Administration rectale de cocaïne ayant entraîné le décès : à propos d'un cas exceptionnel et revue de la littérature

The rectal route is a transmucosal route of administration. Rectal administration of a xenobiotic substance enables local action or direct uptake to the systemic circulation. The xenobiotic is not subjected to the effects of digestive enzymes or gastric acidity. Nevertheless, rectal administration does not entirely circumvent the hepatic barrier as the substance is absorbed at the same time via the iliac veins towards the inferior vena cava and the superior rectal veins towards the portal vein and therefore the liver. This route is especially suited to babies and infants but can be proposed for patients who are nauseous, unconscious or unable to swallow. The use of suppositories, capsules, enemas or ointments is common practice with the rectal route, but this is not the case for a powder inserted directly on the anal tract. For cocaine, this can occur in two situations: drug smuggling and rectal insertion for sexual purposes. In the later situation, only one paper is available in the whole literature, dating 1988. We report the case of a rich, 44-year-old, foreign financier found in the early hours of the morning roaming the streets in a state of extreme agitation. The fire brigade was called and the patient was administered a huge dose of loxapine to calm him down. The patient had a heart attack when the police arrived and could not be resuscitated. According to the call girl who was with him, the patient had gay tendencies and had inserted the cocaine powder in his rectum. Both had been drinking alcohol. The autopsy revealed moderate multi-visceral congestion, not specific to a cause of death. No abnormalities were observed on the total body x-ray. During the autopsy, samples were taken for toxicological testing. The exhaustive screening of the drugs listed in the French Pharmacopeia revealed diazepam (112 ng/ml), nordiazepam (91 ng/ml), and loxapine (2 ng/ml) in the peripheral blood, and the blood alcohol level was 0.56 g/L. All the other analyses were negative, except for cocaine and its metabolites: cocaine (681 ng/ml), benzoylecgonine (4194 ng/ml), ecgonine methylester (56 ng/ml) and cocaethylene (229 ng/ml). The hair specimen tested also positive for cocaine (2.9 ng/mg). The thanatological and toxicological observations are concordant with death due to the use of cocaine and ethyl alcohol. The originality of this observation derives from the administration route (rectal) of the narcotic drug. A review of the literature completes this case report.