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Kerosene-Induced Panniculitis in Iraqi Patients

Authors:
  • College of medicibe University of Baghdad
Journal of Cosmetics, Dermatological Sciences and Applications, 2014, 4, 323-328
Published Online December 2014 in SciRes. http://www.scirp.org/journal/jcdsa
http://dx.doi.org/10.4236/jcdsa.2014.45042
How to cite this paper: Sharquie, K.E., Noaimi, A.A., Younis, M.S. and Al-Sultani, B.S. (2014) Kerosene-Induced Panniculitis
in Iraqi Patients. Journal of Cosmetics, Dermatological Sciences and Applications, 4, 323-328.
http://dx.doi.org/10.4236/jcdsa.2014.45042
Kerosene-Induced Panniculitis in
Iraqi Patients
Khalifa E. Sharquie1*, Adil A. Noaimi1, Maha S. Younis2, Bashar S. Al-Sultani3
1Department of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq
2Department of Psychiatry, College of Medicine, Baghdad University, Baghdad, Iraq
3Department of Dermatology, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq
Email:*ksharquie@ymail.com, adilnoaimi@yahoo.com, Maha.younis@gmail.com, bashar-sami83@yahoo.com
Received 26 September 2014; revised 31 October 2014; accepted 7 November 2014
Copyright © 2014 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
Abstract
Background: Kerosene is a common household stuff that has been used as accidental oral poison-
ing material in children and as suicidal attempt in adults. In the last decade intradermal kerosene
injection has been commonly used to induce dermatitis artefecta as a part of emotional upset. Ob-
jective: To evaluate the clinical cases of intradermal kerosene injection in Iraqi patients. Patients
and Methods: This is a descriptive case study that had been conducted in Department of Derma-
tology Baghdad Teaching Hospital, Baghdad, Iraq during the period from Jan. 2003 to Dec. 2012.
History and full clinical examination were performed including all sociodemographic aspects as-
sociated with this condition. Psychiatric evaluation was done for each patient. Results: All eleven
patients had single lesion except that two had two lesions. They were distributed on accessible
areas on the limbs. The exact diagnosis was not reached for at least few weeks after kerosene in-
jection. The patients denied any kerosene injection, but after a while they all admitted that the
cause of their rash, severe emotional tension was observed at the time of kerosene injection as
they had sociopsychological disturbances. The initial rash was erythematous indurated tender
plaque that was gradually increasing in size simulating the picture of panniculitis and then fol-
lowed by rupture of lesion and associated pyoderma, forming chronic discharging ulcer. Patients
were managed by topical and systemic antibiotics until complete resolution leaving a big ugly scar
that was treated by topical steroids to improve its cosmetic appearance. Conclusions: Kerosene
intradermal injection is an increasing problem among Iraqi adult females and it should be sus-
pected in any patient with chronic discharging ulcer on accessible areas like limbs.
Keywords
Kerosene, Panniculitis, Emotional Tension
*
Corresponding author.
K. E. Sharquie et al.
324
1. Introduction
Kerosene is one of petrolatum products that are commonly used for heating in houses during winter time. Kero-
sene poisoning is frequently encountered in Iraqi hospitals as children and toddlers accidently ingest it, probably
due to its unlabeled containers. In the last few years we have come across cases of kerosene injection as an attempt
for suicide. Kerosene is a hydrocarbon compound that is known to cause toxicity which affects many different
organs according to the dose and route of exposure, whether through ingestion, inhalation, intravenous injection
or dermal injection. The chemical properties of the individual hydrocarbon determine the specific toxicity, while
the dose and route of ingestion affect organs which are exposed to the toxicity. If these hydrocarbons come in
contact with the skin surface, they can cause dryness, scaling and sometimes severe dermatitis [1]. Skin absorp-
tion of kerosene has been demonstrated to be fairly rapid, but it is limited to approximately 10% - 15% after 24
hours of the applied dose [2]. When injected into skin, kerosene causes an intense local inflammatory reaction
with necrosis of the skin, fatty tissue and possibly underlying muscle [3] [4]. Chronic exposure can result in renal
failure and/or degenerative changes of livers or kidneys. Signs and symptoms of overexposure include giddiness,
headache, dizziness, nausea, vomiting, incoordination, narcosis, stupor, coma, unconsciousness, weight loss,
anemia, renal failure, and pains in the limbs peripheral numbness, parasthesia, drying and cracking of skin, and
rashes or spots on skin.
