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. 2020 Sep 3:11:994.
doi: 10.3389/fphys.2020.00994. eCollection 2020.

Livedo Racemosa - The Pathophysiology of Decompression-Associated Cutis Marmorata and Right/Left Shunt

Frank Hartig  1 , Norbert Reider  2 , Martin Sojer  3 , Alexander Hammer  1 , Thomas Ploner  1 , Claus-Martin Muth  4 , Herbert Tilg  1 , Andrea Köhler  1
Affiliations

Livedo Racemosa - The Pathophysiology of Decompression-Associated Cutis Marmorata and Right/Left Shunt

Frank Hartig et al. Front Physiol. .

Abstract

Decompression sickness and arterial gas embolism, collectively known as decompression illness (DCI), are serious medical conditions that can result from compressed gas diving. DCI can present with a wide range of physiologic and neurologic symptoms. In diving medicine, skin manifestations are usually described in general as cutis marmorata (CM). Mainly in the Anglo-American literature the terms cutis marmorata, livedo reticularis (LR), and livedo racemosa (LRC) are used interchangeably but actually describe pathophysiologically different phenomena. CM is a synonym for LR, which is a physiological and benign, livid circular discoloration with a net-like, symmetric, reversible, and uniform pattern. The decompression-associated skin discolorations, however, correspond to the pathological, irregular, broken netlike pattern of LRC. Unlike in diving medicine, in clinical medicine/dermatology the pathology of livedo racemosa is well described as a thrombotic/embolic occlusion of arteries. This concept of arterial occlusion suggests that the decompression-associated livedo racemosa may be also caused by arterial gas embolism. Recent studies have shown a high correlation of cardiac right/left (R/L) shunts with arterial gas embolism and skin bends in divers with unexplained DCI. To further investigate this hypothesis, a retrospective analysis was undertaken in a population of Austrian, Swiss, and German divers. The R/L shunt screening results of 18 divers who suffered from an unexplained decompression illness (DCI) and presented with livedo racemosa were retrospectively analyzed. All of the divers were diagnosed with a R/L shunt, 83% with a cardiac shunt [patent foramen ovale (PFO)/atrium septum defect (ASD)], and 17% with a non-cardiac shunt. We therefore not only confirm this hypothesis but when using appropriate echocardiographic techniques even found a 100% match between skin lesions and R/L shunt. In conclusion, in diving medicine the term cutis marmorata/livedo reticularis is used incorrectly for describing the actual pathology of livedo racemosa. Moreover, this pathology could be a good explanation for the high correlation of livedo racemosa with cardiac and non-cardiac right/left shunts in divers without omission of decompression procedures.

Keywords: PFO; cutis marmorata; decompression illness; livedo racemosa; livedo reticularis; patent ovale foramen; right/left shunt; skin bends.

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Figures

FIGURE 1
FIGURE 1
Maximum diving depth and overall dive time exposures of the 18 divers.
FIGURE 2
FIGURE 2
Evaluation of the screening results of divers with undeserved DCI, skin symptoms, and R/L shunt.
FIGURE 3
FIGURE 3
Anatomical structure of blood supply.
FIGURE 4
FIGURE 4
Skin pattern of livedo reticularis and livedo racemosa.
FIGURE 5
FIGURE 5
Skin pattern of livedo reticularis (top and bottom left) and urticaria (bottom right).
FIGURE 6
FIGURE 6
Skin pattern of livedo racemosa.
FIGURE 7
FIGURE 7
Skin pattern of livedo racemosa in patients with decompression illness.
See this image and copyright information in PMC

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