Volume 61, Issue 1 , Pages 111-113, January 2008
Lichtenberg figures: cutaneous manifestation of phone electrocution from lightning☆
Article Outline
Summary
Introduction
Lichtenberg figures are reddish, fern-like patterns that appear on the skin when a patient is struck by lightning. These appear to be a result of an inflammatory response as current spreads out causing ionisation and heat effects and damage to the small subcutaneous capillaries.
Case report
A 30-year-old lady was brought to the accident and emergency department with a history of momentary loss of consciousness. All that the patient could recollect was that she had been on the phone when she heard a loud bang following which she ‘blacked out’. On examination, she had characteristic cutaneous Lichtenberg figures. These revealed the true diagnosis of a lightning strike conducted through the phone line into the patient.
Discussion
The cutaneous manifestation of a surreptitious lightning strike through a telephone plays an important role in diagnosing the problem and is particularly significant when the patient is unconscious and unable to give a history of events or, as in this case, has retrograde amnesia. Establishing the diagnosis enables us to look for other lightning-associated injuries and to monitor the cardiac status of the patient to avoid any concomitant complications. Also, establishing the diagnosis is extremely helpful to allay patient anxiety as Lichtenberg figures on the skin can be quite dramatic, as seen in this case.
Keywords: Lichtenberg figures, Telephone lightning injuries
Case report
A 30-year-old lady was brought to our accident and emergency department with a history of momentary loss of consciousness. On arrival, the patient was fully conscious with a Glasgow coma scale of 15. She was complaining of a headache and tinnitus in her right ear. She also had paraesthesia on the right side of her face, neck, chest, both hands and right leg. She was very anxious and was experiencing palpitations. All that the patient could recollect was that she had been on the phone when she heard a loud bang following which she ‘blacked out’. When she regained consciousness, she found herself lying on the floor, a few feet away from the telephone. She felt a burning sensation and paraesthesia, mainly on the right side of her body. The burning sensation had resolved by the time she had presented to us, 1
h after the incident.
The weather had been quite stormy on the day and on inspection of the patient, there were characteristic erythematous Lichtenberg figures on the right side of her neck, chest, abdomen, both upper limbs and right lower limb (Figure 1, Figure 2). These revealed the true diagnosis of a lightning strike conducted through the phone line into the patient.
Figure 1
Characteristic Lichtenberg figures seen on the right side of the neck, chest, abdomen and both upper limbs.
Figure 2
Lichtenberg figures on (A) left upper limb, (B) right upper limb and (C) right lower limb.
The patient was found to have an increased respiratory rate and pulse rate. An electrocardiogram examination showed no evidence of arrhythmia. Neurological examination was normal with full power in all the limbs. There was no evidence of an exit burn wound. Examination of the ears showed a perforation in the right tympanic membrane and tests confirmed a sensorineural deafness on that side. Examination of the eyes was normal. The patient had no other associated injuries. She was admitted for observation and discharged the following day. The Lichtenberg figures resolved within 24h. She was quite traumatised by the event and received psychiatric care as she was emotionally very labile. The perforated tympanum healed with conservative management in a few weeks and the patient had some degree of residual sensorineural deafness at her 6 month follow up.
Discussion
Injury from a lightning strike can occur either by a direct strike, side splash (when lightning splashes on to some one standing close to an object struck by lightning) or by step voltage (when current flowing in the ground, following a lightning strike, goes up one leg and conducts back down the other!).1 Cutaneous manifestations range from simple Lichtenberg figures to full thickness burns. Lichtenberg figures are fern-like patterns due to high voltage discharges, first described by the German physicist Georg Christoph Lichtenberg in the late 1700s.2 These are said to occur due to an inflammatory response as current spreads out causing ionisation and heat effects.3 Injury to the subcutaneous capillaries is thought to occur. These signs generally resolve within 24h but can occasionally be associated with deep pigmentation. Depending on the amperage of the current passing through, the patient may have mild effects such as paraesthesia at low amperages, which can progress to tetany, respiratory arrest or cardiac arrest following ventricular fibrillations at higher amperage.4 A direct lightning strike can expose the patient to currents ranging from 3 kA to over 100 kA.5 When the current passes through the body, the pathway of least resistance appears to be the tympanic membrane and often the tympanic membrane is found to be ruptured.6 Damage to the middle ear may result in the patient experiencing tinnitus, ataxia, vertigo and nystagmus. Visual loss can occur for varying durations, occasionally from formation of cataracts. Injuries to the central nervous system can result in haemorrhage, infarction, oedema and necrosis of the brain leading to motor and sensory dysfunction and delayed progressive neurological damage.7 Charcot's paralysis or keraunoparalysis, which is characteristic of lightning injuries, can affect all the limbs temporarily and resolves gradually.8 Depending on the degree of the assault, patients may suffer from retrograde amnesia, confusion, anxiety, and psychotic behaviour, often needing psychiatric help.
However, indirect lightning injuries through the telephone tend to be more subtle and are caused by currents of 3 to 5 kA.5 Patients tend to experience either an electrical shock, acoustic shock or a mixture of both. Irrespective of the strength of the current, characteristic Lichtenberg figures on the skin are pathognomonic of a lightning strike. In addition, superficial burns may be seen if the patient had been in contact with an earthed object such as a refrigerator or radiator. Although palpitations and breathing impairment can occur, cardiac or respiratory arrest and death do not seem to occur.5 The middle ear and eyes can be affected as mentioned above in a direct strike. Although severe injury to the brain does not occur, paraesthesia, burning sensation and local weakness can occur, lasting for varying durations of time. Similarly, although extreme psychiatric upset is not seen, patients are often extremely anxious, may be depressed and emotionally labile.
The cutaneous manifestation of a surreptitious lightning strike through a telephone plays an important role in diagnosing the problem when a patient is brought into the emergency department. This is particularly significant when the patient is unconscious and unable to give a history of events or, as in this case, has retrograde amnesia. Establishing the diagnosis enables us to look for other lightning-associated injuries and to monitor the cardiac status of the patient to avoid any concomitant complications. Also, establishing the diagnosis is extremely helpful to allay patient anxiety as Lichtenberg figures on the skin can be quite dramatic, as seen in this case.
References
- . Lightning accident with eight victims: case report and brief review of the literature. J Trauma. 1996;40:288–290
- Lichtenberg G. Super nova methodo motum ac naturam fluidi electrici investigandi. Gottingen; 1778.
- . Telephone-related lightning injury. Med J Aust. 1986;144:706–709
- . Lightning strikes at a mass gathering. South Med J. 1999;92:708–710
- . Telephone-mediated lightning injury: an Australian survey. J Trauma. 1989;29:665–671
- The lightning-damaged ear. Arch Otolaryngol. 1974;100:117–121
- . Neurologic manifestations of lightning strikes. Neurology. 2003;60:182–185
- . Keraunoparalysis, a ‘specific’ lightning injury. Burns Incl Therm Inj. 1985;12:54–57
☆ This case has been accepted for presentation at the British Association of Plastic, Reconstructive and Aesthetic Surgery, December 2006 (Poster presentation).
PII: S1748-6815(07)00349-X
doi:10.1016/j.bjps.2007.06.020
© 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 61, Issue 1 , Pages 111-113, January 2008
