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MDCT Review of Intravenous Drug Abuse Complications

MDCT Review of Intravenous Drug Abuse Complications

Franco Verde, MD

 

Disclosures

None of the authors have any relevant disclosures

 

Outline

  • Introduction
  • Superficial complications
  • Deeper complications
  • Vascular complications
  • Retained foreign bodies
  • Emboli complications

 

Introduction

  • Intravenous drug use is a serious epidemic plaguing the United States
  • Heroin use has tripled from 2007 to 2014 from 161,000 to 435,000 users
  • Deaths from heroin overdose have tripled from 2010 to 2014 from 3,036 to 10,574
    • Particularly in the Northeast and Midwest states
    • Many drug enforcement agencies now report that heroin as their greatest drug threat

 

Introduction

  • Beyond the socioeconomic impact of intravenous drug use, there are numerous potential complications that result from the intravenous administration of heroin and other injected illicit drugs
  • This educational exhibit reviews the numerous complications that the radiologist may detect in daily practice

 

Introduction

  • Illicit drugs sold on the street such as heroin or cocaine are diluted or “cut” up to 99%.
    • Substances used to dilute the drug includes other pharmaceutical drugs, powered caffeine, various sugars, starch, talc, etc.
    • The manufacturing or storage of the diluted drug can easily be contaminated with soil, dust, and pathogens
    • Once the consumer buys the powered drug, it is prepared for injection by dissolving in water, lemon juice, or other available liquids and subsequently heated, usually in a spoon
    • It may be then filtered through a cotton ball or cigarette filter which allows for additional contamination

 

Introduction

  • The body sites for injection and subsequent complication can depend on how long the patient has been using intravenous drugs
  • In a 2001 observational study, Drake et al noted a time dependent progression among injection sites:
    • Antecubital fossa is the usual starting injection location
    • Upper arm veins followed after 3.5 years of use
    • Hands veins by 4 years
    • Neck, foot, and leg veins after 6 years
    • Femoral, toe and finger veins after 10 years
  • Direct injection into the skin or “skin popping” or intramuscular injections may be performed when peripheral veins are no longer accessible or in an effort to hide injection or “track” marks
  • Arterial injections are sometimes inadvertently performed

 

Cutaneous Infections

  • Cutaneous infections are common in intravenous drug use, occurring in up to 65% of users with one series reporting at least 10% of users having an abscess in the past 6 months
  • As discussed on previous slides, the solution being injected is frequently contaminated with bacteria and fungi
    • These infections are commonly polymicrobial, but typical organisms include Gram-positive cocci (Staph and Strep species) and Anaerobes. Gram-negative bacteria are less commonly isolated (if present, usually Pseudomonas or Serratia species)
    • Typically from the skin and oropharynx

 

Manifestations on Imaging

  • Radiographs are insensitive to detect minor inflammation
  • CT is highly accurate to detect skin thickening, subcutaneous inflammation, gas and abscess formation
  • Appearances include regional skin thickening, subcutaneous fat stranding, and rim enhancing low density fluid collections.
  • Gas can be seen in the setting of necrotizing infections
  • Arterial or venous phase is usually sufficient for characterization
  • 3D full volume rendering may be helpful to fully appreciate the extent of infection.

 

Superficial Complications

Figure 1. 32 year old woman with history of intravenous drug use presents with inguinal pain and drainage for the past few days after attempting to inject heroin. IV contrast enhanced CT images of the pelvis with axial (A) and sagittal reconstruction (B) demonstrates skin thickening and subcutaneous fat stranding at the site of injection (A, B, yellow arrows). Few foci of gas (B, red arrow) are present from injection. Note the track of the fat stranding to the level of the femoral vessels (*) on the axial image.

Superficial Complications

 

Superficial Complications

Figure 2. 33 year old man with history of intravenous drug use presenting for hand pain 5 days after injecting cocaine. Physical exam and bedside ED sonogram was suspicious for hand abscess. IV contrast enhanced CT images of the hand with axial (A), coronal (B) and full volume 3D rendering (C) demonstrates subtle rim-enhancing abscess (A,B, orange arrows) measuring 1.7 cm. Volume rendering demonstrates focal swelling within the first webspace (C, yellow arrow).

