The patient was discovered to have acute lymphocytic leukemia at 18 months of age. Over the next 18 months, the child received chemotherapy. He presented with a history of 2 weeks of fever and pain in the gluteal region which had developed after receiving an intramuscular (IM) injection in the region by a health care provider in a remote northeast peripheral area of Pakistan.
On examination, vital signs were stable without tachypnea, hypotension, tachycardia, or fever. There was no rash, and an indwelling urinary catheter and Port-a-Cath were in place. Lungs were bilaterally clear, equal, and vesicular. No abnormalities were seen in the abdominal examination, and there was no organomegaly. Neurological examination was unremarkable and without neck rigidity. Kernig and Brudzinski signs were absent. The upper outer quadrant of right gluteal region was tender, warm, and fluctuant. Laboratory investigations showed an absolute neutrophil count of 1170 cells/μL with a total white blood cell count of 6650 cells/μL and lymphocyte predominance (65%). Serum electrolytes were normal. A lumbar puncture was performed. The opening pressure was normal, and cells, proteins, and glucose in the cerebro-spinal fluid were within normal limits. Gram stain and cultures were negative for cerebro-spinal fluid.
Surgical drainage of the abscess revealed purulent material which grew Neisseria meningitidis. Gram staining, biochemical testing, and colony morphology and culture were consistent with the diagnosis. A blood culture drawn a day before surgical drainage also grew the same organism. It was sensitive to cefotaxime, cefuroxime, ciprofloxacin, and amikacin. Intravenous (IV) cefotaxime was administered, and the child was discharged 1 week after admission in stable condition on cefotaxime 800 mg every 6 hours for 6 more days. Chemoprophylaxis was not given to the close contacts as it has been more than 2 weeks since exposure began.
An estimated 12 billion injections are administered annually worldwide according to the Centers for Disease Control and Prevention.1 Injection abscess is an iatrogenic infection occurring as an isolated case or as a cluster outbreak. The usual modes are thought to be contaminated injectables or lapse in sterilization protocol. In our patient, it is possible that he had bacteremia before injection, and a local hematoma may have become infected.
Injection abscess occurs in about 0.4% of all IM injection recipients.2 Tattooing and implants are other potential sources of injection abscesses. It can be as high as 32% in IV drug abusers.3
The usual culprits are shown in Table 1. Staphylococcus aureus is very common. No prior reports of meningococcus causing an injection abscess were found in English literature using PubMed/Medline.
Neisseria meningitidis is a gram-negative diplococcus. Typical presentation of meningococcal infection includes bacteremia without sepsis, meningococcemia without meningitis, meningitis with/without meningococcemia, and meningoencephalitis.12
Injection abscess should be differentiated from pyomyositis, a primary, acute, usually staphylococcal (72%-90%) infection of the skin and soft tissues, mostly unrelated to trauma cases.13 Pyomyositis is mostly associated with immunodeficiency, for example, steroid use, diabetes mellitus, leukemia, neutropenia, myelodysplasia, sickle cell anemia, lymphoma, and IV drug abuse.
Treatment is incision and drainage combined with antibiotics. Further antibiotic treatment is best guided by sensitivity patterns. In nonhealing injection abscesses, drainage-irrigation systems can be used to expedite healing.14 In any nonhealing wound, purulent material should be stained and cultured for acid-fast bacilli.5
Most official bodies recommended the following15:
* Buttocks should be avoided for IM injections and used only if a large volume is to be injected. In this case, the upper outer quadrant of the buttock should be used, and the needle directed anteriorly.
* Anterolateral thigh in infants and deltoid in older children are preferred sites.
* A needle length of five-eighth inch is minimum for all IM or deep subcutaneous injections.
* The deeper the injection, the less likely is abscess formation.16
Some authors feel routine skin preparation is unnecessary and may not prevent abscess formation, if the skin is grossly clean.17
Reuse of syringes (8%) and changing needles on the same syringes (31%) in most of the third-world countries and IV drug abuse in developed countries are precipitants of injection abscesses.18 Global estimates of unsafe injection practices range from 15% in Eastern Europe to 50% throughout Asia.1 In Hafizabad, Pakistan, the proportion of injections conducted with a new sterile syringe increased from 24% to 60% after health education programs were conducted in mosques.1
Injection abscess is common where sterility is not. In immunocompromised hosts, unusual organisms such as N. meningitidis can cause infections in uncommon sites including IM injection sites. Prompt recognition with early incision and drainage and antibiotic coverage is the key.
1. Luby S. Injection safety. Emerg Infect Dis.
2. Greenblatt DJ. Intramuscular injection site complications. JAMA
3. Centers for Disease Control and Prevention (CDC). Soft tissue infections among injection drug users: San Francisco, California, 1996-2000. MMWR Morb Mortal Wkly Rep
4. Devi DG, Indumathi VA, Indira S, et al. Injection site abscess due to Mycobacterium fortuitum
: a case report. Indian J Med Microbiol
5. Gremillion DH. Injection abscesses caused by M. chelonae
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6. Sultan F, Tebas P, Wallace RJ Jr, et al. Rapid development of resistance to clarithromycin following monotherapy for disseminated M. chelonae in a heart transplant patient. Clin Infect Dis. 1995;20:443-444.
7. Villanueva A, Calderon RV, Vargas BA, et al. Report on an outbreak of post injection abscesses due to Mycobacterium abscessus
, including management with surgery and clarithromycin therapy and comparison of strains by random amplified polymorphic DNA polymerase chain reaction. Clin Infect Dis
8. Galil K, Miller LA, Yakrus MA, et al. Abscesses due to Mycobacterium abscessus
linked to injection of unapproved alternative medication. Emerg Infect Dis
9. Raghunath R, Ashok AC, Sridaran D, et al. A case of injection abscess due to S. typhi
. Indian J Med Microbiol
10. Lalitha MK, John R. Unusual manifestations of salmonellosis-a surgical problem. Q J Med
11. Berger U, Muller HE. Injection abscess due to Neisseria perflava
12. Apicella MA. Neisseria meningitidis.
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13. Samuel S, Rosenberg AE. Case 29-1997-a 54-year-old diabetic woman with pain and swelling of the leg. N Engl J Med
14. Borodianski VS, Shoîkhet AE, Pinchuk AS, et al. Current methods of treating post-injection abscesses [in Russian]. Klin Khir
15. Royal College of Pediatric and Child Health, Royal College of Nursing. Position statement on injection techniques. March 2002. Department of Health. Immunization Against Infectious Disease
. London: HMSO; 1996.
16. Sako W, Treuting W. Early immunization against pertussis with alum precipitated vaccine. JAMA
17. Dann et al. Preparing skin for injections and venipuncture. Drugs Ther Bull
18. Daly AD, Nxumalo MP, Biellik RJ. An assessment of safe injection practices in health facilities in Swaziland. S Afr Med J