Case: Diagnosis of ruptured cocaine capsules in the rectum of bodypacker

History
A 32-year-old male person on a flight from South America landed at Rhein-Main International Airport in Frankfurt. He showed a conspicuous and slightly delirious behavior. The customs and border police were alert and questioned him if is carrying or if he has consumed drugs. First, he denied. But as his medical condition dramatically worsened, he admitted that he swallowed 24 self-packed capsules with cocaine.
The patient developed heavy attacks of abdominal cramps and became more and more apathetic. He was transferred to our hospital to localize the capsules, to confirm the number, and to check, if one of the capsules had opened and cocaine had come into the bowel lumen, or if the capsules had caused an ileus.

Diagnosis
A contrast-enhanced Dual Energy CT scan of the abdomen was performed. We found 24 capsules with an average size of 2.5 x 3.5 cm and hyperdense content, confirming the patient’s story. Average CT values of that hyperdense content were 203 HU at 80 kV and 140 HU at 140 kV. The capsules were spread all through the small bowel and colon.
However, there was one capsule in the rectum, that was significantly bigger than the others and its content showed lower attenuation values of 139 HU and 77 HU at 80 kV and 140 kV, respectively. DECT further revealed a thin hyperdense layer-like structure that got off from that capsule, therefore the suspicion arose that the capsule actually had ruptured.
Rectoscopy was performed immediately and the torn capsule was secured. The patient recovered on the intensive care unit without further major medical treatment and could be relieved from the rest of his freight with the use of laxatives.

Comments
With the use of DECT, the reliable diagnosis of ruptured cocaine capsule could be made and immediate medical help could be provided. Further, we are happy to be able to report as the first institute on the Dual Energy behavior of Columbian cocaine.

This might be of future relevance for in vivo differentiation of cocaine of different origin or heroin in uncommunicative bodypackers. However, further research on this field is needed to assure our results.

Authors: Ralf W. Bauer, MD, Thomas J. Vogl, MD, J. Matthias Kerl, MD

Fig. 1 Cocaine capsules distributed throughout the whole gut.
Fig. 2 Virtual colonoscopy view.
Fig. 3 Virtual colonoscopy view
Fig. 4 Color-coding of cocaine caspules facilitates detection and counting.
Fig. 5 Ruptured cocaine capsule. Arrows point at the loose outer layer.
Fig. 6 ROI measurements demonstrate typical Dual Energy values of Columbian cocaine.
Fig. 7 The coronal reformate shows large amounts of fluid in the colon lumen. However, no ileus was present.