Ch 296 Injection Drug Users

Question 1

True or False. Drug related deaths produced more mortality than road traffic accidents or violence

Answer 1

True

Question 2

What is the most harmful type of drug abuse with a higher risk of fatal and non-fatal overdose and risk of infection?

A. Opioids
B. Cannabinoids
C. Hallucinogens
D. MDMA

Answer 2

A

Question 3

Of people who inject illicit drugs ___ million are infected with HIV and ___ million are infected with Hep C
A. 1.6 and 6.1
B. 6.1 and 1.6
C. 2.4 and 4.2
D. 3.5 and 5.3

Answer 3

A

Question 4

True or False. CDC does not recommend routine HIV screening in ED. Consent should be an “opt in” option

Answer 4

False

Question 5

Injection drug users are at risk for the ff
A. Tuberculosis
B. Kaposi’s sarcoma related herpes
C. Trauma
D. All of the above

Answer 5

D

HIV, Hepatitis, Kaposi’s sarcoma associated herpes, tetanus, tuberculosis, std

Trauma and intimate partner
P1979

Question 6

Injection drug use may induce immune dysregulation. Which of the following types of dysregulation may be seen?
A. Minor typical lymphocytosis
B. Increased lymphocyte responsiveness to mitogenic stimulation
C. Increased chemotaxis
D. Hypogammaglobulinemia
E. Decreased opsonin production
F. Decreased T-cell and Natural killer cell activity
G. A and C
H. B and E
I. All of the above

Answer 6

F

Exaggerated and atypical lymphocytosis Diminished lymphocyte responsiveness to mitogenic stimulation
Depressed chemotaxis,
Hypergammaglobulinemia
Increased opsonin production,
Decreased T-cell and natural killer cell activity, High levels of circulating immune complexes, Reticuloendothelial abnormalities can be evident with ongoing drug injection

Question 7

Incorrect laboratory results may also occur in injection drug users. Which of the following can be seen?
A. False-negative result on nontreponemal syphilis serologic test
B. Positive result on Coombs test
C. High measures antibody response to vaccination
D. TTP

Answer 7

B

False-positive results on nontreponemal syphilis serologic tests, positive results on Coombs tests, low measured antibody response to vaccination, and thrombotic thrombocytopenic purpura are possible in this population

Question 8

True or False. HIV infected injection drug users are less likely to suppress HIV-1 RNA hence leading to progression of infection

Answer 8

True

Question 9

True or False. It is prudent to suspect infection in all febrile patients with on going drug injection even with modest WBC counts and ESR rates are within normal ranges

Answer 9

True

Question 10

Important information to be obtained in injection drug user patients include

A. Drug type and amount
B. Use of lemon juice
C. Needle use
D. HIV/Hepatitis status and treatment
E. Comorbids
F. AOTA except B
G. All of the above

Answer 10

G

drug type(s) and amount, preparation of materials for injection (e.g., crushing capsules in the mouth, licking needles, blowing on injection sites or blowing out clots in needles, or using saliva, lemon juice, or tap or toilet water for drug reconstitution), reuse of needles, needle sharing and HIV/hepatitis status of drug-sharing partner(s), use of antibiotics, antiretroviral and hepatitis C therapy, and coincident medical and mental illness.
P1979

Question 11

1 in 30 female injection drug users has alloantibody in pregnancy leading to early pregnancy loss and poor obstetric case due to
A. Needle sharing
B. Multiple sexual partners
C. Blood transfusion
D. All of the above

Answer 11

A

Question 12

Noninfectious causes of fever include
A. Acute toxic reactions to substance
B. Reactions to injected adulterants
C. Withdrawal syndromes
D. AOTA

Answer 12

D

Noninfectious causes of fever include acute toxic reactions to substances of abuse, reactions to injected adulterants, and withdrawal syndromes. Cocaine and amphetamines can cause acute fever

Question 13

A patient is brought in by the police, The narrative was that the patient was seen in distress beside drug paraphernalia noting that the drug suspension was filtered through cotton balls. You suspect cotton fever, Findings include:

A. Depressed respiratory rate
B. Bradycardia
C. Inflammatory retinal nodules
D. All of the above

Answer 13

C

Patients with “cotton fever” develop a flulike syndrome within hours after injection with drug suspensions filtered through cotton balls. Findings may include tachypnea, tachycardia, abdominal pain, and inflammatory retinal nodules

