No pain no gain: tender nodules in a competitive bodybuilder

The subculture of bodybuilding is rife with people willing to do whatever is necessary to achieve the perfect physique. One particularly concerning behavior is the injection of site-enhancing-oils (SEO) into lagging muscle groups to achieve instant size and symmetry. The typical SEO is a combination of lidocaine, alcohol, and oil; it is rarely, if ever, administered by a qualified professional. As a result, there are a variety of potential complications that can manifest in the skin and other organ systems. In our case, a 41-year-old former competitive bodybuilder was referred to our clinic for excision of a subcutaneous nodule. The initial histopathology was concerning for lymphoma, but a more thorough history and review of systems were completely negative. The patient underwent a negative systemic lymphoma workup and it was not until we discussed the prospects of radiation and other forms of treatment that he revealed a history of SEO use, as well as other identical nodules on his body. Subsequent excisions revealed a more classic sclerosing lipogranuloma-type reaction pattern. Owing to the taboo nature of SEOs, most patients are reluctant to provide this vital piece of historical information, highlighting the importance of patient rapport and clinical-pathologic correlation in our specialty.