Case and Research Letters
Localized Lipoatrophy in a Boy After an Intramuscular Injection of Penicillin
Lipoatrofia localizada en un niño tras administración de penicilina intramuscular
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Vázquez-Osorio, A. Rodríguez-Vidal, E. Rosón, J. Alonso-González, H. Vázquez-Veiga" "autores" => array:5 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Vázquez-Osorio" "email" => array:1 [ 0 => "rogivaos@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Rodríguez-Vidal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Rosón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Alonso-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "H." "apellidos" => "Vázquez-Veiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Clínico Universitario, Santiago de Compostela, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Pediatría, Hospital Clínico Universitario, Santiago de Compostela, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lipoatrofia localizada en un niño tras administración de penicilina intramuscular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 647 "Ancho" => 975 "Tamanyo" => 115616 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cutaneous ultrasound revealed a marked loss of subcutaneous tissue (asterisk and short arrow) in comparison to the healthy adjacent subcutaneous tissue (circle and long arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Localized lipoatrophy is characterized by the loss of subcutaneous fat in a particular area of the body. In children, the condition is mainly related to subcutaneous or intramuscular injections of drugs or vaccines. Localized lipoatrophy is usually diagnosed clinically, although histopathologic examination can be necessary in some cases to rule out other causes such as connective tissue diseases and neoplasms.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a healthy 8-year-old boy who was referred to our dermatology department for assessment of an asymptomatic lesion on his left thigh that had appeared 4 years earlier. A few weeks before the lesion appeared, the patient was diagnosed with streptococcal pharyngoamygdalitis and received treatment with an intramuscular injection of benzathine penicillin (600 000<span class="elsevierStyleHsp" style=""></span>IU) on the lateral aspect of the left thigh. The lesion grew in proportion to the boy as he grew taller and gained weight. The boy had no personal or family history of autoimmune disease or history of trauma at the site of the lesion.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a 9<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm depressed plaque of similar color to the adjacent skin on the anterolateral aspect of the left thigh. The lesion was covered with normal skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No similar lesions were detected at other sites. No loss of strength or sensitivity was observed in the lower left limb.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Blood tests were carried out, including complete blood count, kidney and liver function, cholesterol, triglycerides, lipase, complement, rheumatoid factor, antistreptolysin O, and antinuclear antibodies. No significant abnormalities were found. The patient tested negative for <span class="elsevierStyleItalic">Borrelia burgdorferi</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ultrasound examination of the lesion revealed a complete loss of subcutaneous tissue alongside adjacent healthy skin. No muscular abnormalities were observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The parents declined to allow a biopsy of the lesion.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with medium-strength topical corticosteroids and topical calcineurin inhibitors was started. No improvement was seen after 2 months of treatment. The lesion has remained stable for 2 years of follow-up and no similar lesions have appeared at other sites.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Localized lipoatrophy can be classified as primary (or idiopathic) or as secondary to minor repetitive trauma injuries, injections of various drugs (penicillin, amikacin, methotrexate, corticosteroids, insulin)<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–5</span></a> and vaccines,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> connective tissue diseases (lupus erythematosus, morphea, dermatomyositis), or malignant neoplasms.