History Of Intravenous Drug Abuse Research Articles

What Are We Teaching About Indigent Patients?

AN ADULT woman without health insurance presented to the emergency department of a private, not-for-profit, university hospital. A male acquaintance had assaulted her and had fractured her forearm. After the assault, she impulsively took an overdose of an anticonvulsant, phenytoin. A friend brought her to the emergency department. Because a history of intravenous drug abuse had scarred the patient's peripheral veins, peripheral intravenous access was not possible. An attempt to place a catheter in her subclavian vein led to a pneumothorax and a chest tube. Intravenous access was then obtained through a jugular vein. As the overdose was an emergency, the arm was splinted and she was admitted to the medicine service on which I was the attending physician. Two days later, she was medically stabilized. The overdose was resolved, the chest tube was pulled. A psychiatrist concluded that the overdose was in response to the stress of the assault

Spectrum of right-sided infective endocarditis: an Indian experience

We studied retrospectively 23 consecutive patients seen at our centre with right heart endocarditis. None of the patients had a history of intravenous drug abuse. All patients were found to have underlying congenital heart disease as a predisposing factor, of which ventricular septal defect (26%) and Fallot's tetralogy (26%) were the commonest. Postoperative endocarditis (26%) also constituted an important clinical subset. Fever (100%) and predominant pulmonary symptoms (69.5%) were the important presenting features. Congestive heart failure was present in 15 patients (65.2%) and predicted an adverse in-hospital outcome. Both the pulmonary and the tricuspid valves were affected equally with presence of vegetations at multiple sites in 10 patients (43.4%). Seven patients (30%) also had concomitant left-sided endocarditis. Medical therapy alone was successful in 15 patients (68.1%) with an overall in-hospital mortality of 31.8%. Five of 6 patients with postoperative endocarditis died, signifying an ominous prognosis of this subgroup when treated medically. The clinical spectrum of right-sided endocarditis in our country differs from the West. The frequent presence of underlying congenital heart disease, the rarity of drug abuse as a predisposing factor, equal involvement of the tricuspid and pulmonary valves and a greater incidence of congestive heart failure are some of these differences.

Acrodermatitis Enteropathica in a Patient With the Acquired Immunodeficiency Syndrome

To the Editor.— We describe a patient with the acquired immunodeficiency syndrome (AIDS) in whom acrodermatitis enteropathica and an essential fatty acid deficiency developed. The development of zinc deficiency in this patient was due to AIDS nephropathy with proteinuria and excessive loss of protein-bound zinc. Zinc deficiency leads to impairment of humoral and cell-mediated immunity and may play an important role in the development or worsening of immunodeficiency in AIDS. Report of a Case.— A 32-year-old white woman with a history of intravenous drug abuse and membranoproliferative glomerulonephritis was referred for mucocutaneous candidiasis unresponsive to ketoconazole therapy (200 mg orally every day). She reported progressive thinning of her hair. The results of her physical examination were noteworthy for thick, well-circumscribed, scaly, green-brown, fissured, hyperkeratotic plaques covering the palms and soles (Figure, top left). Similiar plaques were noted around the umbilicus, rectum, and vagina (Figure, top right). Behind each ear were

Cognitive and Motor Development in Infants at Risk for Human Immunodeficiency Virus

To evaluate the natural course of cognitive and motor development among infants infected with human immunodeficiency virus from birth, the Bayley Scales of Infant Development were administered to 96 infants between 5.5 and 24 months of age. Infants were divided into three groups on the basis of subsequent assessment of human immunodeficiency virus serologic status: seronegative (N = 45), seropositive (N = 12), and seroreverter (N = 39). Groups did not differ in race, infant age at initial testing, maternal age, maternal education level, maternal history of intravenous drug abuse, or percentage of children in foster care placement. Significant group differences were found on the Mental Development Index and Psychomotor Development Index, with the seropositive infants scoring significantly lower than the seronegative or seroreverter infants.

Epidemiology of bacterial endocarditis in The Netherlands. I. Patient characteristics.

