Objective:

To demonstrate the lack of detection of jaundice as a pitfall to teleneurology.

Background:

In the midst of the COVID-19 epidemic, neurology telemedicine has flourished
(Patel, 2021). However, the efficacy of a physician's diagnostic ability to detect jaundice using
telemedicine technology has not been formally assessed. A patient with carotenoid-induced
jaundice, easily observable in person, but absent via telemedicine, has not heretofore been
described.

Design/Methods:

Case Study: This 66-year-old left-handed (pathological) white male without exposure
history, presented with persistent headaches after head trauma. He was taking food a supplement
including, a supplement composed of the carotenoid, lutein.

Results:

Abnormalities on physical examination via telemedicine: General: Orofacial lingual
dyskinesia. Motor Examination: Drift testing: Right pronator drift. Gait examination: unstable
tandem gait. Repeat follow-up visits via telemedicine on a bi-monthly basis for two years
revealed similar findings. In-person examination two years after initial presentation revealed
prominent jaundice particularly involving creases of the hands and the frenulum, but not the
conjunctiva, but otherwise unchanged from prior examinations. Blood and urine evaluations for
origins of jaundice were normal.

Conclusions:

This pattern of jaundice was classic for hypercarotenemia (Vakil, 1985). Whereas in
hyperbilirubinemia, the jaundice is greatest in the conjunctiva and less so in the skin. On
FaceTime, auto-correction of facial image distorts color, reducing yellow chromatic frequencies
such that even gross jaundice will appear absent. Such has been reported associated with
telemedicine visits with jaundice due to severe hepatitis (Baillie, 2022). Elements of autocorrect
from a smartphone-based photo analysis using other technology for natural reproduction of skin
color may eliminate such errors (Patricoski, 2009; Clarke, 2008; Ohya, 1998; Mazzu-
Nascimento, 2021). Until such time as advanced technology becomes available, even in the
absence of visual jaundice in telemedicine, or presence of diseases which cause jaundice or
clinical suspicion of jaundice warrants in-person visitation.