Xylazine, an alpha-2 adrenergic receptor agonist typically used as a sedative and analgesic in veterinary medicine, is being illicitly supplied to persons who inject drugs (PWID), especially in Puerto Rico and Philadelphia, Pennsylvania in the USA. There is a high prevalence (up to 78%) of xylazine in fentanyl in these areas and also a steep increase in fatalities from its overdose.In this case report, we discuss a case of xylazine-induced skin ulcers in a PWID in the city of Philadelphia. The patient is a 37-year-old female who was injecting about eight to ten "bags" of "dope" (fentanyl, which is typically mixed with xylazine in Philadelphia) every day. She typically injected into her veins on the hands and sometimes into the legs. She presented with ulcers on her lower extremities extending from the knees to ankles, associated with copious purulent drainage and a foul smell. There was extensive necrosis of the subcutaneous tissues, abscesses, and tibial osteomyelitis. This led to multiple hospitalizations with bacteremia from Strep pyogenes, methicillin-resistant Staphylococcus aureus, methicillin-sensitive S. aureus, Enterococcus faecalis, Escherichia coli, and Proteus requiring intravenous antibiotics. She required debridement of the wounds and topical care to treat them.In the areas with a high prevalence of the use of xylazine mixed with fentanyl or heroin, abscesses, and painful skin ulcers are very often reported. The mechanism is thought to be due to its direct vasoconstricting effect on local blood vessels and the resultant decreased skin perfusion. Prolonged use can lead to decreased perfusion and impaired wound healing, leading to higher chances of infection of these ulcers. In addition to the topical effect of vasoconstriction, xylazine also leads to hypotension, bradycardia, and respiratory depression.A skin ulcer in a PWID, similar to the ones reported in our case, should raise clinical suspicion for the presence of xylazine in opiates and other substances.

No abstract

No abstract

Background:The US Food and Drug Administration approved the once-monthly injectable extended-release buprenorphine product to treat moderate-to-severe opioid use disorders. The patient in our case report had a liposuction procedure and immediately started having opioid withdrawal symptoms after the procedure. Case Description: The patient is a 27-year-old African-American woman who injects drugs and has morbid obesity. She enrolled in a medications for addiction treatment program and opted to get treated with extended-release buprenorphine monthly injections. She tolerated them well for a span of 6 months. In one clinic visit, she reported opioid withdrawal symptoms and started purchasing and using sublingual buprenorphine from her acquaintances. On review of history, she underwent liposuction surgery and this triggered the opioid withdrawal symptoms. Examining her abdomen revealed surgical scars at the site of the buprenorphine injection and the residual buprenorphine depot was not palpable.A subcutaneous injection of 300-mg extended release buprenorphine was administered in the right periumbilical area in this clinic visit. The following week, she was doing well and denied any withdrawal symptoms. Discussion: This is a unique case of "iatrogenic opioid withdrawal" after a fairly common surgical procedure. The extended-release buprenorphine formulation solidifies when it comes into contact with bodily fluids forming a depot. The depot and surrounding adipose tissue may have been removed during the patient's liposuction procedure, causing an immediate drop in buprenorphine levels leading to acute opioid withdrawal.This case report highlights the precautions that need to be taken before patients go for a surgical procedure like liposuction.