Recent Intravenous Drug Research Articles

Photo Quiz: a Woman with a Pruritic Rash and Unilateral Vision Loss.

A 39-year-old female with a history of hypertension and allergic rhinitis presented with a 4-week history of a diffuse pruritic skin eruption and a 2-week history of progressive vision loss in the right eye. Physical exam was notable for a diffuse eruption of pink, scaly coalescent plaques with a thin rim of white scale on the face, trunk, and extremities (Fig. 1, left). There was no involvement of the mucous membranes. One to 2 weeks following the skin eruption, she experienced blurry vision progressing to complete vision loss without associated trauma. On fundoscopic exam, blood was noted in the anterior chamber of her right eye (hyphema). There was concern for uveitis on exam without other focal neurologic deficits. The patient denied recent travel or prior adverse effects of medications. She smoked cigarettes and marijuana occasionally without recent intravenous drug use.

Donor-Derived Infections With Central Nervous System Pathogens After Solid Organ Transplantation

During the past decade, numerous instances have been reportedofdonor-derived infectionamongrecipientsof solidorgan transplants with pathogens associated with central nervous system (CNS) infections.1-7 Many cases have received significant attention both among the transplant community and the laymedia.Notablepathogenshave includedWestNile virus (WNV), Balamuthia mandrillaris, lymphocytic choriomeningitis virus, and rabies virus. In most cases, donorderived infection was suspected only after symptoms developed in recipients and further testing of archived specimens identified a donor source. In some cases, lack of recipient exposure to the pathogenprompted investigation for donor origin of the infection. Recipient outcomes were often poor; in part because even after identification of infection, effective treatment was not available. In this issueof JAMA, Vora andcolleagues8describe a case of donor-derived rabies in a recipient of a kidney transplant. The investigationwas prompted by the death from rabies of a recipient 18 months after transplant in the absence of exposures.Adetailed inquiry ledbyCenters forDiseaseControl and Prevention investigators confirmeddonor origin of the recipient’s infectionwith a raccoon rabies virus. The report contains a number of unexpected clinical features. Despite the immunosuppressed state of all 4 organ recipients, the affected patient remained asymptomatic for 18months after transplantation, and the 3 other patients did not develop rabies. The authors speculate that either a low dose of rabies virus or differential behavioral of the raccoon rabies variant explains these clinical features. Although the epidemiology and pathogenesis considerations are interesting, the most notable aspect of this report surrounds the implications for improving the safety of solid organ transplantation. Combined with previous cases,1-7 this report highlights a pattern of donor-derived infection caused by unidentified (at the time of procurement) donor infection with pathogens associated with CNS infection. Reducing the riskofdonor-derived infection requiresunderstanding thecurrent system of screening potential donors. Policy governing solid organ transplantation is established by the Organ Procurement and Transplantation Network (OPTN). Assessment of deceased donors for the risk of transmissible disease relies on amultipronged approach. The organ procurement organization (OPO)managing the process obtains amedical and social history from individuals familiar with the donor. Information that might reasonably be expected to affect potential recipients (eg, a history of recent intravenous drug usewould increase risk of acute viral hepatitis or human immunodeficiencyvirus [HIV] infection thatmightnotbedetectedon routine serologic donor screening tests) must be communicated to transplant programs.9 Limitations include the availability of friends and family and their familiaritywith thedonor’s exposures and behaviors. In addition, specific laboratory testingmust beperformedonall deceaseddonors. Required tests include serological testing forHIV, hepatitis C virus, hepatitis B virus, syphilis, cytomegalovirus, and Epstein-Barr virus as well as blood and urine cultures. At the time of a potential recipient being offered an organ for transplantation, the accepting transplant center must, in a time-pressured environment, integrate all this information, including the medical urgency of the potential recipient, andmake a decision regarding whether to accept the organs. Accepting centers necessarily rely on the clinical impression of treating physicians. For situations in which an increased riskof transmissible infection is present, specific informed consent must be obtained from the potential recipient.10 As an added safeguard, OPOs are required to report additional information that becomesavailable after transplant (eg, autopsy results) that might affect recipients. Furthermore, transplant centers must report any recipient events suggestive of donor-derived infection, thereby allowing notification of other centers that received organs from the same donor.For example, if a recipientwithnootherknownexposures is newly diagnosedwith hepatitis C after transplantation, the event should be reported to the OPTN. In the case described by Vora and colleagues,8 suspected donor-derived rabieswas reported to theOPTN, allowing rapidnotificationof the transplant centers caring for other recipients andadministrationof postexposure rabiesprophylaxis.AnOPTNcommittee, theDisease Transmission Advisory Committee (DTAC), reviews all such reports anddecideswhether theevent resulted indonorderived disease. Data are aggregated andused to guide policy development and educational efforts within the transplant community. Under the current system, episodes of unexpected donor-derived infection are rare. During 2008-2011, 113 622 patients received solid organ transplants from 57 488 donors.Donor-deriveddisease (infectionandmalignancy)developed in139 recipients (0.1%) resulting in29deaths (0.03%).11 A relevant comparison to make is that, during the same period, 26 852peoplediedwaiting for anorgan transplantation.12 Despite these safeguards, reports of CNS infection transmissionmandate consideration ofwhatmight be done to furRelated article page 398 Opinion

