Self-inoculation with milk as a cause of recurrent cellulitis Robert Steinman, md; Jack Mendelson, md,
Summary: A 21-year-old patient had six admissions to hospital for recurrent cellulitis over a 6-month period. She underwent extensive investigations, which failed to reveal any underlying predisposing factors. On the final admission she admitted to injecting herself subcutaneously with milk to induce the lesion. Self-inoculation with foreign material must be considered in patients presenting with recurrent cellulitis. Resume: Une patiente agee de 21 ans a ete admise a I'hdpital six fois au cours d'une periode de 6 mois pour cellulite recidivante. Des investigations etendues n'ont pas mis en evidence de facteurs predisposants. Au cours de la derniere admission elle a admis avoir injectee du lait par voie souscutanee pour produire les lesions. L'autoinoculation de substances etrangeres doit etre consideree chez les patients qui se presentent pour cellulite recidivante.
Self-inoculation with foreign materials as a cause of cellulitis has been de¬ scribed in prisoners, who have used lighter fluid, sputum, milk and a variety of chemicals.1 The motivating factors for self-inflicted injury in prisoners in¬ clude the desire to avoid work, the pos¬ sibility of easier escape from a hospital, and withdrawal from threatening cir¬ cumstances.
We report the occurrence of celluli¬ tis secondary to self-inoculation with milk in a nursing assistant. She was ad¬ mitted to hospital on six occasions for recurrent cellulitis, and extensive in¬ vestigation for a possible underlying cause was necessary. On the last admis¬ sion she admitted injecting herself with milk and using her induced illness to obtain affection from her husband. Case report A 21-year-old married female nursing assistant first presented with a 5-day his¬ tory of a painful, warm, swollen and red left hand and a temperature of 39°C. She
From the division of infectious diseases, departments of medicine and microbiology, Jewish General Hospital, Montreal Reprint requests to: Dr. Jack Mendelson, Division of infectious diseases, Departments of medicine and microbiology, Jewish General Hospital, Montreal, Qu6. H3T 1E2
m
sc,
frcp[c]; Joseph Portnoy,
stated that she had been scratched by her eat the day before the onset of symptoms. She was given tetracycline and then ampi¬ cillin orally before admission, with no ef¬ fect. On admission her oral temperature was 38 °C and her body weight was 64 kg. The other significant findings on phys¬ ical examination were limited to the left upper extremity: the dorsum of her left hand was erythematous, with edema ex¬ tending to the distal half of her left fore¬ arm; there was limitation of flexion and extension of the left wrist; and the left axillary nodes were enlarged and tender. Leukocyte count was 5800/mm3, hemo¬ globin value 13.3 g/dl and erythrocyte sedimentation rate (ESR) 26 mm/h. Urin¬ alysis findings, chest radiograph and electrocardiogram were normal. Values of blood urea nitrogen, serum creatinine and liver enzymes were normal. The bones of the left hand were radiographically normal. She received penicillin G, 12 million units/d intravenously (IV) and gentamicin, 40 mg q8h IV for 3 days. Her oral tem¬ perature was 37.2°C throughout her hos¬ pitalization. The condition of her left hand improved rapidly and she was discharged after 4 days. She was readmitted 1 month later with a 2-day history of a red, swollen, painful left hand. She stated that she had injured her left hand 1 day before the onset of symptoms, that her appetite was poor and that she was losing weight. On admission her temperature was 37.2°C and her weight 64 kg. The dorsum of her left hand was red, swollen, tense, hot and painful. The fingers of her left hand and her left wrist were also swollen. The fingers and wrists were immobile and the left elbow had limited mobility. No lymph nodes were palpable. Leukocyte count was 7500/mm3, hemoglobin value 14.6 g/dl and ESR 33 mm/h. The bones of the left hand were radiographically nor¬ mal. She was given nafcillin, 2 g q4h IV, and kanamycin, 500 mg ql2h IM, but her hand remained tense and swollen, with cellulitis extending up the left forearm. An aspirate from the dorsal space of her left hand contained gram-positive cocci in chains but culture yielded no growth. On the 3rd hospital day a deep pocket of greenish-yellow purulent material was drained from the dorsal space. A blood culture drawn on admission had grown microaerophilic streptococci. She was treated with penicil¬ lin G, 2 million units q4h IV for 9 more days, and her condition improved rapidly after incision and drainage. A skin biopsy taken from the dorsum of her left hand at the time of the opera¬ tion revealed evidence of a chronic nonspecific inflammatory response with foreign-body giant-cell reaction. Material in the foreign-body giant cells was refractile
md,
m
sc,
frcp[c]
when examined under polarized light. She was discharged after 2 weeks. She was admitted for the third time 7 weeks later. She stated that she had cut her right hand 1 week before admission and then had had fever, chills and pain and swelling of the dorsum of her right hand that spread to her right forearm. She had received ampicillin orally before admission. On admission her temperature was 39°C. Her right hand was swollen and her right forearm was warm, red and tender from the wrist to the elbow. No lymph nodes were palpable. Leukocyte count was 7300/mm3 and hemoglobin value 13.8 g/dl. She was treated with penicillin G, 2 million units q4h IV, and gentamicin, 80 mg q8h IV (for 2 days). An aspirate of the dorsal space of the right hand revealed occasional pus cells on Gram's staining but no organisms were seen; culture was negative. Blood cultures were also negative. Results of the glucose tolerance test were abnormal. Serum IgA value was slightly decreased, IgG value was normal and IgM value was slight¬ ly increased. Her temperature gradually returned to normal over 6 days and the cellulitis resolved over 1 week. After being treated with penicillin for a total of 12 days she was discharged; she was then taking tolbutamide, 250 mg bid. Before her next admission she was seen in the emergency room in hypoglycemic coma. Her next admission was 3 weeks later. She complained that a blister over the Achilles region of her right ankle had led to cellulitis with edema, lymphangitis ex¬ tending up to her right calf, and tender inguinal nodes. She received penicillin G IV for 10 days and her condition im¬ proved. Normal results were reported for all laboratory determinations, including complete blood counts, serum carotene concentration, D-xylose tolerance test, plasma cortisol concentration, serum iron studies, serum vitamin B12 and folic acid concentrations, latex fixation test, concen¬ trations of serum complement and antinuclear antibodies, and lupus induction test. The tuberculin skin test was positive. Chest radiograph, barium enema examina¬ tion and upper gastrointestinal tract se¬ ries with small bowel follow-through all appeared normal. She then visited her dentist, who extracted a tooth. Readmission became nec¬ essary 1 week later because of fever, erythema and painful swelling of the left side of her face. A periodontal abscess was found. She was treated with penicillin G, 1 million units q6h IV for 4 days, and
discharged.
Her final admission was 3 weeks after her last discharge and 6 months after her first admission. She stated that 5 days before admission she had touched a hot oven and burned her right knee even
CMA JOURNAL/MARCH 8, 1975/VOL. 112 605
though she was wearing corduroy pants. A blister developed and 2 days before admission the knee was red and swollen; her temperature was 390C. On admission her right patellar region was red, swollen and tender with a central ulceration of the skin (diameter, 2 cm). Her temperature was 390C. Leukocyte count was 10 000I mm3. She was treated with penicillin G, 2 million units q4h IV for 5 days. Investigation of leukocyte function and cellular and humoral immunity yielded normal findings.