Intradermal kerosene injection causing fasciitis and necrosis is self mutilation practice that has been reported
among adults [5] [6], however only four cases are documented and all of them are in Arab communities.
In Iraq it is not an uncommon problem among children to have accidental oral ingestion or inhalation of ke-
rosene while for adults oral intake or bathing with kerosene is used as a suicidal attempt.
During Iran-Iraqi war 1980-1988 it is a well known practice among soldiers during army attacks to do intra-
dermal injection of kerosene to induce dermatitis in order to have sick leave (Sharquie observations).
In the last ten years and specifically after American occupation of Iraq there is a new trend among young adults
to induce self infliction by intradermal kerosene injection under the pressure of their emotional problems.
Although household kerosene is a familiar tool for committing suicide whether an attempt or complete by self
burning in Middle East countries [7]. Very few literatures report cases using it for self mutilation [8]. General
studies that assess suicidal behavior are rare in the Arab world given the fact that suicide is considered as a dis-
graceful act prohibited by religion, condemned by society and intrigued by legal consequences [7].
Psychiatric evaluation should be done for the attempters in order to assess the presence of any psychological
disorders. In reviewing the clinical picture, time was an important factor [9]. Delay in management would have
allowed the noxious agents to cause much irreversible necrosis and possible suppuration. Since the injected ma-
terial penetrates slowly, immediate and adequate surgical debridement with possible fasciatomy is the best initial
treatment, followed by repeated and relentless debridement with dressings [10].
So the aim of the present work is to report cases of intradermal kerosene injection causing panniculitis and
fasciitis and to evaluate the different clinical and psychological aspects of this self-induced disease.
2. Patients and Methods
This is a descriptive case study that had been carried out in Department of Dermatology and Venereology Baghdad
Teaching Hospital, Baghdad, Iraq during the period from Jan. 2003 to Dec. 2012.
Eleven casesten females and one male were seen, whose ages range from 17 - 25 year with a mean 21.5
years. Full history and examination was carried out to evaluate the sociopsychological aspects and the emotional
tension of the patients and to evaluate the course of the disease from the time of the injection. Digital photo-
graphs were taken using SONY Cyber-Shot T300 10.1 MP for each patient in good illumination.
Formal consent was taken from each patient after full explanation about the nature and the goal of the present
work. Ethical approval was obtained from the Scientific Council of Dermatology and Venereology-Arab Board
for Medical Specializations.
3. Results
All eleven patients (Table 1) had severe emotional tension as a result of social, economical and psychological
problems. All patients denied the self injection of kerosene but when confronted with the injection, they all ad-
mitted the cause. Psychiatric assessment revealed absence of psychotic disorders or cognitive impairment
K. E. Sharquie et al.
325
Table 1. Showing features of cases with kerosene intradermal injection.
