Filos, Kriton

Kalogeropoulou, Christina

Karamouzos, Vassilios

Karanikolas, Menelaos

Matzaroglou, Charis

Velissaris, Dimitrios

English

PubMed

Dimitrios Velissaris

Charis Matzaroglou

Christina Kalogeropoulou

Vassilios Karamouzos

Kriton Filos

Menelaos Karanikolas

Springer - Publisher Connector

Sepsis requiring intensive care following intramuscular injections: two case reports

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Case report
Open Access
Sepsis requiring intensive care following intramuscular injections:
two case reports
Dimitrios Velissaris1, Charis Matzaroglou2, Christina Kalogeropoulou3,
Vassilios Karamouzos1, Kriton Filos1 and Menelaos Karanikolas1*
Addresses: 1Department of Anaesthesiology and Critical Care Medicine, Patras University Hospital, Rion 26500, Greece
2Department of Orthopaedic Surgery, Patras University Hospital, Rion 26500, Greece
3Department of Radiology, Patras University Hospital, Rion 26500, Greece
Email: DV - dimitrisvelissaris@yahoo.com; CM - orthopatras@yahoo.gr; CK - rat@med.upatras; VK - vkaramouzos@hotmail.com;
KF - filosks@med.upatras.gr; MK* - kmenelaos@yahoo.com
*Corresponding author
Received: 20 April 2009 Accepted: 27 July 2009 Published: 18 August 2009
Cases Journal 2009, 2:7365 doi: 10.4076/1757-1626-2-7365
This article is available from: http://casesjournal.com/casesjournal/article/view/7365
© 2009 Velissaris et al.; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Introduction: Intramuscular injections can rarely result in serious infectious complications such as
abscesses which may progress to bacteraemia and generalized sepsis. These complications are rare,
but can be life threatening, as they can lead to multi-organ failure associated with high morbidity and
mortality.
Case presentation: In this report we present two patients who developed life-threatening
infections after intramuscular injections. They were admitted to the hospital, had prompt surgical
drainage, required ICU admission for severe sepsis, were treated with an early goal-directed therapy
protocol and had a good outcome.
Conclusion: Sepsis is a rare, potentially life-threatening complication after intramuscular injections.
Timely surgical drainage followed by appropriate ICU care and early goal directed therapy is crucial
and may contribute to a good outcome in these rare cases.
Introduction
Intramuscular injections (IM) can lead to local infec-
tious complications, such as abscesses [1,2] skin
necrosis [3] or intra-articular infections, and can rarely
progress to generalized sepsis and multi-organ failure
[4]. Such serious infections are more likely to occur in
immuno-compromised patients but have also been
described in immune-competent persons. They are
usually caused by Staphylococcus aureus and require
timely medical and surgical treatment. Life-threatening
generalized sepsis is rare but has been reported [4,5],
and aggressive care in an ICU is required for optimal
results in these cases. We describe two patients with
multiple abscesses and generalized sepsis caused by
Staphylococcus aureus after intramuscular injections. Both
patients were treated with early surgical drainage, were
supported in the ICU with a goal-directed protocol [6]
and had a good outcome.
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Case presentation
Case report 1
A 54-year-old Caucasian male patient with insulin-
dependent diabetes and remote history of alcohol abuse
was admitted through the Emergency Room with high
fever. Physical examination revealed a small tender,
erythematous, fluctuant mass on the antero-lateral
aspect of the right thigh. He had received just one IM
aminoglycoside injection for treatment of an upper
respiratory infection, approximately 48 hours before
coming to the Hospital. Diagnostic workup [7,8] included
CT of the abdomen and thighs with and without contrast,
which revealed air and fluid collections in the peritoneum
and right thigh (Figures 1, 2, 3). The patient had retro-
peritoneal abscess drainage via bilateral J-shaped lower
abdominal incision and right thigh abscess drainage via
a Moore-type southern incision in the operating room.
After the woundwas closed, drains were left for continuous
retroperitoneal space irrigation. Postoperatively, the
patient was transferred to the ICU and was supported
with a goal-directed therapy protocol [6]. Broad-spectrum
antibiotic therapy consisted of Meropenem (500 mg every
8 h), Vancomycin (500 mg twice daily), Gentamicin
(120 mg once daily) and Fluconazole (400 mg once
