Death following ingestion of cocaine capsules after 48 hours in police custody

Aim

Poisonings among body-packers are well-documented in toxicological and forensic literature. Deaths due to ingestion of narcotic substances are common; however, the toxicological kinetics in such cases are rarely described. A 29-year-old man was admitted to the ICU for status epilepticus (Day 0), followed by recurrent cardiac arrests. His family revealed a history of cocaine capsule ingestion three days prior (Day 3). An abdominal CT scan revealed foreign bodies in the stomach. Given the severe cocaine intoxication and multi-organ failure, emergency gastrotomy was performed to remove the cocaine-containing contents from the stomach. Despite this intervention, the patient continued to experience recurrent cardiac arrests, leading to refractory shock and death on Day 2. The aim of this study is to describe the evolution of cocaine and its metabolites concentrations following the ingestion of cocaine capsules in relation with medical care.

Method

Cocaine and its two main metabolites, benzoylecgonine (BZE) and ecgonine methyl ester (EME), were quantified in blood using high-resolution mass spectrometry (LC-HRMS) (Q-Exactive®, ThermoScientific).

Results

We present the plasma kinetics of cocaine and its metabolites during hospitalization (Day 0, Day 1 and Day 2), along with the measurement of post-mortem blood concentrations taken at autopsy. The plasma concentrations of cocaine, BZE, and EME were respectively: Day 0: 18,680 ng/mL, 11,400 ng/mL, and 15,720 ng/mL; Day 1 (during gastrotomy): 43,928 ng/mL, 62,456 ng/mL, and 81,452 ng/mL; Day 2: 396 ng/mL, 34,532 ng/mL, and 35,480 ng/mL. Post-mortem blood concentrations of cocaine, BZE, and EME were 125 ng/mL, 6,897 ng/mL, and 10,329 ng/mL, respectively.

Conclusion

The death resulted from massive cocaine intoxication following ingestion. We observed extremely high concentrations of cocaine and its metabolites, peaking at the time of gastrotomy. Concentrations subsequently declined, but not enough to prevent from patient's death. Although a multidisciplinary approach has been required to manage high concentrations of drugs, resulting from ingestion of cocaine capsules, it was unfortunately not sufficient in this case to prevent from a fatal issue.