Severe necrotizing soft tissue injury with secondary multidrug-resistant wound colonization and infection in a patient with polysubstance use and suspected toxic adulterant exposure: a case report

Illicitly manufactured opioid preparations may contain toxic contaminants capable of causing severe local tissue injury. However, a causal relationship between a specific illicit preparation and extensive necrotizing lesions is often difficult to establish because analytical confirmation is rarely available. We describe a patient with polysubstance use who developed extensive necrotizing soft tissue injury, suspected sepsis with acute organ dysfunction, and acute kidney injury, followed by secondary healthcare-associated multidrug-resistant wound colonization and/or infection requiring prolonged surgical treatment. A 20-year-old man with a history of polysubstance use was admitted with suspected sepsis, acute kidney injury, and rapidly progressive haemorrhagic and necrotic lesions of both lower extremities after recent physical trauma. Toxicological screening was positive for opiates and tetrahydrocannabinol, but exposure to desomorphine was not analytically confirmed. Admission blood cultures and early wound cultures were negative; however, local microbiological samples were obtained after initiation of broad-spectrum antimicrobial therapy. Despite empirical antimicrobial therapy, progression of tissue necrosis necessitated repeated surgical debridement. Histopathology demonstrated necrosis of the skin and subcutaneous tissue with a suppurative inflammatory infiltrate. Later wound and tissue cultures yielded multiple healthcare-associated organisms, including VIM-producing Pseudomonas aeruginosa and vancomycin-resistant Enterococcus faecium , interpreted as secondary wound colonization and/or infection. This case illustrates the diagnostic difficulty of extensive necrotizing soft tissue injury in a patient with polysubstance use and recent trauma. The initial aetiology remained uncertain, while multidrug-resistant organisms isolated later were interpreted as secondary healthcare-associated wound colonization and/or infection. Repeated surgical debridement, culture-directed antimicrobial therapy, prolonged wound care, and reconstructive treatment were required.