SAEM Clinical Images Series: Xylazine Wounds

A 32 year-old male with PMH significant for opioid use disorder, a prior admission in 2021 for left-sided empyema s/p thoracotomy and decortication, gas bacteremia, and tricuspid endocarditis presented for a left leg wound. The patient reported a wound to his left leg that had become larger over the past 5 months. The pain worsened today, prompting him to come to the emergency department for evaluation. His mother, who was at his bedside, reported that the same type of wound occurred on his right arm “many months ago” and resulted in his arm “falling off”. He injects heroin into his leg and denies licking his needles. He reported intermittent subjective fevers for the few days prior to presentation. He last used heroin 2 hours prior to arrival.

Additional Images

Physical Exam

General: Patient appears very pale, cachectic, chronically ill.

HEENT: Mucus membranes dry.

Extremity: Right arm with exposed bone, wet gangrene noted to stump. Left calf with large wound, exposed muscle, and tendon noted. Movement of numerous maggots also noted throughout wound site. Patient unable to move leg secondary to pain.

Laboratory Data

CBC: Hgb 2.74 (compared to baseline of 9.0); WBC count 17.39

BMP: Na 126; K+ 5.9; Cr 2.7 (up from 0.69)

ESR: >100

CRP: 15.94

Case Question: What infection would be of highest concern if this patient was febrile, had notable crepitus in his left leg, and an elevated lactate?

Necrotizing fasciitis

Case Question: Will naloxone reverse a xylazine overdose?

No, xylazine is a non-narcotic drug and is not an opioid, thus, Narcan will not specifically reverse acute xylazine intoxication. However, fentanyl is the most common drug combined with xylazine. Thus, Narcan is reasonable to administer in the setting of a suspected overdose since the patient’s presentation can be due to combined use.

Xylazine, commonly known as “tranq”, is causing an emerging public health concern that is not only associated with severe respiratory and central nervous system depression but as illustrated by this case, is infamous for disfiguring and life-threatening skin ulcers. Xylazine is a non-narcotic drug mainly utilized for sedation, pain relief, and muscle relaxation in veterinary medicine. In more recent human use, it can be injected into muscles and veins, insufflated, ingested, or smoked. It has a large volume of distribution due to its lipophilicity and is rapidly concentrated in the CNS and kidney, with an elimination half-life of approximately 23-50 minutes.

In regard to treating resulting wounds, antibiotic coverage for secondary infection of xylazine wounds must cover MRSA and coverage for group A streptococci should also be considered.

For managing xylazine withdrawal symptoms, the Philadelphia Department of Public Health’s most recent recommendations include replacement therapy with alpha-2-adrenergic agonists such as clonidine, dexmedetomidine, tizanidine, or guanfacine paired with symptom management for pain using short-acting opioids, ketamine, gabapentin, ketorolac, acetaminophen, or NSAIDs.

Case Discussion

Take-Home Points

When treating xylazine wounds, assess for potential secondary infection including necrotizing fasciitis.
Use medications such as clonidine (alpha 2 receptor agonists) to manage symptoms of withdrawal, along with symptom management agents like short-acting opioids, ketamine, and NSAIDs.

References

Papudesi, Bhavani Nagendra, et al. Xylazine Toxicity – Statpearls – NCBI Bookshelf, www.ncbi.nlm.nih.gov/books/NBK594271/. Accessed 14 Dec. 2023.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.