A 27-year-old male with a history of substance abuse was found unresponsive by EMS for an unknown amount of time and given Naloxone. He became responsive and started complaining of burning pain over his left hip and forearm. In the ED tissue necrosis was evaluated over a large part of greater trochanter as well as forearm. EKG showed prolonged PR interval and peaked T waves with a 6.9 mEq/ L serum potassium level.

Massive cell injury due to chronic use of injecting opioids such as heroin in the hip and forearm can lead to massive infection, sepsis, shock and organ failure. Chronic and persistent tissue puncture with a dirty needle or sharing needles can cause cells to try to adapt in the beginning through atrophy, hypertrophy, hyperplasia and metaplasia. The tissue cells become thicker as it heals itself from daily puncture wounds. Bacteria or an antigen may also enter multiple tissue puncture sites and the blood stream causing infection. This then causes the body to produce an immune response by having the cell ingest the antigen destroying it and attaching epitope pieces onto its MHCII. Macrophage then presents to T-cells which are either destroyed by Cytotoxic T-cells destroying cell with MHCI or activates B-cells which divide into plasma cells making 5 classes of antibodies.

According to McCance and Huether (2019), Chronic swelling and pressure leading to ischemia and hypoxia in damaged tissue and vascular walls can lead to a decrease in cellular mitochondrial phosphorylation resulting in insufficient adenosine triphosphate (ATP) production. Reduced ATP causes the sodium-potassium pump and sodium-calcium channels to fail shifting potassium out of the cell from intracellular to extracellular and increasing intracellular sodium and calcium. All the calcium ions rush into the cells. This cascades into organelles detaching within the cell reducing protein synthesis. Continued hypoxia due to cellulitis, swelling and pressure to the cells causes permanent damage to the mitochondria as well as activating enzyme systems which degrade all organelles eventually leading to death. The damaged organelles and the intracellular calcium destroy the cell causing cell death. Serum potassium increases due to cell death. Normal serum potassium levels are 3.5 and 5.0 mEq/L. Anything above 5.0 mEq/L is considered hyperkalemia. Hyperkalemia will lead to prolonged PR interval and peaked T-wave present in this patient’s diagnostic labs affecting the heart and if left untreated can affect the heart and lead to death.

Recurrence and addictive risk are higher if family members were also addicted to same or similar products. A study by Kendler et al. (2019), states family members have a higher rate of alcohol or illicit substance abuse if their father was an alcoholic. The determinant of the substance abuse may be a gene, family environment and/or both together. In another study by Calco et al. (2017), most of the opioid users were white male, educated, unstable house or homeless, have a history of incarceration and having visited a residential treatment plan. Half of the users don’t have extra sterile needles so they reuse the same needle or share needles.

Reference

Calco, M., MacFarlane, J., Zaccaro, H., Curtis, M., Caban, M., Favaro, J.,

Passannante, M. R., & Frost, T. (2017). Young people who use drugs engaged in harm reduction programs in New York City: Overdose and other risks. Drug and Alcohol Dependence, 178, 106-114. Doi:10.1016/j.drugalcdep.2017.04.032

Kendler, K. S., Ohlsson, H., Sundquist, J. & Sundquist, K. (2019). Maternal

half-sibling families with discordant fathers: a contrastive design assessing cross-generational paternal genetic transmission of alcohol use disorder, drug abuse and major depression. Psychological Medicine, 50, 973–980. doi:10.1017/S0033291719000874

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic

basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.