553664
research-article2014
IJSXXX10.1177/1066896914553664International Journal of Surgical PathologyAbdullGaffar
Original Article
Illicit Injections in Bodybuilders: A Clinicopathological Study of 11 Cases in 9 Patients With a Spectrum of Histological Reaction Patterns
International Journal of Surgical Pathology 2014, Vol. 22(8) 688–694 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896914553664 ijs.sagepub.com
Badr AbdullGaffar, MD1
Abstract The practice of self-injection of anabolic steroids (AS) in bodybuilders is common. AS are not the only materials used by bodybuilders for muscle augmentation or image enhancement. Other materials, for example, plant oils, silicon, Vaseline, and paraffin are also injected either in a pure form or mixed with AS. Muscle bulking is the main aim. However, bodybuilders undergo illicit injections for cosmetic, therapeutic, and sexual purposes. Even though the practice of unsupervised injection is probably common in the sports community, site-specific complications are underreported in the medical literature and mostly limited to case reports. Complications can be clinically and pathologically challenging because some can be confused with nonneoplastic and, more important, with neoplastic lesions. Bodybuilders are reluctant to disclose information because of stigma and legal issues. This study attempts to correlate the clinical manifestations and histomorphological features of different injected materials used for different purposes by bodybuilders in our region. A series of 11 cases out of 9 male bodybuilders was studied. A variety of clinical presentations and histological tissue reactions was identified, with some overlapping features between some cases. We identified 5 basic tissue reaction patterns depending on the injected materials, site, and duration of injection. Certain histological features provide useful hints in the absence of prior knowledge of injection history. However, in other cases, a retrospective enquiry by clinicians is warranted to avoid pitfalls. The medical and sports community should be aware of these injection-site complications. Bodybuilders should be discouraged from this practice by implementing appropriate educational and legislative measures. Keywords bodybuilding, injections, muscle, oil, silicon, steroids
Introduction Because bodybuilders are obsessed about their self-image and appearance, some seek extreme measures such as selfinjections to change their physical appearance.1-6 Anabolic steroids (AS) are the materials most commonly injected into muscles.3,7,8 However, some bodybuilders want quick results and, therefore, use alternative filler materials—for example, mineral oils, plant oils, and silicone.1,2,5,6,9,10 Postinjection complications are expected but probably underreported.4,5,7,10,11 Different clinical manifestations and a wide spectrum of histological reactions can result from different injection materials used by bodybuilders.7,9,11-14 This could be challenging to clinicians and pathologists particularly without prior knowledge of injection history, which is hidden by some bodybuilders.9,11,13 In this study, I attempted to shed some light on the different materials abused by amateur bodybuilders in our region and their corresponding clinical presentations and histopathological patterns. I also aimed to highlight some
histological clues that might help in the recognition of injection-related tissue reactions, avoiding pitfalls and leading to correct diagnosis and subsequent treatment. This is particularly important because some bodybuilders are reluctant to disclose a history of injections for different reasons.
Materials and Methods A retrospective review study was carried out over 8 years. A computer-based search system was used to retrieve all muscle, fascia, tendons, and subcutaneous and skin specimens from May 2005 to October 2013 in patients with a 1
Rashid Hospital, Dubai, UAE
Corresponding Author: Badr AbdullGaffar, Pathology Section, Rashid Hospital, Oud Metha Road 4545, P O Box 53116, Dubai, UAE. Email: [email protected]
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AbdullGaffar given clinical history of local injections or alternatively after pathological examination revealed hints of foreign material or reaction to foreign bodies. The retrieved specimens covered patients with a history of bodybuilding for muscle augmentation. Nonbodybuilders with a history of iatrogenic or self-injections for other purposes, for example, for medications or aesthetic reasons, were excluded from the study. Bodybuilders who performed injections for other reasons, for example, to improve self-image or for therapeutic reasons to alleviate symptoms such as muscle and tendon aches related to vigorous bodybuilding exercises, were included. The file of each patient was retrieved and reviewed for the clinical history and relevant clinical data. Data regarding the site and type of tissue injected, clinical manifestation and its duration, initial clinical impression, types of materials injected, duration of injection, and purpose of self- or illicit injections were collected. The collected specimens were previously fixed in 10% buffered formalin and routinely processed. The hematoxylin and eosin (H&E) slides of the collected cases were retrieved and examined for the patterns of histological reaction, types, and status of the tissue involved. Polarizing light was used to search for the presence or absence of a refractile foreign material. Special stains (periodic acid Schiff, Grocott Methenamine Silver, Giemsa, Gram, and Ziehl Neelsen) were used to search for microorganisms. Prussian blue, Fontana, elastic Van Gieson, Masson trichrome, Von Kossa, Congo red, and Alcian blue stains were performed to assess for nature of deposits and pigmented materials. Immunohistochemistry study for CD45, CD20, CD3, cytokeratin, S-100 protein, D2-40, CD31, desmin, and CD68 were performed as dictated by the H&E findings. Electron microscopy, spectroscopy, and X-ray microanalysis are not available in our institution.
