Substance Abuse: Musculoskeletal ManifestationsDz

Synonyms: Intravenous drug abuse–associated arthritis, brown heroin syndrome.

ICD-9 Code: Drug addiction, 304.9; vasculitis, 447.6; arthralgia, 719.4.

Definition: Various musculoskeletal syndromes are described among substance abuse patients. Symptoms are caused by the offending drug or adulterants within the drug. Implicated drugs include stimulants (e.g., methamphetamines, cocaine), narcotics (heroin), and hallucinogens (D-lysergic acid diethylamide, LSD). Although patients may admit to abusing a particular drug, abuse of multiple drugs is common.

Etiology: Causes vary, including immune complex-mediated disease, foreign body reactions, vessel spasm/toxicity, or other as-yet unidentified mechanisms.

Pathology: Pathology varies, depending on the syndrome. Vascular lesions may be similar to those seen in polyarteritis. Refractile particles caused by talc or other adulterants may be seen in small vessels by polarized microscopy.

Demographics: Those engaging in substance abuse are at risk.

Clinical Syndromes
—Septic arthritis/osteomyelitis: Substance abusers are at higher risk of septic arthritis, septic bursitis, and osteomyelitis. Commonly infected joints include the glenohumeral, sternoclavicular, knee, sacroiliac, and spinal (possibly with septic discitis) joints. Vertebral osteomyelitis and osteomyelitis of appendicular skeleton have been reported.
—Drug withdrawal: Myalgias and arthralgias, with or without fever, may be seen during drug withdrawal.
—Intravenous drug abuse–induced angiitis: Polyarteritis-like angiitis has been seen in those abusing methamphetamines, LSD, and cocaine. Patients have been described with fever, weight loss, arthralgia, myalgia, hypertension, abdominal pain, neuropathy, encephalopathy, pulmonary edema, leukocytosis, hemolysis, proteinuria, medium and large vessel vasculitis, and death.
—Brown heroin: Musculoskeletal manifestations have been described in those abusing brown heroin. Brown heroin gets its color from adulterants (procaine or papaverine) or impurities of the opium plant during manufacture. Symptoms arise days to months after use of brown heroin. Patients may complain of neck or low back pain, myalgia, or stiffness. Joint pain tends to be periarticular, affecting the knees, ankles, tarsus, wrist, elbow, or shoulder. Inflammatory synovitis is uncommon. Laboratory testing abnormalities include increased ESR and hypergammaglobulinemia. A minority test positive for ANA, RF, syphilis, or cryoglobulins. Antibiotics are of no value, but ASA or NSAIDs may be effective.
—Cocaine vasculitis: Cerebral vasculitis, Raynaud’s phenomenon, myositis, rhabdomyolysis, and leukocytoclastic vasculitis have resulted from cocaine abuse. Such patients often have a very high ESR and an abnormal angiogram. Response to corticosteroids or cytotoxic therapy may be disappointing.
—Barbiturate-related connective tissue disorders: Patients using or abusing barbiturates (phenobarbital, primidone) are at low risk of developing arthralgias, Dupuytren contractures, or Peyronie disease. Bilateral rather than unilateral findings are common.

Also see Bacterial Endocarditis, Bacterial Arthritis, and Osteomyelitis.

Infectious Associations: Because of nonsterile injection techniques, patients may be at risk of septic arthritis, osteomyelitis, septic thrombophlebitis, local and systemic candidiasis, and subacute bacterial endocarditis. Septic arthritis and osteomyelitis are more commonly caused by gram-positive infections (e.g., S. aureus, S. pyogenes), but gram-negative (e.g., Pseudomonas, Serratia) infections are seen. Septic arthritis commonly affects the large joints (e.g., knee) but may also involve the spine or sternoclavicular joint.

Cardinal Findings: Cutaneous needle tracks and other stigmata of substance abuse should be carefully sought. Cellulitis and cutaneous abscesses may be associated with intravenous or subcutaneous drug administration. (See above for clinical presentations.)

Comorbid Conditions: Chronic alcoholism, depression, drug withdrawal, infections (e.g., bacterial sepsis, pneumonia, subacute bacterial endocarditis, hepatitis, candidiasis, tuberculosis, HIV), pancreatitis, and schizophrenia are possible comorbid conditions.

Diagnostic Tests: Toxicologic screening may be necessary to identify the offending drug(s). Leukocytosis, with or without eosinophilia, may be seen. Selected visceral angiography may be useful in documenting vasculitis.

Therapy: Discontinuation of the offending agent may improve clinical outcome.

BIBLIOGRAPHY

Kak V, Chandrasekar PH. Bone and joint infections in injection drug users. Infect Dis Clin North Am 2002;6:681–695. PMID:12371122

Lohr KM. Rheumatic manifestations of diseases associated with substance abuse. Semin Arthritis Rheum 1987;17:90–111. PMID:3334286

Merkel PA. Drug-induced vasculitis. Rheum Dis Clin North Am 2001;27:849–862. PMID:11723768