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 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.