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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 11 | 20 |
| 2024 Octubre | 127 | 49 | 176 |
| 2024 Septiembre | 119 | 30 | 149 |
| 2024 Agosto | 153 | 58 | 211 |
| 2024 Julio | 148 | 37 | 185 |
| 2024 Junio | 161 | 43 | 204 |
| 2024 Mayo | 122 | 40 | 162 |
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| 2024 Marzo | 111 | 28 | 139 |
| 2024 Febrero | 152 | 29 | 181 |
| 2024 Enero | 107 | 37 | 144 |
| 2023 Diciembre | 84 | 16 | 100 |
| 2023 Noviembre | 126 | 41 | 167 |
| 2023 Octubre | 150 | 35 | 185 |
| 2023 Septiembre | 125 | 34 | 159 |
| 2023 Agosto | 97 | 23 | 120 |
| 2023 Julio | 125 | 31 | 156 |
| 2023 Junio | 115 | 21 | 136 |
| 2023 Mayo | 133 | 27 | 160 |
| 2023 Abril | 128 | 15 | 143 |
| 2023 Marzo | 97 | 24 | 121 |
| 2023 Febrero | 100 | 25 | 125 |
| 2023 Enero | 77 | 33 | 110 |
| 2022 Diciembre | 109 | 34 | 143 |
| 2022 Noviembre | 66 | 29 | 95 |
| 2022 Octubre | 85 | 16 | 101 |
| 2022 Septiembre | 85 | 38 | 123 |
| 2022 Agosto | 51 | 45 | 96 |
| 2022 Julio | 50 | 25 | 75 |
| 2022 Junio | 34 | 18 | 52 |
| 2022 Mayo | 125 | 21 | 146 |
| 2022 Abril | 185 | 37 | 222 |
| 2022 Marzo | 184 | 44 | 228 |
| 2022 Febrero | 143 | 21 | 164 |
| 2022 Enero | 142 | 40 | 182 |
| 2021 Diciembre | 130 | 38 | 168 |
| 2021 Noviembre | 115 | 48 | 163 |
| 2021 Octubre | 94 | 54 | 148 |
| 2021 Septiembre | 78 | 40 | 118 |
| 2021 Agosto | 93 | 27 | 120 |
| 2021 Julio | 106 | 27 | 133 |
| 2021 Junio | 148 | 33 | 181 |
| 2021 Mayo | 126 | 43 | 169 |
| 2021 Abril | 269 | 63 | 332 |
| 2021 Marzo | 171 | 26 | 197 |
| 2021 Febrero | 142 | 28 | 170 |
| 2021 Enero | 56 | 16 | 72 |
| 2020 Diciembre | 71 | 12 | 83 |
| 2020 Noviembre | 58 | 20 | 78 |
| 2020 Octubre | 53 | 6 | 59 |
| 2020 Septiembre | 59 | 22 | 81 |
| 2020 Agosto | 58 | 11 | 69 |
| 2020 Julio | 52 | 13 | 65 |
| 2020 Junio | 53 | 36 | 89 |
| 2020 Mayo | 39 | 13 | 52 |
| 2020 Abril | 31 | 20 | 51 |
| 2020 Marzo | 27 | 14 | 41 |
| 2020 Febrero | 3 | 0 | 3 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 6 | 0 | 6 |
| 2019 Mayo | 6 | 0 | 6 |
| 2019 Abril | 17 | 4 | 21 |
| 2019 Marzo | 4 | 0 | 4 |
| 2019 Febrero | 7 | 0 | 7 |
| 2019 Enero | 6 | 0 | 6 |
| 2018 Diciembre | 8 | 0 | 8 |
| 2018 Noviembre | 15 | 0 | 15 |
| 2018 Octubre | 11 | 0 | 11 |
| 2018 Septiembre | 6 | 0 | 6 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 48 | 2 | 50 |
| 2018 Enero | 54 | 11 | 65 |
| 2017 Diciembre | 51 | 7 | 58 |
| 2017 Noviembre | 50 | 7 | 57 |
| 2017 Octubre | 39 | 11 | 50 |
| 2017 Septiembre | 30 | 8 | 38 |
| 2017 Agosto | 23 | 7 | 30 |
| 2017 Julio | 34 | 10 | 44 |
| 2017 Junio | 48 | 4 | 52 |
| 2017 Mayo | 28 | 9 | 37 |
| 2017 Abril | 34 | 9 | 43 |
| 2017 Marzo | 14 | 5 | 19 |
| 2017 Febrero | 112 | 13 | 125 |
| 2017 Enero | 25 | 6 | 31 |
| 2016 Diciembre | 40 | 20 | 60 |
| 2016 Noviembre | 25 | 18 | 43 |
| 2016 Octubre | 28 | 17 | 45 |
| 2016 Julio | 1 | 4 | 5 |
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