Oh, look - another girl with a skin bends issue...

[vetdiver]

Hi -

Well, I feel a bit silly posting this, but I am trying to get all the info I can. I have spoken to DAN once and will call again tomorrow when the non-emergency lines are open.

I have now had symptoms consistent with skin bends 3 times. All following dives in cold water (less than 55 degrees) when doing multiple dives with at least one dive below 80 ft. Begins as itching on my upper stomach, then becomes mottling (generally sort of bruise-y looking) and affects my stomach and outer thighs - usually shows up in full with the thigh thing about 5-7 hours after I am out of the water, itching is sooner, maybe an hour or two. The last two times, I have had a bit of shortness of breath, I used an inhaler last night (albuterol) that I have for bronchospasm - so rare in me that this was actually the first time Ive used it since I got it. The skin seems right on with air bubble descriptions, but the breathing thing? I suppose it could indicate that there is an allergic component - or that I am freaking out and need to calm the heck down. I did use cortisol cream on my rash, it goes away, but then, it only lasts a few hours anyways.

A bit about me - I am 39, 5'7" and 130 - I am in pretty good shape (I don't have a lot of fat around the affected areas) and exercise a lot, at least 5 times a week. I am a breast cancer survivor, just checked out clean after 5 years - have had a lot of reconstructive surgery (bilateral mastectomy with implant recon - have not had issues in these areas), but that has been a part of my life for years. I did have a heart scan prior to starting chemo - I imagine a PFO would have been picked up at that time if I was affected.

I have been certified for 15 years and have around 1000 dives at this point in all kinds of conditions, and I have been doing multiple dive days in cold water for a few years now. As recently as May, I was doing 4 dives a day in the Channel Islands - brrr - with no issues. I am pretty careful - use a Suunto, dive 30-32% most of the time, and I try to do 5 min safety stops, especially since this first happened. On deeper dives, I do very slow ascents and try to do a minute stop at 1/2 the deepest depth The last two times, I have not even rinsed off in warm water after diving because I thought that might have been the issue the first time.

This happened last weekend, and I called DAN the next day - they told me it would be wise not to do more than 2 dives a day in cold water and that I should be very conservative. Well, last night, I did 2 dives, VERY conservative, dove probably a 28 or 29% profie on 32% - long safety stop on the second dive (3-4 min on the first). Sure enough, skin stuff a few hours later.

I am just at a loss now. Any ideas? I cannot think of anything that has changed abruptly with my diving to make this a problem so suddenly. Could this be drysuit squeeze (seems unlikely, I have used the same suit for 2 yrs)? Should I just try to hydrate even more/longer safety stops? As I read this, I realize that the last 2 incidents took place when doing multiple dives later in the day rather than first thing in the morning (I would have been more likely to be dehydrated - warm day, I had coffee yesterday morning...I wonder if this is a major factor here, plus I am aging and my body is going through normal age-related changes...) I have heard about a few people who just tolerate this as part of diving - my understanding is that there isn't evidence that this predisposes me to a more severe DCI hit...but I am still concerned.

Thanks for any insight!

 

[TSandM]

I would get a PFO check. The echo they may have done prior to chemo would not have picked up a PFO. Although I'd have to go search on it, I remember reading something that correlated skin bends with a higher incidence of PFO.

You have two good options for a PFO check -- One is transesophageal echo, and the other is transcranial Doppler. I would imagine that both are available in the San Diego area. You should be able to get some insurance coverage for the test, since you have had DCS.

 

[vetdiver]

Hi -

Thanks for the reply. But - it wasn't an echo, it was a MUGA scan, which is live functional ejection fraction testing. If there had been significant shunting, I think it would have been detected (????possibly not, it sounds like they can be tough to pick up sometimes). Regardless, I do have a dr's appointment this week anyways and am intending to get a referral to a diving specialist to get additional input. They may recommend restesting - I have PPO insurance, and I am pushy with regards to medical stuff, so I am not worried the coverage. I just wonder if I had a PFO, if I'd have had issues before now. The more I think about it, the more I wonder if dehydration played a big role in the last 2 incidents.

 

[Dr. Doug Ebersole]

2 cents from a cardiologist. A MUGA was performed prior to chemo to look for your heart muscle function as you probably had some sort of adriamycin based chemotherapy which can cause weakening of the heart muscle. It DEFINITELY will not pick up a PFO. A transesophageal echo or at least a transthoracic echo with a "bubble study" is a much better test for this. That having been said, management of PFOs found in divers is very controversial as you may know. Also, PFO classically is associated with neurologic DCS and not frequently associated with skin bends. However, it is probably worth checking out.

Doug-

 

[vetdiver]

Doug - THANK YOU - it is good to know for sure that the MUGA wouldn't have dx'd a PFO (I ran past vet cardiology for pathology long, long ago - if it ain't under a microscope? I know nada about it!).

I've got excellent medical insurance, might as well use it. I concur that it might be grasping at straws, but it won't hurt. In the meantime, since I have been doing more multi-dive days and fewer individual days containing a single dive each, I am going to kick the coffee and start drinking more water. I definitely am not interested in seeing what other kinds of DCI I can accrue or how well my DAN insurance actually works.

 

[Dr Deco]

Hello vetdiver:

Literature

The etiology of cutis marmorata (CM) following diving is unclear. There does appear to be a relationship to neurological DCS but the events are uncommon enough to make the connection. Nevertheless, some divers have profited, apparently, from a repair of the PFO when the “rash” was associated with other DCS instances.

