Grand mal seizures temporally related to cocaine use: clinical and diagnostic features

The pathophysiology of cocaine abuse

Cocaine is a naturally occurring alkaloid that increases dopamine concentrations in the reward centers of the brain. There has been a marked increase in cocaine abuse over the last two decades. A neuropsychological stimulant, cocaine also reduces somnolence, increases alertness and improves concentration. However, cocaine abuse has many pathophysiological consequences. These fall broadly into four groups: pathology associated with a drug abusing lifestyle, pathology that occurs whilst intoxicated with (but not directly due to) the drug, pathology associated with drug administration and pathology resulting from pharmacological action of the drug. This review provides a detailed description of the physiological, pharmacological, and pathological effects of cocaine, and highlights the forensic and medicolegal implications of cocaine abuse.

Screening for stimulant use in adult emergency department seizure patients

OBJECTIVE

The objective of this study was to determine the prevalence of positive plasma drug screening for cocaine or amphetamine in adult emergency department seizure patients.

METHODS

This prospective study evaluated consecutive eligible seizure patients who had a plasma sample collected as part of their clinical evaluation. Plasma was tested for amphetamine and the cocaine metabolite benzoylecgonine using enzyme-mediated immunoassay methodology. Plasma samples with benzoylecgonine greater than 150 ng/mL or an amphetamine greater than 500 ng/mL were defined as positive. Patient demographics, history of underlying drug or alcohol-related seizure disorder, estimated time from seizure to sample collection, history or suspicion of cocaine or amphetamine abuse, results of clinical urine testing for drugs of abuse, and assay results were recorded without patient identifiers.

RESULTS

Fourteen of 248 (5.6%, 95% CI 2.7%-8.5%) plasma samples were positive by immunoassay testing for benzoylecgonine and no samples (0%, 95% CI 0-1.2%) were positive for amphetamine. Positive test results were more common in patient visits where there was a history or suspicion of cocaine or amphetamine abuse (p < 0.0005).

CONCLUSIONS

During this study period, routine plasma screening for cocaine and amphetamines in adult seizure patients had a low yield. As a result, routine plasma screening would yield few cases of stimulant drug in which there was neither a history nor suspicion of drug abuse in this population.

Crack cocaine ingestion with prolonged toxicity requiring electrical pacing

CASE REPORT

We report a 38-year-old man who experienced prolonged toxicity lasting over 16 hours from the time of ingestion of 1/4 ounce of crack cocaine. His illness included status epilepticus, wide and narrow complex bradyarrhythmias, ventricular arrhythmias, and delayed hyperthermia. His bradyarrhythmias were refractory to medicinal intervention and responsive to application of an external pacemaker. The patient recovered to his baseline state over the ensuing 48 hours.

Multiple cocaine-induced seizures and corresponding cocaine and metabolite concentrations

The etiology of seizures associated with cocaine use is unclear. Because cocaine seizures are relatively uncommon, they should be diagnosed by exclusion and a neurological workup to rule out central nervous system (CNS) catastrophe should be made. This report describes the clinical findings, treatment, and blood cocaine and metabolite concentrations in a patient who, on two separate occasions, had seizures associated with crack cocaine ingestion. Approximately 1 hour after the ingestion incidents, the patient had multiple, generalized seizures that abated spontaneously. His workup for CNS bleeding, infection, and trauma was negative. Cocaine concentrations on the first incident peaked at 2.48 mg/L and on the second incident peaked at 3.9 mg/L. Other clinical findings included tachycardia, hypertension, diaphoresis, and disorientation. Blood cocaine and metabolite analysis revealed extremely high concentrations. Other than the incident of seizures and transient cardiovascular aberrations, these high concentrations were tolerated by the patient without further sequelae. A review of cocaine-induced seizures and treatment is included.

Cocaine: pathophysiology and clinical toxicology

PURPOSE

To review the medical complications of cocaine abuse and the mechanisms of action of cocaine that contribute to medical complications.

DATA SOURCES

Pertinent articles identified through a MEDLINE search of the English-language literature from 1985 to 1996 and through a manual search of bibliographies of all identified articles.

STUDY SELECTION

All articles describing complications of cocaine use including case reports, small reported series, and review articles.

DATA SYNTHESIS

A qualitative description of reported complications.

RESULTS

Since the introduction of freebase and crack cocaine, multiple medical complications have been observed, and all major body organ systems have been affected. Cocaine can cause acute strokes, myocardial infarction, cardiac dysrhythmias, pulmonary edema, rhabdomyolysis, and acute renal failure.

CONCLUSION

Adverse reactions to cocaine should be considered in the differential diagnosis of acute ischemic events that occur in young adults. General awareness of the significant complications of cocaine will facilitate early diagnosis and prompt treatment.

Creatine phosphokinase elevation in patients presenting to the emergency department with cocaine-related complaints

The incidence of creatine phosphokinase (CPK) elevation was evaluated in patients presenting to an urban emergency department with any complaint related to cocaine use within the preceeding 24 hours. Patients with obvious causes of CPK elevation (ie, seizure) were excluded. Forty patients were enrolled. CPK values were elevated in 21 patients (53%). The mean CPK value for patients with an elevated CPK was 1,071 IU/L. There was no statistically significant difference between the patient's initial complaint (muculoskeletal, psychiatric, or cardiovascular) and the incidence of CPK elevation (P = .35). Thirty of the 40 patients admitted to using some other drug(s) in addition to cocaine in the preceding 24 hours. Some degree of skeletal muscle injury and CPK elevation appears to be common in patients using cocaine.

