title: Cutis marmorata in decompression illness may be cerebrally mediated: a novel hypothesis on the aetiology of cutis marmorata.
abstract: BACKGROUND
  Cutaneous decompression sickness (DCS) is often considered to be a mild entity that may be explained by either vascular occlusion of skin vessels by bubbles entering the arterial circulation through a right-to-left shunt or bubble formation due to saturated subcutaneous tissue during decompression. We propose an alternative hypothesis.
  
  
  METHODS
  The case is presented of a 30-year-old female diver with skin DCS on three separate occasions following relatively low decompression stress dives. Also presented are the ﬁndings of cutaneous appearances in previously reported studies on cerebral arterial air embolism in pigs.
  
  
  RESULTS
  There was a close similarity in appearance between the skin lesions in this woman (and in other divers) and those in the pigs, suggesting a common pathway.
  
  
  CONCLUSIONS
  From this, we hypothesize that the cutaneous lesions are cerebrally mediated. Therefore, cutaneous DCS might be a more serious event that should be treated accordingly. This hypothesis may be supported by the fact that cutis marmorata is also found in other ﬁelds of medicine in a non-diving context, where the rash is referred to as livedo reticularis or livedo racemosa. These are associated with a wide number of conditions but of particular interest is Sneddon's syndrome, which describes the association of livedo racemosa with cerebrovascular events or vascular brain abnormalities. Finally, there is a need for further research on the immunocytochemical pathway of cutaneous DCS.
authors.affiliation: 4Department of Anesthesiology/Hyperbaric Medicine, Academic Medical Center, Amsterdam, Cardiothoracic Surgery Onze Lieve Vrouwe Gasthuis, Amsterdam, Oosterpark 9 1091 AC Amsterdam, The Netherlands, Phone: +31-(0)6-5799-3488, E-mail: t.kemper@me.com.
authors.forename: Tom Cpm
authors.initials: TC
authors.lastname: Kemper
authors.affiliation: Department of Cardiology, Central Military Hospital, Utrecht, The Netherlands.
authors.forename: R
authors.initials: R
authors.lastname: Rienks
authors.affiliation: Diving Medical Center, Royal Netherlands Navy, Den Helder, The Netherlands.
authors.forename: P Jam
authors.initials: PJ
authors.lastname: van Ooij
authors.affiliation: Department of Anesthesiology/Hyperbaric Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: R A
authors.initials: RA
authors.lastname: van Hulst
mesh_terms: D000328:Adult; D000818:Animals; D003665:Decompression Sickness / Q000150:complications*; D004195:Disease Models, Animal; D004242:Diving / Q000009:adverse effects*; D004618:Embolism, Air / Q000150:complications*; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000150:complications; D006801:Humans; D020766:Intracranial Embolism / Q000150:complications*; D054068:Livedo Reticularis / Q000209:etiology*; D013552:Swine
keywords: Decompression sickness; animal model; case reports; cerebral arterial gas embolism (CAGE); decompression illness; hypothesis; patent foramen ovale (PFO)