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27 y/o commercial sex worker and IV heroin addict was admitted to the hospital unresponsive with foul-smelling necrotic skin lesions on her arms and legs. In the ED, she received multiple doses of Naloxone and was started on IV Vancomycin and Meropenem. Her condition worsened, and she was then intubated and sent to the ICU.


Historically, she used 2-4 bags of heroin daily. Review of the medical records revealed several ED visits for drug overdoses; these episodes usually responded to Naloxone after which the patient would sign out against medical advice. The lesions on her extremities never progressed to requiring drainage.


After four days in the ICU, her vital signs and blood gases improved, and she was successfully extubated. Her Temperature and WBC with a differential had remained normal throughout her stay. Cultures of blood only showed Staphylococcus epidermidis in 1 of 4 cultures.


Her hospital course can be best explained by: