Digital ischaemia after intra-arterial drug injection

Description

A 62-year-old man presented with recurrent episodes of left-sided digital ischaemia (figure 1). His history was significant for chronic back pain and prescription opiate use. One year previously, he had an episode of ischaemia involving the left hand, requiring amputation of the left thumb and index finger. One month prior, he developed ischaemic digits of the left foot. Extensive serological evaluation of causes of vasculitis and thrombosis was negative. Left upper extremity arteriography demonstrated obstruction of the radial and interosseous arteries (figure 2). The ulnar artery was hypertrophied, suggesting a chronic process. Biopsy of the radial artery revealed polarisable microcrystalline cellulose pill filler material embedded in remote and subacute thrombus (figure 3). When informed of this finding, the patient acknowledged repeated injection of crushed hydromorphone tablets into his arteries over a period of several months after losing venous access. He underwent...

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