Some authors have argued for several years that migraine, neurological DCS and PFO are related in some individuals (1, 2). They have argued that closure is helpful in selected cases (e.g., repetitive problems). It has been suggested (by Duke University physicians in association with DAN) that an attempted diagnosis of a PFO is underperformed (3).

PFO and DCS (and possibly CM) are related to the size of the opening (4, 5). The degree of shunting can vary with the time in a woman’s monthly cycle with mid cycle being the greatest arterialization (6). There is also evidence that the PFO patency can increase with age (7).

Body Position, Etc

I have an idea that arterialization thorough a PFO can be influenced by several factors (8). One is related to “Valsalva-like” maneuvers. These all influence “rebound flow” in the heart. Holding one’s breath while climbing a boat ladder, straining when lifting gear, and coughing all could play a role. Possibly, you recall something of this nature preceding an episode of CM.

Dr Deco :doctor:


References :book:

1. Wilmshurst PT, Byrne JC, Webb-Peploe MM. Relation between interatrial shunts and decompression sickness in divers. Lancet 1989; ii :1302–6.

2. Wilmshurst PT, Nightingale S, Walsh KP, et al. Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons. Lancet 2000;356:1648–51

3. Harrah JD, O'Boyle PS, Piantadosi CA.Underutilization of echocardiography for patent foramen ovale in divers with serious decompression sickness. Undersea Hyperb Med. 2008 May-Jun;35(3):207-11.

4. C. Torti SR, Billinger M, Schwerzmann M, Vogel R, et al. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J. 2004 Jun;25(12):1014-20.

5. Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol. 2001 Sep;38(3):613-23.

6. Klien S, Spiegel M, Engelhardt K, et al. .Menstrual cycle dependent right-to-left shunting: a single-blinded transcranial Doppler sonography study. Undersea Hyperb Med. 2005 Nov-Dec;32(6):403-7.

7. Germonpre P, Hastir F, Dendale P, Marroni A, Nguyen AF, Balestra C.
Evidence for increasing patency of the foramen ovale in divers. Am J Cardiol. 2005 Apr 1;95(7):912-5.

8. Powell, MR, KV Kumar, WT Norfleet, and J Waligora, B Butler. Arterial bubbles with saline contrast via patent foramen ovale but not with hypobaric decompression. Aviation, Space Environ. Med., 66, 273-275, (1995).

 

[vetdiver]

I have an idea that arterialization thorough a PFO can be influenced by several factors (8). One is related to “Valsalva-like” maneuvers. These all influence “rebound flow” in the heart. Holding one’s breath while climbing a boat ladder, straining when lifting gear, and coughing all could play a role. Possibly, you recall something of this nature preceding an episode of CM.

Given that most of my dives are in cold water (our "warm" dives this year were in Socorro, which was 70F), I am ALWAYS straining to lift gear, be it up the ladder, out of the tank holder, or off the back of my car (let's not get started on the long hike to the surf when we shore dive)!!!! As for the breath holding - once the camera is handed up, that isn't a problem ... I do think that I will stop carrying gear back to the car on my back after dives and start using a cart instead.

After Doug's message, I am certainly going to pursue additional CV diagnostics to look for a PFO; and in the meantime? I am on my first day of reduced coffee intake . We have some dives next Sat, so I'll let you know what happens. I also started back on my allergy meds this morning; realized that this time of year was hell for me last year, as well - maybe that will make a difference.

Thanks to everyone who answered. Have a great week.

 

[BlueDevil]

The possible allergy link sounds interesting. While it is probably unlikely to be allergy related it wouldn't hurt to investigate further. Maybe there is something in the water or in your wetsuit? Why don't you go for a couple of long snorkels wearing the same wetsuit etc and see what happens.

I came across a lady recently who has had minor allergic reactions after swimming on a number of occasions, and on this one particular occasion she had a full anaphylactic reaction with urticaria, SOB and hypotension. There seemed to be no evidence for her being stung by anything whilst in the water.

 

[Dr. Doug Ebersole]

Sorry for being AWOL for a few days. I've been diving in North Carolina.

Vetdiver -- You're very welcome. Please let us know what you find out.

Doug

 

[vetdiver]

Well, I did two dives below 80 ft yesterday just fine - I have been hydrating like a fool, and I spoke to another female diver on the boat who has had this in the past. She told me her ascent profile (deep stops, plus an additional stop at 10 ft for as long/longer than my normal safety stop). I will say that I am not a big believer in lots of deep stops, I know there are mixed opinions on it, but I think the idea of doing an addiitonal shallow stop to clear the skin makes a lot of sense. I did this yesterday, as well.

I am still not sure how I feel about allergies playing a part in the skin symptoms - it's certainly possible, but it's happened with 2 sets of different undergarments, so it seems less likely. As it turns out, this has been a terrible week for allergies around here - seems that everyone is suffering, so I think that the breathing thing is unrelated.

Unfortunately, I had some weird mask squeeze on my first dive that gave me a headache halfway through - progressed to near-migraine levels by the end of the second dive. I wound up sick as a dog (this happens when I get terrible headaches), a first since spring of last year!! Nevertheless, I did not have a skin issue, so I consider the whole day a great success, and I feel much more confident about the whole situation.

Doug - meeting with the chamber doc next week - she wants to see my profiles and discuss the whole situation, but I get the feeling that she thinks it can be worked around. Thank goodness. Hope you had a blast in NC.

Allison