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Background: 'Chasing the dragon' involves placing heroin on aluminum foil, heating it from below with a flame, and inhaling the pyrolysate through a straw. It has rarely been associated with the development of a progressive spongiform leukoencephalopathy. Case Report: A 43-year-old woman presented with 2 weeks of bizarre behavior, forgetfulness, and slowed speech and movements. Serum, cerebrospinal fluid, and head computed tomography (CT) scan were normal. The patient progressed to coma and expired during week 4 of hospital admission. The family confirmed that she 'chased the dragon.' Cause of death at post mortem examination was spongiform leukoencephalopathy. Conclusion: The diagnosis of heroin pyrolysate-induced spongiform leukoencephalopathy should be considered in a patient with a history of 'chasing the dragon' and neurobehavioral changes, including confusion, apathy, cerebellar signs, and motor restlessness. Key Words: 'Chasing the dragon'; Spongiform leukoencephalophy; Heroin pyrolysate., INTRODUCTION 'Chasing the dragon' involves placing heroin on aluminum foil, heating it from below with a flame, and inhaling the pyrolysate through a straw. First described in Hong Kong in [...]

Intravenous drug use increases the risk of infection with human immunodeficiency virus type I (HIV-I) and human lymphotropic virus types I (HTLV-I) and II (HTLV-II). After infection with HIV or HTLV, antibodies, or immune proteins, are produced against the virus. Testing for seroprevalence, or the presence of viral antibodies, provides some indication of the prevalence (number of cases) of these infections. The incidence (number of new cases) of HTLV infection was reported to be less than one percent among intravenous drug users (IVDUs) in western European countries, 53 percent among black IVDUs in the western United States, and 27 percent among 56 IVDUs in New York City. However, standard blood tests can not distinguish HTLV-I from HTLV-II infection, and a positive finding of HTLV-specific antibodies is referred to as seropositivity for HTLV I/II. The behavioral and demographic features associated with HTLV seropositivity were assessed in 676 heterosexual IVDUs in San Francisco drug treatment programs between 1985 and 1987. Seropositivity was detected by two different tests in 111 subjects. The duration of heroin use, black or Hispanic race, female sex, and use of drugs in a shooting gallery were associated with an increased risk of HTLV infection. However, HTLV infection was not associated with an increased risk of HIV infection among heterosexual IVDUs. It was estimated that HTLV antibodies would be detected in 3.4 percent of IVDUs each year. HTLV-specific antibodies were not detected in 349 homosexual men from San Francisco who did not use intravenous drugs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Seventy patients hospitalized with chest pain after cocaine use were retrospectively evaluated to define the risk and clinical course of acute myocardial infarction (AMI). AMI developed in 22 patients (31%) and transient myocardial ischemia was in an additional 9 patients (13%). Coronary risk factors did not distinguish those who developed AMI from those who did not. The presenting electrocardiogram was abnormal in 20 of 22 patients who evolved AMI and in 19 of 48 of those who did not. Creatine kinase levels were elevated in 75% of the patients, including 65% of those who did not develop AMI, but creatine kinase-MB elevations were only observed in the AMI group. The route of cocaine administration did not predict AMI and there was no predilection for a particular coronary vascular bed. The length of time between drug use and onset of AMI pain was often quite prolonged median interval, 18 vs 1 hour in the non-AMI group). Eight of the patients with AMI underwent cardiac catheterization and 4 had significant coronary narrowing. (Am J Cardiol 1990;66:1434-1437), Many factors can increase the risk of acute myocardial infarction (AMI; heart attack), including use or abuse of drugs. Cocaine has been used by over 30 million Americans and has been linked to cardiovascular problems such as AMI. To date, only single case studies or studies with very small groups of patients have been reported. To determine the course of AMI and the characteristics of the patient population in which cocaine use leads to AMI, a study was carried out with 70 patients hospitalized with chest pain following self-administration of cocaine. In 22 of these patients (31 percent), the pain progressed to heart attack. The usual coronary risk factors, such as smoking, high blood pressure, high cholesterol levels, diabetes mellitus, and a family history of coronary artery disease, did not distinguish the AMI group. The route of administration (i.e. intravenous, intranasal, smoking of the crack form) was also not related to subsequent development of AMI. Creatine kinase MB levels in the circulation, which are increased in the 24 to 48 hours following AMI, were elevated only in the AMI group. The time from cocaine use to onset of pain was more protracted in the AMI group compared with the non-AMI groups (one hour vs. 18 hours, respectively). Four of eight AMI patients who underwent cardiac catheterization (a diagnostic technique) displayed significant narrowing of one or more of the coronary arteries. (Consumer Summary produced by Reliance Medical Information, Inc.)

