Cactus Spine Wounds: A Case Report and Short Review of the Literature

Introduction. Cactus plants are commonly seen in arid southwestern regions of the United States. Due to their ready availability, they have become a popular houseplant. The spines or glochidia can easily puncture the skin with only minor pressure (ie, bumping or touching the cactus). Removal of the offending spine is difficult, even with tweezers.Case. An 18-year-old woman initially self-removed the spines, and marked discomfort and intense erythematous reaction developed within 8 to 10 hours. Patient presented to the emergency room at Mercy Hospital and Trauma Center (Janesville, Wisconsin), where spine removal was unsuccessful. Results. Following emergency room discharge, she had difficulty walking from pain and swelling and was advised to use heat packs, take amoxicillin/clavulanic acid, and rest with her leg elevated for another 7 days along with using eye drops for eye irritation. The lesions slowly improved over the next several months. Conclusion. The case of multiple barrel cactus spine injuries with severe pain and swelling is presented herein as well as a review of the treatment options and complications of cactus spine injuries.

The cactus plant, a member of the Cactaceae family, is common in the Southwest United States. Due to the succulent’s ability to survive dry areas, cacti have become a popular houseplant. However, the spines can puncture the skin with little pressure from the individual. Presented herein is a case of an 18-year-old woman with several cactus spines lodged in her knee.

An 18-year-old Caucasian woman fell into a barrel cactus and had multiple spines embedded in and around her right knee. The injury caused immediate discomfort with progressive pain and rapid onset of swelling and erythematous to the affected area. According to the patient, she removed 5 or 6 spines with tweezers before presenting to the emergency room (ER) at Mercy Hospital and Trauma Center (Janesville, Wisconsin) with persistent and progressive pain and swelling to the knee about 10 hours post injury. Figures 1 and 2 show the wound presentation. In the ER, her vitals were as follows: pulse 107 beats per minute, oral temperature 99.5ºF, and blood pressure 161/84.

Lidocaine with epinephrine was administered to the wounded area in the ER. Attempted removal of the remaining cactus spines with tweezers was initiated but unsuccessful. During removal, one or more spines had broken off and were not able to be removed. Treatment then consisted of oral 875 mg amoxicillin/25 mg clavulanate (Augmentin, GlaxoSmithKline, Brentford, UK) every 12 hours for 7 days, intramuscular Tdap (tetanus immunization; Adacel, Sanofi Pasteur Inc, Lyon, France), and oral analgesics administered every 4 to 6 hours for 5 days. She was discharged home after 3 hours with follow-up care as an outpatient with directions to use heat packs, take amoxicillin/clavulante acid, elevate the injured leg, and use ophthalmic eye drops (0.2% olopatadine). The area of involvement slowly improved and the reddening lessened over a 30-day period. At the end of the 30 days, a granulomatous nodule (lump) in the punctured area remained but slowly healed several months later. 

Succulents are xerophytes, or plants adapted to arid climates, whose storage structures hold water to enable survival of the plant in severe droughts. There are about 10 000 succulent species¹ divided into 6 families, with specialized stems, leaves, and roots. Cactaceae, or the cactus family, is one of the largest families of succulents in the world, encompassing about 2500 species.¹ Stem succulents of the Cactaceae family have become a popular houseplant due to their availability. Cactaceae is native to the Western hemisphere and has fleshy stems with spines or glochidia (hair-like spines or short prickles) arranged in cluster sites (areoles). The spines may be bristles, hairs, or hooks in various shapes and be curved, long, short, or straight. The outer surface cuticle is thick and waxy, and the root that absorbs water is stored as mucilaginous sap in the tissue.¹

The barrel cactus group contains more than 30 species and is found across the Southwest United States and Northern Mexico. This group includes Ferocactus plants, which generally are spherical when young but may grow to a height of 13 ft when matured.² Flowers may be yellow, pink, red, or purple and may tolerate frost, intense heat, and bright sunlight. Included in this group are F pilosus, F rectispinus, F robustus, F herrerae, F glaucescens, and F cylindraceus, and all may be brightly colored. These cati glochidia are generally barbed and found on the areoles. Usually they detach easily from the plant upon contact; thus lodging in the skin and causing irritation that may be persistent with dermatologic features. Due to the barbed spines, they may be difficult to remove, and even when removed, portions of foreign material may remain.² The skin reaction may be immediate as herein reported or delayed ≥ 24 hours. Of note, a person may not realize a glochid could have detached in their skin after physical contact until the reaction occurs. 

