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"Skin popping" refers to the practice of injecting drugs, most commonly heroin, subcutaneously or into granulation tissue. Pharmaceutical tablets meant for oral consumption are modified into solutions for injection. Excipients-inactive substances that serve as vehicles for medication-are often not filtered out before injection and result in abscess formation, granulomatous inflammation, and scarring. Common excipients used in the production of pharmaceutical tablets include starch, microcrystalline cellulose, magnesium stearate, silica, and polyvinylpyrrolidone (PVP). Identification of these exogenous materials is valuable in confirming the diagnosis of skin popping, especially when patients may not be forthcoming about their drug use. We present a case of subcutaneous oral medication injection in which PVP and cellulose were identified by Fourier transform infrared spectroscopy. Considering the variable cutaneous manifestations of injection drug abuse, recognition of histopathologic and chemical characteristics of exogenous material from oral medications is helpful for diagnosis and intervention.

OBJECTIVES People who inject drugs (PWID) are at increased risk for numerous negative health outcomes. Subcutaneous injections (aka skin popping) can result in greater risk of skin and soft tissue infections (SSTIs), but less is known about PWID who choose this route of administration. This study compares subcutaneous injectors to intravenous injectors, characterizes those who inject subcutaneously, and examines whether subcutaneous injection is associated with SSTIs in the past year. METHODS A cohort of hospitalized PWID (n = 252) were interviewed regarding injection-related behaviors, history of SSTI, and knowledge of subcutaneous injection risk. We examined differences between those who do and do not inject subcutaneously and used a negative binomial regression model to estimate adjusted odds associating subcutaneous injection and SSTI. RESULTS Participants averaged 38 years, with 58.3% male, 59.5% White, 20.6% Black, and 15.9% Latinx. PWID who performed subcutaneous injection were not demographically different from other PWID; however, the mean rate of past year SSTIs was higher for persons injecting subcutaneously than for those who did not (1.98 vs 0.96, P

Crospovidone is an insoluble pharmaceutical disintegrant that has been implicated in a rare foreign body reaction in injection drug users, classically associated with pulmonary angiothrombosis. We recently reported the first known cases of cutaneous crospovidone deposition. We herein report two additional cases with unique clinicopathologic manifestations, both in the setting of suspected injection drug abuse. Additionally, we provide a comprehensive overview of the distinct histomorphology and reproducible histochemistry of crospovidone.

Clostridium botulinum produces botulinum neurotoxin (BoNT), which can lead to death if untreated. In the United States, over 90% of wound botulism cases are associated with injection drug use of black tar heroin. We sought to determine the phylogenetic relatedness of C. botulinum isolated from an injection drug use wound botulism case and isolates from endogenous infant botulism cases in Hawaii. Nineteen C. botulinum type B isolates from Hawaii and one type B isolate from California were analyzed by whole-genome sequencing. The botulinum toxin gene (bont) subtype was determined using CLC Genomics Workbench, and the seven-gene multi-locus sequence type (MLST) was identified by querying PubMLST. Mashtree and pairwise average nucleotide identity were used to find nearest neighbors, and Lyve-SET approximated a phylogeny. Eighteen of the isolates harbored the bont/B5 gene: of those, 17 were classified as sequence type ST36 and one was classified as ST104. A single isolate from Hawaii harbored bont/B1 and was determined to belong to ST110, and the isolate from California harbored bont/B1 and belonged to ST30. A tree constructed with Lyve-SET showed a high degree of homology among all the Hawaiian C. botulinum isolates that harbor the bont/B5 gene. Our results indicate that the bont/B-expressing isolates recovered from Hawaii are closely related to each other, suggesting local contamination of the drug paraphernalia or the wound itself with spores rather than contamination of the drug at manufacture or during transport. These findings may assist in identifying interventions to decrease wound botulism among persons who inject drugs.

Background Clostridium botulinum remains a major threat to a select population of subcutaneous and intramuscular drug users. We conducted a retrospective study of patients who were diagnosed with wound botulism and their clinical presentations to the Emergency Department (ED). Results A total of 21 patients met the inclusion criteria and all had a confirmed history of heroin use disorder. Initial presentation to the ED included generalized weakness (n = 20, 95%), difficulty swallowing (n = 15, 71%), and speech/voice problems (n = 14, 79%). Sixteen patients (76%) also presented with visible skin wounds and fifteen (71%) required mechanical ventilation (MV). Patients who presented with dysphagia as well as dysarthria and/or dysphonia were more likely to require a percutaneous endoscopic gastrostomy (PEG) tube. Patients who required MV and PEG tubes were noted to have a longer hospital length of stay (LOS) due to the severity of the disease progression. Conclusions Emergency physicians should remain vigilant about early recognition of wound botulism, especially in patients who inject drugs.

