Acute Cocaine Toxicity Complicated by Cerebral Edema, Respiratory Failure, and Coronary Vasospasm: A Case Report and Review of Multimodal Management Strategies

The use of the illicit/illegal drug cocaine is associated with many acute medical complications that often progress to chronic health conditions. These complications can affect multiple organ systems and lead to widespread organ failure at times. It is a commonly portrayed narrative in today's society that the nefarious "lacing" of cocaine with fentanyl is the catalyst that leads to the majority of overdose deaths from this substance. While this fact is certainly true, it can often overshadow the additional important fact that a large swath of people sustain major medical complications or die every year from overdoses of cocaine that are not laced with any foreign substance. This case report details a 40-year-old man who was transported to the ED with altered mental status, agitation, and hyperthermia from suspected cocaine use. He had a history of drug abuse and had multiple hospitalizations in the last year for it. Upon arrival at the ED, he exhibited severe hyperthermia (107.1°F), tachycardia, and tachypnea and was unresponsive to stimuli. Initial lab results indicated significant leukocytosis, metabolic acidosis, rhabdomyolysis, and elevated cardiac troponins. The patient required intubation, aggressive cooling, and intravenous sedation. His clinical course was further complicated by demand ischemia, acute kidney injury, and transaminitis. During his hospitalization, cardiac catheterization ruled out significant coronary artery disease, suggesting that the elevated troponin was due to cocaine-induced vasospasm and myopericarditis. It was subsequently discovered that the patient had a brain lesion previously detected on a computed tomography (CT) scan that was not followed up with magnetic resonance imaging (MRI) by patient request. This lesion required neurosurgical evaluation, and it was concluded that there was no need for acute intervention. Following a long and complex intensive care unit (ICU) stay, the patient was eventually stabilized, extubated, and discharged with outpatient follow-up recommendations. This case underscores the multifactorial and systemic effects of cocaine toxicity, illustrating the acute dangers and chronic health implications of its use. It highlights the importance of prompt, multidisciplinary management in acute cases and the need for comprehensive long-term care strategies to address the underlying substance use disorder in the outpatient setting. The case adds to the growing body of literature on cocaine-related complications, offering insights into the challenges of managing such patients in a clinical setting.