Injection of 'Bath Salts' Linked to Necrotizing Fasciitis

Courtesy of Medscape Today:

Deborah Brauser
Posted: 01/19/2012


January 19, 2012 — Intramuscular injection of the street drug known as "bath salts" may cause necrotizing fasciitis, a rare, flesh-eating bacteria syndrome that affects muscle and subcutaneous tissue, new research suggests.
In a case report published in the January issue of Orthopedics, investigators write that 2 days after injecting "bath salts," a young adult patient came to an emergency department with extensive cellulitis/infection of her upper arm.
"The cellulitis initially responded to broad-spectrum intravenous antibiotics but rapidly deteriorated 48 hours later, leading to a forequarter amputation with radical mastectomy and chest wall debridement to obtain healthy tissue margins and control the disease," write Russell Russo, MD, from the Department of Orthopedics at Louisiana State University Health Sciences Center in New Orleans, and colleagues.
The patient made a full recovery after "further minor debridements, negative pressure dressings, directed antibiotic therapy, and skin grafting."

The investigators note that the current popularity of "bath salts" may lead to an increase in cases of these flesh-eating infections. Necrotizing fasciitis can spread quickly through the body, threatening loss of limbs and even loss of life.

"Orthopedic surgeons should be vigilant in diagnosing this process early and should perform an extensive debridement," they write. In addition, "medical centers of all disciplines must be prepared to identify the signs of intoxication while treating the potential side effects" of this illicit drug.

Rapid Timeline
According to the researchers, necrotizing fasciitis was known as "hospital gangrene" during the American Civil War and as "streptococcal gangrene" in the 1940s. "The pathogenesis of the disease has remained constant over time," they write.
As reported by Medscape Medical News, the US Drug Enforcement Administration (DEA) temporarily banned synthetic stimulants marketed as "bath salts" in the fall of 2011.

Nevertheless, the substance remains popular in the United States among teenagers and young adults. The crystals can be swallowed, sniffed, injected, or smoked. In 2011, calls to poison control centers and reports of emergency department visits rose dramatically as a result of ingestion of these so-called "bath salts."
"Unlike common illicit drugs such as cocaine, heroin, lysergic acid diethylamide, phencyclidine, and ecstasy, the dangers of baths salts are unknown and only beginning to emerge," write the investigators.
The female patient in this report was aged 34 years and reported having pain and redness in her forearm after injecting intramuscular "bath salts" at a party. She did not have a fever at the time she presented. She also reported recent use of cocaine, opiates, and benzodiazepines.

This last factor is troubling to at least one commentator who posted on the journal's Web site. She asked whether there was any toxicological evidence to definitively explain the cause of the patient's condition.
"How can we be sure that the infection was a result of her bath salt injection and not from administering any of the [other substances] she took? There have been previous outbreaks of opiates leading to similar problems, e.g. anthrax epidemic in 2010 in Glasgow."
Nevertheless, the researchers note that the best way to treat necrotizing fasciitis includes early recognition, immediate surgical debridement, and treatment with penicillin G and clindamycin antibiotics.
"Necrotizing fasciitis has a rapid timeline to tissue destruction and loss of life."
A past study found that the average time to surgical debridement for surviving this rapidly spreading infection was just 25 hours. Another study found that overall survival from a diagnosis of the infection was as low as 50%.

"These infections are usually associated with crush traumas and farm injuries, but now one must also be prepared and vigilant when presented with a cellulitic patient who has a history of needle use," write the researchers.

"However, the best treatment is prevention with public, street-based education," they write.
The study authors have disclosed no relevant financial relationships.
Orthopedics. 2012;35:124-127. Full article