Forensic Science International 280 (2017) 814

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Forensic Science International

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Death by heroin intoxication in a body pusher with an innovative

packaging technique: case report and review of the literature
Sindi Visentina,* , Greta Bevilacquaa , Chiara Giraudob , Caterina Dengob ,
Alessandro Nalessoa , Massimo Montiscia
a
Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Via Falloppio 50, 35128, Padova, Italy
b
Institute of Radiology, University-Hospital of Padova, Via Giustiniani 2, 35128, Padova, Italy

A R T I C L E I N F O A B S T R A C T

Article history:
Received 7 July 2017 Death due to mechanical or chemical intoxication of heroin body packers, thanks to the continuous
Accepted 29 August 2017 improvement in packaging techniques, are increasingly rare, and almost all the cases reported in the
Available online 8 September 2017 literature refer to drug swallowers. A case of fatal acute heroin intoxication in a body pusher with an
unreported packaging technique is presented, and previous deaths due to heroin body packing are
Keywords: reviewed, taking into consideration imaging techniques performed, cause of death, toxicological analysis
Body pushing on biological and non-biological samples, as well as number, position and type of drug packages
Body packing identied at the dissection of the body.
PMCT
The innovative packaging technique found in the present case, constituted by an external multilayer
Heroin
cellophane casing containing 16 smaller packages of hardened heroin powder, each one covered with
Death
cigarette paper and multiple layers of heat-sealed cellophane, was probably used to avoid both chemical
complications of package rupture and to create a package with morphological and radiological features
different from those reported by previous studies.
Drug dealers, in fact, are continually looking for packaging methods that, besides being safer, minimize
the risk of detection at the radiological examinations performed, thus increasing the number of false
negative ndings. The identication of new types of package is therefore important, in order to identify
packages that do not have the typical radiological signs, both in order to protect the patients health and
to avoid the non-recognition of a drug carrier.
Despite the presence of multilayer composition of both the smaller and the bigger external coverage,
these new types of package did not guarantee the greater safety of the drug dealer.
2017 Elsevier B.V. All rights reserved.

1. Introduction Despite the spread of the phenomenon, the majority of heroin

Body packing refers to the internal concealment of illicit drugs
by swallowing (body stuffer) or insertion into the body cavities,
such as the anus or vagina (body pusher), for transportation across
international borders [13]. Heroin, after cocaine, is the second
most frequently trafcked drug worldwide. However, death due to
package rupture and subsequent heroin intoxication [413] or
from mechanical complications [10,11,14] are rare, and almost all
the cases reported in the literature refer to drug swallowers (i.e.
body stuffer) [10].
* Corresponding author.
E-mail address: sindi.visentin@gmail.com (S. Visentin).
body packing cases have a benign clinical course [15], and to the
best of our knowledge, deaths due to heroin body pushing have not
been reported; probably because of the relatively easier retrieval of
packets in these locations and the absence of the stresses of
peristalsis [10]. Furthermore, the continuous improvement in
packaging techniques, the main types of which are dened in the
literature [16,17], has greatly reduced the mortality rate of body
packers [1,18].
A case of fatal acute heroin intoxication in a body pusher with
an innovative packaging technique is presented, and previously
reported deaths due to heroin body packing are reviewed,
considering imaging techniques performed, cause of death,
toxicological analysis on biological and non-biological samples,
and number, position and type of broken and intact drug packages.

