Esophagitis, Epiglottitis, and Cocaine Alkaloid ("Crack"): "Accidental" Poisoning or

Child Abuse?
SIGMUND KHARASCH, ROBERT VINCI and ROBERT REECE
Pediatrics 1990;86;117-119

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Copyright © 1990 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
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 EXPERIENCE AND REASON-Briefly Recorded

‘ In Medicine one must pay attention not to plausible theorizing but to experience and reason
together. . . . I agree that theorizing is to be approved, provided that it is based on facts, and
systematically makes its deductions from what is observed. . . . But conclusions drawn from
unaided reason can hardly be serviceable; only those drawn from observed fact. ‘ ‘ Hippocrates:
Precepts. (Short communications of factual material are published here. Comments and criticisms
appear as Letters to the Editor.)

CASE REPORT
Esophagitis, Epiglottitis, and
Cocaine Alkaloid (“Crack”): S.F., a 20-month-old girl, was brought to the emergency
room with a recent history of drooling, vomiting, and
“Accidental” Poisoning or intermittent lethargy. The mother reported having a
party at her apartment the night before and admitted to
Child Abuse? alcohol being present but denied any drug use. At 7 AM
the day of admission the mother awoke to feed her baby
breakfast. The mother then took a nap, leaving S.F.
unattended in the apartment. Several hours later the
Acute effects of cocaine abuse have been fre-
mother awoke to find the child at the kitchen table,
quently described in the medical literature. Myo-
drooling and vomiting. Near the child was a cup of
cardia! infarction, angina, chest pain, dysrhyth-
brownish liquid that the mother brought to the emer-
mias, pneumothorax, seizures, and hypertension
gency room. When first seen in the emergency room, the
are not uncommonly seen with the growing number child appeared to be having a toxic reaction and was
of drug abusers in this country.”2 Other systemic sitting forward and drooling. She was not stridorous or
effects of cocaine toxicity, including malignant hy- dyspneic but had two episodes of guaiac positive emesis.
perthermia, rhabdomyo!ysis, and cerebral vascular Her temperature was 36.6vC, her pulse was 136 beats per
accidents have been described with acute cocaine minute, her respiratory rate was 44 breathes per minute,
intoxication.3 and her blood pressure was 92 systolic/fib diastolic. She
With the recent cocaine alkaloid (“crack”) epi- was lethargic but easily arousable. Examination of the
mouth and oral pharynx revealed multiple white burns
demic, a new spectrum of medical as well as social
of the hard palate as well as edema of the uvula and soft
consequences have occurred. Teenage violence and
palate. Results of examination of the heart, lungs, and
death have been given emphasis by the lay press as
abdomen were normal. Results of laboratory test were as
accounts of drug wars continue to appear in print. follows: arterial blood gas value with supplemental oxy-
There is little information, however, identifying gen, pH 7.37, PaCo2 36 mm Hg, Po, 200 mm Hg, bicar-
children as victims of abuse and neglect while they bonate 21 mEqJL, and 02 saturation, 99.7%. A complete
are in the care of persons abusing crack. In a recent blood count showed a hemoglobin of 12 g/dL, a hemato-
report4 it was suggested that infants and children crit of 37%, and white blood count of 7000/tL with a
may be poisoned by passive inhalation of crack normal differential and platelet count. A lateral neck x-
vapors, with subsequent seizures from cocaine tox- ray film was obtained (Figure) that showed a markedly
icity. We describe the case of a 20-month-old girl swollen epiglottis and aryepiglottic folds. When the pa-

with upper airway and esophageal burns secondary tient was examined in the operating room, laryngoscopy
revealed diffuse edema of the supraglottic area with vocal
to chemicals involved in a current form of cocaine
cords that appeared normal. A nasotracheal tube was
abuse; free-basing.
placed without difficulty. Results of flexible endoscopy
showed circumferential white burns at the cricopharyn-
geal portion of the esophagus. The baby was sedated with
fentanyl, paralyzed with pancuronium bromide (Pavu-
lon), and dexamethasone (Decadron) and penicillin were
Received for publication Jul 10, 1989; accepted Sep 25, 1989.
Reprint requests to (S.K.) Dept of Pediatrics, Boston City Hos- started.
pitals, 818 Harrison Aye, Boston, MA 02118. The patient responded to therapy and was extubated
PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the within 48 hours. When laryngoscopy and esophagoscopy
American Academy of Pediatrics. were repeated, mild erythema of the epiglottis and a

