Case Presentation: 17 year old female presented with a 2-day history of acute-onset, worsening left leg numbness and weakness in the L1-L3 distribution. On the day of admission, she developed facial swelling with pink-pustular plaques over her face and scaly erythematous patches over her left shoulder and hand. Past medical history included major depressive disorder, migraines, and heroin abuse with 3 months of abstinence. Unbeknownst to family, she had relapsed the day before her symptoms developed. She injected into her left antecubital vein. She denied any effect from the injection but awoke the following morning with left thigh swelling and her left leg positioned in severe external rotation. She reported using a needle exchange program and the same injection site. She obtained the heroin from a previously regular source, and there were no reports of illness in other users and no known additives. She was discovered to have rhabdomyolysis with creatine kinase (CK) to 57,000 iU/L, elevated troponin to 1.72 ng/mL, transaminitis (AST 1235 iU/L, ALT 201 iU/L), leukocytosis to 19,500/uL, and elevated inflammatory markers (CRP 5.8 mg/dL, ESR 49 mm/hr, and pro-calcitonin to 4.7 ng/mL). Her creatinine remained age-appropriate. Electrocardiogram and chest x-ray were normal. Doppler ultrasound of the left leg was without thrombus. CT pelvis revealed edema around the posterior and medial compartments of the left thigh. MRI of thoracic and lumbar spine showed myositis of the left piriformis and deep fascial inflammation without evidence of abscess. Echocardiogram was normal, and blood cultures were negative. Troponins and CK downtrended with appropriate hydration. Her left lower extremity deficits improved without specific intervention. Her skin findings were attributed to a fixed drug reaction related to her recent heroin use and responded rapidly to topical corticosteroids. Consideration was given to rheumatological or infectious processes; however, the temporal correlation with her heroin relapse and rapid improvement with minimal intervention argue against autoimmune etiologies. While her rash could have represented an embolic phenomenon, such as atypical Janeway lesions, she met no other criteria for endocarditis and did not subsequently develop any other associated symptoms.
Discussion: Acquired neuropathies, non-traumatic rhabdomyolysis, and compartment syndrome have been described as rare sequela of heroin use in the adult literature. The youngest patients described are young adults in their early twenties. Nearly all of these cases had subacute or chronic neurological symptoms and/or significant renal injury from the extent of the rhabdomyolysis. To our knowledge, this is the first pediatric case of heroin-related neuropathy and rhabdomyolysis, and the first to have a fixed drug eruption. Our patient improved rapidly and her neurological symptoms resolved completely. Some pediatric physicians have less experience managing patients after a significant drug reaction. It is crucial that pediatric providers be aware of the consequences of substance use.
Conclusions: Obtaining a confidential social history allowed recognition of her recent heroin relapse, which helped to make a diagnosis.