Case Report - (2023) Volume 11, Issue 4
Received: 03-Apr-2023, Manuscript No. IPJUS-23-13645; Editor assigned: 05-Apr-2023, Pre QC No. P-13645; Reviewed: 19-Apr-2023, QC No. Q-13645; Revised: 21-Apr-2023, Manuscript No. R-13645; Published: 28-Apr-2023
Introduction
Drugs trafficking are a significant problem for many countries, Body packing is one of the common ways to traffic illicit drugs. Intra corporeal drug carriage may lead to potential life-threatening complications with acute overdose syndromes and death due to ruptured package and intestinal obstruction that requires an emergency intervention .Patient management may be adjusted based on clinical symptoms, toxicological data and employment of appropriate radiological procedures and techniques for accurate detection and precise diagnosis. The global support has been the subject of numerous publications and recent review.
Case report
We report cases of body packers that were detained at Fez International Airport under suspicion and brought to hospital for observation, all patients were asymptomatic. A basic diagnostic imaging is done without signs of complication, close monitoring is done with good improvement
Conclusion
This represents a challenge for the attending physicians. The clinic, imaging and toxicological research are essential in the management; Conservative treatment is often started with little need for surgery
Body packers; Cocaine; Radiography role
Cocaine consumption increased in the last century, a new type of dealer appeared, the body stuffer who tries to eat the dumplings to avoid arrest as well as the body packer, or mule, which transports a large quantity of cocaine across borders. They risk their lives, their health, and their freedom for illegal drugs transportation. To the risk of intoxication is added the risk of mechanical obstruction and, or intestinal perforation linked to the large size of the sachets. Imaging plays an important role in management as well as toxicology.
The global support is conservative with some rare cases of interventions in case of complications.
Case 1, 2
A 32 year old male and a 37 year old female arrested from Fez International Airport and admitted to hospital after ingestion of 106 and 112 packs of drugs. On admission, the patients were well oriented in time and place; and showed no signs of intoxication but no abdominal pain. Their abdomens were mildly distended, with sluggish peristaltic sounds. Emergency investigations revealed normal hematological and biochemical parameters. Laboratory data showed a normal venous blood gas, blood glucose, and electrolytes levels.
An abdomen plain radiography and computed tomography (CT) were obtained due to the high suspicion of body packing. They confirmed the presence of multiple packages (Fig.1.). As the patients did not present any clinical sign of acute cocaine toxicity, a conservative approach was proposed by whole bowel irrigation (polyethylene glycol) and administration of metoclopramide. The patients improved thereafter and were subsequently discharged.
Fig.1. A. abdomen X-ray with multiple parallel foreign bodies; B; C. CT image with construction showing foreign bodies intra-abdominal and vagina (arrows).
Case 3
A 29-year-old female was brought to hospital by airport security per-sonnel with suspicion of foreign body ingestion. Suspect admitted ingestion of 8 cocaine packets and put some packets in the vagina. On examination, the suspect was a febrile; her abdomen was soft and lax. Abdominal radiographs (Fig.2.). show radiopaque foreign bodies in gastrointestinal tract and show no signs of bowel obstruction or perforation. Non contrast abdominal CT (Fig. 2.). Reveals multiple spherical and cylindrical shaped hypodense, almost same sized foreign bodies in stomach and vagina. Suspect was given lactulose and passed some packets, with auto remove of packet at the vagina.
Fig. 2. A. radiopaque foreign bodies in gastrointestinal tract in X-ray; B. foreign bodies in stomach and vagina showed in CT scan with construction.
Endoscopy is used to extract the rest of packets. CT followup revealed no remaining packets in abdomen or pelvis. Suspect was generally well, vitally stable. The patient was then discharged in the custody of the police
All Body packing or body mules usually involve three steps:
1. The contraband is packed in appropriate wraps. Drugs are usually packed tightly and wrapped into a sheath like finger of latex gloves, plastic bags, condom, aluminum foil or balloon [1-2].
2. Ingestion or insertion of the substances and transporting it to the final destination .they may mask the packets by ingesting oil, water, or other liquid as all have similar radio densities on plain abdominal X-ray. 3. Evacuation: they use laxatives, cathartics, or enemas to help evacuate the capsules rectally or manually (for vaginal storage).
