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.
A 60-year-old Pakistani male with a history of acute exacerbation of open angled glaucoma of the right eye underwent branding of the right temple and vertex by a faith healer. Four days later, he presented to the hospital with blurry vision in the right eye and cellulitis over the right temporal region. Further examination revealed chemosis, corneal haziness, severe restriction of ocular movements and multiple well circumscribed round full-thickness burns ranging from 2 to 5 cm with no evidence of active drainage. Fundoscopy showed papilledema and hemorrhages with engorgement of veins. On day five, similar signs appeared in the contralateral eye. His past medical history was insignificant except for glaucoma. He had no prior history of sinus headaches or ear infections. Since local infection is the major reason for cavernous sinus thrombosis (CST), the diagnosis was suspected in our patient as the typical sequelae had started after branding. Acute glaucoma can sometimes present with CST; however, he was already on treatment for open angled glaucoma and had no previous infection. The fact that he had acute exudative wounds after branding and had no prior history of ear or sinus infections points towards branding as a cause of CST. Our diagnosis was confirmed by magnetic resonance imaging (MRI). We believe this local inflammation and infection may have spread and reached one of the cavernous sinuses which may turned into an infected clot. The patient partially responded to intravenous broad-spectrum antibiotics (Amoxicillin with clavulanic acid and Ceftriaxone) and local wound management, but suffered permanent blindness.