Lightning strike‑induced cauda equina syndrome: a case report

Peripheral nerve injuries after being struck by lightning have been documented. Here, we report a case of cauda equina syndrome induced by lightning. A 27-year-old man presented with numbness, a burning sensation in the saddle region, and increased urinary urgency after being struck by lightning. He had absent Achilles reflexes and paresthesia in the saddle region upon neurological examination, and magnetic resonance imaging of the spine was normal. Electrophysiological studies indicated involvement of bilateral L5, S1, and S2 myotomes and revealed cauda equina lesions. 
Peripheral nerve injury induced by lightning is rare, and the evaluation of people with neurological complaints using electromyography will help determine the true incidence.

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Lichtenberg figures-morphological findings

Following a witnessed lethal lightning strike of an adult male who was standing outside in a storm, numerous Lichtenberg figures were identified upon external examination of the body. Sectioning across multiple areas of linear erythema in the figures showed no subcutaneous hemorrhage. This was later confirmed on histology which showed only subtle dermal capillary dilatation with no interstitial hemorrhage or inflammation in these areas. The only areas of interstitial hemorrhage were present in adjacent scattered punctate burns from arcing. The documented resolution of Lichtenberg figures within hours would be more in keeping with temporary functional capillary dilatation, shown in this case, rather than with tissue alteration by interstitial hemorrhage or inflammation.

[Lightnings--danger while practising sport]

Certain kinds of sporting disciplines are connected with a high risk of the lightning strike. Although most injuries are non-fatal, the transient or permanent damages of the nervous and ciruculatory systems or other internal organs are common. The concomitant psychological trauma may also be crucial. Various cases could be avoided by following simple safety rules. Wide educational programmes how to act during the stormy weather and elaboration of "stormy guidelines" should concern both sportsmen and people responsible for events safety.

[A case of fatal lightning stroke at an unusual site--the city center]

A case of a fatal lighting stroke involving a young man staying in a storm near the center of a big city is presented. The atypical character of this case lies in the fact that the lightning stroke usually occurs in open areas (mountains, fields, meadows), or involves people trying to find shelter from the storm under a tree or an isolated object in an open area. In the described case, a contributory factor to the lightning stroke was the fact that during the storm, the man was most probably standing on metal heating pipes, built in the 70's and 80's, long stretches of which were erected high above the ground. Metal used in the construction of the pipes most probably attracted lightning and generated the current which electrocuted the man standing on their surface.

[Cataract after lightning injury--case report]

Lightning injuries are dangerous and often deadly trauma. We present a case of 41 year old woman who suffered an indirect lightning injury, dropping into unconsciousness followed by amnesia. Initial irritation of her left eyeball was followed by subtle changes in retinal pigment epithelium without any drop in visual acuity for a period of three months. Subsequently there began a slow deterioration of visual acuity and progression of cataract causing BCVA to drop to 5/50. Patient underwent uncomplicated cataract phacoemulsification with IOL implantation which resulted in restoring BCVA to 5/5 postoperatively. Such cases are scarce in literature.

Lichtenberg figures and lightning: case reports and review of the literature

The Lichtenberg figure (LF) is a recognizable skin pattern that is only seen in individuals struck by lightning. LF, also known as a ferning pattern, is a transient finding. It is not a burn, and biopsies of the skin reveal no pathologic changes. We present 3 case reports of patients who presented with LF after being struck by lightning. The explanation of what LF represents remains unknown. Many researchers believe that LFs are fractal patterns and do not correspond to known vascular or neuroanatomic patterns. We present our ideas on possible mechanisms of the pathophysiology of LFs.

Lichtenberg figures: cutaneous manifestation of phone electrocution from lightning

INTRODUCTION

Lichtenberg figures are reddish, fern-like patterns that appear on the skin when a patient is struck by lightning. These appear to be a result of an inflammatory response as current spreads out causing ionisation and heat effects and damage to the small subcutaneous capillaries.

