We report the case of a 15-year-old Lebanese (Arab) boy who was stung by a jellyfish on 27 September 2018 while on a beach of the Arabian Gulf. He was initially treated with pain medication and local creams; however, his condition deteriorated, with associated excruciating pain and forearm edema. He visited our pediatric emergency service 24 hours later with severe pain, forearm edema, and blue and cold fingers. On examination, the left forearm was swollen and very tense with cellulitis, and there was a large reddish patch on the dorsal aspect of the forearm where the sting occurred. The skin was muffled and cold compared with the right side. The capillary refill was sluggish. The child was able to actively extend the fingers (Fig. 1).
There was no palpable radial or ulnar pulse on the left side.
The brachial artery showed a good signal on a portable Doppler scan, but no signal was retrieved at the level of the radial and ulnar arteries (Figs. 2 and 3).
The main concern was compartment syndrome with the occlusion of the arterial blood supply, which could affect the function of the arm and hand. Informed consent was obtained. Decompression fasciotomy was performed by making a curvilinear incision at the volar aspect of the left forearm. The subcutaneous tissues were dissected. The superficial and deep compartments were both incised and explored. All muscle groups were intact with minimal swelling. The muscle appeared pink and contractile. The cubital and radial arteries were normally pulsating. The wound was left open, and progressive closure was planned depending on the patient’s progress from the vascular point of view of the surgery team.
On day 2, finger perfusion was impaired, and there was no visible pulse in the area of the mid-forearm. Diluted nitroglycerin was applied to the wound directly over the radial artery in an attempt to resolve the arterial spasms, and the carpal tunnel was decompressed.
The patient was kept in the Pediatric intensive care unit (PICU) for the following week on low-molecular-weight heparin (LMWH) and an intravenous antibiotic, nitroglycerine, and morphine infusion. Arm perfusion improved over the next few days. The Doppler signal started to improve on the radial arch and then later on the palmar arch and the fingers. On day 5, the patient was taken to the Operation Room (OR), and both forearm and wrist incisions were closed with no difficulty.
The patient was transferred to the regular ward on the day of surgery and was discharged on day 8 in good condition, with a palpable radial pulse and good triphasic Doppler signals on the fingers.
The patient was advised to continue LMWH for two more weeks, along with oral antibiotics and pain control medications. He was followed-up in the vascular outpatient clinic weekly for the following 4 weeks with normal wall-to-wall color flow and a triphasic waveform.
On day 17, a nerve conduction velocity (NCV) study showed reduced CMAP amplitudes for the left ulnar and radial nerves along with normal distal motor latencies, conduction velocities, and F-wave latencies.
The patient continued to complain of pain in the left shoulder and elbow, with tenderness, muscle spasms, left elbow flexor weakness, and a limited range of motion at the elbow and wrist joints. His motor function improved after he received ten sessions of physiotherapy over a period of 6 weeks.
The patient and his parents found the time to come to the hospital to thank the vascular surgery, pediatric intensive care, and physiotherapy teams after the patient’s complete recovery.
