(659) Krokodil’s Grasp: Desmomorphine-Induced Necrotizing Soft Tissue Infection

Introduction: Desomorphine, a synthetic opioid with rapid onset and brief duration of action, is ten times as potent as morphine. Commonly produced illicitly as Krokodil, it involves codeine tablets and reagents like iodine, red phosphorus, gasoline, paint thinner, and hydrochloric acid. Injecting Krokodil has been associated with severe skin infections, osteonecrosis of the jaw, and multi-organ failure involving the brain, liver, kidneys, and lungs. We present a case of necrotizing skin infection related to Krokodil use, requiring multiple surgeries and prolonged ICU care.

Description: A 33-year-old male with a history of polysubstance abuse, ADD, and upper extremity cellulitis presented to the emergency room with wounds to his bilateral cheeks, jaw, soft palate, and neck, suspected to be from injecting desomorphine and inhaling cocaine per history from the patient. Due to concern for necrotizing soft tissue infection of the bilateral face and soft palate, he underwent emergent debridement of the left face wound. Due to severity of necrosis, a pedicled pectoralis myocutaneous flap with split-thickness skin graft for facial reconstruction and percutaneous tracheostomy were also done. A planned second-stage operation included further soft palate and facial reconstruction with additional skin grafting. The patient was agitated and delirious during his ICU stay but eventually recovered and was discharged home.

Discussion: Injecting desomorphine can cause severe soft tissue infections due to the toxic effects of the reagents used in its production. Our patient presented with facial skin, soft palate, and nasal necrosis associated with suspected desomorphine and cocaine use. Early recognition and aggressive management were crucial for a good outcome in our patient. Though rare in the United States and difficult to detect on screening assays, Krokodil's devastating skin and systemic effects necessitate rapid identification and treatment. Given the increasing prevalence of synthetic opioids and the potential for Krokodil production, individual case reports like ours can increase awareness and heighten clinical suspicion for Krokodil-induced necrosis in patients with a history of substance abuse.