CASE REPORT

A 30-year-old lady was brought to the accident and emergency department with a history of momentary loss of consciousness. All that the patient could recollect was that she had been on the phone when she heard a loud bang following which she 'blacked out'. On examination, she had characteristic cutaneous Lichtenberg figures. These revealed the true diagnosis of a lightning strike conducted through the phone line into the patient.

DISCUSSION

The cutaneous manifestation of a surreptitious lightning strike through a telephone plays an important role in diagnosing the problem and is particularly significant when the patient is unconscious and unable to give a history of events or, as in this case, has retrograde amnesia. Establishing the diagnosis enables us to look for other lightning-associated injuries and to monitor the cardiac status of the patient to avoid any concomitant complications. Also, establishing the diagnosis is extremely helpful to allay patient anxiety as Lichtenberg figures on the skin can be quite dramatic, as seen in this case.

Bilateral macular cyst after lightning visualized with optical coherence tomography

The authors report a 14-year-old girl who was struck by lightning with bilateral macular cyst that was diagnosed with optical coherence tomography (OCT). Her fundus examination revealed bilateral macular lesions that simulated macular holes. The Watzke-Allen sign was negative in the right eye and positive in the left eye. Fluorescein angiography showed a foveal window defect in both eyes. OCT demonstrated a small foveal cyst evident as a hyporeflective lucency, visible just anterior to the retinal pigment epithelium/choriocapillaris complex in both eyes. OCT seems to be useful in the evaluation of lighting maculopathy to rule-out full-thickness macular hole in these cases, and avoid unnecessary surgery.

Dramatic lightning injury with exit wound

This is a case report of an environmental accident due to lightning where one school boy sustained current, blast, and flame effects of it. A bolt of lightning directly struck the pole of a football ground and the scatter struck the child. In addition to burn injuries, he showed an exit wound of lightning in left foot. The exit wound of lightning current is a very rare finding. The body of victim had flame and heat effect of atmospheric electricity on head and neck, face, and trunk. In this incidence of lightning other team mates of the victim were safe. The patient survived the attack.

Notfallmedizinische Versorgung von Blitz- und Stromschlagverletzungen

The pattern of injuries following electrical accidents and the treatment by emergency teams differ depending on whether exposure was to a low-voltage or high-voltage power source or to a lightning bolt. Tissue damage results from the direct effect of current on cell membranes and from conversion of electrical energy into heat. Depending on the magnitude of electrical energy and the duration of exposure, cardiac dysrhythmia, damage to nerve tissue, extensive burns and shock may occur. Multi-system injury is frequently observed, either directly related to electrical shock or secondary to concurrent trauma. Extrication of victims from the energy field must be performed under strict observance of self-protection measures for the rescuers. In high-voltage incidents the rescuers must wait at a distance until the power supply has been turned off and demonstrably grounded. Analgesia, anxiolysis and administration of crystalloid fluids are needed, especially for injuries from high-voltage power sources. Severe burns of the face and neck call for early intubation and ventilation. Monitoring is performed with pulsoximetry, blood pressure measurement and ECG, giving highest priority to the unconscious patient with cardiac and respiratory arrest. Cardio-pulmonary resuscitation (CPR) follows the international guidelines for resuscitation and may be effective after delayed onset and even after prolonged resuscitation attempts.

Lightning fatalities on the South African Highveld: a retrospective descriptive study for the period 1997 to 2000