To learn more concerning the relationship between recreational drug abuse (excluding marijuana and commonly prescribed drugs) and stroke (sudden loss of blood to a region of the brain, due to hemorrhage or a clot), the medical records were reviewed of 214 patients between 15 and 44 who had been admitted to a hospital with that diagnosis during a 10-year period. Data concerning their drug habits were compared with similar data for an age- and sex-matched group (controls) of 214 patients admitted with other diagnoses. Strokes were considered drug-related if they occurred within six hours of drug administration or if the patient tested positive for drugs after hospital admission in a coma. They were also considered drug-related if caused by a clot or other disorder resulting from infections caused by intravenous drug abuse. Results showed that people with cardiac conditions had 7.3 times greater risk for stroke, while drug abusers had a relative risk of 6.5, and people with diabetes mellitus or hypertension at the next lowest levels of risk. The risk for stroke was highest during the six hours after drug use, after which it decreased. Eighty-seven patients were younger than 35: for this subgroup, drug abuse was the most common condition predisposing them to stroke. Seventy-three stroke patients were recreational drug abusers, and, for 47 of these, a strong association was found between their drug use and stroke. Cocaine was used most commonly by these 47, then heroin, amphetamine, methylphenidate, and phencyclidine. Twenty-six percent of the stroke patients (56 people) died in the first phase of their hospital admission, the majority as a result of hemorrhage in the brain. Mortality among drug abusers was higher than nonabusers (36 versus 23 percent). The results show that recreational drug abuse is an important risk factor for stroke. Previous studies may have found it to be less significant because they did not survey large urban areas, such as the one studied here. (Consumer Summary produced by Reliance Medical Information, Inc.)

As of February 1989, intravenous drug abuse alone or with other risk factors accounted for 36,493 (about 30 percent) of the AIDS cases reported in the United States. Testing for antibodies to human immunodeficiency virus type 1 (HIV-1) provides an accurate means of determining rates of seroprevalence (number of people who have antibodies to the virus) and HIV infection. The findings of such tests may be helpful in developing prevention and educational programs aimed at various high-risk groups. Seroprevalence rates among intravenous drug users (IVDU) vary by geographic region and drug use behaviors, such as needle sharing. If testing for HIV antibodies could be performed reliably on a broader scale, the incidence of seroprevalence among IVDUs could be accurately determined. Venipuncture samples (blood obtained from a vein) are difficult to obtain from IVDUs; paper absorbed (PA) fingerstick samples may be a convenient alternative for extensive trials and surveys of seropositivity. (A seropositive or HIV-positive result indicates HIV infection.) This method of collecting blood samples has been successful in large scale newborn studies and some smaller trials with adults. Both PA fingerstick and venipuncture blood samples were collected from 393 IVDUs participating in a drop-in counselling program. PA samples were collected from 145 participants in a methadone treatment program. Serum samples were tested by enzyme immunoassays (EIA) and immunoblot (IB) assays. PA samples were eluted, and the eluates (water soluble material) were tested by EIA. Testing for HIV-1 antibodies by the PA fingerstick method produced results that were qualitatively equal to those of the serum antibody assays. The PA fingerstick method may be useful in large scale HIV surveys and screening programs. Obtaining blood specimens by this method is convenient, less expensive, and safer. PA fingersticks also facilitate specimen storage, transport and processing. (Consumer Summary produced by Reliance Medical Information, Inc.)