Author(s): Wyatt, Ryan H.; Shtull-Leber, Eytan; Kelly, Thomas E. | Abstract: Introduction: Wound botulism is a rare and potentially fatal infectious disease, often seen in patients who abuse injection drugs. It classically presents with dysfunction of bilateral cranial nerves followed by proximal and distal motor weakness, which can progress to respiratory failure.Case Report: We report a case of a 31-year-old female who presented to the emergency department for the fifth time with an eight-day history of isolated dysphagia without any other neurologic symptoms. She reported a history of injection drug abuse via “skin popping,” was admitted to the hospital, and ultimately diagnosed with wound botulism.Conclusion: This case exemplifies the diagnostic pitfalls of rare diseases such as wound botulism and provides insight regarding the diagnosis and treatment of this entity. This case also highlights the unique medical and social challenges emergency physicians face while trying to reliably evaluate patients who abuse controlled substances.

During September 29-October 6, 2017, the County of San Diego Public Health Services (COSD) was notified of two patients with suspected wound botulism and a history of using black tar heroin. On October 9, COSD, which had reported an average of one wound botulism case per year during 2001-2016, sent a health alert through the California Health Alert Network, notifying Southern California providers of these two patients, including their signs and symptoms and black tar heroin exposure. In collaboration with the California Department of Public Health, COSD conducted an investigation to identify additional cases, determine risk factors for illness, estimate cost of medical care, and develop recommendations to prevent further illness. By April 18, 2018, nine (eight confirmed and one probable) patients with wound botulism were identified, all of whom were hospitalized; one of the nine died. All nine were persons who inject drugs; seven specifically reported using black tar heroin and six practiced subcutaneous injection known as skin popping. Clinically compatible signs and symptoms included muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, difficulty breathing, loss of facial expression, or descending paralysis. All patients were treated with heptavalent botulism antitoxin (BAT). Wound botulism is likely underrecognized because of its rarity and the overlapping signs and symptoms with opioid intoxication, overdose, and other neurologic syndromes including Guillain-Barre syndrome, the Miller Fisher variant of Guillain-Barre syndrome, and myasthenia gravis. Prompt diagnosis, administration of BAT, and provision of supportive care can help stop the progression of paralysis and be lifesaving.

Crospovidone, a polymer of poly N-vinyl-2-pyrrolidone, is an inert insoluble disintegrant found in pharmaceutical tablets. This material has been encountered in the lungs of intravenous drug users and embolized with other components such as talc and microcrystalline cellulose. More recently, crospovidone has also been described in the gastrointestinal tract. We present 2 cases of cutaneous crospovidone deposition resulting from subcutaneous injection of crushed tablets, commonly known as "skin popping." Clinical presentation includes painful, inflamed papules, nodules, or ulcers with overlying eschar. Crospovidone has a distinct and reproducible histochemical staining profile. Histologic recognition of this material is important because it can guide clinicians in their diagnosis and management decisions.

Botulism is a rare potentially fatal and treatable disorder caused by a bacteria-produced toxin that affects the presynaptic synaptic membrane resulting in a characteristic neuromuscular dysfunction. It is caused by either the ingestion of the toxin or the bacteria, inhalation, or wound infection. We present our observations with a descriptive case series of wound botulism secondary to black tar heroin (BTH) injection. We report a retrospective single-center case series of 15 consecutive cases of wound botulism presenting to University Medical Center of El Paso. Medical records where reviewed to obtain demographic information, clinical presentation, treatment, and outcome. We identified fifteen patients with mean age of 47 years: twelve men, and three women. All had administered BTH through skin popping and had abscesses in the administration areas. By history, the most common symptoms were dysphagia (66%), proximal muscle weakness of upper and lower extremity (60%), neck flexor muscle weakness (33%), ophthalmoplegia (53%), bilateral ptosis (46%), dysarthria (53%), double vision (40%), blurred vision (33%), and dry mouth (20%). During the examination, the most common features noted were: proximal muscle weakness of upper and lower extremities (73%), ophthalmoplegia (53%), ptosis (46%). In patients with documented wound botulism, the pupils were reactive in 46%. All patients required mechanical ventilation and were treated with the trivalent antitoxin. Eleven patients (73.3%) were discharged home, two were transferred to a skill nursing facility, and two were transferred to long-term acute care facility. In our patients, BTH injection, involving the action of injecting under the skin acetylated morphine derivatives (mostly 6-monoacetylmorphine and 3-monoacetylmorphine), was associated with the development of botulism. The availability of BTH at the US–Mexican border is not surprising since it is frequently produced in Latin America. Its association with the development of botulism should be recognized early to allow a prompt diagnosis and treatment with the antitoxin. A clinical feature worth noting is the presence of normal pupillary light reflex in nearly half of patients. Therefore, the presence of a normal pupillary response does not exclude the presence of wound botulism.

