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Lower extremity manifestations of “skin-popping” an illicit drug use technique: A report of two cases
The Foot 25 (2015) 114–119
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Case Report
Lower extremity manifestations of “skin-popping” an illicit drug use technique: A report of two cases Michael Canales a,b,c,1 , John Gerhard d,∗ , Erin Younce d a
Private Practice, St. Vincent Medical Group, Rockside Physician’s Center, 6701 Rockside Road, Suite 100, Independence, OH 44131, United States PMR + RRA Residency Training Program, St. Vincent Charity Medical Center, Department of Orthopedic Surgery, Podiatry Section: 2351 E. 22nd ST, Suite 342W, Cleveland, OH 44115, United States c Kent State University College of Podiatric Medicine, 6000 Rockside Woods Blvd., Independence, OH 44131, United States d PGY-3, PGY-1 PMR + RRA Residency Training Program, St. Vincent Charity Medical Center, 2351 E. 22nd St., Cleveland, OH 44115, United States b
h i g h l i g h t s • Crack downs on “pill mills” have led to the resurgence of intravenous drug use. • The skin popping technique can lead to devastating wounds. • A team approach is required to manage the social and medical issues.
a r t i c l e
i n f o
Article history: Received 17 September 2014 Received in revised form 28 February 2015 Accepted 3 March 2015 Keywords: Skin popping Krokodil Heroin Osteomyelitis Wound
a b s t r a c t Presented is a rare case of tibial and fibular osteomyelitis and a case of fibular periositis, both a direct consequence of a peculiar drug use technique. The osseous manifestations secondary to presentation of necrotic wounds with indurated rim and serous drainage with associated cellulitis, both resulting from “skin popping.” Due to the complex treatment plan required, the importance of a motivated patient, a strong social support system, a controlled environment, and a multidisciplinary team cannot be overstated. Despite comprehensive efforts, devastating consequences may be unavoidable as individuals plunge downward, victimized by their addiction. Level of clinical evidence: 4. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Among the world’s population, approximately 16 million people between the ages of 15–64 inject illicit drugs on a regular basis [1]; 669,000 Americans reported using heroin in 2012 [2]. Subcutaneous or intramuscular injection is an increasingly popular method of drug abuse and is a major risk factor for soft tissue, bone, and systemic infection [3]. The most commonly injected drug is heroin, although any water-soluble drug may be injected. The onset of effects is approximately 15–30 s for the intravenous delivery and approximately 3–5 min for the intramuscular or subcutaneous administration [1]. Injection can result in abscess formation and infection when pathogens and other contaminants are introduced
∗ Corresponding author. Tel.: +1 216 363 2725; fax: +1 216 363 2721. E-mail address: [email protected] (J. Gerhard). 1 Tel.: +1 216 328 0418/216 363 2725/216 231 3300; fax: +1 216 328 0847/216 363 2721. http://dx.doi.org/10.1016/j.foot.2015.03.003 0958-2592/© 2015 Elsevier Ltd. All rights reserved.
via shared needles, impurities within the drug, and lack of sterile preparation. Manifestations due to the toxic effects of a heroin can include respiratory depression, coma, pulmonary edema, and cardiac dysrhythmias which may lead to myocardial infarction, cerebrovascular accident, end-organ damage due to insoluble contaminants, and death [1–3]. The death rate from heroin overdose doubled in 28 states from 2010 to 2012, including Ohio [4], the state of our institution. “Krokodil” is a street drug that is derived by “cooking” codeine tablets with a solvent (e.g. gasoline, lighter fluid, paint thinner) and other chemicals. The “cooking process” produces the drug Desomorphine. The street price is less expensive than heroin. “Krokodil” has a similar euphoric high as heroin but with a faster onset of action. Desomorphine’s effects are not as long lasting as heroin. The impurities found in Krokodil lead to devastating complications to the user’s skin and organ systems. Krokodil obtained its nickname due to the scaly green patches of skin users develop. The scales are the result of infarction of local vasculature secondary to sclerosis or occlusion by insoluble particulates. Thrombosis and gangrenous changes often result as seen in Figs. 8 and 9.