Studies of the epidemiology of bacterial endocarditis are usually based on a retrospective review of medical records from referral centers serving diverse patient populations. These studies are therefore likely to suffer from selection bias. We conducted a nationwide prospective epidemiologic study of endocarditis in the Netherlands. During a 2-year period, all cases of consecutively hospitalized patients with suspected endocarditis in the Netherlands were reported to us. While hospitalized, patients were visited for an in-person interview and a review of the medical record. Of 559 episodes, 438 met the criteria for endocarditis; these included 89 episodes of prosthetic valve endocarditis and 349 episodes of native valve endocarditis. Adjusted for age- and sex-specific population figures, the incidence was 19 per million person-years. The incidence increased significantly with age, and men were more often affected than women (266 and 172 cases, respectively). Rheumatic and congenital cardiac lesions formed most of the underlying heart diseases. Mitral valve prolapse was present in only 29 patients with native valve endocarditis (8.3%). A history of intravenous drug abuse was present in 32 patients (7.3%). Viridans streptococci, staphylococci, and enterococci together constituted 86% of the isolated bacterial strains. Only 1.1% of the patients had culture-negative endocarditis. Overall case fatality was 19.7% and varied widely according to causative microorganism. The distribution of causal microorganisms, the case fatality rate, and the incidence rate of endocarditis are age related. Therefore, a meaningful comparison of data is only possible between population-based cohorts of patients with endocarditis.

Lymphoma of the maxillary sinus in a patient infected with human immunodeficiency virus type 1

A 27-year-old woman with a history of intravenous drug abuse presented with a stage IE, diffuse, large cell lymphoma of the right maxillary sinus. A test for antibodies to the human immunodeficiency virus was positive. The patient was treated with systemic chemotherapy and local maxillary sinus irradiation which resulted in complete regression of the disease. Therapy was complicated by mucositis, neutropenia, and opportunistic infections. This is the first case report to discuss the presentation and treatment of acquired immunodeficiency syndrome (AIDS)-related lymphoma of the maxillary sinus.

Intracerebral hodgkin's disease in a human immunodeficiency virus-seropositive patient

Intracerebral involvement of Hodgkin's disease (HD) is rarely described, with only 42 cases in the literature. Since the outbreak of the acquired immune deficiency syndrome (AIDS) epidemic, there has been an increasing number of human immunodeficiency virus (HIV)-infected (HIV+) persons who have diffuse non-Hodgkin's lymphoma and, more recently, atypical aggressive HD. The authors report the case of a patient with a history of intravenous drug abuse (IVDA) and Stage IVB HD who, after a drug-induced clinical remission, had intracerebral mixed-cellularity HD. This appears to be the first report of intracerebral HD in a person who is HIV+.

Infective endocarditis of the tricuspid valve in a non-drug user.

A case of infective endocarditis of the tricuspid valve is described in a young female patient with no history of intravenous drug abuse. The patient suffered from symptoms of septic emboli of the lung and right heart failure. She was ultimately treated by tricuspid valve replacement. There was no recurrence of symptoms following surgery.

Serum non-organ specific autoantibodies in human immunodeficiency virus 1 infection.

Serum samples from 66 seropositive subjects (56 with a history of intravenous drug abuse), including asymptomatic carriers and patients with persistent generalised lymphadenopathy (PGL), AIDS related complex (ARC), and AIDS, were tested by indirect immunofluorescence on rat tissue sections and HEp-2 cells for the presence of antibodies to nuclei, smooth muscle, intermediate filaments (anti-IMF) and microfilaments (anti-MF). Counterimmunoelectrophoresis was also used to detect antibodies to extractable nuclear antigens. Smooth muscle antibodies with the V pattern or antinuclear antibodies, mainly of the speckled type, or anti-IMF, occurred in 35 cases, being widely distributed in all groups. Such an autoantibody response resembles the "viral" autoimmunity described in various infectious diseases and in particular that of non-A, non-B post-transfusion hepatitis. Autoantibodies may be of some prognostic relevance, as the prevalence of smooth muscle antibodies V increased as the disease progressed (asymptomatic carriers 20%, those with PGL 29%, those with ARC 47%, and those with AIDS 63%. In the PGL group autoantibody positivity correlated with the presence of skin anergy. The fact that autoantibodies were more frequently detected in patients with circulating immune complexes suggests that these can contain autoantibodies and the corresponding autoantigens.

