Case Presentation: Ms. C was a 44 yo female with a past history of IV methamphetamine and heroin use. She was involved in a motor vehicle collision in 2016, in which she sustained a right femoral neck fracture. At that time, she was transferred to our tertiary care medical center and underwent open reduction and internal fixation; four months later she presented to our institution with a right hip abscess. She underwent incision and drainage in the operating room and was started on intravenous antibiotics, but left against medical advice prior to completing them. She then presented one year later with a draining fistula from the hip region. A peripherally inserted central venous catheter (PICC) was placed and she was started on vancomycin and piperacillin/tazobactam. She was also placed on her home opiate medications on admission, with oxycodone for breakthrough pain. On hospital day three, she was seen by nursing staff and administered her evening dose of medications. Approximately thirty minutes later, she was found pulseless and unresponsive in her bathroom. She failed Advanced Cardiac Life Support (ACLS) protocol for 45 minutes and was pronounced dead. During ACLS, a syringe was found in her clothing, and therefore her body was sent to the coroner’s office for autopsy. It revealed the patient died “as a result of pulmonary embolism of pill material that developed as a consequence of IV drug abuse.” This was the second case of this unusual cause of death on the hospital medicine service in a three month period.
Discussion: The existence of pulmonary disease states associated with intravenous (IV) injection of crushed tablets intended for oral use have been reported in the literature for decades. Most of these disease states have been associated with the long-term effects of insoluble fillers, such as talc, depositing in the pulmonary arterioles and resulting in pulmonary foreign body granulomatosis, pulmonary hypertension and right heart failure. (Darke, 2015) These effects appear to be rare phenomenon and can take months to years to develop. Furthermore, there are treatments for these disease states and patients can live for decades after diagnosis. (Weinkauf, 2013) However, at our institution and within the past two years, we have experienced three cases of sudden death due to pulmonary embolization from injection of pill fragments. Two cases occurred on the hospitalist service and none responded to ACLS protocol.
Conclusions: 1. Further research is needed to determine if the incidence of sudden death due to pulmonary emboli from pharmaceutical pill fragments is increasing in incidence, or is unique to our tertiary care medical center.2. Hospitalists need to be vigilant about the risk of sudden death due to pulmonary emboli from injected pill fragments. Methods to Identify patients at risk and weigh the benefits of PICC use and oral opiate tablets versus the risks associated with each patient encounter need to be developed. Interprofessional teams, involving addiction specialists, can assist in this process.
3. Hospitalists need to take a leadership role in educating staff, patients and families on prevention of sudden death due to pill fragment injection.
References:
Darke S, Duflou J, Torok M. The health consequences of injection tablet preparations. Addiction; 2015. https://doi.org/10.111/add.12930. Accessed November 18, 2018.
Weinkauf JG, Puttagunta L, Nador R, et al. Long-term outcome of lung transplantation in previous intravenous drug users with talc lung granulomatosis. Transplant Proc 2013; 45:2375-7.