Case Presentation

The patient was a 28-year-old man in police cus-tody arrested for illegal possession of drugs by customs agents in a Chicago airport who con-fessed to swallowing several “bags of coke ” prior to boarding his plane in Colombia. The patient was agitated and complained of chest pain. His pupils were equal and reactive, lungs clear to ausculta-tion, and skin diaphoretic and warm to touch, with no cyanosis or needle tracks. His pulse was 140 beats per minute; respiratory rate, 28 breaths per minute; blood pressure, 220/130 mm Hg; and temperature, 39.6°C (103.2°F). The patient’s abdomen was soft and non-tender with normal bowel sounds. An electrocardiogram revealed a sinus tachycardia with large 5-mm ST segment elevation in the anterior leads, consistent with acute myocardial infarction. Otherwise, the patient was healthy and had no previous cardiac disease. The chest radiograph showed no infil-trates or pulmonary edema; a plain radiographic film of the abdominal area (kidney, ureter, and bladder) revealed multiple radio-opaque packets throughout the gastric and intestinal tract. Suspecting ingestion of a sympathomimetic drug, the physician ordered the tests in Table 1 and then gave the patient large doses of benzodi-azepines for sedation and nitroglycerin for chest pain. Because of the acute myocardial infarction, the cardiologist elected to give thrombolytics. However, because thrombolytics were adminis-tered, the general surgeon refused to perform an exploratory laparotomy and removal of the “cocaine packets ” because of the increased risk of bleeding. The patient subsequently developed generalized seizure activity, worsening hyperther-mia, rhabdomyolysis, and intracranial hemor-rhage. He died 48 hours after admission. The sympathomimetic amines and sympath-omimetic-like drugs mimic the actions of the endogenous neurotransmitters that stimulate the sympathetic nervous system. Stimulation of the peripheral nervous system occurs via receptors (alpha or beta) on neurons that involve either adrenergic (epinephrine) or noradrenergic (nor-epinephrine) neurons.1,2 Stimulation of the cen-tral nervous system (CNS) occurs via neurons that involve dopamine and serotonin receptors. Some of the sympathomimetic drugs act directly with receptors on the neurons of the sympathetic ner-vous system to elicit a pharmacologic response