Medline ® Abstracts for References 34,35

A 21-year-old man presented to the emergency department in St James's Hospital by ambulance. He was found collapsed at home by his uncle. He was complaining of severe pain and swelling to his left lower limb, with reduced sensation to his left foot. He was hepatitis C positive from intravenous drug use, and had most recently used both heroin and cocaine 5 days previously on his release from prison. Musculoskeletal exam showed extensive swelling of his left lower limb, with tense calf compartments. Initial laboratory results showed a raised creatine kinase of more than 155,000 IU/l. Urine toxicology was positive for methadone, heroin and benzodiazepines, whereas urinary dipstick was positive for blood, which was confirmed to be myoglobin by subsequent laboratory analysis. Atraumatic rhabdomyolysis is a syndrome characterized by injury to skeletal muscle with subsequent release of intracellular contents, that is myoglobin and creatine kinase. Drugs have direct toxic effects, but may also cause coma-induced rhabdomyolysis, owing to unrelieved pressure on gravity-dependent body parts. Diagnosis is made with history (i.e. recent heroin or cocaine use), elevated serum CK, plus the possible presence of myoglobinuria. Aggressive i.v. rehydration remains the mainstay of treatment. If there is any evidence of compartment syndrome, urgent fasciotomy is required. Electrolyte imbalances should be corrected, unless very mildly abnormal. We have learned from our experience with this case that a high index of suspicionand thereby early recognition is crucial to prevent complications in intravenous drug users presenting with unusual symptoms and signs.

INTRODUCTION: Heroin overdose can cause various rare neurological complications like spongiform leukoencephalopathy, seizures, stroke, toxic amblyopia, transverse myelopathy, mononeuropathy, plexopathy, acute inflammatory demyelinating polyradiculoneuropathy, rhabdomyolysis, compartment syndrome, fibrosing myopathy, and acute bacterial myopathy. We report here the simultaneous presentation of multiple complications of heroin toxicity.

CASE REPORT: A young heroin addict was found unarousable lying in the lotus posture. Examination showed quadriplegia and left leg gangrene. He subsequently developed heroin-induced transverse myelitis, rhabdomyolysis, left leg compartment syndrome, and myoglobin-induced acute renal failure.

DISCUSSION: This case leads us to consider a common linked or systemic mechanism of injury rather than a local mechanism when multiple simultaneous organ failure occurs complicating heroin abuse.