Intravenous drug abusers (IVDU) have been reported to experience multiple attacks of acute hepatitis, many of which have been attributed to non-A, non-B hepatitis (NANB). A specific enzyme immunoassay has been developed for identifying this virus, now characterized as hepatitis C virus (HCV). A group of 346 IVDUs in Amsterdam, who were enrolled in a study to determine the prevalence of human immunodeficiency virus (HIV) infection, were further examined to identify the prevalence, incidence, and risk factors for HCV infection. The percentage of IVDUs who had antibodies to HCV in their blood was very high; 74 percent among those who used illicit intravenous drugs, compared with 10 percent of those who used illicit drugs by other routes of administration. The results indicate that HCV antibodies disappear over time, suggesting that an even greater number of IVDUs had antibodies to HCV. Antibodies to HCV may develop up to 12 months after infection, further reducing the number of positive cases. Continuous and frequent IV drug use were specific risk factors for hepatitis C. Periods of fever, fatigue, and diarrhea are associated with the presence of HCV antibodies, and may be indicative of chronic liver disease. The prevalence rate of hepatitis C among IVDUs in Amsterdam was comparable to that of IVDUs in Spain, but less than that of IVDUs in Germany. (Consumer Summary produced by Reliance Medical Information, Inc.)

Group A beta-hemolytic streptococci bacteria (GASB) generally infect the throats of children and the skin of adults. If left untreated the bacteria can travel to infect the blood (bacteremia) and heart. Although the advent of antibiotics has reduced blood infections with group A beta-hemolytic streptococci, bacterial blood infections are still reported and the incidence may even be increasing, particularly among cancer patients, diabetics and intravenous drug abusers. GASB has been the source of some nosocomial infections, i.e. those acquired during hospitalization. The incidence of GASB blood infections in drug addicts recently admitted to a community hospital in Philadelphia was unusually high. The incidence increased from 2.5 per 10,0000 patients to 17.9. within 18 months. These results were compared with the incidence of infections in the four-year period before the outbreak. Although the number of admitted addicts remained unchanged, the number of addicts with soft tissue infections increased. Practitioners should be watchful for GASB infections in intravenous drug users. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objective: Although the consumption of abusive substances is almost as old as humanity itself, in the last 25 years new drugs of abuse have appeared. This has modified the type of overdose patient treated. We present the results of a study carried out in our hospital with the aim of profiling this type of patient. Methods: Records of patients attended in the Emergency Department of our hospital for a period of three months (March-May 2000) were reviewed and patients presenting because of drug overdose, including alcohol, were identified. The variables studied were age, sex, drug type, target organ, treatment given and evolution. The results were analyzed with the SPSS statistical program. Results: During the period studied, 36.712 patients attended the Emergency Department of which 151 (0.4%) were for overdose of drugs of abuse. Two-thirds (98 cases) were alcohol-only intoxications, and the remaining third (53 cases) overdoses of other drugs: cocaine (49%), amphetamines or ecstasy (21%), cannabis (19%) and heroin (17%); cases of LSD, liquid ecstasy, ketamine and trichloroethylene were also detected. The patients who presented after taking drugs of abuse were younger than those presenting after alcohol overdose (27 years vs 37 years). These patients (drug of abuse group) also needed greater therapeutic intervention (use of antidotes, pharmacological sedation or physical restraints), a longer stay in the Emergency observation unit and, on occasion (4 cases), admission to Reanimation or Intensive Care Units. The presence of patients who had ingested liquid ecstasy (gamma-hydroxybutyrate) or 'Special-K' (ketamine) was also notable, confirming the constant changes in abusive substances in our society. Mortality was 0% for both groups. Conclusion: Overdoses of drugs of abuse continue to be a daily problem in the Emergency Department. Patients seen as a result of drugs such as cocaine, amphetamines or heroin are younger and more often male than those seen as a result of alcohol abuse. Morbidity associated to alcohol abuse is less than with other drugs of abuse, requiring the use of less resources and with a shorter stay in the Emergency Department. In both groups the prognosis is good., Nogue S, Castro M, Medina M, Serrano L, De la Red G, Mestre G, Picon M, Corcuera R, Nicolas JM, Munne P. Intensive Care and Clinical Toxicology Unit, Hospital Clinic, [...]