In illicit drug use, "skin popping" refers to the method of administering drugs by injecting it into the subcutaneous tissue. "Skin popping" can lead to acute and chronic skin manifestations caused by the drug itself and/or by the various adulterants and fillers commonly added to drug substances. Chronic skin manifestations include a foreign-body reaction with formation of granulomas at the site of injection. We present the F-FDG PET/CT findings of extensive subcutaneous granulomas in a 58-year-old woman with a heroin addiction undergoing treatment for infective endocarditis of the mitral valve.

Background Injection-site vein loss and skin abscesses impose significant morbidity on people who inject drugs (PWID). The two common forms of street heroin available in the USA include black tar and powder heroin. Little research has investigated these different forms of heroin and their potential implications for health outcomes. Methods A multiple-choice survey was administered to a sample of 145 participants seeking services at reduction facilities in both Sacramento, CA and greater Boston, MA, USA. Multivariate regression models for reporting one or more abscesses in one year, injection-site veins lost in six months, and soft tissue injection. Results Participants in Sacramento exclusively used black tar (99%), while those in Boston used powder heroin (96%). Those who used black tar heroin lost more injection-site veins ( β =2.34, 95% CI: 0.66–4.03) and were more likely to report abscesses (AOR=7.68, 95% CI: 3.01–19.60). Soft tissue injection was also associated with abscesses (AOR=4.68, 95% CI: 1.84–11.93). Consistent venous access (AOR: 0.088, 95% CI: 0.011–0.74) and losing more injection sites (AOR: 1.22, 95% CI: 1.03–1.45) were associated with soft tissue injection. Conclusion Use of black tar heroin is associated with more frequent abscesses and more extensive vein loss. Poor venous access predisposes people who inject drugs to soft tissue injection, which may constitute a causal pathway between black tar heroin injection and abscess formation. The mechanisms by which black tar heroin contributes to vein loss and abscess formation must be further elucidated in order to develop actionable interventions for maintaining vein health and decreasing the abscess burden. Potential interventions include increased access to clean injection equipment and education, supervised injection facilities, opioid substitution therapy, and supply chain interventions targeting cutting agents.

No abstract available. Article truncated after first 150 words. A 27-year-old Caucasian man with past medical history of opioid abuse (reportedly sober for 10 years on buprenorphine), post traumatic stress disorder, depression and anxiety presented to the emergency department complaining of dysarthria after taking diphenhydramine and meclizine in addition to his prescribed trazodone and buprenorphine to try to sleep. He was discharged to home after his symptoms appeared to improve with intravenous fluid. He returned to the emergency department the following afternoon with worsening dysarthria, dysphagia, and subjective weakness. The patient was non toxic appearing, afebrile, vital signs were stable and his strength was reported as 5/5. Computed tomography of his head did not show any evidence of acute intracranial abnormality. Given his ongoing complaints, he was admitted for observation to the general medicine wards. That night a rapid response was initiated when the nurse found the patient to be unresponsive, but spontaneously breathing. The patient’s clinical status did ...

Background AA amyloidosis due to subcutaneous injection of drugs of abuse has been described in the USA, but all the existing literature is from more than 20 years ago. There is more recent literature from Europe. We have observed a high incidence of AA amyloidosis in the county hospital in San Francisco. Design Here, we describe 24 patients who had kidney biopsy-proven AA amyloidosis from our hospital from 1998 to 2013. All the patients were thought to have AA amyloidosis from skin popping of illicit drugs after having exhausted the intravenous route. These patients with biopsy-proven AA amyloidosis were analysed further. Results All patients were found to have hepatitis C infection, hypertension was not common, most had advanced kidney failure, and acidosis was common as was tubulointerstitial involvement on the kidney biopsy. Other organ involvement included hepatomegaly and splenomegaly in a number of patients; direct myocardial involvement was not seen, but pulmonary hypertension, history of deep vein thrombosis and pulmonary embolism were common. The prognosis of these patients was poor. The mortality rate approached 50% 1 year after biopsy, and most of the patient needed dialysis shortly after diagnosis. Cessation of drug use seemed beneficial but rarely achievable. Conclusion AA amyloidosis from skin popping is common in San Francisco. Most patients with renal involvement end up on dialysis, and mortality rates are exceedingly high.

