Case Presentation
In July 2021, a 21-year-old man went to the emergency department with acute knee and elbow pain following a fall from a height. During the clinical examination, deformity and swelling were discovered in the left elbow and right knee. He had severe acne on his face, but he did not receive any medications. Neurological and vascular examinations of the limbs displayed no abnormalities, and there was no evidence of laceration or abrasion. At that point, radiography and computed tomography (CT) scan were requested revealing a trans olecranon fracture-dislocation of the elbow and a tibial plateau fracture Schatzker type 2.
Instantly, he was admitted to the orthopedic ward and underwent two separate operations. Primarily, the elbow was openly reduced with a single posterior skin incision, the olecranon was fixed with a locking anatomical plate, the radial head was fixed with two screws, and the lateral collateral ligament of the elbow was repaired with an anchor suture. In the second surgery, the tibial plateau fracture was reached with the anterolateral skin incision. Moreover, the fractured segment of the tibial plateau was anatomically reduced, and one cannulated, the partially threaded screw was applied from lateral to medial. The joint depression was then restored, and freeze-dried cancellous allografts were introduced into the defect via a bone window and impacted with tamping to resist the collapse of the articular surface. Afterward, plate osteosynthesis was performed. Besides, before the administration of surgeries, a prophylactic antibiotic (one generation of cephalosporin) was prescribed. Finally, the patient was discharged two days after the last surgery in good overall condition. During the postoperative period, the patient had to wear a long splint on the upper left limb and the right lower limb. In addition, the range of motion exercises for the elbow and knee began immediately following surgery, according to the protocol. After two weeks, the suture was removed.
Two months later, he presented with exacerbation of facial acne and disseminated papulopustular acneiform lesions of the upper trunk. Three months after the surgery, the patient developed two purulent superficial lesions at the site of the surgical incisions. The orthopedic team evaluated the patient’s condition and ruled out device infection-based wound properties as well as normal erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood cell count (CBC). Eventually, the orthopedic surgeon referred the patient to a dermatologist.
Multiple consolidating papules, pustules, and tiny nodules were present on the face and trunk, as well as scattered pustules on the upper and lower limbs around the surgical incision (Figure 1). Biopsies were taken from peri-incisional cutaneous lesions and sent to the laboratory for culture and polymerase chain reaction (PCR) analysis. The usual laboratory evaluation revealed no evidence of bacterial infection, deep mycosis, or atypical mycobacteriosis. Biopsy revealed significant irregular epidermal hyperplasia, intraepidermal and dermal microabscesses, suppurative granulomas, and a mixed infiltration of inflammatory cells and giant cells. The impression of P. acnes-induced SSI was made based on clinical suspicion, severe acneiform eruption around the surgical incision, and resistance to conventional treatments. The patient received 300 milligrams of rifampicin twice a day and 20 milligrams of oral isotretinoin, which resulted in the complete resolution of all skin lesions. After three months, significant improvement was observed, and the rifampicin was discontinued but the oral isotretinoin treatment was continued. After nine months of follow-up, the condition did not recur (Figure 2) .