A review of the Southern Africa medical literature shows a paucity of published data regarding lightning fatalities. The South African Highveld has a lightning ground flash density of 6 to 9 flashes/km/year, with a high incidence of thunderstorm days per year (some 40-70). The Highveld has a largely urban population, many of whom have low socioeconomic status and poor education, housing, and other infrastructures and hence (possibly) are at greater exposure risk. Thirty-eight victims of lightning-related death were identified from the records of the 6 large medicolegal mortuaries on the South African Highveld, serving a population of approximately 7 million, for the period 1997 to 2000. Analysis of the records revealed that 95% of all victims were black, 79% were male, and the average age was 36 years. Lightning strikes occurred from September through to April (normal summer rainfall period), and the most strikes took place in the late afternoon (3:00 pm to 6:00 pm). All except 1 case occurred outdoors. In the autopsy reports, mention was made of singeing of hair in 68% of cases, and mention of damage to clothing was made in 26% of cases. Cutaneous thermal injuries were noted in 34 of the 38 cases, with apparent electrothermal injuries of the feet noted in 4 cases. Fifty-two percent of victims sustained some form of associated blunt-force injury (including abrasions, contusions, etc). Specific keraunopathologic injuries were described in only 2 of the cases. Twenty-one cases had some form of internal organ injury. This study serves to illustrate the relatively high incidence of lightning strikes in the region and calls for a more systematic and detailed investigative protocol in lightning-related deaths.

Skin burn, bilateral iridocyclitis and amnesia following a lightning injury

PURPOSE

To describe a case of lightning injury restricted to the eyes and facial skin.

METHODS

Case history describing the clinical examination of a 54-year-old woman.

RESULTS

Following a lightning stroke the patient suffered from a sharply demarcated facial skin burn and bilateral iridocyclitis with raised intraocular pressure. Initially she had amnesia regarding the incident. She recovered on symptomatic treatment, with dry eyes as the only sequela.

CONCLUSION

We suggest that a lightning current travelled over the outside of the patient's body facilitated by her wet raincoat, a so-called flash-over. Thereby, she was spared from more severe injury, and only the exposed areas of the face and eyes were affected.

[Intracranial haemorrhage secondary to a lightning strike: a case report]

INTRODUCTION

The damage caused to the central nervous system by lightning can be immediate or delayed. Cerebrovascular accidents are usually an infrequent complication of lightning strikes.

CASE REPORT

We report the case of a patient who was hit by lightning and then developed an acute bilateral intraparenchymatous haemorrhage in the basal ganglia and the left internal capsule.

DISCUSSION

Few cases of intracranial haemorrhages secondary to lightning strikes have been reported. We carry out a review and analysis of the literature currently available on the subject. A number of theories have been put forward that attempt to explain the mechanism behind these haemorrhages in patients who have been hit by lightning. The reason why there is a predilection for the basal ganglia is unknown, although it could be linked to the particular features of the vascularisation of the area.

Lightning injury in an outdoor swine herd

Three pigs, weighing 63 kg-70 kg each, from a group of 8 pigs in an outdoor pen that was struck by lightning were necropsied. All 3 pigs presented with hind limb paralysis. The only lesions identified were multiple fractures of the last (seventh) lumbar vertebral body and first sacral vertebral segment, with dorsal displacement of the sacrum and transection of the distal spinal cord and spinal nerves. Hemorrhages extended from the fracture sites into muscles immediately surrounding the lumbosacral junction and retroperitoneally into the pelvic cavity. These hemorrhages were not clearly visible until the pelvic region was dissected. Lesions commonly found in human lightning-strike victims were not present in these pigs. Because vertebral fractures may be the only lesions and may be grossly subtle in heavily muscled pigs, careful pelvic and vertebral dissection is recommended in cases of suspected lightning strike and electrocution.

An unusual case of late ocular changes after lightning injury

We describe a case of late ocular changes after lightning injury. One year after the injury, complete ankyloblepharon, severe dry eye, corneal opacity, healed iritis and mature cataracts were noted in both eyes of the patient.