CXR – normal or with pulmonary granulomata

Symptoms may resolve within 24 hours
P1979

Question 14

Patients withdrawing from barbituates or heroin may appear acutely ill, presenting with which of the following symptoms
A. Chest and abdominal pain
B. Diaphoresis
C. Tachycardia
D. Fever
E. AOTA

Answer 14

E

Question 15

True or False. Clinically well injection drug user patients may be managed as outpatient

Answer 15

True

Outpatient management is reasonable after culture specimens are obtained

Cultures are acquired when NO other source of infection is present in injection drug users to detect bacteremia or endocarditis

Question 16

True or False. Utilizing local needle exchange centers or supervised drug injection centers were found to have no impact in saving lives, preventing disease transmission and improving health

Answer 16

False

Question 17

A 37 year old injection drug user came in due to fever, cough, and dysuria. Upon PE, you note the presence of a heart murmur. What ancillary tests will you order?
A. Chest radiography; blood cultures; ESR CRP; echocardiography
B. CXR; blood cultures; ESR; CRP; TTE or TEE
C. Doppler US to evaluate abscess, septic thrombophlebitis
D. UA
E. Echo
F. A and B
G. AOTA

Answer 17

F

Question 18

A 42 year old injection drug user came in due to fever, nausea, vomiting, rigors and abdominal pain. Upon seeing the patient, you note that the patient is diaphoretic and admits a recent injection. What is your possible diagnosis?
A. Drug withdrawal
B. Cotton Fever
C. Hepatitis
D. ACS

Answer 18

A or B

Question 19

A 23 year old drug injection user comes in due to fever and back pain. On pe you note flank tenderness as well as decreased motor function on the right leg. You suspect an epidural abscess. Which of the following tests is indicated?
A. Blood cultures
B. ESR and CRP
C. Bone radiograph
D. CT or MRI
E. UA

Answer 19

All

Question 20

A 20 year old injection drug user comes in with a painful right arm. On assessment you note localized erythema, tenderness, and localized bruit. Which of the ff is a possible diagnosis?
A. Abscess
B. Pseudoaneurysm
C. Fasciitits
D. All of the above
E. A and C only

Answer 20

D

Question 21

A 50 year old injection drug user comes in due to eye pain and vision loss. Which of the ff are possible differentials?
A. RSV infection
B. N. Meningitidis
C. Kaposi sarcoma
D. Keratoconjunctivitis sicca
E. V. zoster
F. AOTA
G. All except A and B

Answer 21

G

Question 22

Pneumothorax and hemothorax are seen most commonly in injection drug users who practice

A. Pocket shooting
B. Drug dealing
C. Sharing needles
D. Using dull needles

Answer 22

A

Pneumothorax and hemothorax are seen most commonly in association with the practice of “pocket shooting,” in which drug users inject into the supraclavicular fossa to access the subclavian, jugular, or brachiocephalic vein.

Question 23

“Talc lung” is a syndrome that is composed of the following presentations

A. Sudden respiratory distress
B. Diffuse interstitial infiltrates
C. Ingestion of a talc adulterant
D. A and C

Answer 23

B

P 1981

1. Progressive respiratory distress
2. Diffuse interstitial infiltrates
3. Injection of a talc adulterant

Question 24

Which types of emboli are considered in injection drug users who present with dyspnea?

A. Septic
B. Air
C. Needle fragment
D. AOTA

Answer 24

D

P1981

Question 24

True or False. Hypersensitivity reactions in injection drug users who present with dyspnea typically respond to INHALED – B-agonist therapy

Answer 24

True

Question 25

CNS infections may result from contiguous spread of overlying soft tissue infection, embolic complications of distant infections (endocarditis), or local infections (vertebral osteomyelitis). Nervous system infections that commonly occur in this population include:
A. Epidural abscess
B. Bacterial meningitis
C. Fungal meningitis
D. Brain abscess
E. AOTA

Answer 25

E

Nervous system infections that com- monly occur in this population include epidural abscess, bacterial and fungal meningitis, and brain abscess

Question 26

What are the common microorganisms that cause bacterial meningitis in injection drug users?

