From "Blue Man" to "Blue Woman": What is behind these fascinating cases?

A few years ago, a particular phenomenon made headlines around the world: Paul Karason from Washington, known as the Blue Man, had a blue coloration on every inch of his body.<sup>1</sup>

A Life in Blue: The Unusual Fate of Paul Karason

Blue skin – an unusual phenomenon that has caused a worldwide sensation. In the annals of medicine, people whose skin shimmers in an unusual shade of blue repeatedly appear. Was it a mysterious ailment, an unexpected reaction, or even the result of questionable self-medication? We embark on a search for the causes of this fascinating and sometimes eerie discoloration and lift the veil surrounding these "blue people."

Der balue Mann.jpg
The blue man from the USA. Image credits3

The Blue Man Syndrome: Case 1

In 2020, an interesting case was published in the journal Elsevier. A 77-year-old man presented with hyperkalemia of 7.0 after cardiac arrest. He had a history of blackening of his leg while taking amiodarone. Since all other antiarrhythmic drugs had failed to treat his arrhythmia, amiodarone was used anyway. Amiodarone recurred as a gray-blue discoloration of his bilateral lower extremities. This benign side effect of the drug can occur in 1-3% of patients treated with amiodarone.

However, this side effect differs from the normal form of blue man syndrome, which is more likely to occur on sun-exposed areas of the body, such as the face and arms. Although this is a benign side effect, it can be extremely distressing for affected patients. The cause of this skin discoloration is suspected to be a deposition of lysosomal membrane-bound dense bodies, similar to lipofuscin, in the dermis of patients undergoing chronic amiodarone therapy.4

The Blue Man Syndrome: Case 2

In 2023, a 51-year-old Caucasian man presented who had been treated with amiodarone and implantable cardioverter-defibrillators for ventricular arrhythmia and cardiomyopathy for the past three years. He was referred to a medical center due to a blue-gray discoloration of the nose and cheek area – which had been present for a total of three weeks.

The medical team from Iran recognized this as a rare side effect of the drug amiodarone. Interestingly, the research team mentioned in their publication that the accumulation of chemical silver compounds in the patient's skin might play a role. Amiodarone contains amiodarone hydrochloride and lactose, but no silver particles. It is worth noting, however, that in addition to amiodarone, colloidal silver and the medications listed below can also cause blue-gray skin discoloration:

The Blue Man Syndrome: Case 3

A 26-year-old man was admitted to ER in 1992 with a recurrent left-sided pneumothorax. A small area of ​​skin was cleaned with povidone-iodine. Subsequently, an uncomplicated thoracoscopy and talc pleurodesis were performed. Two hours after the procedure, his entire body from the neck down was light blue. The patient was well, and there were no signs of cyanosis. When his skin was wiped with a swab, the blue dye stained the swab, leaving a white streak on his skin. However, the swabbed area of ​​skin turned blue again after one hour. The skin color normalized over the next 24 to 48 hours.6

What could have caused this phenomenon?

The medical team explained the recurring blue coloration as follows: The talc used in the hospital for pleurodesis was traditionally mixed with iodine. The iodine was likely absorbed into the bloodstream through the pleura and then excreted in sweat. However, this still does not explain the blue coloration of the patient's skin. Iodine could have reacted with another substance on the patient's skin, producing the blue color. Besides starch, cleaning products, shower gels, or washing solutions could also have caused this particular effect.6

The Blue Man: a reknowned case from the USA

Paul Karason, became known as the Blue Man. In the early 1990s, he still had a rather light skin tone. Due to various illnesses (including sinusitis, dermatitis, and reflux disease), Paul Karason began taking a homemade colloidal silver solution. He rubbed a silver preparation into his skin. This ultimately led to argyrosis, with which he first became known in 2008 (on the Today show).1 At the age of 62, he died in the hospital of a heart attack. He had been admitted there due to pneumonia. He had recently suffered a stroke.7

The Blue Woman from South Korea

Around the same year, a Blue Woman appeared in another part of the world. In South Korea, a 58-year-old woman entered hospital with progressive blue skin discoloration: The patient's skin had a diffuse blue-gray tone. This was particularly noticeable in sun-exposed areas, such as the face and hands. In addition to these areas, however, the tongue, oral mucosa, gums, conjunctiva, ears, as well as the torso and nail beds were also affected. She, too, had taken colloidal silver solution as a traditional remedy. For about 16 months, she drank 1 liter of this special colloidal silver solution daily. The silver concentration in her serum was quite high at 381 ng/ml (reference value: <15 ng/ml). Scanning electron microscopy revealed electron-dense granules in the intercellular space of the sweat glands.8

Sources:
  1. https://en.wikipedia.org/wiki/Paul_Karason 
  2. https://www.youtube.com/watch?v=FnAgD6J65Xc&list=RDJYj0nrVVxpU&index=2
  3. By Kevyn Jacobs - Original publication: FlickrImmediate source: https://www.flickr.com/photos/kevynjacobs/5229669698/, Fair use, https://en.wikipedia.org/w/index.php?curid=69078099
  4. Fishman TJ. et al. (2020). Amiodarone induced "Blue man syndrome"; an unusual presentation. Heart Lung. 2020 Mar-Apr;49(2):202-203. 
  5. Samadi Takaldani AH. et al. (2023). Amiodarone-induced blue man syndrome: a case report. J Med Case Rep. 2023 Jun 9;17(1):248. 
  6. Mitchell IM. et al. (1992). The blue man phenomenon. Ann Thorac Surg. 1992 Oct;54(4):814.
  7. https://abcnews.go.com/Health/internet-sensation-papa-smurf-dies-blue-people-live/story?id=20368758
  8. Kim Y. et al. (2009). A case of generalized argyria after ingestion of colloidal silver solution. Am J Ind Med. 2009 Mar;52(3):246-50.