Adverse clinical sequela after skin branding : a case series

Adverse clinical sequela after skin branding : a case
series
Shahzad Raza MD1 Mahadi Ali Baig MD2, Khalid Mahmood FCPS3, Soniya Rai MD4
Ana Hearman MD5, Mahadi Abdullah MD6 , Abdul Hakeem MD5
1
Department of Oncology, New York University, NY 10016
2
Departments of Internal Medicine, Our Lady of Mercy Center, NY
3
Department of Internal Medicine, Dow University of Health Science, Civil Hospital,
Pakistan
4
Gulf Medical College, Ajman, UAE
5
Department of Internal Medicine, University of Wisconsin, WI
6
Mount Vernon Hospital, NY
Originial work was done at : Dow University of Health Sciences, Pakistan
Corresponding Author:
Shahzad Raza MD
Clinical Research Associate
Department of Oncology
New York University medical Center
550, 1st Avenue
New York, NY 11016
Phone: (212) – 263-2598
Fax: (212) – 263-2618
E-Mail: shahzad.raza @nyumc.org
Key words:
Branding, Body art, counter-irritation, splenic abscess, cavernous sinus thrombosis
Abstract
Introduction
Branding refers to a process whereby third degree burns are inflicted on the skin with hot
iron rods or metallic objects. Employing the phenomenon of “counter irritation” branding
is widely used in developing countries for therapeutic purposes by faith healers. Some
methods are very crude and inhuman, carrying a large risk for complications. The
purpose of this study is to present the series of complications and review to familiarize
clinicians with this dangerous method of treatment.
Case Presentations:
Four young patients (M=3, F=1) typically “branded” with red hot iron rod for various
medical reasons presented with severe medical complication to our tertiary care hospital.
Mean duration between the procedure and presentation to the hospital was 6 days. Two
patients had septic shock, one patient had cavernous sinus thrombosis and one patient had
multiple splenic abscesses at the time of admission. All patients received standard care of
wound management and systemic infections. One patient died during the course of
treatment
Conclusion:
Severe complications of branding are troublesome and the potential risks outweigh the
benefits. Globally, heightened awareness among both patients and the physician
community in particular is needed, as it will have important implication in patients who
seek branding for various medical complications.
Introduction:
Branding refers to a traditional practice of producing ‘burns’ with hot iron rods or
metallic objects over the skin.[1,2] In several Asian and African societies where traditional
medicine is still the “standard of care,” branding continues to have medical applications
[1,3]
Branding employs the phenomenon of “counter irritation” or the brief use of,
moderate intensity pain to relieve chronic pain; a variety of methods based on this same
principle have been employed among different cultures including cupping (glass cup is
heated by hot coals or flaming alcohol and inverted onto the painful area), scarification
(skin over painful area is cut and allowed to bleed; can be coupled with cupping),
trepanation (scraping of the skull for headaches; producing skin abrasions of the neck for
dental pain) and others.[1,4]
There are various forms of branding which include
•
strike branding
•
hypothermal (freeze) branding
•
chemical branding
•
electrocautery branding
•
laser branding
The most common and most traditional form of branding is “Strike branding” which is
performed by sheet metal strip heated with a propane torch (1900-2100° F) , and the
“strike” is performed by applying the heated strip to skin. The conglomerate of heated
strips forms the desired pattern on the skin post striking. Hypothermal (freeze) branding
was initially introduced by cattle ranchers as an alternative method to heat branding. It
involves immersing a metallic rod similar to strike metal into a solution of liquid nitrogen
or other cooling agents (commonly dry ice 5% in 95% pure alcohol solution).The metal
sheet is then applied onto the skin for a brief period. An indent of the brand is left on the
site. Some times caustic agents are applied directly on undamaged skin or placed within
prior delineated scars with strike or hypothermic branding. Modern methods of branding
as a form of body art include electrocautery branding which uses of hot surgical cautery
pen to apply the burn and laser branding acts by vaporizing tissue in its path of
application. [4]
Some ancient methods are crude and inhumane, making the remedy more unbearable
than the original complaint and carrying a large risk for complications. [2, 3, 4, 5]
Material Methods
Four patients presented to our tertiary care center with severe infectious complications.
