510 - Upper Extremity Acute Compartment Syndrome Due to Cocaine Toxicity

Case Diagnosis: Acute Compartment Syndrome of the Left Forearm

Case Description: A 53 y.o. male presented with severe left forearm pain, paresthesia and worsening pain on passive stretch without history of trauma or prolonged immobilization. Laboratory investigations were significant for positive urinary drug screen for cocaine, thrombocytopenia, severe rhabdomyolysis and acute kidney injury. Hospital course was complicated with DVT, PE and acute ischemic stroke. Heparin was started; however, multiple episodes of bloody stool necessitated discontinuation of heparin and IVC filter placement. Patient also underwent left forearm fasciotomy and further debridement of nonviable tissue.

Discussions: The etiology of acute compartment syndrome (ACS) in the upper extremity is diverse. It is commonly associated with prolonged immobilization following drug toxicity. Our case report illustrates an unusual presentation of cocaine-induced widespread venous and arterial thrombosis causing DVT, PE, and ischemic stroke following cocaine abuse. Cocaine-related complications in the arterial circulation have been well-studied. However, widespread venous thrombosis from cocaine is rare. The mechanism of thrombosis is complex and includes endothelial damage which may also be a pathophysiological cause for ACS in our patient. Cocaine is a potent vasoconstrictor which decreases tissue perfusion, leading to skeletal tissue ischemia and direct myocyte toxicity further causing rhabdomyolysis. Compartment syndrome is a very rare complication of rhabdomyolysis.

Conclusions: ACS of the upper extremity is generally associated with trauma and/or prolonged immobilization in young men. Our patient is a rare presentation of ACS in a middle-aged male without history of trauma or prolonged immobilization in the setting of cocaine toxicity. To our knowledge, there are no reported cases of cocaine-induced ACS. The etiology is likely due to widespread thrombosis versus rhabdomyolysis which are both extremely rare in cocaine toxicity.