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) .