All were typically branded with hot metal rod. Mean duration of branding before
presenting to the hospital was six days. The procedure was done in a local township by
faith healers as a part of a cultural practice. At the time of presentation, two patients had a
septic shock, one patient had cavernous sinus thrombosis and one patient had multiple
splenic abscesses at the time of admission. On examinations all were clearly unwell with
various medical diseases like chronic liver disease, chronic malaria, acute glaucoma and
metastatic melanoma. Patients were managed for burn and wounds induced by branding
and systemic medical complications in addition to the original disease. Here we have
discussed the outcome and complications of these patients.
Clinical cases
Case 1
A 25-year old male with chronic liver disease (Hepatitis C positive) underwent branding
of the anterior abdomen with a heated metal rod for severe pain (Fig. 1). A week later, he
presented with altered mental status, high grade fever with multiple round circumscribed
erythematous and indurated marks on abdomen ranging in size from 3 to 5 cm with black
eschar with active drainage. Past medical history was noncontributory except for hepatitis
C infection for 10 years. Ultrasound of abdomen showed massive free fluid with
splenomegaly and a shrunken liver. The ascitic fluid had a high white cell count with
95% neutrophils. Culture of the ascitic fluid and swab from wounds on the anterior
abdomen grew E.coli which was pan-sensitive to antibiotics. He was treated with a three
week course of Intravenous ceftriaxone and the wound was treated with topical silver
sulfadiazine and clean dressings for 2 weeks.
Case 2
A 35 year old male with a history of chronic malaria and progressive splenomegaly was
treated with hot metal rod branding for severe left sided abdominal pain. A week later he
was admitted with septic shock. Past medical history was non contributory except for
intermittent low grade fever and occasional spikes of high grade with chills. On
examination, he was disoriented, toxic with multiple circular full-thickness burns to the
anterior abdomen ranging in size from 2 to 5 cm across, with central sparing of skin and
yellow discharge from the wounds. Blood and wound cultures grew Staphylococcus
aureus. Repeated abdominal ultrasound showed massively enlarged spleen with multiple
rounded areas of complex echogenecity compatible with multiple splenic abscesses. He
was treated with broad spectrum antibiotics and silver sulfadiazine. Splenectomy was
performed and on gross examination it was confirmed multiple splenic abscesses which
were also positive for Staph .Aureus.
Case 3
A 60-year-old male with a history of acute glaucoma of the right eye underwent branding
of the right temple and vertex. He presented on day four to the hospital with blurry vision
of the right eye and cellulites of the right temple. Examination further revealed chemosis,
corneal haziness, severe restriction of ocular movements and multiple well
cirucumscribed round full-thickness burns ranging 2-5 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. Cavernous sinus thrombosis
was suspected and confirmed on magnetic resonance imaging (MRI). She partially
responded to the broad spectrum antibiotics and local wound management but the course
was complicated with permanent blindness.
Case 4
A 55-year-old female with metastatic melanoma had undergone branding on multiple
sites of cutaneous metastases including the right ear, angle of the mandible, middle of the
neck, and left axillary area with a metal rod heated over coal. (Fig. 2) 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 fullthicknesses ranging in size from 1 to 6 cm across, with central sparing of skin. The burn
margins were erythematous and indurated. Aggressive management of the patient’s
burns was performed on an inpatient basis. Broad-spectrum oral antibiotics were
administered. The wound was treated with topical silver sulfadiazine and clean dressings.
Blood and Wound cultures grew staphylococcus aureus. She was started on Intravenous
vancomycin and levofloxacin. Despite aggressive measures, she died in the hospital after
a week.
Results
We presented four cases of severe complications of branding. Mean duration of skin
branding and admission to the hospital was 6 days. Two patients had septic shock which
was seen in 2nd week where as cavernous sinus thrombosis and splenic abscesses were
seen in 1st and 3rd week following branding. Two patients died in the hospital with
septicemia.
