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Leh F, Stalund IV, Bjånes TK, Ohldieck C, Svarstad E, Leh S. Polyvinylpyrrolidone deposition disease in patients with intravenous opioid use: a case series. Hum Pathol 2021; 116:102-111. [PMID: 34329652 DOI: 10.1016/j.humpath.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022]
Abstract
The polymer polyvinylpyrrolidone (PVP) is an excipient widely used in prescription drugs. Depending on the molecular weight (MW), parenterally administered PVP may accumulate in various tissues. Consequently, moderate and high MW PVP have only been used in oral preparations since the late 1970s. Surprisingly, starting in 2009, pathology departments in Norway received biopsies revealing PVP deposition, all from patients with a history of intravenous drug use. We identified 13 patients with PVP deposition and re-evaluated 31 biopsies and two autopsies. Common indications for biopsy were renal insufficiency, anemia, pathological fractures, and abdominal complaints. We observed PVP deposits in all biopsies (kidney, hematopoietic bone marrow, bone, gastrointestinal tract, lymph node, and skin) and all sampled tissue from the autopsies. Overall, the clinical findings could be related to PVP deposits in the biopsies. In the most seriously affected patients, PVP deposition caused severe organ dysfunction and contributed to the fatal outcomes of two patients. All patients except for one were prescribed opioid substitution drugs (OSDs), and most of the patients admitted to having injected such medications. Several OSDs contain PVP. One methadone formulation that was marketed in Norway from 2007 to 2014 contained large amounts of very high MW PVP, making it the most likely source of PVP deposition. Although the presumed source of PVP in these patients has now been withdrawn from the market, pathologists should be aware of PVP deposits when evaluating biopsies from this patient group.
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Affiliation(s)
- Friedemann Leh
- Department of Pathology, Haukeland University Hospital, Jonas Lies Vei 65, Bergen, 5021, Norway.
| | - Ida Viken Stalund
- Department of Pathology, Haukeland University Hospital, Jonas Lies Vei 65, Bergen, 5021, Norway; Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, Bergen, 5021, Norway.
| | - Tormod Karlsen Bjånes
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Jonas Lies Vei 65, Bergen, 5021, Norway.
| | - Christian Ohldieck
- Department of Addiction Medicine, Haukeland University Hospital, Jonas Lies Vei 65, Bergen, 5021, Norway.
| | - Einar Svarstad
- Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, Bergen, 5021, Norway.
| | - Sabine Leh
- Department of Pathology, Haukeland University Hospital, Jonas Lies Vei 65, Bergen, 5021, Norway; Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, Bergen, 5021, Norway.
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Stalund IV, Riise GN, Leh F, Bjånes TK, Riise L, Svarstad E, Leh S. Case Report: Polyvinylpyrrolidone deposition disease from repeated injection of opioid substitution drugs: report of a case with a fatal outcome. F1000Res 2021; 10:300. [PMID: 34316359 PMCID: PMC8276182 DOI: 10.12688/f1000research.51927.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 04/04/2024] Open
Abstract
Background: Intravenous injection of oral opioid substitution drugs (OSD) is widespread among injecting drug users. Several OSDs contain the polymer polyvinylpyrrolidone (PVP) as an excipient. Parenterally administered PVP of high molecular weight may accumulate in tissues and organs. This phenomenon was first described in the 1950s, when PVP was utilised in medication for parenteral use. We report a case of an opioid-addicted patient with extensive PVP-deposition caused by repeated injections of OSDs. Case presentation: A 30-year-old male drug addicted patient in opioid substitution therapy (OST) was repeatedly referred to his local hospital in a poor general condition. Work-up revealed severe normocytic anaemia, renal insufficiency, pancreas insufficiency and pathological fractures. Biopsies from fractured bones, bone marrow and gastric mucosa showed extensive infiltrates of histiocytes with intracytoplasmic vacuoles. Vacuole content stained slightly bluish in hematoxylin and eosin stain, red in Congo red stain and black in periodic acid methenamine silver stain. The morphological appearance and staining properties were in accordance with the diagnosis of PVP deposition. The patient had been injecting both buprenorphine tablets and a specific methadone syrup for several years. The methadone syrup contained large amounts of high molecular weight PVP, making it the most likely cause of the deposition. His health quickly deteriorated and he died, impaired by multi-organ failure and cachexia, five years after the first diagnosis of PVP-deposition. The autopsy revealed extensive PVP-deposition in all sampled organs and tissues. Conclusions: Histological investigation and the correct identification of PVP in the biopsies led to the discovery of a severe adverse effect from long-standing misuse of a drug. The disseminated PVP deposition likely contributed to multi-organ dysfunction and cachexia with a fatal outcome. The deposited PVP likely originated from repeated injections of a certain methadone syrup.
