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Mégarbane B, Gharnaout N, Djebrani Oussedik N. Pharmacobezoar: a rare cause of body packing misdiagnosis. Clin Toxicol (Phila) 2023; 61:312-314. [PMID: 37017708 DOI: 10.1080/15563650.2023.2192387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
INTRODUCTION Diagnosis of body packing based on the misinterpretation of imaging is rare. CASE REPORT An unaccompanied 55-year-old woman presented with uncontrolled vomiting in the airport transit area. An abdominal radiograph and computed tomography scan revealed multiple radiopaque foreign bodies in the colon. History was unobtainable due to the language barrier. The patient was referred to our institution as a body packer who required surgical extraction of the packets. In the absence of symptoms, she was managed conservatively with antiemetic drugs and whole bowel irrigation. The final diagnosis was radiopaque pharmacobezoars caused by an over-the-counter barium-containing anticancer medication in the setting of severe hypokalemia-associated paralytic ileus following post-chemotherapy vomiting. After the correction of her potassium concentration, the patient was discharged and resumed her trip. CONCLUSION Clinicians should be warned that pharmacobezoars might be mistaken for drug packets on abdominal imaging leading to body packing misdiagnosis.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, APHP, Paris, France
- INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Nawel Gharnaout
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, APHP, Paris, France
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Kévin M, Dufayet L, Nicolas S, Charlotte G, Dion E. Aortic dissection in a body packer: Did cocaine play a part? Forensic Sci Int 2021; 327:110963. [PMID: 34454380 DOI: 10.1016/j.forsciint.2021.110963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/03/2021] [Accepted: 08/17/2021] [Indexed: 11/27/2022]
Abstract
Body packing is defined as the ingestion of drug packets, to conceal them during transportation. We report the case of a 63-year-old cocaine body packer, who died from an aortic dissection. He was arrested in Paris as he disembarked from a flight from Cayenne (French Guinea) and custom officers found cocaine in his suitcase. The patient admitted the ingestion of cocaine packets. He was transferred to the hospital where an initial computerized tomography scan showed hyperdense, uniformly shaped packets located in the colon. On admission, his blood pressure was elevated but he did not exhibit any other signs of adrenergic syndrome. The diagnosis of chronic hypertension unrelated to the cocaine body packing was retained. During hospitalization, 40 h after the ingestion of the cocaine packets, the patient showed acute agitation, sweat and a high blood pressure. Given the context, an emergency thoraco-abdominal-pelvic CT-scan was carried out to rule out a cocaine leakage. None of the packets showed evidence of leakage but the CT-scan assessed an aortic dissection extending to the entire descending aorta. Despite intensive care, the patient passed away on the fifth day. This aortic dissection could have appeared spontaneously in a patient with significant atherosclerosis lesions of the aortic network. Nevertheless, we believe that cocaine impregnation causing high blood pressure might have played a role in the aortic dissection, even without a cocaine leakage from the packets. This case highlights the need to achieve an effective control of the blood pressure in cocaine body packers.
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Affiliation(s)
- Mahé Kévin
- Unité médico-judiciaire, Hôtel-Dieu University Hospital, APHP, 1 place du Parvis Notre-Dame, Paris 75004, France.