Results A total of 11 cases from 9 bodybuilders with a history of either self-injection or illicit injection by nonmedical individuals were found. Two patients had 2 lesions each (Table 1). All the patients were male. The age range was between 20 and 39 years, with a mean age of 30 years. The muscles of the upper arms were commonly injected, but other bulky muscles were also sites of injections. Tendons, skin, and subcutaneous tissues were also sites of injections. Steroids, particularly anabolic androgenic steroids as well as other materials, for example silicone and oils, were used. One patient, however, did not recall the type of injected substance. The duration of injection was variable, but most reported months to years of repeated injections. Most cases presented with painful swellings. Others manifested as asymptomatic large lumps or small nodules. The initial clinical impression varied from soft-tissue
neoplasms, cysts, abscesses, gouty tophi, to rheumatoid nodules. The aim of injections was mostly for muscle augmentation or muscle bulk gain. Two patients were injected for therapeutic purposes because they complained of chronic strains after exercise. Two patients had taken injections for sexual purposes. One homosexual patient injected the gluteal region to enhance the contour of his buttocks, and another heterosexual patient injected his penis to gain penile enlargement. Four patients (cases 1, 4, 8, and 9) initially denied history of injection. They admitted illicit injections retrospectively after enquiries by clinicians. They were concerned about social stigma and questioning regarding illegal abuse of injections. The men admitted acquiring materials from either friends or trainers in the gym, via Internet access or illegal prescriptions. Plant oils and Vaseline were easily available in the market. Among the patients, 5 were lost to follow-up; 4 patients had follow-up; and 2 of them stopped injections. The other 2 continued injections after initial treatment and had recurrent, similar lesions (Table 1). The histopathological tissue reactions were variable and overlapping between some cases depending on the type of injected materials as well as the site and duration of injection (Table 2). The first patient injected AS for a few months, and his specimen showed foreign-body giant cell chronic inflammation with variable sized empty spaces (Figures 1A). The second patient used to repeatedly inject corticosteroids into his heel for 3 years. He developed a bony spur with calcifications and bone formation replacing his tendon (Figures 1B and 1C). A similar lesion developed after repeated injections into his left heel. The third patient injected silicone into his biceps for 2 years. He developed a mass in his muscle that was clinically confused with soft-tissue tumor and was excised. It showed a nodule of florid foreign-body giant cell reaction with variable sized empty spaces and sclerosis (Figure 2). He continued to use the same material in his other arm and developed a similar tumor-like lesion. Patient 4 received injection of an unidentified material for a few months. He developed fat necrosis and calcifications of his chest muscle, which was partly replaced by adipose tissue (Figures 3A and 3B). Patient 5 was a homosexual man who injected liquid silicone into his buttocks. The specimen showed diffuse replacement of the dermis and panniculus by multivacuolated foamy histiocytes. The sixth patient injected a mixture of Vaseline and paraffin oils into his penis for 2 months. The tissue reaction was variable. Deeper foci showed foreign-body giant cell reaction with empty spaces with fibrosis alternating with bulks of amorphous hyaline material (Figures 3C). The dermis, however, showed diffuse multivacuolated foamy histiocytic infiltrate (Figure 3D) similar to case 5. Patient 7 presented with a painful thigh and fever after injection of AS. The muscle tissue showed abscess formation. Patient 8 used to inject
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Table 1. Clinical Features in 9 Bodybuilders With a History of Self-injection or Illicit Injection by Friends or Trainers. Age SN (years) 1
27
2
39
3
32
4
26
5
35
6
27
7
20
8
38
9
30
Location
Injected Tissue
Clinical Presentation
Right upper arm Triceps muscle
Pain and swelling, ×4 weeks Right heel Tendon and Pain and swelling, ×6 muscle weeks Left heel Tendon Pain and swelling, ×4 weeks (for peer review) Right upper arm Biceps muscle Hard nontender lump, ×2 years Left upper arm Biceps muscle Hard nontender lump, ×9 months Left chest wall Pectoralis muscle Pain and swelling, ×1 month Right and left Dermis and Nontender rounded buttocks subcutaneous lumps, ×8 months Penis Skin and Tender nodule and subcutaneous disfigurement, ×4 weeks Left thigh Quadriceps muscle Pain, swelling and fever, ×2 weeks Right wrist and Tendons and Painful, tender nodule middle finger muscles ×2 months
Left upper arm Deltoid muscle
Pain and swelling, ×1 month
Material Injected/ Duration
Inferred Diagnosis NA Bony spur
Reason
Anabolic steroids, ×4 months Corticosteroids, ×3yrs
Bulking
Follow-up NA
Bony spur
Corticosteroids, ×2 years
Therapeutic 5 Years reinjection Therapeutic Stopped injection
Soft-tissue tumor
Silicon, ×2 years
Bulking
Soft-tissue tumor
Silicon, ×1 year
Bulking
1 Year reinjection NA
Cyst, lipoma
Unknown, ×3 months
Bulking
NA
Lipomas
Liquid Silicon, ×4 years
Cosmetic
NA
Lump, cyst, abscess Mineral oil (Vaseline), Sexual paraffin oil, ×2 months
NA
Abscess
NA
Anabolic steroids, ×2 weeks Corticosteroids, ×2.5 years
GCTTS, gout tophus rheumatoid nodule Abscess, ruptured Anabolic steroids, ×1 cyst year
Bulking
Therapeutic Stopped injection
Bulking
Stopped injection
Abbreviations: SN; serial number; NA; not available; GCTTS, giant cell tumor of tendon sheath.
Table 2. Histopathological Features of the Collected Cases. SN 1 2 3
4 5 6 7 8 9
Histopathology
Diagnosis
Pattern
Mixed chronic inflammation, scattered ganglion-like giant cells, small and large empty spaces and fibrosis (Figure 1A) Calcification, bone formation, fibrosis, and degenerate muscle fibers (Figures 1C, 1D) Ovoid well-defined nodule composed of variable sized empty spaces, giant cells, sclerosis, degenerate muscle fibers, chronic inflammation, and lymphoid follicles (Figure 2)
Foreign-body giant cell reaction Bony spur
Foreign-body giant cell chronic inflammation Ossifying (metaplastic)
Foreign-body giant cell reaction
Fat metaplasia, large empty vacuoles rimmed by macrophages, fat necrosis, and microcalcifications (Figures 3A, 3B) Diffuse dermal and subcutaneous infiltrate by multivacuolated foamy histiocytes Large, empty vacuoles rimed by giant cells and onion-ring fibrosis, dermal multivacuolated foamy histiocytes, foreign material, giant cells, and fibrosis (Figures 3C, 3D) Marked acute fibrinopurulent inflammatory exudate, muscle necrosis, and abscess Epithelioid granulomas with multinucleated giant cells and fibrinoid material, chronic inflammation, and sclerosis (Figure 4A) Pseudocyst cavity, xanthomatous chronic inflammation with lymphoid follicles, yellow pigments and microcalcifications (Figures 4B-4D)
Fat necrosis
Foreign-body giant cell chronic inflammation (sclerosing lipogranulomatous) Adipocytic (metaplastic)
Dermal histiocytic infiltrate Mineral oil granuloma (paraffinoma) Pyomyositis (abscess) Chronic granulomatous inflammation Inflamed ruptured cyst
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Foamy histiocytic Mixed pattern (foreign body reaction + foamy histiocytic) Acute inflammatory Necrobiotic granulomatous (rheumatoid nodule like) Xanthogranulomatous chronic inflammation
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Figure 1. A. Case 1 shows mixed chronic inflammation composed of lymphocytes, histiocytes, eosinophils and plasma cells infiltrating the skeletal muscle fibers. Foamy histiocytes, empty vacuoles and fibrosis are evident in the background (hematoxylin and eosin [H&E], original magnification ×200). B. Case 2 shows a fibro-osseous nodule with calcifications and chondroblastic ossification (H&E, original magnification ×40). C. High-power view shows foci of degenerate muscle and tendon fibers replaced by fibrosis and bone (H&E, original magnification ×200).
