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 Table of Contents  
LETTER TO EDITOR
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 311-312

Interference of pulse oximeter reading in an undiagnosed case of Hansen's disease


1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Armed Forces Medical College, Maharashtra, India

Date of Web Publication12-Sep-2019

Correspondence Address:
Dr Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_118_19

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How to cite this article:
Sukhadeve A, Jahan N, Dwivedi D. Interference of pulse oximeter reading in an undiagnosed case of Hansen's disease. Int J Mycobacteriol 2019;8:311-2

How to cite this URL:
Sukhadeve A, Jahan N, Dwivedi D. Interference of pulse oximeter reading in an undiagnosed case of Hansen's disease. Int J Mycobacteriol [serial online] 2019 [cited 2019 Oct 19];8:311-2. Available from: http://www.ijmyco.org/text.asp?2019/8/3/311/266491



Dear Editor,

A pulse oximeter has established its role as a standard monitoring device with its application extending to the operation theater (OT), intensive care units, postanesthesia care units, emergency rooms, and nonoperating room anesthesia and procedures. The pulse oximeter is a surrogate noninvasive method of estimation of the arterial blood oxygen saturation, thereby obviating the requirement of the invasive blood gas analysis, and has been validated for titration of the fraction of inspired oxygen in patients dependent on oxygen.[1] We describe an interesting case of preoperative interference of the pulse oximeter reading, which helped us in diagnosing Hansen's disease in a patient.

An 83-year-old male patient weighing 68 kg diagnosed as a case of perforation peritonitis was taken under emergency for laparotomy. The patient had no comorbidities and was accepted under American Society of Anesthesiologist Physical Status Class II. On arrival in the OT, standard monitoring ensued and pulse oximeter displayed the reading between 82% and 83%, which persisted even after oxygen supplementation. Probe was checked on various people in the OT which displayed the normal reading of 100%. Arterial blood gas analysis revealed the oxygen saturation value of 99.8%. Examination of both the hands of the individual revealed spatula-shaped fingers with bulbous tip and fixed flexion deformity, wasting of the hypothenar and thenar eminence, thickened bilateral ulnar nerves with no evidence of the hypopigmented patches on the skin [Figure 1]. Provisional diagnosis of Hansen's disease was made preoperatively, and then, a neonatal pulse oximeter Y probe was applied while the monitoring was achieved. Intraoperative and postoperative period was uneventful, and later, a dermatologist opinion was sought which confirmed the provisional diagnosis.
Figure 1: Spatula-shaped fingers with bulbous tips, claw hand with atrophy of the thenar and hypothenar eminence

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The pulse oximeter can have fallacious reading in the conditions, causing hypoperfusion, hypothermia, peripheral vasoconstriction, shock, bright light in the OT, dyshemoglobin (including carboxyhemoglobin), nail polish, darker skin pigmentation, venous pulsations, and perhaps most frequently, motion artifact.[2] An entity of “saturation gap” has been described in the literature in patients with leprosy due to dapsone medication, which leads to methemoglobinemia, resulting in the erroneously low oxygen saturation values on pulse oximetry.[3]

Infiltration of Mycobacterium leprae in the skin makes it dry, granular, shiny, and succulent, while arteriopathy with sensory impairment is known to cause the sluggish blood flow to the digits, perhaps affecting the monitoring by pulse oximeter as has been observed in our case.[4] Further to this, bulbous fingertips could not make proper contact with the light-emitting diode of the adult pulse oximeter probe. Troubleshooting was done with a pediatric neonatal pulse oximeter Y sensor probe, which minimized the error when tied circumferentially over the finger and aided in the uninterrupted monitoring.

Incorporation of the signal extraction technology in the newer generation of pulse oximeter looks promising which shows high specificity in detecting the hypoxia during the low perfusion states and motion artifact.[5] This technology can be utilized judiciously in the clinical conditions such as leprosy where the lower perfusion owing to the arteriopathy and skin changes can hamper the normal oxygen saturation monitoring. Availability of the neonatal Y sensor probe in the OT can augment the monitoring in special situations where the deformity of the fingers exists.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ortega R, Hansen CJ, Elterman K, Woo A. Videos in clinical medicine. Pulse oximetry. N Engl J Med 2011;364:e33.  Back to cited text no. 1
    
2.
Chan ED, Chan MM, Chan MM. Pulse oximetry: Understanding its basic principles facilitates appreciation of its limitations. Respir Med 2013;107:789-99.  Back to cited text no. 2
    
3.
Tang AS, Yeo ST, Teh YC, Kho WM, Chew LP, Muniandy P. The mystery of 'saturation gap': A case of dapsone-induced methaemoglobinemia in a pregnant mother with leprosy. Oxf Med Case Reports 2019;2019:omy111.  Back to cited text no. 3
    
4.
Abbot NC, Beck JS, Samson PD, Butlin CR, Bennett PJ, Grange JM. Cold fingers in leprosy. Int J Lepr Other Mycobact Dis 1992;60:580-6.  Back to cited text no. 4
    
5.
Louie A, Feiner JR, Bickler PE, Rhodes L, Bernstein M, Lucero J. Four types of pulse oximeters accurately detect hypoxia during low perfusion and motion. Anesthesiology 2018;128:520-30.  Back to cited text no. 5
    


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