Abstract
Decompression sickness and arterial gas embolism, collectively known as decompression illness (DCI), are serious medical conditions that can result from compressed gas diving. DCI can present with a wide range of physiologic and neurologic symptoms. In diving medicine, skin manifestations are usually described in general as cutis marmorata (CM). Mainly in the Anglo-American literature the terms cutis marmorata, livedo reticularis (LR), and livedo racemosa (LRC) are used interchangeably but actually describe pathophysiologically different phenomena. CM is a synonym for LR, which is a physiological and benign, livid circular discoloration with a net-like, symmetric, reversible, and uniform pattern. The decompression-associated skin discolorations, however, correspond to the pathological, irregular, broken netlike pattern of LRC. Unlike in diving medicine, in clinical medicine/dermatology the pathology of livedo racemosa is well described as a thrombotic/embolic occlusion of arteries. This concept of arterial occlusion suggests that the decompression-associated livedo racemosa may be also caused by arterial gas embolism. Recent studies have shown a high correlation of cardiac right/left (R/L) shunts with arterial gas embolism and skin bends in divers with unexplained DCI. To further investigate this hypothesis, a retrospective analysis was undertaken in a population of Austrian, Swiss, and German divers. The R/L shunt screening results of 18 divers who suffered from an unexplained decompression illness (DCI) and presented with livedo racemosa were retrospectively analyzed. All of the divers were diagnosed with a R/L shunt, 83% with a cardiac shunt [patent foramen ovale (PFO)/atrium septum defect (ASD)], and 17% with a non-cardiac shunt. We therefore not only confirm this hypothesis but when using appropriate echocardiographic techniques even found a 100% match between skin lesions and R/L shunt. In conclusion, in diving medicine the term cutis marmorata/livedo reticularis is used incorrectly for describing the actual pathology of livedo racemosa. Moreover, this pathology could be a good explanation for the high correlation of livedo racemosa with cardiac and non-cardiac right/left shunts in divers without omission of decompression procedures.
Highlights
Decompression illness (DCI) is caused by bubble formation from dissolved inert gas during or after a compressed gas dive
American publications and textbooks still use the terms synonymously. This confusion is more evident in clinical diving medicine, where cutis marmorata/livedo reticularis is the term commonly used to describe the pathology of livedo racemosa
Since the pathomechanism of livedo reticularis (LR) and livedo racemosa (LRC) is fundamentally different, this is true for the pathomechanism of diving-related “cutis marmorata.”
Summary
Decompression illness (DCI) is caused by bubble formation from dissolved inert gas during or after a compressed gas dive. These bubbles may form as a result of supersaturation of a tissue in relation to the ambient pressure. Hitherto one of the most common types has been termed cutis marmorata in the literature, a nonspecific, erythematous macular eruption, occasionally with itching or painful cutaneous red-bluish discoloration. This rash is often followed by onset of neurological symptoms and is mostly associated with a R/L shunt like a patent foramen ovale (PFO) of the heart (Germonpré et al, 1998). This is not correct as livedo reticularis and livedo racemosa are clinically and pathophysiologically totally different entities
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