Body Packing”

ARTICLE Pediatric “Body Packing”

Stephen J. Traub, MD; Gary L. Kohn, MD; Robert S. Hoffman, MD; Lewis S. Nelson, MD

Background: Recent events in the United States have with a naloxone infusion and aggressive gastrointesti- led to increased security at national borders, resulting in nal decontamination. He ultimately passed 53 packets an unexpected increase in drug seizures. In response, drug of heroin, one of which had ruptured. He recovered un- smugglers may begin using children as couriers, includ- eventfully. Patient 2, a 12-year-old boy, presented to ing using them as “body packers.” the emergency department with rectal bleeding. He had recently arrived in the United States from Europe, Objective: To look at the occurrence of body packing, and he confessed to body packing heroin. He was the concealing of contraband within the human body, treated with whole-bowel irrigation and activated char- which is well documented in adults, in the pediatric coal, and he subsequently passed 84 packets. He also re- literature. covered uneventfully.

Patient Reports: Two cases of pediatric body pack- Conclusions: We report the first 2 cases of body packing, in boys aged 16 years and 12 years. Patient 1, a ing in the pediatric literature and review the diagnosis 16-year-old boy, presented with findings consistent with and management of this clinical entity. Pediatricians opioid intoxication after arriving in the United States on should be aware that body packing, regrettably, is not a transcontinental flight. His mental status improved af- confined to the adult population. ter he received naloxone hydrochloride, and he subsequently confessed to body packing heroin. He was treated Arch Pediatr Adolesc Med. 2003;157:174-177

N THE WAKE of the events of PATIENT REPORTS September 11, 2001, security at border crossings in the United PATIENT 1 States has increased dramati- cally. One of the unintended con- A 16-year-old boy who had recently ar- From the Department of sequencesI of this action has been an in- rived in the United States was found unre- Emergency Medicine, New York crease in drug seizures. Faced with this sponsive on a city street. He had arrived that University and Bellevue increase in security, drug smugglers may day after a transcontinental flight from Hospital and Medical Center begin using children as vehicles to trans- Europe. His vital signs were pulse, 138 (Drs Traub, Hoffman, and port their cargo. Recently, a 5-year-old girl beats/min; blood pressure, 130/60 mm Hg; Nelson), and the New York City traveling alone from Colombia to New and respiratory rate, 12 breaths/min and Poison Control Center York was discovered to have more than shallow. The physical examination was (Drs Traub, Hoffman, and 1 Nelson), NY; and the Division 1 kg of heroin in her suitcase. otherwise unremarkable. The patient re- of Pediatric Critical Care, A more dangerous means of smug- ceived 25 g of dextrose, 4 mg of naloxone Department of Pediatrics, gling drugs into the country is by “body hydrochloride, and 100 mg of thiamine hy- Schneider Children’s Hospital, packing.” Body packing is the practice by drochloride, all intravenously. His mental Long Island Jewish Medical which international drug smugglers em- status improved immediately. Center, New Hyde Park, NY ploy human beings to hide cargo in their A urine sample was positive for opi- (Dr Kohn). Dr Traub is now bodies. Cocaine and heroin are by far the ates on toxicologic testing. A routine chest with the Division of Toxicology, drugs most commonly implicated. radiograph indicated abnormal densities Department of Emergency There are no previous reports of body in the stomach, a finding confirmed by Medicine, Beth Israel Deaconess Figure 1 Medical Center, Boston, Mass. packing in the pediatric literature. We de- plain abdominal radiography ( ). Dr Kohn is now with the scribe 2 young body packers, aged 16 years Computed tomography (CT) of the abdo- Division of Pediatric Critical and 12 years, and review the epidemiol- men (Figure 2) demonstrated multiple Care, Morristown Memorial ogy, clinical presentation, diagnosis, and intraluminal foreign bodies. The patient Hospital, Morristown, NJ. management of this condition. admitted to body packing 53 bags of

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, FEB 2003 WWW.ARCHPEDIATRICS.COM 174

©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Figure 1. A plain abdominal radiograph demonstrates multiple Figure 2. A computed tomographic scan of the abdomen demonstrates radio-opacities suspicious for foreign bodies. multiple intraluminal foreign bodies.

