Sudden Death Due To Acute Cocaine Toxicity—Excited Delirium in a Body Packer

Abstract

Excited delirium denotes a life-threatening medical condition characterized by the acute onset of agitated and violent behavior that often results in a sudden and unexplained death. Cocaine-induced excited delirium refers to fatal cocaine intoxication with the following symptoms occurring sequentially: hyperthermia, delirium with agitation, respiratory arrest, and death. We present a case of cocaine-induced excited delirium in a cocaine "body packer" or a "mule", specifically an individual who attempts to smuggle cocaine within the body. Investigators at the scene initially suspected homicide due to the victim's sharp and blunt force injuries. Three rubber packets containing cocaine were removed from the victim's rectum. Blood toxicological analysis revealed an alcohol concentration of 0.016 g/100 and cocaine >1 mg/L. The forensic pathologist should consider cocaine-induced excited delirium when an individual exhibits aggressive behavior, unexpected strength, and resistance to pain who dies suddenly. Further analysis should be performed during the scene investigation and autopsy for evidence of body packing.

DARK Classics in Chemical Neuroscience: Cocaine

“…These cases are rare and exclusively observed in individuals who are “body-packing” or drug “mules;” it is assumed the acute toxicity ensues from rupture of the packets or disintegration of the packages. 94…”

“…These cases are rare and exclusively observed in individuals who are "body-packing" or drug "mules;" it is assumed the acute toxicity ensues from rupture of the packets or disintegration of the packages. 94 The most common drug combination with cocaine is ethanol, which alters the metabolism profile of cocaine as discussed previously. Other combinations of drug coabuse with cocaine include stimulants, sedatives, cannabis, and opiates.…”

Case 251: Nontraumatic Drug-associated Rhabdomyolysis of Head and Neck Muscles

“…Rhabdomyolysis due to cocaine and methamphetamine abuse most proba-bly results from the combined action of three mechanisms: (a) ischemia due to vasoconstriction and hypoperfusion via cocaine-induced vasospasm (11); (b) hyperpyrexia and increased muscle activity associated with excited delirium, a complication that is due to the effects of cocaine on the central nervous system (4,12,13); and (c) direct toxicity of cocaine on muscle cells. Interestingly, cocaine blocks the presynaptic reuptake of the neurotransmitters norepinephrine and dopamine and induces a postsynaptic excess in their concentrations (4).…”

“…Nevertheless, the absence of external neck injuries and indirect signs of neck compression, such as congestion or petechiae, made traumatic rhabdomyolysis less likely and contributed to our decision to rule out neck lesions due to violence. Traumatic neck injuries can also occur during attempts at restraint in the initial management of excited delirium (5,12,13). More generally, drug abusers have a higher risk of injuries and death due to interpersonal violence (15).…”

Death by “Snow”! A Fatal Forensic Case of Cocaine Leakage in a “Drug Mule” on Postmortem Computed and Magnetic Resonance Tomography Compared With Autopsy

“…Therefore, leakages of even tiniest amounts of the substance are highly toxic and pose a danger to life. 4,[8][9][10][11][12][13] This method of intracorporal smuggling is typically organized by drug cartels and serves the purpose of distribution within the destination country. (2) Body pushers hide drug containers within natural orifices, such as the rectum or vagina.…”