Case for Diagnosis
Recurrent Buttock Cellulitis in a Young Man
Celulitis glútea de repetición en un varón joven
D. Morgado-Carrasco
, P. Giavedoni, J.M. Mascaró
Corresponding author
Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, España
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Morgado-Carrasco, P. Giavedoni, J.M. Mascaró" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Morgado-Carrasco" "email" => array:1 [ 0 => "morgadodaniel8@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Giavedoni" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Mascaró" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Celulitis glútea de repetición en un varón joven" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 645 "Ancho" => 900 "Tamanyo" => 135755 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin, ×200.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A healthy 27-year-old heterosexual man visited the emergency department with diffuse edema in the buttocks, fever, and poor overall condition, which had appeared a week earlier. The patient had also presented in the previous year with cellulitis in the same location on up to 12 occasions and had received antibiotic treatment on multiple occasions for this reason. The patient stated that he had no past history of trauma and had not undergone topical or intramuscular treatment in that region.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Examination revealed tense, erythematous plaques (between 5 and 10<span class="elsevierStyleHsp" style=""></span>cm in diameter) that were hot to the touch, and nodules in the gluteal and sacral region, showing marked asymmetry between the 2 buttocks (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Palpation also revealed swollen lymph glands measuring approximately between 1 and 2.5<span class="elsevierStyleHsp" style=""></span>cm. Blood tests revealed leukocytosis with neutrophilia and raised C-reactive protein (CRP) levels (13.65<span class="elsevierStyleHsp" style=""></span>mg/dL). Despite attempts to puncture the nodules, it was not possible to obtain material for study. The patient was admitted to the infectious disease unit and empirical intravenous antibiotic treatment was instated with ceftriaxone and clindamycin.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A pelvic CT scan revealed diffuse bilateral thickening in the superficial and deep soft tissue, which corresponded to radiologic signs of cellulitis and fasciitis. Both gluteus maximus muscles showed hypodense areas measuring approximately 6<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm, and signs of myositis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Two skin biopsies were performed, 1 of which was sent for histopathology study (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and the other for microbiology culture.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">What is your diagnosis?</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Diagnosis and Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">The microbiology culture was negative. Histology revealed multiple empty cystic areas in the dermis and hypodermis, surrounded by an inflammatory histiocyte infiltrate. The study also revealed abundant foam cells and multinucleate giant cells (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><p id="par0025" class="elsevierStylePara elsevierViewall">When questioned again, the patient admitted that he had undergone injections with mineral oil 2 years earlier in the buttocks on up to 30 occasions, for esthetic purposes. A year later, he began to present the symptoms described above. In light of this information, foreign body granuloma was diagnosed and treatment with 40<span class="elsevierStyleHsp" style=""></span>mg per day of prednisone was prescribed; a complete clinical response was achieved. The patient was then discharged with a descending dose of prednisone over 2 weeks. Because he continued to present intermittent episodes, minocycline was prescribed at a dosage of 100<span class="elsevierStyleHsp" style=""></span>mg per day, with no clinical improvement. Alopurinol was later prescribed but was poorly tolerated by the patient and it was therefore decided to change to 400<span class="elsevierStyleHsp" style=""></span>mg per day of hydroxychloroquine; however, the episodes persisted. The patient has since been undergoing intermittent pulse corticosteroid therapy with prednisone and has remained asymptomatic.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The popularity of injectable fillers has increased markedly in recent decades. The materials used include a wide variety of nonauthorized products.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> Mineral oil (petrolatum) has been used for cosmetic purposes to perform injections of permanent dermal filler. This filler has even been used to increase muscle volume<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> and penis size.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,4</span></a> The cosmetic results immediately after injections of petrolatum tend to be satisfactory; however, the long-term complications are disastrous. For this reason, petrolatum is not currently considered legal for use as a filler. Furthermore, it is not generally administered by medical personnel and is most frequently self-injected.