Severe systemic sepsis related to soft tissue inflammation in injecting drug users.

1. Severe systemic sepsis related to soft tissue inflammation in injecting drug users. Dr. Josep Vidal Alaball

2. 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.

3. 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.

4. 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.

5. 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.

6. Continued vigilance is required to detect, promptly treat, and report any further cases.

7. PRESENTATION • LOCAL SIGNS • SYSTEMIC SIGNS

8. LOCAL SIGNS • Local inflammation at a subcutaneous or intramuscular injection side, with variable features: • oedema (often extensive) • myositis • erythema • cellulitis • bruised appearance

9. LOCAL SIGNS • 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

10. 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

11. 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

12. 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

13. MICROBIOLOGICAL INVESTIGATION • 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

14. 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