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

Injected Drug Addiction-Associated Swollen Hands: A Case Report of Methylamphetamine-Related Unilateral Drug Addiction-Related Puffy Hand Syndrome

Puffy hand syndrome occurs in addicts who have injected drugs either intravenously, intradermally, or subcutaneously. It usually presents as bilateral reversible pitting edema of the hands; less frequently, it occurs unilaterally. The forearms and arms may also be affected. The onset of puffy hand syndrome can occur while the patient is still injecting drugs; however, it can initially appear several years after injection of the drug has been discontinued. Infection with hepatitis C is a common comorbidity. A 47-year-old man is described who had a 20-year history of injecting methylamphetamine only into his non-dominant left arm, forearm, and hand and experienced his second episode of unilateral puffy hand syndrome four years after discontinuing injecting the drug and three years after his initial episode; he also had hepatitis C infection. He presented with erythema and pitting edema of his left hand and forearm. Cellulitis was initially suspected, and he was admitted to the hospital for intravenous antibiotics; all cultures were negative for pathogens. The erythema and swelling resolved after five days of therapy. Puffy hand syndrome has been associated with various drugs; it has also been observed to occur in women during pregnancy and occasionally associated with acrocyanosis. The diagnosis is often not originally entertained by the clinician; the condition is often initially treated empirically as an infection. Serologic evaluation is typically negative for rheumatologic diseases, such as systemic lupus erythematosus and scleroderma, and cultures of the skin and blood are usually negative for pathogens. Radiologic assessment (such as roentgenograms, ultrasound to rule out venous thrombosis, computed tomography, magnetic resonance imaging, venogram, and lymphangiogram) may be performed, to exclude other conditions. Skin biopsy of the affected edematous hand occasionally demonstrates granulomatous inflammation and foreign bodies (suggestive of starch or injection additives) in the dermis. The edema for some of the patients with puffy hand syndrome was successfully treated with daily bandaging with compression stockings. The pathogenesis of puffy hand syndrome is considered to be multifactorial: damage to the veins, injury to the lymphatic system, and direct toxicity of the injectable drugs to the vascular structures.

[Puffy hand syndrome: A little-known diagnosis]

INTRODUCTION

Puffy hand syndrome is a rare complication of intravenous drug addiction. Diagnosis is based on the patient's history and clinical examination.

OBSERVATIONS

A woman and two men, aged 42, 39 and 36 years old, are described. All had a history of intravenous drug use of heroin and oral buprenorphine misuse. Puffy hand syndrome appeared during drug addiction (n = 2) or after its withdrawal (n = 1). It was associated with acrocyanosis (n = 1) or injection scars (n = 1). Upper limb ultrasonography showed sequelae of venous (n = 3) or arterial (n = 1) thrombosis. An upper limb lymphoscintigraphy in one patient showed decreased radionuclide uptake of axillary lymph node and subdermal reflux tracer in the forearm. Treatment was based on low-stretch bandages to reduce the volume and then elastic compression sleeve for long-term stabilization.

CONCLUSION

Puffy hand syndrome seen in intravenous drug addicts is poorly understood. It is a chronic complication despite the cessation of drug use. This syndrome has to become more widely known because its management is mandatory, although symptomatic.

[Psychopathology of the misuse of Subutex®: The Popeye syndrome]

INTRODUCTION

High dose buprenorphine (HDB), commonly known as Subutex(®), is nowadays largely prescribed as a replacement therapy for major opiate dependence. Its sublingual administration allows a decrease in the withdrawal syndrome accompanying opiate abuse cessation. Over the past few decades, epidemiological data on people on replacement therapy have emphasized an increase in the misuse of Subutex(®) and more specifically intravenous injections of HDB. These growing practices pave the way to major physical consequences or even death. Several studies have highlighted the infectious, vascular, venous and arterial (pseudo-aneurysm) complications stemming from this habit. Among the possible vascular complications, we can notice the presence of abscess, venous thrombosis, phlegmons, skin necrosis, cellulite, and profound and superficial thrombophlebitis at injection sites. These can evolve into chronic edemas of the tips and subcutaneous nodules. The Popeye syndrome is one of the possible complications of this misuse. This syndrome is characterized by the swelling of both sides of the forearms and hands. These edemas tend to become persistent and to be paired with tissue changes such as skin thickening. Besides, the increase in the hands volume can occur bilaterally or sometimes in an asymmetrical way, accentuated on the hand of the non-dominant limb. This syndrome does not decrease, or just a little, after the stoppage of injections. It can have a psychological, social, psychopathological and esthetic impact.