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The adverse effects of injections of fillers include arterial occlusion, tissue necrosis, embolism, infections, hypersensitivity reactions, migration of the injected material, and even death.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The formation of sclerosing lipogranuloma or paraffinoma, a granulomatous reaction associated with intense fibrosis, is a frequent complication secondary to injection of mineral oil.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,4</span></a> Histology often shows a “Swiss cheese” image, owing to cystic spaces that replace the normal subcutaneous cell tissue.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Complications following the injection of liquid chemical products will present in a period of time that may vary from months to years.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Adverse effects, such as infection and ulceration, are often seen within 18.5 months after the paraffin injections.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> With regard to treatment, complete surgical excision is the best option for preventing recurrence<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a>; however, complete excision is often not possible. Macrolides and tetracyclines have been shown to produce good results where infection is suspected, partly owing to their anti-inflammatory action.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Oral or intralesional corticosteroids can be used to reduce granulomatous immune reactions.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,5</span></a> Other therapeutic alternatives include tacrolimus, etanercept, and alopurinol.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Although most medical professionals no longer inject unauthorized products, unqualified personnel continue to expose themselves and third parties to severe complications. It is therefore very important to take this entity into consideration as a possible diagnosis, as most patients will be reluctant to admit to having undergone these procedures. It should also be remembered that the adverse effects caused by injecting this material may appear after a long period of latency.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "What is your diagnosis?" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis and Discussion" ] ] ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Morgado-Carrasco D, Giavedoni P, Mascaró JM. Celulitis glútea de repetición en un varón joven. Actas Dermosifiliogr. 2020;111:63–64.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 669 "Ancho" => 900 "Tamanyo" => 113797 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 548 "Ancho" => 900 "Tamanyo" => 65663 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 645 "Ancho" => 900 "Tamanyo" => 135755 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin, ×200.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nonmedical-grade Injections of Permanent Fillers: Medical and Medicolegal Considerations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 10 | 30 |
| 2024 October | 175 | 42 | 217 |
| 2024 September | 212 | 33 | 245 |
| 2024 August | 248 | 68 | 316 |
| 2024 July | 260 | 43 | 303 |
| 2024 June | 229 | 76 | 305 |
| 2024 May | 221 | 36 | 257 |
| 2024 April | 191 | 32 | 223 |
| 2024 March | 171 | 31 | 202 |
| 2024 February | 224 | 31 | 255 |
| 2024 January | 307 | 31 | 338 |
| 2023 December | 256 | 16 | 272 |
| 2023 November | 275 | 22 | 297 |
| 2023 October | 209 | 19 | 228 |
| 2023 September | 205 | 32 | 237 |
| 2023 August | 183 | 11 | 194 |
| 2023 July | 244 | 33 | 277 |
| 2023 June | 252 | 17 | 269 |
| 2023 May | 269 | 18 | 287 |
| 2023 April | 274 | 23 | 297 |
| 2023 March | 236 | 33 | 269 |
| 2023 February | 211 | 24 | 235 |
| 2023 January | 248 | 27 | 275 |
| 2022 December | 190 | 42 | 232 |
| 2022 November | 222 | 32 | 254 |
| 2022 October | 188 | 22 | 210 |
| 2022 September | 139 | 36 | 175 |
| 2022 August | 85 | 29 | 114 |
| 2022 July | 63 | 36 | 99 |
| 2022 June | 48 | 29 | 77 |
| 2022 May | 212 | 47 | 259 |
| 2022 April | 244 | 37 | 281 |
| 2022 March | 241 | 52 | 293 |
| 2022 February | 198 | 43 | 241 |
| 2022 January | 175 | 30 | 205 |
| 2021 December | 193 | 40 | 233 |
| 2021 November | 153 | 35 | 188 |
| 2021 October | 190 | 49 | 239 |
| 2021 September | 144 | 41 | 185 |
| 2021 August | 142 | 24 | 166 |
| 2021 July | 114 | 23 | 137 |
| 2021 June | 111 | 24 | 135 |
| 2021 May | 124 | 42 | 166 |
| 2021 April | 306 | 87 | 393 |
| 2021 March | 153 | 25 | 178 |
| 2021 February | 104 | 30 | 134 |
| 2021 January | 118 | 21 | 139 |
| 2020 December | 127 | 12 | 139 |
| 2020 November | 100 | 22 | 122 |
| 2020 October | 88 | 18 | 106 |
| 2020 September | 79 | 12 | 91 |
| 2020 August | 47 | 9 | 56 |
| 2020 July | 29 | 7 | 36 |
| 2020 June | 28 | 14 | 42 |
| 2020 May | 26 | 15 | 41 |
| 2020 April | 58 | 28 | 86 |
| 2020 March | 24 | 12 | 36 |
| 2020 February | 1 | 1 | 2 |
| 2019 September | 1 | 2 | 3 |
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