|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 5 | Page : 52-53
Deepak Vashisht1, Ivaturi Venkata Nagesh2, S Vashisht3
1 Department of Dermatology, 92 Base Hospital, c/o 56 APO, Srinagar, India
2 Department of Medicine, 92 Base Hospital, c/o 56 APO, Srinagar, India
3 Department of Physiologist, 92 Base Hospital, c/o 56 APO, Srinagar, India
|Date of Web Publication||13-Nov-2014|
Dr. Deepak Vashisht
Kishore Bhawan, Top Floor, The Mall, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Vashisht D, Nagesh IV, Vashisht S. Keraunographic tattoo. Indian Dermatol Online J 2014;5, Suppl S1:52-3
Lightning injuries are common but uncommonly reported even though it strikes the earth >100 times each second or 8 million times/day.  It has been an enigma since antiquity. The brilliance, power, and destructive capacity of lighting have made it the subject for religion, superstition, politics, and most recently, scientific investigation.
A 36-year-old male patient presented to the emergency department with history of a lightning strike about 8 h back. He was hiking in mountainous terrain in the open during evening hours. It started raining heavily, so he took shelter under a tree. He had an umbrella in his hand. Lightening flash initially struck the tree and later hit the patient. Patient had a brief period of unconsciousness and on regaining consciousness he felt pain in the upper limb.
Patient was confused and had bradycardia at the time of admission. Detailed examination including blood pressure, respiratory rate and systemic examination including ear and eye examination were normal. Dermatological examination revealed keraunographic markings, pathognomonic of lightning over the scapular region (left) [Figure 1]. He also suffered second-degree linear burns on the shin (right) due to rapid heating by electrical energy.
Complete blood count, urine analysis including myoglobinuria, cardiac enzyme tests, serial electrocardiography monitoring, liver enzymes, and serum electrolytes were all normal.
Patient was admitted and monitored for seven days. He was treated with analgesics for pain in the upper limb. Cutaneous lesions healed spontaneously in four days. He had an uneventful recovery after seven days.
Lightning is very common natural phenomenon and it strikes earth surface >100 times each second.  In spite of this lightning injuries largely go unreported as, they generally occur in rural or exposed environments than in the urban areas where, better lightning protection devices are in place and hence rare. Contrary to common belief these injuries are generally not fatal. The usual response of a lightning strike is to take shelter under a tree or a metallic roof and this tendency usually accounts for more number of casualties. Ritenour et al.  have described the following modes of injury by lightning:
- Direct strike: Usually fatal
- Contact injury: When the patient is touching some metal object struck by lightning
- Side flash: When lightning gets diverted from a nearby object
- Ground current: Lightning strikes directly at the ground and passes underneath to enter into patient's body
- Blast injury: Either caused directly resulting in tympanic membrane rupture or indirectly due to resultant falls.
Cutaneous involvement is in the form of linear, punctuate, and partial- or full-thickness burns; keraunographic markings, arborescent burns, feathering burns, also known as Lichtenberg's flowers are pathognomonic of lightning. These are not true burns as they are not caused due to the damage to the skin. Rather, they reflect extravasated red blood cells into the superficial layers of the skin from cutaneous capillaries secondary to the dielectric breakdown of the skin and subsequent massive electron shower. 
Skin biopsy from these lesions do not reveal any histologic change or damage, although pigment changes in the deeper layers of the skin may persist. , Lightning strikes generally do not result in severe burns; the extremely short duration of exposure to electrical current (0.0001-0.003 s) may prevent deep burns. 
Keraunographic markings do not require any treatment, nevertheless their presence necessitates detailed evaluation for other likely injuries of ear, eyes, blunt trauma including skull, vertebral, rib, and extremity fractures, myalgias and cardiac and neurologic complications. Lightning injuries are fatal in about 10% of its victims. 
Awareness of keraunographic markings would help the dermatologist to diagnose patients of lightning injuries who present in a confused and comatosed state and thus avoid therapeutic mismanagement.
| References|| |
Ritenour AE, Morton MJ, McManus JG, Barillo DJ, Cancio LC. Lightning injury: A review. Burns 2008;34:585-94.
O'Keefe Gatewood M, Zane RD. Lightning injuries. Emerg Med Clin North Am 2004;22:369-403.
Resnik BI, Wetli CV. Lichtenberg figures. Am J Forensic Med Pathol 1996;17:99-102.
Cherington M, Olson S, Yarnell PR. Lightning and Lichtenberg figures. Injury 2003;34:367-71.
Mistovich JJ, Krost WS, Limmer DD. Beyond the basics: Lightning-strike injuries. EMS Mag 2008;37:82-7.
Cherington M, Walker J, Boyson M, Glancy R, Hedegaard H, Clark S. Closing the gap on the actual numbers of lightning casualties and deaths. Eleventh Conference of Applied Climatology; 1999 January 10-15; Dallas. Boston: American Meteorological Society; 1999. p. 379-80.