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Heroin has similar opportunities for pathology as Krokodil. The impurities and complications that these drugs share often make it difficult to confirm one over the other as an offending agent. The Drug Enforcement Agency (DEA) officially identified two samples as being Desomorphine in 2004. Since that time, no other samples have been officially identified. There have been a myriad of press reports proclaiming the presence of Krokodil in the United States, many of which have proven to be spurious or misidentified heroin [5,6]. Long-term intravenous injection of illicit drugs can result in sclerosis of veins leading some to resort to the practice of “skin popping” in which the drugs are introduced subdermally. The skin is pinched and the drug injected into the tented area [7]. Areas on the body that are easy to access and conceal are prime choices. A common complication of skin popping is the development of subcutaneous abscess which can lead to ulceration. This ulcerative lesion is called a “shooter’s patch” which is maintained as the granulation tissue is utilized as a means of injecting illicit drugs [1]. A 2000 study evaluated illicit drug users for the prevalence of abscess and cellulitis. The study, comprised of 169 total subjects, compared intravenous drug abusers versus “skin poppers.” Results of the study revealed that 61% of skin poppers developed an abscess or cellulitis, as compared to the 24% of users that intravenously administered drugs [8]. Appropriate antibiotic therapy requires accurate cultures and sensitivities. Uncomplicated cellulitis in the face of drug abuse typically responds to antibiotic therapy directed at Staphylococcus aureus and Streptococcal species. Abscesses may be polymicrobial and include anaerobic organisms [9]. Thorough surgical debridement, incision and drainage procedures are often required. Culture guided antibiotic therapy has proven to promote rapid healing of the affected tissue [1]. Osteomyelitis may subsequently develop following haematogenous spread or direct inoculation of bacteria. Inadequately treated osteomyelitis can promote continued use of the “shooter’s patch” due to the increased chance of a chronic ulceration and exposed granulation tissue overlying the infected bone. There have been few reported cases of osteomyelitis involving the long bones due to the practice of “skin popping.”
2. Case 1 A 29-year old female presented to the emergency department with a wound on her right anterior leg. The wound had been present for three months but recently became warm and tender (Fig. 1). The patient initially denied knowledge of the etiology of the wound, but eventually admitted to a 14-year history of heroin use, alcohol abuse, and a 14-pack-year smoking history. There were multiple “track marks” noted to the left leg (Fig. 2). The patient reported using the “skin popping” technique at the site of the right leg wound. She denied signs and symptoms of systemic infection. The patient relayed a past medical history which included anxiety and Hepatitis C. On physical exam, the wound measured 6 cm × 5 cm × 0.5 cm. The base of the wound was necrotic with an underlying mixed granular and fibrotic tissue base. Induration and a two centimeter wide area of erythema were discovered at the wound periphery. A straw colored serous drainage emanated from the base of the wound, but no purulence, proximal streaking, tunneling or fluctuance were noted. Mild pain was elicited with palpation of the wound margins and a mild malodor was noted. No neurovascular deficits were observed. The patient was admitted to the hospital. All laboratory tests including complete blood count with differential (CBC) and complete metabolic panel (CMP) were within normal limits, with the exception of a poor nutritional
Fig. 1. (Case 1) Initial presentation – right leg “shooter’s patch”.
status as indicated by a low serum albumin level. Initial radiographs demonstrated no periosteal changes to the right tibia or fibula. Magnetic resonance imaging (MRI) confirmed the absence of bony involvement. Wound cultures were positive for both Streptococcus viridans and Staphylococcus aureas. The patient was taken to surgery for an excisional debridement and application of a negative pressure therapy dressing. A soft tissue biopsy obtained demonstrated collections of necrosis and polymorphonuclear leukocytes. The patient was subsequently discharged on oral antibiotic therapy (Amoxicillin/clavulanic acid) and failed to follow up with any of the specialties within her multidisciplinary team including: podiatric surgery, infectious disease, addiction medicine, and internal medicine. The patient was lost to follow up. Two years following her initial presentation, the patient presented to the emergency department and reported that her right lower extremity wound had healed. The patient’s chief complaint was a wound to her contralateral leg (Fig. 3). The patient initiated skin-popping heroin to the left leg in order to allow the right leg wound to heal. Radiographs of the left leg demonstrated extensive periosteal reactions to the tibia and fibula. Bony destruction and new bone growth were noted to the anterior tibia (Figs. 4 and 5).
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Fig. 3. (Case 1) Two years following initial presentation: the right leg has healed. A new “shooter’s patch” developed to the left leg.