A. Meningococcus
B. Pneumococcus
C. S. aureus bacteremia from endocarditis
D. AOTA

Answer 26

D

Meningococcus, pneumococcus, and Staphylococcus aureus bacteremia from endocarditis are common causes of bacterial meningitis

Question 27

An injection drug user comes in presenting with cranial nerve deficits, altered mental status and progressive symmetric paralysis. What infection should you consider?

A. Tetanus
B. Botulism
C. P. aeruginosa infection
D. N. meningitis infection

Answer 27

A or B

Both tetanus and botulism exist more often in patients who inject drugs and may present with cranial nerve involvement, altered mental status, and progressive symmetric paralysis.

Question 28

In injection drug users who are also HIV positive, a __ CD4 count predisposes them to opportunistic organisms such as toxoplasma

A. High
B. Low
C. Normal
D. CD4 count is irrelevant

Answer 28

B

P1981

Especially <100/mm

Question 29

Stroke syndromes can occur in injection drug users due to:

A. High-flow states during heroin intoxication
B. Sudden infarct due to emboli secondary to hypertensive state from amphetamine, phencyclidine or cocaine
C. Embolized vegetations associated with infectious endocarditis
D. AOTA

Answer 29

C

P1981

Stroke syndromes may occur secondary to low-flow states during heroin intoxication; hypertensive hemorrhage from amphetamines, phencyclidine, or cocaine; and embolized vegeta- tions associated with infectious endocarditis

Question 30

True or False. Delayed leukoencephalopathies, both hypoxic and nonhypoxic have been reported in injection drug users. This is a very common occurrence

Answer 30

False

Question 31

Usual imaging used to evaluate nontraumatic focal back pain in febrile or nonfebrile injection drug users to evaluate for possible injection
A. MRI
B. X-Ray
C. CT scan
D. Imaging in not indicated

Answer 31

A

P 1981

Nontraumatic focal back pain in febrile or nonfebrile injec- tion drug users requires imaging studies, usually MRI, to evaluate for possible infection.

Question 32

Features that suggest infection in chronic back pain include:

A. Pain that resolves when lying down
B. Severe night time pain
C. Improvement with conservative therapy
D. AOTA

Answer 32

B

P1981

In patients with chronic back pain, failure to inquire about a history of IV drug use or ignoring features that suggest infection (e.g., pain that does not resolve when the patient lies down, severe night- time pain, or failure of pain to improve with conservative therapy) can lead to missed diagnosis of a cord-compromising infections.

Question 33

Endocarditis in injection drug users is typically ___ sided, mostly involving the ___ valve followed by the ___ valve and the __ valve respectively

A. Right; Tricuspid; Mitral; Aortic
B. Right; Mitral; Tricuspid; Aortic
C. Right; Aortic; Tricuspid; Mitral
D. Left; Aortic; Mitral; Tricuspid

Answer 33

A

P 1981

Endocarditis in injection drug users is typically right sided (57% to 86% of cases); 55% to 94% of cases involve the tricuspid valve, 20% to 40% involve the mitral and aortic valves, and 5% to 14% involve both sides of the heart17,18 (see Chapter 156, “Endocarditis”).16 Hospitalizations for endocarditis are increasing in the setting of the current opioid epidemic.19

Question 34

Presenting symptoms of infective endocarditis include fever, murmur (65%), cough, pleuritic chest pain, and hemoptysis. What PE finding is most specific for the diagnosis?
A. Left—sided heart murmur that vary with respiration
B. Right-sided heart murmur that is consistent with respiration
C. Right-sided heart murmur that vary with respiration
D. Chest pain

Answer 34

C

P 1981

Presenting signs and symptoms in injection drug users with endo- carditis include fever, murmur (up to 65%), cough, pleuritic chest pain, and hemoptysis. Right-sided heart murmurs that vary with respiration are typically pathologic and more specific for the diagnosis.16 Multiple opacities on chest radiograph, consistent with septic pulmonary emboli, are common in patients with right-sided endocarditis (Figures 296-1 and 296-2).14 Other findings include pyuria (22%) and hematuria (35%) due to glomerulonephritis from immune complex deposition, embolic renal infarction, and perinephric abscess.17,21 Systemic embolization is found in approximately 22% to 50% of cases, and embolic infections may precede the finding of endocarditis in 25% to 60% of cases.1

