heroin and Coma

The spectrum of neurological complications associated with heroin addiction has changed in the past six years because of the progressive knowledge of the neurological complications related to HIV infection. We reviewed 48 heroin addicts with neurological complications and 452 heroin overdose who were seen in the Emergency Unit of our hospital during 1988 and the publications since 1967. Regarding the overdose we present the results of a prospective study leading to determine the causes. We emphasize the relationship with the level of total morphine in serum, instead of conjugate morphine, and with the presence of high levels of benzodiazepines found in the plasma rather than an hypothetic hypersensitivity phenomenon. We resume the neurological complications related with heroin addiction: spongiform leukoencephalopathy, epileptic seizures, stroke, transverse myelopathy and neuromuscular complications such mononeuropathy, plexopathy, acute inflammatory demyelinating polyradiculoneuropathy, rhabdomyolysis, fibrosing myopathy, musculoskeletal syndrome and acute bacterial myopathy. Some of such complications (i.e. transverse myelitis, polyradiculoneuropathy, leucoencephalopathy) must rise the suspicion of an HIV infection. Likewise, in patients assisted for overdosage we believe it's necessary rule out myoglobinuria by means of CPK serum levels and detection of urine hematic pigments without red blood cels in the urine sediment, in order to prevent and treat the renal failure. We report the results of muscular biopsy found in the musculoskeletal syndrome, which are similar to those found in alcoholic myopathy. Finally, we describe the clinical and diagnostic aspects in an unusually neuromuscular complication: the acute bacterial myopathy.

Topics: Cerebrovascular Disorders; Coma; Drug Overdose; Epilepsy; Heroin; Heroin Dependence; Humans; Leukoencephalopathy, Progressive Multifocal; Muscular Diseases; Myelitis, Transverse; Nervous System Diseases; Peripheral Nervous System Diseases

Quantitative results from toxicological analyses of autopsy material are widely compared to ranges in reference works to determine if drug concentrations are in relevant levels for establishing intoxication. This study compares concentrations of commonly used opioids and stimulants from drug addict autopsies and driving under the influence of drugs (DUID) cases to supplement current knowledge of the possible span and overlaps of measured concentrations. The study included whole-blood results from forensic autopsies of drug addicts performed from 2015 to 2020 (n = 220) and DUID cases from 2015 to 2019 (n = 7088). The focus was on heroin/morphine, methadone, cocaine, amphetamine and MDMA concentrations because these drugs are commonly encountered in both fatal intoxications and DUID cases and the potential for abuse is well known. In the DUID group, the opioids heroin/morphine and methadone and the stimulants amphetamine and MDMA were often seen in concentrations above the reported lower comatose-fatal level whereas cocaine was almost always below. Thus, based on our data, the potential for false assessment of intoxication cases when comparing to reported comatose-fatal limits appears greatest on lower end concentrations of heroin/morphine, methadone, amphetamine and MDMA, whereas false assessment of cocaine appears less likely because most control cases are below reported comatose-fatal levels.

Topics: Amphetamine; Analgesics, Opioid; Autopsy; Central Nervous System Stimulants; Cocaine; Coma; Heroin; Humans; Methadone; Morphine; N-Methyl-3,4-methylenedioxyamphetamine; Substance Abuse Detection; Substance-Related Disorders

Abnormal restricted diffusion on magnetic resonance imaging is often associated with ischemic stroke or anoxic injury, but other conditions can present similarly. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices. This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention.. We identified an ad hoc series of patients at our two institutions between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging.. Between two institutions, we identified six patients-ages 33-59 years, four male-with similar presentations of decreased level of consciousness in the context of intoxicant exposure, with acute cytotoxic edema of the cerebellar cortex, hippocampi, and aspects of the basal nuclei. All patients presented with severe cerebellar edema which led to obstructive hydrocephalus requiring aggressive medical and/or surgical management. The five patients who survived to discharge demonstrated variable degrees of physical and memory impairment on discharge and at follow-up.. We present findings of a potentially novel syndrome involving a distinct pattern of cerebellar and hippocampal restricted diffusion, with imaging and clinical characteristics distinct from ischemic stroke, hypoxic injury, and known toxidromes and leukoencephalopathies. Given the potential for favorable outcome despite early obstructive hydrocephalus, early identification and treatment of this syndrome are critical.

Topics: Adult; Alcoholic Intoxication; Amphetamines; Basal Ganglia; Benzodiazepines; Brain Edema; Central Nervous System Stimulants; Cerebellar Cortex; Cerebellum; Cocaine; Coma; Female; Heroin; Hippocampus; Humans; Hydrocephalus; Hydromorphone; Magnetic Resonance Imaging; Male; Middle Aged; Opiate Alkaloids; Pain, Postoperative; Stupor; Substance-Related Disorders; Syndrome

Topics: Coma; Heroin; Humans; Male; Radiography; Respiratory Insufficiency; Travel; Young Adult