Clinical course of crack cocaine body stuffers

STUDY OBJECTIVE

To describe the clinical course of a cohort of patients presenting to the emergency department with acute crack cocaine body-stuffer syndrome.

METHODS

We conducted a retrospective cohort study in the ED of a county hospital with 75,000 visits per year. Our study cohort comprised all patients who presented between January 1993 and April 1995 and who met the definition of a crack cocaine body stuffer. We defined a crack cocaine body stuffer as anyone who admitted to or was strongly suspected of ingesting crack cocaine as a means of escaping detection by authorities, not for recreational purposes or as a means of transporting the drug across borders.

RESULTS

We identified 98 cases; most such patients were brought to the ED by law enforcement agents. Most were male and younger than 30 years. Self-report by patients indicated that the amount of crack cocaine ingested ranged from 1 to more than 15 rocks. Most commonly the drug was unwrapped (28%) or wrapped in a plastic sandwich bag (29%). Generalized seizures developed in 4% of the patients; in all these patients seizures occurred within 2 hours of ingestion. In no patient did dysrhythmias develop. Many patients had minor signs of cocaine intoxication: 54% were tachycardic, 23% were hypertensive, 22% were agitated, and 19% required sedation.

CONCLUSION

Mild cocaine intoxication is common in crack cocaine body stuffers, with seizures occurring within 2 hours of ingestion in a small percentage of patients.

The effects of nimodipine on the EEG of substance abusers

Cocaine abusers have increased EEG beta and areas of reduced cortical blood flow. Since, nimodipine has neuroprotective effects and increases blood flow, we investigated the efficacy of single and multiple doses of the nimodipine in normalizing the EEG of substance abusers. Fourteen subjects received single (0, 30, 60 mg) and eleven received multiple daily (up to 150 mg in 12 hours) doses of nimodipine to determine whether this drug would increase EEG alpha and decrease beta in substance abusers. The EEG was recorded from eight scalp locations (F3, C3, P3, O1, F4, C4, P4 and O2) for three minutes during eyes closed, and eyes open conditions. Single and multiple doses of nimodipine produced significant increases in EEG alpha and decreases in EEG beta in the eyes open condition. Thus, nimodipine may have potential therapeutic implications in the treatment of cocaine dependence. Chronic nimodipine dosing in cocaine-dependent individuals is now needed to confirm its efficacy in the treatment of cocaine dependence.

Seizures associated with poisoning and drug overdose

A retrospective review of cases consulted by the San Francisco Bay Area Regional Poison Control Center during a 2-year period was performed to determine the causes and consequences of seizures associated with poisoning and drug intoxication. Of 233 charts coded as involving seizures, 191 occurred in humans and were available for analysis. The leading causes of seizures reported to the Poison Control Center were cyclic antidepressants (55 cases, 29%); cocaine and other stimulants (55 cases, 29%); diphenhydramine and other antihistamines (14 cases, 7%); theophylline (10 cases, 5%); and isoniazid (10 cases, 5%). Stimulants and diphenhydramine were more likely than other drugs to produce brief, self-limited seizures. In contrast, poisoning by cyclic antidepressants, cardiodepressant antiarrhythmic agents, or theophylline was more likely to be associated with death. Seizures in elderly patients were more likely to result in complications and death. The frequency of seizure-related cases by substance type was also compared with the results of an earlier survey performed in 1981, and found a striking increase in the proportion of seizures caused by cocaine and (23% in 1988 to 1989 compared with 4% in 1981). Poison Control Center data can provide valuable information about the causes and consequences of drug-related medical complications, as well as highlight changing trends in drug-related injury.

Spinal epidural hematoma associated with cocaine abuse

A 41-year-old man rapidly developed quadriparesis moments after injecting cocaine. Investigation discovered a cervical spinal epidural hematoma. This complication of cocaine abuse has not been previously reported.

Seizures associated with poisoning and drug overdose

A retrospective review of cases consulted by the San Francisco Bay Area Regional Poison Control Center during a 2-year period was performed to determine the causes and consequences of seizures associated with poisoning and drug intoxication. Of 233 charts coded as involving seizures, 191 occurred in humans and were available for analysis. The leading causes of seizures reported to the Poison Control Center were cyclic antidepressants (55 cases, 29%); cocaine and other stimulants (55 cases, 29%); diphenhydramine and other antihistamines (14 cases, 7%); theophylline (10 cases, 5%); and isoniazid (10 cases, 5%). Stimulants and diphenhydramine were more likely than other drugs to produce brief, self-limited seizures. In contrast, poisoning by cyclic antidepressants, cardiodepressant antiarrhythmic agents, or theophylline was more likely to be associated with death. Seizures in elderly patients were more likely to result in complications and death. The frequency of seizure-related cases by substance type was also compared with the results of an earlier survey performed in 1981, and found a striking increase in the proportion of seizures caused by cocaine and (23% in 1988 to 1989 compared with 4% in 1981). Poison Control Center data can provide valuable information about the causes and consequences of drug-related medical complications, as well as highlight changing trends in drug-related injury.