1. Abstract Body packing represents the concealment of illegal substances in a person's body with the aim of smuggling. Body packers either swallow drug-filled packets or introduce drug-filled packets into their bodies through rectum or vagina. In the world, the three main smuggled drugs are cocaine, heroin and cannabis products. Complications of body packing include acute narcotic toxicity from drug exposure, intestinal obstruction owing to pellet impaction and bowel perforation with consequent abdominal sepsis. I document here two heroin body packers, who suffered serious toxicity from exposure.
Keywords: Narcotic toxicity; Body packing; Diagnosis
2. Introduction The transportation of illicit substances in body cavities, documented in the last few decades, is considered an expanding and profitable commercial activity throughout the world. Body packing describes the intracorporeal concealment of illicit substance in the alimentary tract. "Body packers" are also known as "drug mules", "swallowers", "internal carriers" or "couriers". A wide range of illicit drugs may be transported in this way, including cocaine, heroin, hashish and amphetamines. First case of body packing, reported in 1973 was that of a patient with complete small bowel obstruction 13 days after swallowing a condom containing hashish [1]. Body packers are persons who illegally carry illicit substance. The packets can be made of various materials, but most often are condoms, which are easily available on the market. The packets are inserted in the mouth, rectum, or vagina to transport across borders without being detected. The most serious complications of this syndrome, known as body packing, are acute intoxication and ileus. I document here two cases of body packing recorded for the first time from Sri Lanka. In spite of increased prevalence of body packing, there are still some controversies in the management of these patients. On the other hand, considering the difference between Iran and Western countries with respect to the type of smuggled substances (mostly opium and crack which is concentrated heroin compared with cocaine and occasionally amphetamines) few studies exist on the management of packers in Iran.
3. Case Reports SD, a 37-year-old male an Austrian transit passenger at the Bandaranaike International Airport, Katunayaka, Sri Lanka, was referred by the airport medical officer to a private hospital in Colombo, and admitted at 2.25 a.m. by the staff of an airline. He had convulsions and cyanosis at the airport and was given diazepam 10 mg intramuscularly. On admission to the Intensive Care Unit (ICU), he was conscious, confused and drowsy. His respiratory rate was 28/minute and the pulse rate was 112/minute. His blood pressure was 130/60 mm. Hg. His pupils were size 5 and reacted to light. He was given diazepam 10 mg and 50 cc of 50% dextrose intravenously and oxygen inhalation. His secretions were sucked out. His naso-gastric aspirate was coffee ground in colour. He was given ranitidine 50 mg IV. He developed two generalized convulsions in the ICU. He was given of intravenous naloxone 1 mg IV.A condom packed with a white powder was extracted from her rectum. She was also given 5 mg of naloxone IV in multiple doses and transferred the following day to the MICU, General Hospital, Colombo at 12.30 p.m. Both were discharged from the MICU after 60 hours. They were conscious and alert. There was no respiratory difficulty. The white powder in condoms of both patients was analyzed and heroin was detected. Both were indicted in the High Court, Colombo, for illegal import and possession of heroin. SD, who had 37 grammes of heroin was convicted and sentenced to 5 years rigorous imprisonment 5 years later. REN who had 41 grammes of heroin was convicted and sentenced to 13 years rigorous imprisonment 2 years later
4. Discussion Both patients developed serious toxic effects of heroin as a result of the damage to the condoms. Prompt therapy with naloxone helped their recovery. Imaging is essential in diagnosing body packing. Upright abdominal radiography and abdominal computed tomography are useful to detect body packing. (Mayo) Body packing has been reported from many countries. In a study assessing the epidemiological data and management methods of 175 body packers in Iran, attempted methods of body packing were ingestion (97.7%), rectal enema (1.7%), and vaginal insertion (0.6%). The mortality rate was (3%). The most common concealed substances were crack (37%), crystal (the street name of methamphetamine in Iran) (17%), opium (13%), and heroin (6%), respectively. The type of packed substances was not specified in 27% of cases [2]. Apart from antidote therapy, management for body packer syndrome may include whole bowel irrigation and percutaneous endoscopic gastrostomy. Antidote therapy with naloxone was also used. Nineteen percent of patients underwent surgery. Indications for surgical intervention were signs and symptoms of intoxication with stimulants or opioids that did not respond to antidote therapy. In this study, forty-eight patients underwent surgery. Indications for surgical intervention were signs and symptoms of intoxication with stimulants or opioids that did not respond to antidote therapy with naloxone (79%), gastro-intestinal obstruction (17%), gastro-intestinal bleeding (2%), and peritonitis (2%). For these 48 patients, 24 (50%) underwent laparotomy and gastrotomy. In a study of 50 body packer deaths in New York City from 1990 to 2001, the majority (37/50) of deaths were caused by acute intoxications due to open or leaking drug packets in the gastrointestinal tract. Intestinal obstruction and life-threatening sympathomimetic toxidrome including seizures, ventricular dysrhythmia, and cardiac arrest has occurred from the rupture of cocaine packages. The first body packer case reported in Portugal in 2009 was fatal, as he has ingested 56 cocaine packets [3]. Early diagnosis is essential and correct treatment of body packing can be lifesaving.
References 1. Deitel M, Syed AK. Intestinal obstruction by an unusual foreign body. Can Med Assoc J. 1973; 109: 211-2.
2. Alipour-faz A, Shadnia S, Mirhashemi SH, Peyvandi M, Oroei M, Shafagh O, et al. “Assessing the Epidemiological Data and Management Methods of Body Packers Admitted to a Referral Center in Iran.” Medicine (Baltimore). 2016; 95: e3656.
3. Dinis-Oliveira RJ, Magalhães T, Carvalho F, Santos A. “A cocaine body packer case report: clinical and forensic aspects”. Clin Toxicol (Phila). 2009; 47: 590-1.
Ravindra Fernando. Body Packer Syndrome in Sri Lanka. Annals of Clinical and Medical Case Reports 2021