A Case Report by David B. Violette Jr, MD

ABSTRACT

Intramuscular and subcutaneous injections of foreign bodies have been used for a number of years for a variety of reasons, including medical and cosmetic purposes. The author describes a case of chronic wound complications secondary to intramuscular gold injections for the treatment of rheumatoid arthritis. The lesions were completely excised, the defect first treated with negative-pressure wound therapy, and, ultimately, split-thickness skin grafting with excellent functional result.

INTRODUCTION

From the dawn of time, man has taken to marking his body with a variety of objectsand substances,includingforeign bodies placed under the skin. This practice continues today with the body modification that is practiced in tattoo parlors and piercing shops throughout the world. Over the years, modern medicine also has been responsible for numerous implantable objects and therapies injected into all layers of the body from subcutaneous and intramuscular all the way to deeper organ spaces, such as the abdomen and brain.

Throughout the 1940s until the late 1980s, intramuscular gold salt injections were used as a major treatment in rheumatoid arthritis. The technique was first described and pioneered by Forestier back in 1929. Following intramuscular injection, gold levels rapidly rise and reach a plateau after 6 to 8 weeks. Proposed mechanisms of gold salts, such as gold sodium thiomalate, have been shown to block prostaglandin E2 and other proinflammatory gene products. Although gold salt intramuscular injections have been shown to improve long-term outcomes in the treatment of rheumatoid arthritis, adverse reactions are seen in up to one-third of patients treated. Most common adverse effects and complications include dermatitis, stomatitis, transient hematuria, and mild proteinuria. Of these, dermatitis accounts for the majority and can mimic numerous other conditions, making diagnosis a challenge. The effects can be local or distant from the injection site.

Treatment of rheumatoid arthritis by gold salt injection has decreased in frequency since 1990 with the advent of drugs such as methotrexate. More recently, treatments have included a class of drugs known as disease-modifying, antirheumatic drugs, such as etanercept, making gold salts largely obsolete. They are still approved and used by clinicians in refractory cases. Nevertheless, in today’s aging population, there are still many thousands of patients who have been treated with gold salt injections over the past 60 years.

CASE PRESENTATION

The patient presented is a generally healthy and functional 87-yearold woman with a medical history that included rheumatoid arthritis for more than 50 years. She stated that she initially had injections into both of her hips with some sort of gold preparation more than 30 years ago. It was noted that the hip areas became hard, but prior to the past 5 years had not ever had any areas of skin breakdown. Within the past several years, however, the skin on the patient’s right hip started to extrude numerous pieces of calcium that the patient saved and brought with her for the first office visit. She wondered if she could retrieve any of the gold.

Since the calcium began to extrude through her skin, the patient described a searing, burning pain consistent with irritation from the jagged pieces of calcium. She had become increasingly frustrated with the numerous abscesses and the inability to control the drainage from her wounds. She was unhappy with the recent initiation of narcotic painmedications to control her discomfort.

Initial serologic markers were sent for rheumatoid arthritis, as well as other inflammatory disorders such as Sjögrens syndrome and systemic lupus erythematosis. Other than a mild elevation in rheumatoid factor and antinuclear antibody, other markers were negative. Nutritional status as measured by albumin, prealbumin, and C-reactive protein was normal. The patient was not diabetic as evidenced by a normal hemoglobin A1c. Biopsy of the wounds demonstrated no evidence of malignancy. Initial radiographic studies including plain X-rays and computed tomography scan of the pelvis showed extensive calcification ofthe subcutaneous and muscle layers of both hips, upper thighs, and gluteal regions.

It was recommended that the patient proceed with operative removal of all dystrophic calcification. The patient received extensive debridement of the area, which ultimately measured 26 x 26 cm (676 cm2 ) and encompassed the entire right hip, upper thigh, and partial gluteal musculature. The removal of all calcium deposits was aided by intraoperative fluoroscopy.

Postoperatively, the patient was treated with a negative-pressure therapy device (V.A.C. Therapy; KCI, San Antonio, Texas) for a period of 6 weeks until such time that a healthy bed of granulation tissue was achieved.

The patient was then returned to the operating room for splitthickness skin grafting from a donor site of the bilateral upper outer thighs. These were covered with a porcine small intestinal submucosa wound matrix (Oasis Ultra Tri-Layer Wound Matrix; Cook Biotech Inc, West Lafayette, Indiana) and bio-occlusive transparentfilm (Tegaderm; 3M Skin &Wound Care, St Paul,Minnesota). The recipient site was stapled to the underlying granulation tissue and covered by an occlusive petrolatum gauze (Xeroform; Covidien, Mansfield, Massachusetts) followed by a negative-pressure therapy device.

The patient was successfully discharged from the advanced wound care center after the second postoperative visit. She was no longer taking any pain medication and was pleased with the good functional outcome.

DISCUSSION

Gold salts and other implantables under the skin are often treated by the body as a foreign object. Over time, the body will attempt to wall off these objects. In this particular case, the body’s own defense mechanisms for insulating the body from the foreign object led to dystrophic calcifications that were ultimately very sharp edged. The body eventually extruded these foreign bodies, and ultimately this cut through the skin, causing numerous abscesses and skin disruptions, as well as disabling pain. This case illustrates the importance of removal of the offending agentVin this case, all the jagged calcium piecesVrather than removal of only a portion. With the irritants removed, the body was free to promote rapid healing. Combined with advanced modality therapy, such as negative-pressure wound therapy and Oasis Tri-Layer Wound Matrix, the patient achieved a successful outcome in a minimum amount of time. This approach should be considered in similar cases of large areas of foreign body implantation causing cutaneous abscesses.

Unfortunately, the 50-year-old gold had experienced phagocytosis many years ago and was not recovered.