Objective: Intoxications are frequent complications in drug users. These overdoses lead to coma or loss of physical control. Within 10 years 50% of all drug addicts have at least one overdose leading to hospitalization. 12% of drug dependent patients die from such an overdose. We therefore conducted a prospective study--still going on--to evaluate the motives and reasons which lead to intoxications in drug addicts. Methods: 20 patients (14 male and 6 female) all polydrug abusers who were admitted to our unit with an overdose were studied. After recovery from the intoxication the patient underwent standardized psychiatric interviews to assess the motives and circumstances that led to the intoxication. 4 questionnaires were used for each patient: Europ ASI (European Addiction Severity Index), AMDP (Arbeitsgemeinschaft fur Methodik u. Dokumentation in der Psychiatrie) IPC (Control of Reinforcement) and a test for judgment for potential suicide. The patients were scrutinized if an intentional intoxication seemed likely. Did the patient expect no harm to his health (risky behavior), did he expect to damage himself, did he expect to die? In self-inflicted harm the conflict that caused this action was looked at. In unintentional overdose it was investigated if the reasons were abstinence, underestimation of the dosage, an unusual combination of drugs or a previous consumption of ethanol. Results: In 12 patients (60%) the intoxication was intentional. In 8 patients (40%) an accidental overdose could be diagnosed. Of the 12 intentional intoxications two were severe suicidal attempts. 5 patients did not mind to die, 5 would not give reasons but were aware of having taken an overdose (risky behavior). In 8 patients the cause was a severe partner conflict (separation or divorce), 2 had general stress and two had other reasons. Of the 8 unintentional intoxications, 6 were under the influence of ethanol and doxepin, 2 took the wrong dose after abstinence. Conclusion: Overdoses in drug users are intentional in about 60%. Psychiatric investigation and intervention is imperative. Unintentional overdoses are due to a combination of substances of unknown interaction for the user. Overdoses after a period of abstinence are also seen. Muller R(1), Pfab R(2), Zilker Th(2) (1) Psychiatrische Klinik (2) Toxikologische Abteilung II. Med. Klinik, Klinikum r. d. Isar TU Munchen, Germany

The initial symptoms of infection with the human immunodeficiency virus (HIV) can resemble symptoms of mononucleosis, an illness characterized by fever, fatigue and swollen glands. The sudden, transient illness associated with HIV infection typically involves fever, sweats, muscle and joint pain, rash, diarrhea, and lymphocytic meningitis, the inflammation of membranes in the spinal cord and brain. The cases are described of two intravenous drug users who both developed a severe illness associated with fever, yeast infection of the mouth or throat, weight loss, muscle and joint pain, and fatigue. Symptoms developed two weeks after needle-sharing and lasted 7 to 10 weeks. Blood tests indicated that both patients were infected with cytomegalovirus and HIV-1. Studies have shown that cytomegalovirus enhances the growth and development of HIV-1, and this interaction between the two viruses may worsen disease activity as compared with infection by HIV alone. One patient recovered from the initial illness within six months but had a decreased number of CD4+ lymphocytes, a type of immune or natural defense cell. Lymphadenopathy, or disease of the lymph nodes, persisted after the sudden illness in the other patient, who is feeling well 21 months after the infection. (Consumer Summary produced by Reliance Medical Information, Inc.)

Cotton fever is usually a benign febrile, leukocytic syndrome of unknown etiology seen in intravenous narcotic abusers. Cotton and cotton plants are heavily colonized with Enterobacter agglomerans. We report a case of cotton fever associated with E agglomerans in which the organism was first isolated from the patient's blood and secondarily from cotton that he had used to filter heroin. Enterobacter agglomerans is with most probability the causal agent of cotton fever. Patients presenting with the classic history should have blood cultures performed and should be started on a regimen of empiric antibiotic therapy.

Sources: Eurosurveillance Weekly. 2003;7; ProMED-mail Post. November 30, 2003. An outbreak of tetanus involving 6 (and possibly 7) injection drug users in England and Wales has officials concerned that others [...]

An electroencephalogram (EEG) can be used to reliably predict which patients with histories of alcohol and drug abuse are prone to relapse. Researchers gave EEGs to 107 substance-dependent patients who [...]

Two patients with seasonal affective disorder (SAD; a condition of moodiness affected by seasonal changes) had fluctuations in cocaine craving that occurred simultaneously with seasonal disquiet or restlessness (dysphoria). This extends the range of disorders associated with cocaine use. (Consumer Summary produced by Reliance Medical Information, Inc.)