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Clinical Cases of Substance Abuse. Objectives Illustrate medical problems which may accompany substance abuse. Illustrate medical problems which may accompany.

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Presentation on theme: "Clinical Cases of Substance Abuse. Objectives Illustrate medical problems which may accompany substance abuse. Illustrate medical problems which may accompany."— Presentation transcript:

1 Clinical Cases of Substance Abuse

2 Objectives Illustrate medical problems which may accompany substance abuse. Illustrate medical problems which may accompany substance abuse. Raise awareness of our biases and stereotypes. Alcohol and drugs do not discriminate, people do. Raise awareness of our biases and stereotypes. Alcohol and drugs do not discriminate, people do.

3 Clinical Case # 1 A physician very conscientious, hard working, productive, in fact highest earner in your group. Has been sick often with influenza type symptoms. She has a husband and two kids. There has been no drop in productivity or any overt signs of any physical or relationship problems at home or work. She is a bit shy and withdrawn by nature but friendly enough. If anything she is a workaholic and you wonder how she manages the responsibilities of home and work. Maybe she is just bright, after all she graduated at the top of her medical school class and was a top notch resident. A physician very conscientious, hard working, productive, in fact highest earner in your group. Has been sick often with influenza type symptoms. She has a husband and two kids. There has been no drop in productivity or any overt signs of any physical or relationship problems at home or work. She is a bit shy and withdrawn by nature but friendly enough. If anything she is a workaholic and you wonder how she manages the responsibilities of home and work. Maybe she is just bright, after all she graduated at the top of her medical school class and was a top notch resident.

4 She presents to ER with a four day history of intense left buttock pain which radiated down her left leg posteriorly. She presents to ER with a four day history of intense left buttock pain which radiated down her left leg posteriorly. She had c/o of fever and night sweats. She had c/o of fever and night sweats. Pain would awaken him from sleep. Pain would awaken him from sleep. She had no cough, chest pain, SOB, or sputum production. She had no cough, chest pain, SOB, or sputum production. She had had no trauma to his pelvis or hips. She had had no trauma to his pelvis or hips. No history of TB, STD or RHD or joint disease. No history of TB, STD or RHD or joint disease. No history of hepatitis and reported a negative test for AIDS 18 months prior. No history of hepatitis and reported a negative test for AIDS 18 months prior.

5 Rectal temp of 103.8. Rectal temp of 103.8. WBC of 17,200 (71P/3B/19L). WBC of 17,200 (71P/3B/19L). Full ROM of the right hip which elicited pain in the left SI area. Full ROM of the right hip which elicited pain in the left SI area. No swelling, redness or fluctuance over the left SI area. No swelling, redness or fluctuance over the left SI area. Left hip also had full ROM and caused pain. Left hip also had full ROM and caused pain.

6 X-rays of the pelvis and hips showed destruction of the left SI joint with loss of the joint space. X-rays of the pelvis and hips showed destruction of the left SI joint with loss of the joint space. 5/5 blood cultures returned positive for a methacillin sensitive Staph. Aureus. 5/5 blood cultures returned positive for a methacillin sensitive Staph. Aureus. Nafcillin. The patient improved rapidly. Nafcillin. The patient improved rapidly. DX – Septic sacroilitis. DX – Septic sacroilitis. SI joint pain ddx - septic hip, psoas abscess, malignancy, sciatica, herniated disc, pyelonephritis, ankylosing spondylitis, or appendicitis. SI joint pain ddx - septic hip, psoas abscess, malignancy, sciatica, herniated disc, pyelonephritis, ankylosing spondylitis, or appendicitis.

7 Infectious complications of IVDA Endocarditis Endocarditis Septic emboli Septic emboli Osteomyelitis Osteomyelitis Septic arthritis Septic arthritis Psoas abscess Psoas abscess Brain and epidural abscess Brain and epidural abscess Viral hepatitis Viral hepatitis Skin infections including that due to methicillin-resistant Staphylococcus aureus (MRSA) Skin infections including that due to methicillin-resistant Staphylococcus aureus (MRSA) All infections commonly associated with HIV, including tuberculosis All infections commonly associated with HIV, including tuberculosis Uncommon infections transmitted by means of IV drug use (tetanus, malaria, syphilis) Uncommon infections transmitted by means of IV drug use (tetanus, malaria, syphilis)

8 Clinical signs and symptoms Fever Fever Night sweats Night sweats Weight loss Weight loss Headache Headache Back or joint pain, particularly hip pain Back or joint pain, particularly hip pain Numbness or weakness Numbness or weakness Visual changes Visual changes Cough Cough Dyspnea Dyspnea Chest or abdominal pain. Chest or abdominal pain.

9 Clinical case #2 19 y/o gentleman presents. A friend tells you, "We we're rolling man and he just started getting weird. He was getting stiff and not making any sense. I was getting scared." 19 y/o gentleman presents. A friend tells you, "We we're rolling man and he just started getting weird. He was getting stiff and not making any sense. I was getting scared." They had been at a dance party when the patient began to have changes in mental status; such as slow to respond, nonsensical responses and acting stiff "like Frankenstein". They had been at a dance party when the patient began to have changes in mental status; such as slow to respond, nonsensical responses and acting stiff "like Frankenstein". He fell over and wouldn't respond to his name. He fell over and wouldn't respond to his name.

10 On exam the patient is an adolescent male, approximately 5'10" tall, muscular and about 10 pounds overweight. On exam the patient is an adolescent male, approximately 5'10" tall, muscular and about 10 pounds overweight. His shirt is sweat soaked. His shirt is sweat soaked. His vital signs are: HR 160 bpm, fast and thready, BP 170/88, respirations 20/min and regular, temperature 103.4O F.. Pupils are 7- 8mm, equal and slow to react. His vital signs are: HR 160 bpm, fast and thready, BP 170/88, respirations 20/min and regular, temperature 103.4O F.. Pupils are 7- 8mm, equal and slow to react.

