A 55-year-old man presented to the emergency room with chief complaints of decreased vision, severe pain, tearing, and photophobia of his left eye after administering a drop of Kermes topical eye drops, which he obtained from a homeopathic/folk medicine man. Apart from hypertension, the patient’s medical history was unremarkable.\nOphthalmic examination revealed best corrected visual acuity of 20/30 in the right eye (OD) and 20/200 in the left eye (OS). Examination of the OD was unremarkable except for mild cataract. Examination of OS revealed swelling and black pigmentation over the upper eyelid. There was conjunctival chemosis along with well-demarcated black elevated areas inferonasally. Evidence of early cicatrization involving the fornix of the conjunctiva and symblepharon formation were present. Some particulate material from the lower fornix was removed and submitted for chemical analysis. Administration of topical fluorescein hydrochloride revealed a large epithelial defect involving the whole cornea []. There was no evidence of perilimbal ischemia. Intraocular pressure was normal in both eyes.\nThe left eye was immediately irrigated with normal saline for 30 min. The patient was instructed to frequently lubricate the left eye with preservative-free artificial tears in addition to the administration of topical Ofloxacin 0.3% drops 4 times a day for 1 week and topical prednisolone acetate 1% 4 times a day for the first week then it was tapered. In addition, topical cyclopentolate 1% drops 2 times a day were prescribed for the first 2 weeks. Over the following several days, the patient’s best corrected visual acuity improved to 20/60. Eyelid swelling along with skin discoloration completely resolved. The corneal epithelial defect healed completely without scarring \n[].\nGas chromatography/mass spectrometry of the submitted sample revealed the main ingredient to be kermesic acid (C18H12O9) consistent with Kermes. In addition to kermesic acid, there were elements of barium, iron, manganese, potassium, and copper. Six months after presentation, symblepharon was still noted, however, the best corrected visual acuity OS was 20/25 without corneal scar.
A 25-year-old Pakistani male with chronic liver disease (Hepatitis C positive) underwent branding of the anterior abdomen with a heated metal rod for severe pain (Figure ). One week later, he presented with altered mental status, high grade fever and multiple round circumscribed erythematous and indurated lesions on his abdomen ranging in size from 3 to 5 cm with black eschar and active drainage. His past medical history was noncontributory except for hepatitis C, diagnosed 10 years earlier. Ultrasound of the abdomen showed massive free fluid with splenomegaly and a shrunken liver. The ascitic fluid had a high white cell count (16,000/mm3) with 95% neutrophils. He was treated with a 3-week course of intravenous ceftriaxone and topical silver sulfadiazine and sterile dressings for 2 weeks. The fact that this was the first presentation with hepatic encephalopathy after branding, and pan sensitive E. Coli grew both from the branding inflicted skin wounds and ascitic fluid, points towards skin wounds inflicted by branding as the likely culprit for bacterial peritonitis and decompensated cirrhosis.