OBJECTIVES

In this article, we will focus on the clinical case of a 43-year-old man, who is hospitalized in an addictology unit for massive injections of HDB. This patient suffers from a Popeye syndrome as well as from an alcoholic dependence.

METHOD

Following the description of psychopathological disorders, our analysis will originate from a clarification relative to the specificities of the practice of intravenous HDB injection to better sharpen the understanding of these misuses in their psychopathological and clinical aspects. We will discuss some proposals for interventions aiming at taking better care of the people suffering from a drug addiction characterized by the injection of HDB replacement therapy.

RESULTS

Adam requested an admission in an addictology ward for treatment of a self-medication by Subutex started 4 years ago. A certain awkwardness can be perceived when he lays his highly damaged and marked hands on the desk. His upper limbs, thus on display, have tripled in volume: this indicates the presence of a Popeye syndrome, consequence of repeated Subutex injections. These observations lead us to question the function and the sense of this injection behavior in the mental economy, as this repeated behavior engages the body specifically. This bruised body, marked with repeated injection holes has become a place of inscription, of representation that shows the impossibility to access other ways of expression. In this sense, taking action is becoming an act of speech. Within this speech, we can notice the existence of a profound state of uneasiness. To put up with the painful feeling of inner emptiness that is calling for a necessary filling, aiming at re-establishing a frail balance, Adam appeals to repeated injections. However, when the tortured body signifies its incapacity to receive an ultimate injection, thus showing its limits and the destruction it is undergoing, it is no longer possible to resort to Subutex injections. As a consequence, Adam came up with the idea of quitting. The withdrawal was initiated by himself and not coupled with medical care. It has led him to feel a gap, beyond the physical uneasiness. Adam has tried to fill in this unbearable feeling of empty body with tobacco, alcohol and food. The body, highly mobilized, translates the presence of a physical conflict where a massive mental anxiety is expressed in a hidden way. During the interview, Adam also addressed the repetitive familial pattern and the transgeneration effects. He seems to be fully aware of these.

DISCUSSION

Several perspectives can be addressed as part of Adam's treatment and especially cognitive-behavioral therapies as they could prove to be of a certain interest. The aim of this therapy would thus be to assess the motivation for change in order to begin a psychotherapeutic work based on personal adherence to the cessation of this misuse. This could be set up in parallel with an anxiety management work.

CONCLUSION

A better understanding and an extensive knowledge of the possible complications linked to the misuse of HDB seems necessary to sensitize and better inform people who suffer from high-risk behaviors and also to enable a more adapted care.

Puffy hand syndrome revealed by a severe staphylococcal skin infection

Puffy hand syndrome develops after long-term intravenous drug addiction. It is characterized by a nonpitting edema, affecting the dorsal side of fingers and hands with puffy aspect. Frequency and severity of the complications of this syndrome are rarely reported. Local infectious complications such as cellulitis can be severe and can enable the diagnosis. Herein, we report the case of a 41-year-old man who went to the emergency department for abdominal pain, fever, and bullous lesions of legs and arms with edema. Bacteriologic examination of a closed bullous lesion evidenced a methicillin sensitive Staphylococcus aureus. The abdomen computed tomography excluded deep infections and peritoneal effusion. The patient was successfully treated by intravenous oxacillin and clindamycin. He had a previous history of intravenous heroin addiction. We retained the diagnosis of puffy hand syndrome revealed by a severe staphylococcal infection with toxic involvement mimicking a four limbs cellulitis. Puffy hand syndrome, apart from the chronic lymphedema treatment, has no specific medication available. Prophylactic measures against skin infections are essential.