Page 18 - JSOM Summer 2019

Most cases of DCS will present within 12 hours of surfacing treatment consists of nematocyst removal from the skin and
from a dive, with more than 90% presenting within 24 hours. then cleansing and debridement with soap and seawater. A de-
8
More than 80% of neurological DCS will present within 1 layed type IV hypersensitivity reaction may occur days to weeks
hour and thus will be likely to be encountered early in the after exposure and present with erythematous macules, plaques,
echelons of care. DCS is treated with hyperbaric recompres- or papules in the distribution of fire coral contact. Treatment
sion and supplemental oxygen. Protocols for treatment are is supportive and includes topical steroids and antihistamines. 9
1
specified in the United States Navy Dive Manual, Revision 7.
2
Surface oxygen suffices for initial treatment if a hyperbaric Portuguese men-of-war inhabit waters of the Atlantic and the
chamber is not available. 1 Indo-Pacific. They have blue, gas-filled bladders and long ten-
tacles. Envenomation by a Portuguese man-of-war can result
10
TABLE 1 Type I DCS in an immediate type I reaction, caused by toxic action or al-
Condition Characteristics lergic action, or result in a delayed type IV reaction, caused
Dull, aching joint pain unaffected by movement by allergic action. Toxic action-induced immediate reaction
Musculoskeletal or rest can result in a linear, erythematous, papular eruption, which
Cutis marmorata – violaceous skin changes with can progress to development of vesicles and necrosis. In se-
Cutaneous marbled or mottled appearance, blanches with vere cases of envenomation by a Portuguese man-of-war, toxic
pressure action-induced immediate reaction can include systemic man-
Painful localized area of swelling involving lymph ifestations to include cardiopulmonary shock, which would
Lymphatic
nodes and contiguous areas warrant resuscitative measures. Allergic action-induced imme-
diate reaction results in anaphylaxis or angioedema, both of
TABLE 2 Type II DCS which are treated with intramuscular epinephrine and intra-
Condition Characteristics venous steroids. Delayed allergic reactions include persistent
Pain on inspiration or expiration, cough, substernal vesicular, urticarial, or eczema-like lesions 48 hours after en-
Pulmonary venomation, development of the latter lesions at sites distant
discomfort
Peripheral – weakness or paresthesia in single nerve from initial envenomation, and cycles of recurrent cutane-
distribution ous reactions after resolution. Delayed allergic reactions are
Spinal cord (central nervous system) – multicord level treated supportively with antihistamines and corticosteroids. 11
weakness or multifocal, nondermatomal paresthesia
Cerebral – mental status changes, facial weakness, In summary, cutis marmorata is one form of type I DCS and
Neurologic
diplopia, hearing loss, hemiparesis, monoparesis, loss is often associated with or precedes more severe signs of DCS.
of coordination It is actual pathology that Special Operators are at risk of
Vestibular – vertigo, tinnitus, hearing loss, nystagmus while training for and conducting missions in the undersea en-
Ocular – visual field defects, diplopia, scotoma, ocular vironment, even when complying with safe diving standards.
muscle impairment, convergence insufficiency As a harbinger of potential DCS progression, recognition and
prompt treatment of cutis marmorata by Special Operators are
Skin rashes occur frequently after diving. However, it is im- of clinical significance.
portant to distinguish cutis marmorata as it is often associated
with or may prelude additional severe signs and symptoms of Acknowledgments
DCS. The differential diagnosis includes itching and mild ur- We thank Julius Caesar G. Arsenal, MD, chief surgeon at
6
ticaria, lymphatic DCS, fire coral dermatitis, and Portuguese Chuuk State Hospital, for initial stabilization and treatment
man-of-war envenomation. of the patient until transport to Guam could be arranged. We
also thank him for photo contributions.
Itching and mild urticaria may present after diving. It is typi-
cally more common with hyperbaric chamber dives. Urticarial Funding Sources
lesions are erythematous and blanche with pressure, but the None.
main distinction from cutis marmorata is papular quality and
elevation. Urticaria is not considered DCS and does not need Financial Disclosure
to be treated with recompression. 1 The authors have no financial relationships relevant to this
article to disclose.
Lymphatic DCS is rare. It typically presents with localized
swelling and involves contingent lymph nodes. It is associated Author Contributions
with severe pain. Areas affected can include the face, breast, AL is the first author. MJ and SR made substantial contribu-
abdomen, and extremities. The treatment is recompression. 1 tions to structuring the article, revising the article, and approv-
ing the final version.
Fire coral dermatitis is caused by contact with fire coral, which
are reef-colonizing organisms found in subtropical and tropi- References
cal waters. Their appearance varies with environment, but they 1. Bove AA, Davis JC. Bove and Davis’ Diving Medicine. Philadel-
generally have branching structure and range from yellow-green phia, PA: The Curtis Center; 2004.
to brown in color. Dermatitis caused by fire coral is seen mainly 2. US Navy Diving Manual. Revision 7 (2016);5:894.
in scuba divers. Fire coral have nematocysts in their tentacles 3. Johes A, Walling H. Retiform purpura in plaques: a morphological
7
that release toxins, which provoke cutaneous changes that may approach to diagnosis. Clin Exp Dermatol. 2007;32(5).
appear ulcerated, eczema-like, vesicular, or urticarial. Diagno- 4. Nord DA, Denoble PJ, Chimiak JM. DAN Annual Diving Report
2017 Edition: A Report on 2015 Diving Fatalities, Injuries, and
sis is aided by history and often concurrent systemic symptoms Incidents. Section 2, Diving Injuries. Durham, NC: Divers Alert
to include malaise, fever, nausea, and abdominal pain. Initial Network; 2017.

16 | JSOM Volume 19, Edition 2 / Summer 2019