Question 35

True or False. Classic findings of embolic phenomena: Janeway lesions, and Roth spots are usually observed early in the course and Osler’s nodules are usually seen in right-sided endocarditis

Answer 35

False

P1981

Diagnosis of infective endocarditis generally requires isolation of microbes in a blood culture and/or demonstration of typical lesions on echocardiography. The classic findings of embolic phenomena, including Janeway lesions and Roth spots, are usually not observed unless the infec- tion is advanced and occur in less than 15% of cases.21 Osler’s nodules are usually not seen with right-sided endocarditis. Obtain at least three sets of blood cultures from separate sites, with at least an hour’s wait between collection of the first and last set, before the initiation of antibiotic therapy

Question 36

What is the most common pulmonary infection in injection drug users?
A. CAP caused by S. Pneumoniae and H. Influenzae
B. Penumonia secondary to K.Pneumoniae
C. Aspiration pneumonia
D. PTB

Answer 36

A

P1982

Community-acquired pneumonia caused by Streptococcus pneumoniae and Haemophilus influenzae remains the most common pulmonary infection in injection drug users. Patients are also at high risk for infec- tion due to S. aureus, including methicillin-resistant S. aureus; Klebsiella pneumoniae infection; aspiration pneumonia; tuberculosis; and, in HIV-positive patients, opportunistic infections caused by Pneumocystis jiroveci, cytomegalovirus, and atypical mycobacteria. Suspect aspiration pneumonia in those with a history of depressed level of consciousness and/or radiographic infiltrate in the posterior or basal lung segments.

Question 37

In patients without risk for Pseudomonas infection, what is thte antibiotic for choice

A. IV quinolone
B. IV ceftriaxone
C. B-lactamase
D. A and B

Answer 37

D

P 1983

In patients without risk for Pseudomonas infection, an IV quinolone and IV ceftriaxone or cefotaxime are reason- able empiric coverage until culture results return.

Question 38

In patients with structural lung disease, malnutrition, recent corticosteroid and antibiotic use, Pseudomonas risk is high. In these. Cases what is the antibiotic regimen?

A. Cefepime + imipenem
B. Cefepime + meropenem
C. Cefepime + Fluoroquinolone
D. IV antipseudomonal fluoroquinolone

Answer 38

C

In those at risk for Pseudomonas infection (structural lung disease, malnutrition, current or recent corticosteroid use or antibiotic use), consider an IV antip- seudomonal -lactamase agent (cefepime, imipenem, meropenem, or piperacillin/tazobactam) and an IV antipseudomonal fluoroquinolone or, alternatively, an antipseudomonal -lactamase agent, IV aminogly- coside, and fluoroquinolone.

Question 39

This drug is given the nickname “the flesh-eating drug” because it contains large amounts of toxic components such as iodine and phosphorus which can damage skin, blood vessels, bone and muscles where limb amputation may be necessary

A. Desomorphine
B. Morphine
C. Metamphetamine
D. Cocaine

Answer 39

A

P1983
Desomorphine (street name Krokodil) typically contains large amounts of toxic components such as iodine and phosphorus and can cause serious damage to skin, blood vessels, bone, and muscles. Limb amputation may be necessary, which has given this drug the nickname “the flesh-eating drug.”2

Question 40

Cellulitis and abscess are typically caused by which organisms in injection drug users

A. S. aureus
B. Streptococcus
C. Community acquired MRSA
D. Eikinella
E. AOTA

Answer 40

A/B/C

P 1982

Cellulitis and abscesses are typically caused by S. aureus, Streptococcus, or community-acquired methicillin-resistant S. aureus.26

Question 41

Clostridium botulinum infection is common in injection drug users who engage in what practice?

A. Skin popping
B. Groin hit
C. Pocket shot
D. Sharing old needles

Answer 41

A

Abscess cultures may also demonstrate polymicrobial growth, with aerobic gram-negative rods, anaerobic cocci, and bacilli. Increased rates of Clostridium botulinum infection exist in injection drug users who engage in skin popping, particularly those using Mexican black tar heroin.

