Fatal sepsis with multiorgan failure due to accidental urine injection in a drug addict case

Local and even systemic inflammation associated with i.v.-injections in drug addicted cases is common. Although in-hospital treatment is sometimes lengthy outcome is usually favourable and fatal courses are rare. We report on an unusual case of accidental i.v.-injection of urine. The patient develop...

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Bibliographic Details
Published in:Clinical toxicology (Philadelphia, Pa.) Pa.), 2005-05, Vol.43 (5), p.519-520
Main Authors: Eyer, F, Pfab, R, Felgenhauer, N, Zilker, T
Format: Article
Language:English
Subjects:
Bacteroides
Escherichia coli
Klebsiella pneumoniae
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Summary:Local and even systemic inflammation associated with i.v.-injections in drug addicted cases is common. Although in-hospital treatment is sometimes lengthy outcome is usually favourable and fatal courses are rare. We report on an unusual case of accidental i.v.-injection of urine. The patient developed a fulminant Gram-negative sepsis with multiorgan failure and disseminated intravascular coagulopathy with an ultimately fatal course. A 33-year old drug addict patient injected accidentally 5 ml of her own urine (drug-free urine kept cool over one week for unanticipated drug-screening) in the femoral vein. She had confused it with her take-home dose of methadone, stored in a similar bottle. Soon after injection she was found confused with shivering and seizures. On admission she was disorientated with blood pressure of 90/60 mm Hg, heart rate of 120/Min and fever of 39.5 degree C. Laboratory tests showed signs of consumptive coagulopathy, leukopenia and electrolyte disorder. Because of respiratory depression the patient was intubated and mechanically ventilated. Escalating empirical antimicrobial treatment started with vancomycin, imipinem and fluconazol the first two days reduced to imipinem after evidence of Escherichia coli and Klebsiella pneumoniae in blood cultures. Severe coagulopathy was effectively treated with tranexamic acid (500 mg i.v. over three days), PPSB and fresh frozen plasma. Vasopressors (norepinephrine and dopamine) were used to maintain mean arterial pressure above 65 mm Hg. Acute renal failure required haemodialysis and ultrafiltration. Corticosteroid treatment with hydrocortisone (240 mg/die) was applied for 8 days. The further course was complicated due to gastrointestinal bleeding and peritonitis with evidence of bacteroides species in ascites fluid. Laparotomy revealed perforation of terminal ileum (mainly due to ischemic bowel lesions) with the need for partial ileum-resection. The patient could be weaned from mechanical ventilation eventually on day 18 with an initially uneventful further course. On day 25 the patient developed a cardiac arrest with primary successful resuscitation but electromechanical dissociation lead to death on day 26. Post-mortem autopsy showed a rough left ventricle without signs of ischemic lesions or the initial expected pulmonary embolism. Origin of myocardial alteration remains unclear. Although serious systemic inflammation associated with i.v.-injection in drug addict patients is rare, one has to be a
ISSN:1556-3650