[SavageGlow]

The patient was a 68-year-old male with a past medical history of chronic kidney disease, tobacco use, cocaine use, frostbite wounds, and housing insecurity who was brought to the emergency department for altered mentation. Vitals on arrival were significant for temperature of 101.2 degrees Fahrenheit, tachycardia of 110 beats per minute, and blood pressure of 170/102 mmHg. He had a Glasgow Coma Scale score of nine (out of 15). Labs showed a creatinine of 2.58 milligrams per deciliter (mg/dL), creatine kinase of 975 units per liter (U/L), and troponin of 843 nanograms per milliliter (ng/mL); the troponin then downtrended to 437 ng/mL. The urine drug screen was positive for cocaine and fentanyl and urinalysis was positive for blood. The patient's mental status improved after naloxone was administered.

On physical exam, the patient was noted to have numerous tense, non-inflammatory bullae with surrounding erythema covering the scalp (Figure 1), right hand (Figure 2), and abdomen. Over the course of his hospital admission, he developed more bullae on his right shoulder, left thigh, bilateral calves, and right metacarpals two, three, and four. The patient also had patchy erythema on his lower extremities that developed into tense, large bullae. The bullae appeared violaceous in color and were tender to palpation (Figures 3-4). The bullae on the top of the scalp eventually ruptured and drained serous fluid.

Blood cultures, serous fluid cultures, and antineutrophil cytoplasmic antibody (ANCA) were all ordered and came back negative. The patient denied any history of blistering skin conditions or reactions to medications causing skin-related manifestations. A dermatology consult was then placed, and a diagnosis of coma bullae was made based on the correlation of the patient’s fentanyl-positive urine drug screen, prior history of drug-induced altered mentation, and the morphology of skin lesions. Regarding the violaceous bullae observed on his bilateral lower extremities, dermatology indicated that these were likely coma bullae with associated vasculitic features, possibly attributable to the patient's concurrent fentanyl and cocaine use. Recommendations were made to continue supportive care and allow the lesions to resolve independently in two to four weeks. If the bullae were to open and spill their contents, the patient was told to place an absorbent dressing.

The patient was scheduled for a wound care evaluation two months after being discharged from the hospital. His skin lesions had formed into dry, hard brown eschars with an underlying malodorous yellow-colored discharge (Figures 5-7). He was told to perform frequent dressing changes, apply collagenase ointment to open/yellow areas, and cleanse all sites within and around the wounds with a pure hypochlorous acid solution. Due to the persistence of his lesions despite several weeks of therapy, general surgery performed an excisional debridement.

[Mr.NoCredit]

Getting high to the point where he doesn’t have to concern himself with anything else but getting high.

Wasting good resources for other folks who really need it.

[Boneshaker]

in other words, homeless, and ingesting drugs that eat you from the inside out. Unfortunately, a problem that is getting worse..and this was a lucky one who got treatment, what about the ones that can't or don't it's endemic of what is happening all over the world due to the loss of governments that actually CARE about it's citizens. tsk tskk