Detection of gold particles in the neck skin after lightning stroke with evaporation of an ornamental chain

A German couple was struck by lightning. Both patients survived this event. Whereas the husband was unconscious for only a few minutes, his wife fell into coma for 24 h. The lightning stroke entered the body of the woman behind the left ear and left it at the left shoe. The stroke caused a partial evaporation of a gold ornamental chain on the neck, resulting in a tattoo of the neck skin. A biopsy of the skin 6 months after the event showed the accumulation of gold particles of different size in the dermis down to the subcutaneous fatty tissue. In semithin sections, histiocytes, multinucleated foreign giant cells, and fibroblasts were visible with uptaken metallic particles. In transmission electron microscopy, gold globules of up to 30 microm in diameter were visible outside the cells in the collageneous matrix of the connective tissue besides smaller metallic particles up to 5 nm inside lysosomes and residual bodies of phagocytic cells. Four different kinds of gold particles could be differentiated: globules, granular irregular particles, tubules, and tanglelike tracks. In scanning electron microscopy, gold particles were demonstrated by backscatter detection in the connective tissue of subcutis, where the EDX elemental analysis showed strong signals of aurum (Au), copper (Cu), and argentum (Ag). The detected metals were quantified by AAS as 70% gold, 21% silver, and 9% copper, which demonstrates the composition of gold alloy of the neck chain of the patient. Tanglelike tracks and elongated gold deposits represent crystals of gold salts, as detected by electron diffraction and polarization microscopy. Attempts to remove the gold particles from the skin to remove the tattoo should not be undertaken because the gold is deep and widespread.

Lightning injury as a blast injury of skull, brain, and visceral lesions: clinical and experimental evidences

The present study attempts to better understand the mechanism of injuries associated with direct lightning strikes. We reviewed the records of 256 individuals struck by lightning between 1965 and 1999, including 56 people who were killed. Basal skull fracture, intracranial haemorrhage, pulmonary haemorrhage, or solid organ rupture was suspected in three men who died. Generally these lesions have been attributed to current flow or falling after being struck. However, examination of surface injuries sustained suggested that the true cause was concussion secondary to blast injury resulting from vaporization of water on the body surface by a surface flashover spark. To investigate this hypothesis, an experimental model of a lightning strike was created in the rat. Saline-soaked blotting paper was used to simulate wet clothing or skin, and an artificial lightning impulse was applied. The resultant lesions were consistent with our hypothesis that the blast was reinforced by the concussive effect of water vaporization. The concordance between the clinical and experimental evidence argues strongly for blast injury as an important source of morbidity and mortality in lightning strikes.

Vestibular signs associated with suspected lightning strike in two horses

Two previously healthy 14-year-old horses developed right-sided unilateral vestibular signs after they had possibly been struck by lightning. Repeated radiographic and endoscopic evaluations did not reveal any significant changes. A brainstem auditory evoked response test indicated a subtle left to right interaural latency difference of waves I, III and V in the more severely affected pony, but its central conduction time remained normal.

Mountain medical mystery. Unwitnessed death of a healthy young man, caused by lightning

A healthy 20-year-old man failed to return home after a jog in the Colorado mountains. His lifeless body was found the next day on an exposed mountain slope. The differential diagnosis in such mysterious, unwitnessed mountain deaths includes cardiac arrhythmia, cerebral hemorrhage, pulmonary embolism, seizures, trauma, high-altitude sickness, and hypothermia. The cause of death in this case was established on postmortem examination. The findings of ruptured tympanic membranes and a melted shoe established this as a case of lightning strike fatality. The National Lightning Detection Network can be a valuable resource to investigators by providing information on the location and date of lightning strikes in the vicinity of the victim.

Hazards of bicycling: from handlebars to lightning

The bicycle, an invention that provides joy and transportation to millions of people, can also be a source of disabling injuries and death. The victims of bicycle accidents are usually in good health and often young. Most of the fatal head injury cases are teenagers. In this article, I have chosen four areas of bicycle trauma that frequently brings the bicycle patient to the attention of a neurologist. These areas are (1) head trauma as a consequence of road collisions; (2) compressive ulnar neuropathy; (3) impotence, probably due to compression of the pudendal nerve or its branches; and (4) lightning-related bicycle injuries. The one thing that all four categories have in common is that they are often preventable. Helmet usage and common sense would lower the number of serious head trauma cases by 50%. Compressive ulnar and pudendal neuropathies can be prevented or reduced if the cyclist would frequently change his or her position in relation to the handlebar and saddle. In the majority of cases of compressive neuropathies, the symptoms improve if the patient takes a holiday from bike riding. Lightning injuries can be avoided or lessened if the cyclist takes proactive measures to limit his or her exposure during thunderstorms. These proactive measures include knowing the climate patterns of the area and knowing where the nearest safe shelter is located.