http://dx.doi.org/10.1016/j.forsciint.2017.08.030
0379-0738/ 2017 Elsevier B.V. All rights reserved.
 S. Visentin et al. / Forensic Science International 280 (2017) 814
2. Case report
The case involves a 32-year-old Nigerian man who was found
dead in his room by his roommate.
2.1. On site inspection and external examination
The corpse, 173 cm in height and 75 kg in weight with an
average body size, was found naked on his bed in a prone position.
The external examination of the body revealed foamy whitish
material partially solidied in the mouth and nostrils, with
abundant leakage of reddish liquid and soiling of the sheet and the
underlying oor. Hypostasis was xed and abundant, tting with
the position in which the corpse was found. Temperature was in
equilibrium with the environment (28  C) and rigor mortis was
present and pronounced.
During the on-site inspection, 16 small (12  8 mm) and 3 big
(40  20 mm) packages were found in the room, above a cabinet.
Testimonial data suggested that the deceased used to push drug
packages into the anus in order to carry illicit substances over the
border, but no travel had been reported in the previous weeks.
2.2. Radiological examination
An unenhanced whole body PMCT was performed 23 h after the
discovery of the body using a 64 multi-detector scanner, and
subsequent multiplanar reconstructions (MPR) were performed.
The images were assessed for the presence, number and character-
istics of the suspected drug packages in the alimentary tract.
During the abdominal scan, two drug packages were detected at
the recto-sigmoid junction, which were further composed by
multiple spherical or hyperdense oval packages (Fig. 1), tting the
dimensions of the packages identied during the on-site inspec-
tion.
2.3. Autopsy ndings
The dissection of the body revealed congested and edematous
brain and lungs (weights: brain 1200 g, right lung 700 g, left lung
600 g), and whitish foam mixed with pinkish uid in the airways.
At the dissection of the gastro-intestinal tract two packages,
with the external casing partially ruptured but without any drug
leakage, were found trapped at the recto-sigmoid junction (Fig. 2a
c) and another completely disrupted and empty package was found
in the rectal ampulla (Fig. 2d).
2.4. Packing techniques
The type of packaging detected in the present case consisted of
a larger package (dimension: 20  40 mm; weight: 5,5 gr),
Fig. 1. Postmortem computed tomography. Drug packages composed by multiple spherical or oval hyperdense packages at the recto-sigmoid junction.
9
containing 16 smaller packages inside (dimension: 12  8 mm;
weight: 0,3 gr). The external casing was composed of four layers of
cellophane, heat-sealed at one end, and each smaller package was
made of hardened brown powder covered with a rst layer of
cellophane, a second layer of cigarette paper, and another two
layers of heat-sealed cellophane (Fig. 3).
2.5. Toxicological ndings on biological and non-biological samples
Samples of peripheral blood and urine taken during the autopsy
were screened for the main classes of drugs of abuse. Conrmation
was performed using the procedures routinely applied in the
laboratory based on a solid phase extraction of the sample followed
by a liquid chromatography tandem mass spectrometry analysis.
The results revealed the presence of high level of 6-mono-
acetylmorphine (6-MAM), morphine and codeine both in blood
and urine samples, the results of the quantitative analyses are
reported in Table 1.
The powder inside the packages, analyzed by gas chromatog-
raphy mass spectrometry, contained heroin (15.5%) and 6-MAM
(9.0%).
2.6. Cause of death
The integrated analysis of data derived from the on-site
inspection, with autopsy ndings and radiological and toxicologi-
cal results, identied the cause of death in acute heroin
intoxication with pulmonary edema, secondary to package rupture
and subsequent drug leakage in the rectum. Due to the testimonial
and circumstantial data and the position and features of the
packets in the gastro-intestinal track, the case was referred to body
pushing.
3. Review of the literature
A systematic literature search of articles published until January
2017 was performed using the PubMed database, ScienceDirect
Scopus and Easyweb of Science. Search terms were [(body packer
OR body stuffer OR body pusher OR drug carrier OR
swallower OR mule OR courier) AND (death OR fatal)
AND (heroin OR opioids)]. An analytical evaluation of the
studies collected was performed, and references from relevant
articles were also reviewed for potential cases. Only cases of death
in consequence of mechanical or chemical complication of heroin
body packing were included.
Ten articles reporting cases of death due to heroin body packing
were identied, for a total of 23 cases, as reported in Table 2. An
article reporting a case series of death due to body packing over the
course of 10 years [10], reported 36 cases of death due to heroin
body packing and 14 cases of death for other causes. However, it
10 S. Visentin et al. / Forensic Science International 280 (2017) 814
Fig. 2. Autopsy specimens. Two packages trapped at the recto-sigmoid junction, with external casing partially ruptured and no drug leakage (ac), and a completely disrupted
and empty package, found in the rectal ampulla (d).
did not provide data for each case, and was therefore excluded
from Table 2. Nevertheless, the results reported in the aforemen-
tioned study are discussed.
Sex, age, hospitalization, cause of death, radiological and
toxicological data, and number, position and types of package
analyzed are summarized in Table 2.
In our review of 23 cases, the age reported ranged from 21 to
59 and only 3 were female. 5 died in a hospital (21.7%), of which
3 after few minutes/hours [5,12,14], 1 after 3 days [9] and 1 after
10 days [11]; while the majority (18 cases) were found dead
(78.3%).
Post-mortem imaging was applied in only 3 cases in which a
plain radiograph of the abdomen was performed, revealing
multiple suspicious drug packages in two cases [4,14] and without
evidence of foreign bodies in the third case [14].
Deaths were due to mechanical causes (obstruction/perfora-
tion) in 4 cases (17.4%) and to acute opioids intoxication in 19 cases
(82.6%). Heroin intoxication was attributed to package rupture/
leaking, even if 5 cases reported no evidence of ruptured packages,
while other cases did not specify package integrity.
Data on toxicological analysis on biological and non-biological
samples were not always reported.
In cases of death due to mechanical causes toxicological
analysis on blood, bile and stomach content were negative [14] or
not reported [11]. In cases of death due to heroin intoxication
morphine levels were negative in one case [9], not reported in
2 cases [5,6], and varied from 0.2 mg/l to 120 mg/l in the remaining
cases. In the case where blood samples were negative for heroin or
its metabolites [9], death occurred after 3 days of hospitalization,
and heroin blood levels at admission were well beyond the lethal
dose. The highest level of morphine reported dates back to 1985
[13].
Toxicological analysis on non-biological samples revealed a
wide range of purity of heroin, both in recent and in past years.
The number of packages identied during autopsy, excluding
3 cases in which packages were surgically extracted by accomplices
through abdominal incision [11], was between 2 and 103. In 5 cases
packages were isolated exclusively from the stomach and in other
9 cases from the stomach and other parts of the gastrointestinal
tract. Six cases reported packages in the small and/or large
intestine, of which just 2 cases reported the presence of packages
exclusively in the rectum or recto-sigmoid portion [11,14]. In the
8 cases reporting the site of rupture, the most frequent involved
area was the stomach (6 cases), followed by the colon (2 cases) and
small intestine (1 cases). In the 4 cases where the cause of death
was identied in mechanical causes, occlusion was reported in the
ileum [11], while perforation was reported in the stomach, distal
jejunum and rectum [14].
The packing reported, which was specied in 19 cases,
consisted in condoms or toy balloons used as containers for loose
powder or in matted powder covered with multilayers of tubular
latex, which can be classied respectively in type 1 and 2 according
to the classication described by McCarron and Wood [16].
4. Discussion
Our case and the literary review conrm that heroin body
packing can still lead to death, despite the reduced mortality rate
due to improvement in packaging techniques and positive
prognosis as a result of medical care on admission to hospital [15].
Few cases reported the use of post mortem cross-sectional
imaging. In particular, although radiological examinations are
routinely performed in clinical practice to detect body packages,
and computed tomography is considered more sensitive than plain
abdominal radiography, approaching 100% sensitivity [1923], in
the post-mortem assessment there is just one case of PMCT
application in a body packing related death, due to methamphet-
amine intoxication [24]. In this case PMCT revealed all the 25 drug
 S. Visentin et al. / Forensic Science International 280 (2017) 814 11