Superficial Complications

 

Superficial Complications

Figure 3. 53 year old man with history of intravenous drug use and skin popping presents with a week of shoulder and upper arm pain after injecting heroin. IV contrast enhanced CT images of the right upper extremity with axial (A), coronal (B) and full volume 3D rendering (C) demonstrates a large rim-enhancing abscess involving the deltoid muscle (A,B, yellow arrows) measuring 6 x 4 cm in transverse dimension extending up to 7 cm in craniocaudal dimension. 3D volume rendering demonstrates an obvious region of focal swelling at site of abscess (C, red arrow).

Superficial Complications

 

Superficial Complications

Figure 4. 55 year old man with a history of intravenous drug use and skin popping presents with a week of shoulder and upper arm pain after injecting heroin. IV contrast enhanced CT images of the left upper extremity with axial (A), coronal (B) and full volume 3D rendering (C) demonstrates a large, irregular, insinuating, rim-enhancing abscess involving the anterior compartment of the upper arm (A,B, yellow arrows) extending from the subacromial region to mid humerus, measuring 6 x 6 cm in axial dimension and extending for up to 19 cm in craniocaudal dimension. Volume rendering demonstrates an marked regional swelling at site of abscess (C, red arrow).

Superficial Complications

 

Superficial Complications

Figure 5. 55 year old woman with long history of intravenous drug use, HIV/AIDS, hepatitis C, presents with increasing neck pain and swelling after injecting into the right neck 3 days ago. IV contrast enhanced CT in axial (A) and coronal (B, C) planes demonstrates a large 5 x 8 x 10 cm multiloculated abscess within the right supraclavicular region (A, B, C red arrows). Note the broken retained needle fragment from injection (B, yellow arrow). Patient was admitted to surgery for emergent debridement.

Superficial Complications

 

Deeper Infections

  • Necrotizing infections are surgical emergencies and should be immediately communicated if suspected
  • CT findings are similar to cutaneous infections and include soft tissue gas, fascial thickening, intra-fascial fluid collections, and muscular edema
  • MRI can be a problem solving tool if the CT is limited

 

Deeper Infections

  • Deeper hematogenous spread can happen involving other organs – such as the psoas/iliopsoas musculature
  • Presentation may include flank or abdominal pain, or a limp
  • 80% of osteomyelitis related to intravenous drug use occurs from direct contiguous spread from infected tissue
  • 20% of cases are from hematogenous spread

 

Deeper Complications

Figure 5. 35 year old man with history of intravenous drug use sent to ED by police (after being arrested for other reasons) for evaluation of open arm wound. Patient endorses wound was present for the past 3 to 4 months. IV contrast enhanced CT of the upper extremity demonstrates a large open wound (A, B, red arrows) with advanced osteomyelitis of the radius and ulna (A, yellow arrow). Volume rendering allows full appreciation of wound extent for the radiologist. One must be careful not to confuse the clip plane (B, red arrowhead) used to create the 3D image for additional pathology.

Deeper Complications

 

Deeper Complications

Figure 6. 23 year old woman with history of intravenous drug use presents to ED with increasing leg, groin, and pelvic pain. Patient has a fever with leukocytosis. IV contrast enhanced CT imaging in sequential axial plane (A) demonstrates large amount of left inguinal inflammation (A, yellow arrows) with developing abscesses (A, red arrows). Additional edema noted through left psoas muscle. Oblique coronal MPR (B) well demonstrates full extent of abscesses and edema (B, red and yellow arrows).

Deeper Complications

 

Vascular Complications

  • Thrombophlebitis is multifactorial from repeated injection, local sepsis, and chemical irritation from agents involved in dilution
  • Pseudoaneurysms and mycotic aneurysms are most feared complication due to risk of rupture
  • Can occur by direct inoculation, bacteremic seeding, contiguous infection and septic emboli
  • S. aureus is the most common cause of infection related aneurysms
  • Most direct pseudoaneurysm cases involve the femoral arteries
  • Mycotic aneurysms are most commonly seen in the intracranial arteries, followed by visceral and upper/lower extremities, often at bifurcations
  • Direct arterial injections can cause severe tissue necrosis locally

 

Vascular Complications

Figure 7. 41 year old woman with history of intravenous drug use presents with leg pain after injecting cocaine into her legs. Axial (A) and coronal (B) IV contrast enhanced CT of the lower extremities demonstrates asymmetric skin thickening and subcutaneous fat stranding, compatible with cellulitis (A, B yellow arrows). Adjacent dilated venous structures are noted (A, B red arrows). Doppler analysis of the area demonstrates tubular dilated structure without blood flow (C, red arrow). Findings are compatible with superficial thrombophlebitis from direct injection.

