Dear Sir, A 44-year-old woman presented with progressive swelling and erythema on the dorsum of both hands (Fig 1). She had had cosmetic paraffin injections into the dorsum of both hands by a non-medical practitioner three days earlier. An MRI scan showed an acute inflammatory reaction and multiple lobulated foreign material in the subcutaneous tissue with a high signal on T2 imaging and a low signal on T1 imaging. Although the patient was apyrexial and the white cell count was normal there was a concern about infection and her hands were elevated and immobilized and she was started on oral antibiotics (cefaclor). Despite this she had increasing swelling and pain especially with finger movement. Her fingertips started to cool confirmed on plethysmography. Compartment syndrome was suspected and fasciotomy recommended. The patient wished to avoid significant scarring. Thus multiple stab incisions were performed and about 150 ml of white caseous material was extruded from each hand. Within hours her symptoms had improved and fingertip blood supply had returned to normal. The patient remained in hospital having further immobilization and intravenous steroid therapy for five days to minimize the acute inflammatory response. Bacterial culture of the aspirate was negative. Histological analysis revealed an acute inflammatory reaction around multiple vacant vacuoles containing foreign materials. At review 2 months later the patient had regained full painless movement but had some increased pigmentation and soft tissue thickening on the back of her hands (Fig 2).
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