Botulism is caused by toxin production from many species of Clostridium, most commonly Clostridium botulinum as well as C. baratii and C. butyricum. Development of wound botulism is associated with injection drug users but has also been described in traumatic injuries with exposure to soil. A patient presented to the emergency department with a complaint of descending, progressive weakness. He recently reported skin popping with heroin injections. Heptavalent botulinum antitoxin was obtained from the [Center for Disease Control and Prevention (CDC)]. On hospital day seven, the anaerobic wound cultures resulted with growth of Clostridium subterminale.

"Skin popping" is a method of injecting illicit drugs into the skin. There are numerous acute and chronic complications associated with skin popping. We present a case of a 48-year-old, African-American female patient with 40 - 60 hyperpigmented, fibrotic, depressed, round papules and plaques on the extremities, which were incidentally noticed during a clinic visit for her acne vulgaris. Skin popping scars are important clues for possible drug abuse. Healthcare practitioners should be aware of and recognize the lesions associated with this practice so further testing can be performed if clinically indicated. Recognition of the lesions and thus earlier treatment of the complications could prevent the complications of skin popping in the skin and other organs.

Presented is a rare case of tibial and fibular osteomyelitis and a case of fibular periositis, both a direct consequence of a peculiar drug use technique. The osseous manifestations secondary to presentation of necrotic wounds with indurated rim and serous drainage with associated cellulitis, both resulting from “skin popping.” Due to the complex treatment plan required, the importance of a motivated patient, a strong social support system, a controlled environment, and a multidisciplinary team cannot be overstated. Despite comprehensive efforts, devastating consequences may be unavoidable as individuals plunge downward, victimized by their addiction. Level of clinical evidence 4.

Key Clinical Message Wound botulism is a potentially lethal condition that can cause paralysis. Its association with black tar heroin is a well‐established fact. It is essential to alert clinicians in recognizing the patients with history of injection drug abuse presenting with clinical features of botulism early on admission for prompt diagnosis and treatment.

Background and objectives AA-type kidney amyloidosis is classically associated with chronic autoimmune or inflammatory disorders. However, some urban centers have reported a high prevalence of injection drug use among patients with kidney AA amyloidosis. Previous reports lack control groups to quantify associations and most predate the opioid epidemic in the United States. Design, setting, participants, & measurements We conducted a case–control study of 38 patients with biopsy-confirmed kidney AA amyloidosis and 72 matched control individuals without this condition from two large hospital systems in Seattle, Washington. We ascertained the pattern and duration of heroin use by medical chart review and determined associations using logistic regression. Results Among case patients, 95% had a prior history of heroin use, 87% had skin abscesses, and 76% and 27% had evidence of muscling and skin popping, respectively. After adjustment for age, race, sex, site, and year of biopsy, any heroin use (past or current) was associated with an estimated 170-times higher risk of kidney AA amyloidosis compared with no heroin use (95% confidence interval, 28 to 1018 times higher; P Conclusions Injection heroin use is strongly associated with kidney AA amyloidosis in the Pacific Northwest. Unique aspects of heroin use, in particular geographic regions or frequent associated soft-tissue infections, may be an important cause of this progressive kidney disease.

Serologic surveillance should be implemented to identify the prevalence of this disease in persons who inject drugs., Outbreaks of serious infections associated with heroin use in persons who inject drugs (PWIDs) occur intermittently and require vigilance and rapid reporting of individual cases. Here, we give a firsthand account of the cases in London during an outbreak of heroin-associated anthrax during 2009–2010 in the United Kingdom. This new manifestation of anthrax has resulted in a clinical manifestation distinct from already recognized forms. During 2012–13, additional cases of heroin-associated anthrax among PWIDs in England and other European countries were reported, suggesting that anthrax-contaminated heroin remains in circulation. Antibacterial drugs used for serious soft tissue infection are effective against anthrax, which may lead to substantial underrecognition of this novel illness. The outbreak in London provides a strong case for ongoing vigilance and the use of serologic testing in diagnosis and serologic surveillance schemes to determine and monitor the prevalence of anthrax exposure in the PWID community.