Vascular Complications

 

Vascular Complications

Figure 8. 47 year old woman with history of intravenous drug use presents for severe groin pain. Axial IV contrast enhanced CT of the pelvis and upper thigh (A) demonstrates three saccular pseudoaneurysms arising from the right common and proximal femoral arteries. Largest pseudoaneurysm measures 1.6 x 1.4 cm and smallest measures 0.8 cm (A, B, red arrows). Surrounding hematoma is also present (A, B, yellow arrows). Coronal MPR (B) and MIP images (C) fully depict all the pseudoaneurysms in a single image which may be helpful for vascular surgical planning.

Vascular Complications

 

Vascular Complications

Figure 9. 55 year old man with a 30 year history of intravenous drug use, HIV/AIDS, ESRD, presents with neck pain. IV contrast enhanced CT of the neck in axial plane (A) with coronal (B) and coronal maximal intensity projection (C) reconstructions. Impressive lobulated saccular 2.9 x 3.1 x 5.5 cm pseudoaneurysm (PSA) of the right common carotid artery secondary to intravenous drug injection. Broken needle tip (bottom A, B, C red short arrow) along the medial aspect of the PSA. Numerous other broken needle fragments present through the neck. Additional needle fragment within the right internal jugular vein (A, B, C gold arrow) which is partially thrombosed.

Vascular Complications

 

Retained Foreign Bodies

  • Most commonly seen are needle fragments
  • Easily identified as linear radiodense fragments on radiography or CT
  • May have associated inflammatory collections, edema or other findings, but may be clinically occult
  • Patients may hide drug material or paraphernalia within body cavities to avoid law enforcement. Small baggies, syringes or other material may be seen.
  • Bowel, anorectal or vaginal areas should be evaluated carefully

 

Retained Foreign Bodies

Figure 10. 58 year old man with history of intravenous drug abuse (in remission 10 years) presents for chronic left hip pain evaluation. Frontal view of the pelvis and lateral view of the left hip demonstrates severe hip osteoarthritis. 2 well seen needle fragments are seen on both views (A, B, red arrows). Magnified view reveals a third fragment projecting over the femoral head (C, yellow arrow).

Retained Foreign Bodies

 

Retained Foreign Bodies

Figure 11. 55 year old man with over 30 year history of intravenous drug use, HIV/AIDS, ESRD, presents with chest pain (same patient as in figure 9). Frontal chest radiograph magnified to the supraclavicular regions demonstrates scattered needle fragments (A, red arrows). There is markedly improved visualization of the number of retained needles with edge enhancement filter available in standard PACS viewer (B, red circles). A tunnel hemodialysis catheter and sternotomy wires are partially visualized.

Retained Foreign Bodies

 

Retained Foreign Bodies

Figure 12. 31 year old woman unknown duration of intravenous drug abuse presented to the ED in police custody with recurrent bacteremia with treatment for renal abscess. IV contrast enhanced axial CT image of the pelvis (A) with oblique coronal reconstructions (B and C) demonstrates 4 air filled tubular structures in the vagina (A, read and yellow arrows). Three structures are the same (A, red arrows) with a larger diameter structure to the left (A, yellow arrow). Only with interactive multiplanar reconstructions are the foreign bodies well visualized as small bore syringes (red arrows) and a vial (yellow arrow). One syringe has an uncapped bent needle (B, red arrow) with the adjacent cap (B, red arrowhead). A fully capped needle is well seen (C, red arrow). The patient apparently panicked and inserted her drug paraphernalia into her vagina prior to police custody.

Retained Foreign Bodies

 

Embolic Complications

  • Septic emboli
    • Primary presentation is pulmonary with multiple cavitary, predominantly peripheral, nodules
    • Also presents as seeding of multiple sites, causing osteomyelitis and septic arthritis
    • Can involves unusually joints such as the pubic symphysis, sacroiliac, sternoclavicular, and sternomanubrial joints
  • Emboli of foreign material such as needles also possible
    • Uncommon, but may require retrieval or surgical removal.
    • Needle embolization should be easily visible on CT

 

Embolic Complications

  • Septic emboli can occlude the vasa vasorum or vessel lumen, potentially leading to infection or aneurysm formation
  • Can originate from peripheral veins from a thrombophlebitis or endocarditis (typically right sided)
  • Patients are often febrile
  • Foreign granulomatosis – such as talc or other contaminants can also embolize to the pulmonary capillary beds
    • Can present similarly to other granulomatous diseases with multiple tiny pulmonary nodules

 

Embolic Complications

Figure 13. 45 year old woman with active polysubstance abuse including injecting intravenous heroin presents with difficultly walking and hip pain. Non-contrast CT of the pelvis in axial (A) and coronal (B) planes demonstrates destruction of the pubic symphysis compatible with osteomyelitis (A, B red arrows). MRSA was cultured directly from pubic symphysis bone biopsy and from blood cultures.

