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Imaging Features of Soft-Tissue Infections and Other Complications in Drug Users After Direct Subcutaneous Injection ("Skin Popping")

¹ Both authors: Department of Diagnostic Imaging, St. James' Hospital and Trinity College, James' St., Dublin 8, Ireland.

View larger version (121K): [in a new window]   Fig. 1A. —22-year-old man with broken IV needle tip in left groin with surrounding abscess formation. Anteroposterior radiograph of pelvis shows radiopaque needle tip.

View larger version (92K): [in a new window]   Fig. 1B. —22-year-old man with broken IV needle tip in left groin with surrounding abscess formation. Contrast-enhanced CT scan of pelvis obtained with soft-tissue window setting shows abscess formation (arrow) around needle tip with diffuse enhancement and central low attenuation.

View larger version (159K): [in a new window]   Fig. 2A. —33-year-old HIV-positive woman with extensive anterior abdominal wall cellulitis that extends into left leg. Focused sonogram of anterior abdominal wall to left of umbilicus shows typical features of cellulitis, including subcutaneous edema (solid arrows) interspersed between echogenic fat lobules (open arrows). A = anterior, P = posterior, M = medial.

View larger version (90K): [in a new window]   Fig. 2B. —33-year-old HIV-positive woman with extensive anterior abdominal wall cellulitis that extends into left leg. CT scan filmed with soft-tissue window setting again shows subcutaneous edema (arrows), as evidenced by extensive areas of high attenuation within fat of anterior abdominal wall but without deeper extension or abscess formation.

View larger version (100K): [in a new window]   Fig. 2C. —33-year-old HIV-positive woman with extensive anterior abdominal wall cellulitis that extends into left leg. CT scan filmed with soft-tissue window setting shows cellulitis extending into swollen left thigh that shows marked edema, represented by areas of increased attenuation in subcutaneous fat (arrowheads).

View larger version (152K): [in a new window]   Fig. 3A. —39-year-old man with superficial skin ulceration and cellulitis of right leg caused by IV drug use. Coronal T1-weighted MR image (TR/TE, 450/13) shows reticular low signal (arrows) in subcutaneous tissues of right thigh and deep skin defect (arrowhead).

View larger version (122K): [in a new window]   Fig. 3B. —39-year-old man with superficial skin ulceration and cellulitis of right leg caused by IV drug use. Unenhanced axial T1-weighted MR image (500/20) with fat saturation shows cellulitis in subcutaneous tissues of medial right thigh.

View larger version (128K): [in a new window]   Fig. 3C. —39-year-old man with superficial skin ulceration and cellulitis of right leg caused by IV drug use. Contrast-enhanced axial T1-weighted MR image (500/20) with fat saturation at same level as B shows enhancement within area of cellulitis (arrows) but no enhancement in adjacent adductor or quadriceps muscles.

View larger version (83K): [in a new window]   Fig. 4. —44-year-old woman with subcutaneous abscess in periumbilical fat. Unenhanced CT scan of abdomen with soft-tissue window setting shows focal homogeneous mass (arrow) of soft-tissue attenuation in left periumbilical region, without surrounding cellulitis, suggestive of abscess.

View larger version (133K): [in a new window]   Fig. 5A. —Incidental finding of right neck abscess in 28-year-old HIV-positive man undergoing routine follow-up for cerebral toxoplasmosis. T2-weighted image (TR/TE, 2,400/90) of head shows mixed-signal-intensity mass involving right sternocleidomastoid muscle and overlying superficial tissues (arrow). Incidental note is made of high-signal-intensity mass (arrowhead) in left thalamus in keeping with known diagnosis of cerebral toxoplasmosis.

View larger version (154K): [in a new window]   Fig. 5B. —Incidental finding of right neck abscess in 28-year-old HIV-positive man undergoing routine follow-up for cerebral toxoplasmosis. Subsequent sonogram of right anterior neck shows fluid collection with thick walls (arrows) containing some low-level internal echoes with through-transmission consistent with abscess. M = medial.

View larger version (105K): [in a new window]   Fig. 6A. —30-year-old man with left groin abscess. Anteroposterior radiograph of left hip shows gas within groin abscess (arrows).

View larger version (136K): [in a new window]   Fig. 6B. —30-year-old man with left groin abscess. CT scan filmed with soft-tissue window setting after contrast material administration shows focal fluid attenuation collection with subtle internal enhancement (small arrow) and gas (arrowhead) in nondependent portions, suggestive of abscess. Focal gas (large arrow) is also seen anterior to collection. Aspiration confirmed presence of abscess.

View larger version (93K): [in a new window]   Fig. 7A. —22-year-old man with muscle affected by pyomyositis progressing to abscess formation. CT scan obtained with soft-tissue window setting shows gross enlargement of left thigh with extensive ulceration (arrowheads) anteromedially and extensive cellulitis (arrow). In addition, increased muscle bulk of hip extensor muscles is present, but without fluid collection.

View larger version (136K): [in a new window]   Fig. 7B. —22-year-old man with muscle affected by pyomyositis progressing to abscess formation. CT scan obtained 4 days after A shows focal abscess with enhancing margins (arrow) in hamstring muscles of left thigh and second abscess medially below ulcer (arrowheads).

View larger version (111K): [in a new window]   Fig. 8A. —34-year-old man with myositis of right deltoid and triceps muscles caused by intramuscular injection of heroin and cocaine mixture. Anteroposterior radiograph of right humerus shows mottled gas (arrows) in soft tissues.

