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 35-year-old Pakistani male with a history of chronic malaria, progressive splenomegaly and a complaint of severe left sided abdominal pain was treated by branding with a hot metal rod 7 days prior to admission. A week later he was admitted for septic shock and severe pain in the left hypochondrium. Past medical history was noncontributory except for an intermittent low-grade fever and occasional spikes of a high-grade fever with chills. On examination, he was disoriented and had multiple circular full-thickness burns to the anterior abdomen ranging in size from 2 to 5 cm across with central sparing of the skin and yellow discharge from the wounds. Blood and wound cultures grew Staphylococcus aureus. Abdominal ultrasound on admission showed a massively enlarged spleen with multiple rounded areas of complex echogenicity showing multiple splenic abscesses which were not seen in previous ultrasounds. He was treated with broad spectrum antibiotics and silver sulfadiazine. A splenectomy was performed and a gross examination confirmed the existence of multiple splenic abscesses which were also positive for Staph. aureus. Culture of pus from the spleen revealed growth of same Staph. aureus that were present on burn wounds complicated by skin branding. The patient died in the fourth week during the course of treatment.