Heroin addict with gangrene of the extremities, rhabdomyolysis and severe hyperkalemia

Abstract

Introduction. Long-time consumption of narcotics leads to altered mental status of the addict. It is also connected to damages of different organic systems and it often leads to appearance of multiple organ failure. Excessive narcotics consumption or abuse in a long time period can lead to various consequences, such as atraumatic rhabdomyolysis, acute renal failure and electrolytic disorders. Rhabdomyolysis is characterized by injury of skeletal muscle with subsequent release of intracellular contents, such as myoglobin, potassium and creatine phosphokinase. In heroin addicts, rhabdomyolysis is a consequence of the development of a compartment syndrome due to immobilization of patients in the state of unconsciousness and prolonged compression of extremities, direct heroin toxicity or extremities ischemia caused by intraluminal occlusion of blood vessels after intraarterial injection of heroin. Severe hyperkalemia and the development of acute renal failure require urgent therapeutic measures, which imply the application of either conventional treatment or a form of dialysis. Case report. We presented a male patient, aged 50, hospitalized in the Emergency Center Kragujevac due to altered mental status (Glasgow Coma Score 11), partial respiratory insufficiency (pO2 7.5 kPa, pCO2 4.3 kPa, SpO2 89 %), weakness of lower extremities and atypical electrocardiographic changes. Laboratory analyses, carried out immediately after the patient?s admission to the Emergency Center, registered the following disturbances: high hyperkalemia level (K+ 9.9 mmol/L), increased levels of urea (30.1 mmol/L), creatinine (400 ?mol/L), creatine phosphokinase - CK (120350 IU/L), CK-MB (2500 IU/L) and myoglobin (57000 ?g/L), with normal levels of troponin I (< 0.01 ?g/L), as well as signs of anemia (Hgb 92 g/L, Er 3.61 x 1012/L), infection (C-reactive proteine 184 ?g/mL, Le 16.1 x 109/L) and acidosis (base excess - 18.4 mmol/L, pH 7.26. Initial examination of the patient revealed swelling and paleness of the right lower leg, signs of gangrene of the right foot and the 1st and the 4th toes of the left foot. The patient had normal values of arterial pressure (130/80 mmHg) and heart rate (64/min-1); roentgenographic lungs examination and computerized tomography (CT) brain examination did not reveal pathological changes in lung and brain parenchyma; toxicological analyses confirmed the presence of heroin in patient?s organism. The patient was treated by intensive conventional treatment (infusion of crystalloid solutions, 8.4% solution of sodium bicarbonate, iv infusion of diuretics, calcium gluconate and short-acting insulin), and also by antibiotics and anticoagulants. Normalization of kalemia and fast regression of electrocardiographic changes were registered. The patient refused the suggested surgical treatment (fasciotomy, foot amputation). After stabilization of kidney function and improvement of his mental state, the patient agreed to undergo surgical procedure. Therefore, on the day 30 of hospitalization the above-knee amputation of the right leg was performed, and on the day 38 the transmetatarsal amputation of the left foot was carried out. After 46 days of hospital treatment, the patient was released and sent to home treatment. Conclusion. The routine laboratory diagnostics, which implies determining of the levels of potassium, urea, creatinine and CK in the serum of all hospitalized heroin addicts can contribute to timely detection of hyperkalemia and acute kidney weakness and undertaking of appropriate therapeutic measures.Uvod. Upotreba narkotika u duzem vremenskom periodu dovodi do promena psihickog stanja zavisnika. Ona je, tako dje, povezana sa ostecenjem razlicitih organskih sistema i cesto dovodi do pojave multiorganske insuficijencije. Ekscesivna upotreba narkotika ili njihova zloupotreba u duzem vremenskom periodu moze dovesti do razlicitih posledica, kao sto su atraumatska rabdomioliza, akutna bubrezna slabost i elektrolitski poremecaji. Rabdomioliza se karakterise ostecenjem skeletne muskulature i posledicnim oslobadjanjem intracelularnog sadrzaja, kao sto su mioglobin, kalijum i kreatin fosfokinaza. Kod heroinskih zavisnika rabdomioliza je posledica razvoja kompartment sindroma zbog nepokretnosti bolesnika u besvesnom stanju i produzene kompresije ekstremiteta, direktne toksicnosti heroina ili ishemije ekstremiteta izazvane intraluminalnom okluzijom krvnih sudova nakon intraarterijske primene heroina. Teska hiperkalemija i razvoj akutne bubrezne slabosti zahtevaju neodloznu primenu terapijskih mera, koje podrazumevaju primenu konvencionalnog ili nekog od oblika dijaliznog lecenja. Prikaz slucaja. Prikazali smo muskarca, starog 50 godina, hospitalizovanog u Urgentnom centru Kragujevac zbog izmenjenog stanja svesti (Glasgow Coma Score 11), parcijalne respiratorne insuficijencije (pO2 7,5 kPa, pCO2 4,3 kPa, SpO2 89%), slabosti donjih ekstremiteta i atipicnih elektrokardiografskih promena. Laboratorijskim analizama ucinjenim neposredno po prijemu bolesnika u Urgentni centar registrovani su sledeci poremecaji: hiperkalemija teskog stepena (K+ 9,9 mmol/L), povisene vrednosti uree (30,1 mmol/L), kreatinina (400 ?mol/L), kreatin fosfokinaze - CK (120350 IU/L), CK-MB (2500 IU/L) i mioglobina (57000?g/L), uz normalne vrednosti troponina I (< 0,01 ?g/L), kao i znaci anemije (Hgb 92 g/L, Er 3,61 x 1012/L), infekcije (C-reaktivni protein - CRP 184 ?g/mL, Le 16,1 x 109/L), acidoze (bazni eksces - 18.4 mmol/L, pH 7,26). Inicijalnim pregledom bolesnika uoceni su otok i bledilo desne potkolenice, znaci gangrene desnog stopala i 1. i 4. prsta levog stopala. Bolesnik je imao normalne vrednosti arterijskog pritiska (130/80 mmHg) i srcane frekvence (64/min-1), rendgengrafskim pregledom pluca i kompjuterizovanom tomografijom mozga nisu uocene patoloske promene u plucnom i mozdanom parenhimu, a toksikoloskim analizama potvrdjeno je prisustvo heroina u organizmu bolesnika. Bolesnik je lecen intenzivnom primenom konvencionalnog lecenja (infuziona primena kristaloidnih rastvora, 8,4% rastvora natrijum bikarbonata, iv primena diuretika, kalcijum glukonata i insulina kratkog dejstva), kao i primenom antibiotika i antikoagulantnih lekova. Registrovano je normalizovanje kaliemije i brza regresija elektrokardiografskih promena. Bolesnik je odbijao predlozeno hirursko lecenje (fasciotomija, amputacija stopala). Nakon stabilizovanja bubrezne funkcije i poboljsanja psihickog statusa prihvatio je hirurski zahvat, tako da je 30. dana hospitalizacije ucinjena natkolena amputacija desne noge, a 38. dana transmetatarzalna amputacija levog stopala. Nakon 46 dana hospitalnog lecenja, lecenje bolesnika je nastavljeno u kucnim uslovima. Zakljucak. Rutinska laboratorijska dijagnostika koja podrazumeva odredjivanje vrednosti kalijuma, uree, kreatinina i CK u serumu kod svih hospitalizovanih heroinskih zavisnika moze doprineti pravovremenom otkrivanju hiperkalemije i akutne bubrezne slabosti i preduzimanju odgovarajucih terapijskih mera.