We review the most common systemic and cutaneous signs of heroin, cocaine, methamphetamine, Ecstasy, and marijuana use. We also provide an overview of the skin and soft-tissue infections frequently found in intravenous drug users and the effects of the adulterants added to the drugs.

Drug abuse is associated with a wide variety of skin alterations. Being aware of the typical signs and symptoms of the drug addicts' skin is of special importance to dermatologists, even though dermatologists are commonly not involved in the treatment of these patients. There is yet a chance for dermatologists to identify drug abusers early by to some extent specific cutaneous signs and after exclusion of several other etiological factors, so that this will lead to further treatment through the respective specialists. The objective of this paper is to draw particular attention to typical skin lesions and diseases which may be associated with drug abuse.

Following the introduction of black tar heroin mainly from Mexico in the 1980s, cases of wound botulism dramatically increased in the western United States. Contamination with spores of Clostridium botulinum of black tar heroin occurs along the distribution line. The heating of heroin powder to solubilize it for subcutaneous injection ("skin popping") does not kill the spores. The spores germinate in an anaerobic tissue environment and release botulinum toxin type A or B. Unless skin abscesses are found in the patient, the clinical diagnosis is often challenging. Facilitation of the compound muscle action potential by repetitive nerve stimulation at 20 to 50 Hz is an important and rapid diagnostic test. Definite diagnosis is made by detection of botulinum toxin in serum or isolation of C botulinum from the abscess. Early treatment with equine ABE botulinum antitoxin obtained from the Centers for Disease Control and Prevention often shortens the time on a ventilator.

Wound infections due to Clostridium botulinum in Germany are rare and occur predominantly in heroin injectors, especially after subcutaneous or intramuscular injection of heroin ("skin popping"), which is contaminated with spores of C. botulinum. We report a rapid geographical clustering of cases in Germany in a region between Cologne, Bonn, and Aachen with wound botulism and consecutive systemic C. botulinum intoxication in intravenous drug users (IDUs) within 6 weeks in October and November 2005.A group of 12 IDUs with wound botulism after "skin popping."Clinical data were available in 11 (92%) of 12 patients; in 7 (58%) of the 12 cases, there was cranial nerve involvement including mydriasis, diplopia, dysarthria, and dysphagia, followed by progressing symmetric and flaccid paralysis of proximal muscles of the neck, arms, trunk, and respiratory muscles. Mechanical respiratory support was necessary. Five of the IDUs were treated with antitoxin, but mechanical respiratory support could not be avoided. The mean ventilation duration was 27.4 days (range 6-77 days). In 4 patients (33%), mechanical ventilation could be avoided; two were treated with antitoxin.This report describes rapid geographical clustering of wound botulism with severe respiratory complications in IDUs after "skin popping," which has not previously been reported either in Germany or any other European country. Based on these observations and those in other European countries, we conclude that there is a trend towards "skin popping," suggesting a change in injection practices in IDUs. Secondly, we conclude that the total number of cases with wound botulism is likely to increase because "skin popping" is the main risk factor.

Background: In 2012, a nephrologist reported the development of a multiorgan thrombotic syndromic complex resembling thrombotic thrombocytopenic purpura (TTP) in patients who were abusing long acting oxymorphone hydrochloride; all patients had hemolytic anemia and thrombocytopenia. Objective: Herein, we report another case involving a 31-year-old woman who self intravenously administered dissolved oral oxymorphone resulting in thrombotic sequelae resembling Degos disease. Methods: Formalin-fixed and paraffin embedded skin biopsies were prepared according to standard protocols for H&E and immunohistochemistry. Results: The clinical presentation and biopsy findings were held to be indicative of Degos disease/malignant atrophic papulosis (MAP) but with unusual clinical features including renal failure and severe respiratory insufficiency. Given the efficacy of eculizumab in the treatment of the acute thrombotic phase of Degos disease/MAP, the patient received this drug, resulting in rapid resolution of signs and symptoms associated with her multiorgan failure. Although she developed recurrent cutaneous ulcers despite complete complement inhibition with eculizumab., her other extracutaneous manifestations did not recur. The patient’s pre and post eculizuamb skin biopsies showed a striking pauci-inflammatory thrombogenic vasculopathy associated with marked endothelial cell injury along with deposits of C3d and C4d within the cutaneous vasculature; the C5b-9 deposits were limited to the pre-eculizumab biopsy. We discovered that her syndromic complex was a self-inflicted one related to the localized administration of dissolved oxymorphone. Conclusion: Our patient’s biopsy along with the rapid response to eculizumab indicates that this distinct thrombotic microangiopathy is another complement mediated thrombotic microangiopathy syndrome. Opioid thrombotic microangiopathy has a varied clinical presentation and can mimic other catastrophic microangiopathy syndromes, all of which have in common a responsiveness to complement inhibition.

