What is the appropriate management for a patient with a history of hidradenitis suppurativa, who is an intravenous drug user, presenting with leukocytosis and hyperlactatemia?

Management of Hidradenitis Suppurativa in an IVDU Patient with Leukocytosis and Hyperlactatemia

For a patient with hidradenitis suppurativa who is an intravenous drug user presenting with leukocytosis (WBC 11.5) and hyperlactatemia (LA 5.5), immediate empiric antibiotic therapy with oral ciprofloxacin is recommended, along with consideration for hospitalization and further diagnostic workup.

Initial Assessment and Immediate Management

Clinical Significance of Current Presentation

• WBC of 11.5 and lactate of 5.5 indicate potential systemic infection or sepsis
• IVDU status increases risk for:
  • Skin and soft tissue infections
  • Endocarditis
  • Bacteremia
• History of hidradenitis suppurativa (HS) provides sites for potential infection and abscess formation

Immediate Actions

1. Assess for signs of sepsis or severe infection:

   • Vital signs (fever, tachycardia, hypotension)
   • Mental status
   • Skin examination for infected HS lesions, injection sites, or other sources

2. Laboratory workup:

   • Blood cultures (minimum of two sets, including from any indwelling catheters) 1
   • Complete blood count with differential
   • Comprehensive metabolic panel
   • C-reactive protein and procalcitonin to assess infection severity 1
   • Blood gases to evaluate acidosis 1

Antibiotic Management

First-Line Therapy

• Begin empiric antibiotic therapy immediately with oral ciprofloxacin 1
  • Particularly beneficial in this patient population as it:
    • Is safe in patients with potential hepatitis (common in IVDU) 1
    • May improve survival and reduce risk of spontaneous bacterial peritonitis 1

Alternative Antibiotic Options

• If unable to use ciprofloxacin, consider:
  • Oral co-trimoxazole (trimethoprim/sulfamethoxazole) 1
  • Oral doxycycline (with caution due to potential drug interactions with HIV medications, which should be considered in IVDU patients) 1

Cautions

• Avoid rifampin in this patient population due to:
  • Potential hepatotoxicity in patients with possible hepatitis 1
  • Potential drug interactions with HIV medications 1

Management of Hidradenitis Suppurativa

Acute Management

• Assess all HS lesions for signs of acute infection requiring drainage
• Consider intralesional triamcinolone (10 mg/mL) for inflamed lesions not requiring drainage 1, 2
• For infected lesions:
  • Incision and drainage if fluctuant
  • Culture of drainage material
  • Antiseptic washes (chlorhexidine) 2

Long-Term Management (After Acute Issues Resolve)

1. For mild disease (Hurley I):

   • Tetracyclines for 12 weeks 2
   • Consider topical clindamycin 1% solution twice daily 1, 2

2. For moderate disease (Hurley II):

   • Clindamycin 300 mg + Rifampin 300 mg twice daily for 10-12 weeks 1, 2
   • Consider adalimumab if inadequate response 2

3. For severe disease (Hurley III):

   • Adalimumab as first-line therapy 2
   • Consider surgical intervention for persistent lesions 2

Special Considerations for IVDU Patients

Screening Recommendations

• Test for HIV, hepatitis B, and hepatitis C 1
• If positive for any of these conditions, coordinate care with appropriate specialists 1

Medication Adjustments

• For HIV-positive patients:
  • Consider doxycycline for dual benefit against HS and prophylaxis against bacterial STIs 1
  • Consider dapsone for added prophylaxis against Pneumocystis jirovecii pneumonia 1
  • Avoid rifampin due to drug interactions with HIV medications 1

Monitoring

• More frequent follow-up to assess:
  • Treatment adherence
  • Development of new infections
  • Drug interactions
  • Hepatic function if hepatitis is present

Pitfalls and Caveats

1. Don't miss sepsis: Elevated WBC and lactate may indicate severe infection requiring immediate intervention and possibly IV antibiotics.

2. Consider endocarditis: IVDU patients with bacteremia have high risk of endocarditis; consider echocardiography if blood cultures are positive.

3. Avoid assuming all lesions are HS: Some lesions may be injection-related abscesses or cellulitis requiring different management.

4. Watch for drug interactions: Many HS treatments may interact with substances used by IVDU patients or medications for HIV/hepatitis.

5. Be vigilant for malignancy: Long-standing HS lesions, particularly in the gluteal or perianal regions, can develop into squamous cell carcinoma 3. Any atypical or non-healing lesion should be biopsied.

This patient requires a careful balance between treating the acute presentation (likely infection with elevated WBC and lactate) while developing a sustainable long-term plan for managing their HS in the context of IVDU and potential comorbidities.