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P29: Oesophageal and gastric obstruction in a cocaine body packer
Posters / Toxicologie Analytique & Clinique (2014) 26, S31-S55
P29
P30
Oesophageal and gastric obstruction in a cocaine body packer
Acute heart failure after venlafaxine overdose: Post-mortem myocardial examination in two cases
P. Hantson (1, 2), A. Capron (2), J.-F. Maillart (3) (1) Department of intensive care; (2) Louvain centre for toxicology and applied pharmacology; (3) Department of abdominal surgery, cliniques St-Luc, université catholique de Louvain, Brussels, Belgium. Introduction. – Body packing may expose the patient to a significant number of complications, including acute poisoning after rupture of the packages, or more exceptionally, intestinal obstruction. Most of the patients can be managed conservatively by oral laxatives. However, surgical intervention has been recommended in cases of package retention beyond 5-7 days to prevent package leakage, rupture and obstruction. We report a recent case of oesophageal and gastric obstruction caused by a large number of cocaine-containing packages. Case observation. – A 49-year-old previously healthy woman originated from East Africa was found stuporous at the railway station of the airport. Her consciousness rapidly deteriorated before the arrival of the first medical rescuers. She was then found with a Glasgow Coma Score of 3/15, bradypnea 4/min, heart rate 60/min, arterial blood pressure 140/90 mm Hg and oxygen saturation (SpO2) 91 %. Pinpoint pupils were also remarkable. Orotracheal intubation was performed. The diagnosis of opioid poisoning was supported by the clinical response to a single i.v. dose of 0,4 mg naloxone. Soon after the admission in the Emergency Department, an abdomen computed tomography (CT) was obtained due to the high suspicion of body packing. It confirmed the presence of multiple packs: 81 in the dilated stomach, 1 in the lower part of the oesophagus and 8 in the sigmoid and rectum. Toxicological analysis revealed: serum morphine 0,73 g/ml, codeine 0,06 g/ml; urine benzoylecgonine 0,015 g/ml, 6-MAM 0,351 g/ml, codeine 17,6 g/ml. As the patient did not present any clinical sign of acute cocaine toxicity, a conservative approach was proposed by whole bowel irrigation (polyethylene glycol). The patient only complained from abdominal discomfort. Extubation was not possible due to persisting opiod syndrome. (The patient admitted later on having ingested morphine and codeine to decrease intestinal peristaltism). On hospital day 4, the patient became mildly tachycardic and hypertensive, and abdominal discomfort worsened. There was no significant increase in urine benzoylecgonone concentration. A new abdomen CT showed no significant progression of the packages; 9 had been removed after laxative therapy. The stomach appeared extremely dilated. A surgical procedure was decided (gastrotomy). On the whole, one pack was removed from the lower oesophagus, 79 from the stomach, and three additional packages were evacuated after palpation of the colon. The post-operative course was not complicated and extubation was possible 48 hours later. The abdomen CT confirmed the complete evacuation. Discussion. – The exact incidence of intestinal obstruction following body packing is not known, but is probably reaching 5 %. The main risk is the rupture of the packages with acute cocaine intoxication. Emergency laparotomy is the only therapeutic option when the patient is becoming symptomatic. In the present observation, conservative therapy failed due the presence of a large amount of packages that had accumulated in the stomach. This high number of packages did not allow removal by endoscopy. The literature data show that surgery is mainly indicated when the packages are located in the stomach or in the small bowel.