daily). Due to hemodynamic instability, dopamine
10 mcg/Kg/min was administered for 7 days. He also
received Hydrocortisone 300 mg/day IV for 6 days, and
Figure 1. CT of the abdomen demonstrating extensive air
and fluid involving the fascias along the psoas muscles, and air
along the epidural space of the spinal canal in the lumbar
region.
Figure 2. CT of the pelvis demonstrating extensive air and
fluid extending through the pelvic fascias to the pelvic muscles.
Figure 3. CT of the thighs revealing skin thickening, increased
subcutaneous fat attenuation and subcutaneous and inter-
muscular fat stranding in the right thigh.
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Cases Journal 2009, 2:7365 http://casesjournal.com/casesjournal/article/view/7365
continuous IV insulin infusion to keep blood glucose
<140 mg/dl. Weaning from mechanical ventilation was
successful on ICU day 9, after bilateral infiltrations on CXR
improved. He developed renal dysfunction (maximum
serum creatinine was 2.4) but urine output remained
adequate (> 0.5 ml/kg/h) and dialysis was not needed.
Multi-resistant Staphylococcus aureuswas isolated from blood
cultures. The patient remained in the ICU for 12 days, and
was then transferred in stable condition to the SurgeryWard,
his general condition gradually improved and he was
discharged home in good condition.
Case report 2
A 73 year old Caucasian female patient with history of
hypertension, congenital hip dislocation, and degenera-
tive arthritis, was admitted to the Internal Medicine Ward
due to anemia (Hb:5.7 gm/dL), persistent low-grade fever
(37.3°C) and lower extremity arthralgia. The main finding
on physical examination was a painful, warm, fluctuant
mass with marked skin erythema and necrosis in the
gluteal area. She had received many Non Steroidal Anti-
inflammatory Drug (NSAID) IM injections for arthritis
pain over the last several months. Diagnostic workup
included a CT-scan of the abdomen, which revealed fluid
collection along the soft tissues on both thighs, extending
into the abdominal cavity. Large intra-peritoneal fluid
collections were recognized on both sides of the bladder,
and smaller fluid collections were present along both
femoral heads within the gluteal muscles bilaterally
(Figure 4). The patient had intra-peritoneal abscess
drainage through a J-shaped lower abdominal incision,
followed by drainage of the femoral fluid collections in the
operating room. Two soft drainage tubes were inserted
through the abdominal wall, drains were left in place on
both thighs, and the surgical wound was closed. Post-
operatively, the patient was admitted to the ICU due to
developing multi-organ failure, (tachycardia, hypoten-
sion, oliguria and deterioration of pulmonary function).
In the ICU she required mechanical ventilation and was
supported with a goal-directed therapy protocol [6] as
described in case one. Broad-spectrum antibiotic therapy
included Vancomycin 500 mg twice daily, Meropenem
500 mg three times daily and Fluconazole 400 mg once
daily. Staphylococcus aureus was isolated from blood
cultures. Adequate urine output was maintained with
continuous IV furosemide infusion at 2 mg/h for 7 days.
Total ICU length of stay was 15 days, and she then
transferred to the orthopaedic surgery ward in stable
condition, gradually improved and was discharged
home.
Demographics and medical history and ICU data are
presented in Table 1.
Discussion
An intramuscular (IM) injection is a minor procedure
whereby a drug is deposited into a muscle via a sterile
needle. Most IM injections should be performed into the
deltoid muscle in the arm, or into the gluteus maximus
muscle in the buttocks. Recent studies [2,3] have high-
lighted the importance of correct IM drug administration,
in order to minimize the risk of potentially serious
complications. Appropriate clinical practice needs to
reflect considerations about appropriate needle length
and gauge, to ensure that patients get the benefit of drug
administration without adverse effects. Muscle tissue is
Table 1. Demographics, medical history and ICU data
Case Age / Sex Medical
History
Drug injected
IM
Admission
SOFA score
Mechanical
Ventilation
Renal Failure/
Dialysis
Inotropic
Support
ICU stay Outcome
1 54 / Male Alcohol abuse,
diabetes
Aminoglycoside 10 9 days Yes/No Dopamine 7 days 12 days Good
2 73 / Female Hypertension,
Arthritis
NSAID 10 10 days Yes/No Dopamine 5 days 15 days Good
Figure 4. CT of the pelvis and lower extremities
demonstrating extensive air and fluid through the upper part
