The 35-year-old showed up at the emergency department following three days of intense penis and scrotal pain, as well as in his groin and right foot. Upon inspection, the team found that he had swelling of the penis, as well as necrosis (death of tissue), ulcers along the shaft, and foul-smelling discharge.
Gangrene was ruled out, as were any sexually transmitted infections, and he was given antibiotics while the team cared for his wounds. It was suggested that they cut away the dead tissue on his penis, which the man refused. However, after 15 days in hospital, his wounds had improved, and infection was contained.
During his stay, the man reported that he had a long history of intravenous (i.v.) drug use, which had damaged other injection sites. With options running low, he turned to the dorsal vein in his penis. After using the vein twice in the prior two weeks, he experienced immediate pain on the third injection.
The team highlight that the use of this vein is associated with penile necrosis as well as gangrene, and so drug users need to be informed of the potential risks involved.
Additionally, they note that 80 percent of the cocaine seized in the United States is laced with levamisole – a medication used to treat parasitic worm infections – in order to increase profits, as well as enhance the effects of the cocaine high. The drug is associated with the development of necrotizing vasculitis (inflammation of the blood vessel walls) as well as necrotic lesions. This may have contributed to the damage done to his penis, though they were unable to conduct a urine test for the presence of the drug as it had been more than 48 hours since he had injected the cocaine.
"Our case highlights the importance of taking a thorough history from i.v. drug users, as they are at risk of injecting drugs into unusual sites, such as the dorsal penile vein," the team conclude in their report.
"It is important for the physician to counsel active i.v. drug users regarding possible complications of injecting drugs in atypical and dangerous injection sites."
The only treatment that could prevent further problems is the cessation of cocaine use, they note. Therefore, counseling and drug rehabilitation programs are recommended. Unfortunately, upon discharge from the hospital, the man refused drug rehabilitation and was later lost to follow-up.