Recurrent Necrotizing Soft Tissue Infections and Atypical Organisms: Manifestations of the Opiate/Opioid Crisis

Author(s):
Mayur Narayan; Jackly Juprasert; Caitlin Finn; Philip Barie

Background:

America is in the midst of an OC. More than 90 Americans die daily from overdoses. Injection drug use (IDU) is a major risk factor for NSTI by inoculating pathogens into soft tissues. Recurrent infection and atypical pathogens may be tangible manifestations of OC

Methods:

Report of two unusual cases of NSTI with IDU and review of pertinent international literature.

Results:

Case 1: 42F with known history of IDU (heroin) presented with a NSTI of the proximal left upper extremity (LUE) with crepitus extending onto the chest wall. Her Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was 5. Of note, she had a NSTI requiring debridement at another facility, 2 mos prior (same extremity, different [healed] site, microbiology unknown). Treatment was with vancomycin (V), piperacillin/tazobactam (P/T), clindamycin (C), and emergency debridement of necrotizing myositis of the triceps brachii. Culture revealed S. anginosus and E. coli. She eloped from the hospital with a large open wound after staff found a glassine envelope labeled “Black Friday” in her bed. She was lost to followup.

Case 2: 22F with known history of IDU (heroin) presented with 5 d of LUE swelling and diffuse pain. LUE needle track marks and swelling from the elbow to the left chest were noted. LRINEC score was 6. Treatment included V, C, P/T, and emergency debridement. Cultures revealed atypical polymicrobial flora including S. anginosus, Prevotella buccae, and Bilophila wadsworthia. Her case was complicated by multiple bacteremias with other atypical organisms including C. tropicalis, C. albicans, S. maltophilia, Abiotrophia defectiva, E. cloacae, and E. coli. She also developed P. cepacia suppurative thrombophlebitis of her right cephalic vein requiring excision. The patient admitted ongoing IDU in hospital, and was diagnosed with Munchausen syndrome. She was discharged after a 2-mo hospital stay and multiple reconstructive procedures.

Results:

Lit review: Case 1 is the first case report of recidivism of NSTI. Only one other published case report describes Munchausen syndrome associated with NSTI. P. cepacia has not been reported previously with NSTI.

Conclusions:

IDU with NSTI may pose increased risk for recidivism and infection with atypical organisms, mandating heightened awareness when managing patients with NSTI related to IDU. Additional co-existent behavioral health issues must also be considered.