Direct Extension of a Psoas Muscle Abscess Leading to Spinal Cord Compression

A 52-yr-old man presented with right groin and back pain associated with nausea, vomiting, chills, discolored urine, and difficulty voiding. On admission, the patient had a temperature of 99.5° F and a white blood cell count of 17,900. A computed tomographic urogram showed multiple bilateral small renal calculi with associated hydronephrosis. He subsequently had a right ureteric stone removal with stent placement. The day after surgery, the patient complained of numbness in his legs, generalized weakness, and difficulty ambulating. He continued to complain of significant back pain and difficulty voiding. On neurologic evaluation, he was found to have mild bilateral lower limb weakness. The patient had a history of recent intravenous drug abuse, and an magnetic resonance imaging of the brain and lumbar spine were performed to rule out any central pathology. Magnetic resonance imaging of the lumbar spine with and without contrast revealed an infectious process, including abscesses in the right psoas and right erector spinae musculature with epidural phlegmon extending from L2 through S1. There was severe spinal canal stenosis with compression of the cauda equina at levels L2–S1 (Fig. 1).FIGURE 1: Abscess of 23 mm in right psoas and erector spinae muscle extending from L2 through S1 causing severe spinal canal stenosis.The patient underwent L2–L5 bilateral decompressive laminectomies, bilateral foraminectomies and evacuation of the epidural/paraspinal abscesses. Cultures obtained from the abscess grew methicillin-sensitive Staphylococcus aureus. After 4 wks of antibiotic treatment, the patient’s symptoms improved, and he was able to ambulate 100 ft during his physical therapy session. Psoas abscesses, spinal epidural abscesses, and vertebral osteomyelitis are interrelated infections. Each shares the same risk factors and may result from a local contiguous source or from hematogenous dissemination.1 Ten percent to 30% of spinal epidural abscesses result from direct extension of local infection, and in this case, from a psoas abscess.2 The thoracic and lumbar areas are the most likely sites of involvement.3 Risk factors for psoas abscesses are intravenous drug use, vascular catheters, and immunosuppression.2 The most commonly cultured organism is S. aureus.3 Patients with psoas and epidural abscesses frequently present with fever, back pain, and neurologic deficits.4 Patients may complain of pain in the hip and thigh because the psoas muscle is innervated by L1, L2, and L3 nerve roots. Imaging investigations such as computed tomography and magnetic resonance imaging are helpful in making a definitive diagnosis. Treatment includes surgical drainage and theadministration of an antibiotic regimen directed at the inciting organisms.1

Candidaemia with uncommon Candida species: predisposing factors, outcome, antifungal susceptibility, and implications for management

The risk factors for and clinical features of bloodstream infection with uncommon Candida spp. (species other than C. albicans, C. glabrata, C. parapsilosis, C. tropicals and C. krusei) are incompletely defined. To identify clinical variables associated with these species that might guide management, 57 cases of candidaemia resulting from uncommon Candida spp. were analysed in comparison with 517 episodes of Candida albicans candidaemia (2001-2004). Infection with uncommon Candida spp. (5.3% of candidaemia cases), as compared with C. albicans candidaemia, was significantly more likely to be outpatient-acquired than inpatient-acquired (15 of 57 vs. 65 of 517 episodes, p 0.01). Prior exposure to fluconazole was uncommon (n=1). Candida dubliniensis was the commonest species (n=22, 39%), followed by Candida guilliermondii (n=11, 19%) and Candida lusitaniae (n=7, 12%).C. dubliniensis candidaemia was independently associated with recent intravenous drug use (p 0.01) and chronic liver disease (p 0.03), and infection with species other than C. dubliniensis was independently associated with age<65 years (p 0.02), male sex (p 0.03) and human immunodeficiency virus infection (p 0.05). Presence of sepsis at diagnosis and crude 30-day mortality rates were similar for C. dubliniensis-related, non-C. dubliniensis-related and C. albicans-related candidaemia. Haematological malignancy was the commonest predisposing factor in C. guilliermondii (n=3, 27%) and C. lusitaniae (n=3, 43%) candidaemia. The 30-day mortality rate of C. lusitaniae candidaemia was higher than the overall death rate for all uncommon Candida spp. (42.9% vs. 25%, p not significant). All isolates were susceptible to amphotericin B, voriconazole, posaconazole, and caspofungin; five strains (9%) had fluconazole MIC values of 16-32 mg/L. Candidaemia due to uncommon Candida spp. is emerging among hospital outpatients; certain clinical variables may assist in recognition of this entity.