| | - Laurène Dufayet
- Unité médico-judiciaire, Hôtel-Dieu University Hospital, APHP, 1 place du Parvis Notre-Dame, Paris 75004, France; Université de Paris, UFR de médecine, 75010 Paris, France; INSERM UMRS 1144, Faculté de Pharmacie de Paris, 75006 Paris, France; Centre antipoison et de Toxicovigilance de Paris, Assistance Publique des Hôpitaux de Paris - Hôpital Fernand Widal, 75010 Paris, France
| | - Soussy Nicolas
- Unité médico-judiciaire, Hôtel-Dieu University Hospital, APHP, 1 place du Parvis Notre-Dame, Paris 75004, France
| | - Gorgiard Charlotte
- Unité médico-judiciaire, Hôtel-Dieu University Hospital, APHP, 1 place du Parvis Notre-Dame, Paris 75004, France
| | - Elisabeth Dion
- Imagerie médicale, Hôtel-Dieu University Hospital, APHP, Paris, France
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Arora A, Jain S, Srivastava A, Mehta M, Pancholy K. Body Packer Syndrome. J Emerg Trauma Shock 2021; 14:51-52. [PMID: 33911438 PMCID: PMC8054804 DOI: 10.4103/jets.jets_41_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/13/2020] [Accepted: 06/30/2020] [Indexed: 01/08/2023] Open
Abstract
"Body packers" are persons who voluntarily or through coercion, swallow or insert drug-filled packets into body cavity, generally in an attempt to smuggle them across secure borders. The drugs most often involved in body packing are heroin and cocaine. Body packers can present in the emergency department as a result of ruptured drug packets, bowel obstruction, or for medicolegal purposes. Suspected cases are diagnosed with X-ray and computed tomography scan of the abdomen. Symptomatic patients require urgent removal of packets. We present a case of foreign national male in whom a drug packet got ruptured and 49 other packets were retrieved with help of laxatives and manual evacuation.
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Affiliation(s)
- Akant Arora
- Department of Emergency Medicine, Max Superspeciality Hospital, New Delhi, India
| | - Sandeep Jain
- Department of Emergency Medicine, Max Superspeciality Hospital, New Delhi, India
| | - Ayush Srivastava
- Department of Emergency Medicine, Max Superspeciality Hospital, New Delhi, India
| | - Manish Mehta
- Department of Emergency Medicine, Max Superspeciality Hospital, New Delhi, India
| | - Kartik Pancholy
- Department of Emergency Medicine, Max Superspeciality Hospital, New Delhi, India
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Malhotra R, Singh A. Imaging of drug mules. Emerg Radiol 2021; 28:809-14. [PMID: 33738658 DOI: 10.1007/s10140-021-01924-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
Cocaine, heroin, methamphetamine, and hashish are the primary drugs transported by a body packer, who swallows such packages. A body pusher or stuffer transports drug packages in rectum or vagina. Plain radiography is the primary imaging modality used in the evaluation of concealed drugs and has sensitivity of 85-90%. The imaging features include well-defined opacities in the bowel with crescents of air near ovoid opacities. The imaging signs include double condom sign, halo sign, parallelism sign, and tic tac sign. A low-dose CT is an efficient noninvasive and accurate technique of locating packages internally for all types of concealment.
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Abedzadeh AA, Iqbal SS, Al Bastaki U, Pierre-Jerome C. New packaging methods of body packers: Role of advanced imaging in their detection. A case study. Radiol Case Rep 2019; 14:627-633. [PMID: 30923589 PMCID: PMC6424096 DOI: 10.1016/j.radcr.2019.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 02/25/2019] [Accepted: 03/02/2019] [Indexed: 01/08/2023] Open
Abstract
Body packing is one of the common ways to traffic illicit drugs. Drug mules usually swallow or insert drugs within the gastrointestinal tract or other orifices. Detection of such drug packets has become difficult because of the constantly improving packaging techniques and the sophistication used by traffickers. Suspected obstruction or perforated hollow viscus requires employment of appropriate radiological procedures and techniques for accurate detection and precise diagnosis. A delay diagnosis and inappropriate action may carry disastrous physical consequences for the body packers. It is crucial for radiologists to acquire enough experience to deduce different types of drug packets from their imaging characteristics and to accurately guide emergency physicians and security officials. The packets are not always radiodense, therefore they can be difficult to detect on conventional abdominal radiographs. In this report, the authors illustrate 5 cases with different packaging methods and materials that give rise to radiological challenges.
