Penile necrosis after cocaine injection into the dorsal vein

A 35-year-old man presented to the emergency room with extreme pain in his penis and scrotum. He explained that his symptoms began after injecting cocaine into the dorsal vein of his penis 3 days prior and the pain escalated. He told clinicians that immediately after the cocaine injection he felt severe pain radiating to the inguinal region and right foot. At the same time, he described seeing swelling and whitening on the underside of his penis, along with signs of necrosis and ulceration on the lateral side.

Physical examination indicated that the patient had stable vital signs (temperature 37°C, heart rate 86 bpm, and blood pressure 117/63 mm Hg). His mental state was normal and he was fully aware of his surroundings. He admitted to injecting drugs in the past, adding that in the past 2 weeks he had injected cocaine into his dorsal vein with no ill effects.

Pulmonary auscultation identified bilateral vesicular breathing. On cardiac examination, clinicians noted normal S1 and S2 heart sounds. Abdominal examination showed no signs of enlarged liver or spleen. The results of the neurological examination were unremarkable. Upon examination of his genitals, clinicians noted ulcers and swelling over the proximal ventral junction of the penis and scrotum with a foul-smelling discharge of serous fluid. There was no crackling.

The patient had swollen lymph nodes on both sides of the groin which were painful on palpation and stellate purpura with necrosis of the dorsum of the penis. Lab tests revealed a white blood cell count of 11.9 g/dL, an erythrocyte sedimentation rate of 43.0 mm/h and a C-reactive protein level of 52.71 mg/L. The patient had normal liver function and electrolytes. His urine drug screen was positive for cannabis, cocaine and methadone.

Contrast computed tomography (CT) of the pelvis revealed subcutaneous swelling of the penis, with ulceration on the right side of the tip of the penis. CT scan findings also included left inguinal lymphadenopathy, with nodes measuring up to 1.7 cm, which was likely reactive.

Clinicians determined that the symptoms were not due to Fournier’s gangrene and started IV treatment including:

  • Piperacillin/tazobactam (Zosyn, 3.375 g every 6 hours)
  • Vancomycin (Vancocin, 1.5 g every 12 hours)
  • Clindamycin (Cleocin, 300 mg every 8 hours)
  • Topical bacitracin/polymyxin (one application every 6 hours)

The patient refused to undergo surgical debridement. With antibiotic therapy and local wound care, her symptoms gradually improved. A blood culture showed no signs of growth, and clinicians determined he had no vasculitis or coexisting sexually transmitted disease.

After 5 days of treatment, the patient was switched from IV antibiotics to oral trimethoprim/sulfamethoxazole and amoxicillin/clavulanic acid to complete a total of 10 days of treatment. He improved clinically but was unwilling to attempt a drug rehabilitation program. He was then lost sight of.

Discussion

Clinicians presenting with this Case warned that given the highly addictive nature of cocaine, it is essential to obtain a full history of intravenous drug users – especially long-term users – who may be injecting sites other than the arms when their usual site becomes unavailable, as in the case of this patient.

Described case authors The factors that increase this likelihood, including: onset of drug use at a later age (OR 1.039, 95% CI 1.009-1.069), more time spent as an injecting drug user (OR 1.071, 95% CI 95% 1.041-1.102) and higher injection frequency (OR 1.255, 95% CI 1.072-1.471).

Because cocaine blocks the presynaptic reuptake of noradrenaline and dopamine, it stimulates central and peripheral adrenergic mechanisms, thereby increasing noradrenaline levels, which in turn causes vasoconstriction of the cardiac and peripheral vasculature, the authors noted. authors. In addition, the drug causes significant vasoconstriction by directly stimulating the alpha-adrenergic receptors.

The case authors noted that the risks of injecting cocaine include vasculitis, which can lead to gangrene. Effects specific to injection in the groin area include Fournier’s gangrene, superficial penile necrosis, and scrotal gangrene. Genital skin can be affected by cocaine use, they noted, “regardless of the route of cocaine administration or the type of vascular complication that occurs.”

These risks may be increased with the use of cocaine adulterated with the anthelmintic levamisole, which increases cocaine’s cost-effectiveness and mind-altering effects, and is found in about 80% of cocaine seized in the United States, according to the US Drug Enforcement Agency. .

Due to its inhibitory effect on monoamine oxidase and catechol-O methyltransferase activity, levamisole increases the level of the neurotransmitter catecholamine in nerve synapses, thereby potentiating the effects of cocaine, the case authors said. The drug has also been implicated in the development of necrotizing vasculitis. “Levamisole-induced vasculitis presents as reticular purpuric lesions that become necrotic, compared to palpable purpura or Wegener’s granulomatosis-like lesions in pure cocaine-induced vasculitis,” the authors explained.

Levamisole has an immunostimulating effect which results in the production of autoantibodies (antinuclear and antineutrophil antibodies), which are usually positive in patients with levamisole-induced vasculitis. The level of levamisole in blood or urine can be determined with tests administered within 48 hours of last use, the authors explained, due to its short half-life of 5.6 hours.

The research also linked the use of levamisole and anti-cardiolipin antibodies to decreased levels of serum complement component 3, the case authors noted, adding that their patient tested negative for anti-cardiolipin cytoplasmic antibodies. perinuclear neutrophils (P-ANCA), cytoplasmic anti-neutrophil cytoplasmic antibodies (C-ANCA), and anti-cardiolipin antibodies. They explained that it was not possible to determine if this patient’s vasculitis was due to exposure to levamisole, since he presented more than 48 hours after his last cocaine use.

IV drug users should be advised to seek help and should be encouraged to enroll in drug treatment programs, they advised, as quitting cocaine is the only definitive treatment.

As the second most widely used illegal drug in the United States, cocaine use among adults ages 25 to 64 has increased nearly 30% annually since 2013, according to a CDC report. Cocaine caused 14,666 drug overdose deaths in 2018 alone, which is about one in five drug overdoses death at national scale.

“Intravenous (IV) drug use leads to severe vein damage, including erythema, thrombophlebitis, vasoconstriction, necrosis, development of venous ulceration, and venous occlusion,” the authors wrote. case.

The group cited a study by chronic venous disorders in more than 700 people who inject illicit drugs which revealed that those who inject in the legs (with or without injecting in the arms) were nine times more likely to develop venous ulcers than those who inject only in the arms and upper body, and 35 times more likely than those who never injected.

They concluded by inviting physicians “to counsel active intravenous drug addicts on possible complications to inject drugs in atypical and dangerous injection sites.

  • Kate Kneisel is a freelance medical journalist based in Belleville, Ontario.

Disclosures

The authors of the case report noted no conflict of interest.

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