A 41-year-old man was admitted to hospital with painful necrotic leg ulcers (Figure 1). He exhibited narcotic-seeking behaviour, such as requesting narcotics daily, refusing non-narcotic analgesia and hiding narcotics, but he denied using injection drugs. The patient’s ulcers were irregular, with a peculiar black scale on the intact skin. Skin biopsy showed an extensive ulcer with neutrophilic inflammation, and heavy growth of Proteus vulgaris and Morganella morganii was seen on tissue culture. Our presumptive diagnosis was pyoderma gangrenosum with secondary infection. We prescribed prednisone, wound care and antibiotics, and our patient’s lesions began to improve. At the same time, we managed his opioid withdrawal symptoms. About a month into our patient’s stay in hospital, we learned from his roommate and family that he had been injecting a synthetic morphine derivative known as krokodil.
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