There are three main, naturally occurring, epidemiological types of botulism: food-borne, intestinal colonization (infant botulism) and wound botulism. The neurological signs and symptoms are the same for all three epidemiological types and may include respiratory paralysis. Wound botulism is caused by growth of cells and release of toxin in vivo, is associated with traumatic wounds and abscesses and has been reported in drug users, such as those injecting heroin or sniffing cocaine. Up to the end of 1999 there were no confirmed cases of wound botulism in the UK. Between the beginning of 2000 and the end of December 2002, there were 33 clinically diagnosed cases of wound botulism in the UK and Ireland. All cases had injected heroin into muscle or by 'skin popping'. The clinical diagnosis was confirmed by laboratory tests in 20 of these cases. Eighteen cases were caused by type A toxin and two by type B toxin.

Background: Identifying women with past and present drug abuse is an essential aspect of prenatal care. Case: Despite having typical telltale physical signs of prior subcutaneous drug injections, a 33-year-old pregnant woman who had regular prenatal care visits with multiple obstetric care providers was only identified as a drug abuser after a cesarean section, when her skin scars were identified by one provider as the result of “skin popping” related to injections of illicit drugs before this pregnancy. Conclusion: This case demonstrates that obstetricians must become aware of the telltale signs of drug abuse, such as subcutaneous injections (skin popping) with illicit drugs leading to scaring of the arms and other parts of the body.

It is estimated that worldwide, 16 million people, aged 15-64 years inject illicit drugs regularly. When peripheral venous access becomes obliterated, drug users start injecting into the subdermal area of the skin - "skin popping". When this area ulcerates, the well vascularised granulation tissue called a "shooter's patch" is maintained as a portal for continuing injection. These "shooter's patches" are usually on the limbs, but have been reported on the breast and the penis. We present a case of a reconstructive muscle flap being used in an unforeseen manner as a shooters patch. Surgeons rely on muscle flaps to provide a robust reconstructive option, but we have learnt that drug users value them for their rich vascularity and high absorption.

A 40-year-old gentleman presented with a 7-day history of a painful ulcer over the lateral aspect of his right lower leg. He was an intravenous drug user for the last 15 years and on a methadone programme for the previous 12 months. He admitted to the practice of “skin popping” (injecting drugs subcutaneously) over his right leg as he had exhausted all of the venous access sites. The ulcer had been present for the last 2 years and he did not seek any medical attention as this area was used as a “shooters patch” to inject illicit drugs. Clinical examination revealed a 22 15 cm ulcer over the lateral aspect of his right lower leg with a central area of necrosis approximating 12 8 cm (Fig. 1). The base of the ulcer extended down to the fibula. Radiographic examination

Diseases caused by clostridia are often mediated via toxins. For botulism and tetanus, specific neurotoxins produced by Clostridium botulinum and Clostridium tetani affect different areas in the nervous system to cause weakness or spasticity. In 1995, the California Department of Health Services (CDHS) documented an increase in the reported number of cases of wound botulism (WB) that started in 1994. A total of 96 cases of tetanus were reported to occur in California between 1988 and 2000. Necrotizing soft tissue infections (NSTIs) and necrotizing fasciitis are not reportable conditions in California. The proportion of cases with necrotizing fasciitis was over 80% at two of the three hospitals, and the mortality rate ranged from 10 to 27%. The recent epidemic of wound botulism (WB), tetanus, and NSTIs among injecting drug users (IDUs) in California is likely due, in great part, to skin popping of black tar heroin (BTH) contaminated with Clostridium species. Injection drug use is a complicated issue, and IDUs are a difficult population to reach with prevention messages. These messages will have to address drug rehabilitation to decrease the risk of infection with blood-borne pathogens along with the risk for WB, tetanus, and NSTIs. In recent years, California clinicians have seen increasing numbers of serious Clostridium infections among IDUs, including WB, tetanus, and necrotizing fasciitis. The recent epidemics of WB, tetanus, and NSTIs among IDUs in California are likely due, in great part, to skin popping of BTH contaminated with Clostridium species.