S43
M. Batista (1), S. Fonseca (2), J.-P. Cosyns (2), V. Haufroid (3), A. Capron (3), P. Hantson (1, 3) (1) Department of intensive care; (2) Department of pathology; (3) Louvain centre for toxicology and applied pharmacology, cliniques St-Luc, université catholique de Louvain, Brussels, Belgium. Introduction. – Venlafaxine (VEN) is a bicyclic antidepressant that may be associated with severe cardiotoxicity following large overdose. There are few post-mortem descriptions of ultrastructural changes in the myocardium. We describe two cases, with also the determination of VEN and metabolite concentration in the cardiac tissue. Case series. – A 38-yr-old woman who had ingested 4,2 g of extended-release VEN developed cardiogenic shock 6 hr post-ingestion. The peak serum concentration was: VEN 2153.3 ng/ml, O-desmethylvenlafaxine (ODV) 960.1 ng/ml. A severe left ventricular failure was demonstrated at echocardiography. Related complications were acute renal failure, rhabdomyolysis and ischemic liver injury. The patient was treated by major doses of vasopressors and inotropes. She died on day 11 from multiple organ failure following recent S pneumoniae septicaemia. The heart light microscopic examination revealed multiple foci of dissolution with degenerative changes of the myocardial fibres accompanied by dark micro-deposits and large quantities of granular deposits (also present in the proximal renal tubules). Electron microscopy showed degenerative changes including cytoplasmic vacuolization, lytic appearance and swollen mitochondria. The following post-mortem tissue concentrations were noted: heart, VEN 18 mg/kg, ODV 21 mg/kg; kidney, VEN 5 mg/kg, ODV 1,2 mg/kg. – A 38-yr-old woman ingested an unknown amount of VEN and verapamil. The peak serum concentration was: VEN 7135 ng/ml, ODV 3434 ng/ml, verapamil 1205 ng/ml. She presented cardiogenic shock refractory to inotropes and vasopressors and died on day 7 from multiple organ failure. Myofibrillar hyaline degeneration without inflammation was noted in the myocardium. Tissue concentration was: VEN 50,6 mg/kg, ODV 74,2 mg/kg. Discussion. – Degenerative and poorly inflammatory changes may be observed in the myocardium after fatal VEN overdoses with cardiotoxicity. As the patients usually required large doses of catecholamines, the ultrastructural changes may also be partly due to catecholamines-induced myocardial injury or to ischemic-hypoxic injury. Until now, post-mortem tissue concentrations of VEN were not reported for the heart. It appears from our observations that a significant amount of VEN and ODV can be found in the myocardium. P31
Seizures and sustained encephalopathy following an accidental 4-aminopyridine overdose M. Ballesta Méndez (1), V. Van Pesch (2), A. Capron (3), P. Hantson (1,3) (1) Department of intensive care; (2) Department of neurology; (3) Louvain centre for toxicology and applied pharmacology, cliniques St-Luc, université catholique de Louvain, Brussels, Belgium. Introduction. – 4-aminopyridine (4-AP) is a drug that enhances interneuronal and neuromuscular synaptic transmission. It can be used as adjunctive treatment for patients with multiple sclerosis (MS). Accidental or intentional overdose results in significant neurotoxicity. Case observation. – A 58-year-old woman with secondary progressive MS was treated for more than 3 years by 4-AP (10 mg/bid) with an excellent tolerance. She was admitted to the ER with coma and
P29
P30
Oesophageal and gastric obstruction in a cocaine body packer
Acute heart failure after venlafaxine overdose: Post-mortem myocardial examination in two cases
P. Hantson (1, 2), A. Capron (2), J.-F. Maillart (3) (1) Department of intensive care; (2) Louvain centre for toxicology and applied pharmacology; (3) Department of abdominal surgery, cliniques St-Luc, université catholique de Louvain, Brussels, Belgium. Introduction. – Body packing may expose the patient to a significant number of complications, including acute poisoning after rupture of the packages, or more exceptionally, intestinal obstruction. Most of the patients can be managed conservatively by oral laxatives. However, surgical intervention has been recommended in cases of package retention beyond 5-7 days to prevent package leakage, rupture and obstruction. We report a recent case of oesophageal and gastric obstruction caused by a large number of cocaine-containing packages. Case observation. – A 49-year-old previously healthy woman originated from East Africa was found stuporous at the railway station of the airport. Her consciousness rapidly deteriorated before the arrival of the first medical rescuers. She was then found with a Glasgow Coma Score of 3/15, bradypnea 4/min, heart rate 60/min, arterial blood pressure 140/90 mm Hg and oxygen saturation (SpO2) 91 %. Pinpoint pupils were also remarkable. Orotracheal intubation was performed. The diagnosis of opioid poisoning was supported by the clinical response to a single i.v. dose of 0,4 mg naloxone. Soon after the admission in the Emergency Department, an abdomen computed tomography (CT) was obtained due to the high suspicion of body packing. It confirmed the presence of multiple packs: 81 in the dilated stomach, 1 in the lower part of the oesophagus and 8 in the sigmoid and rectum. Toxicological analysis revealed: serum morphine 0,73 g/ml, codeine 0,06 g/ml; urine benzoylecgonine 0,015 g/ml, 6-MAM 0,351 g/ml, codeine 17,6 g/ml. As the patient did not present any clinical sign of acute cocaine toxicity, a conservative approach was proposed by whole bowel irrigation (polyethylene glycol). The patient only complained from abdominal discomfort. Extubation was not possible due to persisting opiod syndrome. (The patient admitted later on having ingested morphine and codeine to decrease intestinal peristaltism). On hospital day 4, the patient became mildly tachycardic and hypertensive, and abdominal discomfort worsened. There was no significant increase in urine benzoylecgonone concentration. A new abdomen CT showed no significant progression of the packages; 9 had been removed after laxative therapy. The stomach appeared extremely dilated. A surgical procedure was decided (gastrotomy). On the whole, one pack was removed from the lower oesophagus, 79 from the stomach, and three additional packages were evacuated after palpation of the colon. The post-operative course was not complicated and extubation was possible 48 hours later. The abdomen CT confirmed the complete evacuation. Discussion. – The exact incidence of intestinal obstruction following body packing is not known, but is probably reaching 5 %. The main risk is the rupture of the packages with acute cocaine intoxication. Emergency laparotomy is the only therapeutic option when the patient is becoming symptomatic. In the present observation, conservative therapy failed due the presence of a large amount of packages that had accumulated in the stomach. This high number of packages did not allow removal by endoscopy. The literature data show that surgery is mainly indicated when the packages are located in the stomach or in the small bowel.
