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EV0657

Paradoxical coma bullae in methamphetamine use: cutaneous markers of severe rhabdomyolysis

PARADOXICAL COMA BLISTERS IN METHAMPHETAMINE USE: CUTANEOUS MARKERS OF SEVERE RHABDOMYOLYSIS

Coma bullae developing at pressure sites may be a visible marker of severe rhabdomyolysis and acute kidney injury due to prolonged immobility following stimulant use.

The aim is to report coma bullae as a marker of rhabdomyolysis and acute kidney injury (AKI) following intravenous methamphetamine use; although stimulant intoxication typically presents with agitation, profound immobility can occur after high-intensity use. The case involves a 30-year-old man who developed necrotic bullae on his shoulder and thigh following intravenous methamphetamine use and prolonged immobility; the morphology, distribution over pressure points, and laboratory findings were evaluated with pressure-induced coma bullae, levamisole-associated vasculopathy, and necrotizing soft tissue infection considered in the differential diagnosis. Laboratory findings revealed severe rhabdomyolysis with a creatine kinase (CK) level of 15,112 U/L, acute kidney injury with a creatinine level of 2.6 mg/dL, AST predominance with AST of 385 and ALT of 167 U/L (ratio 2.31), and no neutropenia, with a white blood cell count of 12,500/uL. The authors note that AST predominance in the context of markedly elevated CK supports a muscular source, but that the ratio alone is not specific. In the diagnostic reasoning, the distribution over pressure points, prolonged immobility, and co-occurrence of rhabdomyolysis and AKI supported coma bullae; the absence of neutropenia and the classic retiform pattern involving the ears or face made levamisole-associated vasculopathy less likely. It was emphasized that necrotizing infection must be urgently ruled out in the presence of pain, a toxic appearance, rapid spread, crepitus, or imaging findings suggestive of deep infection. The working diagnosis was pressure-induced coma bullae with severe rhabdomyolysis and AKI. In conclusion, stimulant exposure does not exclude immobilization injury; because bullae at pressure sites may indicate occult muscle injury and renal risk, CK, creatinine, electrolytes, and urine output should be assessed early, rhabdomyolysis should be treated while surgical emergencies are ruled out, and the skin–muscle–kidney axis should be considered rather than immediately labeling the lesion as vasculitis or infection.

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