A 23-year-old man presented with an erythe- matous edematous patch with centrally grouped vesicles on the left ankle (Fig. 1). The skin lesion occurred following a coral injury while he was skin-scuba diving at the island of Hinan, China 2 days prior to his presentation. This was associated with stinging pain and mild itching. He stated that the accident had occurred near the coral reef and at the time, he had felt stinging pain on his left ankle which was not covered by the diving suit. On physical examination, there were no remarkable findings including a normal body temperature except for the skin lesion. His past medical history was not significant. Histopathologic findings re¬vealed the extensive epidermal necrosis with subepidemal blisters and neutrophils in the blister cavity (Fig. 2) and interstitial, perivascular and periadnexal inflammatory cell infiltration throughout the dermis (Fig. 3). There was also panniculitis predominantly infiltrated with neutrophils and some eosinophils and lymphohistiocytes without the evid¬ence of foreign body granulomas (Fig. 4). Radio logical examination of his left ankle showed nonspecific findings and no foreign body materials, and laboratory testing showed only leukocytosis including neutrophilia with a mildly elevated ESR. We did not perform a bacterial culture and sensitivity test.
Fig. 1. Erythematous edematous patch with central grouped vesicles on the left ankle.
Fig. 2. (A) Histopathologic findings show extensive epi-dermal necrosis with subepi-dermal blisters (H&E, x10). (B) There are some neutro-phils within the blister cavity (H&E, x20).
Because his vaccination history was uncertain, we gave him an anti-tetanus immunoglobulin injection and treated him with systemic steroids in combination with antibiotics (a 1st generation cephalosporin for 1 week and a 3rd generation cephalosporin for the following 2 weeks). For local therapy, we applied mupirocin ointment and a topical steroid cream. After 3 days of treatment, the pain and erythema were both improved but the swelling on the left lower leg was still present. So we changed the antibiotic regimen to levofloxacin for 7 days; afterwards, his symptoms began to resolve slowly. We have observed him for 5 months and his skin lesion is almost completely resolved without any signs of delayed hypersensitivity reactions. cialis canadian pharmacy
Fig. 3. Mild to moderate interstitial, perivascular, and periadnexal inflammatory cell infiltrate of neurophils in the dermis (H&E, x10).
Fig. 4. Panniculitis mainly infiltrated with neutrophils, some eosinophils, and lymphohistiocytes (H&E, x10).