Discussion During the course of this patient's multiple admissions, many physicians saw her. Each admission resulted in
several additional investigations in attempts to determine the cause of the recurrent cellulitis. Self-induced injury was considered after the third admission but it could not be proved. After we had learned of the report of infections resulting from self-inoculation by Shepard and Sawyers1 we suggested this possibility to the patient's husband. He found some milk-filled syringes at home. Confronted with this evidence the patient admitted that she had injected herself with milk to induce the cellulitis. She then admitted to her family doctor that she was very depressed and had marital problems. In retrospect, the report of a foreign-
body granuloma in the skin biopsy done during her second admission should have provided a clue that the patient was responsible for the lesions. It was also suspected, but not proved, that the abnormal glucose tolerance test and episode of hypoglycemia were self-induced. The possibility of self-inoculation with a variety of materials must be considered in patients with repeated episodes of cellulitis. Reference 1. SHEPARD GH, SAWYERS JL: Management of infections from self inoculation with lighter fluid and other foreign agents. Ann Surg 170: 292, 1969
Hemophilus parainfluenzae meningitis A. J. WORT, MB, BS, FRCP[C]
Summary: Although Hemo phi/us influenzae is a common cause of meningitis, other members of the Hemophilus genus are rarely the infecting organism. Of 56 cases of meningitis due to Hemophilus species obseved at one hospital in the period 1970-74, 53 were due to H. influenzae and 3 to H. parainfluenzae. In the cases of H. parainfluenzae meningitis the clinical picture was complicated by 'associated sepsis, and therapy with ampicillin was not entirely satisfactory. R6sume: M.ningite . Hemophilus parainfluenzae Bien que Hemophilus influenzae soit une cause fr6quente de m6ningite, d'autres membres du genre Hemophilus sont rarement les microorganismes pathogenes. Sur 56 cas de meningite caus6e par le genre Hemophilus qui ont 6t6 observ6s dans un h6pital durant Ia p6riode 1970-74 on en comptait 53 qui 6taient attribuables . H. influenzae et 3 a H. parainfluenzae. Dans ces derniers cas le tableau clinique 6tait compliqu6 de septic6mie et le traitement a I'ampicilline n'6tait pas compl.tement satisfaisant.
Occasional cases of sepsis due to Hemophilus parainfluenzae have been reported but there are few published From the division of microbiology, The Izaak Walton Killam Hospital for Children, and the department of microbiology, Dalhousie University, Halifax Reprint requests to: Dr. A. J. Wort, Division of microbiology, The Izaak Walton Killam Hospital for Children, Halifax, NS B3J 3G6
reports of meningitis due to this organism,1-4 and there are virtually no useful data on its incidence. During the past 4 years H. parain fluenzae has been isolated from three patients admitted to this hospital with purulent meningitis. Bacteriologic methods Primary cultures of the centrifuged deposit from the cerebrospinal fluid (CSF) sample were plated on horse blood agar streaked with staphylococci and on chocolate agar with added Isovitalex (BBL*). All plates were examined after overnight incubation in a candle jar at 370C. The identification of Hemophilus species depended on observation of satellitism around the staphylococci and on colonial morphology on chocolate agar. A confirmatory test 4Baltimore Biological Laboratories, division of Bioquest Limited. Products are marketed in Canada by Becton, Dickinson and Company, Ltd., Mississauga, Ont.
for growth-factor dependency using Mueller-Hinton agar as the nutrient base was also carried out.5 All three strains isolated from the three patients required Factor V but not Factor X and were nonhemolytic on horse blood agar - the two identifying characteristics of H. parainjluenzae. All organisms were tested for sensitivity to antibiotics using chocolate agar and standard antibiotic disks. All strains were reported resistant to penicillin G (2 units) but sensitive to a wide range of other antibiotics including ampicillin (5 p.g) and chloramphenicol (5 pg"
Case reports Case 1 A 2½-year-old girl had been admitted to another hospital 2 days before with a diagnosis of otitis media and tonsillitis. She had remained febrile despite treatment with penicillin and was therefore transferred to this hospital. During the journey
Table I-CSF findings in three cases of Hemophilus parainfluenzae meningitis Hospital day
Protein mg/dl
1 3 11 16 19 30
10 63 220 326 495 71
1 3
170 60
1 5 16 *Normal, . 8/mm3.
