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Why is there pain, swelling, bruising 4 days after corticosteroid injection?

Hi,

My girlfriend went to the urgent care center on Monday evening because she had a cold that had been hanging on for almost 2 weeks. She was still coughing, wheezing and having throat issues. The Dr gave her a shot of a corticosteroid, methylprednisone she thinks, in her upper right arm.

Other than a small bruise at the injection site, there were no other symptoms tat evening or the whole next day. On Wednesday evening, she started experiencing some mild discomfort that slowly turned into pain and we noticed some swelling. Thursday, both the pain and swelling got worse throughout the day and by Thursday night, it hurt enough to make falling asleep difficult. Friday morning, she woke up crying because the pain was so intense and she could not move her arm because of it. It is now late Friday night and she is in even worse pain now: the pain runs the hole length of her arm and up into her neck. The swelling is in the upper arm, neck and even the back of her head. She has had a headache that also has gotten progressively worse. The fingers on her right arm are also going numb.

Ice and 800mg of ibuprofen (4x 200mg otc) make it bearable as long as she does not use the arm or move around too much at all, but when the ibuprofen wears off, its too much for her to take. If this is something that will go away after some time, is not a real emergency, then she wants to just grin and bear it. All we can find online is that the hospital will just give her NSAIDs and tell her to ice it.

We can not find any information on this other than SIRVA. Hr symptoms are almost identical to it, but this was not a vaccine, although the injection site is awfully high on her arm. Any ideas?

Thanks

16 Responses
1081992 tn?1389907237
Hi, does she have allergies, asthma or other immune system conditions? This might be an allergic or hypersensitivity reaction to either the steroid itself in the injection, or to other substances in the injection (excipients).

Some steroid shots are composed of steroid crystals which are meant to be slow-dissolving, and meant to have a sustained action. If that is what she was given, then that might explain why this is going on for so long (too long and also too severe to be ignored), and might be a clue that it is the steroid molecule itself causing the reaction. If things this morning are worse and not better, then I would be VERY VERY worried. Treatment at an ER might include antihistamines.

I think you should be looking at "steroid flare" also known generally as "cortisone flare", rather than the SIRVA reaction to a vaccine shot (which I believe is more an injury caused by an error in where the needle tip went).
1 Comments
Thanks for the reply. She woke up this morning not in worse pain than last night, but it is about the same. Took Ibuprofen, got fresh ice put on it, both about 20- 25 minutes ago and pain is subsiding as I type this. I can tell it is getting better just by looking at her.

I did look at steroid flare, as well. Very possibly it could be that, or as you said, a hypersensitivity/allergy to the methylpredsilone. The only thing that does not make sense is why the pain did not start until 48 hours after the injection and why there is black/blue discoloration appearing in different parts of the arm.

The only other thing is that she says that her fingers feel like they are "on fire" and she had some pain in the crook of her elbow, but that is most likely cased by her keeping her arm bent at a 45-60 degree angle for almost 36 hours now, non-stop.

The smart thing would be to go to the ER, but alas, she has no insurance and let's face it, walking into the ER and telling them you are in debilitating pain because you got a shot 6 days ago is not going to get you anything except looks that make you feel like a junkie looking for a hit. It is sad that this is the way it has become, but it is the truth from personal experience and unless its life threatening, the Dr. won't even see you at the ER without a Payment of at least $100 and then we get mush other than instructions to take NSAIDs OTC and to ice it and told to follow up with her Dr. Luckily, he is actually open on Saturdays, so going to call him when he opens.
1081992 tn?1389907237
Also worrying is the fact that it is spreading. If the spreading is not reversed, I would take her to the ER right away. Probably most would say to take her regardless. I don't know if an urgent care center is good enough for this, if you called them they might say to go to the ER instead.

It doesn't seem to be an infection introduced by the needle, or else the injection site would be worse than anywhere else and you see no pus there. On the other hand, there's maybe this: since corticosteroids are immune suppressors, the steroid might possibly have led to cellulitis, which can get very serious.
https://www.webmd.com/skin-problems-and-treatments/guide/cellulitis

It doesn't seem to be typical cellulitis, however the immune suppression from the methylprednisolone might have allowed a bacteria or fungus that was already there to thrive. But then again you don't mention fever.

-------

Also in the future please acquaint yourself (and her) with the symptoms of anaphylaxis, because although that's probably not likely here you should still be aware of the worst possibility -- just to be on the safe side.
1 Comments
Anaphylaxis was the very first thing we thought of and were immediately able to rule out going by her symptoms. Also looked at the possibility of infection, but again ruled it out because of the reason you said: no pus and the injection site itself is no worse then it was before. And I did not look into cellulitis, but did come across the possibility of fungal or bacterial presence, but have checked constantly for a fever and none has ever materialized.
1081992 tn?1389907237
Yep, I understand about not wanting the ER, for the reasons you say.