Malignant melanoma in a burn scar

Cancers of various sorts are occasionally encountered in burn scars. These lesions are usually squamous cell carcinomas, and the burn scars are usually old. Very rarely, malignant melanoma is encountered. An 87-year-old nursing home patient who had been burned by a lightening strike at age 16 was evaluated. She had sustained a wound covering 2% or 3% of her body surface involving her neck and the upper portion of her anterior trunk that had required several grafts. A lesion was noted over the suprasternal notch approximately 3 months before admission. The biopsy was reported as malignant melanoma. She was subsequently treated by wide reexcision with an associated Z-plasty for neck release. Because of the patient's age and the presence of four areas of regional lymph nodes nearby into which metastasis might spread, no lymph node dissections were carried out. The specimen from the reexcision was reported as squamous cell carcinoma in situ, melanoma in situ, and multinucleated giant cell reaction, acute and chronic infiltrates. The wound margins were clear.

[Misinterpretation of fetal high voltage and lightning accidents]

From medicolegal practice it is known that in deaths caused by low voltage, electric marks may be absent or inconspicuous so that they may remain undetected during the scene examination. That this may happen even in fatal high-voltage accidents is demonstrated by 4 examples from our own autopsy material. The cases reported shared the following features: The decedents were found outdoors under a high-voltage line with a several metres long conductive object being in the immediate vicinity of the body; no extensive burns as those seen after the impact of an electric arc; inconspicuous electric marks on the hands; clearly visible electrothermal skin lesions limited to body regions covered by clothing (especially soles of the feet). Another case report demonstrates that even fatal lightning accidents are not always recognized correctly.

Lightning: the multisystem group injuries

In this article, we present our experience of group lightning injury. Individual injuries are most common after single strikes. The largest group previously reported was 10 patients. In our series, 17 victims were hit by a single strike; 11 were admitted to the hospital and 6 were discharged from the accident and emergency department. Although injured under the same circumstances, these patients presented with a wide range of symptoms and signs. We also describe a characteristic burn pattern, the "tip-toe sign."

Myocardial injury due to lightning

The report deals with a 27-year-old male who was standing in a tent and was injured by lightning as it struck a tree about 1.5 m away. He immediately lost consciousness and exhibited ventricular fibrillation when the emergency physician arrived. A clinical picture of hypoxaemic brain damage emerged after initially successful resuscitation. Brain death was diagnosed on the fifth day after injury. The discrete external findings (remaining arborescent skin marks) contrasted markedly with the severe thermal damage to the pectoral muscle and cardiac musculature found during the autopsy. The histological cardiac findings indicated severe acute myocardial infarction affecting virtually all parts of the myocardium.

Lichtenberg figures

The majority of cutaneous injuries seen in victims struck by lightning are superficial and heal without sequelae. Common cutaneous findings associated with lightning strike include punctate full-thickness burns, linear charring, and contact burns from overlying metal objects. Branching or ferning marks are an uncommon and unusual cutaneous manifestation. These ferning patterns are called Lichtenberg figures. Similar-appearing electrical phenomena were first noted by an 18th-century physicist of the same name. A case report with review of the literature is presented. The histopathologic features of the figures are described for the first time.