No. Age Gender Site Type
1 23 M Both Forearm Ulcer & Pyoderma
2 19 F Forearm Ulcer & Pyoderma
3 21 F Forearm Ulcer & Pyoderma
4 20 F Thigh Ulcer & Pyoderma
5 17 F Buttock Ulcer & Pyoderma
6 25 F Arm Ulcer & Pyoderma
7 23 F Wrist Ulcer & Pyoderma
8 24 F Both Popliteal Fossae Ulcer & Pyoderma
9 20 F Forearm Ulcer & Pyoderma
10 23 F Forearm Ulcer & Pyoderma
11
F
Forearm
Ulcer & Pyoderma
for any reason. There was no history of alcohol/drug abuse or serious anti-social behavior. The site of injection
was usually on accessible areas and all seen on the limbs. One case study of patient number eleven is reported
here. A thorough psychiatric semi-structured interview has been conducted with one of the patients as a detailed
example:
A 19-year old Iraqi Muslim single girl, a student in the college of education, living in Baghdad with her par-
ents and younger two brothers, was brought to the emergency Department of Baghdad Teaching Hospital Medi-
cal City in March 2010 after three days of outpatient treatment by a private local doctor, where she received cor-
tisone ointment and analgesic tablets for suspected erosive contact dermatitis on her left arm without improve-
ment. The lesion was expanding to involve the whole arm with generalized redness and swelling and in ability to
move it freely with intensifying pain and tenderness for which she was referred for consultation. The Patient
admitted using a 5 ml disposable syringe filled with household kerosene injecting it into her left arm just below
the cubital fossa. This was in response to her total failure in her first term examination four days before consul-
tation. She was taught about this method by a friend in the college. Urgent surgical debridement of the all ne-
crotic and a vascular tissues was done under anesthesia. Minor injury to the flexors of the forearm occurred, but
did not affect full movement. She had neither previous medical or psychiatric problems nor family history of
mental illness. She was described as a pleasant friendly girl by her mother with no record of impulsivity or anti-
social behavior. The patient denied any emotional or family conflict. Both parents were college graduates and
government employees living in comfortable accommodation with a reasonable financial status. On assessing
her mental state, she was fully conscious and alert with the injured arm wrapped up to the wrist and an intra-
venous fluid containing anti-biotic running in the healthy arm, but looked pale and gloomy. Speech was cohe-
rent and logical, there were no thought or perceptual disorders, her affect were sad and congruent with her
mood. She expressed full ignorance of the toxic nature of kerosene and denied any suicidal thoughts justifying
her act as a self punishment for school failure. She denied feeling psychological relief by the injection and ex-
pressed regret and concerns about future disfigurement or paralysis. The patient was jointly followed up in the
skin clinic and psychiatry outpatient clinic in the Medical City Teaching Hospital according to an appointment
protocol.
In eight cases the injection was on the upper arms specifically on the forearms while three cases on the lower
limbs specifically thigh, buttock, popliteal fossae.
Patients were seen after few days to few weeks following the injection. The course of the disease started as
erythematous plaques that were hot and tender simulating a picture of panniculitis, after awhile there was rup-
ture of the lesions leaving discharging deep ulcers. No smell of kerosene was detected in any lesion. These ulc-
ers were managed by antiseptic clearance, topical and oral antibiotics were given, and the healing time took few
too many weeks. In all cases there was disfiguring scar at the site of injection and one patient with the wrist in-
jection left severe fibrosis and contracture of the wrist and hand.
The scars were managed by strong topical steroid ointment with oral antihistamine to improve the cosmetic
appearance (Figure 1 and Figure 2).
K. E. Sharquie et al.
326
Figure 1. Showing female patient with kerosene intradermal injec-
tion presented with pyoderma of right upper arm.
Figure 2. Showing panniculitis is and pyoderma in the left wrist in
female patient.
4. Discussion
US Occupation of Iraq caused severe economic, social and psychological problems among population and one of
these medical problems is doing kerosene injection. Kerosene is a mixture of hydrocarbons [11] [12], which can
cause severe inflammation and necrosis of all layers of the skin even and can involve the fascia and the underlying
muscles. But clinically as seen in the present work all features of panniculitis were observed. So we preferred the
term panniculitis rather than fasciitis. As a kind of chronic ulcer it might also simulate the picture of pyoderma
gangrenosum. In searching the medical literatures, we came across only four cases of so called fasciitis and pan-
niculitis, which were all in Arab world [8]-[10]. In Iraq, there is an increasing report about this problem within the
K. E. Sharquie et al.
327
last ten years [13].
