Necrotic arm lesions in an intravenous drug user

Abstract

A 62-year-old woman with a history of long-term intravenous drug use and chronic Hepatitis C virus infection was admitted to another hospital unresponsive with profound hypotension. Her symptoms were attributed to a drug overdose leading to a depressed mental status, and possibly septic shock with aspiration pneumonia. She was placed on mechanical ventilation, and treated with vasopressors, high-dose corticosteroids and several broad-spectrum antibiotics. Blood and urine cultures were negative. When she failed to improve after 1 week she was transferred to the intensive care unit at our institution. On transfer, she was unresponsive, intubated, on mechanical ventilation, and hypotensive on vasopressors. We also noted that she had multiple ulcerated skin lesions on both upper extremities (Fig. 1). The lesions involved the dorsum of both hands and wrists, medial aspects of both arms, and the left antecubital fossa. The edges of the lesions were necrotic and the base was macerated. The WBC count was 22,500 mm with 85% neutrophils and 7% band forms. The creatinine was 3 mg/dL. An acute renal failure was attributed to acute tubular necrosis. HIV testing was negative. The CT scans of the chest, abdomen, pelvis, and MRI of the head were unrevealing, and a lumbar puncture was unremarkable. A skin biopsy of the leading edge of the ulcer was performed.