Extremity complications of drug abuse

Syndrome des « grosses mains » des toxicomanes : intérêt des bandages peu élastiques

BACKGROUND

Puffy hand syndrome is a complication of intravenous drug abuse, which has no current available treatment. Arm and forearm edema are voluminous and cause functional and aesthetic disturbances. We report two cases successfully treated by low-stretch bandages.

OBSERVATIONS

A 40-year-old man and a 34-year-old woman, both intravenous drug users, with puffy hand syndrome were hospitalized for 11 days. Treatment included daily multilayer bandaging. Lymphedema volumes calculated by utilizing the formula for a truncated cone decreased by 16% on the left side and 12% on the right side for the first patient and 31 and 17% for the second. Hand circumference decreased 4.3 cm on the left side and 3.2 cm on the right side in case 1, and 2.5 cm and 1.9 cm respectively for case 2. The patients were taught self-bandaging techniques during their hospital stays. Elastic gloves were fitted at the end of treatment. Reduction of lymphedema volume remained stable after 18 months in one patient while for the second patient further treatment and hospitalization were required due to poor compliance.

DISCUSSION

The pathogenesis of this edema is probably multifactorial: venous, lymphatic insufficiency and the direct toxicity of injected drugs. Lymphedema treatment currently consists of low-stretch bandaging and wearing elastic garments, which is effective in decreasing the volume of puffy hand syndrome.

Volumineux œdèmes des mains chez des patients toxicomanes intraveineux au long cours

Narcotic addiction may induce systemic and local complications. Intravenous injections of drugs can cause venous thrombosis, and septic or embolic complications. The puffy hand sign is a more uncommon complication of hard-core injection addicts. Three long-term intravenous drug users, two males, one female, mean age 30.6 years (26-37) presented puffy hands. These patients had been drug addicts for four to twelve years (mean duration 7.3 years) and had stopped heroin injections for 3-5 years (mean 4.6), participating in a buprenorphine substitution program. The edema appeared several years after drug cessation (1.5-5, mean 2.3). Typically the puffiness was bilateral, the hands swollen from the proximal segments of the fingers to the wrist. In one patient, the edema was localized both in the hands and in the feet. The edema was not pitting and unaffected by elevation. Duplex ultrasound examination of the extremities was normal. Lymphangiography performed in one patient was consistent with deep lymphatic destruction. Puffy hand syndrome appears to be the end result of lymphatic obstruction. Repeated injections of drugs in or outside the veins destroy the lymphatics. Buprenorphine may play an important role in the puffy hand sign. Although it is supposed to be administered orally, many drug addicts use it as an i.v. solution. Because buprenorphine is poorly soluble, it causes lymphatic obstruction. This type of hand for which no therapy exists must be differentiated from deep palmar space infection with dorsal edema which requires incision and drainage.

Cutaneous complications of intravenous drug abuse

Injection drug abuse is a world-wide problem responsible for numerous minor to life-threatening and fatal complications. The skin is the tissue most evidently affected by intravenous drug addiction. A wide spectrum of cutaneous complications may occur in intravenous drug users. These include acute or delayed local complications, hypersensitivity reactions, cutaneous manifestations of systemic infections or becoming the site of toxigenic infections. Between 1996 and 2001, in our institution in south-eastern France, we observed cutaneous complications after crushed buprenorphine tablet injections in 13 patients. This paper reviews and classifies adverse effects of parenteral drug abuse on the skin.

Subclavian artery false aneurysm associated with brachial plexus palsy: a complication of parenteral drug addiction

A 35-year-old female drug addict developed a painful left supraclavicular swelling and profound left arm weakness associated with left hand paresthesia and swelling after cocaine injection into the left base of her neck. Arteriogram confirmed a 3.7-cm false aneurysm of the left subclavian artery and a filling defect of the proximal left axillary artery. Emergent intraoperative treatment consisted of false aneurysm resection, embolectomy, and placement of a prosthetic graft. Distal circulation was restored, but the neurological deficit persisted in the left arm and a fever developed in the patient, necessitating rehospitalization 3 weeks after discharge. False aneurysm, a vascular complication of parenteral drug abuse, may lead precipitously to death by exsanguination if not efficiently and effectively diagnosed and treated.

Ischemic injury of the hand from intra-arterial propylhexedrine injection

A number of adverse consequences can result in the upper limb from parenteral drug abuse. Propylhexedrine, a drug similar to amphetamine, is easily obtained and causes severe injury to the limb when injected intra-arterially. This report describes an inadvertent case of intra-arterial propylhexedrine injection into the radial artery, the natural course of which resulted in digital amputations. The cause and diagnosis of this injury is discussed, and a protocol for treatment is presented.

Tissue injuries associated with parenteral propylhexedrine abuse

Propylhexedrine, the active ingredient in Benzedrex Inhalers, is extracted from the wicks of the inhalers by drug abusers for intravenous injection to provide a "desirable high." Six representative cases treated over a one-year period are presented to exemplify the potential for soft tissue injury. Because the actual constituents of the injected material prepared from the inhalers were not established, solutions were prepared from Benzedrex Inhalers according to the formula provided by one of the patients. The extract was then subjected to vigorous qualitative and quantitative analyses; the presence of essentially pure propylhexedrine hydrochloride was confirmed in varying concentrations. To examine the progression of injury following injection of the prepared extract, the ears of 12 New Zealand white rabbits were injected either intra-arterially or subcutaneously. The opposite ear of each rabbit served as a control. Both clinical and pathologic observations demonstrated injury consistent with intense local vasoconstriction. Injury did not appear to relate to impurities in the solution or other embolic phenomena. Finally, the laboratory findings are discussed with regard to the clinical examples. In sum, the insult to tissue from intravascular or local injection with propylhexedrine appears to respond, although poorly, to efforts to reverse the intense pharmacologic vasoconstriction.