A 55-year-old Pakistani female with metastatic melanoma underwent branding with a metal rod heated over coal to multiple sites of cutaneous metastases including the right ear, angle of the mandible, middle of the neck and left axillary area (Figure ). The metallic ash was then rubbed onto the resulting wounds. Three days later she presented with fever, tachycardia and hypotension. Physical examination revealed multiple circular full-thickness burns and blisters with central sparing ranging in size from 1 to 6 cm in diameter. The burn margins were erythematous and indurated. Aggressive management of her burns was performed on an inpatient basis. Broad-spectrum oral antibiotics were administered and the wound was treated with topical silver sulfadiazine and clean dressings. Since normal skin acts as a defense mechanism in the body, in our patient, who was already immunocompromised, branding created third degree burns and breached the intact skin seeding the metastatic lesions with infection. Blood and wound cultures grew the same Staphylococcus aureus. She was started on intravenous vancomycin and levofloxacin. Despite aggressive measures, she died in the hospital a week later. Thus, it was either inflicting third degree burn wounds in our immunocompromised patient, or wound contamination due to unsterile techniques that had led to complications in our patient, or a combination of both.
A 74-year-old man presented to the Emergency Department at King Khaled Eye Specialist Hospital 3 days after self-application of latex from C. procera in his left eye (OS). He reported a painless decrease in vision. There was no history of previous trauma, surgery, or other ophthalmic disorder. Apart from hypertension, the patient had no medical illness.\nOphthalmic examination revealed best-corrected visual acuity of 20/40 in the right eye (OD) and hand motion vision in the OS. Intraocular pressure using applanation tonometry was within normal range in both eyes. Examination of the OD was unremarkable except for a mild cataract. Slit-lamp examination of the OS revealed quiet conjunctiva, no corneal epithelial defect, diffuse corneal edema with significant Descemet's folds and small pigmented keratic precipitates [ and ], nuclear sclerosis of the lens, and a hazy view of the fundus. B-scan ultrasonography of the OS showed no pathology of the posterior pole. Specular microscope SP-3000 P showed 2224 endothelial cells/mm2 in the OD and 593 cells/mm2 in the OS, with abnormal morphology.\nThe patient was started on topical prednisolone acetate 1% four times a day for the first week, after which it was tapered. In addition, topical cyclopentolate 1% drops three times a day were prescribed for the first 2 weeks. In the first follow-up at 1 week after presentation, his best-corrected visual acuity in the OS improved to 20/300. Slit-lamp examination showed a reduction in corneal edema and an increase in clarity with fewer Descemet's folds. In the second follow-up at 2 weeks after presentation, his best-corrected visual acuity improved to 20/200. Slit-lamp examination showed a clear cornea with no residual edema []. One month later, his best-corrected visual acuity was 20/80 in the OS. Six months later, the cornea remained clear with best-corrected visual acuity of 20/60 in the OS. The latex was sent for analysis and revealed the elements shown in . The result of phytochemical screening of petroleum ether and methanol leaf extracts of C. procera revealed the presence of glycosides, protein, triterpenoids, steroids, and flavonoids. The presence of these components in this species is an indication that it may have some medicinal potential. The latex of the C. procera was tested and was found completely varying in pH values. It has an acidic nature with pH of 4.2 at room temp of 25°C. The amount of magnesia was found in highest amount in latex. The level of chromium was completely absent [].