Tuesday, December 11, 2007

Iatrogenic or Not?

Your opinion is sought.
The patient is a 42 y.o. woman with a long history of cystic acne. Typically she gets a few lesions a year. She has many ice pick scars from previous lesions. She was offered isotretinoin years ago but declined and indeed the lesions are less frequent now. She presents for intralesional triamcinalone when whe wishes to have the cysts treated. She was seen on December 5, 2007 with a tender cyst on the medial aspect of the left eyebrow. It looked like a typical acne cyst and was injected with Kenalog 3 mg per cc. Two days later she started to develop eyelid edema. She went to the Emergency Room and was given parenteral Rocephin and Cipro 500 mg bid. The swelling persists.

On examination, one can see where the initial cyst was. It's ~ 90% resolved. Below it there's a firm linear band that feels like a lymphangitic vessel.

I assume this must be related to the initial inflammatory lesion or the intralesional injection. I searched MEDLINE but could come up with no similar cases. If this is secondary to intralesional steroids, it is not reported. Could the original lesion have been a pyogenic infection that looked like her past cysts and could eyelid edema be secondary to lymphatic obstruction? The ER doc recommended another dose of Rocephin.
Addendum: The patient has never had fever, headache or other findings suggestive of a pyogenic infection.

Has anyone seen a similar case? Diagnostic and therapeutic suggestions are welcome.

1 comment:

  1. I have seen two cases like that. The first one was lymphedema chronic and the second Lupus erythematosus profundus (Kaposi-Irgang)-after biopsy. I believe is the first one. About treatment of lymphedema chronic was Trental, Detralex and antibiotic with good effect for 2-3 months but the lesion was recurrent again.I refer this patient to angiosurgeon.


We welcome your comments. We endeavor to serve your patients and you. If you want us to respond, please add your name and email address. Some people have trouble uploading comments. In that case, please send comments directly to djelpern@gmail.com. Thank you.