Nephrol Dial Transplant (2002) 17: 675-676
© 2002 European Renal Association-European Dialysis and Transplant Association
Images in Nephrology
Recreational drug abuse in a dialysis patient
(Section Editor: G. H. Neild)
Renal Unit, Royal Free Hospital, London, UK
A 45-year-old woman developed cellulitis of the left breast following injection of recreational drugs into a collateral mammary vein (Figure 1
). She had a history of injecting drugs both subcutaneously and intravenously since the age of seventeen.
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The patient first presented four years earlier with a right femoral vein thrombosis and a large abscess of the right thigh which had developed after injecting recreational drugs intravenously. On examination she had hepatosplenomegaly. Further investigation revealed 2 g proteinuria per day and advanced renal impairment. She was HCV positive and HIV negative.
Renal function did not improve and she started haemodialysis. A renal biopsy showed AA amyloid (Figure 2). She had a history of chronic suppurating skin infections from ‘skin popping’ with many disfiguring scars. This was the likely cause of her AA amyloid [1–3]. A serum amyloid P (SAP) scan, following intravenous administration of 123I human SAP, demonstrated a small total body amyloid load with abnormal uptake confined to the spleen (Figure 3). The absence of renal signal is due to poor organ perfusion in end-stage renal failure. The remainder of the image represents a normal distribution of tracer throughout the blood pool.
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The patient remains dialysis dependent, dialysing through tunnelled dialysis lines as she is unsuitable for either CAPD or an arterio–venous fistula. Her forearm veins have been destroyed by repeated use for her drug habit. Her dialysis has been plagued by repeated line infections, often caused by the patient misusing them. This has resulted in increasing venous occlusions. There are now life-threateningly few options for dialysis access. Currently both femoral veins are occluded and MR venography has shown that only the right brachiocephalic vein remains patent. In the photograph (Figure 1
) one can see the dialysis lines and the dilated collaterals across her chest. The patient's breast cellulitis demonstrates an uncommon variant of the complications that arise from recreational drug injection and her exploitation of her dilated breast collaterals has proved a painful lesson.
Notes
Correspondence and offprint requests to: Dr B. Thompson, Renal Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK. 
References
- Neugarten J, Gallo GR, Buxbaum J, Katz LA. Amyloidosis in subcutaneous heroin abusers (‘skin poppers’ amyloidosis). Am J Med1986; 81: 635–640[ISI][Medline]
- Tan AU Jr, Cohen AH, Levine BS. Renal amyloidosis in a drug abuser. J Am Soc Nephrol1995; 5: 1653–1658[Abstract]
- Menchel S, Cohen D, Gross E, Frangione B, Gallo G. AA protein-related renal amyloidosis in drug addicts. Am J Pathol1983; 112: 195–199[Abstract]
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