A case of recurrent sterile abscesses following tetanus-diphtheria vaccination treated with corticosteroids

Background Vaccinations have been widely used worldwide since their invention to prevent various diseases, but they can also have some adverse effects ranging from mild local reactions to serious side effects. These adverse effects are generally self-limited and resolve within a short time without any treatment. While a sterile abscess following vaccination is a rare condition in adults, many cases have been reported regarding children in the literature. Here, we report a case of recurrent sterile abscesses, which occurred after a Td vaccination, treated with corticosteroids. Case presentation A 22-year old woman was admitted to our department with a complaint of swelling at the site of the vaccination. On physical examination, this mass was about 6 × 6 cm in size and fluctuating, but there were no pain complaints and no redness present. She had received her Td vaccination 3 weeks ago and the swelling had started at the site of the injection 4 days following this immunization. Oral amoxicillin/clavulanic acid and local antibiotic cream were administered for 10 days. The laboratory values were unremarkable. Despite the administration of antibiotics, the swelling did not regress, and on the contrary, continued to increase in size. On ultrasound, two interconnected abscesses were observed in the subcutaneous area, and did not involve the muscle tissue. Later, the abscesses were completely drained, and the samples were cultured. The current antibiotics were continued. The gram staining of the samples revealed abundant leukocytes but no microorganisms. The solid and liquid cultures of the materials remained negative. Despite the administration of multiple drainages and antibiotics, the mass recurred. Finally, the patient was considered to have a sterile abscess due to Td immunization. The antimicrobials were stopped. Local and oral corticosteroids were initiated. The swelling regressed significantly, and the treatments continued for 7 days. The patient has been doing well and has had no recurrence for over a year. Conclusions Corticosteroids appeared to improve the patient and therefore we suggest that the efficacy and route of administration of steroids in this situation should be explored further.

MON-069 Uncontrolled Central Precocious Puberty Patient Against GnRH Agonist, After Showing Granuloma Formation and Sterile Abscess to Both Leuprorelin Acetate and Triptorelin Actate

For more than 30 years, Gonadotropin-releasing hormone (GnRH) agonist has been the treatment of choice for central precocious puberty (CPP) to expect regression of secondary sexual characteristics, delayed menarche, and maximization of linear growth. There are several kinds of GnRH agonists such as leuprorelin, triptorelin, goserelin and histrelin, etc. In Korea, leuprolide acetate and triptorelin acetate are most common used drugs, and a monthly depot preparation is typically used for suppression of the HPG axis. Local complications related to GnRH agonists, including erythematous macules, granulomas, subcutaneous nodules, and sterile abscesses, occur in 10~15% of patients, and sterile abscesses have been known to occur in less than 2~3% of patients. In present case, we would like to introduce a case of CPP patient who was treated with GnRH agonist, but not suppressed and experienced recurrent vaginal bleeding, after showing granuloma formation and sterile abscess to both leuprorelin acetate and triptoreline actate. A 8.9 year-old girl visited our clinic with breast development and vaginal bleeding. On physical examination, she had enlarged breasts (Tanner stage 4) with pigmentation of the areola. Her height and weight was measured as 144.4cm (98th percentile) and 44.2kg (98th percentile) respectively. Her bone age was advanced as 12~12.6 years of age by TW3 method. Therefore, Leuprolide acetate (Lorelin depot®, Dongkook pharm) 3.75mg was administered to the patient every 4 weeks, and until the 6th injection, she exhibited no other complications. However, after 7th injection, the patient presented with granuloma and subcutaneous nodule at the left injection site and elevated hormone levels. Although that we switched to triptorelin acetate from 8th injection, the patient also showed a sterile abscess at the injection site. We switched from triptorelin acetate to leuprolide acetate again, however, after 2 months of the switch, the patient showed abrupt vaginal bleeding and elevated hormone levels. Therefore, after assumption of unsuppression of HPG axis, leuprolide acetate 3.75mg was administered every 2 weeks for 2 months. However, her vaginal bleeding occurred monthly and hormonal level was still unsuppressed, and also, the granuloma appeared again at the injection site. So, we discussed with her parents about her uncontrolled symptoms, and we discontinued the treatment. There are many theories about the cause of local complications of GnRH agonist, but the mechanism has still not been revealed. Further studies are required to identify the mechanism and the relationship between treatment effect and local complications, which could induce uncontrolled CPP.

Pulsatile sterile abscess in the left breast following transapical transcatheter aortic valve implantation: a case report

Background Over the last decade, transcatheter treatment of degenerative aortic valve stenosis has been established as an alternative to surgical aortic valve replacement. Late complications of transcatheter treatment of aortic stenosis (AS) are infrequent. Case summary We report an 87-year-old woman treated successfully with 23 mm Sapien 3 transapical transcatheter aortic valve implantation for severe AS. She presented 4 months later with a pulsatile mass in the left breast. After exclusion of other diagnoses, the mass was attributed to a sterile abscess communicating with the pericardial cavity due to post-operative chest infection and pleural effusion. Multimodality imaging helped to define the anatomy of the abscess and the mechanism of the pulsation. Discussion This is the first report of a pulsatile sterile abscess occurring as a complication of transapical aortic valve implantation. Multimodality imaging confirmed that the pulsation was due to extension of the abscess into the pericardial cavity, excluded direct communication with the left ventricle, and facilitated successful non-surgical management.

Sterile "Abscess" of the Spleen and the Sickle Cell Trait

Dear Editor:I read with interest the case report by Dr P Magro et al. [MJHID 9: e2017023, 2017] regarding a boy with sickle cell trait (AS), who was appropriately treated for Plasmodium falciparum malaria and who, upon ultrasound imaging, was thought to have multiple abscesses in the spleen, eventually interpreted as splenic infarction.