JEADV
LETTER TO THE EDITOR
Pseudoaneurysm following a
freshwater stingray injury
Editor
Complications of aquatic envenomations can pose clinical challenges to dermatologists.1 We report here a rare, potentially
threatening complication of a stingray stabbing.
A 48-year-old man, born in Brazil and working as a fisherman
along the Oyapock river, was referred to our Dermatology
Department for a painful swelling of the right forearm, associated
with fever for 2 days. He had been stabbed by a stingray 3 months
earlier on this very area, as he was retrieving fish from his nets
along a small tributary river of the Oyapock. He had then come to
the Emergency Department where he was treated with corticosteroids, analgesics and antibiotics. The wound healed completely
within a week, but a swelling had then appeared and kept increasing until a 6-cm-wide mass was observable (Fig. 1a,b). An infectious cause was initially feared, and a skin biopsy contemplated.
However, a proper physical examination reported a palpable thrill
and audible heart sound in the swelling. A Doppler ultrasound
was then performed, which identified a breach in the wall of the
radial artery, an extravasation of blood, and a typical waveform of
pseudoaneurysm, positive during the systole and negative in diastole (Fig. 1c). On the second day of hospitalization, the patient
complained of dysesthesia in the radial area. Surgery was then
deemed necessary, and the patient underwent incision and arterial
ligation. At 1-month follow-up, the patient had completely
healed.
In the Brazilian Amazon, stingrays of the Potamotrygonidae
family are the most frequent agents of animal-induced aquatic
injuries.2 A picture of a Potamotrygon hystrix is presented in
Figure 2, with its tail and stinger. Most injuries happen during
the dry season, usually on sandy terrains bordering muddy
waters.2 Fishermen are the most exposed profession. The first
symptoms include intense pain and local oedema.2,3 As treatment, most authors agree that hot water immersion is useful by
its activity against thermolabile venoms and vasodilatation.4
Our patient did not benefit from immersion in hot water when
he was seen in the Emergency Department and was given corticosteroids, which have no indication in stingray injury. This
report underlines the importance of improving awareness and
knowledge of this condition in doctors practicing in tropical
areas. Ulcers can appear in late stages of stingray injuries.2
Among the complications, tetanus,5 skin infections2,4 and
necrosis have been reported. Severe presentations are usually
caused by thoracic, spinal or neck trauma.6 However, to date,
JEADV 2019
this observation is the first report of pseudoaneurysm complicating a stingray injury.
False aneurysms are typically caused by vessel trauma, with
a wall disruption and extravasation of blood in an extraluminal region.7 Pseudoaneurysms are frequent consequences
of vascular procedure such as angioplasty8 and can be identified by certain ultrasound features such as ‘to-and-fro’ waveform.8 In this observation, the stinger probably caused an
arterial trauma 3 months earlier, which initially healed but
induced the formation of false aneurysm. Though an
Figure 1 Clinical aspect of a thrilling nodule of the right arm (a)
and a scar indicating the location of the sting (b); doppler ultrasonography showing a ‘to-and-fro’ waveform aspect, typical of
pseudo aneurysm (c).
© 2019 European Academy of Dermatology and Venereology
Letter to the Editor
2
R. Blaizot,1,2,*
G.Desrousseaux,3 M.-P. Joly,3 A. Vie,4
5
,1
X. Lu, A. Senchyna,4 K. Oganov,6 C. Marty,7 H. Cisse
P. Couppie1,2
e Rosemon Hospital, Cayenne,
Department of Dermatology, Andre
mes Amazoniens et Pathologies
French Guiana, 2EA 3593, Ecosyste
Tropicales, University of French Guiana, Cayenne, French Guiana,
3
e Rosemon Hospital, Cayenne,
Department of Vascular Medicine, Andre
French Guiana, 4Department of General Medicine, University of French
West Indies, Pointe-
a-Pitre, Guadeloupe, 5Department of Orthopaedics,
Andr
ee Rosemon Hospital, Cayenne, French Guiana, 6Department of
e Rosemon Hospital, Cayenne, French
Emergency Medicine, Andre
Guiana, 7French Red Cross, Cayenne, French Guiana
*Correspondence: R. Blaizot. E-mail: Blaizot.romain@gmail.com
1
References
Figure 2 Potamotrygon hystrix laying on the sand of a small river
of French Guiana: the stinger on the tail is clearly visible.
endovascular approach would be preferred in case of visceral
localization, surgery remains the first-line treatment in case of
radial pseudoaneurysm8 and was justified given the continuously increasing size of the lesion.
Though a pseudoaneurysm is not a dermatologic disorder
stricto sensu, this observation shows how such patients can be
referred to dermatologists, who must be familiar with this
aspect. Dermatologists should particularly bear in mind the
possibility of pseudoaneurysm after a stingray stabbing, or
other aquatic envenomations involving large stings. When
faced with a swollen mass in a vascular area, dermatologists
should look for a thrill to avoid performing a dangerous skin
biopsy on a vascular lesion. Echography and Doppler ultrasonography are cheap and non-invasive tools, which can
establish the diagnosis.
JEADV 2019
1 Haddad V, Lupi O, Lonza JP, Tyring SK. Tropical dermatology: marine
and aquatic dermatology. J Am Acad Dermatol 2009; 61: 733–750; quiz
751–2.
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3 Haddad V, Neto DG, de Paula Neto JB, de Luna Marques FP, Barbaro KC.
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DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005; 25(Suppl 1):
S173–S189.
8 Mahmoud MZ, Al-Saadi M, Abuderman A et al. “To-and-fro” waveform in
the diagnosis of arterial pseudoaneurysms. World J Radiol 2015; 7: 89–99.
DOI: 10.1111/jdv.15648
© 2019 European Academy of Dermatology and Venereology