A 75-year-old woman was admitted with acute breathlessness. The patient had a background of recurrent pulmonary emboli and atrial fibrillation and, up until 4 weeks before admission, had been on long term anticoagulation with warfarin for this condition since 2001.
We elucidated that following an emergency department attendance at another hospital (with a fall and minor head injury) the warfarin had been stopped partly due to “extensive facial bruising”.
Past medical history included mild hypothyroidism, essential hypertension, hip and knee replacements for osteoarthritis, and acne rosacea (diagnosed in 1985) for which she had been taking oral minocycline 100 mg modified release capsules once daily for 12 years. Additional medication included lansoprazole 30 mg once daily, paracetamol 1g four times daily, Adcal D3 (calcium/vitamin D3 supplement) three times daily, and a beclomethasone 100 μg inhaler.
On further questioning the patient reported that she had noticed a change in the pigmentation of the skin over several months and commented that friends and medical personnel had also remarked on facial “bruising” during this time.
On examination she was apyrexial with an irregularly irregular pulse rate of 80 beats/min, a blood pressure of 138/76 mm Hg, and a respiratory rate of 18/min. Atrial fibrillation was confirmed by electrocardiogram (ECG). The chest was clear to auscultation with oxygen saturation by pulse oximetry being 91% on air. Arterial blood gas measurements taken at the time confirmed this and demonstrated mild hypoxaemia with a pO2 8.9 kPa and normal pH and pCO2. The abdomen was soft and non-tender and there were no focal neurological signs. There were no signs of deep vein thrombosis or pelvic masses.
Extensive pigmentation was present on the face and was described by the patient as similar on presentation as compared to when her warfarin was stopped. Symmetrical, bilateral, confluent, blue-grey macules were noted in a photosensitive distribution over the eyebrows, malar region, nasal bridge and chin (). Concomitant pigmentation of the sclera was also visible.
Blue-grey pigmented macules mimicking bruising. Note the photosensitive distribution including the malar region, bridge of nose and chin together with sparing of the orbital recesses.
Additionally, the finding of blue-grey discolouration of the proximal portion of the nails bilaterally in the hands further supported the diagnosis of minocycline induced hyperpigmentation ().
Proximal nail hyperpigmentation.