If she tries benadryl, please let me know how that goes.

"black/blue discoloration"
Histamine is the 1st part of a cascade of immune chemicals that also can lead to heparin that can cause blood vessel leakage/bruising, as well as bradykinin and Substance P which causes pain. So the pain is an offshoot of the real problem, and should subside when that is removed.  I know you realize that, I'm just reinforcing it.

"her Dr. ... is actually open on Saturdays, so going to call him when he opens."
I'd be surprised if you are told anything other that "go to the ER". They have to say that for self defense.

1 Comments
He actually told her to come in if it does not start to get better. Which she is contemplating. Well, she actually fell back asleep. Once the Ibuprofen kicks in, she is fine; not able to use her arm normally by any means, but can actually use it in a limited fashion with no pain.  So, letting her sleep for now.

There was one more thing that was totally confusing and maybe even a it worrisome. The swelling went into her neck and then up the back of her head a little ways, which is where she has had a constant headache since this all started Wednesday night, as well. Only thing I was able to even guess is that it is some sort of lymphatic issue, with the back of the head being a little puffy.

Its funny because she did have a couple times where small hives appeared, especially when the black and blue discoloration was present. it has since receded fully and now there is just some puffiness in the upper arm and the continued pain through the whole arm and then the numbness and "on-fire" feeling in the fingers,which I think are unrelated and cause by the weird angle she is sitting/laying at just pinching a nerve in the neck (existing minor sciatica and cervical nerve issues).

When she wakes up, I am going to see if she wants to try benadryl, have the Walmart brand in liquid form here already
1081992 tn?1389907237
"does not make sense is why the pain did not start until 48 hours after the injection"
There are two parts to the immune system: innate immunity knows inherently that e.g. the outer covering of a bacteria is bad, so the reaction is immediate. But the acquired immunity has to learn. The first antibodies (IgM) eventually get replaced via trial and error with much more effective ones (IgG). That can take 48 hours.

All that might explain the delay; but then the next exposure would have an *immediate* reaction because the ground work has already been done. I say that so that you know you should really really be aware if she should avoid all steroids in the future, or if different ones might be okay.  E;g;, if she does have overactive immunity, there would be times when docs want to rightly give her steroids.

Maybe skin testing should be done with topicals.

1081992 tn?1389907237
"The swelling went into her neck and then up the back of her head a little ways..."
The way that spread was what made me think of cellulitis.

"Only thing I was able to even guess is that it is some sort of lymphatic issue, with the back of the head being a little puffy."
That's not a bad logical guess, but in actuality the lymphatic vessels drain up the arm then over into the chest and into blood circulation near the heart.

"He actually told her to come in if it does not start to get better."
Well, I am surprised :)
One thing I'd maybe want a doc for is to be sure the kidneys aren't affected. For example, a reaction to penicillin might cause damage to kidneys. It might also cause hives, which you might guess is from histamine.

You might order (in most states) yourself and without a script a blood test for creatinine/BUN.  Or be very aware of dark urine. Probably not likely, but possible.

1081992 tn?1389907237
'the numbness and "on-fire" feeling in the fingers'
Are they very swollen?



1 Comments
No swelling at all in the hand or fingers. some pain hat is shooting down the arm is getting there, but not bad. The numbness and fiery feeling is intermittent and sporadic in nature.

Thought of kidneys and urine has been normal. The immune response you describe fits perfectly with the timeline here. It is not the first time she has had a steroidal injection, although she believes is the first time she has had methylpresilidone. She has had multiple topicals for various minor reasons before, as well.

It really sounds like its going to be an allergic reaction or hypersensitivity from the info you provided. Not being able to find anything else other than SIRVA, I was focused on improper injection technique and although it was not a vaccine, it is well stated, repeatedly, that it is not the contents of the needle, but rather, the placement of the needle and what it hits. It was just frustrating because its always vaccines in the upper arm, nothing else and I have no idea why. So I started looking into the possibility of bursatitis; figuring the dr hit the bursa. Guess what the most common form of treatment is for both SIRVA and bursatitis? LOL, Steroidal injections directly into the affected area. So, how could a steroid cause either one if it is a treatment for both?

Frustrating really. So, then it was frustrating because Ibuprofen worked like it was a miracle drug, but she is well past the limit she should take within a 24 hour period and there are still 16 hours left to go before that resets again, so what does she do for pain now? hopefully benedryl will help, but is there anything else that can treat the inflammation?
Avatar universal
The dr in question runs an urgent care center, but he is also a pcp. It is simply a normal dr office that has the ability to give you some advanced treatments; like steroidal injections, some prescription meds and thats about it. they do not have a lab  or any advanced testing equipment at all. But they are literally less than 500 feet from the entrance to the ER at the hospital, so its convenient.
1081992 tn?1389907237
"how could a steroid cause either one if it is a treatment for both?"
Just as an antibiotic can still kill a bacteria while it causes an autoimmune attack.