Discussion
The study of folk medicine in relation to ancient cultures has revealed a variety of
customs and practices which have survived till today. One of the commonest ancient
techniques used for centuries to remit pain symptoms involves “Counter irritation” which
is the application of a secondary man-made irritant to the site of the original injury, the
primary irritant like mineral/herbal irritants, massage, firing irons, setons, etc.
In eastern societies where modern health practice is inaccessible to every person, patients
who seek brandings include musculoskeletal disorders like backache, sciatica, arthritis,
paralysis, facial palsy, ascites, splenomegaly, lymphadenopathy, jaundice, glaucoma,
migraine headaches and sore throat. [1] The role of branding as a body art is recognized
however its role in disease management or a subjective control of pain is unclear. [4]
However, it is proposed that secondary inflammation from the applied irritant which
included vasodilation, enzyme release, swelling, edema, blebs, vesicles and suppuration
may aid leucocytes and opsonins in inflammatory area (acted upon) and leads to bacterial
destruction. The toxins are also more rapidly removed by their influence. [4] The effects
alone cannot be explained when counter irritations of the surface decidedly affect distant
organs. However the influence of counter-irritants may be summed up in reflex action;
i.e. the production and conduction of an impulse from the periphery to nerve centers,
thereby modifying the nerve functions and blood supply in distant parts. [6,7] The duration
of pain suppressive action and total body surface area ( TBSA) involved with branding
depends upon nature of the material, its strength, the duration of its action, the mode of
application, and the part to which it is applied and not necessarily on subjective pain
complain.
In our case series, faith healers used hot metal rod with coal for branding. But severe
medical complications of this procedure and the potential risks for the treatments
outweigh the benefits of controlling pain for few days In addition, management of
wounds can be challenging in these patients. The diagnosis usually is made clinically,
and patients are likely to present complaining of symptoms suggestive of infection. They
have diminished resistance against infection and other external noxious agents like any
third degree burns and parenteral antibiotics fail to penetrate the dead tissue due to poor
blood supply. Management includes local irrigation of the burn with saline and gentle
debridment of the eschar if necessary. Infected limbs should be elevated and rested.
Silver sulfadiazine or another appropriate antimicrobial agent should be applied to the
wound as required.[4] If cellulitis is present, antibiotic coverage should be initiated. In the
long-term, such procedures can cause disfigurement from contractures (especially over
joint surfaces), scars, loss of hair, keloids, orthokeratotic hyperkeratosis, acanthosis, and
squamous cell carcinoma (Marjolin’s ulcer). Other medical complications include foreign
body reaction, oral and tooth complications, aspiration and hypoxia, edema and swelling,
infections, and viral transmission, including hepatitis and HIV .[5,8,9-11]
Recently, these techniques have gotten more and more fashionable in western
countries.[4,5], where it is increasingly practiced as body art, it would be done in more
sterile conditions or with more precautions against serious infection, and not as counter
irritation in people whose health were already seriously compromised. Branding in
western society, is also being described a behavior associated with higher levels of
substance use, sexual intercourse, smoking, marijuana use, suicidal ideation, and suicidal
and homicidal attempts, a careful assessment and discussion of these associated behaviors
and risks is an integral aspect in the proper management of these patients, as well.[12,13,14]
Conclusion
This article describes the complications of skin branding which still has therapeutic
implications in some cultural societies. Severe medical complications of skin branding
are worrisome and risk of complications prevail over the remuneration of these
procedures. Universal recognition of the complications of skin branding among both
patients and the physician community in particular is needed, as it will have crucial
implications in patient management, who seek branding for a variety of medical reasons
without modern medical resources.
Acknowledgment
We sincerely thankful to Professor Khalid Mahmood and Dr. Mahadi Abdullah for their
sincere intellectual thoughts and valuable guidance
No author has any conflict of interest for this research study.
Source of Funding: None
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Figure Legends
Fig 1: Distributed in a circular pattern on the abdomen are round, regularly shaped
symmetric necrotic ulcers with black eschar and on the right lower abdomen and
extending onto the proximal thigh was a large shallow ulcer with yellow crusting but no
frank purulence; all areas of skin breakdown produced by branding with a metal rod.
Fig 2: Patient with metastatic melanoma presented with multiple areas of branding over
the skin.