Well, let’s get the hat-tips up fron first. My kind friend and autism advocate Liz Ditz at I Speak of Dreams tweeted me last night to point me to a NPR “Shots” blogpost by Nancy Shute, journalisticus awesomeii and current president of the National Association of Science Writers.
Together, these two erudite women have led me to forego having breakfast this morning.
Shute cited a new report in the journal Orthopedics (free html and PDF) where Dr. Russell Russo and colleagues at the LSU Health Sciences Center in New Orleans describe the case of a 34-year-old woman who presented with a two-day history of a bad swollen and painful forearm. A small red puncture wound was visible and she admitted to injecting herself intramuscularly with a “bath salt” product – intramuscular after she was unable to find vascular access. Sadly, this was a person with a serious substance abuse disorder as she also tested positive for cocaine, opiates (drugs like morphine or OxyContin), and benzodiazepine (drugs like Valium, Klonopin, or Xanax).
Bath salts are the colloquial name for a class of products marketed similarly to synthetic marijuana but very different in chemical composition. While also smoked and snorted, bath salts contain one or more stimulant drugs called synthetic cathinones – specifically mephedrone (or 4-methylmethcathinone, 4-MMC) or MDPV (or methylenedioxypyrovalerone). My neuroscience researcher and blogger colleague DrugMonkey is an authority on these compounds and has written extensively at his blogs. This category search is a good place to start but this single post and its links are best.
The woman’s condition responded briefly overnight to a course of broad-spectrum, intravenous antibiotics (penicillin G and clindamycin).
Then all hell broke loose.
Hours later, when the patient was reexamined, she was found to have progressive erythema that had developed past the earlier skin markings and an area of skin sloughing around the injection site with a malodorous drainage. The diagnosis of a fast-spreading infection, such as necrotizing fasciitis, was assumed, and the patient immediately underwent emergent surgical debridement and exploration.
What this means is her skin was removed on her forearm and decaying tissue was scrubbed off into a basin. I won’t show the pictures here but you can go to Figure 2 of the paper if you’d like.
No clear margins proximally of healthy muscle were available, so an incision was made in the anterolateral approach to the shoulder. In the time it took to expose the anterior upper arm, muscle in the forearm that had previously been contractile and pink had turned dusky and noncontractile. We disarticulated the shoulder to obtain clear margins of the disease to prevent disease progression. The general surgery team was placed on standby to aid with further chest wall and neck debridement as indicated, and massive blood transfusion protocols were instituted.
More experienced readers in medicine can tell me how long it took to expose the anterior upper arm but my guess is that it would be a half-hour or so.
To me, that qualifies as how Nancy Shute described the situation: “the infection was moving so fast they could see flesh dying right before their eyes.”
And here’s why the general surgery team was placed on standby:
To prevent the spread of disease and obtain healthy viable tissue, a complete forequarter amputation was performed, removing both scapula and clavicle while debriding all noncontractile, unhealthy muscle. The general surgery team also elected to perform a right radical mastectomy and further chest wall debridement to prevent further progression of the disease.
Necrotizing fasciitis is a frightening and rapidly progressive infection. Even with removal of her arm and shoulder, including the entire shoulder blade and collarbone, and breast (likely because of lymphatic vessels that run from lymph nodes in the armpit from the breast), the woman is lucky to have survived. These types of cases are most often associated with aggressive streptococcal organisms but hers was particularly prolific:
Bacterial isolates included alphahemolytic Streptococcus, Streptococcus viridans, Peptostreptococcus micros, Gemella morbillorum, and Actinomyces odontolyticus.
Figure 4 of the paper just breaks my heart – that’s her right side with her head to the left (you can see her healthy left arm at the top of the picture).
Of course, one is pretty hardpressed to say that this case was due to injection of the bath salts per se. The woman most likely had poorly-cleaned “works,” didn’t properly sterilize the injection area, and/or the bath salts product was contaminated with the offending microorganisms at the point of manufacture.
Unfortunately, the authors did not have a sample of the bath salts product the woman used. That was the least of their worries in treating her.
The bottom line eloquently voiced by my physician wife is, “Bath salts or not, don’t go injecting crap. There really is a reason we use sterile, prepackaged, single-use needles.”
Yup. And that seemingly overkill use of two separate antiseptic wipes or swabs.
This is why.
Russo, R., Marks, N., Morris, K., King, H., Gelvin, A., & Rooney, R. (2012). Life-threatening Necrotizing Fasciitis Due to ‘Bath Salts’ Injection Orthopedics DOI: 10.3928/01477447-20111122-36