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Localized lipoatrophy secondary to drugs is characterized by the presence of depressed, asymptomatic lesions with a color and appearance similar to that of the adjacent skin. The lesions typically appear a few weeks or months after the injection and are usually located on the anterolateral aspect of the thighs, buttocks, or abdominal region.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The lesions tend to regress after a few months or years, although this depends on the drug involved and the degree of lipoatrophy. Lesions secondary to insulin injection tend to resolve spontaneously. Kumar et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> presented 2 cases of localized lipoatrophy caused by amikacin in which the lesions disappeared spontaneously after 2 and 3 months, respectively. Avilés-Izquierdo et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> reported a case associated with intramuscular corticosteroid injection in which the lesions regressed after 2 months. In the cases associated with methotrexate and penicillin that have been reported, the progression of the lesions is unknown due to lack of follow-up.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the case of our patient, the lesion remained stable after 2 years of follow-up. Haas et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> associated the persistence of the lesions in their patient with the possible existence of an underlying autoimmune disease. In the case of our patient, neither the clinical data nor the test results suggested the existence of an underlying autoimmune disease at any time during follow-up.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The etiology and pathogenesis of localized lipoatrophy are not clearly defined. The triggering mechanism is probably different for each drug. Insulin-induced lipoatrophy appears to be associated with local hyperproduction of tumor necrosis factor-α and interleukin-6, which would lead to a dedifferentiation of adipocytes.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The injection itself could also play an important role in the development of lipoatrophy by causing macrophages to release cytokines, which in turn enhance the lipocyte catabolism and inhibit lipogenesis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In addition, hypoperfusion of the anterolateral aspect of the thigh due to anatomic variants of the lateral circumflex femoral artery would explain the lipoatrophy at that site.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In the case of our patient, the injection of the drug, the anatomy and vascularization of the anterolateral aspect of the thigh, and the existence of ischemic phenomena caused by arterial trauma could explain the development of lipoatrophy.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The diagnosis of localized lipoatrophy is mainly clinical, although in some cases a skin biopsy can be necessary in order to rule out underlying disease. Histologic examination reveals a reduction in the size of the fat lobules of the hypodermis, with no evidence of fat necrosis, calcification, granulomas, or atypia. Cutaneous ultrasound can also be a useful tool in the diagnosis of patients with clinical suspicion of localized lipoatrophy. With cutaneous ultrasound, it is possible to quickly and safely observe—underneath a normal epidermis and dermis—a marked reduction in the subcutaneous tissue without the involvement of muscular tissue.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Because localized lipoatrophy tends to resolve spontaneously, many cases require no treatment. However, in cases in which the lesions persist, creating a significant cosmetic deficiency, some form of treatment may be indicated. Although no definitive treatment exists, intralesional corticosteroids have been used to treat lesions caused by insulin injections, with favorable results in some cases.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> This beneficial effect seems to be caused by the immunomodulating properties of the corticosteroids and to their capacity to induce the differentiation of adipocytes. However, because the reported cases are isolated, and because intralesional corticosteroid injections can themselves cause lipoatrophy, this treatment should be indicated with caution.