heroin. He was treated with activated charcoal, whole- Body packers may present to health care providers bowel irrigation, and a continuous infusion of nalox- in 3 ways: with signs and symptoms of drug toxicity one. By hospital day 4, he had passed 53 packets rec- owing to leaking or ruptured packets, with symptoms of tally, one of which had ruptured. A second CT scan of gastrointestinal obstruction or perforation, or asymp- the abdomen did not show any intraluminal foreign bod- tomatic, either because they fear the consequences of ies. He was discharged to the custody of law enforce- packet rupture or because they are under arrest. ment authorities. In the stable patient, the initial history and physical examination focuses on ascertaining the type of drug PATIENT 2 and number of packets ingested as well as the presence or absence of gastrointestinal obstruction. Body packers A 12-year-old boy presented to the emergency depart- usually know the exact amount of cargo they carry, but ment with a chief complaint of rectal bleeding. He con- they have reasons to be deceitful, and the history may fessed to body packing 87 packets of heroin and stated therefore be unreliable. The presence of cramping, bloat- that he had begun to pass packets per rectum. He had ing, and abdominal pain suggests obstruction. Rectal no other somatic complaints. His vital signs, including and/or abdominal examination may reveal the presence his respiratory rate, were within reference ranges. His men- of drug packets.6,7 Careful chest and abdominal exami- tal status was normal, and his pupils were midrange and nations in patients who present with gastrointestinal reactive. An abdominal examination revealed normal symptoms may reveal signs of obstruction, or even per- bowel sounds. foration, of the bowel or esophagus.8,9 A plain abdominal radiograph demonstrated mul- In the unstable patient or the patient with altered tiple abnormal opacities consistent with drug packets. mental status, the presence of a “toxidrome” (physical He was treated with whole-bowel irrigation and acti- findings suggesting a particular toxic ingestion) may vated charcoal, and he ultimately passed 84 packets. suggest a diagnosis. Cocaine causes hypertension, Barium-enhanced radiography after the passage of these tachycardia, hyperthermia, dilated pupils, diaphoresis, packets indicated no foreign bodies in the gastrointesti- and agitation. Heroin causes respiratory depression, nal tract, and it was concluded that 3 packets had constricted pupils, decreased bowel sounds, and a passed prior to his initial visit. He was subsequently dis- depressed level of consciousness. These findings can charged. help establish a diagnosis despite a paucity of histori- cal information. COMMENT The plain abdominal radiograph is 75% to 95% sen- sitive for drug packets,3,6 and 3 specific signs should be Body packing is the smuggling of illicit drugs using the sought. Multiple radiodense foreign bodies may repre- human body as a vehicle. Individual packets of 8 to 12 g sent drug packets, but they may also represent normal stool. of a drug (usually cocaine or heroin) are wrapped with The “double-condom” sign is formed when air trapped be- waterproof materials, such as latex glove fingers2 or con- tween layers of condoms renders them more visible.10 A doms,3 then sealed. The body packer (or “mule”) usu- “rosette-like finding” represents air trapped in a knot when ally swallows these packets, sometimes more than 200 a condom is tied.11 Computed tomography is frequently per trip,4 although retrograde packing of the rectum and used to image the abdomen, but the failure of CT to iden- vagina have also been reported.5 The mule then boards tify packets has been described.12 Contrast-enhanced plain a flight to a destination country and sometimes uses con- abdominal radiography, which has a sensitivity and speci- stipating agents to retard bowel motility.3 On arrival, body ficity of 96%, may be a superior method.13 Ultrasonogra- packers pass their contraband, often with the aid of laxa- phy has been suggested as a useful method,14 although sen- tives, cathartics, or enemas. sitivity and specificity have not been established.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, FEB 2003 WWW.ARCHPEDIATRICS.COM 175

©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Secure Airway, Breathing, Circulation. Remove Any Packets From Vagina and Rectum. Consider Regional Poison Control Center Consultation.