606 CMA JOURNAL/MARCH 8, 1975/VOL. 112
102 76 41
CSF constituents Glucose Leukocytes mg/dl Case 1 40 6656 (98% polymorphs) 59 66 344 (92% monocytes) 66 231 (91% monocytes) 48 393 (96% monocytes) 41 59(93% monocytes) Case 2 50 450 (91% polymorphs) 48 35 (50% polymorphs) Case 3 26 1536 (97% polymorphs) 56 96 (58% monocytes) 62 16 (98% monocytes)
Summary: A 21-year-old patient had six admissions to hospital for recurrent cellulitis over a 6-month period. She underwent extensive investigations, which failed to reveal any underlying predisposing factors. On the final admission she admitted to injecting herself subcutaneously with milk to induce the lesion. Self-inoculation with foreign material must be considered in patients presenting with recurrent cellulitis. Resume: Une patiente agee de 21 ans a ete admise a I'hdpital six fois au cours d'une periode de 6 mois pour cellulite recidivante. Des investigations etendues n'ont pas mis en evidence de facteurs predisposants. Au cours de la derniere admission elle a admis avoir injectee du lait par voie souscutanee pour produire les lesions. L'autoinoculation de substances etrangeres doit etre consideree chez les patients qui se presentent pour cellulite recidivante.
Self-inoculation with foreign materials as a cause of cellulitis has been de¬ scribed in prisoners, who have used lighter fluid, sputum, milk and a variety of chemicals.1 The motivating factors for self-inflicted injury in prisoners in¬ clude the desire to avoid work, the pos¬ sibility of easier escape from a hospital, and withdrawal from threatening cir¬ cumstances.
We report the occurrence of celluli¬ tis secondary to self-inoculation with milk in a nursing assistant. She was ad¬ mitted to hospital on six occasions for recurrent cellulitis, and extensive in¬ vestigation for a possible underlying cause was necessary. On the last admis¬ sion she admitted injecting herself with milk and using her induced illness to obtain affection from her husband. Case report A 21-year-old married female nursing assistant first presented with a 5-day his¬ tory of a painful, warm, swollen and red left hand and a temperature of 39°C. She
From the division of infectious diseases, departments of medicine and microbiology, Jewish General Hospital, Montreal Reprint requests to: Dr. Jack Mendelson, Division of infectious diseases, Departments of medicine and microbiology, Jewish General Hospital, Montreal, Qu6. H3T 1E2
m
sc,
frcp[c]; Joseph Portnoy,
stated that she had been scratched by her eat the day before the onset of symptoms. She was given tetracycline and then ampi¬ cillin orally before admission, with no ef¬ fect. On admission her oral temperature was 38 °C and her body weight was 64 kg. The other significant findings on phys¬ ical examination were limited to the left upper extremity: the dorsum of her left hand was erythematous, with edema ex¬ tending to the distal half of her left fore¬ arm; there was limitation of flexion and extension of the left wrist; and the left axillary nodes were enlarged and tender. Leukocyte count was 5800/mm3, hemo¬ globin value 13.3 g/dl and erythrocyte sedimentation rate (ESR) 26 mm/h. Urin¬ alysis findings, chest radiograph and electrocardiogram were normal. Values of blood urea nitrogen, serum creatinine and liver enzymes were normal. The bones of the left hand were radiographically normal. She received penicillin G, 12 million units/d intravenously (IV) and gentamicin, 40 mg q8h IV for 3 days. Her oral tem¬ perature was 37.2°C throughout her hos¬ pitalization. The condition of her left hand improved rapidly and she was discharged after 4 days. She was readmitted 1 month later with a 2-day history of a red, swollen, painful left hand. She stated that she had injured her left hand 1 day before the onset of symptoms, that her appetite was poor and that she was losing weight. On admission her temperature was 37.2°C and her weight 64 kg. The dorsum of her left hand was red, swollen, tense, hot and painful. The fingers of her left hand and her left wrist were also swollen. The fingers and wrists were immobile and the left elbow had limited mobility. No lymph nodes were palpable. Leukocyte