Dr. Hani M.Kafaween, MD, JBS*
Dr. Haitham Rbehat, MD, JBS*
Majida Sweis, RN
Khitam Nimer Hawil, RN
*Jordanian Board of Surgery

Correspondence:
Dr. Hani M.Kafaween, MD, JBS*
Department of General Surgery, Royal medical services, Amman, Jordan

A 17 year old single female lady, was admitted to the emergency room (ER) following an argument with her family. The patient had injected an unknown amount of kerosene on both cubical fossae of upper limbs about five days prior to presentation in the ER.

She was admitted to another hospital for 4 days where she was treated for erosive material contact dermatitis to both upper limbs.

Then she was admitted to our surgical ward, where the proper diagnosis was done by high suspicion of the appearance of the lesions, and the smell of kerosene. The patient realized that her condition was getting worse. Then she told us the real story, which was, self injection of kerosene in both cubital fosse as a suicidal attempt.

She experienced severe pain which became intolerable with inability to sleep. Both upper limbs where swollen with loss of function. The pain was so severe, despite the administration of a full dose of narcotic analgesic.

There was nothing significant in her medical history, but a lot of social problems. Clinical examination in the ER showed an ill-looking, but alert patient, well-oriented in time and place. She was in agonizing pain, with a temperature of 38.5oC, blood pressure 100/70 mmHg, pulse 98/minute and respiratory rate 21/minute. All other systems were essentially normal. Urine output was also satisfactory.

Physical examination of the right upper limb revealed indurated, severely tender weeping red areas of skin with hotness, redness and swelling from mid arm to mid forearm mainly cubital fosse.
(Figure 1)

Figure 1: Right elbow

The left upper limb revealed indurated, severely tender weeping red areas of skin with hotness, redness, and swelling from mid arm to mid forearm with areas of skin necrosis through which a deep necrotic tissue came out. (Figure 2)

Figure 2: Left elbow

Both upper limbs were generally warm, but capillary refilling of the fingers was delayed. The peripheral pulsations felt and were weak. Bedside Doppler stethoscope auscultation of peripheral arteries on admission was not helpful. Plain X-ray films of both elbows didn't show any evidence of bony injury but gas in the subcutaneous and fascial planes. Intracompartmental pressure was not measured.

Blood count, urine analysis, electrolytes and urea, blood sugar and liver function tests during admission were within normal limits. Blood culture was negative. We made a provisional diagnosis of self-inflicted acute necrotizing fasciitis with compromised venous return secondary to injection of kerosene. Immediate management included admission to the ward, commencement of broad-spectrum antibiotics, and elevation of both upper limbs. Within a few hours of admission the patient was taken to the operating room (OR) where she had multiple fasciotomy incisions extending to the deep fascial layers. (Figure 3, 4).

Figure 3


Figure 4

The kerosene smell was very characteristic after cutting into the subcutaneous layer, and the operating field was obviously ischemic. Swabs were taken for culture and sensitivity, which were negative. There was obvious improvement in the capillary refill of the fingers after the fasciotomies.
Dressing was then applied and pulse oximetery showed oxygen saturation of 97%. Repeated sessions of wound debridement with removal of devitalized skin and subcutaneous tissues were carried out with repeated wound swabs, all of which proved negative.

She was seen by the psychiatrist in view of the emotional circumstances that led to the injury and was diagnosed as suffering from personality disorder. Histopathology specimens sent at the time of the initial surgical debridement showed a massive, variable acute inflammation, with aggregation of neutrophils, and focal fat necrosis with hemorrhage. Further wound debridement continued until the necrotizing process gradually ceased and healthy granulation tissue appeared. (Figure 5)

Figure 5

Skin grafts were applied later with subsequent complete wound healing.

Kerosene is available for domestic use in developing countries mainly for heating and cooking purposes. It is primarily a mixture of hydrocarbons. If these hydrocarbons come in contact with the skin surface, they can cause dryness, scaling and sometimes severe contact dermatitis (6). When injected under the skin kerosene causes an intense local inflammatory reaction with necrosis of the skin, fatty tissue and possibly underlying muscle (it may involve all soft tissue layers) (2, 7). Burn accidents following explosion or misuse of kerosene, and to a lesser extent poisoning secondary to ingestion, constitute significant emergency admissions mainly at winter time (8, 9). Most of the cases reported in the literature were self-inflicted with the intention of committing suicide so they will not give a proper history.

In the reported cases, the authors advocated aggressive, timely and repeated surgical debridement until reaching viable tissue, followed by possible skin graft (4). Aggressive and repeated continuous surgical treatment in our case was rewarding in that we avoided amputation.

In reviewing the clinical picture of this case, time was an important factor. Delay in management would have allowed the noxious agent to cause much irreversible necrosis and possible suppuration (4,9) Since the injected material penetrates slowly, immediate and adequate surgical debridement with possible fasciotomy is the best initial treatment, followed by repeated and relentless debridement with dressings. Systemic effects may accompany the local disturbance, which is usually characterized by fever, leucocytosis and lymphangitis. For this reason, antibiotics should be given to protect against staphylococcus, the most likely offending microorganism in these cases. Treatment may be changed as required when culture results become available. The psychiatrist diagnosed the patient as having personality disorder, which we tended to agree with. The most common injury in patients with personality disorder is wrist cutting. Mentally disturbed patients have been known to inject milk or faeces into themselves, inducing severe cellulitis. This type of patient needs continuous psychiatric follow up and a solution for their social frustration. Self-injections of kerosene are rare, unusual and can produce severe tissue damage, especially if prompt surgical treatment is delayed. Psychotherapy is also an integral part of the management (9, 10, and 11).