SHM Converge Scientific Abstract ePoster Gallery-The Tale of "Tranq Rash:" a Case of Xylazine-Induced Ulcerations in a Patient Who Injected Illicit Fentanyl

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A 37-year-old woman with chronic hepatitis C and opioid use disorder presented with two weeks of painful, foul-smelling ulcerative wounds on her bilateral arms and legs, along with subjective fevers and chills. She reported recent injection fentanyl use and reused dirty needles, though she denied sharing needles. On exam, she was afebrile and hemodynamically stable, but had multiple well-circumscribed ulcerating lesions with purulent drainage. Workup showed elevated inflammatory markers, negative blood cultures, a negative HIV test, normal transthoracic echocardiogram without vegetations, and no osseous abnormalities on X-rays.<br /><br />She was diagnosed with xylazine-induced skin ulceration complicated by purulent cellulitis. Xylazine is a veterinary alpha-2 adrenergic agonist increasingly found as an adulterant in illicit fentanyl. It has been associated with necrotic ulcerations in people who inject drugs, sometimes even at sites distant from injection sites. Proposed mechanisms include direct tissue toxicity, vasoconstriction, and local hypoxia. These wounds can become secondarily infected with organisms such as MRSA and beta-hemolytic streptococci, and may progress to cellulitis, abscess, osteomyelitis, or pyomyositis.<br /><br />She was treated with aggressive wound care and IV antibiotics, and started on buprenorphine for opioid use disorder. She was discharged to inpatient substance use rehabilitation. At follow-up, she reported gradual wound improvement after stopping illicit fentanyl use.<br /><br />Key takeaways are that hospitalists should recognize xylazine-associated “tranq rash,” consider secondary infection in these ulcers, and manage patients with wound care, antibiotics when indicated, harm reduction, infectious disease screening, and linkage to addiction treatment.

Asset Subtitle

Stephen Gurley

Meta Tag

Author List Alyssa Greenhouse, Carlos Saldana Ochoa, Stephen Gurley

Category Clinical Vignettes

Concept Xylazine

Concept Skin ulcer

Concept Skin Necrosis

Concept Wound Care

Concept Fentanyl

Distinguished Non-Finalist

Presenter Organization Emory University Division of Hospital Medicine

Presenting Author Stephen Gurley

Track Adult

Keywords

xylazine

tranq rash

fentanyl adulterant

skin ulceration

purulent cellulitis

opioid use disorder

injection drug use

wound care

MRSA infection

buprenorphine

Xylazine

Skin ulcer

Skin Necrosis

Wound Care

Fentanyl