CHAPTER 296: INJECTION DRUG USERS

Reporter: Juster John P. Abueg – 1st Year Resident

POST – REPORT QUIZ

1. Which practice among injection drug users is most commonly associated with the development of
pneumothorax and hemothorax?
A) Intravenous injection into the forearm
B) Injection into the supraclavicular fossa
C) Subcutaneous injection into the abdomen
D) Injection into the deltoid muscle

The answer is B
Pneumothorax and hemothorax are most commonly seen in association with the practice of "pocket
shooting," where drug users inject into the supraclavicular fossa to access the subclavian, jugular, or
brachiocephalic vein. Option A, intravenous injection into the forearm, is less commonly associated
with these complications. Options C and D involve injection sites that are not typically associated with
pneumothorax or hemothorax

2. What is a characteristic symptom of "talc lung"?

A) Persistent fever
B) Progressive respiratory distress
C) Severe chest pain
D) Rapid improvement with antibiotic therapy

The answer is B
"Talc lung" is a syndrome characterized by progressive respiratory distress and diffuse interstitial
infiltrates caused by the injection of talc adulterants. Option A, persistent fever, is not specifically
mentioned as a characteristic symptom of talc lung. Option C, severe chest pain, is not highlighted as
a typical feature of talc lung either. Option D, rapid improvement with antibiotic therapy, is
inconsistent with the nature of talc lung, which typically requires supportive management rather than
antibiotic therapy.

3. Which neurological condition is more common in injection drug users and may present with
symptoms such as altered mental status, cranial nerve involvement, and progressive symmetric
paralysis?
A) Epidural abscess
B) Bacterial meningitis
C) Hypoxic stroke syndromes
D) Tetanus

The answer is D
Both tetanus and botulism are more common in injection drug users and may present with symptoms
such as cranial nerve involvement, altered mental status, and progressive symmetric paralysis. Option
A, epidural abscess, and Option B, bacterial meningitis, are neurological conditions commonly seen in
injection drug users but do not typically present with the described symptoms. Option C, hypoxic
stroke syndromes, is mentioned as a possible consequence of low-flow states during heroin
 intoxication but does not typically present with cranial nerve involvement or progressive symmetric
paralysis.

4. Which statement accurately reflects the importance of considering injection drug use history in
patients presenting with chronic back pain?
A) Neglecting to inquire about IV drug use history may lead to missed diagnoses of cord-
compromising infections.
B) MRI imaging is typically sufficient to diagnose infectious causes of back pain in injection drug users.
C) Chronic back pain in injection drug users is often associated with trauma rather than infectious
causes.
D) Opportunistic infections in injection drug users with HIV typically present with prominent systemic
symptoms.

The answer is A
Neglecting to inquire about IV drug use history may lead to missed diagnoses of cord-compromising
infections. Emphasis was given with the importance of considering a history of IV drug use in patients
presenting with chronic back pain, as failure to do so can result in missed diagnoses of potentially
serious infections. Option B is incorrect because while MRI imaging may be used to assess for
potential infection, it is not sufficient to diagnose all cases. Option C is incorrect because causes
maybe from various infectious causes, not just trauma, can contribute to chronic back pain in
injection drug users. Option D is incorrect because opportunistic infections in injection drug users
with HIV may have a subtle presentation, possibly manifesting solely as local pain, rather than
prominent systemic symptoms.

5. The incidence of endocarditis in intravenous drug users is reported to be 40 times that of the general
population with the majority of cases involving the right side of the heart and the tricuspid valve. The
organism that is most commonly implicated in these patients is
(A) Haemophilus parainfluenzae
(B) Pseudomonas aeruginosa
(C) Staphylococcus aureus
(D) Anaerobes

The answer is C
The intravenous street drug users present another special but all too common situation in the ED.
These patients are prone to various infections due to underlying disease such as HIV, poor health, or
little medical care. The incidence of endocarditis is 40 times that of the general population. The right
side of the heart and the tricuspid valve are more commonly involved, and the most commonly
implicated organism is S. aureus. Antibiotic options should consider that up to two-thirds of these
cases with S. aureus in large urban areas have methicillin resistance. Furthermore, empiric therapy
for infective endocarditis is direct initially to treatment against S. aureus (methicillin-specific or
methicillin-resistant S. aureus) and Streptococcus and Enterococcus species, with consideration of
local sensitivities and pathogens.

6. A 50-year-old injection drug user with a history of chronic obstructive pulmonary disease presents to
the emergency department with respiratory symptoms. Given the patient's risk factors for
Pseudomonas infection, which antibiotic regimen would be most appropriate for initial empiric
coverage?
A) IV moxifloxacin and IV ceftriaxone
 B) IV cefepime and IV levofloxacin
C) IV ceftriaxone and IV vancomycin
D) IV cefotaxime and IV azithromycin

The correct answer is B

The patient's risk factors for Pseudomonas infection, including chronic obstructive pulmonary disease,
indicate the need for broad-spectrum coverage. It is recommended considering an IV
antipseudomonal b-lactamase agent, such as cefepime, along with an IV antipseudomonal
fluoroquinolone for patients at risk for Pseudomonas infection. Option A, IV moxifloxacin and IV
ceftriaxone, lacks coverage for Pseudomonas infection. Option C, IV ceftriaxone and IV vancomycin,
does not provide adequate coverage for Pseudomonas. Option D, IV cefotaxime and IV azithromycin,
also lacks coverage for Pseudomonas infection.

