What would you do?

[beyond all hope]

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Interesting case

41 yo anabolic steroid user, had been shooting up into his vastus lateralis for year, p/w 1 month swelling of vastus lateralis, intermittant subjective fevers, headaches and anxiety, had been taking a week of Keflex without MD supervision for same.

PE: Afebrile/VSS, NAD, nontoxic but anxious, well-hydrated, leg exam showed approx 15 cm of swelling and hard induration over vastus, normal skin temp/color, no lymphadenopathy, rest of PE normal.

I'll tell you what happened after I hear some responses...

 

[DrQuinn]

Interesting case

41 yo anabolic steroid user, had been shooting up into his vastus lateralis for year, p/w 1 month swelling of vastus lateralis, intermittant subjective fevers, headaches and anxiety, had been taking a week of Keflex without MD supervision for same.

PE: Afebrile/VSS, NAD, nontoxic but anxious, well-hydrated, leg exam showed approx 15 cm of swelling and hard induration over vastus, normal skin temp/color, no lymphadenopathy, rest of PE normal.

I'll tell you what happened after I hear some responses...

CT vs. U/S to r/o pyomyositis/fluid collection/DVT (I probably would go for CT instead of U/S). IVF, CBC, basic lytes, coags cause surg/ortho would want them, sed rate, CPK. Plain films. Smack him in the head for usin' roids.

Q

 

[Seaglass]

CT but thinking its most probably calcification of hematoma, labs.

 

[doctawife]

CT but thinking its most probably calcification of hematoma, labs.

Agree. But I'd want a CBC to eval for leukocytosis just to check. Depending on what part of the country you're in, Keflex may or may not treat a S. aureus infection, although the exam doesn't sound much like a resolving cellulitis/abscess. In Houston we've got a ~65-75% CA-MRSA rate, so if he was from 'round here I doubt the Keflex would be doing anything for him, even if he was taking it regularly. Which would argue for a non-infectious etiology.

Just my $0.02

 

[Hard24Get]

Reminds me of The Man Whose Arms Exploded. In this case, the hematoma got superinfected and he tried to drain the pus out himself. He admitted to picking needles up off the floor and blowing off the debris before reusing...

And for what little it's worth, I agree with Dr. Quinn. 😳

Interesting case

41 yo anabolic steroid user, had been shooting up into his vastus lateralis for year, p/w 1 month swelling of vastus lateralis, intermittant subjective fevers, headaches and anxiety, had been taking a week of Keflex without MD supervision for same.

PE: Afebrile/VSS, NAD, nontoxic but anxious, well-hydrated, leg exam showed approx 15 cm of swelling and hard induration over vastus, normal skin temp/color, no lymphadenopathy, rest of PE normal.

I'll tell you what happened after I hear some responses...

 

[12R34Y]

Since he's posting this my guess is that the patient is probably dead or horribly ill (otherwise where's the fun in the story?)

He's probably got a horrible necrotizing infection that killed him within 24 hours of something like that. I'm really just being ornery, but since he's posting it here it can't be something simple/normal like cellulitis/abscess.

looking forward to course.

later

 

[leorl]

Reminds me of The Man Whose Arms Exploded. In this case, the hematoma got superinfected and he tried to drain the pus out himself. He admitted to picking needles up off the floor and blowing off the debris before reusing...

And for what little it's worth, I agree with Dr. Quinn. 😳

That's so gross. his whole upper body looks like loops of colon.

 

[beyond all hope]

Bedside US showed no significant fluid collection but the muscle layers looked edematous. Definately looked different from opposite side.

I was going to send the guy home with PO clindamycin, (Keflex does not handle community MRSA, as was mentioned previously) FU w/surgery, but he had a rectal temp of 100.9, so sent basic labs.

WBC/Hb normal
Platelets 680.
Chem 8 normal.

CT was ordered...

 

[Annette]

Further info on what he is injecting. Any etOH use? Why the low platelets? What was the "normal" Hgb, WBC?

In addition to the labs and work up already done, cardiac ascultation in a quite room if at all possible. Preferably TEE, but consider bedside 2D as the ED is usually too noisy to hear anything but a 5-6/6. If anything on the echo, multiple blood cultures. Vanc, zosyn. Admit to medicine, consult surgery, ID. No heparin/lmwh. SCD on unaffected leg. Q4 and PRN temp checks. Monitor for tachycardia, hypotension, other signs of SIRS, shock. Consult CVS re: valve replacement.

If something on CT and nothing on echo, surgery admit, ID consult.
? compartment syndrome 2 to infection? Nec fas?

Anxious stupid bodybuilders make me nervous.

 

[DrQuinn]

Ah, can't wait for the CT. BTW, CBC or ESR wouldnt' have changed my disposition... we need to know what's deep down in there... and I wouldnt' stick a needle in it until I knew.

BTW, what was his initial HR when he showed up in the ED? It is my "Q rule" that anyone with a HR greater than 90 generally warrants a slightly longer look.

Q

 

[12R34Y]

Bedside US showed no significant fluid collection but the muscle layers looked edematous. Definately looked different from opposite side.

I was going to send the guy home with PO clindamycin, (Keflex does not handle community MRSA, as was mentioned previously) FU w/surgery, but he had a rectal temp of 100.9, so sent basic labs.

WBC/Hb normal
Platelets 680.
Chem 8 normal.

CT was ordered...

Just curious.....why clinda? We only give clinda to CA-MRSA (ie all skin infections nowadays) if they are allergic to sulfa (Bactrim). Thought Bactrim was the mainstay. Clinda has much more adverse effect profile.

just curious.

Oh, and forgot to add that clinda is soooooo expensive compared to bactrim. My wife's clinda 10-day script for a tooth abscess was over 100.00 !!!!!

bactrim equals CHEAP and in my patient population clinda could never be afforded.

later

 

[DrQuinn]

One way to cut down on the clinda costs is to write them for Clindamycin 150 milligrams, TWO tabs qid, instead of 300 milligrams. Cuts it to 30-45 I think.

Q

 

[beyond all hope]

So, the CT was done which showed a large collection of pus in the muscle. It appeared to have a wall around it, so it was read as intramuscular abscess. Probably was a pyomyositis a few weeks earlier.

Agree with Q that labs and ESR would not have changed my decision to CT. Keep a broad DDx: abscess, pyomyositis, hematoma, soft tissue mass, vascular structure, retained foreign body.

(recently I&Ded an 'abscess' in the buttock, s/p stab wound months prior. Started squirting blood. Turns out it was a pseudoaneurysm of the inferior gluteal artery. After being unable to get it with interventional rads, surgery went in and tied it off after he dropped to Hb 8.)

Gave Vanc and Clinda for broad gram positive protection. Surgery saw him and decided not to touch it until after Abx.

--Wouldn't go crazy about a cardiovascular workup without a murmur or cardio symptoms.--

Of course, right around sunrise after he was admitted but still in the ED he developed 'roid rage and had to be calmed down by my frazzled resident. (I wasn't there at the time.)