Fig. 3. Packaging type. Each bigger package (a) was composed of an external casing
made of four layers of heat-sealed cellophane, and contained 16 smaller packages
(b) made of hardened brown powder covered with a rst layer of cellophane, a
second layer of cigarette paper, a third and a fourth layer of heat-sealed cellophane
(c).
The sites where drug packages were found in our review (i.e.,
mainly in the stomach) conrm that death in body packing is
mainly due to swallowing of the packages, while body pushers
deaths are extremely rare. In fact, just two of the cases reported
could hypothetically be classied as body pushing [11,14], since
packets were detected in the last part of the gastrointestinal tract,
and in only one case the death was due to heroin intoxication,
while all the cases (36) of death reported by previous case series
referred to body stuffers [10]. Although the distinction between
body pusher and body stuffer can not always be made with a high
degree of probability, the presented case, due to the testimonial
and circumstantial data as well as the characteristics and position
in which the packets were identied, can be classied as a case of
body pushing. It is also unlikely that the packages may pass
through the segments of the bowel with a small diameter of the
lumen, such as the pylorus and ileocecal valve (i.e., 1.0 cm1.2 cm in
diameter), without causing any injury, and be though trapped in
the wider recto-sigmoid portion (i.e., ca. 2.5 cm in diameter [14]).
Toxicological analysis performed on the blood and urine
samples collected during autopsy revealed the presence of 6-
MAM (0.181 mg/l), morphine (3.229 mg/l) and codeine (0.201 mg/
l), while alcohol and other drugs were excluded. The presence of 6-
MAM and a concentration of morphine greater than 0.25 mg/l are
in agreement with a rapid death consequent to the rupture of the
package [27]. In line with most of the published literature dealing
with opiate-related deaths, heroin has been searched but not
detected in blood and urine.
Post-mortem concentrations of morphine vary signicantly in
death due to package rupture. Gill and Graham [10] reported
concentrations between 0.1 and 32.4 mg/l and in our review they
ranged from 0.2 mg/l to 120 mg/l. Death in one case was referred to
heroin overdose even if morphine was not detected in post mortem
uids, due to the presence of a concentration beyond the lethal
dose at hospital admission [9]. One case reported a difference in
the concentration of morphine detected in blood samples taken at
different sites of 5.3 mg/l (iliac blood: 1.4 mg/l; aortic blood:
6.7 mg/l), which can be due to the post-mortem alteration of the
body, in which the abdomen and intestine were opened by
accomplices before charring of the body. A broad difference
between heroin purity was reported in different studies (2590%),
without evidence of a minor risk of death in cases with low purity
of the substance.
The packaging type reported in our review are referable to one
of the categories described by McCarron and Wood in 1983 [16],
who classied the cocaine packages into three types, while a fourth
type was added in 2002 [17].

