A heroin addict with focal weakness

Abstract

A 24-year-old female with 5 year history of heroin abuse experienced painless stiffness of elbow joints and weakness of shoulder and upper limb muscles. She was injecting herself 4-6 times daily alternatively in the upper extremities, sparing the lower limbs. Electromyography (EMG) showed myopathic changes in clinically affected and unaffected muscles. Magnetic resonance imaging (MRI) revealed muscle fibrosis in directly injected muscles, whereas in subcutaneous fat and within muscles of anterior and posterior compartments of both thighs, not directly injected, there were signal changes supportive of oedema and inflammation. EMG and MRI were congruent in showing abnormalities in muscles not directly injected, suggesting long distant effects of heroin or adulterants with a mechanism either toxic or immunologically mediated.

Keywords: Heroin myopathy; focal myopathy; muscle fibrosis.

Figure 1.

(A, B) Severe wasting of patient's shoulder and proximal limb muscles. MRI (Philips 1,5T Akieva System) through mid-thighs. (C, F) Coronal and axial T1W images (TR 45-TE7) showing asymmetric focal hypointense areas. (D) Axial T2W (TR4600-TE 100) and (E)STIR images (TR 80-TE 6330) 10 mm thick showing enlarged muscles, edema-like hyperintense signal(white arrows) within and around muscles of anterior and posterior compartments and in subcutaneous fat.