18 y.o. man, recently returned from vacation in Ecuador, who presents with new onset seizure one hour after arrival in the ED with post-ictal confusion but no focal neurological deficits. Seizure was generalized (witnessed by physician). The patient received Ativan and Valium, after which he experienced no additional seizures. He did require intubation and ventilation. Of note, he had a dental procedure in Ecuador to relieve pain of an emerging wisdom tooth.
Patient is lethargic, with resolving confusion, afebrile, all vital signs stable with HR 80, BP 141/86.
HEENT: NC/AT, pupils slightly dilated, EOMI, tympanic membranes clear, CV: RRR, no MRG, Resp: CTA/B, Abd: S/NT/ND + BS, Ext: No CCE, Neuro: CN 2-12 grossly intact, Skin: Warm, no pallor.
Initial laboratories: WBC 13, H&H 16.5/47.9, Plts 313, PT 14.5, PTT 22.4, INR 1.25, Calcium 10.9, all other electrolytes WNL, AST/ALT 38/46
Drugs of Abuse: Cocaine, cannabinoid, benzodiazepine, opiate all presumptive positive, no amphetamine detected
Urinalysis: moderate ketones
CT Brain w/o contrast:
â€¢ No mass effect or midline shift
â€¢ Ventricles are normal in size and configuration
â€¢ Basilar cisterns are unremarkable
â€¢ Gray and white matter attenuation is preserved
â€¢ There are no intra-axial or extra-axial collections
â€¢ The calvarium is intact
â€¢ Mastoid air cells are clear
â€¢ Paranasal sinuses are clear
PA and Lateral Chest Radiograph:
â€¢ Trachea is midline
â€¢ Cardomediastinal silhouette is normal in size shape and position
â€¢ The lungs are clear bilaterally with sharp costophrenic angles and posterior recesses
â€¢ There are several oval densities projecting in the region of the stomach that appear to demonstrate air fluid levels on the lateral views
â€¢ The remainder of the visualized portion is unremarkable
â€¢ Bones demonstrate no evidence of fracture
â€¢ There is mild elevation of the left hemidiaphragm
Examination shows at least two separate spherical foreign bodies with thin slightly sclerotic rims in the stomach shadow. Several similar spheres are present in the left mid to lower abdomen and in the right mid abdomen. They are in the range of 2.5 to 3 cm in diameter.
â€¢ Metabolic disorders
â€¢ Alcohol withdrawal
Dx: Cocaine overdose secondary to rupture of latex cocaine packet
Dx Confirmed by: Abdominal radiograph, physical evidence of packet, exploratory laparotomy to remove additional packets, sigmoidoscopy
One day after emergency room admission, patient underwent exploratory laparotomy. Via gastrotomy, 10 cocaine packets were removed from the stomach. Additionally, mobilization of the small bowel using Kocher maneuver and dissection of lateral bowel attachments to liver and abdominal wall allowed manipulation of 5 additional packets down to the terminal ileum. Finally, a single packet was removed from the cecum via appendectomy. Patient did require medical intensive care unit care and intubation/ventilation for 12 days post admission.
Illicit drug importation into the United States occurs via several channels. In terms of acute medical consequences, smuggling of cocaine by body packers is most commonly associated with drug toxicity and fatality. The body packer is an international smuggler who ingests carefully packaged drugs in order to export them from their country of origin. The goal is avoidance of detection by law enforcement agencies as well as retrieval once the target import country is reached. While care is taken to ensure safe transit through the gastrointestinal tract without rupture, these measures are not always effective. Rupture then leads to acute cocaine intoxication and in turn, the morbidity and mortality associated with such an overdose.
Oral ingestion of small amounts of cocaine often has little toxicity because gastric acid hydrolyzes the drug to its inactive metabolite -- benzoylecgonine. However, rupture of a cocaine packet in the bowel may have significant morbidity and mortality. In patients with suspected oral ingestion or suspected body packing, monitoring for signs and symptoms of acute cocaine intoxication is imperative.
Toxic effects are most apparent in the cardiovascular and central nervous systems. Signs of acute cocaine intoxication include tachycardia, hypertension, mydriasis, and agitation. Patients with acute cocaine intoxication may present with signs/symptoms such as altered mental status, chest pain, syncope, palpitations, dyspnea, abdominal pain and seizures. Life-threatening complications include cardiac arrhythmias, myocardial infarction, cardiogenic shock, seizures, rhabdomyolysis, metabolic acidosis, hyperpyrexia, and intracranial hemorrhage.
Management of patients suspected of body packing in terms of observation time remains unclear. Many of these patients remain asymptomatic, and there is no clear relationship between quantity of cocaine ingested and the development of clinical symptoms. There is currently no consensus on suggested observation periods for these patients and proposed times range from 6-72 hours. Multiple case reports indicate that cocaine body packers can develop symptoms of acute cocaine intoxication at least 24 hours after ingestion, occasionally leading to death.
In terms of imaging, there is currently no gold standard for imaging patients suspected of body stuffing or body packing. However, computed tomography (CT) is generally seen as the best technique for packet detection although false negatives have been reported. Recent data indicates that unenhanced (non-contrast) multi-detector CT without bowel preparation is a fast, reliable and reproducible method for detection of ingested packets. Detection is improved by viewing at lung settings (window width 1000 Hounsefield units (HU), window level â€“700 HU) in addition to the usual abdominal CT settings (window width 350 HU, window level 50 HU). On abdominal radiography, packets may be visualised as oval or round soft tissue densities highlighted by a gas halo. Sensitivity of abdominal radiography is reported as 47-95% with supine radiographs providing superior images than erect.
Radiological signs: Double condom sign (air trapped in between packet layers from wrapping technique or fermentation), rosette sign (air trapped in packet knots)
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