Varicose veins are twisted, gnarled and swollen veins which are usually seen in lower extremities  . These are more common in women than men  . Some associated risk factors and causes are: obesity, pregnancy, menopause, aging, prolonged standing and leg injury. Some other factors also exist that are less pervasive like the direct intravenous injection   . Intravenous drug abuse usually performs by drug users in the upper and lower extremities. Direct intravenous injection can have side effects which many of such cases have been reported so far. These include: infection, aneurysm, vascular necrosis and deep vein thrombosis. Based upon the radiologic texts, the present complication has relatively low incidence in general population and is valuable to be presented as a case report.
2. Case Presentation
A 26-year-old male referred to the clinical center with a bulging and pain in right inguinal area (Figure 1). The sociodemographic and clinical characteristics of this patient are shown in Table 1. Hehas had a history of substance abuse intravenously in his femoral vein two years ago. He noted that he had not been injected in this area from two years ago. No special past medical history such as: local or systemic infection, chronic non-communicable diseases existed. On examination, the patient was not febrile. Vital signs were normal. In the physical examination, no lymphadenopathy was detected. The femoral, popliteal, and distal pulses were touched. Vascular packets with extension to the groin as well
Figure 1. (a) Right inguinal demonstrates focal superficial protrusion, note prominent superficial veins at the periphery of the main lesion (arrows), (b) Gary scale ultrasound imsges from focal inguinal bulging demonstrates injection site (between arrows) con- nected femoral vein and varicose packets, FA (femoral artery), FV (femoral vein).
Table 1. Sociodemographic and clinical characteristics of the patient.
as prominent vessels around the mass were observed. The blood flows distri- buted from the femoral vein into the packets following Valsalva maneuver, and the direct connection with femoral vein was obvious. Dopler ultrasonographic evaluation conducted to assess the exact blood flow patterns and the existed connection between the femoral vein and varicose packets. Changes in blood flow after Valsalva maneuver was also represented in Figure 2. The patient was followed for treatment. At first, the patient underwent conservative management and then medical and surgical.
The leading causative agent of varicose veins is unknown. It involves about sixty percent of the general population in the modern countries with further epidemiologic prevalence in women  . Here in the present paper, we report a case of 26-year-old male with varicose vein secondary to direct intravenous drug abuse diagnosed by duplex ultrasound.
The mechanisms of varicosity are not obviously clarified. Reflux and incompetency occurring in the vein valves, and also dilation of the vein wall are primarily lead to venous varicosis  . Once the vessel wall escalating tensionshappen, the expression/activity of matrix metalloproteinases (MMP) are also increasing  . Endothelial cell damage causes a cascade of leukocyte infiltration and inflammation, leading to more vein wall injury. In addition to the common risk factor for the disease like: prolonged standing, superficial or deep vein clots, female gender, multiple pregnancies, increasing age and heavy lifting; there are some other various factors that cause such disorders with mentioned mecha- nisms. Unusual etiologies of varicose veins in the lower extremities was evaluated in study conducted by Seung Chai Jung et al.  . They reported that the major rare factor of developing varicose vein was vulvoperineal varicosity, fol-
Figure 1. (a) Duplex ultrasound image after valsalva at injection site demonestrates venous Doppler pattern; (b) Color duppler ultransound images after valsalva maneuver from injection site demonstrates deep to superficial direction of flow, note engorged va- ricose packets also.
lowed by round ligament varicosity, persistent sciatic vein incompetence, intraosseous perforating vein incompetence, Klippel-Trenaunay syndrome, congenital venous malformation, and portosystemic collateral-related varicose vein. In our study, the varicose vein packets developed following direct intravenous injecting in the femoral vein. Senbanjo et al. examined the types of drug used to inject in the groin and its local consequences and complicataions. The concluded that heroin was the most common drug with was abused and deep vein thrombosis was the most prevalent complication  . The diagnosis of the disease is not so difficult but the etiologic factor is important and always is questionable. Diagnosis is often delayed and patients are not managed precisely for long period of time.
This case report establishes new horizon for clinicians in order to consider more probable etiologic factors for venous disorders. Such unusual cases may be detected with the combined modalities of CT venography and Duplex sonography.
Conflict of Interest Statement
None of the contributing authors have any conflict of interest, including specific financial interests or relationships and affiliations relevant to the subject matter or materials discussed in the manuscript.
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