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.
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.