Treating an intramuscular abscess following toothpick injury in a diabetic patient

Abstract Rationale: Toothpick puncture (TPP) is a penetrating injury that can result in bringing pathogens to the deep space. Such penetrating wounds are typically of pinpoint size with initial symptoms appearing subtle. Consequently, the injury itself is often neglected by patients, or is not detected during physical examinations by medical doctors. Reported complications from such injuries include osteomyelitis and septic arthritis, mostly due to delayed treatment. Patient concerns: A diabetic patient aged 83-year-old presented a 2-day history of skin redness, swelling, and tenderness over his forearm following a TPP a week earlier. Laboratory investigations showed leukocytosis with neutrophilic predominance and a high level of C-reactive protein. Before his operation, cultures of aspirated fluid from the injured site revealed the presence of Streptococcus anginosus , Streptococci viridans , Prevotella intermedia , and Pavimonas (Peptostreptococcus) micra . Diagnosis: Intramuscular abscess associated with toothpick injury. Interventions: Surgical irrigation with debridement and adjunctive antibiotics of ceftriaxone and clindamycin were given with a satisfactory response. Cultures of debrided tissue showed the presence of P intermedia and P (Peptostreptococcus) micra . Outcomes: A split-thickness skin graft was done. Patient was discharged on the 30th postoperative day. Lessons: Toothpick injury, initial symptoms of which are subtle, can in some cases, lead to serious complications especially when managements are delayed. In such situations (including the present case), surgical irrigation and debridement are administrated for the eradication of infections, removal of potentially retained toothpick, and tissue cultures analyzed. Adjunctive antibiotics is recommended to combat both the aerobic and anaerobic microorganisms of the gastrointestinal tract, skin surface, and oral cavity.