Sorry, I don't know about handling the pain. Just some guesses: a TENS unit?

OTC long shots: Celery seed as a diuretic? Quercetin to oppose Substance P and bradykinin?
1 Comments
sorry for the long delay. she woke up, i went to get Benedryl and then had kids to deal with...

so, when she got up, she noticed the bluish-black marks again and in the light it looks like someone had a pen and made little tick marks all over the place. none more than a quarter inch or so in length and some look like little check marks or close to that.. I am assuming this is the process you described above involving the histamines leading to heparin...

When i got to the Pharmacy, I wanted to ask the Pharmacist if there was something other than benedryl, as in something that would not make her as drowsy... When she walked up to the consultation window, i said, "My girlfriend went to the doctor for a cold on Monday and he gave her a shot of Methylpreds...."... thats all i got out and she cut me off and said, "2 benedryl." So, obviously allergic reactions to methylpredlisone are common enough that she already knew what i was asking before i even got it out.. of course, i still told her all the symptoms and she assured me that it is an allergic reaction and benedryl is the only thing that you want to take wen this occurs. The one thing she did not say and i did not ask was is it a one time thing or are we talking 2 benedryl every 12 hours or day and for how long?

But it seems that an allergic reaction is the culprit here, at least the one that is presenting with the most obvious symptoms.

Avatar universal
"Just as an antibiotic can still kill a bacteria while it causes an autoimmune attack. "
I thought the same thing at first, but after thinking about it (and i could be way off here), in the case of bursatitis, injection of the steroid is to be done directly into the bursa, which in order to get bursatitis in this way would require basically the same thing.. injection to high on the arm hits the bursa and it gets inflamed. So, highly unlikely if you hit it with a corticosteroid, which reduces inflammation. the trauma caused by the hot would actually get cured , or at least relieved in the same stab to the point that it would not be noticeable.

That sounds good at least....lol and in the case of Sirva, I can understand how it could be the cause and a treatment at the same time. SIRVA, being caused by injecting the vaccine into the subcutaneous fatty layer instead of into the actual muscle. The vaccine is full of bacteria which are already antigenic, but even a corticosteroid that is produced by our body would be treated as an antigen in the subcutaneous fatty layers directly beneath the skin because they simply have no purpose there....

Again, sounds good to me, but i could be wayyyy off here...

anyways, she took the benedryl about 35 minutes ago now i guess, also, she has ADHD and took one of her meds for that since it is a stimulant; trying to negate the drowsy effect; not sure if this will work but she is still awake but the pain is there, although more manageable at the moment. She is playing a video game but it is cay=using her wrist to hurt a bit. I attribute that to the fact she has kept her entire right arm completely still and i the same bent position for 2 days now, so he triceps is a bit sore from all the activity the wrist is giving it....

She found that a name brand for MethylPredlisone is Medrol Dose pack and said she has taken that before, but i think I recall reading somewhere that the injectable form can have an allergic reaction while the orally taken Medrol dose pack will not and vice-a-versa... Not sure if you know anything about that. Either way, if it looks like a goat, smells lie a goat and sounds like a goat, it is most likely a goat, so i think an allergic reaction is the culprit here. Guess time will tell.
1081992 tn?1389907237
If it was me, I'd baby that limb for a day or two - not use it or bump it or anything. I'd consider the tissue to be in a vulnerable state. That's my guess. Some immune chemicals are even proteases, btw.

That's valuable info from the pharmacist. Yes, there are such drugs as non-sedating H1 blockers, but I don't know if they would be less effective for this or not. Might as well go with the tried and true.

You can try finding any case studies for medrol (probably depo, not solu-medrol) and steroid flares. Yes, the injectable would have different excipients than the oral version, but from the pharmacist's words I'd guess that it is the drug not the excipients at fault.

I would take the benadryl as long as the swelling or any other signs exist. I'd call that pharmacist to ask how much for the subsequent dosing. (In some immune conditions like MCAS, patients take double dose for long periods without harm. I'd also look up MCAS to see if she fits that. E.g., does she get inappropriate flushing.)
1081992 tn?1389907237
Also btw, I didn't get from the start why the doc gave a steroid injection and not tablets or a spray. Did they say why an injection was used to suppress the airway symptoms?

I did run across a Cochrane review saying that sprays are not effective, maybe that relates.
1081992 tn?1389907237
methylprednisolone tabs are harsh on the stomach,  prednisone not as much but still some.

maybe she has a very sensitive stomach and that's why they did the injection instead?
1 Comments
She said he never even asked and because of her wheezing and tightness he wanted to give her the shot. He also prescribed antibiotics and said it would work well together.

She doesn't fit the bill for MCAS. She has been without the severe pain for the longest stretch, but it is starting to swell again and come back s gonna have her take more ibuprofen and see...
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