Figure 2. A. Case 3 shows a well-defined lipoma-like mass. Note the remaining skeletal muscle bundles pushed at the periphery (hematoxylin and eosin [H&E], original magnification ×20). B. The mass consists of variable sized vacuoles with multinucleated giant cells, vacuolated macrophages, foamy histiocytes with a background of mild chronic inflammatory infiltrate, and wisps of collagen fibers (H&E, original magnification ×200). C. Other foci show marked sclerosis with entrapped vacuoles (H&E, original magnification ×200). D. Foci of lymphoid follicles, fibromyxoid stroma with degenerate atrophic skeletal muscle fibers, and scattered vacuoles are evident (H&E, original magnification ×100).
corticosteroids for several years into his hand tendons. The biopsy showed necrobiotic epithelioid granulomas with central fibrinoid material and giant cells (Figure 4A). Serology for connective tissue diseases, including rheumatoid arthritis and gout, was negative. The last patient injected AS into his deltoid muscle for 1 year. The specimen showed a cavity with xanthogranulomatous
Figure 3. A. Case 4 shows skeletal muscle fibers replaced and infiltrated by adipose tissue (hematoxylin and eosin [H&E], original magnification ×100). B. Other areas show fat necrosis and calcifications (H&E, original magnification ×100). C. Case 6 shows hyaline amorphous eosinophilic material surrounded by chronic inflammation and fibrosis. A multinucleated giant cell is seen engulfing foreign material (H&E, original magnification ×200). D. The dermis shows marked infiltration by foamy histiocytes (H&E, original magnification ×200).
inflammation, yellow pigments, and calcifications (Figures 4B-4D). None of the above specimens showed refractive polarizing bodies. Von Kossa stain highlighted the calcification spots. Special stains for iron, mucin, and microorganisms were negative. The yellow pigments and amorphous granular material were negative for periodic acid Schiff and periodic acid Schiff-diastase. CD45, CD20, and CD3 markers delineated the inflammatory lymphocytic infiltrate in certain cases. CD68 marker highlighted the histiocytic infiltrate and
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Figure 4. A. Case 8 shows foci of epithelioid granulomas with multinucleated giant cells and central fibrinoid material. The surrounding tissue shows chronic inflammation, fibromyxoid stroma, and fibrosis (hematoxylin and eosin [H&E], original magnification ×100). B. Case 9 shows a cyst-like cavity composed of inflammatory fibrous wall with scattered lymphoid follicles. Note the displaced peripheral skeletal muscle bundles (H&E, original magnification ×20). C. The cavity wall shows xanthogranulomatous inflammation, calcifications, and fibrosis (H&E, original magnification ×100). D. Foci of yellow pigmented round bodies were seen (H&E, original magnification ×400).
giant cells in most of the cases. The foamy cells were negative for the remaining markers. The empty lymphatic channel-like spaces were negative for CD31 and D2-40.
Discussion Even though the use of AS is particularly common among regular visitors to gyms and fitness centers, many of the side effects of AS injections are only reported in case reports.4-6,10,11 A larger review study focusing on this issue is lacking in the literature. The exact prevalence and incidence of AS injection site complications are probably underreported in the medical literature.7,10 In addition, bodybuilders use other substances as image enhancers, either in a pure form or mixed with AS.1,2,5,6,9,10,13 Because bodybuilders tend to deny history of injection, the recognition of the different histological features of different injected materials by pathologists is important to avoid erroneous diagnosis, unnecessary aggressive treatment, or delayed management.11,13 It also helps focus the attention of the medical and fitness community on the different clinical manifestations that can mimic medical and surgical conditions as well as on the infection hazards and local and potentially systemic complications associated with illicit injections by bodybuilders.1,5,8,10,14 Similarly, legal issues
regarding illegal prescriptions and purchase could be raised depending on the legislation of each country. This study showed variable clinical side effects and variable corresponding tissue reactions, depending on the type of injected material and site and duration of injection. Most of the cases presented clinically as painful swellings. Others manifested as asymptomatic small hard nodules or large masses with disfigurement. Some lesions were initially confused with soft-tissue tumors, and patients underwent surgery for a complete excision. Other lesions were managed by incision. The histological patterns varied from case to case, with some overlapping features between some cases. Even though the various histological reactions were rather nonspecific, 5 major patterns of tissue responses could be recognized. Cases 1, 3, 6, and 9 showed a chronic inflammation of foreign-body giant cell reaction with variable degrees of fibrosis. The presence of empty spaces with multinucleated giant cells is characteristic and suggestive of injected material, particularly tissue fillers.5-7,11 Cases 2 and 4 showed metaplastic degenerative changes. Secondary ossification is claimed to be common in silicone or after repeated traumatic injuries to the muscle because of frequent injections.7 Fatty changes in the form of fat necrosis and metaplasia were not reported previously. Case 5, and to some extent case 6, showed diffuse foamy histiocytic infiltrate without inflammation, giant cells, empty spaces, or fibrosis. This is particularly common in silicone, to a lesser extent in AS and corticosteroids, and partly in oils.5,7,12,15 However, epithelioid granulomas are not features of silicone.5 Case 7 showed acute fibrinopurulent exudate. Abscess formation is related to contamination caused by nonsterile techniques or sharing. Abscesses can present as acute painful masses.3,14 Case 8 showed necrobiotic epithelioid granulomas mimicking rheumatoid nodules. This rheumatoid nodule-like granulomatous inflammation was identified in steroids, both AS and corticosteroids, but not in other materials.7,12,15 Patterns similar to the above, except the fatty changes, were recognized in previously reported cases.1-17 There is controversy regarding the factors that result in different tissue reactions to injected materials. The factors include type and amount of injected material, suspension medium, tissue injected, level of injection, duration and frequency of injection, and secondary infection.7,15 Early stages tend to have vacuolated histiocytes, granular macrophages, and giant cells, but later stages develop empty spaces, microcysts, fibrosis, and calcifications.5 Other authors, however, claim that changes do not vary with type of steroids, dosage, injection technique, sites, or time interval between injections.7,12 In our study, the tissue reaction patterns varied according to type of injected material, site, and duration of injection. Variations were noticed in steroids. However, variation in tissue reactions could be related to impurities in steroids—for example, oils and