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Affiliation(s)
- Ayoub Ahmad Abedzadeh
- Department of Radiology, Rashid Hospital, 315 Umm Hurair Second, PO Box 4545, Dubai, United Arab Emirates
| | - Shaikh Sayeed Iqbal
- Department of Radiology, Rashid Hospital, 315 Umm Hurair Second, PO Box 4545, Dubai, United Arab Emirates
| | - Usama Al Bastaki
- Department of Radiology, Rashid Hospital, 315 Umm Hurair Second, PO Box 4545, Dubai, United Arab Emirates
| | - Claude Pierre-Jerome
- Department of Radiology, Ackershus University Hospital, Sykehusveien, 75, 1470 Oslo, Norway
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Luginbühl M, Junker T, Keller DI. A patient full of surprises: a body packer with cocaine intoxication, pneumococcal pneumonia and HIV infection. BMC Emerg Med 2018; 18:29. [PMID: 30180803 PMCID: PMC6123965 DOI: 10.1186/s12873-018-0180-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 08/28/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Smuggling of illegal drugs by hiding them inside one's own body, also called body packing, is a worldwide phenomenon. Cocaine is the most frequently transported drug. Body packing is a potentially lethal practice. The most serious complications of body packing are gastrointestinal obstruction or perforation and drug toxicity due to packet leakage or rupture. CASE PRESENTATION A 30-year-old confirmed body packer was brought to our emergency department from jail because of agitation and mydriasis. He presented with a high respiratory rate of 40/min but normal oxygen saturation on ambient air, a heart rate of 116 bpm, a blood pressure of 116/68 mmHg and a temperature of 38.0° Celsius. Blood tests were suggestive of infection, urine analysis was positive for cocaine. Abdominal and thoracic computed tomography scans showed pulmonary infiltrates as a possible focus of infection; signs of bowel obstruction or perforation were absent. Given his clinical presentation, we suspected severe infection rather than massive cocaine intoxication to be the main problem. We therefore withheld immediate surgical decontamination. Instead, we started broad-spectrum antibiotic treatment with piperacillin/tazobactam plus clarithromycin for suspected severe community-acquired pneumonia or abdominal sepsis and treated the patient with intravenous midazolam for symptomatic cocaine intoxication. After detection of urinary pneumococcal antigen, the antibacterial regimen was changed to ceftriaxone and vancomycin for pneumococcal pneumonia. In addition, we found human immunodeficiency virus (HIV) type 1 infection as underlying disease. The patient recovered from his acute illness and was discharged after 7 days of treatment with ceftriaxone plus vancomycin. Antiretroviral therapy was started in an outpatient setting. CONCLUSIONS With this case report, we emphasize the need to look for alternative diagnoses to intoxication and gastrointestinal obstruction in acutely ill body packers with atypical presentation. Special risks, such as underlying HIV infection and potential antimicrobial resistance according to the individual's geographical origin, should be taken into account while treating these patients.
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Affiliation(s)
- Miriam Luginbühl
- Department of Internal Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Timo Junker
- Emergency Department, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Cappelletti S, Ciallella C. Commentary on false negative findings of plain radiographs in body packing. Clin Imaging 2017; 45:122-123. [PMID: 28528792 DOI: 10.1016/j.clinimag.2017.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/13/2017] [Indexed: 11/24/2022]
Abstract
The use of terms "body packing" and "body pushing", both encompassed in the idiomatic expression "body packing", is still misunderstood by clinicians. "Body packing" is a general term used to indicate the internal transportation of drug packages within the gastrointestinal tract; while "Body pushing" refers to the insertion of drugs in anatomical cavities or body orifices, such as the anus, the vagina, and the ears. With the present paper, we would like to analyze and clarify some issues concerning the confounding definitions of body packing and the main reasons why some drug packages may be undetected at plain abdominal radiography, providing important false negative findings, as in the case commented.
