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Citation
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Boukerma KA, Farah S, Magny R, Megarbane B, Houzé P, Labat L. Toxicol. Anal. Clin. 2022; 34(3, Suppl): S92. |
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Abstract
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From: 30th meeting of SFTA- 59th meeting of TIAFT - September 2022
Aim
To describe a fatal cocaine poisoning in a body stuffer resulting from extremely high plasma concentrations. Body stuffing refers to the swallowing of small amounts of poorly wrapped drug aiming to conceal it. Usually, complications are due to the direct drug toxicity (Roberts et al., Am J Emerg Med 1986:24-27). We report a 34-year-old male who developed seizures after swallowing small drug packs in a parking. Rapidly, he presented a cardiac arrest when the prehospital medical team arrived (no flow, 1min). During tracheal intubation, a plastic pack containing a white powder was extracted from the patient's mouth. Due to refractory cardiac arrest, venoarterial ECMO was implemented on intensive care unit (ICU) admission. Despite optimal supportive care, multiple organ failure developed, and the patient died 24h after ICU admission.
Method
Four blood and one urine samples were collected between ICU admission and death onset. The small pack containing a white powder was sent to the laboratory. Extensive toxicological screening was performed using immunological and enzymatic methods, LC-DAD/MS, LC-HR/MS and GC-MS. Plasma concentrations of cocaine and its two major metabolites benzoylecgonine and ecgonine methyl ester (EME) were determined using a specific LC-MS/MS assay. Toxicological analysis of the powder was performed using a specific GC-MS method.
Results
Cocaine and tetrahydrocannabinol screening was positive in urine. Plasma concentrations of cocaine, benzoylecgonine and EME were 8600, 13,420 and 9540ng/mL, respectively in the earliest sample collected 2.8hours post-cardiac arrest onset. In the last sample collected at 21.3hours post-cardiac arrest, plasma cocaine concentration declined to 1240ng/mL whereas benzoylecgonine and EME concentrations increased to 32,720 and 12,700ng/mL, respectively. Cocaine elimination half-life was estimated at 6h. During the first 4hours, metabolic ratios were 1.5 (benzoylecgonine/cocaine) and 1 (EME/cocaine) before a marked increase in benzoylecgonine/cocaine and EME/cocaine ratios up to 11-26 and 6-10, respectively. Positive tetrahydrocannabinol was confirmed in LC-HR/MS. No usual adulterant as levamisole or phenacetin compounds was detected in blood and urine. Quantitative analysis GC-MS analysis reported a pure cocaine powder.
Conclusion
The acute toxicity including sudden cardiac arrest in this body stuffer appeared in relation to extremely high plasma cocaine concentrations. Such elevated concentrations were rarely observed in body stuffers/packers (Soichot et al., ToxAC 2018;30:229-238) with metabolic ratios of ∼1 in the first hour post-ingestion. Here we described the time-course of plasma concentrations of cocaine and its metabolites during a 21h-period before the patient's death. There was a marked increase in cocaine metabolite concentrations and metabolic ratios, particularly the benzoylecgonine/cocaine ratio. Prolongation to 6h of cocaine elimination half-life was consistent with the previously reported value of 7.6h in a body packer (De Prost et al., Hum Exp Toxicol 2010;29:49-53). However, our report presents limitations related to the lack of information regarding cocaine consumption by the patient and the small sample number not allowing performing a toxicokinetic study. By contrast, to body packers, body stuffers mostly carry small cocaine amounts. However, cocaine concentration can be extremely high following the low-quality pack rupture in the stuffer's mouth like in our case. Drug purity found in our analysis supported a street deal with the attempt to conceal the sales product. Nevertheless, body stuffers are often drug users, which could be questioned in our patient, as suggested by the positive tetrahydrocannabinol screening. Our body stuffer developed a fatal cardiac arrest in relation to elevated plasma concentrations of cocaine and its metabolites resulting from a cocaine pack rupture. Toxicokinetic data are still expected to better understand the physiopathology of cocaine toxicity in such cases.
Language: en |