A thirty-six-year-old otherwise healthy man presented to the emergency department thirty-six hours after intramuscular injection of anabolic steroids into the anterior aspect of the right thigh. He reported progressive right thigh pain and swelling, subjective fever and chills, and an inability to bear weight on the right lower extremity. On initial examination, he was nontoxic-appearing, afebrile, and hemodynamically stable but anxious about the rapidly declining condition of the lower extremity. The right thigh was markedly swollen with an enlarging area of ecchymosis centered at the injection site anterolaterally. The thigh was firm and tender to palpation, with crepitus from the inguinal crease to the knee.
Initial laboratory abnormalities included an elevated white blood cell count and creatine kinase level. Computed tomography (CT) scanning revealed diffuse intramuscular and subcutaneous gas extending from the right hemipelvis distally beyond the knee, with greatest involvement in the vastus lateralis muscle (Fig. 1). Broad-spectrum antibiotics were administered immediately.
Emergent operative debridement including removal of the majority of the vastus lateralis muscle, which was largely liquefied and necrotic, was performed. Culture specimens were obtained, and all necrotic tissue was removed. Fasciotomies were performed on the posterior compartment of the thigh, as well as the anterior, lateral, and superficial posterior compartments of the leg, where muscle remained pink and contractile.
Gram stain demonstrated the presence of gram-positive rods. Use of broad-spectrum antibiotics, including penicillin and clindamycin, was continued. The preliminary diagnosis was clostridial myonecrosis, which was confirmed by positive culture.
Following surgical debridement, the patient was transferred to the intensive care unit, where severe systemic abnormalities developed during the next several hours (Fig. 2). Toxin-mediated hemolysis caused a dramatic drop in the hemoglobin level postoperatively, in spite of only moderate intraoperative blood loss. Plasma exchange was initiated accordingly. Acute anuric renal failure also developed in the setting of massive muscle destruction, and hemodialysis was started on the second hospital day.
Despite daily debridements over the next three days, the patient's condition failed to improve substantially. Five days after admission, the decision was made to proceed with hip disarticulation.
After the amputation, the patient began to recover. Kidney function gradually improved and dialysis was discontinued. By the time of discharge to a rehabilitation facility, the patient was walking short distances with walker assistance.
The contents of the vial from which the injected steroids were drawn were confirmed to be contaminated with Clostridium perfringens both by culture and by meat broth assay (Fig. 3).
Anabolic steroids are commonly abused, administered intramuscularly by individuals without appropriate training, and distributed in an unregulated market. As a result, in addition to commonly observed side effects such as aggressive behavior, acne, liver malfunction, virilization in females, and testicular atrophy in males7, both local and systemic complications associated with the intramuscular administration of these drugs occur frequently and are well described in the literature.
Local complications including peripheral nerve palsy and localized infection are documented dangers. Injuries to the sciatic5 and radial4 nerves have been reported after injection into the gluteal region and posterior part of the arm, respectively. A variety of injection-site infections, ranging from soft-tissue abscesses8 to septic arthritis of the knee4 to atypical mycobacterial infection, have also been reported6.
Intramuscular administration of anabolic steroids with shared needles has also been linked to the transmission of HIV, hepatitis B, and hepatitis C, but with less frequency than in intravenous drug users8.
To our knowledge, this account is the first report of an acute life-threatening soft-tissue infection such as clostridial myonecrosis resulting from an anabolic steroid injection. Also known as gas gangrene, clostridial myonecrosis is a necrotizing soft-tissue infection most often caused by Clostridium perfringens, an anaerobic gram-positive rod found in soil and gastrointestinal tracts of humans and animals9. The disease is characterized by rapidly progressive muscle necrosis and systemic toxicity, and is most often encountered in orthopaedic patients with contaminated traumatic crush injuries9.
While traumatic injury is the most common cause of clostridial myonecrosis, inoculation may occur by other routes as well. Assadian et al. reported two cases of drug users injecting a combination of cocaine and heroin into the soft tissue of the groin, both resulting in gas gangrene10. Thus, clostridial myonecrosis may occur following intramuscular injection of a variety of contaminated substances.
Regardless of the etiology, a high index of suspicion is required for timely diagnosis and initiation of treatment early in the disease process, when the only evidence of infection may be intense localized pain and tenderness, typically twenty-four to forty-eight hours following inoculation9,10. Shortly thereafter, crepitus may be noted in affected areas, and ecchymosis or hemorrhagic bullae may develop and progress rapidly over the involved muscle compartments9,10. Gas may be seen on radiographs or CT scans along fascial planes and within muscle compartments11. After a presumptive diagnosis is made, treatment depends on the administration of appropriate antibiotics, emergent surgical debridement, and supportive care for systemic effects of the infection9.
In conclusion, necrotizing soft-tissue infections such as clostridial myonecrosis should be considered among the complications resulting from intramuscular injection of anabolic steroids and other drugs. Comprehensive knowledge of the potential adverse effects of these drugs will aid the clinician in prevention counseling as well as rapid recognition and treatment of serious complications such as this.