Commentary on “A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug user”

Abstract

To the Editor: In a recent article in JAAD Case Reports, Haskin and colleagues1Haskin A. Kim N. Aguh C. A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug user.JAAD Case Rep. 2016; 2: 174-176Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar implicate krokodil as the cause of skin lesions in a young woman with ongoing intravenous drug abuse. The only evidence supporting krokodil as the cause is the history from the patient. With no analytical confirmation, either from bodily fluids from the patient or from the injected substance, it is difficult to accept that krokodil (illegally synthesized desomorphine) caused the lesions in question. There are no substantiated cases of krokodil use in North America, despite a flurry of lay media reports in 2013 and one similarly unsubstantiated case report here in Saint Louis.2Thekkemuriyi D.V. John S.G. Pillai U. ‘Krokodil’–a designer drug from across the Atlantic, with serious consequences.Am J Med. 2014; 127: e1-e2Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The US Drug Enforcement Agency's 2014 Drug Threat Assessment Report stated that “there are no confirmed cases of krokodil abuse in the United States.”3US Drug Enforcement Administration. 2014 Drug Threat Assessment Report. Available from: URL: www.dea.gov/resource-center/dir-ndta-unclass.pdf. Accessed June 1, 2016Google Scholar The 2015 report, released on November 4, 2015, had no further mention of krokodil.4US Drug Enforcement Administration. 2014 Drug Threat Assessment Report. Available from: URL: www.dea.gov/docs/2015%20NDTA%20Report.pdf. Accessed June 1, 2016Google Scholar Levamisole, a common adulterant in cocaine, can produce skin lesions similar to those described by Haskin and colleagues.5Jeong H.S. Layher H. Cao L. Vandergriff T. Dominguez A.R. Pyoderma gangrenosum (PG) associated with levamisole-adulterated cocaine: Clinical, serologic, and histopathologic findings in a cohort of patients.J Am Acad Derm. 2016; 74: 892-898Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 6Han S. Hsu A. Bui R. Ellison R.T. A Fatal Case of Levamisole-Induced Vasculitis.Skin Dis Skin Care. 2016; 1: 1Google Scholar, 7Lee K.C. Ladizinski B. Nutan F.N.U. Systemic complications of levamisole toxicity.J Am Acad Derm. 2012; 67: 791-792Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The US Drug Enforcement Agency has found levamisole in some samples of seized heroin.8Casale E.M. Casale J.F. Identification of levamisole and lidocaine acetylation reaction impurities found in heroin exhibits.Microgram J. 2011; 8: 16-23Google Scholar Likewise, soft-tissue infections and contaminants in injected heroin can cause similar findings. With no objective proof of krokodil use and with other possible explanations, we conclude that it is unlikely that krokodil caused this patient's skin lesions. We assert that krokodil use in the United States remains unproven and unlikely.9Mullins M.E. Schwarz E.S. “Krokodil” use in the US is an urban legend, not medical fact.Am J Med. 2014; 127: e25Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 10Bowen K.P. Barusch N.M. Lara D.L. Trinidad B.J. Caplan J.P. McKnight C.A. Don't feed the “krokodil”: Desomorphine fear outpaces reality.Psychosomatics. 2015; 56: 312-313Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug userJAAD Case ReportsVol. 2Issue 2PreviewKrokodil is a commonly used street name for desomorphine, an injectable opioid derivative that is associated with severe dermatologic effects. We report a case of a woman who had extensive ulcerations after a single use of this narcotic. To our knowledge, this is the first case report of the cutaneous manifestations of krokodil use in the dermatologic literature. Full-Text PDF Open AccessReply to: “Commentary on ‘A new drug with a nasty bite: A case of krokodil-induced skin necrosis in an intravenous drug user’”JAAD Case ReportsVol. 2Issue 5PreviewTo the Editor: I thank the authors for their reply to our article. Levamisole, an adulterant most commonly found in cocaine, can be associated with skin vasculitis resulting in ulcerating lesions.1,2 The most common cutaneous findings are characteristic purpuric lesions, including retiform purpura or palpable purpura, which often occur in conjunction with leukocytoclastic vasculitis. These lesions favor acral surfaces such as the helical rim or fingertips and are often antineutrophil cytoplasmic antibody positive. Full-Text PDF Open Access