Heroin-associated anthrax with minimal morbidity

In 2010, during an outbreak of anthrax affecting people who inject drugs, a heroin user aged 37 years presented with soft tissue infection. He subsequently was found to have anthrax. We describe his management and the difficulty in distinguishing anthrax from non-anthrax lesions. His full recovery, despite an overall mortality of 30% for injectional anthrax, demonstrates that some heroin-related anthrax cases can be managed predominately with oral antibiotics and minimal surgical intervention.

Development of a filter to prevent infections with spore-forming bacteria in injecting drug users

BACKGROUND

In heroin injectors, there have been a number of outbreaks caused by spore-forming bacteria, causing serious infections such as anthrax or botulism. These are, most likely, caused by injecting contaminated heroin, and our aim was to develop a filter that efficiently removes these bacteria and is also likely to be acceptable for use by people who inject drugs (i.e. quick, simple and not spoil the hit).

METHODS

A prototype filter was designed and different filter membranes were tested to assess the volume of liquid retained, filtration time and efficiency of the filter at removing bacterial spores. Binding of active ingredients of heroin to different types of membrane filters was determined using a highly sensitive analytical chemistry technique.

RESULTS

Heroin samples that were tested contained up to 580 bacteria per gramme, with the majority being Bacillus spp., which are spore-forming soil bacteria. To remove these bacteria, a prototype filter was designed to fit insulin-type syringes, which are commonly used by people who inject drugs (PWIDs). Efficient filtration of heroin samples was achieved by combining a prefilter to remove particles and a 0.22 μm filter to remove bacterial spores. The most suitable membrane was polyethersulfone (PES). This membrane had the shortest filtration time while efficiently removing bacterial spores. No or negligible amounts of active ingredients in heroin were retained by the PES membrane.

CONCLUSIONS

This study successfully produced a prototype filter designed to filter bacterial spores from heroin samples. Scaled up production could produce an effective harm reduction tool, especially during outbreaks such as occurred in Europe in 2009/10 and 2012.

Necrotizing fasciitis: manifestations, microbiology and connection with black tar heroin

A 10-year review of records of the King County Medical Examiner's Office found 87 deaths due to necrotizing fasciitis and related necrotizing soft tissue infections. In 64 of these cases there were sufficient details to provide an analysis of the manifestations, microbiology, and source of infection. One half (32) of the cases were due to injection of black tar heroin, the nearly exclusive form of heroin in the Northwest United States. Of those due to black tar injection, 24 were clostridial infections with various species represented, eight of which were Clostridium sordellii. Of the 32 cases not associated with drug injection, streptococcal species predominated, with Streptococcus pyogenes isolated in 14 cases. Only three of 32 cases not associated with injection drug use were clostridial infections. These differences were statistically significant. Staphylococcus aureus was isolated from 14 cases; two were methicillin-resistant strains. Overall, 28 of the 64 cases were polymicrobial infections, 15 due to black tar injection and 13 not associated with drug injection. This study supports the conclusion that necrotizing fasciitis due to black tar heroin injection is predominantly a clostridial disease, and in this way differs significantly from necrotizing fasciitis due to other causes.

Ophthalmoplegia and slurred speech in an intravenous drug user

A 35-year-old heroin user presented with acute, progressive diplopia and slurred speech. Krishna and colleagues discuss the diagnosis and management of this patient.

[Candida albicans meningo-encephalo-myelo-radiculitis at an addict]

Beside immunodepression induced by the human immunodeficiency virus, fungal infections of the central nervous system are extremely rare in heroin-addict patients. We report here a case of meningo-encephalitis with myelo-radicular lesions in a 25-year-old intravenous heroin addict but non-HIV patient, who was admitted for an acute confusion associated with gait disorders. The diagnosis of Candida albicans meningo-encephalo-myelo-radiculitis was established by magnetic resonance imagery and mycological and serological examinations of cerebrospinal fluid. The infection was cured with amphotericin B lipid complex and 5-fluorocytosine. Early diagnosis and antifungal therapy for 6 months resulted in a favorable outcome. The detection of circulating Candida mannan in cerebrospinal fluid with a more sensitive technique combined to MRI were particularly decisive to confirm Candida infection diagnosis, allowing an appropriate antifungal therapy.

Mycotic aneurysm of the superior mesenteric artery in a young woman

Aneurysm of the superior mesenteric artery (SMA) is rare. We, in this study, present the case of a 21-year-old woman with a history of heroin abuse who was admitted to our hospital for infective endocarditis complicated by floating vegetation at the posterior mitral valve. After receiving 2-week antibiotic treatment, the patient had acute abdominal pain. Computed tomography demonstrated an aneurysm at the SMA. The mycotic aneurysm was resected and the mitral valve was repaired successfully. This report reviews the pathophysiology of mycotic aneurysms of the SMA and role of computed tomography in the differential diagnosis of this condition from acute mesenteric ischaemia.