7. A 30-year-old man presents to the ED with right upper extremity pain, redness, and swelling after
skin-popping black tar heroin 3 days ago. He also notes a fever but denies shortness of breath,
diplopia, dysphagia, or weakness. Vital signs are BP 130/90 mmHg, HR 92 bpm, RR 20 cpm, and Temp
37.6°C. The right upper extremity is swollen and red, with a central blackened eschar. A bulla has
ruptured, releasing serous fluid, which does not have an odor. The arm is tender, but crepitus is
absent. The rest of the physical examination is normal except for multiple hyperpigmented sites on
the extremities. What is the next MOST appropriate series of actions?
(A) Obtain IV access, send blood to the lab, give parenteral antibiotics, obtain radiograph of the upper
extremity, and get a surgery consult
(B) Prescribe cephalexin and have the patient follow up in 2 days
(C) Give IV antibiotics and admit
(D) Obtain IV access and send blood to the lab

The answer is A
This patient has necrotizing fasciitis, a life-and-limb-threatening soft tissue infection often associated
with, but not limited to, injection drug use. Diabetes is also a strong comorbidity. The patient requires
IV access, laboratory studies, a film to rule out soft tissue gas, a surgical consult, and parenteral
antibiotics. Oral antibiotics and discharge are both inappropriate. Admission will be necessary but
surgery must be involved early. Commonly associated clinical signs and symptoms such as
hypotension, crepitus, bullae, skin necrosis, and gas on radiographs are frequently absent. Pain out of
proportion may be an early clue. The emergency physician should maintain a very high index of
suspicion. Necrotizing fasciitis is usually a polymicrobial, aerobic, and anaerobic infection but reports
of virulent group A streptococci and Enterobacter species are increasing. Broad-spectrum antibiotics
and timely surgical debridement are required.

8. What diagnostic approach is recommended for confirming vertebral osteomyelitis, particularly in

cases involving unusual or fastidious organisms such as Mycobacterium, Candida, or Eikenella?
A) MRI imaging of the affected area
B) Routine blood culture testing
C) Culturing drainage from a contiguous abscess
D) Administration of broad-spectrum antibiotics

The answer is C
Culturing drainage from a contiguous abscess is recommended for confirming vertebral osteomyelitis,
especially in cases involving unusual or fastidious organisms. Option A, MRI imaging, may aid in
 diagnosing vertebral osteomyelitis, but culturing drainage is essential for confirming the diagnosis
and identifying the causative organism. Option B, routine blood culture testing, may also be helpful,
but it is not specific to confirming vertebral osteomyelitis. Option D, administration of broad-
spectrum antibiotics, may be initiated empirically but is not part of the diagnostic approach for
confirming the infection

9. A 35-year-old male presents to the ED complaining of severe pain and swelling in his right knee. He
reports a history of injection drug use and states that the symptoms began approximately two days
ago. The pain has progressively worsened, and he is now unable to bear weight on the affected knee.
He denies any recent trauma to the knee. On examination, the patient's right knee is warm,
erythematous, and markedly swollen. There is tenderness to palpation over the joint line, and passive
range of motion is significantly limited due to pain. The patient is febrile with a temperature of
38.5°C. Which of the following is NOT part of the patient's treatment plan?
A) Start the patient on empiric antibiotic therapy providing wide-spectrum coverage
B) Initiation of Therapeutic arthrocentesis/washout
C) Initiation of CT-guided needle biopsy for epidural abscess or a bone sample culture
D) Initiation of Physical Therapy

The answer is C
Option C, which is the use of CT-guided needle biopsy for epidural abscess or bone sample culture is
often required for diagnosis of Osteomyelitis and not Septic Arthritis since blood culture may be
insufficient clinching a diagnosis. Further more, option A, B, D, are included in the suggested
treatment plan for Septic Arthritis. Treatment includes immobilization; empiric antibiotic therapy
providing wide-spectrum coverage, including coverage for methicillin-resistant S. aureus; physical
therapy; therapeutic arthrocentesis/washout; and occasional open drainage.

10. A 20-year-old woman who is an injection drug user presents with a 3-day history of right eye pain
with decreased vision. She denies trauma or prior similar events but recalls having a high fever. Vital
signs are BP 130/85 mmHg, HR 80 bpm, RR 20 cpm, and Temp 38°C. Visual acuity is 20/50 in the right
eye and 20/20 in the left. Extraocular movements are intact. The right eye is red and chemotic. The
pupils are 3 mm each and reactive. Both eyes have intraocular pressures of 18. Slit lamp examination
reveals a cloudy anterior chamber without hypopyon or hyphema. There is no corneal fluorescein
uptake. The vitreous is hazy. On funduscopy, several fluffy yellow-white lesions are seen on the retina.
What is the MOST likely etiologic agent?
(A) Staphylococcus
(B) Cytomegalovirus
(C) Toxoplasma
(D) Candida

The answer is D
Endophthalmitis due to injection drug use (IDU) is more commonly caused by fungal, rather than
bacterial, infection. Onset of symptoms such as pain, decreased vision, or blurred vision may be acute
or indolent. Fluffy yellow-white retinal lesions and vitreous haziness are key features. Infection will
progress to involve the anterior chamber, and the yellow-white lesions will grow in the vitreous.
Endophthalmitis or chorioretinitis due to candida species is associated with the use of black tar
heroin. A prodrome of high fever is followed within 3-4 days by ocular symptoms, cutaneous lesions,
and costochondral involvement. Aspergillus species are the second most common cause of fungal
endophthalmitis in IDU, but cutaneous and musculoskeletal features are absent. Staphylococcus
aureus and Streptococcus species are the most common organisms associated with IDU-related
bacterial endophthalmitis. Toxoplasma and cytomegalovirus are associated with chorioretinitis in HIV-
positive injection drug