International Journal of Infectious Diseases 14 (2010) e823–e824
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Medical Imagery
Necrotizing myositis of the deltoid following intramuscular injection of anabolic steroid [(Figure_1)TD$IG]
Figure 1. CT scan showing gas and fluid collection in the deltoid and pockets of gas within the soft tissue.
A 25-year-old male bodybuilder was admitted in septic shock. He had marked limitation of left shoulder movement with nonfluctuant swelling extending from the acromio-clavicular joint to the postero-lateral and anterior deltoid. Lesions consistent with herpes labialis were also noted. A computed tomography scan demonstrated collections of both gas and fluid within the deltoid muscle and numerous pockets of gas within the soft tissues conforming to the fascial planes (Figure 1). On further questioning he admitted to injecting himself with anabolic steroids into the left deltoid region six days prior to admission. He underwent emergency drainage with debridement of large areas of necrotic muscle and a fasciotomy of the upper arm. Gemella morbillorum and Veillonella were isolated from culture of pus. Dialister pneumosintes was grown from blood cultures. The strains were
identified by 16 s rDNA sequencing. He was treated with benzyl penicillin and clindamycin. Histology showed necrotic skeletal muscle tissue with mixed inflammatory infiltrate. Despite extensive muscle debridement he retained excellent shoulder function. The use of anabolic steroids for performance enhancement amongst young adults is well known. According to a Home Office estimate, there are more than 40 000 users of anabolic steroids in the UK.1 As many as 36% of anabolic steroid users are not athletes.2 The pathogens recovered in the setting of anabolic steroid injection-related abscess include Staphylococcus aureus, Streptococcus, and Pseudomonas.1,3 Both solitary and multiple abscesses have been reported. A solitary abscess may result from a ‘spot shot’, where injection is used to build a specific muscle group, such as the deltoid or the pectoral muscle.4 The common mode of acquisition
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Medical Imagery / International Journal of Infectious Diseases 14 (2010) e823–e824
of infection is thought to be related to needle contamination with skin flora and due to contaminated drug.1 G. morbillorum is part of the normal flora of the respiratory tract and was once classified as a member of the viridans Streptococcus family. Veillonella and Dialister are rare anaerobic pathogens. They are part of the normal oral and gut flora. Systemic infection has been documented following injection use,5 after endoscopic procedures,6 and in immunocompromised patients.7 Herpes viruses are known to activate periodontal bacteria by impairing local defense mechanisms.8 High doses of anabolic steroids with an intact steroid nucleus are immunosuppressive, while steroids with an altered nucleus are known to stimulate the T lymphocytes.9 We are unsure as to the chemical nature of the steroid in this case as it was acquired illicitly. Although the exact mode of infection is uncertain, the triad of anabolic steroid-mediated immunosuppression, reactivation of herpes simplex, and anaerobic bacteremia with seeding of a traumatized area in the deltoid could explain the pathogenesis in this patient. Acknowledgements We acknowledge the NPHS microbiology laboratory, Cardiff for confirming the identities of the isolated pathogens. Conflict of interest: No conflict of interest to declare. References 1. Marquis CP, Maffulli N. Anabolic steroid related abscess—a risk worth taking? Injury Extra 2006;37:451–4.
2. Bahrke MS, Yesalis CE, Kopstein AN, Stephens JA. Risk factors associated with anabolic androgenic steroid use among adolescents. Sports Med 2000;29:397– 405. 3. Bergman RT. Contaminated drug supply. Phys Sportmed 1993;21:8. 4. Rich JD, Dickinson BP, Flanigan TP, Valone SE. Abscess related to anabolicandrogenic steroid injection. Med Sci Sports Exerc 1999;31:207–9. 5. Oh S, Havlen PR, Hussain N. A case of polymicrobial endocarditis caused by anaerobic organisms in an injection drug user. J Gen Intern Med 2005;20:C1–2. 6. Marriott D, Stark D, Harkness J. Veillonella parvula discitis and secondary bacteremia: a rare infection complicating endoscopy and colonoscopy? J Clin Microbiol 2007;45:672–4. 7. Strach M, Siedlar M, Kowalczyk D, Zembala M, Grodzicki T. Sepsis caused by Veillonella parvula infection in a 17-year-old patient with X-linked agammaglobulinemia (Bruton’s disease). J Clin Microbiol 2006;44:2655–6. 8. Slots J. Herpesviral–bacterial synergy in the pathogenesis of human periodontitis. Curr Opin Infect Dis 2007;20:278–83. 9. Marshall-Gradisnik S, Green R, Brenu EW, Weatherby RP. Anabolic androgenic steroids effects on the immune system: a review. Cent Eur J Biol 2009;4: 19–33.
Stephen Granta Jonathan Dearinga Sujoy Ghoshb Andrew Collierb Abhijit M. Balb* a Departments of Orthopaedics and Diabetes & Endocrinology, Ayr Hospital, Ayr Scotland, UK b Department of Medical Microbiology, Crosshouse Hospital, NHS Ayrshire and Arran, Kilmarnock KA2 0BE, Scotland, UK *Corresponding author. Tel.: +44 (0)1563 827422 E-mail address:
[email protected] (A.M. Bal) Corresponding Editor: Vikas Trivedi, Meerut, India