Epidemiological characteristics of subarachnoid hemorrhage in an urban population

Several risk factors for unfavorable outcome from subarachnoid hemorrhage (SAH) have been identified. The prevalence of such risk factors varies among ethnic groups and among men and women. The influence of ethnic background and gender as factors in the outcome after SAH has not been adequately studied and is the focus of the present investigation. Outcome in 145 consecutive patients was dichotomized as good and moderately disabled vs severely disabled, vegetative, and dead. A multiple logistic regression model was used to examine the factors of gender, ethnic group (white and non-white), age, admission neurological grade, pre-existing hypertension, and intravenous drug abuse. Our data reveal that hypertensive, white males, with a history of intravenous drug abuse, have a high risk of unfavorable outcome following SAH. These observations are important for the design and interpretation of future studies relating to SAH.

Embryonal Carcinoma of the Testis Presenting as a Left Heart Mass

A 31-year-old man with a history of intravenous drug abuse and tooth abscess was admitted for evaluation of possible infective endocarditis. Echocardiography showed that he had a left atrial mass. The mass removed from the left atrium had the same histology as the primary embryonal carcinoma discovered in the right testicle during hospitalization. The patient made a smooth recovery after surgical intervention and chemotherapy. This is believed to be the first reported case of metastasis from embryonal carcinoma of the testis to the left side of the heart that was successfully removed at surgery.

Causes of Death in Hospitalized Intravenous Drug Abusers

The authors reviewed at autopsy the causes of death of 274 patients with evidence of intravenous drug abuse who had been admitted to a large public hospital. There were 127 who died from diseases unrelated to intravenous drug abuse, and in 41% of these, chronic alcoholism was implicated. Deaths from overdose syndromes and drug-related organ pathology comprised only 11% of all cases. The mean age at death was 39 years. There was a male/female ratio of 3.6:1. Half of all patients died from infection--72 from acquired immunodeficiency syndrome (AIDS) alone. These findings indicate that persons hospitalized with a history of intravenous drug abuse usually die from causes other than overdose and that AIDS and chronic alcoholism are significant problems. Emphasis should be placed upon detecting "hidden" intravenous drug deaths to provide more accurate statistical information.

Hepatitis C infection in two urban hemodialysis units

We determined the prevalence of antibodies to the hepatitis C virus (anti-HCV) in 90 patients and 37 staff members of two hemodialysis units utilizing a recently developed anti-HCV recombinant based assay. Eleven patients (12%) were anti-HCV(+). Of these, eight (73%) had antibodies to the hepatitis B core antigen (anti-HBc) indicating prior hepatitis B infection; one patient was hepatitis B surface antigen (HBsAg)(+). All staff members were anti-HCV(-), although seven (19%) of them were anti-HBc(+). Alanine aminotransferase elevations were present at the time of the study in four anti-HCV(-) patients and in only one anti-HCV(+) patient. All anti-HCV(+) (mean 59 +/- 74; range 3 to 269 units) and 85% of anti-HCV(-) patients (mean 16 +/- 27; range 0 to 204 units) had received multiple blood transfusions (P = 0.348). Among 50 patients tested for human immunodeficiency virus (HIV), 43% of anti-HCV(+) as compared to only 7% anti-HCV(-) were positive (P = 0.003). There was a history of intravenous drug abuse (IVDA) in eight (72%) of the anti-HCV(+) patients and in only seven (9%) of the anti-HCV(-) group (P = 0.00001). The results of this serologic survey suggests that anti-HCV positivity is prevalent, although much less than anti-HBc, among our dialysis patients, whereas it was not detected among staff members. The prevalence rate of anti-HCV was statistically significantly higher among anti-HIV(+) and IVDA patients but not in multi-transfused patients.

Intracranial hemorrhage and hemophilia: Case report and management guidelines

Hemophiliacs, as a result of low coagulation factor levels, may suffer spontaneous intracranial hemorrhage. A case of intracranial hemorrhage in a hemophiliac patient with a history of intravenous drug abuse and HIV infection is reported. Factor replacement, airway management, and risks of HIV exposure to emergency department personnel are discussed.

Gangrenous Herpetic Whitlow in a Human Immunodeficiency Virus-Positive Patient

An unusual case of a gangrenous herpetic whitlow is reported. The patient, a 37-year-old man with a ten-year history of intravenous drug abuse, was antibody positive for human immunodeficiency virus. Progressive, extremely painful paronychia of the left third and fourth fingers gradually developed, which persisted despite a variety of treatment protocols, including antibiotics and radiotherapy, ultimately necessitating amputation of the distal portions of the digits. Characteristic herpes-type intranuclear inclusions within epidermal cells were identified in histologic sections of the specimen. Immunohistochemistry using rabbit antihuman herpes virus antibody confirmed the diagnosis. This apparently represents the first documented case of herpetic gangrene in an immunocompromised patient.