Asymptomatic

Evidence of Drug Toxicity Gastrointestinal Decontamination Gastrointestinal Perforation Activated Charcoal or 1 g/kg (Maximum 50 g) PO or per NG Tube Mechanical Obstruction Administer Every 4-6 Hours × 4 Doses Cocaine Heroin Whole-Bowel Irrigation 500 mL/h (Children); 2 L/h (Adolescents) PO or per NG Tube Until Clear Rectal Effluent Treat Symptoms Treat Symptoms Agitation and/or Seizures All Symptoms Benzodiazepines Naloxone Hydrochloride, IV Bolus Pass Bags per Rectum Diazepam, 0.1-0.2 mg/kg IV Bolus 2-5 mg IV Until No More Suspected Lorazepam, 0.05-0.10 mg/kg IV Repeat Until Clinical Response Neuromuscular Blockade (Severe Cases) Total Given = Response Dose Vecuronium Bromide, 0.1 mg/kg IV Naloxone, IV Infusion Repeat Abdominal Imaging Study Hyperthermia Two Thirds of the Response Contrast-Enhanced Abdominal CT and/or Benzodiazepines Dose per Hour Contrast-Enhanced Plain Radiography Diazepam, 0.05-0.10 mg/kg IV Lorazepam, 0.05-0.10 mg/kg IV Active Cooling Ice Immersion Remaining Packets No Remaining Packets Fan/Misting Neuromuscular Blockade (Severe Cases) Vecuronium, 0.1 mg/kg IV Hypertension Discharge Benzodiazepines Diazepam, 0.1-0.2 mg/kg IV Surgical Intervention Lorazepam, 0.05-0.10 mg/kg IV Other Agents Phentolamine, 0.05-0.10 mg/kg IV Sodium Nitroprusside, 0.3-3.0 µg/kg per min Nitroglycerine, 0.25-0.50 µg/kg per min

Figure 3. Suggested algorithm for the management of “body packers.” CT indicates computed tomography; IV, intravenous; NG, nasogastric; and PO, by mouth.

Toxicologic testing of urine samples lacks the sen- The treatment of patients who present with symp- sitivity to be a useful screening tool. Although one large toms of drug toxicity depends on the drug being smuggled. study found a sensitivity of 97%,4 sensitivities as low as Symptomatic heroin body packers are usually treated 17% to 30% have also been reported.6,15 conservatively with naloxone, which completely re- For all patients, the airway, breathing, and circula- verses the clinical findings of opiate toxicity. Sympto- tion should be secured. Drug packets in the rectum or matic cocaine body packers require immediate pharma- vagina should be carefully removed, but only if they can cological and surgical therapy. Agitation, seizures, be easily grasped with the fingers. Gastrointestinal de- hyperthermia, and hypertension are treated initially with contamination should be performed unless the patient benzodiazepines. Hyperthermia may require external is being prepared for surgery. Activated charcoal will cooling and neuromuscular blockade, and hyperten- adsorb any free drug; multiple doses should be given to sion may require additional pharmacological agents, increase the amount of charcoal near the drug packets such as phentolamine mesylate, nitroglycerine, or so- at any given time. Although activated charcoal admin- dium nitroprusside. ␤-Blockade is absolutely contrain- istration is theoretically of benefit for all drugs, dicated21 because it may lead to unopposed ␣-adrener- it is most important for drugs for which an effective an- gic stimulation and a paradoxical increase in blood tidote is not available, such as cocaine. Whole-bowel ir- pressure. After initial stabilization, cocaine-intoxicated rigation with a polyethylene glycol/electrolyte lavage body packers should be brought to the operating room solution will help propel packets through the gastroin- for surgical decontamination. testinal tract.16 The end point of whole-bowel irrigation Patients presenting with symptoms of gastrointes- is a clear rectal effluent devoid of packets. Oil-based tinal obstruction or perforation should also undergo im- cathartics and laxatives should be avoided because mediate operative intervention. There is no role for con- they may weaken packets17,18 and contribute to packet servative management in these cases. rupture.17 At our institution, patients who present without Endoscopy plays little role in the management of symptoms are treated conservatively with activated char- body packers. Although successful endoscopic removal coal, whole-bowel irrigation, and observation in an in- of packets has been reported19 so has packet rupture.20 tensive care unit. Conservative therapy fails (defined as Packets accessible to the endoscopist usually represent the development of bowel obstruction or acute cocaine a small fraction of the gastrointestinal burden, and the toxicity) in only about 5% of patients,2,3,7 who then re- risks inherent in routinely removing them usually out- quire surgical treatment. When the treating physician be- weigh the benefit. lieves that the patient has passed all packets, contrast-

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, FEB 2003 WWW.ARCHPEDIATRICS.COM 176

