Brachial plexus lesions and rhabdomyolysis following heroin abuse. Indications for an immunological cause

: On the morning after taking alcohol in large amounts together with intranasal heroin, a 25-year-old man experienced pain, swelling and blistering in both arms together with right brachial plexus paresis. Creatine kinase (1930 U/l), acute phase proteins and IgE (238 IU/ml) were elevated. The pain was largely relieved by guanethidine block (given once only), and the swelling and blisters responded to methylprednisolone (80 mg daily for 7 days, then gradually reduced). Function returned in the lower division of the brachial plexus within ten days, but the upper division was still paretic 2.5 months later. After injecting heroin intravenously, a 27-year-old man woke up next morning with fever (39 degrees C) and proximal flaccid paralysis of the right arm. In addition to leucocytosis (25,600/microliters), creatine kinase was raised to 28,890 U/l and pANCA to a titre of 1:50 (antineutrophil cytoplasm antibody, perinuclear fluorescence pattern). The cerebrospinal fluid showed increases in cell count (15/microliters) and protein (73 mg/dl). Acute renal failure supervened after two days but was successfully treated. The paresis was still present at four months, though improved. A 21-year-old woman developed an upper brachial plexus lesion after attempting suicide with intravenous heroin accompanied by flunitrazepam (20 mg by mouth) and a bottle of whisky. She had raised levels of C-reactive protein (12 mg/dl) and IgM (4.0 milligrams). The paresis cleared up within six weeks without specific therapy. In view of the immunological abnormalities it seems possible that the immune system was involved in the pathogenesis of the plexus lesions and the rhabdomyolysis.