Life-threatening Necrotizing Fasciitis Due to ‘Bath Salts’ Injection

Abstract

Necrotizing fasciitis is an orthopedic emergency. The ability to quickly and accurately diagnose this rapidly spreading disease can save a patient's life and limb. However, the diagnosis is complex because necrotizing fasciitis usually manifests as a less severe cellulitis or abscess while the majority of the damages rage beneath the surface of the skin. Although the diagnosis is not new, the potential causes and vectors continually change. This article reports a new source of necrotizing fasciitis in an intramuscular injection of "bath salts," a rapidly emerging street drug that is legal in some states and evades authorities with its innocuous name. The patient presented 2 days after injection of bath salts with extensive cellulitis extending to the mid portion of her upper arm. The cellulitis initially responded to broad-spectrum intravenous antibiotics, but rapidly deteriorated 48 hours later, leading to a forequarter amputation with radical mastectomy and chest wall debridement to obtain healthy tissue margins and control the disease. The patient made a full recovery after further minor debridements, negative pressure dressings, directed antibiotic therapy, and skin grafting. The recent emerging popularity of this highly obtainable, injectable substance may lead to an increase in cases of necrotizing fasciitis. Orthopedic surgeons should be vigilant in diagnosing this process early and should perform an extensive debridement.

Use of synthetic cathinones and cannabimimetics among injection drug users in San Diego, California

“…The high prevalence of injection as a route of administration is perhaps not surprising, given that this was a sample of IDUs who were already experienced in this practice. However, injection of SCs has the potential to cause serious harm (Russo et al, 2012). Qualitative interviews with eleven Irish IDUs who injected mephedrone (an SC) revealed that several suffered burning, skin erosion, soft tissue infections, blood clots, and wounds at the injection site (Van Hout and Bingham, 2012).…”

“…First, use and injection of synthetic drugs may exacerbate injection and non-injection-related consequences. For example, injection of SC has been associated with soft tissue damage such as cellulitis, abscesses, and infection with necrotizing fasciitis (Dorairaj et al, 2012; Russo et al, 2012; Zawilska and Wojcieszak, 2013). The limited available data also suggest that polydrug use (i.e., sequential or simultaneous use of different drugs) is common among users of synthetic drugs (Bruno et al, 2012; Van Hout and Bingham, 2012; Vandrey et al, 2012), and polydrug use is known to be associated with more severe drug dependence, overdose, and HIV/STI risk (Coffin et al, 2003; Lankenau and Clatts, 2005; Leri et al, 2003; Peters et al, 1998).…”

“Legal Highs” – An Emerging Epidemic of Novel Psychoactive Substances

“…In some cases, intoxication with synthetic cathinones resulted in kidney and liver failure (Zawilska & Wojcieszak, 2013). Recently, cases of local injury with necrotizing fasciitis following intravenous or intramuscular cathinones' injection have been reported (Dorairaj, Healy, McMenamin, & Eadie, 2012;Russo et al, 2012). Clinical effects of 2C drugs are dose dependent.…”

Necrotizing soft tissue infections after injection therapy: Higher mortality and worse outcome compared to other entry mechanisms

“…Postoperative wound infections have been reported to have a significantly higher survival in one study 10 while the use of injection drugs could be identified as a predisposing risk factor for NSTIs. 4 However, several small studies and cases reports have been published describing fulminant Necrotizing Soft Tissue Infections after the intramuscular injection of ampicillin 16 or bath salts, 17 the local injection of corticosteroids to treat a trigger finger 18 or after a Bacilli-Calmette-Guerin vaccination of a newborn. 19 The aim of this study was to analyze a specific subgroup of patients with an iatrogenic etiology of Necrotizing Soft Tissue Infections and compare them with other sources of infections in order to identify risk profiles or prognostic factors.…”