Page 16 - JSOM Summer 2019

Mottled, Blanching Skin Changes After Aggressive Diving

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Amanda M. Lau, MD *; Mickaila J. Johnston, MD ; Shayna C. Rivard, MD 3

ABSTRACT
The initial livedo skin changes of cutis marmorata, also known
as cutaneous decompression sickness (DCS), are transient in
nature. Accordingly, early images of violaceous skin changes
with variegated, marbled, or mottled appearance are rare, FIGURE 1 Cutis
whereas later images of deep, erythematous, or violaceous marmorata. Skin
skin changes are readily available. This case presents the op- changes on arrival at
portunity to view the early skin changes characteristic of cuta- the emergency room of
Chuuk State Hospital.
neous DCS, which would likely manifest at Level I care in the
setting of a diving injury during Special Operations missions in Source: Julius Caesar
austere environments. The unique diving context also allows G. Arsenal, MD (chief
an overview of DCS in addition to a review of skin eruptions surgeon, Chuuk State
associated with various marine life. As diving is frequently Hospital).
used by Naval Special Warfare, topics presented in this case
have significant relevance to Special Operations.

Keywords: skin; dermatology; cutis marmorata; cutaneous
decompression sickness

Introduction
Cutis marmorata is characterized by a dark red or purple FIGURE 2 Cutis marmorata.
rash with a netlike or reticular appearance. The affected skin Transient, reticulate, and
blanches with pressure and can be pruritic. The eruption can violaceous eruption.
spread peripherally and eventually becomes deeply erythema-
tous or violaceous. Cutis marmorata is one form of DCS and Source: Julius Caesar G. Arsenal,
can stand alone, but it is frequently associated with more se- MD (chief surgeon, Chuuk State
Hospital).
vere signs of DCS. It is treated with hyperbaric recompression
and supplemental oxygen. 1

Here we present a case of cutis marmorata in conjunction with
neurological symptoms in a 57-year-old man after aggressive
diving.

Case Presentation • First dive: maximum depth of 35 m for 50 minutes with
a 2.5-hour surface interval
A 57-year-old man presented with a mottled, violaceous rash • Second dive: maximum depth of 28 m for 24 minutes
over the anterior chest and abdomen 20 minutes after surfac- with a 50-minute surface interval
ing from a third scuba dive (Figures 1 and 2). • Third dive: maximum depth of 18 m for 30 minutes

He was diving in the Marianas with air. The following is his Based on US Navy Diving Tables, he owed over 300 minutes
dive profile: of decompression time.
*Correspondence to amanda.m.lau.mil@mail.mil; or lauam@as40.navy.mil
1 Dr Lau is an undersea medical officer/diving medical officer, United States Navy. Dr Johnston is an undersea medical officer/diving medical
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officer, United States Navy; Fellow of the American College Nuclear Medicine; and an associate professor at the Uniformed Services University
of the Health Sciences. Dr Rivard is an assistant professor in the Department of Dermatology of the Uniformed Services University of the Health
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Sciences.
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