Marked by the Mix

Author: Zainab O Adigun / Editor: Sarah Edwards / Codes: DC8, DP2, SLO1 / Published: 27/10/2025

A 40-year-old man with a history of chronic polysubstance use, including cocaine and ketamine, presents to the Emergency Department (ED) with worsening of longstanding bilateral leg ulcers, generalised rash and painful hand swelling. He reports a decline in health over the past couple of days, including fatigue, pain and foul-smelling ulcers. His chronic leg ulcers have been managed intermittently in both hospital and community settings. He was recently discharged from hospital a few days ago with acute infection of his leg ulcers and was treated with antibiotics which showed good improvement. He has been compliant with wound dressing and visits to community tissue viability team.

He still uses cocaine and ketamine. He denies use of any new medication, food or skin product. He says however that the only thing he noted was that the cocaine he used a couple of days ago tasted different and he suspects a “foul-play”

On examination, he looks well-kept albeit pungent odour in the examination room. He is alert and haemodynamically stable with mild tachycardia. Both lower legs are covered with wound dressing. Dressings are removed, revealing extensive ulceration with areas of purpuric rash but no clear signs of active infection such as pus or fluctuance. Also noted is generalised purpuric rash all over his 4 limbs and minimally in his trunk. The small joints of his hands are swollen, shiny and tender. He has no focal neurological deficit and no meningitis sign.

Initial blood test revealed neutrophilic leucocytosis and an elevated CRP which have been persistently raised with normal electrolytes, lactate and renal function.