A 32 year old park ranger in a renowned Staten Island quagmire presents to your ED on a fine November eve complaining of pain, itching and swelling of her ears and hands.
It’s been cold for a few weeks now, but it hasn’t gone below freezing.
Your patient tells you that she has been working in the humid cold air of her boggy paradise for prolonged hours in the past 3 days. She states that initially her symptoms started with itching, but progressed to erythema and edema about 12 hours later.
She states that she now feels numbness, burning and itching, and that after rewarming her ears and hands she noticed blue nodules on her skin.
Physical exam reveals the hands below. No skin breakdown. Neuro exam reveals decreased sensation to fine touch in both hands.
Her hands look like this:
What type of environmental injury does this patient have? (frostbite, trench foot, chilblains, panniculitis, parsnip or trench mouth). Chilblains (good guess): – Mild, uncomfortable inflammatory condition. – Long-term intermittent exposure to damp, nonfreezing ambient temperatures. – The most common areas affected by chilblains are the hands, ears, lower legs, and feet. – Skin lesions occur ~12h after symptoms begin. – Treatment: Supportive. Warm area and avoid exposure. For more severe cases, some physicians use topical corticosteroids. For refractory cases, one can also use nifedipine, as it has been shown to have some benefit in one small RCT. Non freezing injuries: ~ Chilblains: above ~ Panniculitis: Mild degree of necrosis of subcutaneous fat (mostly seen in children and “women involved in equestrian activities”. Adipose fibrosis and cosmetic defects may occur with resolution. ~ Trench Foot: Direct soft tissue injury caused by direct cooling and accelerated by wet conditions. Mostly seen in military. Early tingling and numbness progresses to pale, mottled, anesthetic, pulseless and immobile foot. After warming, hyperemia ensues within 2-3 days, with erythema and edema and possible bullae. Anesthesia, hyperhydrosis and cold sensitivity can be long term complications. ~ Cold urticaria: Type I hypersensitivity to cold. Treat with antihistamines. Freezing injury: 
Frostbite:
How were 0˚ and 100˚ determined in the Fahrenheit temperature scale? 0˚: Originally the coldest day measured in Mr. Fahrenheit’s hometown of Danzig in 1708/09. It was later changed to the coldest temperature that brine can be cooled to. 100˚: The average temperature of the human body as calibrated by…. horse blood. Yes, horse blood. “Unscientific” you are thinking? I didn’t say it. It was created by Daniel Gabriel Fahrenheit and is only used in the US, Bahamas, Belize, the Cayman Islands and Palau. It is the bane of the existence of many immigrants to the US. N.B. Fahrenheit was friends with Herman Boerhaave of the famed Boerhaave Syndrome (esophageal rupture secondary to vomiting).
References: (1) 1 – Tintinalli, Judith E., and J. Stephan. Stapczynski. “202 – Frostbite and other localized cold injuries”.”Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill, 2011. N. pag. Print. (2) Uptodate.com: Chilblain. (3) Rustin, M.h.a., Julia A. Newton, N.p. Smith, and Pauline M. Dowd. “The Treatment of Chilblains with Nifedipine: The Results of a Pilot Study, a Double-blind Placebo-controlled Randomized Study and a Long-term Open Trial.” British Journal of Dermatology 120.2 (1989): 267-75. Web (4) Wikipedia: “Fahrenheit Scale”. Written by Itamar Goldstein MD Special thanks to Dr. James Willis for his guidance.
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