Skin popping refers to the act of subcutaneous injection of intravenous drugs, a practice that often results in the development of cellulitis and the formation of soft tissue abscesses. Although the foot and ankle represent common injection sites, few data have described the presentation and natural history of this pathologic entity. The objective of the present study was to retrospectively assess the descriptive demographic data of a patient cohort admitted for lower extremity skin and soft tissue infection caused by intravenous drug abuse. Fifty skin popping lesions in 49 patients were identified during a 733-day data collection period (August 1, 2010 to August 31, 2012) that had been treated by the in-patient podiatric surgical service for lower extremity infection caused by intravenous drug abuse at an urban, level-one trauma center. With respect to patient race, our hospital has a typical in-patient census of 55% black patients and 25% white patients. The present patient cohort consisted of 12% black patients and 65% white patients. The mean length of stay was 5.71 ± 3.56 days, and 42 patients (85.71%) underwent some form of surgical debridement, with 31 (63.27%) having undergone a formal procedure in the operating room. Six patients (12.24%) left the hospital against medical advice or refused intervention at some definitive point of care, and 36 (73.47%) did not return for scheduled outpatient follow-up visits. Three cases (6%) resulted in minor amputation. The microbiologic culture data and common antibiotic prescriptions used in the diagnosis and treatment, respectively, of these patients have been summarized. We hope these original descriptive data can be used by other physicians treating patients at similar urban practices to improve the care of these sometimes difficult-to-treat patients and better serve this population as a whole.

Drug abusers, particularly those who inject drugs s.c. ("skin popping"), may develop amyloidosis. Chronic infections are thought to play a pathogenetic role in this setting. A patient is presented who had a history of "skin popping" cocaine and heroin and developed nephrotic syndrome, with an elevated serum creatinine and a creatinine clearance of 61 mL/min. Renal biopsy demonstrated amyloidosis. Treatment with colchicine was initiated, and proteinuria decreased to near normal levels after 12 months. Concomitant with the decrease in proteinuria, creatinine clearance improved, although a repeat renal biopsy failed to show any significant improvement in amyloid burden. These observations suggest that colchicine may be a useful treatment in reversing the proteinuria of renal amyloidosis associated with drug abuse. Furthermore, clinical improvement may occur before any demonstrable regression in the amyloidosis.

Drug abusers frequently develop typical medical sequelae of their addiction. For instance, smoking or snorting cocaine and other drugs can cause respiratory problems, atrophy of the nasal mucosa, and perforation of the nasal septum [16]. On the other hand, needle marks may be present on the skin from recent injections, or “tracks” may be present over veins from past injections. However, injections are not always confined to obvious sites. Many users will inject into the axilla, under the tongue, under the breast, in the legs, and even into the dorsal vein of the penis [16]. In addition, many heroin addicts begin with subcutaneous injections called “skin popping” and return to this mode of application when extensive clogging makes their veins inaccessible (Fig. 8). As addicts get more desperate for the “kick”, cutaneous ulcers may be found in improbable sites [2].

Sara had been addicted to heroin for over 30 years and had been committed to numerous terms in jail and state prison, spending over 22 years behind bars. Her numerous convictions included possession of drugs, being under the influence of drugs, prostitution, disorderly conduct, petty theft, and grand theft. Every one of her crimes and incarcerations resulted directly from her drug use. Every time she was released from incarceration, she immediately returned to heroin use. Her preferred method of use was intravenous injection. She also frequently injected a combination of heroin and cocaine, commonly referred to as a “speedball.” She developed numerous disfiguring scars and deep pits from “skin popping” and “mainlining” (intravenous injections) on her arms, hands, and neck from repeated injections.

D H 1 HE DIFFERENTIAL DIAGNOSIS of renal failure in intravenous (IV) drug abusers is arge. IV heroin abusers may develop a distincive form of focal segmental glomerulosclerosis nown as heroin-associated nephropathy. They lso are at increased risk for the development of epatitis C virus (HCV) infection and its renal omplications, including membranous and memranoproliferative glomerulonephritis with or ithout associated cryoglobulinemia. Other nfections, such as hepatitis B or human immunoeficiency virus, may lead to membranous or embranoproliferative glomerulopathy and huan immunodeficiency virus–associated nehropathy. Long-term IV drug users who resort o the practice of “skin popping” are predisposed o develop secondary amyloidosis-related kidney isease. We report an unusual presentation of enal disease in a white “skin popper” with hronic HCV infection.