Initially, stabbing and burning sensations, swelling, and erythematous changes may occur and potentially persist for a few days after glochidium removal. Inadvertent, but symptomatic, implantation in the conjunctiva, cornea, palate, or tongue may all occur. If the offending spine or foreign material is not removed or only partially removed, then within 24 to 72 hours papules and a black puncture site “dot” may develop and glisten as well as become erythematous at the injured site. The asymptomatic, dome-shaped, granulomatous dermatitis may appear in groups of vesicles or pustules. Focal ulceration may occur, and the glochidia may potentially be felt. Such lesions may last up to 9 months and be followed by postinflammatory hyperpigmentation. The actual cause of this reaction has been theorized to be an allergic, toxic, or plant material-related with infectious or inflammatory characteristics.^3,4 These lesions may culture numerous organisms on ulceration, including Mycobacterium marinum, Staphylococcus aureus, and Clostridium tetani. Enterobacter and Nocardia have also been cultured. Microscopic examination of the biopsy may reveal granulomas with a strong positive periodic-acid Schiff staining reaction.³ 

Removal of glochidia may be difficult, because yanking them may fracture the spines and embed them into the puncture site. Table 1 presents various options for removal. Although an individual’s initial response is to pull the glochidium from the injured skin, this may leave residual materials or embedded fractured spines that can lead to prolonged symptoms and secondary sequelae. No uniform method has yet to be proven. A reasonable approach —which could be potentially successful — is initial spine removal with tweezers followed by applying a layer of polyvinyl acetate glue and a mesh pad to the wounded site. After the glue has dried, removal of the pad and underlying glochidia has proven as effective a method for spine removal as any approach. Removal by oral suction is never advised as glochidia may then imbed in the mouth. Unroofing the lesions may reduce the antigen burden and discomfort. Various complications may arise from cactus spine injuries and have been reported in the literature.^3-5 Most concerns are related to embedded or fractured glochidia.¹

Extremities tend to be particularly vulnerable, especially fingers, hands, and knees.^4,5 Granulomas and dermatitis of the hands may take months to heal.^3,4 Migration of the glochidia to the mediastinum, knee cartilage, or ocular involvement due to rubbing has been reported.^6-10 Members of the Army training in the southwest and immunocompetent patients with cactus injuries have also been reported.^11-14 A continual topic of discussion are removal techniques for dislodging spines, which date back 20 years.^15-17 Diagnostic magnetic resonance and ultrasound tests may be helpful in patients with cactus spine injuries. 

Initially, the patient presented herein attempted to remove the offending glochidia with gentle extraction, but by the next morning she had progressive discomfort and erythematous reactions with intense central reddening and peripheral erythema surrounding the injured site.  Following the ER visit without further extraction results, she was treated with antibiotics and heat packs. She did show slow, steady improvement and achieved full wound healing 5 months post injury. 

An 18-year-old Caucasian woman was punctured by barrel cactus spines upon physical contact with the plant. She performed an immediate self-removal of the glochidia with tweezers and experienced marked erythema and discomfort within 8 to 10 hours following the injury. After receiving ER treatment, which included further inability to extract the remaining embedded glochidia materials, antibiotics and Tdap immunization was administered. Healing was slow but progressive, and patient was doing well 5 months post injury. 

From the Northwestern System at Cadence Health (Emeritus), Hospital, Glen Ellyn, IL; Child Development, Whitehouse Grading LLC, Muskego, WI; and Student University of Wisconsin-Whitewater, Whitewater, WI 

Address correspondence to:
Raymond A. Dieter, Jr, MD, MS
22W240 Stanton Rd 
Glen Ellyn, IL 60137
brdrad@att.net

Disclosure: The authors disclose no financial or other conflicts of interest.