Hepatotoxicity associated with cocaine abuse

Cocaine and Opioid-Induced Acute Liver Injury: A Rare Case Report

Drug overdose has been a public health burden in the United States. Repeated use of cocaine and heroin may increase the risk of severe acute liver failure. We present the case of a middle-aged man with no significant past medical condition except a chronic history of drug abuse who presented to our hospital after an overdose of cocaine and heroin. Patient received Narcan by paramedics and continued treatment in the emergency room (ER). Patient has exhibited multiple organ failures, such as acute liver failure, rhabdomyolysis, acute kidney injury, and acute respiratory hypoxic hypercapnic respiratory failure likely due to respiratory center depression. The patient was placed on a non-rebreather mask then a bilevel positive airway pressure (BiPAP) machine. Patient failed the BiPAP trial, was intubated and later extubated after five days, and discharged on room air. The patient was admitted to the intensive care unit due to toxic encephalopathy. Liver enzymes were markedly elevated during admission and trended down after supportive management, Narcan, and N-acetylcysteine treatment.

The Role of Acetyl Cysteine in Cocaethylene (Non-Acetaminophen) Acute Liver Failure

Background

Acute liver failure can result from acetaminophen overdose, viral infection, toxins, and other disease conditions. Liver transplant is available in limited fashion and the criteria are strict as to who should get an available liver. N- Acetyl Cysteine (NAC) has been used in non-acetaminophen induced liver failure with success. Here we report a case of acute liver failure from cocaethylene that was reversed with NAC along with other medical therapy.

Case Presentation

A 50-year-old female patient presented to the Emergency Department (ED) with a two-day history of coffee ground vomiting and hematemesis. She reported occasional substance abuse and heavy alcoholism. She reported shortness of breath and chest pain from the recurrent forceful vomiting. The rest of the review of systems was unremarkable except a fall from intoxication. Physical examination revealed anicteric conjunctiva and nontender abdomen and her vital signs were within normal limits. Initial blood work revealed acute liver and renal failure. The patient was started with general medical management and liver transplant service rejected the case due to active substance abuse. She underwent brief hemodialysis and was started on NAC. Over the course of her hospital stay her liver function and kidney function improved significantly and patient was discharged to home.

Conclusion

In cases where liver transplant is not an option for various reasons including active substance abuse, a trial of N-Acetyl Cysteine may be beneficial and should be considered in the Emergency Department.

Mitochondrial complex I dysfunction induced by cocaine and cocaine plus morphine in brain and liver mitochondria

Mitochondrial function and energy metabolism are affected in brains of human cocaine abusers. Cocaine is known to induce mitochondrial dysfunction in cardiac and hepatic tissues, but its effects on brain bioenergetics are less documented. Furthermore, the combination of cocaine and opioids (speedball) was also shown to induce mitochondrial dysfunction. In this work, we compared the effects of cocaine and/or morphine on the bioenergetics of isolated brain and liver mitochondria, to understand their specific effects in each tissue. Upon energization with complex I substrates, cocaine decreased state-3 respiration in brain (but not in liver) mitochondria and decreased uncoupled respiration and mitochondrial potential in both tissues, through a direct effect on complex I. Morphine presented only slight effects on brain and liver mitochondria, and the combination cocaine+morphine had similar effects to cocaine alone, except for a greater decrease in state-3 respiration. Brain and liver mitochondrial respirations were differentially affected, and liver mitochondria were more prone to proton leak caused by the drugs or their combination. This was possibly related with a different dependence on complex I in mitochondrial populations from these tissues. In summary, cocaine and cocaine+morphine induce mitochondrial complex I dysfunction in isolated brain and liver mitochondria, with specific effects in each tissue.

Fetal gender and cocaine exposure as determinants of cord blood gamma-glutamyl transferase activity

OBJECTIVE

The serum activity of the hepatic enzyme gamma-glutamyl transferase (GGT) is elevated in the newborn relative to older age groups. Few reports to date have studied the influence of perinatal factors on neonatal serum GGT and no study has assessed the influence of maternal drug ingestion.

STUDY DESIGN

Cord blood was randomly collected from 234 liveborn infants and correlated with a range of maternal and fetal perinatal variables to assess influences on cord blood GGT.

RESULTS

Our study showed that the range of cord blood GGT activity in 234 randomly selected term newborns was 22 to 556 IU/l. In a subgroup of 75 newborns, GGT activity was independently influenced by only two of the variables studied - cocaine exposure and fetal gender (p=0.009, r=0.39). Females had a lower GGT than males (95+/-66 vs 130+/-90 IU/l, p<0.001) while GGT activity in cocaine-exposed newborns was lower than in cocaine-nonexposed newborns (96+/-48 vs 142+/-109, p<0.01). Birth weight, race, gestational age, and maternal serum GGT were not found to significantly influence cord blood GGT activity. Maternal GGT was uniformly normal and was not affected by any of the variables tested.

CONCLUSION

Our findings demonstrate that the reference range for cord blood GGT activity is wide and appears to be influenced by fetal gender and cocaine exposure.