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AbdullGaffar aluminum that are used to enhance the action of steroids or prolong their effect or used as a transport medium. Injections into muscle, skin, panniculus, and tendons result in different morphologies depending on the duration although the material injected is similar. The mechanism of different tissue reactions to steroid injections is related to local and systemic factors.11 Local factors are unrelated to the contents of the injection or its chemical contents. Factors unrelated to the type of injected material that can modify the tissue reaction include infection caused by contamination or physical effects caused by repeated trauma by needles. The localized response could be related to interaction of different tissues with steroids or other mixed chemical agents. They might have an effect on the inflammatory histiocytic/macrophage system. The type of inflammation, that is, nonspecific chronic inflammation or granulomatous, will vary according to the type of hypersensitivity reaction. Steroids have systemic effects on mobilizing inflammatory and immune cells, which can result in delayed hypersensitivity reaction. Chong et al18 identified 4 histological reaction patterns (panniculitislike, pseudolymphoma, lupus profundus–like, and necrotizing rheumatoid nodule-like granuloma) in vaccination and desensitization injections. They related these patterns to the adjuvant aluminum salt used as a vehicle in different injections. Even though mineral oils and silicone are considered inert materials, different tissue reactions could occur. Clinical differential diagnoses might include soft-tissue tumors, both benign and malignant.2,3,11,13 Factitial pseudotumors commonly result from non-AS material, particularly mineral oils, albeit tumor-like lesions were occasionally reported secondary to AS injections.3 Intact or ruptured cysts are also common initial clinical impressions. Abscesses are usually easily recognized.3,14 Tissue reactions to injections could be histologically confused with other inflammatory lesions—for example, necrobiotic epithelioid granulomas or soft-tissue neoplasms, such as lipomatous tumors. Histological hints to injections in the absence of foreign material include multinucleated giant cells, empty spaces, foamy histiocytes, or histiocytes with violaceous granular cytoplasm.5,11,15,18 Yellow pigments/crystals are also useful clues. Other features, for example fibrosis, granulomas, and calcifications, are either nonspecific or do not point to injection material. In difficult cases, a detailed clinical history is helpful to avoid extensive investigations and unnecessary aggressive treatment. The management of persistent or symptomatic nodules or masses is usually by complete excision to prevent further local or systemic complications, for example, disfigurement and movement restriction caused by muscle damage and scarring, ulcers, lymphangitis, septicemia,
and oil embolism.2,6,10 Some patients seek surgical removal of injection-related lumps for better aesthetic results. There are many reasons why bodybuilders use injections. The main aim is to have muscle bulking either by muscle mass gain with AS or by limb enlargement using non-AS materials. Cosmetic and sexual reasons could also exist. AS are the main material used by bodybuilders to increase muscle mass and power.3,4,7,8,11,14 Other substances include tissue fillers, for example, mineral oils and silicone.1,5,6,17 Plant oils like sesame seed and walnut oils are also used.2,9,10,13 The are commonly used as alternatives to AS for bulking and cosmetic purposes or mixed with AS.13 Some homosexual or heterosexual men in gyms and fitness centers seek these fillers for sexual purposes, for example, penile enlargement or buttocks contouring depending on their sexual desires.4,16,17 Awareness of these injection-site complications and other potential infection hazards and implementation of educational measures by the medical and sports community should discourage amateur bodybuilders from this risky and medically unsupervised, but unfortunately common, injection practice.1,5,8,10,14 Strict regulations and monitoring of gyms are also warranted to control and limit this risky illicit practice. This study is not without limitations. There were 5 patients who did not have follow-up. The identity of injection material was not known in one patient. Specialized instruments to further analyze the exact nature of injected materials are not available in our laboratory. Finally, the sample in this study does not reflect the magnitude of the problem related to unsupervised injections by bodybuilders in our region. A survey study targeting bodybuilders in gyms and fitness centers should reveal the true prevalence of this phenomenon. In conclusion, different materials injected by bodybuilders for different purposes have a wide spectrum of clinical and histomorphological features that can be mimicked by other nonneoplastic and neoplastic lesions. Prior knowledge of injection history is important; however, certain histological hints might help pathologists reach the correct diagnosis and, therefore, guide clinicians to appropriate management. Unsupervised injections by bodybuilders should be discouraged and controlled to avoid infection hazards and unwanted local and potentially lifethreatening systemic complications. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
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References 1. Henriksen TF, Lovenwald JB, Matzen SH. Paraffin oil injection in bodybuilders calls for preventive action. Ugeskr Laeger. 2010;172:219-220. 2. Munch IC, Hvolris JJ. Body building aided by intramuscular injections of walnut oil. Ugeskr Laeger. 2001;163:6758. 3. Kienbacher G, Maurer-Ertl W, Glehr M, Feierl G, Leithner A. A case of a tumor stimulating expansion caused by anabolic androgen steroids in body building [in German]. Sportverletz Sportschaden. 2007;21:195-198. 4. Larance B, Degenhardt L, Copeland J, Dillon P. Injecting risk behaviour and related harm among men who use performance-and image-enhancing drugs. Drug Alcohol Rev. 2008;27:679-686. 5. Darsow U, Bruckbauer H, Worret WI, Hofmann H, Ring J. Subcutaneous oleomas induced by self-injection of sesame oil for muscle augmentation. J Am Acad Dermatol. 2000;42:292-294. 6. Ghandourah S, Hofer MM, Kiessling A, El-Zayat B, Schofer MD. Painful muscle fibrosis following synthol injections in a bodybuilder: a case report. J Med Case Rep. 2012;6:248. 7. Fernandez-Flores A, Valerdiz S, Crespo LG, Rodriguez R. Granulomatous response to anabolic steroid injections. Acta Dermatovenerol Croat. 2011;19:103-106. 8. Melnik B, Jansen T, Grabbe S. Abuse of anabolic-androgenic steroids and bodybuilding acne: an underestimated health problem. J Dtsch Dermatol Ges. 2007;5:110-117. 9. Koopman M, Richter C, Parren RJM, Janssen M. Bodybuilding, sesame oil and vasculitis. Rheumatology (Oxford). 2005;44:1135.
10. Banke IJ, Prodinger PM, Waldt S, et al. Irreversible muscle damage in bodybuilding due to long-term intramuscular oil injection. Int J Sports Med. 2012;33:829-834. 11. Weinreb I, Goldblum JR, Rubin BP. Factitial soft tissue pseudotumor due to injection of anabolic steroids: a report of 3 cases in 2 patients. Hum Pathol. 2010;41; 452-455. 12. Balogh K. The histologic appearance of corticosteroid injection sites. Arch Pathol Lab Med. 1986;110:1168-1172. 13. Khankhanian NK, Hammers YA, Kowalski P. Exuberant local tissue reaction to intramuscular injection of nandrolone decanoate (Deca-Durabolin): a steroid compound in a sesame seed oil base- mimicking soft tissue malignant tumors. Mil Med. 1992;157:670-674. 14. Rich JD, Dickinson BP, Flanigan TP, Valone SE. Abscess related to anabolic-androgenic steroid injection. Med Sci Sports Exerc. 1999;31:207-209. 15. Weedon D, Gutteridge B, Hockly RG, Emmett A. Unusual cutaneous reactions to injections of corticosteroids. Am J Dermatopathol. 1982;4:199-203. 16. Cohen JL, Keoleian CM, Krull EA. Penile paraffinoma: self-injection with mineral oil. J Am Acad Dermatol. 2002;47:S251-S253. 17. Glicenstein J. The first “fillers,” Vaseline and paraffin: from miracle to disaster. Ann Chir Plast Esthet. 2007;52: 157-161. 18. Chong H, Brady K, Metze D, Calonje E. Persistent nodules at injection sites (aluminum granuloma): clinicopathological study of 14 cases with a diverse range of histological reaction patterns. Histopathology. 2006;48:182-188.