PEDIATRICS Vol. 86 No. 1 July 1990 117

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 Free-base or alkaloid cocaine is obtained by con-
version and extraction of cocaine hydrochloric acid
by means of kits readily available from drug para-
phernalia shops. Crack is prepared by mixing street
cocaine, which is heat labile and is not suitable for
smoking, with an alkali solution such as buffered
ammonia, sodium bicarbonate, baking soda, or, as
in case we described, a lye solution.8 The alkali
removes the hydrochloride salt creating the un-
charged cocaine moiety. A solvent such as ether is
added and the solvent mixture is evaporated leaving
relatively pure cocaine crystals or crack that is heat
stable and can be smoked. Free-base cocaine is
desirable for two reasons; it is cheaper and when
smoked it is delivered rapidly to the lung and brain
Figure. Lateral neck x-ray film showing markedly swol-
len epiglottis and aryepiglottic folds. to produce an immediate euphoric effect compa-
rable to that of intravenous cocaine.9 The effect is
short lived and intensely habituating, however.
persistent circumferential burn of the upper esophagus
were shown. A central line was placed and total paren- Crack lung, a recognized complication of free-base
teral nutrition was started. Feedings with oral fluids and cocaine use, includes pneumothorax, pneumome-
a soft diet were attempted 2 weeks later; however, the diastinum, and pneumopericardium secondary to
baby had guaiac positive emesis and diminished oral barotrauma from crack inhalation. Pulmonary dif-
intake with subsequent weight loss. According to results fusion abnormalities have also been noted in abu-
of a repeat esophagoscopy, there was a narrow stricture sers of crack.2
at the level of the cricopharyngeus. A gastrostomy tube The half-life of cocaine metabolite in a urine
was inserted at this time and the child cannot be fed assay is approximately 48 hours. This suggests that
orally and receives central hyperalimentation. our patient had recent exposure and the lack of
The final toxicologic analysis of the unknown liquid
systemic symptoms suggests low-dose exposure. A!-
revealed the following: pH 12, sodium 165,000 mg/L, and
though this child may have been poisoned from
potassium 690 mg/L, values that are consistent with lye
ingestion. No controlled substances, including cocaine,
sidestream exposure to crack vapors, ingestion of
were found in the remaining 15 mL of liquid. The urine cocaine also must be considered as a cause. Finally,
toxic screen of the child was positive for cocaine metab- complications from the alkali used in processing
olites by the enzyme-multiplied immunoassay technique. crack have not been described previously, although
caustic ingestions remain a significant cause of
pediatric morbidity. Liquid lye is responsible for
DISCUSSION the most serious of these ingestions and may result
in esophageal burns as well as upper airway burns
The spectrum of child maltreatment presents
with life-threatening obstruction.’#{176}
unique challenges to physicians caring for children
Esophageal burns occur rapidly by liquefaction
in many settings. Sobel5 first called our attention
necrosis, and severe burns, as in this case, may
to repetitive “accidental” poisoning as a subtle form
progress to stricture formation in areas of anatomic
ofchild abuse and Dine and Mcgovern6 underscored
narrowing after 2 to 3 weeks.” Treatment of caustic
this phenomenon in their description of intentional
burns to the airway and esophagus require prompt
poisoning of children. Meadow7 first described
stabilization of the airway, including intubation for
Munchausen syndrome by proxy in 1977 and since
patients in whom signs of airway obstruction are
that time more blatant forms of child abuse have
present. Although it is controversial, many otolar-
been described in the medical literature. In addition
yngologists recommend treatment with steroids and
to these cases of aberrant behavior by caretakers,
antibiotics in hope of preventing stricture forma-
there is a range of neglect on the part of caretakers
tion.’2
that can result in inadequate supervision of vulner-
able children. The abuse ofdrugs and alcohol within
CONCLUSION
a family may accentuate the issue of neglect. A!-
though the mother continued to deny recent drug The increasing problem of drug abuse is well
use, the cocaine in the child’s urine and unused lye known to all of us and particularly relevant to the
are highly suggestive of crack abuse. Social service emergency room physician who must deal with the
investigation concluded that parental neglect was myriad of symptoms of acute intoxications. Chil-
the factor that led to our patient’s toxic ingestion. dren as innocent bystanders are victims of child

