Unilateral palmar and axillary hyperhidrosis post electrical flash burn

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1. Text A 31-year-old plumber sustained 5% partial thickness electric flash burn to his face, left and right hand. The points of entry were his right index and middle finger tips, with the exit point on his right thigh. This happened when he drilled into high voltage electric cables in a pit. On admission he had no evidence of any deep tissue injury and his creatine kinasewas 112 while his 12 lead ECG remained normal. The wounds on his right hand were subsequently debrided and skin grafted. Post operatively he had severe pain to his right hand. Physical examination revealed no cause for the pain. X-ray and CT scan of his hand showed no evidence of any bony injury or subluxation. Neurological examination was unremarkable. An indwelling axillary catheter was inserted for regional analgesia. He continued to have physiotherapy and splint to his hands. Two months after his discharge, on review at outpatients clinic, the function of his hands were noted to have improved despite pain in carpometacarpal area of the right index and middle fingers. He also developed significant right palmar and axillary hyperhidrosis and this was present at room temperature with only a T-shirt on. In order to demonstrate the hyperhidrosis of the right hand, we performed an iodine starch test by spraying both hands with dry iodine powder and subsequently placing both palms on plain starch paper. The distribution of the hyperhidrosis can clearly be seen more so on the right as compared to the left in Fig. 1. He had no relevant past medical or medication history. After 19 months, the hyperhidrosis persisted and he received botulinum toxin injections of 100 mU into his axilla, which produced symptomatic relief.