Working Diagnosis:
Intramuscular right biceps abscess secondary to testosterone injections

Treatment:
Patient underwent two ultrasound-guided drainages by interventional radiology and was given Augmentin. Initial cytology and cultures were negative. He later required surgical incision and drainage, as the fluid collection had tracked down between his brachialis and extensor carpi radialis longus and brevis with pus extravasating from the skin. His Augmentin was extended to cover Corynebacterium species and Propionibacterium Acnes seen on repeat cultures.

Outcome:
Patient followed up with orthopedic surgery. His pain resolved, and the wounds in his right upper arm healed by the second week following his surgery. His right forearm wound gradually healed with placement of a wound vacuum to manage some residual serosanguinous drainage. Return to sports/work activities was based on wound healing. He was given instructions for no participation in contact sports with exudative or draining lesions. He was advised on light activity with range of motion exercises for his right arm and hand.

Author's Comments:
Contaminated products, unsterile needles, and poor skin preparation increase the risks of localized, systemic, and bloodborne infections from intramuscular injections of anabolic steroids. Abscesses have been reported in bodybuilders injecting into a specific muscle to increase isolated muscle growth. This leads to increased complications such as deep tissue infections or intramuscular abscesses in both common (i.e., gluteus, deltoid) and non-traditional areas (i.e., biceps). The pathogens are typically staphylococcus, streptococcus, pseudomonas, or atypical mycobacteria. Corynebacterium species, which are part of the normal skin flora, grow favorably in lipophilic conditions and are also commonly isolated.

Editor's Comments:
Anabolic steroid (AS) use has many known adverse effects. These can be systemic, including cardiac, reproductive, hematologic, and behavioral effects, or local effects such as tendon rupture and infection, as seen in this case study. The high cost and lack of regulations for AS products on the market may lead to sharing of muti-use vials and unsterile administration can predispose to both localized as well as systemic infections (including HIV and hepatitis).

An appropriate differential diagnosis for acute, localized and asymmetric upper extremity soft tissue swelling should include the diagnoses listed above as well as Paget Schroetter syndrome (an effort induced thrombosis of the subclavian and axillary veins). In patients with infection, a high index of suspicion for AS use (with repeat history taking when needed), close interval follow-up, and education are important to ensure optimal outcomes and to help prevent repeat infections in susceptible individuals. Furthermore, clinicians must be aware that although case reports of infection from AS use typically involve adults, AS use has been reported in young adolescents. Educating these younger patients regarding risks of AS use represent an opportunity for prevention.

References:
Evans NA. Local Complications of Self-administered Anabolic Steroid Injections. Britain Journal of Sports Medicine. 1997 Dec;31(4):349-50.

Rich JD, Dickinson BP, Flanigan TP, Valone SE. Abscess Related to Anabolic-androgenic Steroid Injection. Medicine and Science in Sports and Exercise. 1999 Feb;31(2):207-9.

Bernard K. The Genus Corynebacterium and Other Medically Relevant Coryneform-like Bacteria. Journal of Clinical Microbiology. 2012 Oct;50(10):3152-8.

Faigenbaum AD, Zaichkowsky LD, Gardner DE, Micheli LJ. Anabolic steroid use by male and female middle school students. Pediatrics. 1998 May;101(5):E6. doi: 10.1542/peds.101.5.e6.

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