11 Retinas are normal, no bulging disks, and no nystagmus. Retinas are normal, no bulging disks, and no nystagmus. The patient appears awake but is confused and unable to answer questions. The patient appears awake but is confused and unable to answer questions. Blood is drawn for blood chemistries and a CBC. Blood is drawn for blood chemistries and a CBC. Patient has a violent tonic-clonic seizure. Patient has a violent tonic-clonic seizure.

12 Acute Clinical effects 1) "serotonin syndrome " usually associated with hyperthermia, mental status changes and cardiovascular instability. 1) "serotonin syndrome " usually associated with hyperthermia, mental status changes and cardiovascular instability. 2) severe hyponatremia induced cerebral and pulmonary edema. 2) severe hyponatremia induced cerebral and pulmonary edema. 3) idiosyncratic hepatotoxicity. 3) idiosyncratic hepatotoxicity. The hyperthermia may be related to the key role serotonin plays in the hypothalamus in thermo- regulation. (Mueller) The hyperthermia may be related to the key role serotonin plays in the hypothalamus in thermo- regulation. (Mueller)

13 MDMA induced Serotonin Syndrome A key finding in these cases has been hyperthermia. A key finding in these cases has been hyperthermia. Neurologic effects in this syndrome include mydriasis, confusion agitation, hallucinations, seizures and coma. Neurologic effects in this syndrome include mydriasis, confusion agitation, hallucinations, seizures and coma. The seizures may increase the risk of hyperthermia, rhabodomyolysis and acidosis. The seizures may increase the risk of hyperthermia, rhabodomyolysis and acidosis. Respiratory depression may occur. Respiratory depression may occur.

14 Cardiovascular effects in this syndrome include hypotension, transient hypertension tachycardia, SVT, ventricular arrhythmias and asystole (Brown, Mueller, Walubo, Dar) Cardiovascular effects in this syndrome include hypotension, transient hypertension tachycardia, SVT, ventricular arrhythmias and asystole (Brown, Mueller, Walubo, Dar) Disseminated intravascular coagulopathy (DIC) has been reported and is believed secondary to hyperthermia (Walubo, Henry, Milroy, Logan, Dar) Disseminated intravascular coagulopathy (DIC) has been reported and is believed secondary to hyperthermia (Walubo, Henry, Milroy, Logan, Dar) Renal failure secondary to rhabdomyolysis. These patients are frequently acidotic, which increased the risk of renal damage during rhabdomyolysis. Renal failure secondary to rhabdomyolysis. These patients are frequently acidotic, which increased the risk of renal damage during rhabdomyolysis. Metabolic acidosis and hyperkalemia, secondary to hyperthermia and seizures. The acidosis may increase the risk of ventricular arrhythmia. Metabolic acidosis and hyperkalemia, secondary to hyperthermia and seizures. The acidosis may increase the risk of ventricular arrhythmia.

15 Severe hyponatremia induced cerebral and pulmonary edema Severe Hyponatremia with serum sodium as low as 101 mmol/L have been reported. Severe Hyponatremia with serum sodium as low as 101 mmol/L have been reported. This may be due to the MDMA-induced increased vasopressin release. This may be due to the MDMA-induced increased vasopressin release. A low dose (40 mg) of MDMA increased vasopressin level on an order of 4 to 5 times normal in adult volunteers. (Henry) A low dose (40 mg) of MDMA increased vasopressin level on an order of 4 to 5 times normal in adult volunteers. (Henry) Also reported are decreased Serum Osmolality as low as 248 mOsmol/kg and hyperkalemia. Also reported are decreased Serum Osmolality as low as 248 mOsmol/kg and hyperkalemia.

16 Coma, Cerebral Edema and Seizures. Coma, Cerebral Edema and Seizures. Respiratory arrest, Pulmonary Edema. Respiratory arrest, Pulmonary Edema. It is common for users of MDMA to drink large amount of water in an attempt to avoid dehydration and hyperthermia. It is common for users of MDMA to drink large amount of water in an attempt to avoid dehydration and hyperthermia. Large fluid intake puts the patient at risk for MDMA-induced hyponatremia which results from a pharmacologic effect of the drug compounded by excessive fluid ingestion. Large fluid intake puts the patient at risk for MDMA-induced hyponatremia which results from a pharmacologic effect of the drug compounded by excessive fluid ingestion.

17 Hepatotoxicity and Liver failure Elevated Liver Transaminases and Fulminant Hepatic Failure has been reported in a number of cases. Elevated Liver Transaminases and Fulminant Hepatic Failure has been reported in a number of cases. This appears to be an idiosyncratic event. This appears to be an idiosyncratic event. Onset of hepatic injury is delayed in most cases by 2 to 3 days after the ingestion of MDMA. Some cases it was up to 15 days. Onset of hepatic injury is delayed in most cases by 2 to 3 days after the ingestion of MDMA. Some cases it was up to 15 days. a subset of the population may be at risk for liver toxicity. These patients are missing a liver enzyme called CYP2D6, which is necessary to metabolize MDMA. It is deficient or totally absent in 5-10% of whites and African Americans and 1-2% of Asians. a subset of the population may be at risk for liver toxicity. These patients are missing a liver enzyme called CYP2D6, which is necessary to metabolize MDMA. It is deficient or totally absent in 5-10% of whites and African Americans and 1-2% of Asians.


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