An unusual cause of iron deficiency anaemia in an intravenous drug user

Abstract

A40-year-old intravenous drug user was admitted to the department of medicine with a painful swollen left leg. He freely admitted to injecting heroin (diamorphine) intravenously and had recently injected into his left leg. He had a 10-year history of illicit drug use and had previously attempted to stop with the use of methadone. There was no history of hepatitis, human immunodeficiency virus (HIV) infection or the sharing of syringes used for injection. Clinical examination revealed a thin, unkempt, middle-aged gentleman, who had pallor of the skin and the mucous membranes. He had evidence of drug ‘tramline’ marks, venous thrombophlebitis in his groins and both upper and lower limbs (Figure 1). There was no evidence of lymphadenopathy or signs of endocarditis. Chest and abdominal examination revealed no abnormalities. He had evidence of swelling, erythema and tenderness in the anterior lower left leg and there was no calf tenderness. The signs in his leg were consistent with cellulitis. Initial investigations revealed a severe hypochromic microcytic anaemia, a haemoglobin level of 4.3 g/dl with low serum iron, low ferritin and raised iron binding capacity consistent with iron deficiency anaemia. Electrolytes, liver function tests and clotting were normal. He was transfused four units of red packed cells and treated with intravenous antibiotics. He denied any history of maleana, haematemesis, rectal bleeding or haematuria. He denied usage of non-steroidal inflammatory drugs or aspirin. A Doppler ultrasound of his leg revealed no evidence of thrombus. A chest X-ray revealed no abnormalities. A transoesophageal echocardiogram showed no evidence of endocarditis. Tests for HIV, hepatitis B or C revealed no abnormalities. A gastroscopy revealed no abnormality and duodenal biopsies revealed no evidence of coeliac disease. Colonoscopy revealed no abnormality. Red cell isotope scanning using 51-chromium-labelled red cells and mesenteric angiography revealed no cause for blood loss. Repeated samples of urine revealed no red blood cells. He eventually admitted to injection with syringes into his groin, often hitting his femoral artery rather than the femoral vein, with concomitant loss of arterial blood on multiple occasions. We assumed that this was the most likely cause of his iron deficiency anaemia.

Trends and Outcomes of Cardiovascular Surgery in Patients With Opioid Use Disorders

“…Injection of opioid tablets intended for oral use may also contribute to the increase in blood transfusions. Just as in our study population, increased rates of anemia have been reported among IVDUs, although there is no consensus regarding the etiology . Microangiopathic hemolytic anemia generally occurs where red blood cells directly contact diseased blood vessels, especially in cases of inflammation, emboli, and pulmonary hypertension .…”

“…Just as in our study population, increased rates of anemia have been reported among IVDUs, although there is no consensus regarding the etiology. [37][38][39] Microangiopathic hemolytic anemia generally occurs where red blood cells directly contact diseased blood vessels, especially in cases of inflammation, emboli, and pulmonary hypertension. 40 Since these risk factors are all reported among IVDUs, it is possible that IVDUs are predisposed to microangiopathic hemolytic anemia and, hence, increased postoperative blood transfusions.…”

Anemia Burden, Types and Associated Risk Factors among Kenyan Human Immunodeficiency Virus-1 and Mycobacterium Tuberculosis Co-infected Injection Substance UsersAnemia Burden, Types and Associated Risk Factors among Kenyan Human Immunodeficiency Virus-1 a

“…Consequently, the current study found very high rates and levels of anemia in HIV and TB co-infected ISUs with a majority presenting with severe anemia. A case study in a heroin addicted injection drug user suggested that hitting the groinal femoral artery with a syringe instead of the femoral vein could be causing iron deficiency anemia in the patient ( 37 ). Additionally, Cocaine use has been linked with iron build up in the brain hence depleting iron supply for hemoglobin synthesis ( 38 ).…”