Fig. 2. (Case 1) The appearance of the left leg at initial presentation, note the multiple “track marks” from intravenous drug abuse.
previous and this latest admission were suitable as the patient was not found to have any liver or renal manifestations that can often accompany the chronic drug abuser, thus this was not a concern. Once again, the patient failed to follow up with all specialties of her multidisciplinary team. Even though the patient missed several podiatry appointments, she was pursued via extraordinary efforts in order to assess the patient outside of regular clinic hours. All attempts to contact the patient were unfruitful and the course of healing of the left leg was unable to be followed. She did present to our institution 18 months later with worsening of her left leg Shooter’s Patch (Fig. 7); she refused intervention and left the hospital against medical advice. The patient’s current status is unknown. 3. Case 2
Wound cultures were positive for Group G Streptococci and Staphylococcus aureus. Laboratory values remained unremarkable. The patient was taken to surgery for an excisional debridement and application of a negative pressure therapy dressing. A left tibial bone biopsy revealed a considerable amount of leukocytes (Fig. 6) and a bone culture was positive for Staphylococcus epidermidis and Staphylococcus aureus. In an effort to disallow unfettered intravenous access through a peripherally inserted central catheter or any similar semi-permanent port, it was determined that oral antibiotics would be the most prudent route of administration given the patient’s history. The patient was discharged on oral antibiotic therapy, cephalexin 500 mg every six hours for six weeks, as well as negative pressure therapy. Both antibiotic choices during
A 26-year old African American female presented with bilateral lower extremity wounds. She reported her wounds are the result of “skin popping” the street drug “Krokodil” and heroin for the past “few” years. Radiographs from that visit show no sign of bony involvement. The patient had a past medical history including schizophrenia as well as polysubstance abuse. At that time the patient refused admission to the hospital. The patient was lost to follow up. Three years later, the patient presented with bilateral lower extremity wounds (Fig. 8). A wound of the right posterior calf measured 4 cm × 4 cm × 0.6 cm. A large wound on the left leg measured 19 cm × 6 cm × 1.4 cm. Both wounds were full thickness in
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Figs. 4 and 5. (Case 1) Radiographs – left leg two years following initial presentation: extensive periosteal reactions to both the tibia and fibula, as well as bony destruction and new bone growth to the anterior tibia. Fig. 7. (Case 1) 3.5 years following initial presentation: regression of the left leg shooter’s patch.
nature with a mixture of fibrotic and granular tissue as well as an adhered eschar and extensive necrosis. No proximal streaking, lymphadenopathy, or purulence were noted. The patient was admitted and empiric parenteral antibiotic therapy was initiated (piperacillin/tazobactam and vancomycin). Radiographs revealed periosteal reaction to the distal fibula (Figs. 9 and 10). The patient underwent sharp excisional debridement of her wounds in the operating room (Figs. 11 and 12). A negative pressure therapy dressing was applied to the left leg two days postoperatively. The right leg was treated with topical mupirocin ointment and a compressive dressing. Wound cultures were positive for Klebsiella
Fig. 6. (Case 1) Histopathology, tibial bone biopsy – confirmation of osteomyelitis by presence of leukocytes and anucleated osteoblast lacunae.
Fig. 8. (Case 2) The appearance of the bilateral leg wounds prior to debridement. Note the small wound to the right leg and the “shooter’s patch” wound to the left leg.
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Figs. 9 and 10. (Case 2) Radiographs – right leg: periosteal reaction to the distal fibula.
pneumonia, Pseudomonas aeruginosa, methicillin resistant Staphylococcus aureus (MRSA), and Enterococcus avium. Consultations were ordered establishing a multidisciplinary team comprised of the podiatry, internal medicine, infectious disease, addiction medicine, and psychiatry services. The patient was discharged to a skilled nursing facility and converted to oral antibiotics consisting of PO trimethoprim/sulfamethoxazole 160/800 mg every 12 h and PO ciprofloxacin 750 mg every 12 h for two weeks duration. Antibiotic route was chosen for identical reason to the patient in Case 1. The patient was eventually transferred to a group
Fig. 13. (Case 2) The appearance of the left leg wound following negative pressure therapy and local wound care. The wound bed ready to accept split thickness skin graft.
home. She received counseling for her addiction and followed up in the wound care center for several weeks. Local wound care and serial debridements were performed, preparing the wound bed to accept a split thickness skin graft (Fig. 13), and was subsequently applied. Unfortunately, the patient began to leave the group home for days at a time and consistently failed to follow up with her clinic appointments and has not returned since the procedure. This patient’s current status is also unknown. 4. Discussion
Figs. 11 and 12. (Case 2) Clinical appearance of the bilateral leg wounds following initial debridement.