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Affiliation(s)
- Simone Cappelletti
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedic Sciences, "Sapienza" University of Rome, Rome, Italy; State Police Health Service Department, Ministry of Interior, Rome, Italy.
| | - Costantino Ciallella
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedic Sciences, "Sapienza" University of Rome, Rome, Italy
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Bahrami-Motlagh H, Vakilian F, Hassanian-Moghaddam H, Pourghorban R. Added value of lung window in detecting drug mules on non-contrast abdominal computed tomography. Radiol Med 2016; 121:472-7. [PMID: 26830789 DOI: 10.1007/s11547-015-0618-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 12/21/2015] [Indexed: 01/08/2023]
Abstract
We evaluated the added value of lung window in non-contrast computed tomography (CT) of suspected body packers or stuffers. Forty suspected drug mules who were referred to our tertiary toxicology center were included. The final diagnosis of drug mule was based on the detection of packs in stool examination or surgery. Non-contrast CT scans were retrospectively interpreted by two blinded radiologists in consensus before and after reviewing the lung window images. The diagnostic performance of abdominal window scans alone and scans in both abdominal and lung windows were subsequently compared. Seven body packers and 21 body stuffers were identified. The sensitivity, negative predictive value (NPV), and diagnostic accuracy of scans in detection of drug mules (either drug packers or stuffers) raised from 60.7, 52.1, and 72.5 to 64.2, 54.5, and 75.0 %, respectively, with a more number of packs being detected (114 vs. 105 packs). In the body packers group, the diagnostic performance of both abdominal windows scans and combined abdominal and lung windows scans were 100 %. In the body stuffers group, the sensitivity, NPV, and diagnostic accuracy of scans increased from 47.6, 52.1, and 55.0 to 52.3, 54.5, and 57.5 %, respectively, after the addition of lung windows. Reviewing the lung window on non-contrast abdominal CT can be helpful in detection of drug mules.
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Shahnazi M, Hassanian-Moghaddam H, Gachkar L, Ahmadi N, Zamani N, Bahrami-Motlagh H, Faghihi Langroudi T, Arjmand Shabestari A, Mohammad Alizadeh A. Comparison of abdominal computed tomography with and without oral contrast in diagnosis of body packers and body stuffers. Clin Toxicol (Phila) 2015; 53:596-603. [PMID: 26065361 DOI: 10.3109/15563650.2015.1054501] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
CONTEXT Toxicity due to body packing/pushing/stuffing is a major concern in many countries. Of different imaging techniques, computed tomography (CT) scan is described as the method of choice in detecting body couriers, but there is no study to concomitantly compare with- and without-contrast abdominopelvic CTs to determine the more accurate one for this purpose. OBJECTIVE We aimed to evaluate the efficacy of abdominopelvic CT "with" and "without" oral contrast in diagnosis of existence, number, and type of packets in body packers/pushers and stuffers. MATERIALS AND METHODS In a prospective observational case series, all suspected cases of body packing/stuffing were included and underwent abdominopelvic CT with and without oral contrast in a one-year period. CT scans were reported by three independent attending radiologists blind to the demographic and clinical results and compared to our defined "gold standard" which was surgery or expulsion of packets. The existence and number of packets detected by each method were compared to define the better method of diagnosis. RESULTS Of 11 suspect body packers/pushers, 10 carried packs. Abdominopelvic CT with and without oral contrast detected six and seven of them, respectively. In 24 body stuffers, CT without oral contrast was more accurate in diagnosis of existence (9/24 vs. 7/24, p = 0.003) and number (sensitivity and positive predictive values of 29.2% vs. 37.5% and 100% vs. 100% for CTs with and without oral contrast, respectively, p = 0.021). DISCUSSION AND CONCLUSIONS There is a remarkable gap between detection of existence and number of packets/baggies reported by the radiologists and the real condition of the patients. A close teamwork between radiologists and toxicologists is needed to manage these problematic cases.
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Affiliation(s)
- Makhtoom Shahnazi
- Department of Radiology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Scineces , Tehran , Iran
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