Table 2.
Complications of Illicit Drug Use That Can Mimic Infectious Syndromes
| Syndrome | Agent | Clinical Features | Laboratory and Imaging Findings |
|---|---|---|---|
| Skin and soft-tissue syndromes | |||
| Skin ulceration | Krokodil [14] | Rash with scaly, green appearance, ulcerations, destruction of skin, muscle, cartilage, gangrene and skin sloughing | Nonspecific |
| Vasculitis | Levamisole [18, 20, 21] | Characteristic lesions are stellate lesion with erythematous borders and a necrotic center frequent on ears and cheeks | Agranulocytosis; positive titers of pANCA, cANCA, anti-cardiolipin, ANA, and anti-dsDNA; evidence of acute kidney injury in acute tubular necrosis pattern |
| Cocaine [26] | Urticarial vasculitis, Churg-Strauss vasculitis, necrotizing granulomatous vasculitis, palpable purpura, Buerger disease | Nonspecific | |
| Pneumonia and other pulmonary syndromes | |||
| Crack lung [27, 28] | Cocaine | Within 48 h of cocaine smoking: fever, dyspnea, pleuritic chest pain, hemoptysis, hypoxemia, respiratory failure | Imaging shows diffuse alveolar infiltrates, interlobular septal thickening, peribronchial nodules, ground glass opacities, nonspecific consolidation BAL with eosinophila, hemosiderin-laden macrophages, IgE deposition, hyaline membrane formation peripheral eosinophila |
| Subclinical alveolar hemorrhage [27, 28] | Cocaine (chronic use) | Largely asymptomatic; possible hemoptysis or nonspecific pulmonary symptoms | Diffuse alveolar hemorrhage with hemosiderin-laden macrophages in BAL fluid |
| Bronchospasm [27] | Cocaine | Bronchospasm with presentation resembling asthma; can be severe | Nonspecific |
| Pulmonary edema [28, 29] | Cocaine, amphetaminelike substances, heroin | Shortness of breath, cough | Radiographic evidence of bilateral or unilateral pulmonary edema; BAL fluid may reveal high protein concentrations |
| Pulmonary granulomatosis [27, 29] | Various drugs (intravenous drug injection or inhalation) | Pulmonary hypertension; interstitial fibrosis | Biopsy shows perivascular granulomatosis |
| Sepsis-like syndromes | |||
| Cotton fever [30–32] | Heroin | Fever, other typical sepsis features typically occurs 10–30 min after injection; usually self-limited | Leukocytosis, other sepsis features, negative blood cultures |
| Sympathomimetic effects [9–12, 33, 34] | MDMA, piperazine derivatives, synthetic cannabinoids, cathinone derivatives |
Tachycardia, hyperthermia, maybe be rhabdomyolysis with acute kidney injury | Synthetic cannabinoids, cathinone derivatives and piperazine derivatives not detected in standard urinary toxicology screens |
| Neurological syndromes | |||
| Stroke [11, 35] | Cocaine, methamphetamine, MDMA, synthetic cannabinoids, cathinone derivatives, marijuana | Abrupt onset of focal neurological symptoms, possibly accompanied by change in mental status or loss of consciousness | Evidence of ischemic or hemorrhagic stroke on brain imaging |
| Cranial nerve palsies [36, 37] | Black tar heroin contaminated with botulism and tetanus | Cranial neuropathy (including diplopia, opthalmoplegia, ptosis, and facial nerve palsy); may be accompanied by cellulitis, with possible necrotizing fasciitis and gangrene | Nonspecific |
| Seizures [9–11, 33] | Synthetic cannabinoids, cathinone derivatives, piperazine derivatives | Seizures; possibly status epilepticus | Synthetic cannabinoids and cathinone derivatives not detected in standard urinary toxicology screens |
| Leukoencephalopathy | Heroin [38] | Altered mental status, restlessness, apathy, cerebellar speech disturbance, ataxia, hyperactive reflexes, spasticity, tremor, choreoathetoid movements, hypotonia, areflexia, respiratory failure | Mild CSF pleocytosis; cerebellar signal abnormalities on MR images |
| Levamisole-adulterated cocaine [22] | Confusion, altered mental status, language impairment, visual changes, focal neurological deficits | White matter lesions on MR images, primarily affecting frontal lobes | |
| Gasteroenteritis syndromes | |||
| Intestinal ischemia [39, 40] | Methamphetamine, cocaine | Acute abdomen, abdominal pain, nausea, vomiting, diarrhea, melena, bloody stool, fevers, signs of shock | Colitis or abdominal perforation on imaging |
| Cannabinoid hyperemesis syndrome [41, 42] | Marijuana, synthetic cannabinoids | Abdominal pain, nausea and vomiting with relief of symptoms during warm bathing or showering | Marijuana but not synthetic cannabinoids at standard toxicology screening |
Abbreviations: ANA, antinuclear antibody; BAL, bronchoalveolar lavage; cANCA, cytoplasmic antineutrophil cytoplasmic antibodies; CSF, cerebrospinal fluid; IgE, immunoglobulin E; MDMA, 3,4-methylenedioxy-methamphetamine; MR, magnetic resonance; pANCA, perinuclear anti-neutrophil cytoplasmic antibodies.