Cystic Parenchymal Changes Associated with Spontaneous Pneumothorax in an HIV-Positive Patient

A 31-year-old HIV-positive Hispanic man with a history of intravenous drug abuse was admitted with sudden onset, sharp, bilateral chest pain with shortness of breath. The pain was predominantly in the posterior thorax and was not pleuritic in nature. The patient also reported fevers to 39.0°C for two days prior to admission. In the more distant past, the patient described a cough productive of yellow sputum and a 40.82 kg (90 pound) weight loss over the eight months prior to admission. Physical examination revealed a temperature of 39.3°C, decreased breath sounds at both lung bases, and oral thrush.

Unusual Pathogens in Narcotic-Associated Endocarditis

We report the cases of three adults with a history of intravenous drug abuse who developed endocarditis caused by Corynebacterium xerosis, Neisseria subflava, and Neisseria flavescens, respectively. No cases of endocarditis caused by C. xerosis or N. flavescens and only one case caused by N. subflava have previously been reported in association with narcotic addiction. The prominent clinical features in all patients included poor response to antibiotic therapy, persistent fever, and major embolic events. Stigmata of infection with human immunodeficiency virus, as manifested by oral candidiasis, cervical lymphadenopathy, and serologic evidence, were present in two of the three patients. At our institution, where Staphylococcus aureus remains the most frequent etiologic agent of narcotic-associated endocarditis, the occurrence of these three cases in a 9-month period is striking. We speculate that infection with human immunodeficiency virus may play a role in the pathogenesis of endocarditis caused by these unusual organisms.

Human Immunodeficiency Virus Surveillance at a Sexually Transmitted Diseases Clinic in Copenhagen

During four study periods, each of 3-4 weeks' duration in 1987 and 1988, all patients attending the Copenhagen outpatient Venereal Disease Clinic were encouraged to have a test for human immunodeficiency virus (HIV) antibody. Anonymous testing or testing for research purposes only without any data was also offered. Patients known to be HIV antibody-positive were not re-tested. A total of 1753 patients (1118 men, 635 women) were counselled and testing recommended. Testing was refused by 255 patients, 57 of whom had been tested (all negative) within the previous 3 months. HIV serology was therefore unknown in 11.7% (198 of 1696 persons), including 120 of 922 heterosexual men (13%), 16 of 159 homo/bisexual men (10%) and 62 of 615 women (10%). There was no substantial difference between the four study periods in the numbers refusing the test. Sixteen of the 1498 patients tested were HIV antibody-positive, including one woman and 3 men with a history of intravenous drug abuse and 11 homo/bisexual men; one heterosexual man with HIV antibodies had no known risk behaviour. It is concluded that HIV testing with informed consent at a sexually transmitted disease clinic will not include all persons, and therefore will not exclude a self-selection bias. Surveillance studies using unlinked HIV testing are therefore necessary and it is recommended that they should be performed in Denmark. In this study, unlinked HIV testing of the serum specimens taken for syphilis serology would have decreased the percentage of 'non-attenders' from 12.4% to 0.8% during the final study period.

Intramedullary Spinal Cord Abscess

Abstract Viral myelitis and bacterial epidural infections are common in intravenous drug abusers, but primary infections of the spinal cord are extremely rare. We report a 50-year-old active intravenous drug user who developed tetraplegia from an intramedullary abscess caused by Pseudomonas cepacia. Despite neurosurgical drainage and appropriate antibiotic therapy, no improvement was seen. Earlier intervention and a high index of suspicion is required in patients with a history of intravenous drug abuse and spinal cord symptoms. (Neurosurgery 26:145-146, 1990)

Intramedullary spinal cord abscess

Viral myelitis and bacterial epidural infections are common in intravenous drug abusers, but primary infections of the spinal cord are extremely rare. We report a 50-year-old active intravenous drug user who developed tetraplegia from an intramedullary abscess caused by Pseudomonas cepacia. Despite neurosurgical drainage and appropriate antibiotic therapy, no improvement was seen. Earlier intervention and a high index of suspicion is required in patients with a history of intravenous drug abuse and spinal cord symptoms.