118 PEDIATRICS Vol. 86 No. 1 July 1990

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abuse simply by being in close proximity to illicit 3. Jara F, Shannon M. Cocaine-an update. Clin Toxicol Rev.
1988;11:1-4
drugs. Pediatricians should recognize these compli- 4. Bateman DA, Heagarty MC. Passive freebase cocaine
cations and anticipate varied forms of drug inges- (‘crack’) inhalation by infants and toddlers. Am J Dis Child.
tions in younger patients. All suspicious or unclear 1989;143:25-27
5. Sobel R. The Psychological implications of Accidental Poi-
clinical appearances should include a toxic drug soning in Childhood. Pediatr Clin North Am. 1970;17:653-
screen for medical as well as social management. 685
6. Dine MS, McGovern ME. Intentional poisoning of chil-
SIGMUND KHARASCH, MD dren-an overlooked category of child abuse: report of seven
cases and review of the literature. Pediatrics. 1982;70:32-35
ROBERT VINcI, MD 7. Meadow R. Munchausen syndrome by proxy: the hinterland
ROBERT REECE, MD of child abuse. Lancet. 1977;2:343-345
8. Perez-Reyes M, Guiseppi DS, Ondrusek G, Jeffcoat A, Cook
Dept of Pediatrics
C. Freebase cocaine smoking. Clin Pharmacol Ther.
Boston City Hospital 1982;32:459-465
Boston, MA 9. Jekel JF, Podlewski H, Patterson SD, Allen DF, Clarke N,
Cartwright P. Epidemic free-base cocaine abuse. Lancet.
1986;5:459-462
10. Moore WR. Caustic ingestions: pathophysiology, diagnosis,
and treatment. Clin Pediatr. 1986;25:192-196
REFERENCES
11. Moulin D. Upper airway lesions in children after accidental
1. Cregler LL, Maric H. Medical complications of cocaine ingestions of caustic substances. J Pediatr. 1985;16:48-51
abuse. N EngI J Med. 1986;315:1495-1499 12. Dicostanzo J, Noirclere M, Jouglard J, et al. New therapeutic
2. Bates CK. Medical risks of cocaine use. West J Med. approach to corrosive burns of the upper gastrointestinal
1988;148:440-444 tract. Gut. 1982;21:218-237

ARTIFICIAL LIVER FROM GORTEX!

With the aid of a few strands of “angel’s hair” (po!ytetrafluoroethy!ene

[PTFE], ‘Gore-Tex’), research workers in the US have created the first artificial
organ capable of functioning for more than just a few days. The “organoid,” an
artificial liver constructed by Thompson and colleagues from hepatocytes seeded
on to a mixture of expanded PTFE, collagen, and heparin-binding growth factor
1 (HBGF-1), has survived in the peritonea! cavity of a rat for several
months’. .PTFE
. fibres are indestructible, which makes them ideal for building
artificial organs, as we!! as for ski and other tough clothing; they are also
biologically inert...
Thompson and colleagues. .have used this technique
. to implant liver cel!s
from Wistar rats (which can conjugate bilirubin) into Gunn rats (which cannot).
After 10 days serum bilirubin levels in the host had fallen by 50%. Within 3
weeks, levels had dropped by over 60% and remained there for the duration of
the experiment.

REFERENCES

1. Thompson JA, Haudenschild CC, Anderson KD, et al. Heparin-binding growth factor 1 induces
the formation oforganoid neovascular structures in vivo. Proc NatlAcad Sci USA. 1989;86:7928-
7932.

Organoid advances. Lancet. 1989;335:220. Noticeboard.

Noted by J.F.L., MD

EXPERIENCE AND REASON 119

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Esophagitis, Epiglottitis, and Cocaine Alkaloid ("Crack"): "Accidental" Poisoning or
Child Abuse?
SIGMUND KHARASCH, ROBERT VINCI and ROBERT REECE
Pediatrics 1990;86;117-119
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