In type 1, condoms, toy balloons, or ngers of latex gloves are

used as the container for the drug, which is in the form of loose
Table 1
Toxicological ndings.
powder. Some packages have two to four layers of wrappings,
and most commonly are made of a condom stuffed with drug,
Peripheral blood Urine tied, folded back over itself, and tied again at the opposite end.
Heroin Type 2 contains matted powder covered with ve to seven layers
6-MAM 0.181 mg/l 1.042 mg/l of tubular latex, each layer having the consistency of a latex
Morphine 3.229 mg/l 2.471 mg/l
Codeine 0.201 mg/l 0.453 mg/l
glove, and tied tightly with a smooth tie at each end.
Type 3 consists of hardened drug paste wrapped in aluminum
foil and overwrapped with three to ve layers of tubular latex
tied at both ends.
packages, including 2 disintegrated and uid intruded packages in Type 4 is constructed of a dense paste (resulting from dissolving
the stomach. However, false negatives have been reported in living cocaine hydrochloride in an alcohol watery solution), which is
subjects in the literature [25,26]. PMCT in the presented case introduced into a device and, when hardened, packaged in
allowed the identication of 2 intact packages, while it did not tubular latex and covered with colored parafn or berglass.
allow the identication of the third ruptured package, in the rectal
ampulla, probably because of the dispersion of all the content. The type of packaging detected in the presented case has not
Indeed, it is reasonable to assume that the rupture of the package been reported in previous cases, and can be called a cluster
dispersed the content preventing its detection. package, being composed of a bunch of several small packages
12 S. Visentin et al. / Forensic Science International 280 (2017) 814

Table 2
Review of the literature.