• The most substances involved in body packing are cocaine and heroin, but other substances reported are methamphetamine, hashish, ecstasy and oxycodone [3]. But Cocaine is the most commonly smuggled drug transported by body packers due to its higher financial worth
• The most common site of concealment for both ‘body-packing’ and ‘body-stuffing’ remains the abdominal cavity, the external auditory canal, the superior oropharynx and the glans penis [4-5].
The rectum and vagina have also been reported as occasional sites [6].
• Body packers may present to a health care facility for the following reasons
1. After detention by law enforcement agency for carriage of suspected contrabands
2. Systemic toxicity
3. Gastrointestinal obstruction or perforation due to the carried packets
The clinical manifestations of acute cocaine poisoning are summarized in the (Tab.1.).
| Central Nervous System | • Ischemia and cerebrovascular infarction |
| • Transient ischemic attack | |
| • Subarachnoid hemorrhage | |
| • Intraparenchymal hematoma | |
| • Epileptic crisis | |
| • Vasculitis | |
| • Migraine attack | |
| • Abnormal movements (dystonia, | |
| choreoathetosis, akathisia) | |
| • Psychiatric disorders (agitation, psychosis, | |
| hallucinations) | |
| • Hyperthermia | |
| Cardiovascular | • Chest pain |
| • Acute coronary syndrome | |
| • Tachycardia | |
| • Hypertension | |
| • Aortic dissection | |
| • Malignant tachyarrhythmia | |
| • Left heart dysfunction and edema pulmonary | |
| Ent and Pulmonary | Perforation of the nasal septum |
| • Epiglottitis | |
| • Hemoptysis | |
| • Pneumothorax | |
| • Bronchoconstriction (after crack inhalation) | |
| • Non-cardiogenic pulmonary edema | |
| Renal | • Acute renal failure |
| • Kidney infarction | |
| • Acute tubular necrosis secondary to rhabdomyolysis | |
| Digestive | • Small intestinal perforation |
| • Mesenteric ischemia |
Tab.1. Clinical effects of acute poisoning by cocaine.
• Radiography plays an important role in initial suspicion and confirmation of the diagnosis and recognizing complications.
• Abdominal x-ray study is the most common modality used. It’s one of the noninvasive, rapid, and widely available radiological examinations to rule out body packer. It is a relative accessible and low cost method for screening and diagnosing body packers with accuracy of 40%- 90% [7].
• The specific signs that abdominal X-rays should be scrutinized for, reported by Niewiarowski et al. include the ‘‘double condom sign’’, ‘‘tic-tac sign’’, ‘‘parallelism sign’’, ‘‘dense wrapping material’’ and multiplicity of foreign bodies [8].
• CT scan is superior to plain abdominal X-ray as it yields higher contrast resolution images and provides accurate information of the location, size, and amount of drug packages. Use of CT scan for detecting drug packets not only allows us to assess associated complications like bowel obstruction or perforation quickly, it also allows us to handle the intoxicated patient promptly due to ruptured packages [9-10]. On CT, signs to be detected are similar to those on conventional abdominal X-rays
• Sonography is another useful modality in detecting the presence of drug packets in body packers as it is low cost and radiation free. It allows to detecting free fluid, the presence of free fluid not only can indicate bowel perforation; it also acts as window to reveal more clearly the presence of drug packets. • The lack of an antidote makes cocaine intoxication dangerous
• The current management of asymptomatic body packers is mainly conservative; most packages are eliminated within 30 h, although some body packers may have taken anticholinergic agents or opiates to slow the transit time [11].
• Indications for surgical treatment include gastrointestinal obstruction, perforation, acute narcotic intoxication, and retention of capsules beyond five days despite conservative management.
• Endoscopic extraction of cocaine packets from the upper digestive tract is limited and comes mainly from patients who had refused surgery; it should not be attempted in the presence of multiple packages.
These patients risk their lives and know the medico-legal manifestations. Illicit transport across borders remains active. This represents a challenge for the attending physicians. The clinic, imaging and toxicological research are essential in the management; Conservative treatment is often started with little need for surgery.
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