Recreational drug abuse in a dialysis patient

(Section Editor: G. H. Neild)

Barbara Thompson, Aine Burns and Andrew Davenport

Renal Unit, Royal Free Hospital, London, UK

A 45-year-old woman developed cellulitis of the left breast following injection of recreational drugs into a collateral mammary vein (Figure 1Go). She had a history of injecting drugs both subcutaneously and intravenously since the age of seventeen.



View larger version (100K):
[in this window]
[in a new window]
 
Fig. 1.  Cellulitis of the left breast with Tessio lines in situ and dilated collateral veins (arrows).

 
The patient first presented four years earlier with a right femoral vein thrombosis and a large abscess of the right thigh which had developed after injecting recreational drugs intravenously. On examination she had hepatosplenomegaly. Further investigation revealed 2 g proteinuria per day and advanced renal impairment. She was HCV positive and HIV negative.

Renal function did not improve and she started haemodialysis. A renal biopsy showed AA amyloid (Figure 2Go). She had a history of chronic suppurating skin infections from ‘skin popping’ with many disfiguring scars. This was the likely cause of her AA amyloid [13]. A serum amyloid P (SAP) scan, following intravenous administration of 123I human SAP, demonstrated a small total body amyloid load with abnormal uptake confined to the spleen (Figure 3Go). The absence of renal signal is due to poor organ perfusion in end-stage renal failure. The remainder of the image represents a normal distribution of tracer throughout the blood pool.



View larger version (124K):
[in this window]
[in a new window]
 
Fig. 2.  Renal histology with Congo red staining revealing extensive amyloid deposition in the glomerulus and in the tubules.

 


View larger version (90K):
[in this window]
[in a new window]
 
Fig. 3.  SAP scan demonstrating abnormal uptake of tracer in the spleen.

 
The patient remains dialysis dependent, dialysing through tunnelled dialysis lines as she is unsuitable for either CAPD or an arterio–venous fistula. Her forearm veins have been destroyed by repeated use for her drug habit. Her dialysis has been plagued by repeated line infections, often caused by the patient misusing them. This has resulted in increasing venous occlusions. There are now life-threateningly few options for dialysis access. Currently both femoral veins are occluded and MR venography has shown that only the right brachiocephalic vein remains patent. In the photograph (Figure 1Go) one can see the dialysis lines and the dilated collaterals across her chest.

The patient's breast cellulitis demonstrates an uncommon variant of the complications that arise from recreational drug injection and her exploitation of her dilated breast collaterals has proved a painful lesson.

Notes

Correspondence and offprint requests to: Dr B. Thompson, Renal Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK. Back

References

  1. Neugarten J, Gallo GR, Buxbaum J, Katz LA. Amyloidosis in subcutaneous heroin abusers (‘skin poppers’ amyloidosis). Am J Med1986; 81: 635–640[ISI][Medline]
  2. Tan AU Jr, Cohen AH, Levine BS. Renal amyloidosis in a drug abuser. J Am Soc Nephrol1995; 5: 1653–1658[Abstract]
  3. Menchel S, Cohen D, Gross E, Frangione B, Gallo G. AA protein-related renal amyloidosis in drug addicts. Am J Pathol1983; 112: 195–199[Abstract]




This Article
Extract
FREE Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Thompson, B.
Articles by Davenport, A.
PubMed
PubMed Citation
Articles by Thompson, B.
Articles by Davenport, A.