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The blue patient
  1. Adrian Spiteri
  1. Correspondence to Dr Adrian Spiteri, Emergency Department, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK; spiteri.adrian{at}

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Clinical introduction

A 46-year-old man was brought to the ED after being found in an enclosed sauna minimally responsive, clammy and confused.

On arrival he was alert, smiling and recalled sniffing a ‘herbal’ bottle followed by nausea, dizziness, poor balance, inability to stand up, shortness of breath, palpitations, sweating and confusion. He had a past history of back pain.

He had blue-purplish skin with central and peripheral cyanosis (figures 1 and 2). His observations were: HR 134 bpm, BP 108/68 mm Hg, RR 32/min, temperature 36.3°C and blood glucose 7.2 mmol/L.

Figure 1

Facial and oral colour on presentation.

Figure 2

Hand colour on presentation.

Pulse-oximeter saturation was 85% on air that only improved to 93% on 15 L/min oxygenation. An arterial blood sample was dark coloured.


What is the diagnosis?

  1. Carbon monoxide …

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  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement I allow data sharing of the original article as needed by the EMJ. The data for this image challenge is available to me after looking after the patient personally and obtaining consent to publish the case from the patient. There is additional unpublished information of the case in my possession that has not been included due to word count restrictions.