oxymorphone and Purpura--Thrombotic-Thrombocytopenic

Topics: Analgesics, Opioid; Humans; Oxymorphone; Purpura, Thrombotic Thrombocytopenic; Thrombotic Microangiopathies

We report the case of a 22 year-old-woman who presented with upper extremity cellulitis secondary to an infiltration of illicit intravenous drug use. She confessed to the intravenous use of Opana ER (an extended release oral formulation of oxymorphone) which is an opioid drug approved only for oral use. She was found to have clinical evidence of profound thrombotic microangiopathy which resulted due to the intravenous use of Opana ER. She showed full clinical improvement after withholding drug and supportive clinical care. Recent report of Opana ER intravenous abuse was published from Tennessee county and has now been increasingly recognised as one of the causes of thrombocytopenia which mimicks clinically as thrombotic thrombocytopenic purpura. Physicians should be aware of this association as the lack of familiarity to this can pose serious management dilemmas for our patients (especially the polysubstance abusers).

Topics: Analgesics, Opioid; Female; Humans; Opioid-Related Disorders; Oxymorphone; Purpura, Thrombotic Thrombocytopenic; Substance Abuse, Intravenous; Thrombotic Microangiopathies; Young Adult

Topics: Adult; Emergency Service, Hospital; Female; Humans; Narcotics; Oxymorphone; Plasmapheresis; Purpura, Thrombotic Thrombocytopenic; Substance Abuse, Intravenous

In January 2013, the Centers for Disease Control and Prevention reported an illness associated with intravenous (IV) abuse of oral Opana ER (oxymorphone) in Tennessee. The clinical presentation of this syndrome was reported to resemble that of thrombotic thrombocytopenic purpura in the 15 patients reported; 12 were treated with plasma exchange. We report a similar case series of 15 patients with 18 episodes of thrombotic microangiopathy associated with recent IV abuse of oral Opana ER. In our series, we demonstrate that therapeutic plasma exchange is unnecessary; supportive care and treatment of underlying infections and renal dysfunction (without use of plasma exchange) resulted in clinical improvement in all patients. Thus, it appears that plasma exchange with associated costs and risks can be safely omitted in patients with thrombotic microangiopathy resulting from IV abuse of oral Opana ER.

Topics: Adult; Diagnosis, Differential; Female; Humans; Male; Middle Aged; Oxymorphone; Plasma Exchange; Purpura, Thrombotic Thrombocytopenic; Substance Abuse, Intravenous; Thrombotic Microangiopathies; Treatment Outcome; Young Adult

Topics: Anemia, Hemolytic; Delayed-Action Preparations; Emergencies; Female; Humans; Oxymorphone; Plasma Exchange; Purpura, Thrombotic Thrombocytopenic; Substance Abuse, Intravenous; Young Adult

On August 13, 2012, a nephrologist reported to the Tennessee Department of Health (TDH) three cases of unexplained thrombotic thrombocytopenic purpura (TTP), a rare but serious blood disorder characterized by microangiopathic hemolytic anemia and thrombocytopenia. The annual incidence is approximately 1 per 100,000 population. Known risk factors for TTP include infection with Shiga toxin-producing Escherichia coli (STEC) and the use of drugs, including platelet aggregation inhibitors, quinine, and cocaine. The three patients were intravenous (IV) drug users who resided in a rural county in northeast Tennessee. To identify other cases of TTP-like illness that might be associated with injection-drug use, TDH conducted a statewide investigation. By the end of October, a total of 15 such cases had been reported; none were fatal. A case-control study was conducted, and investigators determined that the cases of TTP-like illness were associated with dissolving and injecting tablets of Opana ER (Endo Pharmaceuticals), a recently reformulated extended-release form of oxymorphone (an opioid pain reliever) intended for oral administration. Fourteen of the 15 patients reported injecting reformulated Opana ER. Seven of the 15 were treated for sepsis in addition to TTP-like illness. Twelve patients reported chronic hepatitis C or had positive test results for anti-HCV antibody. Health-care providers who prescribe Opana ER and pharmacists who dispense it should inform patients of the risks from the drug when used other than as prescribed. Health-care providers should ask patients with TTP-like illness of unknown etiology about any IV drug abuse. Suspected cases can be reported to public health officials.

Topics: Adult; Analgesics, Opioid; Case-Control Studies; Delayed-Action Preparations; Disease Outbreaks; Female; Humans; Male; Middle Aged; Oxymorphone; Purpura, Thrombotic Thrombocytopenic; Risk; Sepsis; Substance Abuse, Intravenous; Tennessee; Young Adult