Sudden death from superior mesenteric artery thrombosis in a cocaine user

Abstract

Cocaine-mediated tissue injury is well established, particularly myocardial ischemia and infarction. Gastrointestinal complications including mesenteric ischemia, ischemic colitis and intestinal perforation occur less frequently. Cocaine-induced visceral arterial thrombosis is a rare finding. We report a case of a 49-year-old chronic cocaine user with superior mesenteric artery (SMA) thrombosis. The patient presented with a 24-h history of abdominal pain, nausea and vomiting. Physical examination documented tachycardia and a soft, non-rigid abdomen with voluntary guarding. Abdominal X-ray did not show any evidence of peritoneal free air or bowel obstruction. Laboratory investigations revealed elevated white blood cells and a high anion gap; a blood gas analysis was not done. Three hours after initial presentation, the patient had a cardiac arrest and died. At autopsy, the jejunum was ischemic, without obvious infarction. The SMA was occluded at its origin by significant atherosclerosis with superimposed thrombus. The myocardium had fibrosis, without acute infarction, and severe triple coronary artery atherosclerosis. Toxicological blood analysis confirmed cocaine use. This report emphasizes the need to consider chronic stimulant drug abuse in accelerated atheroma and thrombosis of visceral arteries.

Histologic Changes In Recreational Drug Misuse

“…Cocaine, methamphetamine, and 3,4-methylenedi-oxymethamphetamine (MDMA) are frequently en-countered stimulant drugs that are associated with cardiovascular complications, including coronary artery atherosclerosis at a younger age, myocardi-al fibrosis, cardiomegaly, and myocardial infarction (40 –49). Other complications include coronary artery dissection (50–51) (Image 22), aortic dissection (52, 53), and thrombosis of other vessels, including effects on the gastrointestinal tract (54). Acute stimulant use may result in myocardial contraction band necrosis (see illustrative case).…”

Gastrointestinal causes of sudden unexpected death: A review

“…Acute intestinal ischaemia precipitated by superior mesenteric artery thrombosis has a high mortality of about 60-75%. 29 It can present as a rare complication of chronic cocaine use, and the diagnosis is extremely difficult to make. The mechanisms behind cocaine-induced tissue damage are very well understood, and it is known that cocaine causes arterial vasoconstriction, activation of intravascular thrombosis cascades and accelerated atherosclerosis.…”

“…This article discusses the various congenital and acquired gastrointestinal conditions 1,2,4–63 that have resulted in sudden unexpected death. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, are described in detail.…”

Acute mesenteric ischaemia and unexpected death

“…22 The possibility of drug effect should also be considered in the young, where chronic cocaine usage has been associated with accelerated atherogenesis and thrombosis of the superior mesenteric artery. 23 Finally, those with intestinal ischaemia from venous thrombosis tend to be younger, aged from 43 to 85 years (median 65 years), with the following: heart disease and atherosclerosis (62%), hypertension (67%), thrombophilic disorders (35%), chronic obstructive pulmonary disease (35%) and smoking (30%). 21 …”