Unusual skin findings in a patient with liver disease

A 38-year-old Cambodian man was admitted for management of increasing abdominal girth. The patient had a history of hepatic cirrhosis as a result of chronic active hepatitis B and was taking furosemide, spironolactone and propranolol. He was thought to be poorly compliant with these drugs and was admitted for management of his ascites. Physical examination by the on-call medical resident was remarkable for stigmata of liver disease, including tense ascites, spider nevi and pedal edema. The resident was puzzled by the presence of symmetrical hyperpigmented macules on the patient's abdomen (Fig. 1) and linear ecchymoses on the thighs (Fig. 2). The Cambodian interpreter who was present informed the resident that the abdominal macules resulted from burns caused by the application of small pieces of smouldering cloth, a practice referred to as “moxibustion.” The linear ecchymoses on the thighs were described as resulting from “coining,” or vigorous rubbing of an area with a lubricated coin. The interpreter further explained that the charm belt worn by the patient (Fig. 1) was thought to have medicinal properties.

Figure 1. Photo: Courtesy David Fisman

Figure 2. Photo: Courtesy David Fisman

Both moxibustion and coining are traditional Southeast Asian medical techniques. The marks left by these practices may be misinterpreted by those unfamiliar with their appearance as representing cutaneous signs of disease or as suggesting a history of physical abuse.^1,2 Their presence may indicate that the patient has a different perspective or level of acceptance of Western medical practices.

David Fisman Associate Medical Officer of Health Hamilton Department of Social and Public Health Services Hamilton, Ont.