Transcript unexplained illness and death among injecting

Severe systemic sepsis related
to soft tissue inflammation in
injecting drug users.
Dr. Josep Vidal Alaball
BACKGROUND
• Since mid-April’00 over 30 drug users who inject
heroin have died from an unexplained illness.
• Most of those who died have been in Dublin,
Glasgow and the Manchester area, but a few cases
have occurred elsewhere in Britain such as North
East Scotland.
• The drug users affected have injected heroin
intramuscularly or subcutaneously.
• It is unknown if a particular type or supply of
heroin is affected.
BACKGROUND
• The clinical course of those proceeding to death
has usually been rapid and is consistent with
infection by a toxin producing micro-organism.
• Although microbiological investigations are
continuing, a range of anaerobic Clostridium
species have been identified from cases,
including Clostridium novyi and Clostridium
perfrigens both of which may produce powerful
toxins.
• Clostridium species have long been
recognised to produce similar illness in
animals, and several were important causes
of gas gangrene arising from traumatic
wounds in soldiers (First World War)
• However the syndrome currently described
has not been previously seen in injecting
drug users.
BACKGROUND
• Surveillance of cases continues although the
incidence of new cases appears to be
declining.
• No similar cases has been reported from the
rest of Europe.
• It is possible that there may have been a
particular batch of heroin that was
contaminated with toxin producing Clostridia
but which had a limited route of distribution.
• Continued vigilance is required to
detect, promptly treat, and report
any further cases.
PRESENTATION
• LOCAL SIGNS
• SYSTEMIC SIGNS
LOCAL SIGNS
• Local inflammation at a subcutaneous or
intramuscular injection side, with variable
features:
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oedema (often extensive)
myositis
erythema
cellulitis
bruised appearance
LOCAL SIGNS
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abscess like (with little or no pus)
blackened/blistered centre
necrosis
necrotising fascitis
• Usually painful
• NOT associated with high fever
• In early stages difficult to differentiate from
other types of soft tissue inflammation
SISTEMIC SIGNS
• Occurred several days after development of
local lesion
• Dramatic deterioration
• Circulatory collapse with hypotension
• Sometimes: DIC or adult respiratory
distress syndrome
• WCC > 30,000 cells/mm3
SISTEMIC SIGNS
• Elevated creatinine kinase
• Often patient remain mentally alert until an
advanced stage
• By the time patients develop serious illness
deterioration to death is often inexorable
despite antimicrobial and surgical treatment
DIAGNOSIS
• Ask about injecting practice
• Ask about substances mixed with the heroin
for injection
• Examine all injection sites for signs of local
inflammation
• Drug abusers may appear well until quite
late in the illness
MICROBIOLOGICAL
INVESTIGATION
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Biopsy tissues from local inflammatory lesions
Pus/swab local lesion
Blood cultures (at least 3 sets)
Serum, acute and convalescent
Other body fluids
Notify hospital microbiologist you have a
suspect case
MANAGEMENT
• Prompt treatment is crucial
• Consider early surgical treatment
(exploration, drainage, debridement)
• Antimicrobial therapy. Should include one
or more agents known to be active against
anaerobes (penicillin, metronidazole,
clindamycin, possibly in combinations)
• Observation in a high dependency unit