Cameo
CUTANEOUS STIGMATA OF DRUG ADDICTION MICHAEL I. FELLNER, M.D. AND LESLIE H. WEINSTEIN, M.D.
A 32-year-old black man was admitted to Bird S. Coler Hospilal for swelling of the extremities. He had been admitted to Sydenham Hospilal on October 3, 1977 for treatment of skin blisters secondary to repeated subcutaneous injections of heroin and cocaine. At that time, ihe diagnosis made was chronic lymphedema of the upper extremities, nephrotic syndrome with anasarca, pericardial and bilateral pleural effusions, hypertension, congestive heart failure and anemia. Past medical history revealed he had used heroin and cocaine intravenously and subculaneously for seven years. Swelling of all extremities starled in the right arm in April 1977. By November 1977, the edema had markedly increased. He complained of joint pains in his ankles and knees inlermittently since 1970. He noticed that blisters developed at sites of "skin popping" which later scarred at the sites of these subcutaneous injections. Paroxysmal nocturnal dyspnea and three pillow orthopnea developed by October 1977. Physical examination revealed a well developed, obese Black man with widespread anasarca. Pertinent positive physical findings included: multiple exudates and arteriolar narrowing of the fundi, positive S4 and a grade 2/6 systolic ejection murmur on cardiac auscultation, hepatomegaly and 4-1- pitling edema in all extremities, most severe in ihe right arm. The skin showed multiple hypertrophic and alrophic scars of ovoid and irregular configuration located at sites of drug injection (Figs. I and 2). Bolh hypo- and hyperpigmenlation were present in ihese lesions. Pertinent laboratory results included: VDRLnonreactive, rheumatoid factor-negative, LE prepnegative, serum complement 24 (normal value 30 to 1001. Skin biopsy specimen of an atrophic area revealed fibrosis of the dermis and epidermis, while a biopsy specimen of a normal appearing adjacent area revealed
Supported by the |ohn A. Hartford Foundation, Inc. Address for reprints: Michael |. Fellner, M.D., Department of Dermatology, Bird S. Coler Hospital, Roosevelt Island, NY 10044.
From the Department of Dermatology, New York Medical College, and the Bird S. Coler Hospital, Roosevelt Island. New York
chronic dermatitis wilh round cell infiltrales. Direct immiinotluorescent sludies were negative except for weak perivascular slaining wilh IgG.
Comment
Table 1 summarizes the reported cutaneous stigmata seen in drug abusers.'=^ Hyperpigmentation at sites of drug injection is the most common cutaneous marker of drug addicts. This is often seen in a linear pattern or "track" following the course of an injected vein. Pemphigus erythematosus has also been reported''^ in association with heroin addiction and our patient gives a history of bullae formation at the sites of subcutaneous injection of street drugs. However, immunofluorescent studies done two years after the last reported subcutaneous injection of heroin were negative in our patient. We Iheorize thai repeated subcutaneous injections of nonpharmaceulical drugs contatninated with talc, bacteria and other foreign maiter lead to the production of antiepithelial antibodies which resulted in blisters that fortiied around areas of injection. In addition, a serum sickness type reaction could account for ihe patient's nephrotic
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INTERNATIONAL JOURNAL OF DERMATOLOGY
May 1979
Vol. 18
Eig. 1. Lett, righl arm and trunk showiiij; marked lymphedema and scarring. Fig. 2. Right, legs showing lymphedema and hypopigmented scarring. Table 1. Cutaneous Signs of Drug Addiction 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Abscess Atrophic scirs Camptodactylia Cheilitis Edema Excoriations Fixed drug eruption Hypo- and hyperpigmented scars Hypertrophit scars l.uindice
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Maculopapular eruptions Melanosis in sun-exposed areas Necrotizing angitis Pruritus Pseudo acanlhosis nigricans Tatloos Tourniquet pressure pigmentation Tracks Urticaria Cutaneous anasarca
syndrome in which antigen-atitibody complexes are deposiled iti the glotiieruli and complement is activated with subsequetit damage of Ihese vessels. Both the weak perivascular staining with IgG in the skin biopsy specimen and the low serum complement are consistent with this iheory.
of local lymphatics And (2) nephrolic syndrome with loss of albumin. This picture of atiasarca in addicts needs further research including immunofluorescent sludies of lymphatic vessels for antigen-antibody deposits.
Our patient also exhibited widespread anasarca that was more severe in those extremities w h i c h received m u l t i p l e subcutaneous injections of illicit drugs, i.e., the right arm. This edema is produced by two mechanisms: (1) local fibrosis and blockage
References 1. Weidman, A., and Fellner, M. ].: Cutaneous manifestations of heroin and other addictive drugs. NY State ). Med. 71:2643, 1971. 2. Fellner, M. |., and Wimnger, ).: Pemphigjs erythematosus and heroin aridi{ tion. Int. |. Dermatol. 17:308, 1978.