Outbreak of Clostridium histolyticum infections in injecting drug users in England and Scotland

Clostridial infections in injecting drug users in the United Kingdom are a relatively new phenomenon that came to light in 2000 when cases of serious illness and deaths due to Clostridium novyi were recorded. In the period December 2003 to April 2004, the Anaerobe Reference Laboratory received twelve referrals of an extremely rare isolate, Clostridium histolyticum, from cases of infection in injecting drug users submitted from nine different hospitals in England and Scotland. Molecular typing of these isolates by two different methods of pulsed-field gel electrophoresis and PCR ribotyping revealed they are all indistinguishable, indicating a common source of the infections, most probably a batch of heroin that was recently distributed across the UK.

Outbreak of Necrotizing Fasciitis Due to Clostridium sordellii among Black-Tar Heroin Users

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.

Bartonella spp. antibodies in forensic samples from Swedish heroin addicts

A high frequency of Bartonella elizabethae seropositivity (39%) was recorded among intravenous heroin addicts in Stockholm, Sweden, who died from a lethal injection. Some of the B. elizabethae-seropositive individuals also had antibodies to B. henselae Houston-1, B. grahamii, and B. quintana, but none had antibodies to B. henselae Marseille or B. vinsonii subsp. vinsonii. Hepatitis was a frequent finding but no case had peliosis hepatitis. There was no case of endocarditis, but in three persons active subacute-to-chronic myocarditis was found; two of these cases were Bartonella-positive and HIV-negative.

[Serious bacterial and fungal infections in intravenous drug addicts]

Invasive infections caused by bacteria and fungi are common complications of intravenous drug abuse. Various vital organs and structures may be affected, e.g. the cardiac valves, the larger arteries, the bones, the joints and the central nervous system. However, due to the high frequency of low-virulent microbes of skin and oral origin, the clinical picture may be atypical with subacute course and few focal signs and symptoms. The complexity of this problem is illustrated by eight cases of serious bacterial and fungal infections recently diagnosed at our hospitals. All patients were HIV negative intravenous heroin addicts. The clinical spectrum was wide and included skin abscesses, pyomyositis, spondylodiscitis, septic arthritis, costal osteomyelitis, infective endocarditis, recurrent bacteraemia, and multiple brain abscesses.

[Clinical wound botulism in injecting drug addicts]

Wound botulism among drug abusers was first described in the USA in 1982. From 1988 to 1995, 46 laboratory confirmed cases were reported in California. The condition occurred for the first time in Norway in 1997 when three cases of suspected wound botulism among drug users who injected heroin subcutaneously or intramuscularly were reported. Two of these cases are presented here with neurophysiological findings and differential diagnosis.

[Wound botulism in heroin addiction]

Botulism is a rare disease which usually is caused by preformed botulinum toxin in food. However, this article describes a case of wound botulism in a 29-year-old male heroin addict who developed progressive diplopia, dysphagia and proximal weakness of skeletal limb muscles. He needed mechanical ventilation for two weeks. The clinical diagnosis of botulism was supported by neurophysiological tests. Assays for detection of botulinum toxin and Clostridium botulinum were negative. The patient had not eaten any contaminated food the last two weeks before symptoms appeared, but he had multiple contaminated skin wounds. After treatment with botulinum antitoxins and antibiotics he gradually recovered, and six weeks later he was discharged from hospital in good condition. To the best of our knowledge this is the first case of wound botulism reported in Norway.

Epidemiology of Candida albicans isolates from heroin addicts analysed by DNA typing

Candida albicans is a ubiquitous commensal organism of humans. Several studies have examined outbreaks of candidiasis in heroin addicts utilizing a variety of methods to assess the epidemiological relatedness of the isolates and suggested the association of certain subtypes with disease in this patient population. The aim of the present study was to assess a separate group of isolates of C. albicans from heroin addicts in Spain using a DNA typing method. Results showed that, of the 34 isolates from heroin addicts, 20 were in subgroup IA, 10 were in subgroup IB and no isolates were of the subtype IA2. In addition, four isolates were in a recently described subgroup IC. Control isolates from the same geographical region (Spain) showed a distribution similar to the Spanish heroin addict isolates (12 subgroup IA, three subgroup IB, two subgroup IC and no isolates of the subtype IA2). In this study isolates from the same locality appeared similar irrespective of the patient population from which they were isolated. These results indicated that there may be differing geographical diversity of C. albicans than has previously been reported and that the newly described genotypic subgroup (IC) of C. albicans may be more widespread than previously shown.