New Evidence on Intravenous Cocaine Use and the Risk of Infection with Human Immunodeficiency Virus Type 1

To examine whether recent intravenous use of cocaine might be associated with increased risk of human immunodeficiency virus type 1 (HIV) infection, the authors studied 2,597 active intravenous drug users: 2,399 with recent cocaine injection and 198 with recent injection of heroin or other drugs but not cocaine. These subjects were adult residents of Baltimore City and the surrounding Maryland counties, recruited via outreach into the community between February 1988 and March 1989. In contrast to the first report on the cocaine-HIV association, the present study sample was not recruited solely from drug treatment programs. In the present study, estimated HIV seroprevalence was 26.4% for recent cocaine injectors as compared with 10.6% among all other recent intravenous drug users; the relative odds estimate was 3.03. In the untreated segment of the sample, HIV seroprevalence was 26.0% for recent cocaine injectors as compared with 8.9% among others (relative odds (RO) = 3.61). The estimated degree of association did not change appreciably when multiple logistic regression was used to hold constant potentially confounding and/or mediating variables such as receptive anal intercourse, number of sex partners, and use of injection equipment obtained at shooting galleries (RO = 2.64). Augmenting these cross-sectional data, preliminary prospective data showed excess risk of HIV seroconversion among recent cocaine injectors (estimated relative risk = 2.11). While other research has examined the cocaine-HIV association, the present study differs in that it has allowed a test for whether the association was a spurious artifact of studying drug users recruited solely from drug treatment programs, a broad array of alternative determinants of HIV infection have been held constant, and the association has been examined with seroconversion data. The results lend support to the abiding concern about the risk of HIV infection among cocaine users.

Primary Aspergillus osteomyelitis of the sternum

We report 2 cases of primary sternal osteomyelitis caused by Aspergillus; previously reported cases have been complications of sternotomy. Both patients were healthy young men with recent intravenous drug abuse. No other focus or predisposing factors were found. Both were treated with partial sternectomy and chondrectomy; 1 received long-term amphotericin B therapy. Both are doing well 2 1 / 2 years after operation. Drug usage, acquired immunodeficiency syndrome, and medical immunosuppression may lead to other cases.

Epidemiology of Acute Non-A, Non-B Hepatitis in a Large County Hospital Outpatient Population

The epidemiology of acute non-A, non-B (NANB) hepatitis in a large county hospital was determined by reviewing all acute hepatitis serology profiles over a 26-month period. Acute NANB hepatitis was identified in 77 patients from their clinical history, negative serologic findings, and elevated hepatic enzyme levels. The age and sex distributions for hepatitis A, B, and NANB are in agreement with previous epidemiologic studies. However, the frequency of various risk factors for NANB obtained from this epidemiologic investigation vary from those previously reported. Information regarding risk factors was available for 69 of the 77 patients identified. A history of recent intravenous drug abuse (IVDA) was obtained in 45 patients (65.2%). In the 6 months prior to presentation, blood transfusion was documented in five patients (7.2%). Eighteen patients (26.1%) denied having had a previous transfusion or IVDA. In our population a history of transfusion is obtained less frequently from patients with acute NANB hepatitis than previously reported. IVDA is the predominant risk factor for acute NANB hepatitis.

Prevalence and risk factors of HIV infections among drug users and drug-using prostitutes in Amsterdam.

In December 1985 we started a study to determine the prevalence and risk factors of HIV infection among drug users and drug-using prostitutes in Amsterdam. Recruitment took place at methadone posts (not drug-free; i.e. a low-threshold programme on which some drug users continue to use hard drugs, but at a lower level) and the weekly evening sexually transmitted diseases (STD) clinic for drug-addicted prostitutes. Three hundred and ten drug users have so far been tested and interviewed. Eighty-one per cent reported intravenous drug use; 83% of the 166 females and 15% of the 144 men reported prostitution. Female prostitutes practised mainly vaginal and orogenital intercourse and reported frequent use of condoms (89% of vaginal and 64% of orogenital contact). Male prostitutes practised mainly orogenital and manual contact. At entry 88 of the 310 (28%) were HIV-antibody-seropositive; 85 of these 88 were intravenous drug users and three were male homosexuals. HIV-antigen was detected in two seropositive and one seronegative intravenous drug-user. Antibodies to HTLV-I were found in four out of 308. Risk factors independently associated with HIV-antibody seropositivity among intravenous drug users were: frequency of borrowing used needle or syringe, date of first intravenous drug use, recent intravenous drug use, time living in Amsterdam and German nationality. Of medical history data, an attack of herpes zoster in the previous 5 years had the greatest value in the prediction of the presence of HIV antibodies (relative risk 20.90; 95% confidence interval 2.41-167.27).(ABSTRACT TRUNCATED AT 250 WORDS)