A Case of Cellulitis Associated with Coral Injury: DISCUSSION

20 Feb
2011

Coral is an aquatic organism that belongs to the phylum Cnidari. It is composed of many calcified polyps that contain tentacles with venom-filled cells called nematocysts. There are two types of coral injuries: stings and lacerations. Of the two, stings are caused injected nematocysts which contain toxins like calcium carbonate and are generated from hard coral reef structures. The coral injuries occur most commonly on forearms, elbows, knees, and other areas unprotected by gloves or the diving suits which are used for sports diving and other marine-related activities. The initial responses of coral injuries including stinging pain, erythema, and swelling occur immediately to within several hours around the wound. These symptoms result from coral poisoning. Systemic symptoms such as low grade fever also may be present but do not necessarily indicate an infection.

Coral injuries can be complicated with foreign body reactions, localized eczematous reactions, and/ or secondary bacterial infections. Foreign body reactions, which result in granuloma formation, may occur because of retained bits of calcareous material and proteins from injected nematocysts. A delayed and persistent contact dermatitis has also been reported to occur following coral stings which occur off the eastern coastline of the Red Sea. In that report, the shiny and lichenoid coalescent papules with severe itching developed 3 weeks later after injuries which occurred to people who had a history of seafood allergy, atopic dermatitis, or previous contact with coelenterates. The delayed reactions to cnidarians stings are not uncommon and may occur 2 ~ 14 days after the occurrence of a sting injury. It usually presents as a erythematous papular or papulonodular eruption with severe itching at the same site of the stings. It takes several weeks to heal and may respond to topical or systemic steroids in combination with antihi- stamines. Injuries that occur in the marine en­vironment can be also infected with marine organisms such as Streptococcus species, Escherichia coli, Pseudomonas aeruginosa, Mycobacterium marinum, Staphylococcus aureus, Vibrio cholerae, Vibrio vul­nificus, or Vibrio parahemolyticus which are the most common pathogens isolated from seawater and marine wounds. Therefore, coral injury accom­panied with a secondary bacterial infection may lead to cellulitis with ulceration and tissue necrosis. As all the factors mentioned above are responsible for the slow healing of a coral injury, we need to deal with the appropriate management for each of them.
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In our case, no foreign body materials of his left ankle were found on physical and radiological examination. However, there were clinical and laboratory findings of cellulitis including redness, swelling, local heating, tenderness, and leukocytosis with neutrophilia and an elevated ESR. In addition, the histopathologic findings showed epidermal ne­crosis with diffuse infiltrate, composed mainly of neutrophils that extended throughout the dermis and into the subcutaneous fat. An initial outpatient therapy for secondary bacterial infection in the marine environment should be targeted against Vibrio species, which includes ciprofloxacin or tri- methoprim-sulfamethoxazole. In the case of in- patients, parenteral antibiotics appropriate for initial therapy include cefotaxime, ceftazidime, chloram- phenicol, gentamicin, and tobramicin. In our case, we treated him with cephalosporin in combination with systemic corticosteroids for 3 weeks. Although the erythema and pain were getting better, the swelling on the leg was not. We then replaced cephalosporin with levofloxacin, a quinolone de­rivative. As for local therapy, mupirocin ointment and topical corticosteroids were applied along with aspiration and saline wet dressing of vesicles.

According to previous reports, the complete healing period varies from 1 week to 15 weeks. It may be more delayed if a secondary infection or delayed hypersensitivity reaction occurred. In our case, the acute reaction accompanied with cellulitis began to subside slowly and we considered the possibility of a delayed reaction; we arranged for follow up observation. We report a case of cellulitis caused by a coral injury which revealed extensive epidermal necrosis with subepidermal blisters and neutrophilic panniculitis on histopathologic exami­nation.
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