Analysis of hepatitis C virus isolates among healthy blood donors and drug addicts in Chiang Mai, Thailand

Hepatitis C virus (HCV) isolates obtained from 25 anti-HCV antibody-positive healthy blood donors and 29 drug addicts in Chiang Mai, Thailand, were analyzed. HCV RNA was detected in 23 blood donor samples (92%) and 24 drug addict blood samples (83%) by PCR for a portion of the NS5 region. Subtype analysis revealed that HCV type 3a (HCV-3a) was the prevailing subtype (30%), which was followed in prevalence by HCV-1a (21%), -1b (13%), -3b (13%), and -6a (2%). Six (13%) of the 47 isolates showed low sequence similarities with known types and subtypes. The sequence variants could be grouped into four branches in a molecular evolutionary phylogenetic tree.

Immunologic and viral markers in the circulation of anti-HIV negative heroin addicts

To assess the degree of immune system activation associated with addiction or hepatotropic viruses infection, we examined 60 HIV-negative heroin addicts for the presence of hepatitis B virus (HBV) infection markers, hepatitis C virus antibodies (anti-HCV), various auto-antibodies, and serum levels of soluble interleukin-2 receptors (sIL-2R). In addition, 28 anti-HCV positive patients comprising the disease control group, were also examined. Our results demonstrated a high prevalence of anti-HCV antibodies (61.7% and 90% with 1st and 2nd generation ELISA, respectively). Eighty-seven percent (87%) of the addicts positive for anti-HCV by the latter and 92.8% of the disease control patients, were also positive with 2nd generation recombinant immunoblot assay (RIBA-II). In 88.9% of anti-HCV positive addicts, antibody to C22-3 was the predominant (anti-C33c in 81.5%). Antibodies to C33c and C22-3 polypeptides were also more frequent in disease control group (92.8% and 85.7%, respectively). Anti-HCV antibodies were associated with increased transaminases (ALT or AST, P < 0.05), as well as with longer duration of addiction (P < 0.005). HBV infection markers (HBsAg, anti-HBc only and anti-HBs) were also present in the addicts (5%, 28.3% and 26.7%, respectively). Rheumatoid factors (RF) were detected in 36.7%, antinuclear antibodies (ANA) in 11.7%, antibodies (IgG and/or IgM) against cardiolipin (anti-CL) and double stranded DNA (anti-ds DNA) in 20% and 50%, respectively. RF, ANA, anti-CL and anti-dsDNA antibodies were also detected in the disease control group (32.1%, 89.3%, 28.5% and 28.5% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Methicillin-resistant Staphylococcus aureus bacteremia linked to intravenous drug abusers using a "shooting gallery"

Over a 15-month period, seven intravenous drug abusers had 10 admissions because of bacteremia due to methicillin-resistant Staphylococcus aureus. Seven episodes of probable bacterial endocarditis occurred in four patients; one patient had septic thrombophlebitis and two had soft tissue infections. All seven patients patronized a local "shooting gallery" where paraphernalia were provided and drugs were often administered by a "street doctor." All isolates were phage type 29/77/83A/84/85 and demonstrated resistance only to methicillin, oxacillin, and penicillin. This strain of methicillin-resistant S. aureus has a phage type and antibiogram that is distinct from nosocomial methicillin-resistant S. aureus and was probably acquired by intravenous drug abusers during visits to the "shooting gallery". The "shooting gallery" is an integral part of the drug culture and a likely source for the transmission of antibiotic-resistant organisms.

AIDS-like immunologic alterations in clinically unaffected drug users

Peripheral blood lymphocyte subpopulations (PBLS) and HLA-DR phenotype have been evaluated in 30 IV drug users who were not affected by acquired immune deficiency syndrome (AIDS). A strongly significant reduction in helper/suppressor ratio was found in these subjects as compared to the control population. When the group under study was subdivided according to the presence or absence of signs of lymphadenopathy syndrome (LAS), the apparently unaffected individuals still had significant modifications in PBLS when compared with controls. These modifications were more marked in subjects within the LAS+ subgroup, who also showed a greater DR5 frequency than those belonging to the LAS- subgroup. The authors concluded that AIDS-like laboratory alterations are present in clinically unaffected IV drug users; the possible role of DR5 in conditioning different individual susceptibility is considered.

Infective endocarditis in heroin addicts: epidemiological observations and some unusual cases

The total number of cases of heroin-induced endocarditis occurring over a four-year period were reviewed in order to explain an increase in the number of cases in the last year studied (1975). Brown heroin was noted to be used more frequently by addicts during the period of increased incidence. Cultures of "street samples" of brown and white heroin as well as cocaine were obtained in order to elucidate a possible relationship between the increased use of brown heroin and the increased number of endocarditis cases. Despite frequent contamination of both white and brown heroin, none of the common endocarditis-causing pathogens were isolated from the samples. Staphylococcus aureus, the most common etiological agent, frequently resulted in tricuspid endocarditis. That the accepted criteria for tricuspid endocarditis may be present without actual cardiac valve involvement is demonstrated by a most unusual case of hepatic vasculature infection.