The course of care for the treatment of “skin popper’s” wounds is arduous; it requires teamwork, endurance, and most certainly compassion. The patient’s lack of motivation to heal the “shooter’s patch” is the most challenging barrier, as it is the primary means to the abuser’s offending habit. An example seen in a study by Pirozzi, et al. where 73.47% of their skin popping subjects did not return for scheduled outpatient visits [10]. The patient requires physical and medical attention, but also full emotional, social, and even spiritual support. If these needs are not met, devastating consequences may result. It is imperative that a multidisciplinary team including a foot and ankle specialist, internal medicine, infectious disease and
M. Canales et al. / The Foot 25 (2015) 114–119
addiction medicine be involved in the treatment of these complicated patients. References [1] Iyer S, Subramanian P, Pabari A. A devastating complication of ‘skin popping’. Surgeon 2011;9(October (5)):295–7. [2] Murphy E, DeVita D, Liu H, Vittinghoff E, Leung P, Ciccarone D, et al. Risk factors for skin and soft tissue abscess among injection drug users: a case control study. Clin Infect Dis 2001;33(1):35–40. [3] Volkow ND. Heroin: abuse and addiction. NIDA research report series; 2005 http://www.drugabuse.gov/publications/research-reports/heroin-abuseaddiction [accessed 14.02.14]. [4] Rudd R, Paulozzi L, Bauer M, Burleson R, Carlson R, Dao D, et al. Increases in heroin overdose deaths – 28 states, 2010 to 2012. Centers Dis Control Prev 2014;63(39):849–54.
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[5] Gahr M, Freudenmann R, Hiemke C, Gunst I, Connemann B, Schonfeldt-Lecuona C. Desomorphine goes crocodile. J Addict Dis 2013;32(1):118. [6] Desomorphine. DEA office of diversion control, drug & chemical evaluation section; 2013, October http://www.deadiversion.usdoj.gov/drug chem info/ desomorphine.pdf [accessed 14.02.14]. [7] Skin Popping. (n.d.) Segen’s Medical Dictionary. (2011). Retrieved February 4 2015 from http://medical-dictionary.thefreedictionary.com/ Skin+Popping [8] Binswanger I, Kral A, Bluthenthal R, Rybold D, Edlin B. High prevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco. Clin Infect Dis 2000;30(March (3)):579–81. [9] Ebright JR, Pieper B. Skin and soft tissue infections in injection drug users. Infect Dis Clin North Am 2002;16(September (3)):697–712. [10] Pirozzi K, Van J, Pontious J, Meyr A. Demographic description of the presentation and treatment of lower extremity infections secondary to skin popping in intravenous drug abusers. J Foot Ankle Surg 2014;53(March–April (2)): 156–9.
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Case Report
Lower extremity manifestations of “skin-popping” an illicit drug use technique: A report of two cases Michael Canales a,b,c,1 , John Gerhard d,∗ , Erin Younce d a
Private Practice, St. Vincent Medical Group, Rockside Physician’s Center, 6701 Rockside Road, Suite 100, Independence, OH 44131, United States PMR + RRA Residency Training Program, St. Vincent Charity Medical Center, Department of Orthopedic Surgery, Podiatry Section: 2351 E. 22nd ST, Suite 342W, Cleveland, OH 44115, United States c Kent State University College of Podiatric Medicine, 6000 Rockside Woods Blvd., Independence, OH 44131, United States d PGY-3, PGY-1 PMR + RRA Residency Training Program, St. Vincent Charity Medical Center, 2351 E. 22nd St., Cleveland, OH 44115, United States b
h i g h l i g h t s • Crack downs on “pill mills” have led to the resurgence of intravenous drug use. • The skin popping technique can lead to devastating wounds. • A team approach is required to manage the social and medical issues.
