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 32-year-old white woman, who was undergoing transgender body modifications and no previous medical history, presented to our emergency department (ED) with a chief complaint of right forearm pain, associated with redness and blistering. The patient was a tattoo fanatic who underwent solar branding on her right forearm approximately 2 weeks before presentation. The patient first noticed the blistering of the branded area 3 days after her body modification. Over the next few days, the entire branded area became very warm, swollen, painful to touch, and developed cellulitis with weeping blisters. Given her dire situation, the patient finally sought medical care in the local urgent care center. The patient was diagnosed with a superficial infection of her right forearm full thickness burn and prescribed oral clindamycin. The patient continued to develop painful blisters for the next week and did not notice any improvements in her cellulitis despite the antibiotic treatment, prompting her to come to our ED for a second medical opinion.\nDuring her physical examination, the patient was noted to have painful blisters, redness, and swelling of the right forearm and hand (Figure ). She did have a full range of motion of the hand; however, there was mild pain noted on the flexion of the hand. There were no signs of sepsis, and her vital signs and her laboratory panel which included white blood cell count were all within normal limits. The rest of the physical examination was also unremarkable. The patient was admitted to the Burn Surgery Service for intravenous (IV) antibiotics and possible operative interventions.\nThe patient was started on IV clindamycin 600 mg every 8 hours, and once adequate pain control was achieved, a bedside debridement was performed in the Burn Unit. The following day, the patient was taken to the operating room for tangential excision of her wound and split-thickness skin autograft (STSG) placement onto her right forearm. The left anterolateral thigh was chosen as the donor site. The grafted site was dressed with xeroform, followed by a layer of bacitracin ointment and then wrapped with Kerlex and Coban dressings. A right forearm elbow splint was fitted and placed by the occupational therapy service for further graft protection. Postoperatively, the patient was transferred back to the floors without complications, and antibiotics were stopped. The right forearm dressing was taken down on postoperative day 4 to evaluate the STSG. The entire graft was viable and taken. Subsequently, the graft staples were removed on postoperative day 5.\nThe patient recovered exceptionally well and was discharged home a few days later. Two weeks later, the patient returned to the burn clinic for a follow-up appointment. The skin graft and the donor site healed remarkably well (Figure ). The patient reported no pain and had a full range of motion of the hand and wrist. The patient was discharged from the burn service and advised to use over-the-counter moisturizer or lotion as needed.