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Cocaine-Related Vasculitis Causing Scrotal Gangrene

Attending Physician, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Mei-Yu Jang, MD

Attending Physician, Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital

Chuan-Sheng Wang, MD

Attending Physician, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital

Kun-Bow Tsai, MD

Attending Physician, Department of Pathology, Kaohsiung Municipal Hsiao-Kang Hospital

Shu-Hui Chuang, RN

Nurse, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital

Huang-Chi Chen, MD

Attending Physician, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital

Jer-Ming Chang, MD PhD

Attending Physician, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital

Reprints: Dr. Huang-Chi Chen, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University 482, San-ming Rd., Kaohsiung, 812, Taiwan, Republic of China, fax 886-7-806-3346, chenhuangchi{at}gmail.com

OBJECTIVE: To describe a case of possible cocaine-related vasculitis resulting in gangrene of the scrotum and review the literature on cocaine-related vascular complications.

CASE SUMMARY: A 22-year-old male presented with fever, painful swelling of the right scrotum, and a blackened ulcerated lesion on the right scrotum 3 hours after smoking crack cocaine. Blood and urine cultures and serologic tests were negative, and the D-dimer level was normal. Echocardiogram showed no evidence of vegetation and results of a chest X-ray were normal. Despite treatment for presumptive orchitis with intravenous levofloxacin 750 mg/day, the ulcerated lesion of the right scrotum progressed the next day. The patient received debridement of the necrotic tissue and pathology revealed some degenerated vessels with fibrinoid deposits and inflammatory infiltrates, suggestive of vasculitis. No further tenderness and swelling of the scrotum occurred and the patient was discharged after 10 days. When he returned for follow-up, the wound had healed completely.

DISCUSSIONS: Cocaine-related vascular complications, including ischemic stroke, myocardial infarction, and peripheral occlusive disease, all of which have various possible mechanisms, are of clinical importance. Vasculitis is one of the mechanisms of vascular complications associated with cocaine use. According to the Naranjo probability scale, cocaine was the possible causative agent of the patient's vasculitis, which led to scrotum gangrene. To our knowledge, this is the first report in the literature of scrotum gangrene developing after crack cocaine was smoked.

CONCLUSIONS: This case report describes a rare occurrence of gangrene of the scrotum associated with cocaine smoking, which is consistent with cocaine's potent vasoconstrictive activity. Cocaine abuse has the potential to cause clinically significant ischemic events anywhere in the body, independent of the method of administration.

Key Words: cocaine, scrotum gangrene, vasculitis

Published Online, February 3, 2009. www.theannals.com, DOI 10.1345/aph.1L487