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Affiliation(s)
- Ida Viken Stalund
- Department of Pathology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, 5021 Bergen, Norway
| | - Gro Nygard Riise
- Department of Medicine, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
| | - Friedemann Leh
- Department of Pathology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
| | - Tormod Karlsen Bjånes
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
| | - Lars Riise
- Kvam Municipality, Grovagjelet 16, 5600 Norheimsund, Norway
| | - Einar Svarstad
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, 5021 Bergen, Norway
| | - Sabine Leh
- Department of Pathology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, 5021 Bergen, Norway
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Stalund IV, Riise GN, Leh F, Bjånes TK, Riise L, Svarstad E, Leh S. Case Report: Polyvinylpyrrolidone deposition disease from repeated injection of opioid substitution drugs: report of a case with a fatal outcome. F1000Res 2021; 10:300. [PMID: 34316359 PMCID: PMC8276182 DOI: 10.12688/f1000research.51927.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Intravenous injection of oral opioid substitution drugs (OSD) is widespread among injecting drug users. Several OSDs contain the polymer polyvinylpyrrolidone (PVP) as an excipient. Parenterally administered PVP of high molecular weight may accumulate in tissues and organs. This phenomenon was first described in the 1950s, when PVP was utilised in medication for parenteral use. We report a case of an opioid-addicted patient with extensive PVP-deposition caused by repeated injections of OSDs. Case presentation: A 30-year-old male drug addicted patient in opioid substitution therapy (OST) was repeatedly referred to his local hospital in a poor general condition. Work-up revealed severe normocytic anaemia, renal insufficiency, pancreas insufficiency and pathological fractures. Biopsies from fractured bones, bone marrow and gastric mucosa showed extensive infiltrates of histiocytes with intracytoplasmic vacuoles. Vacuole content stained slightly bluish in hematoxylin and eosin stain, red in Congo red stain and black in periodic acid methenamine silver stain. The morphological appearance and staining properties were in accordance with the diagnosis of PVP deposition. The patient had been injecting both buprenorphine tablets and a specific methadone syrup for several years. The methadone syrup contained large amounts of high molecular weight PVP, making it the most likely cause of the deposition. His health quickly deteriorated and he died, impaired by multi-organ failure and cachexia, five years after the first diagnosis of PVP-deposition. The autopsy revealed extensive PVP-deposition in all sampled organs and tissues. Conclusions: Histological investigation and the correct identification of PVP in the biopsies led to the discovery of a severe adverse effect from long-standing misuse of a drug. The disseminated PVP deposition likely contributed to multi-organ dysfunction and cachexia with a fatal outcome. The deposited PVP likely originated from repeated injections of a certain methadone syrup.
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Affiliation(s)
- Ida Viken Stalund
- Department of Pathology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, 5021 Bergen, Norway
| | - Gro Nygard Riise
- Department of Medicine, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
| | - Friedemann Leh
- Department of Pathology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
| | - Tormod Karlsen Bjånes
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
| | - Lars Riise
- Kvam Municipality, Grovagjelet 16, 5600 Norheimsund, Norway
| | - Einar Svarstad
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, 5021 Bergen, Norway
| | - Sabine Leh
- Department of Pathology, Haukeland University Hospital, Post box 1, 5021 Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, 5021 Bergen, Norway
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Wagner CT, Martowicz ML, Livesey SA, Connor J. Biochemical stabilization enhances red blood cell recovery and stability following cryopreservation. Cryobiology 2002; 45:153-66. [PMID: 12482381 DOI: 10.1016/s0011-2240(02)00124-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Glycerolized red blood cells (RBC) are approved for long-term cryopreservation. However, the need to remove the glycerol cryoprotectant prior to transfusion has limited the usefulness of this cryopreservation method. This report describes using non-cryoprotectant biochemical stabilization techniques to substitute for the standard glycerol cryoprotectant. The glycerolized RBC method was compared to a newly developed LC-V method that combines transfusable cryoprotectants (hydroxyethyl starch and dextran) and specific non-cryoprotectant biochemical stabilizers (nicotinamide, nifedipine, and flurbiprofen). Results demonstrate that the biochemical stabilizers significantly reduce cryopreservation-induced hemolysis compared to cryopreservation in their absence and that thaw hemolysis levels approach those of standard 40% (w/v) glycerolized RBC (3.1+/-0.2% for 40% glycerol compared to 8.7+/-0.9% for the LC-V protocol). Furthermore, LC-V cryopreserved RBC exhibit a significantly enhanced post-thaw stability compared to glycerolized RBC as determined by osmotic fragility index (0.557+/-0.034 for 40% glycerol compared to 0.478+/-0.016 for the LC-V protocol). Analysis of biochemically stabilized RBC proteins revealed a transient translocation of carbonic anhydrase to the membrane fraction. However, the enhanced RBC recovery and stability could not be attributed to this event. Finally, DSC analysis demonstrated that the biochemical stabilizers of the LC-V process were not functioning as surrogate cryoprotectants in that they did not affect the quantity or quality of ice formed. Overall, this work demonstrates that cryopreservation-induced RBC damage may be corrected or prevented through specific biochemical stabilization and represents a significant step toward a directly transfusable cryopreserved RBC product.