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research-article2014
IJSXXX10.1177/1066896914553664International Journal of Surgical PathologyAbdullGaffar
Original Article
Illicit Injections in Bodybuilders: A Clinicopathological Study of 11 Cases in 9 Patients With a Spectrum of Histological Reaction Patterns
International Journal of Surgical Pathology 2014, Vol. 22(8) 688–694 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896914553664 ijs.sagepub.com
Badr AbdullGaffar, MD1
Abstract The practice of self-injection of anabolic steroids (AS) in bodybuilders is common. AS are not the only materials used by bodybuilders for muscle augmentation or image enhancement. Other materials, for example, plant oils, silicon, Vaseline, and paraffin are also injected either in a pure form or mixed with AS. Muscle bulking is the main aim. However, bodybuilders undergo illicit injections for cosmetic, therapeutic, and sexual purposes. Even though the practice of unsupervised injection is probably common in the sports community, site-specific complications are underreported in the medical literature and mostly limited to case reports. Complications can be clinically and pathologically challenging because some can be confused with nonneoplastic and, more important, with neoplastic lesions. Bodybuilders are reluctant to disclose information because of stigma and legal issues. This study attempts to correlate the clinical manifestations and histomorphological features of different injected materials used for different purposes by bodybuilders in our region. A series of 11 cases out of 9 male bodybuilders was studied. A variety of clinical presentations and histological tissue reactions was identified, with some overlapping features between some cases. We identified 5 basic tissue reaction patterns depending on the injected materials, site, and duration of injection. Certain histological features provide useful hints in the absence of prior knowledge of injection history. However, in other cases, a retrospective enquiry by clinicians is warranted to avoid pitfalls. The medical and sports community should be aware of these injection-site complications. Bodybuilders should be discouraged from this practice by implementing appropriate educational and legislative measures. Keywords bodybuilding, injections, muscle, oil, silicon, steroids
Introduction Because bodybuilders are obsessed about their self-image and appearance, some seek extreme measures such as selfinjections to change their physical appearance.1-6 Anabolic steroids (AS) are the materials most commonly injected into muscles.3,7,8 However, some bodybuilders want quick results and, therefore, use alternative filler materials—for example, mineral oils, plant oils, and silicone.1,2,5,6,9,10 Postinjection complications are expected but probably underreported.4,5,7,10,11 Different clinical manifestations and a wide spectrum of histological reactions can result from different injection materials used by bodybuilders.7,9,11-14 This could be challenging to clinicians and pathologists particularly without prior knowledge of injection history, which is hidden by some bodybuilders.9,11,13 In this study, I attempted to shed some light on the different materials abused by amateur bodybuilders in our region and their corresponding clinical presentations and histopathological patterns. I also aimed to highlight some
histological clues that might help in the recognition of injection-related tissue reactions, avoiding pitfalls and leading to correct diagnosis and subsequent treatment. This is particularly important because some bodybuilders are reluctant to disclose a history of injections for different reasons.
Materials and Methods A retrospective review study was carried out over 8 years. A computer-based search system was used to retrieve all muscle, fascia, tendons, and subcutaneous and skin specimens from May 2005 to October 2013 in patients with a 1
Rashid Hospital, Dubai, UAE
Corresponding Author: Badr AbdullGaffar, Pathology Section, Rashid Hospital, Oud Metha Road 4545, P O Box 53116, Dubai, UAE. Email: [email protected]
Downloaded from ijs.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on February 23, 2015
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AbdullGaffar given clinical history of local injections or alternatively after pathological examination revealed hints of foreign material or reaction to foreign bodies. The retrieved specimens covered patients with a history of bodybuilding for muscle augmentation. Nonbodybuilders with a history of iatrogenic or self-injections for other purposes, for example, for medications or aesthetic reasons, were excluded from the study. Bodybuilders who performed injections for other reasons, for example, to improve self-image or for therapeutic reasons to alleviate symptoms such as muscle and tendon aches related to vigorous bodybuilding exercises, were included. The file of each patient was retrieved and reviewed for the clinical history and relevant clinical data. Data regarding the site and type of tissue injected, clinical manifestation and its duration, initial clinical impression, types of materials injected, duration of injection, and purpose of self- or illicit injections were collected. The collected specimens were previously fixed in 10% buffered formalin and routinely processed. The hematoxylin and eosin (H&E) slides of the collected cases were retrieved and examined for the patterns of histological reaction, types, and status of the tissue involved. Polarizing light was used to search for the presence or absence of a refractile foreign material. Special stains (periodic acid Schiff, Grocott Methenamine Silver, Giemsa, Gram, and Ziehl Neelsen) were used to search for microorganisms. Prussian blue, Fontana, elastic Van Gieson, Masson trichrome, Von Kossa, Congo red, and Alcian blue stains were performed to assess for nature of deposits and pigmented materials. Immunohistochemistry study for CD45, CD20, CD3, cytokeratin, S-100 protein, D2-40, CD31, desmin, and CD68 were performed as dictated by the H&E findings. Electron microscopy, spectroscopy, and X-ray microanalysis are not available in our institution.
