The lack of HCV clustering or transmission pairs is likely due to the smaller sample size than in other studies, as well as may relate uniquely to the geographically wide sexual networks in LAC compared to other urban areas. The lack of evidence of HIV-HCV co-transmission may reflect the low prevalence of HCV infection in the cohort, but may also suggest that co-transmission occurs infrequently, and that HCV infection is more often acquired following HIV infection, instead of simultaneously or preceding HIV infection, particularly in non-IDU settings. The lack of HCV DRMs is likely due to the few observed HCV infections.Methamphetamine is a central nervous system stimulant and is the second most commonly used illicit drug after cannabis.The effects of methamphetamine include euphoria, arousal, increased sexual pleasure, and psychomotor agitation. In particular, methamphetamine use is reported to prolong sexual performance and to delay and enhance orgasm. Worldwide, it is estimated that around 51 million individuals have used methamphetamine at least once in the last 12 months. The usage of methamphetamine is becoming increasingly popular in urban areas among gay and bisexual men with HIV. In San Francisco and Los Angeles, 11–13% of gay and bisexual men reported using methamphetamine in the past 6 months. Methamphetamine use for sexual pleasure is well documented. In addition to enhanced sexual pleasure, homosexual men have reported using methamphetamine to self-medicate the negative effects associated with HIV serostatus and may engage in hyper sexual behaviors without sexual protection. Concomitant illicit drug use occurs frequently with methamphetamine users and is associated with high-risk sexual behaviors. As methamphetamine is commonly used with other drugs, such as cocaine and rohypnol, container for growing weed it has been shown to promote high-risk sexual behavior, such as sex without condoms, anonymous sex, and receptive anal sex.
In contrast to its use for sexual enhancement, methamphetamine use has also been associated with genital self-mutilation. Methamphetamine is commonly administered via the following routes: intranasal, oral ingestion, pulmonary inhalation, and IV injection. In this case report, we describe two cases presenting to our urban county hospital associated with complications related to penile injection of methamphetamine. Both patients developed penile abscesses and required urgent surgical incision and drainage.A 47-year-old man with a history of methamphetamine use, prior penile abscesses, urethral foreign body insertions, HIV, hepatitis C, and diabetes mellitus presented to the emergency department with severe penile pain, fevers, and scrotal swelling. Several days prior to admission, the patient reported injecting methamphetamine into his corpus cavernosum. He denied any fever or difficulty emptying his bladder. He reported having sex with men without prophylactic condoms. He denied other active substance abuse and/or suicidal ideation. On exam, needle fragments were identified around the abscess cavity.Initial laboratory evaluation demonstrated a white blood cell count of 14,000/L, hematocrit of 40%, platelets of 316,000/L, creatinine of 1.01 mg/dL, and lactic acid of 0.8 mg/dL. Urinalysis was nitrate negative, positive for leukocyte esterase and had 10–20 white blood cells, 0–2 red blood cells, and squamous epithelial cells. Bedside ultrasound performed in the emergency room showed no apparent fluid collections in the penis. A contrast CT scan of the pelvis is shown in Figure 1. The patient was taken to the operating room on the day of admission for incision and drainage of complex penile abscesses.The abscess cavity was opened whereby 100 cc of purulent foul-smelling fluid drained spontaneously.The cavity was interrogated with a clamp and washed out with normal saline and packed wet to dry with gauze. An ultrasound of the right corporal base was performed which also demonstrated a 2 cm fluid collection, which was also drained similarly. There was no obvious involvement of the urethra. The patient’s postoperative hospital course was uneventful. He was placed on IV vancomycin and ertapenem .The patient was discharged two weeks following initial presentation.
His intraoperative wound cultures speciated with Streptococcus viridans spp.A 33-year-old male with no significant past medical history presented to the emergency department for evaluation of fevers, chills, and sharp penile pain, which began the day following a self-administered injection of methamphetamine into his penis. He denied any other significant past medical or surgical history. His family history was noncontributory. The patient endorsed a history of depression and reported having sex with only women. Laboratory studies showed a white blood cell count of 22,000/L, hematocrit of 37%, a platelet count of 374,000/L, creatinine of 1.11 mg/dL, and lactic acid of 3.9 mg/dL. CT scan of the pelvis with contrast is shown in Figure 2. Despite negative CT imaging, the patient was immediately taken to the operating room for incision and drainage after progressively worsening in the emergency department. A 17-French flexible cystoscopy confirmed no evidence of urethral erosion, injury, or stricture. After placement of a Foley catheter, a 7 cm incision along the right lateral aspect of the penis was performed whereby pus was drained. The abscess cavity was copiously irrigated and packed wet to dry. There was no involvement of the corpora or urethra. His postoperative course was complicated by pulmonary edema managed conservatively with diuresis. Initially, he was started on vancomycin and ertapenem antibiotics until his intraoperative wound culture grew sensitive Group A Streptococcusspp. He was discharged home with amoxicillin/clavulanate 875 mg/125 mg twice daily for 14 days based off antibiotic sensitivities.Here we discuss two case reports of penile abscesses following intracorporal injection of methamphetamine from an urban, county hospital. Both patients underwent surgical incision and drainage in conjunction with IV antibiotics. Prior literature has reported on the penile veins, specifically the dorsal vein of the penis, being used for IV drug administration and is associated with necrotizing ulcers. Prolonged IV drug users suffer from venous sclerosis and thus may resort to more dangerous sites of injection that is femoral, axillary, jugular, or penile veins. As a result from penile injections, penile gangrene has been reported.In both cases, the patients had a previous history of psychiatric disorders. The psychological reasons for penile injections are unknown. The first patient identified as a man who has sex with men . The second patient identified as a man who has sex with women . The use of methamphetamine has been reported to be up to 11– 13% among MSM from urban US cities. Although methamphetamine is often used to enhance sexual pleasure, no prior data suggests an association between penile injection drug use and sexual orientation. However, it has been documented that MSM who inject methamphetamine are more objectively impulsive. Treatment for methamphetamine addiction is limited with no approved medication for dependence. The route of drug abuse of methamphetamine does seem to impact treatment outcomes, as injectors have the poorest treatment prognosis as compared to intranasal users and smokers.