Embiolic Complications

 

Embolic Complications

Figure 14. 31 year old woman with active intravenous drug abuse presents with one week of fever. Non-contrast CT of the chest in axial (A, B), and coronal (C) planes demonstrates multiple solid nodules, some cavitary, predominately throughout the lower lobes with a few nodules in the upper lobes (red arrows). Note the ill-defined margins of the nodules with subtle hazy ground glass opacity. Nodules are consistent with septic emboli. Blood cultures were positive for methicillin-susceptible Staphylococcus aureus (MSSA).

Embiolic Complications

 

Conclusions

  • Intravenous drug abuse is a significant epidemic, increasing in amount and is important for radiologists to be able to recognize common complications
  • CT is the most common modality for which these findings and complications to be detected; MRI and US are useful adjuncts and problem solvers
  • Commonly expected complications to encounter include cutaneous and deeper infections, with potentially more serious vascular and embolic phenomena very important to identify due to complication risks
  • Retained foreign bodies are common in long term use and can be associated with serious vascular complications

 

References

  • U.S. Department of Justice, Drug Enforcement Administration, 2016 National Drug Threat Survey; U.S. Department of Justice, Drug Enforcement Administration, All Domestic Field Division Reporting, January 2013 – June, 2015.
  • Young AW, Rosenberg FR. Cutaneous stigmas of heroin addiction. Arch Dermatol 1971; 104: 80-6.
  • Trends in injection drug use among persons entering addiction treatment -- New Jersey, 1992-99. (MMWR) Morb Mortal Week Rep 2001; 50: 378-91.
  • Hirsch CS. Dermatopathology of narcotic addiction. Hum Pathol 1972; 3: 37-53.
  • Heng MC, Feinberg M, Haberfelde G. Erythematous cutaneous nodules caused by adulterated cocaine. J Am Acad Dermatol 1989; 21: 570-2.
  • Kirchenbaum SE, Midenberg ML. Pedal and lower extremity complications of substance abuse. J Am Podiatr Assoc 1982; 71: 380-7.
  • Redmond WJ. Heroin adulterants and skin disease. Arch Dermatol 1979; 115: 111 (Letter).

 

References

  • Darke S, Ross J, Kaye S. Physical injecting sites among injecting drug users in Sydney, Australia. Drug Alcohol Depend 2001; 62: 77-82.
  • Stone MH, Stone DH, MacGregor H. Anatomical distribution of soft tissue sepsis sites in intravenous drug misusers attending an accident and emergency department. Br J Addiction 1990; 85: 1495-6.
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  • http://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/infections-of-joints-and-bones/osteomyelitis
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References

  • Monroe EJ, Tailor TD, McNeeley MF, Lehnert BE. Needle embolism in intravenous drug abuse. Radiology Case Reports. 2012;7(3):714. doi:10.2484/rcr.v7i3.714.
  • Hagan IG, Burney K. Radiology of Recreational Drug Abuse. RadioGraphics 2007 27:4, 919-940. DOI: http://dx.doi.org/10.1148/rg.274065103
  • [Two cases of psoas abscesses caused by group A beta-haemolytic streptococcal infection with a cutaneous portal of entry]. Routier E1, Bularca S, Sbidian E, Roujeau JC, Bagot M. Ann Dermatol Venereol. 2010 May;137(5):369-72. doi: 10.1016/j.annder.2010.02.020. Epub 2010 Apr 2.
  • Del Giudice, P. Cutaneous Complications of Intravenous Drug Abuse. The British Journal of Dermatology. 2004;150(1) 

 

References

  • Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O'Gara P, Taubert KA, American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015;132(15):1435. 
  • ParéJP, Cote G, Fraser RS. Long-term follow-up of drug abusers with intravenous talcosis. Am Rev Respir Dis. 1989;139(1):233. 

Acknowledgements

  • Franco Verde, MD
  • Constantine Burgan, MD
  • Elliot K Fishman, MD

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