Results A total of 11 cases from 9 bodybuilders with a history of either self-injection or illicit injection by nonmedical individuals were found. Two patients had 2 lesions each (Table 1). All the patients were male. The age range was between 20 and 39 years, with a mean age of 30 years. The muscles of the upper arms were commonly injected, but other bulky muscles were also sites of injections. Tendons, skin, and subcutaneous tissues were also sites of injections. Steroids, particularly anabolic androgenic steroids as well as other materials, for example silicone and oils, were used. One patient, however, did not recall the type of injected substance. The duration of injection was variable, but most reported months to years of repeated injections. Most cases presented with painful swellings. Others manifested as asymptomatic large lumps or small nodules. The initial clinical impression varied from soft-tissue
neoplasms, cysts, abscesses, gouty tophi, to rheumatoid nodules. The aim of injections was mostly for muscle augmentation or muscle bulk gain. Two patients were injected for therapeutic purposes because they complained of chronic strains after exercise. Two patients had taken injections for sexual purposes. One homosexual patient injected the gluteal region to enhance the contour of his buttocks, and another heterosexual patient injected his penis to gain penile enlargement. Four patients (cases 1, 4, 8, and 9) initially denied history of injection. They admitted illicit injections retrospectively after enquiries by clinicians. They were concerned about social stigma and questioning regarding illegal abuse of injections. The men admitted acquiring materials from either friends or trainers in the gym, via Internet access or illegal prescriptions. Plant oils and Vaseline were easily available in the market. Among the patients, 5 were lost to follow-up; 4 patients had follow-up; and 2 of them stopped injections. The other 2 continued injections after initial treatment and had recurrent, similar lesions (Table 1). The histopathological tissue reactions were variable and overlapping between some cases depending on the type of injected materials as well as the site and duration of injection (Table 2). The first patient injected AS for a few months, and his specimen showed foreign-body giant cell chronic inflammation with variable sized empty spaces (Figures 1A). The second patient used to repeatedly inject corticosteroids into his heel for 3 years. He developed a bony spur with calcifications and bone formation replacing his tendon (Figures 1B and 1C). A similar lesion developed after repeated injections into his left heel. The third patient injected silicone into his biceps for 2 years. He developed a mass in his muscle that was clinically confused with soft-tissue tumor and was excised. It showed a nodule of florid foreign-body giant cell reaction with variable sized empty spaces and sclerosis (Figure 2). He continued to use the same material in his other arm and developed a similar tumor-like lesion. Patient 4 received injection of an unidentified material for a few months. He developed fat necrosis and calcifications of his chest muscle, which was partly replaced by adipose tissue (Figures 3A and 3B). Patient 5 was a homosexual man who injected liquid silicone into his buttocks. The specimen showed diffuse replacement of the dermis and panniculus by multivacuolated foamy histiocytes. The sixth patient injected a mixture of Vaseline and paraffin oils into his penis for 2 months. The tissue reaction was variable. Deeper foci showed foreign-body giant cell reaction with empty spaces with fibrosis alternating with bulks of amorphous hyaline material (Figures 3C). The dermis, however, showed diffuse multivacuolated foamy histiocytic infiltrate (Figure 3D) similar to case 5. Patient 7 presented with a painful thigh and fever after injection of AS. The muscle tissue showed abscess formation. Patient 8 used to inject
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Table 1. Clinical Features in 9 Bodybuilders With a History of Self-injection or Illicit Injection by Friends or Trainers. Age SN (years) 1
27
2
39
3
32
4
26
5
35
6
27
7
20
8
38
9
30
Location
Injected Tissue
Clinical Presentation
Right upper arm Triceps muscle
Pain and swelling, ×4 weeks Right heel Tendon and Pain and swelling, ×6 muscle weeks Left heel Tendon Pain and swelling, ×4 weeks (for peer review) Right upper arm Biceps muscle Hard nontender lump, ×2 years Left upper arm Biceps muscle Hard nontender lump, ×9 months Left chest wall Pectoralis muscle Pain and swelling, ×1 month Right and left Dermis and Nontender rounded buttocks subcutaneous lumps, ×8 months Penis Skin and Tender nodule and subcutaneous disfigurement, ×4 weeks Left thigh Quadriceps muscle Pain, swelling and fever, ×2 weeks Right wrist and Tendons and Painful, tender nodule middle finger muscles ×2 months
Left upper arm Deltoid muscle
Pain and swelling, ×1 month
Material Injected/ Duration
Inferred Diagnosis NA Bony spur
Reason
Anabolic steroids, ×4 months Corticosteroids, ×3yrs
Bulking
Follow-up NA
Bony spur
Corticosteroids, ×2 years
Therapeutic 5 Years reinjection Therapeutic Stopped injection
Soft-tissue tumor
Silicon, ×2 years
Bulking
Soft-tissue tumor
Silicon, ×1 year
Bulking
1 Year reinjection NA
Cyst, lipoma
Unknown, ×3 months
Bulking
NA
Lipomas
Liquid Silicon, ×4 years
Cosmetic
NA
Lump, cyst, abscess Mineral oil (Vaseline), Sexual paraffin oil, ×2 months
NA
Abscess
NA
Anabolic steroids, ×2 weeks Corticosteroids, ×2.5 years
GCTTS, gout tophus rheumatoid nodule Abscess, ruptured Anabolic steroids, ×1 cyst year
Bulking
Therapeutic Stopped injection
Bulking
Stopped injection
Abbreviations: SN; serial number; NA; not available; GCTTS, giant cell tumor of tendon sheath.
Table 2. Histopathological Features of the Collected Cases. SN 1 2 3
4 5 6 7 8 9
Histopathology
Diagnosis
Pattern
Mixed chronic inflammation, scattered ganglion-like giant cells, small and large empty spaces and fibrosis (Figure 1A) Calcification, bone formation, fibrosis, and degenerate muscle fibers (Figures 1C, 1D) Ovoid well-defined nodule composed of variable sized empty spaces, giant cells, sclerosis, degenerate muscle fibers, chronic inflammation, and lymphoid follicles (Figure 2)
Foreign-body giant cell reaction Bony spur
Foreign-body giant cell chronic inflammation Ossifying (metaplastic)
Foreign-body giant cell reaction
Fat metaplasia, large empty vacuoles rimmed by macrophages, fat necrosis, and microcalcifications (Figures 3A, 3B) Diffuse dermal and subcutaneous infiltrate by multivacuolated foamy histiocytes Large, empty vacuoles rimed by giant cells and onion-ring fibrosis, dermal multivacuolated foamy histiocytes, foreign material, giant cells, and fibrosis (Figures 3C, 3D) Marked acute fibrinopurulent inflammatory exudate, muscle necrosis, and abscess Epithelioid granulomas with multinucleated giant cells and fibrinoid material, chronic inflammation, and sclerosis (Figure 4A) Pseudocyst cavity, xanthomatous chronic inflammation with lymphoid follicles, yellow pigments and microcalcifications (Figures 4B-4D)
Fat necrosis
Foreign-body giant cell chronic inflammation (sclerosing lipogranulomatous) Adipocytic (metaplastic)
Dermal histiocytic infiltrate Mineral oil granuloma (paraffinoma) Pyomyositis (abscess) Chronic granulomatous inflammation Inflamed ruptured cyst
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Foamy histiocytic Mixed pattern (foreign body reaction + foamy histiocytic) Acute inflammatory Necrobiotic granulomatous (rheumatoid nodule like) Xanthogranulomatous chronic inflammation
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Figure 1. A. Case 1 shows mixed chronic inflammation composed of lymphocytes, histiocytes, eosinophils and plasma cells infiltrating the skeletal muscle fibers. Foamy histiocytes, empty vacuoles and fibrosis are evident in the background (hematoxylin and eosin [H&E], original magnification ×200). B. Case 2 shows a fibro-osseous nodule with calcifications and chondroblastic ossification (H&E, original magnification ×40). C. High-power view shows foci of degenerate muscle and tendon fibers replaced by fibrosis and bone (H&E, original magnification ×200).
