Makindo Medical Notes

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.

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: Due to frequent injection, non-sterile technique, sharing equipment, and skin-popping. Includes cellulitis, skin abscesses, thrombophlebitis, necrotizing fasciitis, gas gangrene, and pyomyositis.
• Tetanus caused by exotoxin produced by Clostridium tetani.
• Skeletal infections: Including septic arthritis and osteomyelitis. These are the third most common complication of IV drug use.
• Pulmonary infections.
• Ocular infections: Including fungal and bacterial endophthalmitis.
• CNS infections: Meningitis, epidural abscess, and brain abscess.
• Malaria (uncommon).

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, especially endocarditis, cannot be excluded in the initial ED evaluation.
• Flucloxacillin is 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

• Fever in IV Drug User (PUO)