Question 42

What mode of injection can cause local gangrene and rapidly progressive and fatal fournier’s gangrene

A. Groin hit
B. Pocket shot
C. Skin popping
D. Antecubital vein injection

Answer 42

A

Question 43

What mode of injection can cause cutaneous abscess formation involving the carotid triangle resulting to airway obstruction, vocal cord paralysis and laryngeal edema

A. Pocket shot
B. Groin hit
C. Skin popping
D. Femoral vein injection

Answer 43

B

Question 44

Treatment for all uncomplicated small abscesses, large furuncles, carbuncles

A. I&D, oral antibiotics
B. Oral antibiotics only
C. IV antibiotics
D. I&D only

Answer 44

A

Incise and drain all uncomplicated small abscesses, large furuncles, and carbuncles. Treat injection drug users with superficial cellulitis without evidence of systemic involvement with oral antibiotics to cover strepto- cocci and methicillin-resistant S. aureus (see Chapter 152, “Soft Tissue Infections,” Table 152-2).27

Question 45

Management for toxic-appering patients not responding to oral therapy

A. Admission, Blood cultures, IV antibiotics, update tetanus immunization surgical mangement if needed
B. Step up oral antibiotics
C. Admission for observation
D. Load IV antibiotics and OPD ff up

Answer 45

A

P1982 For admitted febrile or toxic-appearing patients, obtain blood and wound specimens for culture and start broad-spectrum IV antibiotic therapy. Base antibiotic coverage on community microbial prevalence and host factors. Appropriate choices include a penicillinase-resistant synthetic penicillin or vancomycin plus an antipseudomonal aminogly- coside, antipseudomonal penicillin, or cephalosporin (see Chapter 152, “Soft Tissue Infections”). Update tetanus immunization.4

Question 46

Intra-arterial drug injection can result in an infected arterial pseudoaneurysm. Complications include life-threatening hemorrhage, sepsis, chronic claudication and limb loss. A pseudoaneurysm is similar to in gross apperance to an abscess. What PE finding suggests pseudoaneurysm over an abscess?

A. Pulsations
B. Bruit
C. Pain
D. Fever
E. A and B

Answer 46

E

A pseudoaneurysm is similar in gross appearance to an abscess; the presence of pulsations and a bruit suggest this diagnosis

Question 47

True or False. Osteomyelitis is more frequent in axial skeleton than in the extremities

Answer 47

True

Question 48

Most commonly involved structures in osteomyelitis in injection drug users

A. Vertebral column -> Sternoclavicular joint -> Sacroiliac -> extremities
B. Extremities -> Sacroiliac -> sternoclavicular joint-> vertebral column
C. Extremities -> Sternoclavicular joint -> Sacroiliac-> Vertebral column
D. Vertebral column-> extremities -> sternoclavicular joint-> sacroiliac

Answer 48

A

steomyelitis involves the vertebral column in approximately 50% of cases, particularly the lum- bar segments, followed by the sternoclavicular joint in approximately 18% of cases, the sacroiliac joints, and the extremities, especially the hip and knee joints, in 17% of cases.
Osteomyelitis coexists with spinal epi- dural abscess in approximately 80% of cases.32 Symptoms may be present for days in the case of bacterial infections or weeks in the case of fungal or mycobacterial infections.

Question 49

Suspected unusual infections or fastidious organisms require biopsy or needle aspiration of joint spaces and bony infections. Which oragnisms are in consideration?

A. S. Aureus
B. K. pneumoniae
C. E. corrodens
D. S. pneumoniae

Answer 49

C

P1983
Culture any drainage from a contiguous abscess. Biopsy or needle aspi- ration of joint spaces and bony infections may be necessary, especially in the case of infection with unusual or fastidious organisms, such as Myco- bacterium, Candida, or Eikenella. Eikenella corrodens osteomyelitis may occur in injection drug users who lick their needles prior to injection.
Base antimicrobial choice on culture results. Therapy is typically required for 4 to 6 weeks. Unstable injection drug users who are suspected of having osteomyelitis should receive vancomycin to cover S. aureus and ceftazidime to cover Pseudomonas (see Chapter 281, “Hip and Knee Pain,” Table 281-4).

Question 50

An injection drug user can in with a 4 day history of fever, that was follows by choorioretiniits and endophthalmitis after 2 weeks. What is the possible infecting organism?

