Krokodil (Desomorphine)-induced osteonecrosis of the maxilla: a case report and literature review

Abstract

Introduction: Desomorphine is an opioid formerly used to treat acute pain. It is simple to manufacture, which has recently led to an increase in its clandestine production under the name “Krokodil”. This article presents a case of oral problems related to its use first ever reported in France. Observation: A 36-year-old male patient presented with bone exposure in sector 1. He admitted to actively consuming “Krokodil IV” for several years. In the course of the clinical and radiological examinations, the patient was diagnosed with osteochemonecrosis of the maxillary induced by krokodil, considering that severe intrinsic and extrinsic adverse effects have been attributed to the drug. Discussion: A systematic literature review was conducted using articles from the Medline and Web of Science databases. To treat such a condition, two authors have described a process consisting of total excision of the necrotic tissue with 0.5 cm margins, combined with discontinuing the intake of the drug. However, these observations should be considered with caution because of the absence of any prospective studies. Conclusion: There are a number of etiologies for osteonecrosis in the context of radiotherapy, intake of bisphosphonates, and administration of bone resorption inhibitors. Unfortunately, in the case of krokodil, its high addictive nature makes it difficult for the patient to wean off the drug. Further, the heterogeneity of its manufacturing make it challenging to pharmacokinetically analyze its prolonged use. In view of the current literature, surgical therapy associated with weaning appears to be the most appropriate treatment, without being able to rule out addiction or necrotic relapses.

DARK Classics in Chemical Neuroscience: Heroin and Desomorphine

“…178 Subsequently, cases (both confirmed and suspected) have been reported in other European countries, such as France, 204 Italy, 205 Norway, 206 Spain, 207 and Poland, 208,209 with a significant part of them imported from Eastern Europe through immigrants from former Soviet republics. 204 It is noteworthy that various reviews mention cases reported in the Czech Republic, Sweden, Belgium, and Portugal, 190,208,210,211 but reliable information about these cases could not be found by the authors of the current review. In North America, some cases have been reported in both Canada 212,213 and the US 186,191,214−218 (in newspapers and scientific articles), most of which are heavily based on patient history and the admission of krokodil use by drug users.…”

“…Since its appearance in Russia, the drug quickly spread to other neighboring former Soviet republics, especially Ukraine (which had around 20 000 cases in 2011), , as well as Georgia, − Armenia, , and Kazakhstan. , The first western European country to report cases of krokodil use was Germany in 2011 . Subsequently, cases (both confirmed and suspected) have been reported in other European countries, such as France, Italy, Norway, Spain, and Poland, , with a significant part of them imported from Eastern Europe through immigrants from former Soviet republics . It is noteworthy that various reviews mention cases reported in the Czech Republic, Sweden, Belgium, and Portugal, ,,, but reliable information about these cases could not be found by the authors of the current review.…”

“…Another serious health complication presented by users of krokodil is jaw osteonecrosis, whose main feature is jawbone exposure in the oral cavity. Numerous such cases have been reported recently. ,,, A possible explanation for this devastating pathology is given in van Kempen and Brand’s work . According to their study, symptoms of krokodil-associated osteonecrosis are comparable to phosphorus and bisphosphonate-induced necrosis of the jaw. , The intravenously administrated homemade drug exposes the user’s blood to a high concentration of residual phosphorus compounds, which cannot be efficiently removed by the kidneys.…”

“…Numerous such cases have been reported recently. 201,202,204,249 A possible explanation for this devastating pathology is given in van Kempen and Brand's work. 249 According to their study, symptoms of krokodilassociated osteonecrosis are comparable to phosphorus and bisphosphonate-induced necrosis of the jaw.…”

How Do Drugs Affect the Skeleton? Implications for Forensic Anthropology

“…Due to the toxic substances in the manufacturing process of this highly addictive drug, as well as the injectable equipment and hygiene, the risk of infection is much larger and more severe than that of any other drug with the same administration [64]. Some of these drugs have also shown to cause necrosis of the mandible and maxilla [65,66].…”