Case Reports
Don’t Get Hung Up on Fishhooks: A Guide to Fishhook Removal
In the sport of fishing, barbed fishhooks often are used for their effectiveness in maintaining the fish on the hook once it is caught.
Sea urchin injuries are commonly seen in coastal regions near both warm and cold salt water with frequent recreational water activities or fishing. Sea urchins belong to the class Echinoidea with approximately 600 species, of which roughly 80 are poisonous to humans.1,2 When a human comes in contact with a sea urchin, the spines of the sea urchin (made of calcium carbonate) can penetrate the skin and break off from the sea urchin, becoming embedded in the skin. Injuries from sea urchin spines are most commonly seen on the hands and feet, as the likelihood of contact with a sea urchin is greater on these sites. The severity of sea urchin spine injuries can vary widely, from minimal local trauma and pain to arthritis, synovitis, and occasionally systemic illness.1,3 It is important to recognize the wide variety of responses to sea urchin spine injuries and the impact of prompt treatment. Many published reports on injuries from sea urchin spines describe arthritis and synovitis from spines in the joints.1,2,4-6 Fewer reports discuss nonjoint injuries and the dermatologic aspects of sea urchin spine injuries.3,7,8 We pre-sent a case of a patient with a puncture injury from sea urchin spines that resulted in painful granulomas.
Case Report
A 29-year-old otherwise healthy man was referred to our dermatology clinic by the university student health center due to continued pain in the right thigh. Five weeks prior to presentation to the student health center, the patient had fallen on a sea urchin while snorkeling in Hawaii. Sea urchin spines became lodged in the right thigh, some of which were removed in a local medical clinic in Hawaii. He was given oral antibiotics prior to his return home. A plain film radiograph of the affected area ordered by the student health center showed several punctate and linear densities in the lateral aspect of the right mid thigh (Figure 1). These findings were consistent with sea urchin spines within the superficial soft tissues of the lateral thigh.
Figure 1. Anteroposterior radiograph of the right femur showed sea urchin spines embedded in the skin (circled).
At the time of presentation to our dermatology clinic, the patient reported sharp intermittent pain localized to the right thigh. The patient denied any fever, chills, or pain in the joints. On physical examination, there were several firm nodules on the right thigh, ranging from 4 to 20 mm in diameter (Figure 2). The nodules were tender to palpation with some surrounding edema. Drainage was not noted. Several scars were visible at sites of the original puncture injuries and removal of the spines.
Figure 2. Several firm nodules (4–20 mm) were noted on the right lateral mid thigh.
Two 6-mm punch biopsies were performed on representative nodules on the right thigh for histopathologic examination. Along with the biopsy tissue, firm, brown-black, linear foreign bodies consistent with sea urchin spines were extracted with forceps (Figure 3). Histopathologic examination revealed a dense, diffuse, mixed inflammatory cell infiltrate in the dermis predominantly composed of lymphocytes, histiocytes, and numerous eosinophils. Proliferation of small vessels was noted. In one of the biopsies, small fragments of necrotic tissue were present. These findings were consistent with granulomatous inflammation and granulation tissue due to a foreign body.
Figure 3. Extracted sea urchin spines.
At the time of suture removal 2 weeks later, the biopsied areas were well healed with minimal erythema. The patient reported decreased pain in the involved areas. He was not seen in clinic again due to resolution of the nodules and associated pain.
