterwards, there was some dust on the floor but it was too much bother to get a rag and wipe it up, he just swiped it with the palm of his hand. Yes, he was wearing shorts at the time. And no, he doesn’t recall washing his hands right afterwards.

OK, now we’re getting somewhere. Back to the computer, where you learn that human sweat, which is acidic in nature, will “corrode” metals or turn them into salt compounds. And the salt compound of copper is green (think Statue of Liberty). So the waxing and waning of the patient’s skin discoloration could be due to sweat. That would certainly explain why the color on the back of his neck intensifies when his hand rests on his neck for a while.

Well, everything seems to fit, but what to do about it? Is any testing necessary? You decide to run it by the toxicologist on call at your local poison center. He loves stuff like this. You get him on the phone and he enjoys the story. He agrees that exposure to copper salts are the likely cause of the patient’s skin discoloration. He reassures you that it is doubtful that any significant absorption has occurred in this assymptomatic child and no testing is needed. The only recommendation he has is that the patient wash well with soap and water.

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One last trip down the hall to share the information with the patient and his parents. They are relieved and head home. Soon, you are also relieved and head home. Maybe that last case was kind of cool after all.

on the Web
TRIP (www.tripdatabase.com)
Access multiple electronic search engines and textbooks simultaneously.
PUBMED Clinical Queries
(www.ncbi.nlm.nih.gov/pubmed)
Archived by National Library of Medicine with pre-set filters to identify diagnostic, prognostic, therapeutic, etiology or clinical prediction guides.
Google Scholar
(www.scholar.google.com)
Provides large number of often dated references, but sometimes allows free access to the entire article.

ToxED (www.toxed.com/)
Poisindex (www.micromedex.com/products/poisindex/)
Clinical Pharmacology
(www.clinicalpharmacology-ip.com)
STATREF (online.statref.com)

“Finding the Evidence”

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