a r t i c l e
i n f o
Article history: Received 17 September 2014 Received in revised form 28 February 2015 Accepted 3 March 2015 Keywords: Skin popping Krokodil Heroin Osteomyelitis Wound
a b s t r a c t Presented is a rare case of tibial and fibular osteomyelitis and a case of fibular periositis, both a direct consequence of a peculiar drug use technique. The osseous manifestations secondary to presentation of necrotic wounds with indurated rim and serous drainage with associated cellulitis, both resulting from “skin popping.” Due to the complex treatment plan required, the importance of a motivated patient, a strong social support system, a controlled environment, and a multidisciplinary team cannot be overstated. Despite comprehensive efforts, devastating consequences may be unavoidable as individuals plunge downward, victimized by their addiction. Level of clinical evidence: 4. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Among the world’s population, approximately 16 million people between the ages of 15–64 inject illicit drugs on a regular basis [1]; 669,000 Americans reported using heroin in 2012 [2]. Subcutaneous or intramuscular injection is an increasingly popular method of drug abuse and is a major risk factor for soft tissue, bone, and systemic infection [3]. The most commonly injected drug is heroin, although any water-soluble drug may be injected. The onset of effects is approximately 15–30 s for the intravenous delivery and approximately 3–5 min for the intramuscular or subcutaneous administration [1]. Injection can result in abscess formation and infection when pathogens and other contaminants are introduced
∗ Corresponding author. Tel.: +1 216 363 2725; fax: +1 216 363 2721. E-mail address: [email protected] (J. Gerhard). 1 Tel.: +1 216 328 0418/216 363 2725/216 231 3300; fax: +1 216 328 0847/216 363 2721. http://dx.doi.org/10.1016/j.foot.2015.03.003 0958-2592/© 2015 Elsevier Ltd. All rights reserved.
via shared needles, impurities within the drug, and lack of sterile preparation. Manifestations due to the toxic effects of a heroin can include respiratory depression, coma, pulmonary edema, and cardiac dysrhythmias which may lead to myocardial infarction, cerebrovascular accident, end-organ damage due to insoluble contaminants, and death [1–3]. The death rate from heroin overdose doubled in 28 states from 2010 to 2012, including Ohio [4], the state of our institution. “Krokodil” is a street drug that is derived by “cooking” codeine tablets with a solvent (e.g. gasoline, lighter fluid, paint thinner) and other chemicals. The “cooking process” produces the drug Desomorphine. The street price is less expensive than heroin. “Krokodil” has a similar euphoric high as heroin but with a faster onset of action. Desomorphine’s effects are not as long lasting as heroin. The impurities found in Krokodil lead to devastating complications to the user’s skin and organ systems. Krokodil obtained its nickname due to the scaly green patches of skin users develop. The scales are the result of infarction of local vasculature secondary to sclerosis or occlusion by insoluble particulates. Thrombosis and gangrenous changes often result as seen in Figs. 8 and 9.
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115
Heroin has similar opportunities for pathology as Krokodil. The impurities and complications that these drugs share often make it difficult to confirm one over the other as an offending agent. The Drug Enforcement Agency (DEA) officially identified two samples as being Desomorphine in 2004. Since that time, no other samples have been officially identified. There have been a myriad of press reports proclaiming the presence of Krokodil in the United States, many of which have proven to be spurious or misidentified heroin [5,6]. Long-term intravenous injection of illicit drugs can result in sclerosis of veins leading some to resort to the practice of “skin popping” in which the drugs are introduced subdermally. The skin is pinched and the drug injected into the tented area [7]. Areas on the body that are easy to access and conceal are prime choices. A common complication of skin popping is the development of subcutaneous abscess which can lead to ulceration. This ulcerative lesion is called a “shooter’s patch” which is maintained as the granulation tissue is utilized as a means of injecting illicit drugs [1]. A 2000 study evaluated illicit drug users for the prevalence of abscess and cellulitis. The study, comprised of 169 total subjects, compared intravenous drug abusers versus “skin poppers.” Results of the study revealed that 61% of skin poppers developed an abscess or cellulitis, as compared to the 24% of users that intravenously administered drugs [8]. Appropriate antibiotic therapy requires accurate cultures and sensitivities. Uncomplicated cellulitis in the face of drug abuse typically responds to antibiotic therapy directed at Staphylococcus aureus and Streptococcal species. Abscesses may be polymicrobial and include anaerobic organisms [9]. Thorough surgical debridement, incision and drainage procedures are often required. Culture guided antibiotic therapy has proven to promote rapid healing of the affected tissue [1]. Osteomyelitis may subsequently develop following haematogenous spread or direct inoculation of bacteria. Inadequately treated osteomyelitis can promote continued use of the “shooter’s patch” due to the increased chance of a chronic ulceration and exposed granulation tissue overlying the infected bone. There have been few reported cases of osteomyelitis involving the long bones due to the practice of “skin popping.”
