Heroin or Covid-19? Neurological, Hepatic, Renal, Cardiac, and Pulmonary Complications are All in One Case

the many patients of the COVID-19 clinic, where we are fighting the pandemic today. In this context, our case will shed light on the importance of differential diagnosis in the MODS clinic. A 29-year-old male patient was admitted to our emergency department with fever, malaise, shortness of breath, numbness and weakness in the right upper extremity, and occasional changes in consciousness. He stated that there was no history of any disease and drug use in the patient’s history. When the vital signs of the patient are evaluated; fever was 38.1, respiratory rate was 18/min, blood pressure was 100/60 mmHg, saturation was 95%, heart rate was 106 beats/min. In the physical examination of the patient, the patient was cooperative and orientated. Glasgow Coma Score was 15. Although the patient was tachypneic, respiratory sounds were bilaterally rough and occasional rales were heard by auscultation. In Abstract Multiple organ dysfunction syndromes (MODS) can occur for different reasons such as trauma, infection, and toxicity. Therefore, differential diagnosis can be difficult in patients who develop a MODS clinic. A 29-year-old male patient was admitted to our emergency department with complaints of fever, weakness, shortness of breath, numbness and weakness in the right upper extremity, and occasional changes in consciousness. In thorax computed tomography imaging; In the bilateral lung parenchyma, band formations were observed in ground glass. There was heroin use in his story. It caused a bad course in his clinic. He was discharged on the eighth day, provided that he had no active complaints and that his vital signs were positive and stable. It was aimed to discuss the causes of MODS in a patient who was admitted to the emergency room with heroin use and COVID-19 clinic in the light of the literature.


Introduction
Multi-organ dysfunction syndrome (MODS) can occur for different reasons, including trauma, infection, and toxicity [1].
Therefore, differential diagnosis can be difficult in patients who develop MODS clinic. For example, heroin may be among the toxic causes. Heroin, which is two times more potent opioid than morphine, is used by substance addicts for intravenous use or as a powder by inhalation. Although non-fatal overdose is common, rarely fatal overdoses are encountered [2]. There are data in the literature that heroin toxicity causes pulmonary edema, shock, myocardial damage, acute renal failure, rhabdomyolysis, and leukoencephalopathy. However, they all rarely occur in the same case [3][4][5]. The 2019 novel coronavirus (COVID-19) presents with a variety of phenotypes that range from asymptomatic to profound, rapid multiple organ dysfunction syndrome and death.
Proposed mechanisms for MODS in COVID-19 are multifactorial but include a hypercoagulable state with micro and macro-circulatory thrombosis [6]. In this case, we will examine the use of heroin, which is a toxic cause in the patient who presented with the MODS clinic, among the many patients of the COVID-19 clinic, where we are fighting the pandemic today. In this context, our case will shed light on the importance of differential diagnosis in the MODS clinic.

Case Presentation
A 29-year-old male patient was admitted to our emergency department with fever, malaise, shortness of breath, numbness and weakness in the right upper extremity, and occasional changes in consciousness. He stated that there was no history of any disease and drug use in the patient's history. When the vital signs of the patient are evaluated; fever was 38.1, respiratory rate was 18/min, blood pressure was 100/60 mmHg, saturation was 95%, heart rate was 106 beats/min. In the physical examination of the patient, the patient was cooperative and orientated. Glasgow Coma Score was 15. Although the patient was tachypneic, respiratory sounds were bilaterally rough and occasional rales were heard by auscultation. In the neurological examination, While motor function was normal in the right upper extremity, the patient was evaluated as hypoesthesia in the sensory examination. Other than that, there were no findings to suggest an acute pathology in other system examinations. Sinus tachycardia was observed on the patient's electrocardiogram.
Laboratory examinations and images of the patient were planned and taken to the observation room.   In the light of our current anamnesis, physical examination, and laboratory findings; we had to turn to the pandemic COVID-19 clinic, which is our current problem. We had the idea that the thorax bt image of the patient developed due to COVID-19 and all other pathologies appeared as a complication of this. We planned hospitalization by meeting with internal medicine and infectious diseases. However, the patient's subsequent relative stated that the patient had a high amount of heroin use last night, hiding it. This made us think that the current situation may also be a complication related to heroin use. Since the patient had a progressively worsening multiorgan dysfunction, we asked for an internal medicine consultation considering that the patient could benefit shown as fever in 88%, fatigue in 38%, dry cough in 67%, myalgia in 14.9, and dyspnea in 18.7%. The appearance of pneumonia is the most common and severe symptom of the infection. In this group of patients, respiratory distress occurred after five days of the disease, and 3.4% of patients developed acute respiratory distress syndrome. Critical illness (respiratory failure, septic shock, and/ or multi-organ dysfunction) was observed in up to 6% of cases Yang et al., [10] in their study conducted in 2020, 92 COVID-19 cases were examined and there were 14 patients with MODS clinic with multiple organ involvement. Of these, procalcitonin showed a significant increase in 12 cases, suggesting a possible infection, and 4 cases were associated with myocardial injury [11].
In line with what we said, a retrospective study involving 41 patients with COVID-19 reported that most of the infected patients with SARS-CoV-2 showed clinically mild symptoms, although few patients showed poor prognosis and eventually died from acute respiratory distress syndrome and MODS [12]. At the time when our case was admitted to the hospital, our hospital was a pandemic hospital, we approached every patient with this suspicion, and the patient's clinic was similar to COVID-19 patients with poor prognosis, and this led us as a preliminary diagnosis. In addition to all these, heroin use can cause similar situations. There are various hypotheses for the pathogenesis of heroin intoxication complications, including the primary toxic role of heroin, hypoxia, ischemia-reperfusion injury, anaphylactic reactions, and the toxic role of adulterants [4]. In the other case and review study of Feng et al., A case with multiorgan damage after heroin intoxication was shown similarly to our case [13]. Patients with heroin intoxication complicated by MODS have a higher mortality rate in the early period and when they do not receive effective medical services.
To normalize ischemia and hypoxia, respiratory and circulatory failure must be treated timely and effectively, because if this is not achieved, major organ functions can become permanent, increasing morbidity and mortality [14]. Also, there are resources that we can get support from the literature to explain the neurological complaints in our case. A case that caused complaints by causing myelinopathy in the brain associated with intravenous heroin overdose has also been reported [15].

Conclusion
In our case, we emphasized the differential diagnosis of heroin use and the covid-19 clinic. As seen in both our case and sample cases, pathologies that affect all organs and systems related to heroin use may occur. Again, in COVID-19 cases, it is obvious that the picture progresses to multiorgan insufficiency as the clinical worsening. The excessive number of COVID-19 cases, which is the most important problem of our day, should not cause us to ignore the cases that cause other similar clinics. In these cases, history and initial complaints and their duration are very important and will prompt us to think from all sides. Again, in these cases, early diagnosis and treatment have great importance; Its effect on reducing morbidity and mortality should not be underestimated.

Acknowledgement
The conception and design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work and revising it critically for important intellectual content; and final approval of the manuscript was done by Abuzer Coşkun, Assoc.

Availability of Data and Materials:
All data is available on request without restriction.

Conflict of Interest: None declared.
Informed Consent: Written informed consent was not necessary because the study was performed retrospectively by screening patient files.
Ethical Approval: Written with permission from the patient and local hospital administration.

Human Rights:
The study was made in following the Declaration of Helsinki for Human Research.