Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Net Letter
2016:82:1;112-112
doi: 10.4103/0378-6323.162322
PMID: 26728836

Facial cellulitis and Ludwig's angina associated with calcium hydroxylapatite injection in an immunocompetent patient

Chiau-Sheng Jang1 , Wen-Chieh Chen2 , Jui-Hsun Fu3 , Chieh-Shan Wu1 , Kai-Che Wei1
1 Department of Dermatology, Kaohsiung Veterans General Hospital, Taiwan
2 Department of Dermatology and Allergy, Technische Universität München, Munich, Germany
3 Department of Radiology, Kaohsiung Veterans General Hospital, Taiwan

Correspondence Address:
Kai-Che Wei
Department of Dermatology, Kaohsiung Veterans General Hospital, No. 386, Dazhong First Road, Zo-Ying Dist., Kaohsiung, 813
Taiwan
How to cite this article:
Jang CS, Chen WC, Fu JH, Wu CS, Wei KC. Facial cellulitis and Ludwig's angina associated with calcium hydroxylapatite injection in an immunocompetent patient. Indian J Dermatol Venereol Leprol 2016;82:112
Copyright: (C)2016 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

A 30-year-old female presented to us with swelling, local rise of temperature and tenderness on her right lower cheek two weeks following a local injection of calcium hydroxylapatite filler for facial lifting. A gradual downward and lateral extension of the erythema and swelling was observed in the following week which involved the submental and submandibular regions and the upper neck [Figure - 1]a and [Figure - 1]b. This occurred despite administering oral antibiotics including cefadroxil, amoxicillin and rifampicin. A CT scan revealed a soft tissue swelling in the right cheek, masticator space, buccal space, bilateral submandibular and submental regions [Figure - 1]c and [Figure - 1]d. Dental examination showed no evidence of odontogenic infection. A clinical diagnosis of deep neck space infection was made. The patient was started on intravenous ampicillin/sulbactam (3 g every 6th hourly) for 12 days, following which the swelling and tenderness gradually subsided. A follow up CT scan after two months revealed complete resolution of the soft tissue inflammation. No recurrence was noted one year after completion of therapy.

Figure 1: (a and b) Swelling over the right cheek, submental and submandibular regions and upper neck 2 weeks following the filler injection. (c and d) CT scan image showing soft tissue swelling in the right masticator space, buccal space and submandibular regions. Multiple hyper-dense globules and clumps in the skin over the bilateral mid-face region, consistent with calcium hydroxylapatite deposition (white arrow)

The incidence of complications associated with calcium hydroxylapatite fillers is low. The most common complications are pain, erythema, bruising and nodules. Infection is uncommon, and we were unable to find any previous reports of deep neck space infection.[1],[2] The most devastating complication is descending necrotizing fasciitis, which requires early diagnosis and aggressive treatment. Odontogenic infections are the most common cause of deep neck space infection.[3],[4] Skin infections seldom cause deep neck space infection, and it has been reported to occur in 7 of 80 patients in one study,[3] and 1 of 185 patients in another.[4] Deep neck space infection associated with filler injection is considered to be extremely rare. We were able to find only one previous report of deep facial abscess following dermal filler injection in the English literature.[5] Fever, swelling, local rise of temperature and tenderness are the typical presentations of deep neck space infections, as seen in our patient. Satisfactory response to intravenous antibiotics confirms the diagnosis. Although surgical drainage is the mainstay of therapy, conservative medical management does not increase mortality or length of hospitalization in uncomplicated cases.[6]

CT scan imaging is a useful tool to differentiate deep neck space infections from non-infected facial swellings. Three dimensionally reconstructed CT scan images can further reveal the severity and extent of involvement, which is critical for treatment selection. The CT scan report in our case indicated the location and distribution of the filler as well. Calcium hydroxylapatite has radiographic features similar to the bone mineral matrix, with attenuation values typically in the range of 280–700 HU (Hounsfield units).[7] In two dimensional axial CT scans, it can be observed as hyper-dense clumps within soft tissue, with a density similar to that of compact bone [Figure - 2]a. A three dimensional image reconstructed from the original CT data can reveal the location and techniques adopted during the calcium hydroxylapatite filler injection. In our case, linear streaks over the bilateral infraorbital areas (tear trough) and several lumps over the bilateral zygomatic areas and cheeks were identified in the reconstructed CT image [Figure - 2]b,[Figure - 2]c,[Figure - 2]d. It indicated that the patient had received calcium hydroxylapatite injections for peri-orbital augmentation, facial lifting and jaw line contouring. The cross-linked network shape of the filler implied that fanning and cross hatching injection techniques had been used over both cheeks.

Figure 2: (a) Calcium hydroxylapatite can be identified in the original two dimensional axial CT scan(white arrow). (b and c) Three dimensionally reconstructed image shows linear streaks over the bilateral infraorbital areas indicating the usage of threading technique. (c and d) The cross linked network shape of the filler over the zygomatic areas and cheek indicates the usage of the fanning or cross-hatching techniques for facial lifting

Three dimensional CT reconstruction is a useful tool for the early diagnosis of such infections, and it can also be used to reveal the filler injection sites and techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

References
1.
Daines SM, Williams EF. Complications associated with injectable soft-tissue fillers: A 5-year retrospective review. JAMA Facial Plast Surg 2013;15:226-31.
[Google Scholar]
2.
Pavicic T. Calcium hydroxylapatite filler: An overview of safety and tolerability. J Drugs Dermatol 2013;12:996-1002.
[Google Scholar]
3.
Suehara AB, Goncalves AJ, Alcadipani FA, Kavabata NK, Menezes MB. Deep neck infection: Analysis of 80 cases. Braz J Otorhinolaryngol 2008;74:253-9.
[Google Scholar]
4.
Huang TT, Liu TC, Chen PR, Tseng FY, Yeh TH, Chen YS. Deep neck infection: Analysis of 185 cases. Head Neck 2004;26:854-60.
[Google Scholar]
5.
Rousso JJ, Pitman MJ. Enterococcus faecalis complicating dermal filler injection: A case of virulent facial abscesses. Dermatol Surg 2010;36:1638-41.
[Google Scholar]
6.
Plaza-Mayor G, Martinez-San Millan J, Martinez-Vidal A. Is conservative treatment of deep neck space infections appropriate? Head Neck 2001;23:126-33.
[Google Scholar]
7.
Ginat DT, Schatz CJ. Imaging features of midface injectable fillers and associated complications. AJNR Am J Neuroradiol 2013;34:1488-95.
[Google Scholar]

Fulltext Views
403

PDF downloads
184
Show Sections