Flesh and Blood
Local health officials are investigating an unusual outbreak of a nasty bug hitting Portland heroin users.
BY CHRIS LYDGATE
Fatal drug overdoses are as frequent in Oregon as ever, according to the state medical examiner, who reported 185 deaths this year through October.
Local doctors estimate that as many as 70 percent of Portland's injecting drug users are carriers of Hepatitis C.
For the past six months, a dangerous and disfiguring organism has been slowly rippling through Portland's heroin users, leaving a trail of question marks in its wake.
The culprit, a common bacterium called Streptococcus anginosus milleri, ordinarily leads a harmless existence in the mouth or intestinal tract. But when it finds a way into the skin, especially of a person with a weakened immune system, the organism is capable of causing necrotizing fasciitis--better known by its tabloid nickname, "flesh-eating bacteria."
Since July Portland has seen 11 reported cases of necrotizing fasciitis, all at the Old Town Clinic on West Burnside Street, in the heart of skid row. All these cases occurred among heroin users who developed abscesses as result of "skin-popping," a method of injecting drugs into muscle tissue, primarily used by addicts whose veins have collapsed because of repeated injections.
"This is serious business," says clinic medical director Dr. Neal Rendleman.
Although abscesses are practically an occupational hazard among junkies, necrotizing fasciitis is a very unusual disease, according to the Centers for Disease Control and Prevention, which estimates there are fewer than 1,500 cases per year in the United States. "We have not heard of clusters of this infection in drug users before," says Dr. Paul Cieslak, an epidemiologist with the Oregon Heath Division.
Rendleman describes the typical necrotizing fasciitis abscess as "a cave of foul, dead, fat, oozing crap" that swells up as big and hard as an apple. The pressure inside the abscess is so great that it cuts off the flow of blood to the surrounding tissue, which liquefies and is then consumed by the sprawling bacterial colony.
Rendleman says one patient lost muscles in the buttock and upper thigh to the infection; another lost large parts of her shoulder muscle. From yet another patient, he drained an abscess that left a hole "the size of a volleyball." All patients responded well to treatment, beating the odds: The CDC estimates that necrotizing fasciitis kills approximately 20 percent of its victims.
It remains unclear exactly how the infection is spread from one user to another. Sharing needles is an obvious possibility, but contaminated heroin may itself be the source. Streptococcus is "certainly capable" of surviving in the dark, gummy, tar heroin prevalent on the West Coast, according to Karen Stefonek, an epidemiologist with the Oregon Health Division. Last year public health officials in California reported an outbreak of tetanus from tainted heroin, and in 1995 California witnessed several cases of botulism caused by bad dope.
Rendleman speculates that the source of infection may be the folks who smuggle the drugs into the country. He cites a technique known as "body-packing," in which drug couriers swallow condoms filled with heroin and sneak across the border. A tiny hole in a condom could allow the drug to be contaminated with bacteria from the courier's intestines. "Your thrifty dealer is not going to throw it out because there's a nick in a condom," Rendleman says. "And a nick visible to the naked eye is big enough for a million bacteria to walk through, arm in arm, singing the Marseillaise."
Other Portland doctors who work with drug addicts say they have not encountered the bug. Necrotizing fasciitis is not usually reported to state or county health divisions, but that doesn't mean it isn't out there. "There's some of it going on out there that we just don't know about," says epidemiologist Stefonek.
State and county public health officials are investigating the cluster of cases, which constitutes, "an unusual occurrence of disease," according to County Health Officer Gary Oxman of the Multnomah County Health Department. "We'll take a look at it and see if there's something we can do preventively."
Meanwhile, local health workers had better add another dangerous condition to the grim roster of drug-related diseases.
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Willamette Week | originally published December 22, 1998