Mycobacteremia from Crushed Hydromorphone Tablet Injection

Mycobacterium abscessus is a fast growing, non-tubercular mycobacterium (NTM) found in water. NTM bacteremia is usually seen in immunocompromised patients who have intravascular catheters. Mycobacterium abscessus bacteremia is often caused by exposure to contaminated water supply in hemodialysis units. A 28-year-old female with poorly controlled diabetes mellitus, end stage renal disease (on hemodialysis via Ash catheter), and recurrent deep vein thrombosis presented to the hospital with proximal right leg deep vein thrombosis. On day nine of admission, the patient spiked a fever. Blood cultures revealed Mycobacterium abscessus bacteremia. The patient was observed to be crushing oral hydromorphone and injecting it into her ash catheter using needles retrieved from the sharps disposal container in her room. Although the Michigan Automated Prescription System (MAPS) report for narcotic abuse was unremarkable, a thorough review of her electronic medical chart revealed multiple hospitalizations with drug seeking behavior. This is the first reported case of crushed oral opioid injection resulting in mycobacteremia. Injecting crushed opioids has become more prevalent. Many opioid abusers resort to injecting them in order to achieve the psychotropic effects quicker. A heightened awareness about nontraditional modes of prescription drug abuse and surveillance by prescribers is necessary. This case raises an ethical question: should such patients be prescribed narcotics in the future, as the outcome of injecting oral medications can be fatal.