Shock following subcutaneous injections of polymethylmethacrylate.

A 35-year-old transsexual (male to female) went to emergency with 24 h of mild fever, cough and dyspnoea. Four days before he had been submitted to multiple gluteus subcutaneous injections of polymethylmethacrylate (PMMA) microspheres. Patient had a past medical history of uncontrolled hypertension. On admission patient had Glasgow Coma Scale Score of 15, tachypnea and tachycardia, with central cyanosis and was sweating. No fever. Blood pressure was 100/70 mmHg and respiratory rate 40/min. Arterial blood gas analysis under 15 l/min oxygen therapy by a non-rebreathing mask with reservoir showed global respiratory insufficiency and sever acidemia (pH 7.22, pO2 31 mmHg, pCO2 49 mmHg, HCO3− 17.6 mEq/L, SatO2 55%, lactate 6.17 mmol/L). Heart auscultation revealed audible S1 and S2 and chest auscultation revealed bilateral rales. The remaining physical examination just was unremarkable with exception of mild redness, warmth and swelling of the gluteus. No fluctuation was detected and no indication for surgical approach was considered. Chest X-ray showed bilateral lung infiltrates (Fig. 1A). At this time was intubated and mechanically ventilated. On intensive care unit (ICU) admission presented with hypotension, tachycardia, oligoanuric renal failure, mixed acidemia and pO2/FiO2 ratio of 40. Biochemistry showed: normocytic normochromic anaemia, high white blood cells count, coagulation times prolonged, acute renal lesion with hyperkalemia, hyperbilirubinemia 1.49 mg/dL [0.3--1.2], conjugated bilirubin 0.79 [0--0.2], hepatic cytolysis high lactate dehydrogenase and C-reactive protein. Patient was started on empirical antibiotic therapy with meropenem due to the inflammatory signs in gluteus.