Initial diagnosis is very essential in order to achieve successful management of these cases, so any panniculi-
tis like pictures on accessible area commonly the upper arms of young female, kerosene injection should be
highly suspected. Immediate management including hospital admission and urgent surgical debridement should
be carried out to evacuate the remaining kerosene in the tissue with full antibiotic cover, while the condition is
seen as chronic discharging ulcer and management including cleaning with antiseptic, topical antibiotic and sys-
temic antibiotics cover. In late cases scarring could be managed by topical steroid ointment and cosmetic sur-
gery might be arranged.
Emotional tensions that can lead to skin diseases are those like dermatitis artefecta, trichotillomenia, delusion
of parasitosis and others. These cases are not uncommon problems seen in daily clinical practice.
Self-inflicted dermatosis induced by kerosene is not well documented in Iraqi medical literatures, but during
Iran-Iraq war 1980-1988, cases of intradermal kerosene injection are practiced by soldiers during the army at-
tacks in order to have sick leave [14] [15]. It is well known that children may ingest kerosene instead of water,
while adults may burn themselves by bathing with kerosene [7] [13]-[16].
In the last ten years cases of intradermal kerosene injection had been seen as a part of emotional problems but
unfortunately all cases are misdiagnosed initially as most doctors are not aware of this problem.
So the aim of the present report is to present the clinical picture of these cases to encourage doctors to have
right initial diagnosis.
In conclusion self-induced panniculitis by intradermal kerosene injection is a distinctive entity that should be
managed early to have right treatment and to avoid future complications. Psychological evaluation should be
carried out in all cases.
Disclosure
This study was an independent study and not funded by any drug companies.
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... Most reported cases are in Arab countries (KSA, Jordan, Iraq) (15 cases). [2][3][4][5][6] Iraq is the highest of Arab countries (11 cases). [4] The difficulty arises in management as cases are unique to each exposure in terms of dose injected, site of intended versus actual injection, and quantification of the exact dose of exposure. ...
... [2][3][4][5][6] Iraq is the highest of Arab countries (11 cases). [4] The difficulty arises in management as cases are unique to each exposure in terms of dose injected, site of intended versus actual injection, and quantification of the exact dose of exposure. The lethal dose of kerosene for 70 kg adult is 100 ml. ...
... [2,3] Intradermal injection has been reported in 32% of cases (10 cases). [4] All treated medically as a case of panniculitis and skin ulceration [Chart 2]. Patients recovered without complications except one who has developed injection site fibrosis and contracture in the wrist and hand. ...
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... It is self mutilation practice that has been reported among adults; however only four cases were documented and all of them were in Arab communities. In Iraq it is not uncommon problem among children to have accidental oral ingestion or inhalation of kerosene while in adult oral intake or bathing with kerosene were used as a suicidal attempt [9] [10]. ...
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Background: Many skin diseases can be evoked by psychological problems. Dermatological conditions could also lead to psychological disorders; hence psychodermatology is an emerging subspe-cialty that focuses on the interface of psychiatry and dermatology. Objective: To assess the frequency of the major disorders of so-called psychocutaneous disorders which are commonly seen among Iraqi population. Patients and Methods: This case descriptive study had been done in Department of Dermatology-Baghdad Teaching Hospital, Medical City, Baghdad, Iraq during the period from March 2011 to October 2013. All cases were collected and categorized according to the disease problem. Patients were interviewed to search for the main triggering and precipitating factors involved in pathogenesis of these disorders. The clinical picture was well described in order to reach a final diagnosis. Psychological interview and analysis were performed for all patients to reach the specific emotional and psychiatric disease by consultant psychiatrist. Results: A total of 100 patients with major psychocutaneous disorders were seen and evaluated. Nineteen were males and 81 were females with female to male ratio: 4.26:1. Their ages ranged from 7-73 (26.5 ± 5.217) years. The frequency of these diseases was as follows: trichotillomania 53%, dermatitis ar-tifacta 37%, delusion of parasitosis 6% and neurotic excoriation 4%. Conclusions: The major psy-chocutaneous diseases in Iraqi population were: trichotillomania, dermatitis artifacta and these are problems of mainly young females while delusion of parasitosis and neurotic excoriations were diseases of middle age females.
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