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 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.