count was 7500/mm3, hemoglobin value 14.6 g/dl and ESR 33 mm/h. The bones of the left hand were radiographically nor¬ mal. She was given nafcillin, 2 g q4h IV, and kanamycin, 500 mg ql2h IM, but her hand remained tense and swollen, with cellulitis extending up the left forearm. An aspirate from the dorsal space of her left hand contained gram-positive cocci in chains but culture yielded no growth. On the 3rd hospital day a deep pocket of greenish-yellow purulent material was drained from the dorsal space. A blood culture drawn on admission had grown microaerophilic streptococci. She was treated with penicil¬ lin G, 2 million units q4h IV for 9 more days, and her condition improved rapidly after incision and drainage. A skin biopsy taken from the dorsum of her left hand at the time of the opera¬ tion revealed evidence of a chronic nonspecific inflammatory response with foreign-body giant-cell reaction. Material in the foreign-body giant cells was refractile
md,
m
sc,
frcp[c]
when examined under polarized light. She was discharged after 2 weeks. She was admitted for the third time 7 weeks later. She stated that she had cut her right hand 1 week before admission and then had had fever, chills and pain and swelling of the dorsum of her right hand that spread to her right forearm. She had received ampicillin orally before admission. On admission her temperature was 39°C. Her right hand was swollen and her right forearm was warm, red and tender from the wrist to the elbow. No lymph nodes were palpable. Leukocyte count was 7300/mm3 and hemoglobin value 13.8 g/dl. She was treated with penicillin G, 2 million units q4h IV, and gentamicin, 80 mg q8h IV (for 2 days). An aspirate of the dorsal space of the right hand revealed occasional pus cells on Gram's staining but no organisms were seen; culture was negative. Blood cultures were also negative. Results of the glucose tolerance test were abnormal. Serum IgA value was slightly decreased, IgG value was normal and IgM value was slight¬ ly increased. Her temperature gradually returned to normal over 6 days and the cellulitis resolved over 1 week. After being treated with penicillin for a total of 12 days she was discharged; she was then taking tolbutamide, 250 mg bid. Before her next admission she was seen in the emergency room in hypoglycemic coma. Her next admission was 3 weeks later. She complained that a blister over the Achilles region of her right ankle had led to cellulitis with edema, lymphangitis ex¬ tending up to her right calf, and tender inguinal nodes. She received penicillin G IV for 10 days and her condition im¬ proved. Normal results were reported for all laboratory determinations, including complete blood counts, serum carotene concentration, D-xylose tolerance test, plasma cortisol concentration, serum iron studies, serum vitamin B12 and folic acid concentrations, latex fixation test, concen¬ trations of serum complement and antinuclear antibodies, and lupus induction test. The tuberculin skin test was positive. Chest radiograph, barium enema examina¬ tion and upper gastrointestinal tract se¬ ries with small bowel follow-through all appeared normal. She then visited her dentist, who extracted a tooth. Readmission became nec¬ essary 1 week later because of fever, erythema and painful swelling of the left side of her face. A periodontal abscess was found. She was treated with penicillin G, 1 million units q6h IV for 4 days, and
discharged.
Her final admission was 3 weeks after her last discharge and 6 months after her first admission. She stated that 5 days before admission she had touched a hot oven and burned her right knee even
CMA JOURNAL/MARCH 8, 1975/VOL. 112 605
though she was wearing corduroy pants. A blister developed and 2 days before admission the knee was red and swollen; her temperature was 390C. On admission her right patellar region was red, swollen and tender with a central ulceration of the skin (diameter, 2 cm). Her temperature was 390C. Leukocyte count was 10 000I mm3. She was treated with penicillin G, 2 million units q4h IV for 5 days. Investigation of leukocyte function and cellular and humoral immunity yielded normal findings.
