Dhaga Syndrome Involving the Upper Arm: Another Uncommon Location

Dear Editor, We read with interest a recent article entitled “Dhaga Syndrome: Unveiling Two Cases and Navigating Diagnosis and Treatment” that described a rare presentation of an endemic condition. The authors were right in stating that most of these cases hail from India and result from the complication of the sacred thread (or moli dhaga) ligature.[1] Most cases of “dhaga syndrome” (or “rubber band syndrome”) in the literature involve the wrist region in the pediatric age group and present with skin lesions ranging from localized bruising to extensive soft tissue damage.[1,2] We, hereby, describe an uncommon location of dhaga syndrome in the upper arm, which is another site of tying a scarred thread in Indian villages. A 4-year-old child presented to us with a 4-month old wound over the left upper arm. There was a history of small bruise in the beginning that poured pus after a few weeks, and dressings were done by an indigenous practitioner. Due to nonhealing and expanding wound, they consulted us. Regular dressing resulted in gradual decrease in the pus discharge, and after superficial eschar was removed over the semi-circumferential wound, some black remnants of the foreign material were noted and removed from the wound. These black thread remnants corresponded to the black religious threads worn in many villages [Figure 1]. A similar thread was also noted over the neck of the child. Parents also confirmed the presence of black dhaga in the upper arm since the first birthday. Regular dressing, in this case, led to gradual healing without further intervention over a course of 6 months.Figure 1: The clinical image shows the presence of a semi-circumferential, extensive soft tissue damage (a) following the “dhaga syndrome”. Few black shredded remnants of the black thread are visible within the wound (b). There is presence of similar black thread over the neck of the childReligious thread is a common etiology of the dhaga syndrome. Kite thread (“maanja”) is another material described as a rare cause of dhaga syndrome.[2] Forgotten sacred thread can lead to circumferential constriction and a cascade of events leading to defects that may require surgical exploration, and often pieces of rubber band or thread are recovered from the wound.[1,3] There may occasionally be underlying bony changes like periosteal reaction with indentation, termed constriction sign, in the first description of dhaga syndrome in the year 2004.[4] Overall good outcome following dressing, surgical debridement with or without removal of remnant dhaga pieces is noted. A high index of suspicion is pivotal for early diagnosis of these conditions and prevention of damage to vital structures.[1,4] Societal education and awareness, however, should go hand-in-hand to decrease the complication burden of this rare entity. The differential diagnosis of dhaga syndrome should be kept in any constricting scar with soft tissue damage or discharge. Knowledge of this uncommon condition can help misdiagnose the condition and help with appropriate management. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.