Although the exact psychological motivation for penile injection is unclear, more research is required, as this may become a growing trend among methamphetamine users. The diagnosis of a penile abscess is usually clinical along with supportive imaging studies, such as ultrasound or CT scans. More recent data suggest the use of magnetic resonance imaging to determine the extent of infection or inflammation, which can aid in surgical drainage of scrotal or penile pathology. For diagnosing other soft tissue abscesses, ultrasound is more sensitive than CT, but CT is more specific for superficial soft tissue abscesses. However, Case 2 in our report did not have radiological evidence of a penile abscess, yet pus was clearly identified in the operating room. Thus, clinicians must have a high index of suspicion for penile abscess with a patient who has a history of penile injection, along with penile pain and other signs of infection, such as fevers or a leukocytosis. MR imaging could be used if clinical symptomology is less clear. Although penile abscesses are relatively uncommon, a few case reports have been reported in the literature. Common etiologies of penile abscesses include trauma, injections, iatrogenic, or idiopathic. In the cases presented, we suspect the abscesses formed as a result of direct contamination from repeated intracorporal injections. Most penile abscesses are treated with surgical incision and drainage along with antibiotic therapy. Incision and drainage of abscesses, especially in patients with a history of IVDU, carry some risk of needle stick injuries to healthcare providers as a result of needle breakage.Therefore, healthcare providers should avoid blunt manual dissection at the time of surgical exploration. The most common complication following penile abscesses is penile curvature from fibrosis.Cannabis elicits in humans a complex subjective experience, a combination of mood elevation, heightened sensitivity to external stimuli, and relaxation ,cannabis square pot which results from the interaction of its main psychoactive constituent,9-tetrahydrocannabinol , with CB1 cannabinoid receptors in the brain . Functional imaging studies have shown that this drug-induced state is associated with changes in cerebral blood flow and glucose metabolism in limbic and paralimbic areas of the cortex that are involved both in the control of normal emotional behavior and the pathogenesis of depression . The idea that the mood-elevating properties of cannabis might be harnessed to treat depression was proposed first in the mid-19th century, but soon was disputed on account of the multiple side effects and inconsistent efficacy of the drug . Surprisingly, this controversy is still unsettled. Indeed, although clinical trials of cannabis in affective disorders have yielded mixed results , many patients continue to report benefits from its use in primary or secondary depressive syndromes . One likely explanation for these contrasting data is suggested by the diversity of functions served by CB1 receptors in the brain , which makes it difficult to separate the mood-elevating actions of 9-THC from its unwanted psychotropic effects. Synthetic cannabinoid agonists target the same receptors engaged by 9-THC and are limited, therefore, by equally narrow therapeutic indexes. An alternative way of enhancing cannabinoid function might be to use drugs that interfere with the deactivation of the endocannabinoids, anandamide and 2-arachidonoylglycerol . We have recently described a class of such drugs, which act by blocking the intracellular hydrolysis of anandamide by fatty-acid amide hydrolase . The index compound of this class, URB597, inhibits FAAH activity with nanomolar potency and has no affinity for CB1 receptors or other cannabinoid-related targets . This high degree of selectivity is paralleled by a lack of overt cannabinoid-like actions: For example, even when administered at doses that completely inhibit brain FAAH activity, URB597 does not cause catalepsy, hypothermia, or hyperphagia, three key signs of cannabinoid intoxication in the rodent . Notably, however, URB597 elicits profound anxiolytic-like effects in rats, which are prevented by the CB1 antagonist rimonabant . These findings suggest that FAAH inhibitors such as URB597 may selectively modulate mood states by enhancing anandamide’s interaction with a subset of brain CB1 receptors that are normally engaged in the processing of emotional information.
Here, we further tested this hypothesis, first, by examining the impact of URB597 on emotional and hedonic behavior and, second, by determining whether URB597 influences brain monoamine pathways that participate in the control of mood and reward.We have used the selective FAAH inhibitor URB597 to examine whether anandamide signaling modulates brain circuits involved in the control of mood and emotion. Our results show that administration of URB597, at doses that inhibit FAAH activity and elevate brain anandamide levels, enhances stress-coping behaviors and increases spontaneous firing of serotonergic and noradrenergic neurons in the midbrain. These actions are blocked by the CB1 antagonist rimonabant and are not accompanied by overt rewarding effects. We interpret these findings to indicate that endogenous anandamide interacts with a subset of brain CB1 receptors that concertedly regulate monoaminergic neurotransmission and stress responses. This interaction can be magnified, and consequently unmasked, by blocking intracellular anandamide degradation with URB597. Three lines of evidence suggest that anandamide modulates the emotional response to stress. First, stressful stimuli affect anandamide mobilization in brain regions that are involved in the control of emotions. In rats, for example, an electric shock to the paw elevates anandamide levels in the midbrain , whereas in mice, physical restraint decreases anandamide levels in the amygdala . Second, pharmacological blockade or genetic ablation of CB1 receptors exacerbates normal reactions to acute stress, presumably by disabling an endocannabinoid modulation of these reactions . Third, URB597 prolongs the time spent by rats in the open quadrants of an elevated maze , reduces the number of ultrasonic vocalizations emitted by rat pups after parental separation , lowers restraint stress-induced corticosterone release in mice , and prolongs nonopioid stress-induced analgesia in rats .