©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 2. Aldrighetti L, Paganelli M, Giacomelli M, Villa G, Ferla G. Conservative manage- What This Study Adds ment of cocaine-packet ingestion: experience in Milan, the main Italian smuggling center of South American cocaine. Panminerva Med. 1996;38:111-116. Body packing has not previously been reported in the pe- 3. McCarron MM, Wood JD. The cocaine “body packer” syndrome. JAMA. 1983; 250:1417-1420. diatric literature, and many pediatricians are not familiar 4. Gherardi RK, Baud FJ, Leporc P, Marc B, Dupeyron JP, Diamant-Berger O. De- with this clinical entity. We report 2 cases of pediatric body tection of drugs in the urine of body-packers. Lancet. 1988;1(8954):1076-1078. packing and review the diagnosis and management of this 5. Wetli CV, Mittlemann RE. The “body packer syndrome”: toxicity following in- condition. We hope that this report will alert and educate gestion of illicit drugs packaged for transportation. J Forensic Sci. 1981;26:492- the physicians who may care for these patients. 500. 6. Utecht MJ, Sonte AF, McCarron MM. Heroin body packers. J Emerg Med. 1993; 11:33-40. 7. Caruana DS, Weinback B, Goerg D, Gardner LB. Cocaine-packet ingestion. Ann enhanced radiography and/or CT should be performed Intern Med. 1984;100:73-74. to document a “clean” gastrointestinal tract. 8. Hutchins KD, Pierre-Louis PJ, Zaretski L, Williams AW, Lin R-L, Natarajan GA. Heroin body packing: 3 fatal cases of intestinal perforation. J Forensic Sci. 2000; The management of body packers is challenging; an 45:42-47. algorithm is presented (Figure 3), but it may not be ap- 9. Johnson JA, Landreneau RJ. Esophageal obstruction and mediastinitis: a hard propriate for all patients. Consultation with a regional pill to swallow for drug smugglers. Am Surg. 1991;57:723-726. poison control center is advisable. 10. Pinsky MF, Ducas J, Ruggere MD. Narcotic smuggling: the double-condom sign. J Can Assoc Radiol. 1978;29:79-81. 11. Sinner WN. The gastrointestinal tract as a vehicle for drug smuggling. Gastro- CONCLUSION intest Radiol. 1981;6:319-323. 12. Hahn I, Hoffman RS, Nelson LS. Contrast CT scan fails to detect the last heroin Body packing is well described in adults, but not in chil- packet [abstract]. J Toxicol Clin Toxicol. 1999;37:644-645. 13. Marc B, Baud FJ, Aelion MJ, et al. The cocaine body-packer syndrome: evalua- dren. We report 2 cases of pediatric body packing and tion of a method of contrast study of the bowel. J Forensic Sci. 1990;35:345- describe the epidemiology, diagnosis, and management 355. of this condition. Pediatricians should be aware that body 14. Heirholzer J, Cordes M, Tantow H, Keske U, Maurer J, Felix R. Drug smuggling packing, once thought to be strictly an adult problem, is by ingested cocaine-filled packages: conventional x-ray and ultrasound. Abdom now a pediatric problem as well. Imaging. 1995;20:333-338. 15. Bogusz MJ, Althoff H, Erkens M, Maier RD, Hofmann R. Internally concealed cocaine: analytical and diagnostic aspects. J Forensic Sci. 1995;40:811-815. Accepted for publication September 20, 2002. 16. Hoffman RS, Smilkstein MJ, Goldfrank LR. Whole bowel irrigation and the co- Corresponding author: Stephen J. Traub, MD, Depart- caine body-packer: a new approach to a common problem. Am J Emerg Med. ment of Emergency Medicine, Beth Israel Deaconess 1990;8:523-527. Medical Center, One Deaconess Road, Boston, MA 02215 17. Visser L, Stricker B, Hoogendoorn M, Vinks A. Do not give paraffin to packers. Lancet. 1998;352:1352. (e-mail: [email protected]). 18. White N, Taylor K, Lyszkowski A, Tullett J, Morris C. Dangers of lubricants used with condoms [letter]. Nature. 1988;335:19. REFERENCES 19. Choudhary AM, Taubin H, Gupta T, Roberts I. Endoscopic removal of a cocaine packet from the stomach. J Clin Gastroenterol. 1998;27:155-156. 20. Suarez CA, Arango A, Lester JL. Cocaine-condom ingestion: surgical treatment. 1. US Customs Service. Unaccompanied 5-year-old girl caught smuggling heroin JAMA. 1977;238:1391-1392. on commercial flight from Colombia [press release]. April 22, 2001. Available 21. Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coro- at: http://www.customs.ustreas.gov/hot-new/pressrel/2002/0423-00.htm. Ac- nary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990;112: cessed July 28, 2002. 897-903.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, FEB 2003 WWW.ARCHPEDIATRICS.COM 177