of the thighs. Air and fluid was also depicted along the fascias
of the muscles on both buttocks.
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usually spared the harmful effects of substances injected
into it, probably because of its abundant blood supply.
However, deep IM injections can cause abscesses and
granulomas, whereas more superficial IM injections may
result in increased incidence of local reactions, such as
irritation, inflammation and necrosis [1,2,9].
In this report we present two patients who developed
sepsis and multiple organ failure after IM injections.
Injection safety is a complex problem, and unsafe practices
can place patients at increased risk of infection [3,6].
However, even when properly administered, IM injections
can result in severe tissue trauma, by creating a local entry
point for bacteria. Although aminoglycosides are often
administered as IM injections, we could not find any
published reports of necrotizing fasciitis or other serious
local infection after aminoglycoside injections. In contrast,
several reports of serious or fatal complications from
NSAID injections have been published [3,10-12].
Sepsis and multi-organ failure are the leading causes of
death in critically ill patients [13]. Much of modern critical
care practice is based, in principle, on restoring aberrant
respiratory, cardiovascular and other functions to physio-
logic levels in an attempt to maintain or restore adequate
organ perfusion. Goal-directed therapy has been used
for severe sepsis and multiple organ dysfunction in
the Intensive Care Unit [6], and consists of maintaining
CVP > 8-12 mmHg, MAP > 65 mmHg, urine output >
0.5 ml/kg/h, SvO2 > 70%, SaO2 > 93% and hematocrit
> 30%. Both patients required mechanical ventilation and
received broad-spectrum antibiotics, IV fluids and phar-
maceutical agents (dopamine) to achieve and maintain
the aforementioned physiologic goals.
These two cases highlight the potential for severe tissue
necrosis following IM injections. The pathogenesis
explaining skin necrosis is uncertain, but damage to an
end-artery is a plausible hypothesis. Other causes to
consider, especially when deep tissue necrosis is also
present, are the cytotoxic effect of the drug or additives in
the injectate. Both our patients had skin necrosis that
progressed to bacteremia and sepsis from multi-resistant
Staphylococcus aureus, a finding consistent with previously
published cases [1,2].
Serious complications, including limb amputation and life-
threatening sepsis related to IM injectionshave been reported
in the past [1-5]. However, we believe this report is an
important addition to previously reported cases of sepsis and
multi-organ failure following IM injections, because both
patients became severely ill (SOFA [14] score 10 on ICU
admission) and were treated with early surgical intervention
[5], followed by prolonged ICU care with a goal-directed
therapy protocol [6]. We believe that timely radical surgical
intervention followed by goal-directed ICU care probably
contributed to the good outcome in both cases.
Conclusion
Minor medical interventions, such as intramuscular
injections, can rarely result in life-threatening infections.
If a serious infection occurs, isolation of the offending
pathogen is helpful in ensuring that appropriate antibiotic
therapy is given. Timely radical surgical intervention with
abscess drainage is crucial and may help improve
outcome. Goal directed therapy in the ICUmay contribute
to a good outcome in patients who develop sepsis and
multi-organ failure.
Abbreviations
CT, computed tomography; ICU, intensive care unit; IM,
intramuscular injections; NSAID, non-steroidal anti-
inflammatory drug.
Consent
Written informed consent was obtained from patients for
publication of this case report and accompanying images.
A copy of the written consent is available for review by the
journal’s Editor-in-Chief.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
DV collected data and edited the manuscript. CM did
orthopaedic consultation and surgical management.
CK did radiology consultation and evaluated CT images.
VK helped with manuscript editing and submission.
KFdirectedpatient care.MKwrote andedited themanuscript.
Acknowledgement
This research project was financially supported in its
entirety by Department Funds.
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Sepsis requiring intensive care following intramuscular injections: two case reports

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