Keraunopathology. An analysis of 45 fatalities

An analysis of 45 victims of fatal lighting strike revealed the incident occurred most frequently in the early afternoon during midsummer in a field of one form or another. The scene of death, damage to clothing, and alterations of metallic objects on the victim are described. A terminal cardiac rhythm of ventricular fibrilation was recorded in half for whom data were available, and asystole was found in 40%. All but four had cutaneous injuries, and nearly one-third had pathognomonic patterns of erythematous arborization. When examined, tympanic membranes were found to be ruptured in > 80%. This study also revealed that craniocerebral injury and cardiac contusion can be serious direct consequences of lightning strike. A correlative approach to the investigation and autopsy of lightning victims is suggested.

Acute electrical burns

Electric current can damage an individual by thermal heating of the tissues; by disregulating autonomously functioning organ systems, such as the circulatory and respiratory systems; or by once-only or continuing stimulation of the nerves and striated muscles. In the first case, the result is coagulation necrosis, and in the second case life-threatening events can occur, such as arrhythmia or apnea. In the third case, vigorous nerve stimulation can lead to paralysis and vasospasm. Massive muscle contractions due to nerve stimulation or the direct triggering of striated muscles can cause ruptures, ligamentous tears, fractures, and joint dislocations, while prolonged current passing through the thoracic wall may stimulate tetany of the intercostal muscles and diaphragm resulting in asphyxia. This article is confined to a description of thermal or Joule heating of tissues when they form part of an electric circuit and to the effects of direct nerve and muscle stimulation. Other articles discuss nonthermal effects. The injuries a person sustains as the result of an electrical accident depend on a large number of interrelated factors, such as the properties of the electrical power supply, the magnitude and duration of current flow, the current pathway, and skin conditions. It makes a vast difference whether a person is hit by a lightning bolt (extremely high voltage, short current flow) or receives a shock from an electrical power supply (low to high voltage, relatively long current flow). Wide variation in the physical properties of lightning discharges and the discharges from electrical power supplies at home and in industry means that all kinds of injuries can be encountered.

Lightning injury of the tympanic membrane

A number of cases of otologic injuries by lighting strikes have been described in the otolaryngological literature. The mechanism of these injuries remains uncertain. We report 3 cases of lightning injury that presented to us. Analysis of these cases suggests that the mechanism of injury is direct conduction of electricity from the scalp to the soft tissues of the external auditory canal to the tympanic membrane. The conduits of the electrical surge are the subcutaneous blood vessels, smaller vessels being damaged more than larger vessels. Since the tympanic membrane central vessels are smaller than the canal vessels, the central area of the tympanic membrane would be most vulnerable, and this is seen clinically. A review of the literature supports this proposed mechanism of injury.

Lightning injury: a case report

A 40-year-old Thai male was struck by lightning while he was riding his motorcycle during a day of gathering clouds and threatening rain. There were third degree burns around the mastoid areas corresponding to the metal arms of the spectacles, also around the neck where a silver chain with pendant (Buddha image) hung, as well as a full thickness vertical lesion down the center of the chest and abdomen where the zip of the jacket made its mark. Fern-like skin erythema was also seen around the later wound. These are stigmas of lightning skin injuries and the patient survived with no memory of the event.

Deaths caused by lightning

Though a rare cause of death, lightning is reported to be responsible for more fatalities each year in this country than any other type of natural disaster. Lightning injuries differ significantly from other high voltage electrical injuries because of the high current flow, but extremely short duration, of the lightning stroke. We present a series of cases over the period of 1985 to 1991 in Cook County, Illinois in which lightning was the direct cause of death. Our discussion reviews the nature of lightning, the effects it may have on humans, and the ways in which deaths due to lightning might be prevented.

[Deaths in swine by a lightning strike in the sty]

It is reported on deaths of pigs due to lightning stroke in the barn. During a severe thunder storm 11 clinically healthy pigs with an average weight of approx. 22 kg died simultaneously and suddenly in the barn. The animals were kept on a floor of metal slats. The pens were separated by metal bars. A water pipe leading into the barn from outside had contact to the bars. Two pigs were submitted for an examination approx. three hours post mortem. The macroscopic and microscopic necropsy findings are described.