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In corticosteroid-induced localized lipoatrophy, it has been shown that the intralesional administration of saline solution, autologous fat, or poly-L-lactic acid can have beneficial effects and improve the cosmetic appearance of the lesion.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Avoiding injections in the anterolateral aspect of the thighs, rotating injection sites, and changing insulin pen needles are recommendations that can help patients and their family members prevent localized lipoatrophy secondary to drug injection.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vázquez-Osorio I, Rodríguez-Vidal A, Rosón E, Alonso-González J, Vázquez-Veiga H. Lipoatrofia localizada en un niño tras administración de penicilina intramuscular. Actas Dermosifiliogr. 2016;107:620–622.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 78600 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Semicircular depressed plaque measuring 9<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm, covered with normal skin and located on the anterolateral aspect of the left thigh.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 647 "Ancho" => 975 "Tamanyo" => 115616 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cutaneous ultrasound revealed a marked loss of subcutaneous tissue (asterisk and short arrow) in comparison to the healthy adjacent subcutaneous tissue (circle and long arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Semicircular lipoatrophy after intragluteal injection of benzathine penicillin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 11 | 20 |
| 2024 October | 127 | 49 | 176 |
| 2024 September | 119 | 30 | 149 |
| 2024 August | 153 | 58 | 211 |
| 2024 July | 148 | 37 | 185 |
| 2024 June | 161 | 43 | 204 |
| 2024 May | 122 | 40 | 162 |
| 2024 April | 109 | 19 | 128 |
| 2024 March | 111 | 28 | 139 |
| 2024 February | 152 | 29 | 181 |
| 2024 January | 107 | 37 | 144 |
| 2023 December | 84 | 16 | 100 |
| 2023 November | 126 | 41 | 167 |
| 2023 October | 150 | 35 | 185 |
| 2023 September | 125 | 34 | 159 |
| 2023 August | 97 | 23 | 120 |
| 2023 July | 125 | 31 | 156 |
| 2023 June | 115 | 21 | 136 |
| 2023 May | 133 | 27 | 160 |
| 2023 April | 128 | 15 | 143 |
| 2023 March | 97 | 24 | 121 |
| 2023 February | 100 | 25 | 125 |
| 2023 January | 77 | 33 | 110 |
| 2022 December | 109 | 34 | 143 |
| 2022 November | 66 | 29 | 95 |
| 2022 October | 85 | 16 | 101 |
| 2022 September | 85 | 38 | 123 |
| 2022 August | 51 | 45 | 96 |
| 2022 July | 50 | 25 | 75 |
| 2022 June | 34 | 18 | 52 |
| 2022 May | 125 | 21 | 146 |
| 2022 April | 185 | 37 | 222 |
| 2022 March | 184 | 44 | 228 |
| 2022 February | 143 | 21 | 164 |
| 2022 January | 142 | 40 | 182 |
| 2021 December | 130 | 38 | 168 |
| 2021 November | 115 | 48 | 163 |
| 2021 October | 94 | 54 | 148 |
| 2021 September | 78 | 40 | 118 |
| 2021 August | 93 | 27 | 120 |
| 2021 July | 106 | 27 | 133 |
| 2021 June | 148 | 33 | 181 |
| 2021 May | 126 | 43 | 169 |
| 2021 April | 269 | 63 | 332 |
| 2021 March | 171 | 26 | 197 |
| 2021 February | 142 | 28 | 170 |
| 2021 January | 56 | 16 | 72 |
| 2020 December | 71 | 12 | 83 |
| 2020 November | 58 | 20 | 78 |
| 2020 October | 53 | 6 | 59 |
| 2020 September | 59 | 22 | 81 |
| 2020 August | 58 | 11 | 69 |
| 2020 July | 52 | 13 | 65 |
| 2020 June | 53 | 36 | 89 |
| 2020 May | 39 | 13 | 52 |
| 2020 April | 31 | 20 | 51 |
| 2020 March | 27 | 14 | 41 |
| 2020 February | 3 | 0 | 3 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 6 | 0 | 6 |
| 2019 April | 17 | 4 | 21 |
| 2019 March | 4 | 0 | 4 |
| 2019 February | 7 | 0 | 7 |
| 2019 January | 6 | 0 | 6 |
| 2018 December | 8 | 0 | 8 |
| 2018 November | 15 | 0 | 15 |
| 2018 October | 11 | 0 | 11 |
| 2018 September | 6 | 0 | 6 |
| 2018 March | 1 | 0 | 1 |
| 2018 February | 48 | 2 | 50 |
| 2018 January | 54 | 11 | 65 |
| 2017 December | 51 | 7 | 58 |
| 2017 November | 50 | 7 | 57 |
| 2017 October | 39 | 11 | 50 |
| 2017 September | 30 | 8 | 38 |
| 2017 August | 23 | 7 | 30 |
| 2017 July | 34 | 10 | 44 |
| 2017 June | 48 | 4 | 52 |
| 2017 May | 28 | 9 | 37 |
| 2017 April | 34 | 9 | 43 |
| 2017 March | 14 | 5 | 19 |
| 2017 February | 112 | 13 | 125 |
| 2017 January | 25 | 6 | 31 |
| 2016 December | 40 | 20 | 60 |
| 2016 November | 25 | 18 | 43 |
| 2016 October | 28 | 17 | 45 |
| 2016 July | 1 | 4 | 5 |
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