Figure 2. A. Case 3 shows a well-defined lipoma-like mass. Note the remaining skeletal muscle bundles pushed at the periphery (hematoxylin and eosin [H&E], original magnification ×20). B. The mass consists of variable sized vacuoles with multinucleated giant cells, vacuolated macrophages, foamy histiocytes with a background of mild chronic inflammatory infiltrate, and wisps of collagen fibers (H&E, original magnification ×200). C. Other foci show marked sclerosis with entrapped vacuoles (H&E, original magnification ×200). D. Foci of lymphoid follicles, fibromyxoid stroma with degenerate atrophic skeletal muscle fibers, and scattered vacuoles are evident (H&E, original magnification ×100).
corticosteroids for several years into his hand tendons. The biopsy showed necrobiotic epithelioid granulomas with central fibrinoid material and giant cells (Figure 4A). Serology for connective tissue diseases, including rheumatoid arthritis and gout, was negative. The last patient injected AS into his deltoid muscle for 1 year. The specimen showed a cavity with xanthogranulomatous
Figure 3. A. Case 4 shows skeletal muscle fibers replaced and infiltrated by adipose tissue (hematoxylin and eosin [H&E], original magnification ×100). B. Other areas show fat necrosis and calcifications (H&E, original magnification ×100). C. Case 6 shows hyaline amorphous eosinophilic material surrounded by chronic inflammation and fibrosis. A multinucleated giant cell is seen engulfing foreign material (H&E, original magnification ×200). D. The dermis shows marked infiltration by foamy histiocytes (H&E, original magnification ×200).
inflammation, yellow pigments, and calcifications (Figures 4B-4D). None of the above specimens showed refractive polarizing bodies. Von Kossa stain highlighted the calcification spots. Special stains for iron, mucin, and microorganisms were negative. The yellow pigments and amorphous granular material were negative for periodic acid Schiff and periodic acid Schiff-diastase. CD45, CD20, and CD3 markers delineated the inflammatory lymphocytic infiltrate in certain cases. CD68 marker highlighted the histiocytic infiltrate and
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Figure 4. A. Case 8 shows foci of epithelioid granulomas with multinucleated giant cells and central fibrinoid material. The surrounding tissue shows chronic inflammation, fibromyxoid stroma, and fibrosis (hematoxylin and eosin [H&E], original magnification ×100). B. Case 9 shows a cyst-like cavity composed of inflammatory fibrous wall with scattered lymphoid follicles. Note the displaced peripheral skeletal muscle bundles (H&E, original magnification ×20). C. The cavity wall shows xanthogranulomatous inflammation, calcifications, and fibrosis (H&E, original magnification ×100). D. Foci of yellow pigmented round bodies were seen (H&E, original magnification ×400).
giant cells in most of the cases. The foamy cells were negative for the remaining markers. The empty lymphatic channel-like spaces were negative for CD31 and D2-40.
Discussion Even though the use of AS is particularly common among regular visitors to gyms and fitness centers, many of the side effects of AS injections are only reported in case reports.4-6,10,11 A larger review study focusing on this issue is lacking in the literature. The exact prevalence and incidence of AS injection site complications are probably underreported in the medical literature.7,10 In addition, bodybuilders use other substances as image enhancers, either in a pure form or mixed with AS.1,2,5,6,9,10,13 Because bodybuilders tend to deny history of injection, the recognition of the different histological features of different injected materials by pathologists is important to avoid erroneous diagnosis, unnecessary aggressive treatment, or delayed management.11,13 It also helps focus the attention of the medical and fitness community on the different clinical manifestations that can mimic medical and surgical conditions as well as on the infection hazards and local and potentially systemic complications associated with illicit injections by bodybuilders.1,5,8,10,14 Similarly, legal issues
regarding illegal prescriptions and purchase could be raised depending on the legislation of each country. This study showed variable clinical side effects and variable corresponding tissue reactions, depending on the type of injected material and site and duration of injection. Most of the cases presented clinically as painful swellings. Others manifested as asymptomatic small hard nodules or large masses with disfigurement. Some lesions were initially confused with soft-tissue tumors, and patients underwent surgery for a complete excision. Other lesions were managed by incision. The histological patterns varied from case to case, with some overlapping features between some cases. Even though the various histological reactions were rather nonspecific, 5 major patterns of tissue responses could be recognized. Cases 1, 3, 6, and 9 showed a chronic inflammation of foreign-body giant cell reaction with variable degrees of fibrosis. The presence of empty spaces with multinucleated giant cells is characteristic and suggestive of injected material, particularly tissue fillers.5-7,11 Cases 2 and 4 showed metaplastic degenerative changes. Secondary ossification is claimed to be common in silicone or after repeated traumatic injuries to the muscle because of frequent injections.7 Fatty changes in the form of fat necrosis and metaplasia were not reported previously. Case 5, and to some extent case 6, showed diffuse foamy histiocytic infiltrate without inflammation, giant cells, empty spaces, or fibrosis. This is particularly common in silicone, to a lesser extent in AS and corticosteroids, and partly in oils.5,7,12,15 However, epithelioid granulomas are not features of silicone.5 Case 7 showed acute fibrinopurulent exudate. Abscess formation is related to contamination caused by nonsterile techniques or sharing. Abscesses can present as acute painful masses.3,14 Case 8 showed necrobiotic epithelioid granulomas mimicking rheumatoid nodules. This rheumatoid nodule-like granulomatous inflammation was identified in steroids, both AS and corticosteroids, but not in other materials.7,12,15 Patterns similar to the above, except the fatty changes, were recognized in previously reported cases.1-17 There is controversy regarding the factors that result in different tissue reactions to injected materials. The factors include type and amount of injected material, suspension medium, tissue injected, level of injection, duration and frequency of injection, and secondary infection.7,15 Early stages tend to have vacuolated histiocytes, granular macrophages, and giant cells, but later stages develop empty spaces, microcysts, fibrosis, and calcifications.5 Other authors, however, claim that changes do not vary with type of steroids, dosage, injection technique, sites, or time interval between injections.7,12 In our study, the tissue reaction patterns varied according to type of injected material, site, and duration of injection. Variations were noticed in steroids. However, variation in tissue reactions could be related to impurities in steroids—for example, oils and
