An uncommon lymphoma mimic: lipogranulomas
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CASE REPORT
An uncommon lymphoma mimic: lipogranulomas John Karp 1
&
Prem Ruben Jayaram 2 & John Walsh 2 & Frances E. Walstra 3 & Paul Ian Mallinson 2
Received: 9 May 2020 / Revised: 9 May 2020 / Accepted: 2 June 2020 # ISS 2020
Abstract A lipogranuloma is a complication of injecting exogenous oily composites, forming a nodule composed of foreign body histiocytes. These may be seen in the setting of use of anabolic steroids. We present a case of a 52-year-old male with rapidly growing intramuscular masses with accompanying lymphadenopathy and constitutional symptoms. A diagnosis of lymphoma was initially made in view of the multifocal nature of his disease. CT and PET/CT scans were used to profile the extent of disease. However, US-guided biopsy samples demonstrated acute-on-chronic fibro-inflammatory connective tissue, but no evidence of malignancy. A follow-up CT scan showed resolution of most of these masses. Subsequently, a history of self-injected anabolic steroids was obtained. Familiarity of imaging characteristics of lipogranuloma may be helpful in avoiding the pitfall of misdiagnosis in this clinical setting. Keywords Lipogranuloma . Oleoma . Androgenic anabolic steroids . Ultrasound . PET . CT
Introduction A lipogranuloma, also known as an oleoma, is a foreign body granuloma, which results from the injection of an oily substance subcutaneously or intramuscularly. These may be caused by site-enhancing oils (SEOs) or by androgenic anabolic steroids (AASs), which stimulate muscle hypertrophy. SEOs are a variable, slowly degrading mixture of medium chain triglycerides, alcohol, anaesthetics and purified oils, such as sesame or poppy seed oil, used for directly and immediate cosmetic effect [1, 2]. AASs are used to enhance performance and boost cosmetic appearances via muscle hypertrophy. These are classically both injected intramuscularly within the bodybuilding community [1–6]. The management of this patient was largely based on clinical suspicion, as the patient failed to disclose their use of AASs until late in their care. Although foreign body type granulomas were visualized upon histopathological review,
unfortunately a definitive diagnosis could not be made. Injecting anabolic steroids may lead to tissue necrosis, blood stream infections, secondary anabolic steroid symptoms, accidental intravenous injection causing a pulmonary oil embolus, fibrosis and permanent nerve injury following accidental intraneural injection could have caused serious morbidity [1, 7, 8]. AASs are illegal without prescription in much of Europe and North America and are often obtained via illicit sources, often not produced to pharmaceutical grade and as such carry higher risk of biological and toxic contaminants [9]. This case presented a diagnostic dilemma due to the nonspecific nature of lipogranulomata. Furthermore, their diffuse and multifocal nature mimicked possible lymphoma or metastatic cancer [10]. Lipogranuloma vary in appearance and, while benign, can cause a significant amount of morbidity. The low-grade disco
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