Area surrounding the abscess is usually red, painful and swollen and the skin
surrounding the abscess can feel warm to the touch.

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  • Pocket of infection that forms at the site of injury.
  • Usually filled with pus.


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Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


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A 40–year-old male patient with type 2 diabetes, taking a “flozin” (SGLT2 inhibitor), calls your office because he is having difficulty urinating and quite a bit of pain in the perineal area. He has not felt well for several days and was running a low-grade fever. He went to his chiropractor 2 days ago when he only had pain and swelling in the scrotum and the chiropractor adjusted his … well, we won't go there….He is now noting that his temperature is higher (he doesn't have a thermometer and is reading his temperature via his old mood ring from the 1990s). You suggest that he present to your office.

Examination reveals an obese male who is waddling into the office because of pain in his scrotal area. Vitals: blood pressure 150/100 mm Hg, pulse 112 bpm, respirations 20 bpm, and temperature 39.0°C. Other significant findings include a swollen scrotum that is dusky red, exquisitely tender to touch, and without crepitus. You do not have extended laboratory access in your office, but a urine dipstick is negative for blood and leukocyte esterase. His blood sugar, which is usually fairly well controlled, is elevated at 320 mg/dL.

Your next step for this patient will be which of the following?

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The correct answer is B. You answered B.

The correct answer is “B.” This presentation likely represents Fournier gangrene (and remember that SGLT2 inhibitors, such as this patient is on, increase the risk of Fournier). The erythematous, swollen scrotum with pain out of proportion to examination and associated signs of fever, tachycardia, and elevated blood sugar make Fournier gangrene the most likely diagnosis. While crepitus is common with Fournier gangrene due to presence of gas-forming anaerobic bacteria, its absence does not rule out gangrene. Without early surgical debridement and IV antibiotics, infection can progress rapidly to sepsis and multiorgan failure. Therefore, “B,” emergent surgical referral, is the best option for this patient. Antibiotics, particularly oral (options “A” and “B”), are inappropriate as a sole therapy. Broad-spectrum IV antibiotics may be part of initial management, but “D” is incorrect because the patient emergently needs surgical debridement to remove the necrotic tissue.

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