Authors Sex/ Hospitalization Post Cause Toxicological analysis Packages

age mortem of
imaging death
HI/M
Biological samples Non biological Total n/site Ruptured Type
n/site
Blood (mg/l) Other (mg/l) Weight Heroin purity
(g) (other
substances)
Cappelletti et al. M/ No RX of the HI Morphine (0.8) Urine: morphine 764a NR (piracetam) 69 0 1
[1,4] NR chest and piracetam (tr) (11), piracetam (tr). 1 esophagus
the Bile: morphine (42) 22 stomach
abdomen piracetam (tr). 2 duodenum
Gastric content: 44 colon-
morphine (5.9), rectum
codeine (2.4), 6-
MAM (1.4),
piracetam (tr).
Cox and Kayembe M/ 3 days No HI NR NR 968 NR (caffeine) 66 stomach NR NR
[5] 43 and colon
Kumral et al. [6] M/ No No HI Morphine Urine: morphine, 6- 584 44.52% (5.36% 60 stomach 0 2
30 (0.292) MAM and codeine. 6-MAM)
Jakhar et al. [7] M/ No No HI NR Stomach: morphine, 267a 5.627.8% 50 2 stomach 12
35 caffeine and codeine. (caffeine, 42 stomach
Intestine, liver, codeine) 6 small
spleen and kidney: intestine
morphine and 2 colon
codeine.
Sribanditmongkol M/ No No HI Morphine Bile: morphine, 48 90% 39 stomach 8 stomach 1
et al. [8] 31 codeine.
Urine: morphine,
codeine.
Gastric content:
heroin, 6-MAM.
M/ No No HI Morphine Urine: morphine, 6- 30 51.79% 15 stomach 3 stomach 1
39 (80.67) MAM, codeine.
6-MAM (17.67) Gastric content:
Codeine (14.72) heroin, 6-MAM.
Olumbe and Kalebi F/38 3 days No HI Negativec Gastric contents: NR NR 88b NR 1
[9] heroin 5 stomach
83 colon
Hutchins et al. [14] M/ No RX of the M Negative Negative (bile, 18a NR 2 rectum 0 2
52 abdomen stomach content).
M/ No RX of the M Negative Negative (bile, 458a NR 57 small 0 2
44 abdomen stomach content). intestine
and colon
M/ No No M Negative Negative (bile, 538a NR 50 0 2
NR stomach content). 1 esophagus
19 stomach
30 small
intestine
M/ Few hours No HI Morphine (20.6) Gastric content: 338a NR 31 stomach NR 1
32 Codeine (1.97) morphine (673), (various)
6-MAM codeine (48.1), 6- stomach
MAM (3110).
Urine: morphine,
codeine, 6-MAM.
Wetli et al. [11] M/ No No HI Morphine (35.8) Gastric uid: 881a NR 84 NR 2
24 Codeine (1.2) morphine, diacetyl 27 stomach (various)
morphine. 13 small
intestine
44 colon
F/44 No No HI Morphine: aorta Bile: morphine (270). NR NR NRd NRd NR
(6.7); Stomach: high levels 7 Stomach (various)
pulmonary of morphine, heroin, 4 recto-
artery (6.2); iliac and 6-MAM sigmoid
(1.4) colon
M/ 10 days NR HI Morphine: Vitreous humor: NR NR 4e NRe NR
44 inferior vena morphine (0.17). 1 colon
cava (0.27) aorta Bile: morphine (57). 3 rectum
(0.68)
M/ No No M NR NR NR NR 77 small 0 NR
59 intestine
M/ No No HI Morphine (0.99) NR NR 65% 2d esophagus NRd 1
21 Codeine (0.04)
M/ No No HI Morphine (0.60) NR NR NR 46 1 1
23 Codeine (0.03) 5 oral cavity NR
 S. Visentin et al. / Forensic Science International 280 (2017) 814 13

