Vascular injury associated with IVDU includes inadvertent arterial injection with resultant vasospasm or thrombosis, septic thrombophlebitis, venous and arterial pseudoaneurysms and infected hematomas. Arterial injection rarely results in major vessel occlusion; instead, a commonly observed effect is pain, edema, and patchy mottling of the affected limb due to ischemia.35 Peripheral pulses are usually preserved. Tissue necrosis and gangrene are the consequence of persistent focal ischemia. The etiology is thought to be a combination of vasospasm of distal vessels, embolization of particulate matter, and endothelial injury leading to thrombosis and vasculitis.36
For limb ischemia, the vascular surgeon should be involved early to decide if surgical intervention or intraarterial thrombolysis is indicated. However, the majority of cases involve distal vessels, and treatment is primarily supportive medical management with heparinization. Limb edema can progress to compartment syndrome or rhabdomyolysis. Fasciotomy may be required for compartment syndrome. For patients who develop rhabdomyolysis, careful monitoring of fluid balance and renal function is required.
Infected pseudoaneurysm is one of the most common vascular complications reported in IVDUs.3738 Although pseudoaneurysms can form in any artery, they are most often reported in the femoral, followed by the radial and brachial arteries. Venous pseudoaneurysms are relatively rare and are usually secondary to septic phlebitis. The femoral vein is the vessel most often involved. Patients with either infected arterial or venous pseudoaneurysms usually present with fever and a painful mass, typically in the groin. Although similar in gross appearance to an abscess, the presence of pulsations and often a bruit should suggest this diagnosis. Because of the disastrous hemorrhagic consequences of attempted incision and drainage or medical management with a course of antibiotics, all painful masses, particularly in the groin, should be imaged, usually with duplex ultrasonography. Treatment for infected pseudoaneurysm usually involves resection of the infected vessel. Broad-spectrum antibiotics should be initiated in the ED and should cover the most likely organisms. Early revascularization at the time of resection of the pseudoaneurysm may be necessary.39
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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.