S43
M. Batista (1), S. Fonseca (2), J.-P. Cosyns (2), V. Haufroid (3), A. Capron (3), P. Hantson (1, 3) (1) Department of intensive care; (2) Department of pathology; (3) Louvain centre for toxicology and applied pharmacology, cliniques St-Luc, université catholique de Louvain, Brussels, Belgium. Introduction. – Venlafaxine (VEN) is a bicyclic antidepressant that may be associated with severe cardiotoxicity following large overdose. There are few post-mortem descriptions of ultrastructural changes in the myocardium. We describe two cases, with also the determination of VEN and metabolite concentration in the cardiac tissue. Case series. – A 38-yr-old woman who had ingested 4,2 g of extended-release VEN developed cardiogenic shock 6 hr post-ingestion. The peak serum concentration was: VEN 2153.3 ng/ml, O-desmethylvenlafaxine (ODV) 960.1 ng/ml. A severe left ventricular failure was demonstrated at echocardiography. Related complications were acute renal failure, rhabdomyolysis and ischemic liver injury. The patient was treated by major doses of vasopressors and inotropes. She died on day 11 from multiple organ failure following recent S pneumoniae septicaemia. The heart light microscopic examination revealed multiple foci of dissolution with degenerative changes of the myocardial fibres accompanied by dark micro-deposits and large quantities of granular deposits (also present in the proximal renal tubules). Electron microscopy showed degenerative changes including cytoplasmic vacuolization, lytic appearance and swollen mitochondria. The following post-mortem tissue concentrations were noted: heart, VEN 18 mg/kg, ODV 21 mg/kg; kidney, VEN 5 mg/kg, ODV 1,2 mg/kg. – A 38-yr-old woman ingested an unknown amount of VEN and verapamil. The peak serum concentration was: VEN 7135 ng/ml, ODV 3434 ng/ml, verapamil 1205 ng/ml. She presented cardiogenic shock refractory to inotropes and vasopressors and died on day 7 from multiple organ failure. Myofibrillar hyaline degeneration without inflammation was noted in the myocardium. Tissue concentration was: VEN 50,6 mg/kg, ODV 74,2 mg/kg. Discussion. – Degenerative and poorly inflammatory changes may be observed in the myocardium after fatal VEN overdoses with cardiotoxicity. As the patients usually required large doses of catecholamines, the ultrastructural changes may also be partly due to catecholamines-induced myocardial injury or to ischemic-hypoxic injury. Until now, post-mortem tissue concentrations of VEN were not reported for the heart. It appears from our observations that a significant amount of VEN and ODV can be found in the myocardium. P31
Seizures and sustained encephalopathy following an accidental 4-aminopyridine overdose M. Ballesta Méndez (1), V. Van Pesch (2), A. Capron (3), P. Hantson (1,3) (1) Department of intensive care; (2) Department of neurology; (3) Louvain centre for toxicology and applied pharmacology, cliniques St-Luc, université catholique de Louvain, Brussels, Belgium. Introduction. – 4-aminopyridine (4-AP) is a drug that enhances interneuronal and neuromuscular synaptic transmission. It can be used as adjunctive treatment for patients with multiple sclerosis (MS). Accidental or intentional overdose results in significant neurotoxicity. Case observation. – A 58-year-old woman with secondary progressive MS was treated for more than 3 years by 4-AP (10 mg/bid) with an excellent tolerance. She was admitted to the ER with coma and