A. Candida
B. Mycobacterium
C. Aspergillus
D. S. Aureus

Answer 50

A

P 1983
Candida species infection occurs in as many as 20% of patients with injection drug use–related osteo- myelitis. Candidal infections are probably hematogenous in origin and have been reported from the use of contaminated reconstituted lemon juice to mix drugs before injection. An initial flulike syndrome lasting 3 to 4 days is followed by the appearance of metastatic lesions involving the skin, eye (chorioretinitis and endophthalmitis), and then bones and joints several days to weeks later. Rarely, Aspergillus species may cause osteomyelitis of the sternum in injection drug users.

Question 51

True or false. MRI is the modality of choice for osteomyelitis in injection drug users

Answer 51

True

Question 52

True or false. Septic arthritis in injection drug users usually involves the knee or hip. Sternoclavicular septic arthritis strongly suggests injection drug use

Answer 52

True

Question 53

Rates of which kind of hepatitis are increasing secondary to injection drug use?
A. A
B. B
C. C
D. D
E. Non-A

Answer 53

C

Question 54

A 35 year old injection drug user came into the ED due to sudden onset pain, redness, lid swelling and decreased in visual acuity on his right eye. Which is true regarding this condition?

A. Ophthalmologic infections in injection users are due to lymphogenous spread
B. Inflammation is present only in the anterior chamber
C. White-centereed, flame shaped embolic hemorrhages. Cotton exudates and macular holes may be present
D. Strep is the most common pathogen followed by S. aureus

Answer 54

C

P1984
Ophthalmologic infections in injection drug users are usually the result of hematogenous seeding from a primary source of infection or from opportunistic infections associated with HIV disease. Bacterial endo- phthalmitis often presents acutely, with pain, redness, lid swelling, and decrease in visual acuity. Inflammation is usually present in both the anterior and posterior chambers. White-centered, flame-shaped embolic hemorrhages (Roth spots), cotton-wool exudates, and macular holes may be present. S. aureus is the most commonly isolated organism, followed by Streptococcus species. Treatment involves subconjunctival, intravitreal, and systemic antibiotic therapy. Surgical intervention, such as vitrectomy, may be needed.38

Question 55

Treatment of fungal ophthalmologic infections in injection drug users includes
A. Amphotericin B
B. Amphotericin lipid complex
C. Fluconazole
D. Intravitreous antifungal therapy
E. Early Vitrectomy

Answer 55

All

Fungal organisms, often Candida or Aspergillosis, but sometimes rarer organisms such as Torulopsis, Helminthosporium, and Penicillium species, are causes of endophthalmitis among injection drug users, notably from Mexican black tar heroin injection. In injection drug users coinfected with HIV, cytomegalovirus infection, toxoplasmosis retinitis, and choroidal Cryptococcus and Mycobacterium avium-intracellulare complex infections must also be considered. Symptoms include blurred vision, pain, poorly reactive pupil, and decreased visual acuity and can progress over days to weeks. White cotton-like lesions are seen on the choroid retina, with vitreous haziness. Uveitis, papillitis, and vitreitis also have been reported. Microbiologic diagnosis is made from the results of blood and vitreous culture. Treatment includes amphotericin B, amphotericin lipid complex, and fluconazole, with or without intravitre- ous antifungal therapy and early vitrectomy.

Question 56

Treatment of fungal ophthalmologic infections in injection drug users includes
A. Amphotericin B
B. Amphotericin lipid complex
C. Fluconazole
D. Intravitreous antifungal therapy
E. Early Vitrectomy

Answer 56

All

Fungal organisms, often Candida or Aspergillosis, but sometimes rarer organisms such as Torulopsis, Helminthosporium, and Penicillium species, are causes of endophthalmitis among injection drug users, notably from Mexican black tar heroin injection. In injection drug users coinfected with HIV, cytomegalovirus infection, toxoplasmosis retinitis, and choroidal Cryptococcus and Mycobacterium avium-intracellulare complex infections must also be considered. Symptoms include blurred vision, pain, poorly reactive pupil, and decreased visual acuity and can progress over days to weeks. White cotton-like lesions are seen on the choroid retina, with vitreous haziness. Uveitis, papillitis, and vitreitis also have been reported. Microbiologic diagnosis is made from the results of blood and vitreous culture. Treatment includes amphotericin B, amphotericin lipid complex, and fluconazole, with or without intravitre- ous antifungal therapy and early vitrectomy.