Black Market Steroid Injection Gone Wrong

CASE PRESENTATION

A 35-year-old healthy man was referred to our emergency room by his physician because of painful skin necrosis over the left buttock approximately 5 × 4 cm and painful skin necrosis with purulent discharge on the right approximately 6.5 × 4 cm (Fig.1).

Figure 1
A 35-year-old healthy male referred by his physician due to painful skin necrosis approximately 5 × 4 cm and painful skin necrosis with purulent discharge on the right approximately 6.5 × 4 cm.

The patient stated that he is a recreational “body builder” and uses illicit substances to rapidly gain muscle mass. He has been using testosterone and various anabolic steroids for the past 4 years and 3 weeks before his referral changed his regimen to include a new steroid, Trenbolone. He recalled feeling pain upon injection, which led to him injecting more slowly and in an alternating pattern to both gluteus maximus muscles. The patient recalled persistent tenderness and induration in the injection sites followed by “darkening of the skin,” extreme pain, and secretion.

The patient was prescribed a course of first-generation cephalosporin, followed by a course of amoxicillin and clavulanic acid by his physician with no improvement and thereafter was referred to our center.

In the Plastic and Reconstructive Surgery Department, he underwent surgical wound debridement. The necrosis seemed to involve the skin, subcutaneous fat, and a small portion of the gluteus maximus muscle. Wound cultures were positive for Staphylococcus aureus and treated locally with mafenide acetate irrigation and wound dressings. Wound closure options included surgical closure by skin graft, local flaps, or healing by secondary intention. Because of the patient’s concern of further scarring and donor site morbidity, the wound was designated for healing by secondary intention. The patient was discharged with clean wounds and a hydrocolloid dressing 7 days after being admitted to the department. On ambulatory follow-up, the wound healed well with good granulation tissue filling the wound and peripheral epithelialization was observed shrinking the wound on the left to 3.5 × 3 cm and the wound on the right to 5 × 3 cm by 3 weeks after discharge (Figure 2) . At 6 weeks after discharge, wound dressings were changed to polyurethane (Figure 3) and complete epithelialization was observed by 2 months after discharge (Figure 4 ). No complications were noted.

Figure 2
On ambulatory follow-up, the wound healed well with good granulation filling the wound and peripheral epithelialization shrinking the wound on the left to 3.5 × 3 cm and the wound to the right to 5 × 3 cm by 3 weeks after discharge.
Figure 3
At 6 weeks, wound dressings were changed to polyurethane. Almost complete epithelialization 1.5 months after discharge.
Figure 4
Complete epithelialization by 2 months after discharge.
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