ANSWER 100
The initial diagnosis was a deep vein thrombosis. This complication is not unusual in
intravenous drug users and can be associated with sepsis although there was no sign of
this on the initial investigations. She has been treated for the thrombosis and for alcohol
withdrawal and her opiate use.
There are a number of possibilities for her acute deterioration. The deep vein thrombosis
would have predisposed her to a pulmonary embolus, but the normal respiratory rate, lack
of elevation of jugular venous pressure and normal oxygen saturation make this unlikely.
As an intravenous drug user she might have taken more drugs even under supervision in
hospital.
The tachycardia and lowered blood pressure raise the possibility of haemorrhage which
might be precipitated by the anticoagulants. However, the raised CRP, white cell count and
abnormal electrolytes in a warm, well-perfused patient suggest sepsisas the likely cause.
In an intravenous drug user one would think of infective endocarditis which may occur on
the valves of the right side of the heart and be more difficult to diagnose. Lung abscesses
from septic emboli are another possibility in an intravenous drug user with a deep vein
thrombosis, and a chest X-ray should be taken although the lack of respiratory symptoms
makes this less likely. In this case the intravenous line has been left in place longer than
usual because of the difficulties of intravenous access and it has become infected. Lines
should be inspected every day, changed regularly and removed as soon as possible. The
previous hospital admissions raise then possibility of infections such as methicillin-reistant
Staphylococcus aureus(MRSA). In this case MRSA was found in blood cultures and treated
with intravenous vancomycin with good effect.
On recovery and discharge there were problems with the question of anticoagulation.
Warfarin treatment raised difficulties because of the unreliability of dosing, attendance at
anticoagulant clinics and blood sampling. It was decided to continue treatment as an out-
patient with subcutaneous heparin for 6 weeks.
- Patients using intravenous drugs often pose problems in venous access, and sampling for
tests such as international normalized ratio (INR). - Indwelling venous lines should be changed regularly and removed as soon as possible.