View larger version (111K): [in a new window]   Fig. 8B. —34-year-old man with myositis of right deltoid and triceps muscles caused by intramuscular injection of heroin and cocaine mixture. CT scan obtained with soft-tissue setting shows high-attenuation areas of cellulitis (arrow) and low-attenuation areas of subcutaneous gas (arrowheads).

View larger version (88K): [in a new window]   Fig. 8C. —34-year-old man with myositis of right deltoid and triceps muscles caused by intramuscular injection of heroin and cocaine mixture. Coronal T2-weighted MR image (TR/TE, 2,000/80) of left arm shows high signal in triceps muscle (T) with extensive subcutaneous cellulitis. S = superior, I = inferior, M = medial.

View larger version (78K): [in a new window]   Fig. 8D. —34-year-old man with myositis of right deltoid and triceps muscles caused by intramuscular injection of heroin and cocaine mixture. Axial T2-weighted MR image (2,000/80) of left arm shows diffuse increased signal in left deltoid (D) and triceps muscles but no focal area of pyomyositis. M = medial, A = anterior, P = posterior.

View larger version (101K): [in a new window]   Fig. 9A. —28-year-old man with bilateral buttock cellulitis and pyomyositis of right gluteal muscles that progressed to necrotizing fasciitis requiring surgical débridement. CT scan filmed with soft-tissue setting shows enlarged right gluteus medius and maximus muscles with overlying skin defect (solid arrow) and marked bilateral subcutaneous reticulation caused by cellulitis (arrowheads). Some low attenuation is seen within enlarged gluteus muscles (open arrow).

View larger version (76K): [in a new window]   Fig. 9B. —28-year-old man with bilateral buttock cellulitis and pyomyositis of right gluteal muscles that progressed to necrotizing fasciitis requiring surgical débridement. T2-weighted MR image (TR/TE, 2,500/80) of upper thighs after débridement shows large surgical defect (arrow) in posterior right thigh. In addition, extensive bright T2 signal (arrowheads) is seen in fascial planes of left thigh, typical of fascial thickening seen in necrotizing fasciitis. This patient subsequently died within 24 hr of overwhelming systemic sepsis.

View larger version (83K): [in a new window]   Fig. 10. —Digital subtraction angiogram of right superficial and deep femoral arteries in 38-year-old woman shows pseudoaneurysm (arrow) arising from superficial femoral artery associated with repeated "groin hits."

View larger version (105K): [in a new window]   Fig. 11. —19-year-old man who frequently injected heroin into superficial neck veins because of poor venous access in his limbs. Coronal T1-weighted MR image (TR/TE, 800/16) of neck shows lack of flow void in left external jugular vein (arrow) caused by acute venous thrombosis after episode of injection into vein.

View larger version (100K): [in a new window]   Fig. 12A. —35-year-old man admitted with severe left-sided lower back pain radiating to left leg. He had numerous presentations previously with left groin abscesses that required repeated surgical drainage. Coronal T2-weighted MR image (TR/TE, 2,000/80) of lumbar spine shows diskitis at level of L4–L5 disk with abnormal high signal from center of disk space (open arrow) and adjacent vertebral bodies (solid arrows) caused by extension from large adjacent abscess of psoas muscle.

View larger version (75K): [in a new window]   Fig. 12B. —35-year-old man admitted with severe left-sided lower back pain radiating to left leg. He had numerous presentations previously with left groin abscesses that required repeated surgical drainage. Sagittal T2-weighted image (2,000/80) shows extension into L4–L5 disk, where abnormally high signal in center of disk (open arrow) and in adjacent vertebral bodies (solid arrows) exists.

View larger version (99K): [in a new window]   Fig. 12C. —35-year-old man admitted with severe left-sided lower back pain radiating to left leg. He had numerous presentations previously with left groin abscesses that required repeated surgical drainage. Contrast axial T1-weighted image (750/20) at same level as B shows infected psoas muscle pyomyositis (arrowheads) extending into adjacent tissue planes.

View larger version (117K): [in a new window]   Fig. 13A. —23-year-old woman with recurrent right groin abscesses who presented with pyrexia, back pain, and raised inflammatory markers. Delayed posterior three-phase bone scintigram shows nonspecific finding of increased radioisotope uptake (arrowhead) in right sacroiliac joint.

View larger version (91K): [in a new window]   Fig. 13B. —23-year-old woman with recurrent right groin abscesses who presented with pyrexia, back pain, and raised inflammatory markers. CT scan obtained with bone window setting shows bone destruction (arrow) at right sacroiliac joint. Adjacent soft-tissue swelling was discerned with soft-tissue settings. These findings were suspicious for osteomyelitis affecting right sacroiliac joint, which was confirmed by subsequent joint aspiration.

View larger version (70K): [in a new window]   Fig. 14A. —54-year-old man, longtime injector of cocaine and heroin, with bilateral groin complications. At initial presentation, venogram shows meniscus sign (arrow) caused by acute right common femoral vein thrombosis.

View larger version (87K): [in a new window]   Fig. 14B. —54-year-old man, longtime injector of cocaine and heroin, with bilateral groin complications. Patient presented 6 months later with discharging sinus from contralateral groin. Sinograph revealed tortuous irregular sinus tract that communicated with adjacent thrombosed left common femoral vein. Arrowheads show thin catheter in sinus tract opening with short irregular connection to thrombosed vein.

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