Table 2 (Continued)
Authors Sex/ Hospitalization Post Cause Toxicological analysis Packages
age mortem of
imaging death
HI/M
Biological samples Non biological Total n/site Ruptured Type
n/site
Blood (mg/l) Other (mg/l) Weight Heroin purity
(g) (other
substances)
BZE (0.02) 4 esophagus
Ethanol (0.03%) 12 stomach
23 small
intestine
M/ No No HI Morphine (52.6) NR 760a NR 82 0 12
39 Ethanol (0.02%) 57 stomach
1 duodenum
24 colon
M/ No No HI Morphine (4.4) NR NR 73% (6-MAM, 7 recto- 1 2
37 Codeine (0.15) acetyl codeine) sigmoid colon
colon
NR/ No No HI Morphine (39.4) NR 490a NR 35 colon NR 2
NR Codeine (0.2) (various)
Diazepam (0.65) colon
6-MAM
Introna and M/ Few hours No HI Morphine (6.4) Bile: morphine. NR NR 66 1 small 1
Smialek [12] 37 Urine: morphine. 65 small intestine
intestine
1 colon
M/ No No HI Morphine: NR NR NR 34 stomach 1 stomach 1
30 cavity uid (9.6)
Joynt and Mikhael F/49 No No HI Morphine (120) Liver: morphine (63), 583a 25% (40% 103 3 stomach 1
[13] 6-MAM (184) 6-MAM (6), codeine Caffeine, 1% 93 stomach
Codeine (1.7) (9), caffeine (202). Acetylcodeine, 10 small
Caffeine (400) Bile: morphine (818), <1% 6-MAM) intestine
codeine (6), caffeine
(324).
Peritoneal uid:
morphine (212), 6-
MAM (28), codeine
(9.5), caffeine (242).

NR = not reported.
M = mechanical causes.
HI = heroin intoxication.
BZE = benzoilecgonine.
a
Total weight of the packages.
b
Other 9 packages expelled in the hospital before death.
c
At hospital admission: high heroin concentration in gastric lavage uid (597.70 mg/l) and in blood (10.58 mg/l).
d
Other probably extracted by accomplices through abdominal incision, and various packet fragment were nd in the peritoneal cavity and in the gastrointestinal tract.
e
Other 80 packages found at the exploratory laparotomy performed in hospital: 22 stomach, 23 colon (other 30 ruptured).

that are held together by an external casing. The spherical or oval
hyperdense packages that can be detected at the radiological
examination in this kind of package, being far smaller than the last
generation packages that usually have standard dimension and
weight [1,3,28] and are probably mechanically manufactured,
could lead to the misidentication of the packages at the
radiological examination performed on living subjects.
Drug dealers, in fact, are continually looking for a packaging
method that, besides being safer, minimizes the risk of detection at
the radiological examinations performed, requested by the
authorities, thus increasing the number of false negative at
imaging [1,3,28]. The identication of new types of package is
therefore important, in order to identify packages that do not have
the typical morphological and radiological features, both in order
to protect the patient's health and to avoid the non-recognition of a
drug carrier.
Despite the presence of multilayer composition of both the
smaller and larger external coverage, this new type of package did
not guarantee the greater safety of the drug dealer.
In conclusion, the presented case, to the best of our knowledge,
is the rst case of a heroin body pushers death, and a type of
packaging never before described is reported that, due to the
morphological features of the package, can be misidentied at
radiological examination especially if broken and, despite being
apparently safer than others, did not avoid rupture and death for
acute heroin intoxication.
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