T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 373;2 nejm.org July 9, 2015 e2 Images in Clinical MedicineA 31-year-old man presented with a 1-week history of pruritic rash on his left foot, which developed after he brushed against coral while snorkeling in the Caribbean Sea. After contact with the coral, he reported the onset of a burning sensation in the foot, which was followed 1 hour later by the development of an intensely pruritic rash. The physical examination revealed an erythematous, cerebriform plaque on the lateral aspect of the left foot. On the basis of the patient's history and cutaneous findings, a diagnosis of coral dermatitis was made. Coral dermatitis is a form of contact dermatitis that is caused by numerous species of coral that produce nematocysts, which are specialized organelles that discharge dermatologic toxins. Envenomation may result in both acute and delayed reactions. Acute reactions are thought to be forms of irritant contact dermatitis and typically present with urticarial or vesiculobullous plaques immediately or within hours after exposure. Delayed reactions are more likely to be forms of allergic contact dermatitis that are mediated by type I and type IV hypersensitivity reactions and are characterized by firm, localized papules that arise days to weeks after exposure. In rare cases, superficial epithelioid granulomas may be noted on biopsy. The patient was treated with triamcinolone ointment, and the lesion resolved after 2 weeks.

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Background Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary‐care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU. Methods Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator. Results Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%–77.9%), 12 as uncertain (1.5%, CI 0.75%–2.5%), 21 as rarely appropriate (2.5%, CI 1.6%–3.9%), and 174 were unable to be classified (21.1%, CI 18.3%–24.0%). The most common unclassifiable indication was “initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology” (n = 101). Conclusion Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU.

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