The purpose of this study was to explore to what extent alcohol is a factor in non-fatal overdoses on the basis of records of ambulance emergencies, and to what extent this varies across gender and age. Furthermore, we wanted to investigate whether alcohol intake, in relation to an overdose, is associated with the risk of recurrent overdoses, and if so, whether such an association varies across gender and age. To investigate the role of alcohol intake in non-fatal overdoses, analyses were conducted both at the event level and at the individual level. Bivariate associations were explored in table analyses and by comparisons of means. To determine whether alcohol intake was associated with experiencing recurrent overdoses, survival analyses were conducted applying Kaplan-Meier estimation and Cox regression models. Furthermore, a linear regression model was estimated to assess the impact of gender age and number of overdoses on the proportion of overdoses in which alcohol was involved. Between groups of clients who had overdosed once, several times or many times, we found that there was a U-shaped relationship. The proportion of overdoses with alcohol involved was highest among those who had overdosed once and those who had overdosed more than ten times. The probability for a recurrent overdose was higher among those who were reported with no alcohol intake in the first overdose. Being female and having alcohol involved in the first overdose registered during our observation period reduced the risk for a recurrent overdose. However, age seemed to be a gradient with respect to alcohol's association with recurrent overdoses. While alcohol was associated with a significantly lower risk for recurrence in the two youngest age groups, this is not the case in the oldest age group. A possible explanation might be that it is a change in the pattern of drug use as an effect of aging where infrequent heroin use in combination with frequent alcohol intake increases with increasing age. For this type of drug users the individual's risk of recurrent overdoses may be lower due to fewer events of heroin intake.

Topics: Adult; Age Factors; Alcoholism; Coma; Comorbidity; Drug Overdose; Emergencies; Ethanol; Female; Heroin; Humans; Illicit Drugs; Male; Middle Aged; Norway; Recurrence; Regression Analysis; Respiratory Insufficiency; Risk; Sex Factors

We report a case of death due to the effects of heroin concealed in a woman who was attempting to smuggle the drug into Kenya concealed within her gastro-intestinal tract. She was arrested at a Nairobi airport. While under police detention, she expelled a pellet par anum containing the drug then collapsed, after being forcefully fed on a heavy meal. She was taken to hospital in coma where she expelled nine pellets and died three days later. Her blood level of heroin at admission was well beyond the lethal dose. Details are provided of the circumstances leading to her admission into hospital, her stay in hospital and the autopsy findings. At autopsy 88 pellets were retrieved from her body. The main pathological findings included pulmonary and cerebral edema. Despite the presence of free heroin in the gastric contents, toxicological analysis did not demonstrate any heroin or its metabolites in blood or tissue extracts. This case illustrates the challenges in postmortem evaluation of narcotic fatalities and the need to consider all factors such as antemortem history, toxicology results and autopsy findings in forensic diagnosis

Topics: Adult; Autopsy; Brain Edema; Coma; Drug Implants; Fatal Outcome; Female; Gastrointestinal Tract; Heroin; Humans; Kenya; Pulmonary Edema; Syndrome

Stroke is an infrequent but recognized complication of heroin addiction. Two heroin addicts, aged 34 and 19 years, developed ballistic movements after intravenous heroin overdose. Patient 1 presented bilateral ballism 1 week after intravenous heroin injection. Magnetic resonance imaging (MRI) showed bilateral ischemic lesions of the globus pallidus, suggesting a generalized cerebral hypoxia during the comatose state as pathogenic mechanism. Patient 2 presented an acute left hemiballismus when consciousness was restored with naloxone. MRI demonstrated an ischemic infarct in the right striatum. An embolic mechanism of stroke was suspected in this patient, considering the normal results of blood analysis, echocardiogram and cerebral arteriograms. Ballistic movements ceased after administration of haloperidol; both patients remained without abnormal movements thereafter.

Topics: Adult; Anti-Dyskinesia Agents; Basal Ganglia; Brain Ischemia; Coma; Corpus Striatum; Drug Overdose; Globus Pallidus; Haloperidol; Heroin; Humans; Magnetic Resonance Imaging; Male; Movement Disorders; Naloxone; Narcotic Antagonists; Substance Abuse, Intravenous; Tomography, X-Ray Computed

We report a case of biopsy proven myocardial damage after opiate-induced rhabdomyolysis. Myocardial biopsy showed focal lesions formed by small mononuclear inflammatory cells with a few neutrophils, associated with degenerated and necrotic myocardial fibers, interstitial edema and congestion of intrinsic blood vessels. These findings were similar to those seen with other drug overdoses if combined with strenuous muscular effort or hypoxic coma. We hypothesize that myocardial damage is a consequence of intracapillary myohypoxia associated with prolonged hypoxic coma following opiate overdose.

