what is wrong?
Our patient had a brachial artery pseudoaneurysm. The astute ED physician recognized it immediately and did not attempt an I+D. this condition was first described in the mid 1800’s. A right brachial artery interposition bypass with vein bypass was done with closure of the R antecubital fossa wound with an adjacent tissue transfer. 6-acetylmorphine rose to 15 on hospital admission presumably from IV drug use. She signed out AMA but continued to take her antibiotics. . Cultures of the pseudoaneursym grew MRSA and blood cultures grew Pseudomonas. With an estimated 16 million IV drug users world wide, this problem will become more prevalent.
Infected femoral artery pseudoaneursyms (mycotic) are the most common arterial complications in IV drug abusers in a study from India. In this study by Saini, 40% were Staph aureus, 20% pseudomonas, 15% E coli. With the rest being Strep, and Acinetobacter. The current approaches are: ligation of the artery with local debridement, concomitant revascularization and delayed revascularization. Delayed bypasses involve a temporary bypass graft or a vein graft. Amputation was a complication of treatment in 4 of 72 patients.
Nearly one-third of patients in one survey of injection drug users admitted to licking their needles prior to injection. Int J Drug Policy 2008;19(4):342. This is done to test the quality of the drug, but exposes IV drug users to multiple pathogens. A second source of infection is using bottled water which is not sterile and often contains gram negative organisms. Counseling on these two risks may mitigate infections.
Saini N, Luther A, Mahajan A, Joseph A. Infected pseudoaneursyms in intravenous drug abusers: ligation or reconstruction? 2014. Int J Appl Basic Med Res. Sep;4(Suppl1):S23-S26.
Lenartoya M, Tak T. Iatogenic pseudoaneursym of the femoral artery: case report and literature review. Clin Med Res 2003Jul;1(3):243-247.
Tufnell J. On the influence of vegetations on the valves of the heart, in the production of secondary arterial disease. Q J Med Sci (Dublin). 1853;15(2):371-382.