[Acute right heart failure after intravenous application of heroin and flunitrazepam]

A 32-year-old woman was admitted to the emergency department because of acute dyspnea and syncope. A few minutes before the onset of symptoms, she had self-administered an intravenous injection of one gram of heroin combined with grinded flunitrazepam tablets.

Signs of acute cor pulmonale were detected on transthoracic echocardiography despite lack of pulmonary embolism in computed tomography. It was assumed that microembolisms were the cause of acute pulmonary hypertension after intravenous injection of heroin and flunitrazepam.

Because of lack of thrombus in CT scan therapeutic anticoagulation with unfractionated heparin and oxygen insufflation was initiated resulting in rapid improvement of oxygen saturation and blood pressure. On the following day pulmonary pressure in transthoracic echocardiography was already decreased significantly. Without signs of deep venous thrombosis in duplex scan and only a marginal sub segmental perfusion deficit in ventilation-perfusion-scintigraphy therapeutic anticoagulation was recommended for three months.

The most likely cause of micro embolisms in this case are particles of talc, which are often used to cut heroin, or the microcrystalline cellulose used in tablets. There have been reports of tissue necrosis due to arterial embolism/vasospasm by crystalloid or oily substances (embolia cutis medicamentosa) in the extremities after intraarterial injection of grinded flunitrazepam tablets. Therefore it seems plausible that intravenous application may cause a serve but transient deficit of perfusion in pulmonary circulation.