Topics: Adult; Biopsy; Cardiomyopathies; Cell Hypoxia; Coma; Drug Overdose; Heart; Heroin; Humans; Male; Myocardium; Narcotics; Necrosis; Rhabdomyolysis

Topics: Adult; Coma; Family Practice; First Aid; Heroin; Humans; Illicit Drugs; Male

Topics: Coma; Emergencies; Heroin; Humans; Naloxone; Respiration, Artificial; Respiratory Insufficiency

Topics: Ataxia; Coma; Depression; Electroencephalography; Female; Heroin; Heroin Dependence; Humans; Male; Mental Disorders; Muscular Diseases; Myelitis, Transverse; Nervous System Diseases; Neuritis; Neurocognitive Disorders; Nystagmus, Pathologic; Parkinson Disease, Secondary; Sexual Dysfunction, Physiological; Sleep Wake Disorders; Substance Withdrawal Syndrome; Tremor

Complications resulting from drug abuse more frequently affect the lung than any other organ. The spectrum of pulmonary complications associated with drug abuse is wide. The current practice of using mixtures of drugs is mainly responsible for the increase in pulmonary complications. The chief complications observed in a series of 241 drug abuse patients were aspiration pneumonitis (12.9 percent), pulmonary edema (10.0 percent), and pneumonia (7.5 percent).

Topics: Adult; Alcoholism; Barbiturates; Cannabis; Cocaine; Coma; Female; Heroin; Humans; Lung Abscess; Lung Diseases; Male; Pneumonia; Pneumonia, Aspiration; Pulmonary Atelectasis; Pulmonary Edema; Pulmonary Embolism; Pulmonary Fibrosis; Substance-Related Disorders

Topics: Adult; Coma; Endocarditis, Bacterial; Heroin; Heroin Dependence; Humans; Jaundice; Male; Sepsis; Staphylococcal Infections; Substance-Related Disorders

Topics: Acute Kidney Injury; Adult; Coma; Contracture; Female; Heroin; Humans; Ischemia; Male; Muscles; Muscular Diseases; Pressure; Pressure Ulcer; Secobarbital; Skin Diseases; Substance-Related Disorders

Topics: Acute Kidney Injury; Adolescent; Adult; Alcoholic Intoxication; Arm Injuries; Brachial Plexus; Coma; Hemoglobins; Heroin; Humans; Leg Injuries; Male; Myoglobin; Paralysis; Peripheral Nerve Injuries; Pressure; Secobarbital; Substance-Related Disorders

Topics: Breath Tests; Coma; False Negative Reactions; False Positive Reactions; Heroin; Humans; Medical History Taking; Methods; Nalorphine; Pharmaceutical Preparations; Pupil; Substance Withdrawal Syndrome; Substance-Related Disorders

Topics: Acute Kidney Injury; Adult; Aspartate Aminotransferases; Barbiturates; Chlorpromazine; Coma; Drug-Related Side Effects and Adverse Reactions; Female; Glutethimide; Heroin; Humans; Kidney Function Tests; L-Lactate Dehydrogenase; Male; Methadone; Methamphetamine; Muscular Diseases; Myoglobinuria; Phosphocreatine; Pyruvate Kinase; Quinine; Substance-Related Disorders

Topics: Acidosis; Acidosis, Respiratory; Adolescent; Adult; Carbon Dioxide; Coma; Female; Heroin; Humans; Hypoventilation; Hypoxia; Lung; Lung Compliance; Male; Pulmonary Alveoli; Pulmonary Circulation; Pulmonary Diffusing Capacity; Pulmonary Edema; Pulmonary Ventilation; Radiography; Respiration; Spirometry; Substance-Related Disorders; Vital Capacity

Topics: Adult; Blister; Clinical Enzyme Tests; Coma; Diagnostic Errors; Heroin; Humans; Male; Pulmonary Edema; Sepsis

Topics: Adolescent; Adult; Anti-Bacterial Agents; Arrhythmias, Cardiac; Black or African American; Body Temperature; Coma; Drug Combinations; Ethnicity; Female; Heroin; Humans; Hypoxia; Male; Nalorphine; New York City; Pneumonia; Puerto Rico; Pulmonary Edema; Retrospective Studies; Substance-Related Disorders

Topics: Acute Disease; Administration, Oral; Adult; Coma; Female; Furosemide; Heroin; Humans; Hydrocortisone; Injections, Intravenous; Intubation, Intratracheal; Methadone; Nalorphine; Oxygen Inhalation Therapy; Penicillin G; Pulmonary Edema; Radiography; Substance-Related Disorders; Time Factors

Topics: Adult; Coma; Female; Hepatitis B; Heroin; Humans; Male; Osteomyelitis; Pulmonary Edema; Sepsis; Substance-Related Disorders

Topics: Adolescent; Brain Diseases; Coma; Decerebrate State; Electroencephalography; Heroin; Humans; Hypoxia; Male; Neurologic Examination; Substance-Related Disorders; Time Factors; Vision Disorders

Topics: Adult; Coma; Heroin; Humans; Male; Positive-Pressure Respiration; Pulmonary Edema; Radiography; Shock, Septic; Substance-Related Disorders

Topics: Adult; Amobarbital; Barbiturates; Biopsy; Blister; Coma; Erythema; Heroin; Humans; Male; Nalorphine; Necrosis; Prednisone; Secobarbital; Skin; Skin Diseases; Sweat Glands

Topics: Adult; Animals; Anti-Bacterial Agents; Apnea; Blood Gas Analysis; Coma; Furosemide; Heroin; Humans; Hydrocortisone; Hydrogen-Ion Concentration; Injections, Intravenous; Male; Milk; Substance-Related Disorders