2. Case 1 A 29-year old female presented to the emergency department with a wound on her right anterior leg. The wound had been present for three months but recently became warm and tender (Fig. 1). The patient initially denied knowledge of the etiology of the wound, but eventually admitted to a 14-year history of heroin use, alcohol abuse, and a 14-pack-year smoking history. There were multiple “track marks” noted to the left leg (Fig. 2). The patient reported using the “skin popping” technique at the site of the right leg wound. She denied signs and symptoms of systemic infection. The patient relayed a past medical history which included anxiety and Hepatitis C. On physical exam, the wound measured 6 cm × 5 cm × 0.5 cm. The base of the wound was necrotic with an underlying mixed granular and fibrotic tissue base. Induration and a two centimeter wide area of erythema were discovered at the wound periphery. A straw colored serous drainage emanated from the base of the wound, but no purulence, proximal streaking, tunneling or fluctuance were noted. Mild pain was elicited with palpation of the wound margins and a mild malodor was noted. No neurovascular deficits were observed. The patient was admitted to the hospital. All laboratory tests including complete blood count with differential (CBC) and complete metabolic panel (CMP) were within normal limits, with the exception of a poor nutritional
Fig. 1. (Case 1) Initial presentation – right leg “shooter’s patch”.
status as indicated by a low serum albumin level. Initial radiographs demonstrated no periosteal changes to the right tibia or fibula. Magnetic resonance imaging (MRI) confirmed the absence of bony involvement. Wound cultures were positive for both Streptococcus viridans and Staphylococcus aureas. The patient was taken to surgery for an excisional debridement and application of a negative pressure therapy dressing. A soft tissue biopsy obtained demonstrated collections of necrosis and polymorphonuclear leukocytes. The patient was subsequently discharged on oral antibiotic therapy (Amoxicillin/clavulanic acid) and failed to follow up with any of the specialties within her multidisciplinary team including: podiatric surgery, infectious disease, addiction medicine, and internal medicine. The patient was lost to follow up. Two years following her initial presentation, the patient presented to the emergency department and reported that her right lower extremity wound had healed. The patient’s chief complaint was a wound to her contralateral leg (Fig. 3). The patient initiated skin-popping heroin to the left leg in order to allow the right leg wound to heal. Radiographs of the left leg demonstrated extensive periosteal reactions to the tibia and fibula. Bony destruction and new bone growth were noted to the anterior tibia (Figs. 4 and 5).
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Fig. 3. (Case 1) Two years following initial presentation: the right leg has healed. A new “shooter’s patch” developed to the left leg.
Fig. 2. (Case 1) The appearance of the left leg at initial presentation, note the multiple “track marks” from intravenous drug abuse.
previous and this latest admission were suitable as the patient was not found to have any liver or renal manifestations that can often accompany the chronic drug abuser, thus this was not a concern. Once again, the patient failed to follow up with all specialties of her multidisciplinary team. Even though the patient missed several podiatry appointments, she was pursued via extraordinary efforts in order to assess the patient outside of regular clinic hours. All attempts to contact the patient were unfruitful and the course of healing of the left leg was unable to be followed. She did present to our institution 18 months later with worsening of her left leg Shooter’s Patch (Fig. 7); she refused intervention and left the hospital against medical advice. The patient’s current status is unknown. 3. Case 2
Wound cultures were positive for Group G Streptococci and Staphylococcus aureus. Laboratory values remained unremarkable. The patient was taken to surgery for an excisional debridement and application of a negative pressure therapy dressing. A left tibial bone biopsy revealed a considerable amount of leukocytes (Fig. 6) and a bone culture was positive for Staphylococcus epidermidis and Staphylococcus aureus. In an effort to disallow unfettered intravenous access through a peripherally inserted central catheter or any similar semi-permanent port, it was determined that oral antibiotics would be the most prudent route of administration given the patient’s history. The patient was discharged on oral antibiotic therapy, cephalexin 500 mg every six hours for six weeks, as well as negative pressure therapy. Both antibiotic choices during
A 26-year old African American female presented with bilateral lower extremity wounds. She reported her wounds are the result of “skin popping” the street drug “Krokodil” and heroin for the past “few” years. Radiographs from that visit show no sign of bony involvement. The patient had a past medical history including schizophrenia as well as polysubstance abuse. At that time the patient refused admission to the hospital. The patient was lost to follow up. Three years later, the patient presented with bilateral lower extremity wounds (Fig. 8). A wound of the right posterior calf measured 4 cm × 4 cm × 0.6 cm. A large wound on the left leg measured 19 cm × 6 cm × 1.4 cm. Both wounds were full thickness in
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117
Figs. 4 and 5. (Case 1) Radiographs – left leg two years following initial presentation: extensive periosteal reactions to both the tibia and fibula, as well as bony destruction and new bone growth to the anterior tibia. Fig. 7. (Case 1) 3.5 years following initial presentation: regression of the left leg shooter’s patch.