In California, black tar heroin (BTH) use among injection drug users (IDUs) has resulted in an increased number of cases of wound botulism due to Clostridium botulinum, tetanus due to Clostridium tetani, and necrotizing soft-tissue infections due to a variety of clostridia. From December 1999 to April 2000, nine IDUs in Ventura County, California, developed necrotizing fasciitis; 4 died. Cultures of wound specimens from 6 case patients yielded Clostridium sordellii. Some of the patients appeared to have the toxic shock syndrome previously reported to be characteristic of toxin-mediated C. sordellii infection, which is characterized by hypotension, marked leukocytosis, and hemoconcentration. The suspected source of this outbreak was contaminated BTH that was injected subcutaneously or intramuscularly ("skin popped"). This outbreak of C. sordellii infection serves as another example of how BTH can potentially serve as a vehicle for transmitting severe and often deadly clostridial infections, and reinforces the need to educate IDUs and clinicians about the risks associated with skin popping of BTH.

The prevalence of and risk factors for abscesses and cellulitis were investigated among a community sample of injection drug users (IDUs). Participants were interviewed, and those with symptoms were examined. Of 169 IDUs, 54 (32%) had abscesses ( ), cellulitis ( n= 35 n= ), or both ( ); 27% had lanced their own abscesses; and 16% had self-treated with 5 n= 14 antibiotics they purchased on the street. IDUs who skin-popped (injected subcutaneously or intramuscularly) were more likely to have an abscess or cellulitis than those who had injected only intravenously (odds ratio, 4.9; 95% confidence interval, 2.2‐11). The likelihood of abscesses and cellulitis increased with frequency of skin-popping and decreased with increasing duration of injection drug use. Abscesses are extremely prevalent among IDUs in San Francisco. Skin-popping is a major risk factor, and self-treatment is common. Abscesses and cellulitis are a common problem among injection drug users (IDUs). Few previous studies have examined the prevalence of and risk factors for abscesses among IDUs. In this cross-sectional survey of street-recruited IDUs, we estimated the prevalence of abscesses and cellulitis among IDUs by examining all participants who reported symptoms of local infection. We also examined the risk factors for these infections and estimated the prevalence of related behaviors.

Context.—Wound botulism (WB) is a potentially lethal, descending, flaccid, paralysis that results when spores of Clostridium botulinum germinate in a wound and elaborate neurotoxin. Since 1988, California has experienced a dramatic increase in WB associated with injecting "black tar" heroin (BTH), a dark, tarry form of the drug.Objective.—To identify risk factors for WB among injecting drug users (IDUs).Design.—Case-control study based on data from in-person and telephone interviews.Participants.—Case patients (n=26) were IDUs who developed WB from January 1994 through February 1996. Controls (n=110) were IDUs newly enrolled in methadone detoxification programs in 4 counties.Main Outcome Measures.—Factors associated with the development of WB.Results.—Among the 26 patients, the median age was 41.5 years, 15 (58%) were women, 14 (54%) were non-Hispanic white, 11 (42%) were Hispanic, and none were positive for the human immunodeficiency virus. Nearly all participants (96% of patients and 97% of controls) injected BTH, and the mean cumulative dose of BTH used per month was similar for patients and controls (27 g and 31 g, respectively; P=.6). Patients were more likely than controls to inject drugs subcutaneously or intramuscularly (92% vs 44%, P

The complications of drug abuse encompass a spectrum of glomerular, interstitial, and vascular diseases. They comprise the heroin-associated nephropathy seen in African-American intravenous drug addicts, which, however, has given way in the 1990s to HIV-associated nephropathy. Infections with methicillin-resistant Staphylococcus aureus may cause acute glomerulonephritis by releasing bacterial superantigens. Hepatitis C has supplanted hepatitis B and may give rise to membranoproliferative glomerulonephritis and cryoglobulinemia. Addicts who inject drugs subcutaneously ('skin popping') may develop amyloidosis. Cocaine causes rhabdomyolysis, severe hypertension, occasionally renal failure in the absence of rhabdomyolysis, and may hasten progression to uremia in patients with underlying renal insufficiency. 'Ecstasy', an amphetamine-like recreational drug, has caused acute renal failure, electrolyte disturbances, and malignant hypertension. In Belgium and some other European countries, women taking Chinese herbs in a slimming regimen have developed a severe and irreversible interstitial fibrosis that is assuming epidemic proportions.