Clinical case
Male patient 25 years old from Trujillo and from the locality, transgender, without significant pathological history who started the current disease of 2 months characterized by an increase in volume in both buttocks accompanied by signs of inflammation due to flushing, heat and induration with progression of these signs of descending migratory form to bilateral pediatric region, which makes it difficult for the patient to walk after the intramuscular administration of 100 ml of unknown substance in both gluteal regions for aesthetic purposes in a clandestine manner by unauthorized personnel in the month of July. present year, so it consults a physician who prescribes Glucocorticoid type Dexamethasone 8 mg / BID treatment for 7 days without clinical improvement; 1 week prior to admission, an increase in unquantified body temperature was associated, without a predominance of hours that gave rise to the administration of antipyretics, myalgia and generalized arthralgias.
Personal Pathological Background:
- Bronchial asthma since childhood- Last crisis since adolescence.
- Denies chronic pathologies and drug allergy.
- Denies surgical interventions and previous hospitalizations.
Family Pathological Background:
- Living mother- Bronchial asthma.
- Father alive - Apparently healthy.
- Brothers 4 - Apparently healthy.
Psychobiological Background:
- Acolytic habits accented without reaching the type Beer intoxication.
- Habits Tabáquicos: occasional IPA 2.
- Caffeine habits 2 cups-day.
- Sexuality: Homosexual Promiscuous- without protection.
- Occupation: Stylist.
Functional Physical Exam:
- Evacuation pattern according to Bristol 4.
Physical exam:
- TA: 110-80mmHg FC: 100 lpm FR: 20 rpm
Patient in regular clinical conditions, afebrile, hydrated, eupneic. Skin and Mucous: Moist and Normocolored. Neck: Movable, no previous anterior cervical adenopathies, retroauricular or periauricular, Thyroid not palpable or visible, Torax: Normoexpansible, Tattoos (deposits of exogenous pigments) in posterior thoracic region. Cardiopulmonary: Apex in 5th Intercostal space with mid clavicular line Rhythmic Cardiac Noises murmur not audible, audible breath sounds in both hemitorax without aggregates. Abdomen: Multiple tattoos are observed, soft, depressible, hydro-acoustic noises present not painful to superficial or deep palpation. No hepatosplecnomegaly. Extremities: Increase in volume is observed with signs of phlogosis (heat, flushing, induration) in the internal and posterior lateral region of both legs (from the twin region to the ankles), pain at the compression of left gastrocnemius muscle, peripheral pulses present and synchronous Neurological Conscious, oriented in space time and person without motor or sensory deficit. Osteotendinous reflexes preserved. No meningeal signs.
Para-clinic:
VDRL: Not reactive
HIV (ELISA): Negative
PCR (Quantified): 3.2 mg-dl
Hepatitis Markers:
Surface Antigen (HBsAg): 0.02 EU-ml
ANTICORE: 1.98 EU-ml
Hepatitis C: Not Reactive.
Blood culture: 31-08 -17: Negative for bacterial growth.
Echogram Doppler of Lower Members:
Normal gauge veins. No thrombi. Single-phase venous flow pattern. Normal dissection Arterial system without alterations.
Echogram of Skin and Soft Parts of Lower and Gluteal Members Left:
In left lower limb and left gluteal region there is evidence of increased echogenicity in subcutaneous cellular tissue without the presence of collections, it correlates with the inflammatory process. In the lower right limb at the level of the leg there is an increase in right echogenicity. No collections or edema are observed in the explored area. It correlates with inflammatory process.
Development.
The skin is the largest and most extensive organ that the human being has, it weighs approximately 5 kg, it represents the main defense barrier of the organism against external agents. Constituted by three layers that go from superficial to deep.
Superficial and vascular epidermis, whose primary function is protection.
Dermis and subcutaneous cellular tissue, deeper layer and with blood supply and finally we have the hypodermis.
For practical purposes only the first two are studied, the skin in turn also depends on certain structures called cutaneous attachments corresponding to the nails, hairs, sebaceous glands and sweat glands.
There is a constant balance between the microorganisms and the host, so that the alteration of this balance may favor the appearance of infectious processes in skin as it is in this clinical case.
The cutaneous manifestations of an infectious process can be produced by several fundamental mechanisms.
Primary local infection with in situ replication of the bacteria (eg impetigo)
Circulating exotoxins, staphylococcal scalded skin syndrome.
Immunological mechanisms, such as vasculitis in streptococcal infection.
Affectation of the skin as part of a systemic picture, meningococcal sepsis.
Manifestation of a disseminated intravascular coagulopathy, as also occurs in meningococcal sepsis or in some Rickettsia infections.
Skin and soft tissue infections are defined according to their location regardless of the microorganism that produces it, it must be borne in mind that skin infections affect only the epidermis, dermis and subcutaneous cellular tissue, while soft tissue infections affect the deep facial and muscle.
The bacteria most frequently involved in these processes correspond to the microorganism of the normal transient flora of the skin and therefore we will have infections by S.aureus, S. pyogenes, with less incidence we will be able to observe S. agalactiae, great negatives, clostridium and other anaerobes.
Continuing with the clinical case, we must make relevance in the antecedent that the patient possesses, being the administration of unknown substance without means of biosecurity and sterility of the used implements, originating in said zone an intoxication by moldable substances that triggered a skin infection and soft parts in said area; abscess cellulitis in gluteus.
Understand the term cellulite; Inflammation of the dermis and subcutaneous cellular tissue that is characterized by edema, erythema and pain of the affected area (what are known as signs of phlogosis). It is usually associated with associated lymphangitis and constitutional symptoms. The most frequently implicated microorganisms are S. pyogenes and S. aureus, although in certain circumstances pneumococcus, Salmonella or Enterobacteria can also produce it. . Cellulitis can occur by contiguity due to another type of infection, such as impetigo, or as a consequence of bacteremia. It can generate complications such as arthritis, osteomyelitis, thrombophlebitis, bacteremia or necrotizing fasciitis.
The etiological diagnosis can be achieved in 25% of cases with blood culture or culture of aspirate from the area of maximum inflammation.
Antibiotic treatment should always be administered systemically; consider endovenous treatment initially, with drugs that cover large positive bacteria as long as the aforementioned microorganisms are suspected, which prevails with a higher incidence rate.
Credits:
- http://www.aeped.es/sites/default/files/documentos/piel.pdf
- https://es.wikipedia.org/wiki/Piel
- Harrison. (2004). Principles of Internal Medicine. Fifteenth edition. Madrid. Editorial Mc graw Hill.