nature with a mixture of fibrotic and granular tissue as well as an adhered eschar and extensive necrosis. No proximal streaking, lymphadenopathy, or purulence were noted. The patient was admitted and empiric parenteral antibiotic therapy was initiated (piperacillin/tazobactam and vancomycin). Radiographs revealed periosteal reaction to the distal fibula (Figs. 9 and 10). The patient underwent sharp excisional debridement of her wounds in the operating room (Figs. 11 and 12). A negative pressure therapy dressing was applied to the left leg two days postoperatively. The right leg was treated with topical mupirocin ointment and a compressive dressing. Wound cultures were positive for Klebsiella
Fig. 6. (Case 1) Histopathology, tibial bone biopsy – confirmation of osteomyelitis by presence of leukocytes and anucleated osteoblast lacunae.
Fig. 8. (Case 2) The appearance of the bilateral leg wounds prior to debridement. Note the small wound to the right leg and the “shooter’s patch” wound to the left leg.
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Figs. 9 and 10. (Case 2) Radiographs – right leg: periosteal reaction to the distal fibula.
pneumonia, Pseudomonas aeruginosa, methicillin resistant Staphylococcus aureus (MRSA), and Enterococcus avium. Consultations were ordered establishing a multidisciplinary team comprised of the podiatry, internal medicine, infectious disease, addiction medicine, and psychiatry services. The patient was discharged to a skilled nursing facility and converted to oral antibiotics consisting of PO trimethoprim/sulfamethoxazole 160/800 mg every 12 h and PO ciprofloxacin 750 mg every 12 h for two weeks duration. Antibiotic route was chosen for identical reason to the patient in Case 1. The patient was eventually transferred to a group
Fig. 13. (Case 2) The appearance of the left leg wound following negative pressure therapy and local wound care. The wound bed ready to accept split thickness skin graft.
home. She received counseling for her addiction and followed up in the wound care center for several weeks. Local wound care and serial debridements were performed, preparing the wound bed to accept a split thickness skin graft (Fig. 13), and was subsequently applied. Unfortunately, the patient began to leave the group home for days at a time and consistently failed to follow up with her clinic appointments and has not returned since the procedure. This patient’s current status is also unknown. 4. Discussion
Figs. 11 and 12. (Case 2) Clinical appearance of the bilateral leg wounds following initial debridement.
The course of care for the treatment of “skin popper’s” wounds is arduous; it requires teamwork, endurance, and most certainly compassion. The patient’s lack of motivation to heal the “shooter’s patch” is the most challenging barrier, as it is the primary means to the abuser’s offending habit. An example seen in a study by Pirozzi, et al. where 73.47% of their skin popping subjects did not return for scheduled outpatient visits [10]. The patient requires physical and medical attention, but also full emotional, social, and even spiritual support. If these needs are not met, devastating consequences may result. It is imperative that a multidisciplinary team including a foot and ankle specialist, internal medicine, infectious disease and
M. Canales et al. / The Foot 25 (2015) 114–119
addiction medicine be involved in the treatment of these complicated patients. References [1] Iyer S, Subramanian P, Pabari A. A devastating complication of ‘skin popping’. Surgeon 2011;9(October (5)):295–7. [2] Murphy E, DeVita D, Liu H, Vittinghoff E, Leung P, Ciccarone D, et al. Risk factors for skin and soft tissue abscess among injection drug users: a case control study. Clin Infect Dis 2001;33(1):35–40. [3] Volkow ND. Heroin: abuse and addiction. NIDA research report series; 2005 http://www.drugabuse.gov/publications/research-reports/heroin-abuseaddiction [accessed 14.02.14]. [4] Rudd R, Paulozzi L, Bauer M, Burleson R, Carlson R, Dao D, et al. Increases in heroin overdose deaths – 28 states, 2010 to 2012. Centers Dis Control Prev 2014;63(39):849–54.
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