Case Presentation: A 70-year-old woman with morbid obesity and non-alcoholic steatohepatitis cirrhosis was initially treated at an outside hospital for hematemesis. She received aggressive volume resuscitation, a blood transfusion, and was found to have esophageal varices. She was transferred for endovascular management of her varices. During transfer, she had nausea treated with an antiemetic administered intramuscularly in her left gluteus muscle. On exam, she had diffuse anasarca with 4+pitting edema in the lower extremities. Her variceal bleed resolved but she subsequently developed persistent leakage of clear yellow fluid from her left gluteal injection site several days after admission. This continued despite pressure dressings, ultimately requiring placement of an ostomy bag over the area of drainage (fig 1). Fluid studies revealed hypocellularity and similar protein concentrations to serum fluid, consistent with interstitial edema. Point of care ultrasound (POCUS) revealed a cobblestone appearance (fig 2) of the subcutaneous tissue without a discrete fluid collection or fistula/tract. Aggressive intravenous diuretic therapy was continued with gradual improvement in her anasarca. The fluid leak resolved without need of suturing or applying glue to the leak site.
Discussion: Hospitalist providers should be familiar with the differential diagnosis for cutaneous leakage of fluid. The most common causes can be categorized according to pathophysiology, including low oncotic pressure (e.g., cirrhosis, nephrotic syndrome), high hydrostatic pressure (e.g., heart failure, venous obstruction), capillary leak syndrome (e.g., sepsis), and lymphatic impairment (e.g., after lymph node dissection). Less common causes include fluid collection or abscess, lymphocutaneous fistulas, or fistulae to urinary tract. An emerging technology in evaluating skin and soft tissue is the POCUS exam, which has several applications, including the ability to identify edema and rule out fluid collections or fistulous tracts[1]. In our case, simple fluid studies and bedside POCUS exam allowed us to quickly exclude more worrisome considerations on our differential, while avoiding costly and invasive testing. The hypocellularity, as well as creatinine and lipoprotein levels similar to serum levels, suggested interstitial fluid rather than a pathological connection to ascites fluid or elsewhere[2-6]. The cobblestone appearance seen on POCUS exam was consistent with subcutaneous edema, and no discrete fluid collection or tract was visualized[7]. Given these findings and the patient’s clinical presentation, we surmise that our patient had anasarca secondary to her underlying cirrhosis exacerbated by administration of intravenous fluids and blood products. The intramuscular injection caused localized skin trauma allowing for a focus for fluid leakage.
Conclusions: A framework for approaching the differential in a patient with a leaking cutaneous wound is invaluable to the practicing hospitalist to ensure timely and accurate treatment. Laboratory evaluation of fluid and POCUS can be effective, non-invasive, cost-efficient, and rapid ways to assess for an underlying fluid collection or cutaneous fistula.