Fever in IV Drug User (PUO)
🌡️ Fever in IV Drug User (PUO) may be the result of apparent or occult bacterial, viral, or fungal infection, febrile reactions to injected materials, or even fever of unknown origin.
ℹ️ About
- 💉 Sharing of needles and spoons
- ⚗️ Contaminated drugs or solvents
- 🛡️ Unpredictable immune status, poor psychosocial conditions
- 🚿 Often less than optimal hygiene and nutritional status
🧬 Aetiology
- 🦠 At risk of bloodborne and local spread infections from injections
Sources and Clinical
- 🫀 DVT/PE: Femoral vein is common. May have aneurysms. Pleural rub, dyspnoea.
- 🦵 Compartment syndrome from local injections.
- 🦴 Psoas abscess from local injections.
- 🦴 Septic arthritis from local injections.
- ❤️ Endocarditis: Often right-sided. New murmurs. V waves in tricuspid endocarditis. Chills, pleuritic chest pain, back pain, heart murmur, splenomegaly, and peripheral embolic phenomena.
- ☣️ Clostridium infection with IM heroin.
- 🧬 Viral: HIV-1, hepatitis B or C.
- 🩹 Skin and soft tissue infections: Cellulitis, abscesses, thrombophlebitis, necrotizing fasciitis, gas gangrene, pyomyositis.
- 💀 Tetanus caused by exotoxin from Clostridium tetani.
- 🦴 Skeletal infections: Septic arthritis, osteomyelitis (3rd most common complication).
- 🫁 Pulmonary infections.
- 👁️ Ocular infections: Fungal/bacterial endophthalmitis.
- 🧠 CNS infections: Meningitis, epidural abscess, brain abscess.
- 🦟 Malaria (rare).
🔎 Investigations
- 🧪 FBC, U&E, CRP, ESR, Blood cultures, lactate.
- 🧬 Viral serology - Hepatitis and HIV.
- 🩻 CXR, Echocardiogram.
💊 Management
- 🏥 Admit all febrile IV drug users because serious infections (esp. endocarditis) cannot be excluded in the initial ED evaluation.
- 💊 Flucloxacillin – useful against Staphylococcus aureus.
- 💊 Vancomycin – may be needed if MRSA is present.
- 🗣️ ED physicians must always ask about past and present drug use in all patients presenting to the emergency department.
References