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Affiliation(s)
- Christopher T Wagner
- Cell Biology Research, LifeCell Corporation, One Millennium Way, Branchburg, NJ 08876, USA.
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Boelens JJ, Zaat SA, Meeldijk J, Dankert J. Subcutaneous abscess formation around catheters induced by viable and nonviable Staphylococcus epidermidis as well as by small amounts of bacterial cell wall components. JOURNAL OF BIOMEDICAL MATERIALS RESEARCH 2000; 50:546-56. [PMID: 10756313 DOI: 10.1002/(sici)1097-4636(20000615)50:4<546::aid-jbm10>3.0.co;2-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of catheters is often complicated by infection, mainly due to Staphylococcus epidermidis. Recently, a novel poly(vinylpyrrolidone)-grafted silicone elastomer catheter (SEpvp) was introduced. Less bacteria adhered to SEpvp than to conventional SE catheters in vitro. The frequency of S. epidermidis infection associated with SEpvp and SE was assessed in a rabbit model. Unexpectedly, abscesses were induced by the injection of low numbers of S. epidermidis along subcutaneously inserted SEpvp. No abscesses were seen around SE, even when very high numbers of S. epidermidis were injected. This bioincompatibility reaction observed around the SEpvp was independent of the host, bacterial strain, and method of inoculation. Abscesses were also induced by nonviable S. epidermidis and by bacterial cell wall components. Because these incompatibility reactions were not observed in the absence of bacteria, biocompatibility testing should include experiments in which the inflammatory effects of the combination of catheter and (non)viable bacteria are tested.
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Affiliation(s)
- J J Boelens
- Department of Medical Microbiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Adeyeye CM, Barabas E. Povidone. ACTA ACUST UNITED AC 1993. [DOI: 10.1016/s0099-5428(08)60252-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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Takahashi K, Eto K, Takeya M, Naito M, Yaginuma Y, Ichihara A. LONG-TERM POLYVINYLPYRROLIDONE STORAGE. Pathol Int 1983. [DOI: 10.1111/j.1440-1827.1983.tb02144.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sharpe JR, Sadlowski RW, Finney RP, Halkias DG. Evaluation of povidone-iodine as vesical irrigant for treatment and prevention of urinary tract infections. Urology 1981; 17:335-8. [PMID: 7222323 DOI: 10.1016/0090-4295(81)90258-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This is a preliminary study evaluating diluted solutions of povidone-iodine (PVP-I) as urinary bladder irrigants for the treatment and prevention of urinary tract infection. Diluted povidone-iodine solutions were used as indwelling catheter irrigants and as instillations into the urinary bladder following intermittent catheterization. The diluted PVP-I solutions had no efficacy in either the treatment or prevention of urinary tract infections when used as indwelling urethral or suprapubic catheter irrigants. There was a suggestion of a slight decrease in the incidence of urinary tract infections during the use of PVP-I in the intermittent catheterization group in this uncontrolled study, but the percentage of positive urine cultures was greater than desired. The absence of any unfavorable data has led us to conclude that the diluted PVP-I caused no undesirable side effects in any of the patients treated with this agent, PVP-I bladder irrigation warrants further investigation in special cases such as lower urinary tract fungal infections.
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