Discussion During the course of this patient's multiple admissions, many physicians saw her. Each admission resulted in
several additional investigations in attempts to determine the cause of the recurrent cellulitis. Self-induced injury was considered after the third admission but it could not be proved. After we had learned of the report of infections resulting from self-inoculation by Shepard and Sawyers1 we suggested this possibility to the patient's husband. He found some milk-filled syringes at home. Confronted with this evidence the patient admitted that she had injected herself with milk to induce the cellulitis. She then admitted to her family doctor that she was very depressed and had marital problems. In retrospect, the report of a foreign-
body granuloma in the skin biopsy done during her second admission should have provided a clue that the patient was responsible for the lesions. It was also suspected, but not proved, that the abnormal glucose tolerance test and episode of hypoglycemia were self-induced. The possibility of self-inoculation with a variety of materials must be considered in patients with repeated episodes of cellulitis. Reference 1. SHEPARD GH, SAWYERS JL: Management of infections from self inoculation with lighter fluid and other foreign agents. Ann Surg 170: 292, 1969
Hemophilus parainfluenzae meningitis A. J. WORT, MB, BS, FRCP[C]
Summary: Although Hemo phi/us influenzae is a common cause of meningitis, other members of the Hemophilus genus are rarely the infecting organism. Of 56 cases of meningitis due to Hemophilus species obseved at one hospital in the period 1970-74, 53 were due to H. influenzae and 3 to H. parainfluenzae. In the cases of H. parainfluenzae meningitis the clinical picture was complicated by 'associated sepsis, and therapy with ampicillin was not entirely satisfactory. R6sume: M.ningite . Hemophilus parainfluenzae Bien que Hemophilus influenzae soit une cause fr6quente de m6ningite, d'autres membres du genre Hemophilus sont rarement les microorganismes pathogenes. Sur 56 cas de meningite caus6e par le genre Hemophilus qui ont 6t6 observ6s dans un h6pital durant Ia p6riode 1970-74 on en comptait 53 qui 6taient attribuables . H. influenzae et 3 a H. parainfluenzae. Dans ces derniers cas le tableau clinique 6tait compliqu6 de septic6mie et le traitement a I'ampicilline n'6tait pas compl.tement satisfaisant.
Occasional cases of sepsis due to Hemophilus parainfluenzae have been reported but there are few published From the division of microbiology, The Izaak Walton Killam Hospital for Children, and the department of microbiology, Dalhousie University, Halifax Reprint requests to: Dr. A. J. Wort, Division of microbiology, The Izaak Walton Killam Hospital for Children, Halifax, NS B3J 3G6
reports of meningitis due to this organism,1-4 and there are virtually no useful data on its incidence. During the past 4 years H. parain fluenzae has been isolated from three patients admitted to this hospital with purulent meningitis. Bacteriologic methods Primary cultures of the centrifuged deposit from the cerebrospinal fluid (CSF) sample were plated on horse blood agar streaked with staphylococci and on chocolate agar with added Isovitalex (BBL*). All plates were examined after overnight incubation in a candle jar at 370C. The identification of Hemophilus species depended on observation of satellitism around the staphylococci and on colonial morphology on chocolate agar. A confirmatory test 4Baltimore Biological Laboratories, division of Bioquest Limited. Products are marketed in Canada by Becton, Dickinson and Company, Ltd., Mississauga, Ont.
for growth-factor dependency using Mueller-Hinton agar as the nutrient base was also carried out.5 All three strains isolated from the three patients required Factor V but not Factor X and were nonhemolytic on horse blood agar - the two identifying characteristics of H. parainjluenzae. All organisms were tested for sensitivity to antibiotics using chocolate agar and standard antibiotic disks. All strains were reported resistant to penicillin G (2 units) but sensitive to a wide range of other antibiotics including ampicillin (5 p.g) and chloramphenicol (5 pg"
Case reports Case 1 A 2½-year-old girl had been admitted to another hospital 2 days before with a diagnosis of otitis media and tonsillitis. She had remained febrile despite treatment with penicillin and was therefore transferred to this hospital. During the journey
Table I-CSF findings in three cases of Hemophilus parainfluenzae meningitis Hospital day
Protein mg/dl
1 3 11 16 19 30
10 63 220 326 495 71
1 3
170 60
1 5 16 *Normal, . 8/mm3.
606 CMA JOURNAL/MARCH 8, 1975/VOL. 112
102 76 41
CSF constituents Glucose Leukocytes mg/dl Case 1 40 6656 (98% polymorphs) 59 66 344 (92% monocytes) 66 231 (91% monocytes) 48 393 (96% monocytes) 41 59(93% monocytes) Case 2 50 450 (91% polymorphs) 48 35 (50% polymorphs) Case 3 26 1536 (97% polymorphs) 56 96 (58% monocytes) 62 16 (98% monocytes)
