Heroin addict with gangrene of the extremities, rhabdomyolysis and severe hyperkalemia
Authors: Radovanovic Milan , Milovanovic Dragan , Ignjatovic-Ristic Dragana , Radovanovic Mirjana 
Published: October 2012

Introduction. Long-time consumption of narcotics leads to altered mental
status of the addict. It is also connected to damages of different organic
systems and it often leads to appearance of multiple organ failure. Excessive
narcotics consumption or abuse in a long time period can lead to various
consequences, such as atraumatic rhabdomyolysis, acute renal failure and
electrolytic disorders. Rhabdomyolysis is characterized by injury of skeletal
muscle with subsequent release of intracellular contents, such as myoglobin,
potassium and creatine phosphokinase. In heroin addicts, rhabdomyolysis is a
consequence of the development of a compartment syndrome due to
immobilization of patients in the state of unconsciousness and prolonged
compression of extremities, direct heroin toxicity or extremities ischemia
caused by intraluminal occlusion of blood vessels after intraarterial
injection of heroin. Severe hyperkalemia and the development of acute renal
failure require urgent therapeutic measures, which imply the application of
either conventional treatment or a form of dialysis. Case report. We
presented a male patient, aged 50, hospitalized in the Emergency Center
Kragujevac due to altered mental status (Glasgow Coma Score 11), partial
respiratory insufficiency (pO2 7.5 kPa, pCO2 4.3 kPa, SpO2 89 %), weakness of
lower extremities and atypical electrocardiographic changes. Laboratory
analyses, carried out immediately after the patient?s admission to the
Emergency Center, registered the following disturbances: high hyperkalemia
level (K+ 9.9 mmol/L), increased levels of urea (30.1 mmol/L), creatinine
(400 ?mol/L), creatine phosphokinase - CK (120350 IU/L), CK-MB (2500 IU/L)
and myoglobin (57000 ?g/L), with normal levels of troponin I (< 0.01 ?g/L),
as well as signs of anemia (Hgb 92 g/L, Er 3.61 x 1012/L), infection
(C-reactive proteine 184 ?g/mL, Le 16.1 x 109/L) and acidosis (base excess -
18.4 mmol/L, pH 7.26. Initial examination of the patient revealed swelling
and paleness of the right lower leg, signs of gangrene of the right foot and
the 1st and the 4th toes of the left foot. The patient had normal values of
arterial pressure (130/80 mmHg) and heart rate (64/min-1); roentgenographic
lungs examination and computerized tomography (CT) brain examination did not
reveal pathological changes in lung and brain parenchyma; toxicological
analyses confirmed the presence of heroin in patient?s organism. The patient
was treated by intensive conventional treatment (infusion of crystalloid
solutions, 8.4% solution of sodium bicarbonate, iv infusion of diuretics,
calcium gluconate and short-acting insulin), and also by antibiotics and
anticoagulants. Normalization of kalemia and fast regression of
electrocardiographic changes were registered. The patient refused the
suggested surgical treatment (fasciotomy, foot amputation). After
stabilization of kidney function and improvement of his mental state, the
patient agreed to undergo surgical procedure. Therefore, on the day 30 of
hospitalization the above-knee amputation of the right leg was performed, and
on the day 38 the transmetatarsal amputation of the left foot was carried
out. After 46 days of hospital treatment, the patient was released and sent
to home treatment. Conclusion. The routine laboratory diagnostics, which
implies determining of the levels of potassium, urea, creatinine and CK in
the serum of all hospitalized heroin addicts can contribute to timely
detection of hyperkalemia and acute kidney weakness and undertaking of
appropriate therapeutic measures.