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AbdullGaffar aluminum that are used to enhance the action of steroids or prolong their effect or used as a transport medium. Injections into muscle, skin, panniculus, and tendons result in different morphologies depending on the duration although the material injected is similar. The mechanism of different tissue reactions to steroid injections is related to local and systemic factors.11 Local factors are unrelated to the contents of the injection or its chemical contents. Factors unrelated to the type of injected material that can modify the tissue reaction include infection caused by contamination or physical effects caused by repeated trauma by needles. The localized response could be related to interaction of different tissues with steroids or other mixed chemical agents. They might have an effect on the inflammatory histiocytic/macrophage system. The type of inflammation, that is, nonspecific chronic inflammation or granulomatous, will vary according to the type of hypersensitivity reaction. Steroids have systemic effects on mobilizing inflammatory and immune cells, which can result in delayed hypersensitivity reaction. Chong et al18 identified 4 histological reaction patterns (panniculitislike, pseudolymphoma, lupus profundus–like, and necrotizing rheumatoid nodule-like granuloma) in vaccination and desensitization injections. They related these patterns to the adjuvant aluminum salt used as a vehicle in different injections. Even though mineral oils and silicone are considered inert materials, different tissue reactions could occur. Clinical differential diagnoses might include soft-tissue tumors, both benign and malignant.2,3,11,13 Factitial pseudotumors commonly result from non-AS material, particularly mineral oils, albeit tumor-like lesions were occasionally reported secondary to AS injections.3 Intact or ruptured cysts are also common initial clinical impressions. Abscesses are usually easily recognized.3,14 Tissue reactions to injections could be histologically confused with other inflammatory lesions—for example, necrobiotic epithelioid granulomas or soft-tissue neoplasms, such as lipomatous tumors. Histological hints to injections in the absence of foreign material include multinucleated giant cells, empty spaces, foamy histiocytes, or histiocytes with violaceous granular cytoplasm.5,11,15,18 Yellow pigments/crystals are also useful clues. Other features, for example fibrosis, granulomas, and calcifications, are either nonspecific or do not point to injection material. In difficult cases, a detailed clinical history is helpful to avoid extensive investigations and unnecessary aggressive treatment. The management of persistent or symptomatic nodules or masses is usually by complete excision to prevent further local or systemic complications, for example, disfigurement and movement restriction caused by muscle damage and scarring, ulcers, lymphangitis, septicemia,
and oil embolism.2,6,10 Some patients seek surgical removal of injection-related lumps for better aesthetic results. There are many reasons why bodybuilders use injections. The main aim is to have muscle bulking either by muscle mass gain with AS or by limb enlargement using non-AS materials. Cosmetic and sexual reasons could also exist. AS are the main material used by bodybuilders to increase muscle mass and power.3,4,7,8,11,14 Other substances include tissue fillers, for example, mineral oils and silicone.1,5,6,17 Plant oils like sesame seed and walnut oils are also used.2,9,10,13 The are commonly used as alternatives to AS for bulking and cosmetic purposes or mixed with AS.13 Some homosexual or heterosexual men in gyms and fitness centers seek these fillers for sexual purposes, for example, penile enlargement or buttocks contouring depending on their sexual desires.4,16,17 Awareness of these injection-site complications and other potential infection hazards and implementation of educational measures by the medical and sports community should discourage amateur bodybuilders from this risky and medically unsupervised, but unfortunately common, injection practice.1,5,8,10,14 Strict regulations and monitoring of gyms are also warranted to control and limit this risky illicit practice. This study is not without limitations. There were 5 patients who did not have follow-up. The identity of injection material was not known in one patient. Specialized instruments to further analyze the exact nature of injected materials are not available in our laboratory. Finally, the sample in this study does not reflect the magnitude of the problem related to unsupervised injections by bodybuilders in our region. A survey study targeting bodybuilders in gyms and fitness centers should reveal the true prevalence of this phenomenon. In conclusion, different materials injected by bodybuilders for different purposes have a wide spectrum of clinical and histomorphological features that can be mimicked by other nonneoplastic and neoplastic lesions. Prior knowledge of injection history is important; however, certain histological hints might help pathologists reach the correct diagnosis and, therefore, guide clinicians to appropriate management. Unsupervised injections by bodybuilders should be discouraged and controlled to avoid infection hazards and unwanted local and potentially lifethreatening systemic complications. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
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10. Banke IJ, Prodinger PM, Waldt S, et al. Irreversible muscle damage in bodybuilding due to long-term intramuscular oil injection. Int J Sports Med. 2012;33:829-834. 11. Weinreb I, Goldblum JR, Rubin BP. Factitial soft tissue pseudotumor due to injection of anabolic steroids: a report of 3 cases in 2 patients. Hum Pathol. 2010;41; 452-455. 12. Balogh K. The histologic appearance of corticosteroid injection sites. Arch Pathol Lab Med. 1986;110:1168-1172. 13. Khankhanian NK, Hammers YA, Kowalski P. Exuberant local tissue reaction to intramuscular injection of nandrolone decanoate (Deca-Durabolin): a steroid compound in a sesame seed oil base- mimicking soft tissue malignant tumors. Mil Med. 1992;157:670-674. 14. Rich JD, Dickinson BP, Flanigan TP, Valone SE. Abscess related to anabolic-androgenic steroid injection. Med Sci Sports Exerc. 1999;31:207-209. 15. Weedon D, Gutteridge B, Hockly RG, Emmett A. Unusual cutaneous reactions to injections of corticosteroids. Am J Dermatopathol. 1982;4:199-203. 16. Cohen JL, Keoleian CM, Krull EA. Penile paraffinoma: self-injection with mineral oil. J Am Acad Dermatol. 2002;47:S251-S253. 17. Glicenstein J. The first “fillers,” Vaseline and paraffin: from miracle to disaster. Ann Chir Plast Esthet. 2007;52: 157-161. 18. Chong H, Brady K, Metze D, Calonje E. Persistent nodules at injection sites (aluminum granuloma): clinicopathological study of 14 cases with a diverse range of histological reaction patterns. Histopathology. 2006;48:182-188.
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