CUTANEOUS STIGMATA OF DRUG ADDICTION MICHAEL I. FELLNER, M.D. AND LESLIE H. WEINSTEIN, M.D.
A 32-year-old black man was admitted to Bird S. Coler Hospilal for swelling of the extremities. He had been admitted to Sydenham Hospilal on October 3, 1977 for treatment of skin blisters secondary to repeated subcutaneous injections of heroin and cocaine. At that time, ihe diagnosis made was chronic lymphedema of the upper extremities, nephrotic syndrome with anasarca, pericardial and bilateral pleural effusions, hypertension, congestive heart failure and anemia. Past medical history revealed he had used heroin and cocaine intravenously and subculaneously for seven years. Swelling of all extremities starled in the right arm in April 1977. By November 1977, the edema had markedly increased. He complained of joint pains in his ankles and knees inlermittently since 1970. He noticed that blisters developed at sites of "skin popping" which later scarred at the sites of these subcutaneous injections. Paroxysmal nocturnal dyspnea and three pillow orthopnea developed by October 1977. Physical examination revealed a well developed, obese Black man with widespread anasarca. Pertinent positive physical findings included: multiple exudates and arteriolar narrowing of the fundi, positive S4 and a grade 2/6 systolic ejection murmur on cardiac auscultation, hepatomegaly and 4-1- pitling edema in all extremities, most severe in ihe right arm. The skin showed multiple hypertrophic and alrophic scars of ovoid and irregular configuration located at sites of drug injection (Figs. I and 2). Bolh hypo- and hyperpigmenlation were present in ihese lesions. Pertinent laboratory results included: VDRLnonreactive, rheumatoid factor-negative, LE prepnegative, serum complement 24 (normal value 30 to 1001. Skin biopsy specimen of an atrophic area revealed fibrosis of the dermis and epidermis, while a biopsy specimen of a normal appearing adjacent area revealed
Supported by the |ohn A. Hartford Foundation, Inc. Address for reprints: Michael |. Fellner, M.D., Department of Dermatology, Bird S. Coler Hospital, Roosevelt Island, NY 10044.
From the Department of Dermatology, New York Medical College, and the Bird S. Coler Hospital, Roosevelt Island. New York
chronic dermatitis wilh round cell infiltrales. Direct immiinotluorescent sludies were negative except for weak perivascular slaining wilh IgG.
Comment
Table 1 summarizes the reported cutaneous stigmata seen in drug abusers.'=^ Hyperpigmentation at sites of drug injection is the most common cutaneous marker of drug addicts. This is often seen in a linear pattern or "track" following the course of an injected vein. Pemphigus erythematosus has also been reported''^ in association with heroin addiction and our patient gives a history of bullae formation at the sites of subcutaneous injection of street drugs. However, immunofluorescent studies done two years after the last reported subcutaneous injection of heroin were negative in our patient. We Iheorize thai repeated subcutaneous injections of nonpharmaceulical drugs contatninated with talc, bacteria and other foreign maiter lead to the production of antiepithelial antibodies which resulted in blisters that fortiied around areas of injection. In addition, a serum sickness type reaction could account for ihe patient's nephrotic
001 1-9059/79/0500/0305/500.60 © Inlernalional Society of Tropical Dermaioiogy, Inc.
305
306
INTERNATIONAL JOURNAL OF DERMATOLOGY
May 1979
Vol. 18
Eig. 1. Lett, righl arm and trunk showiiij; marked lymphedema and scarring. Fig. 2. Right, legs showing lymphedema and hypopigmented scarring. Table 1. Cutaneous Signs of Drug Addiction 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Abscess Atrophic scirs Camptodactylia Cheilitis Edema Excoriations Fixed drug eruption Hypo- and hyperpigmented scars Hypertrophit scars l.uindice
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Maculopapular eruptions Melanosis in sun-exposed areas Necrotizing angitis Pruritus Pseudo acanlhosis nigricans Tatloos Tourniquet pressure pigmentation Tracks Urticaria Cutaneous anasarca
syndrome in which antigen-atitibody complexes are deposiled iti the glotiieruli and complement is activated with subsequetit damage of Ihese vessels. Both the weak perivascular staining with IgG in the skin biopsy specimen and the low serum complement are consistent with this iheory.
of local lymphatics And (2) nephrolic syndrome with loss of albumin. This picture of atiasarca in addicts needs further research including immunofluorescent sludies of lymphatic vessels for antigen-antibody deposits.
Our patient also exhibited widespread anasarca that was more severe in those extremities w h i c h received m u l t i p l e subcutaneous injections of illicit drugs, i.e., the right arm. This edema is produced by two mechanisms: (1) local fibrosis and blockage
References 1. Weidman, A., and Fellner, M. ].: Cutaneous manifestations of heroin and other addictive drugs. NY State ). Med. 71:2643, 1971. 2. Fellner, M. |., and Wimnger, ).: Pemphigjs erythematosus and heroin aridi{ tion. Int. |. Dermatol. 17:308, 1978.
