Body packing is a rising problem with increased drug industry and selling. Body packers hide illicit drugs in their bodies for different purposes. They conceal amounts of the drug to cross borders between countries and do the same in trials to hide them when they get caught by police; the latter usually pack small amounts and are called mini packers (Introna and Smialek 1989).
Cocaine and heroin are the most concealed drugs (Wetli et al. 1997; Kashani and Ruha 2004). Amphetamine and rarely cannabis are other reported drugs with a combination of drugs in several cases. The type of the drug depends on the drug market of the area and crossed borders (Heinemann et al. 1998; Gill and Graham 2002). Several other drugs were reported as lidocaine that is mixed with cocaine as it is cheaper and not detected (Nichols and Davis 1992). Diazepam liquid form and benzodiazepine were also reported (Wilcher 2011). In case of an expensive drug, the body of a dead packer is opened to retrieve the drug followed by disposal of the dead body (Wetli et al. 1997).
The number of packs in the case differs and can reach up to 57 packs (Ray et al. 2018). Different packaging materials are used and it depends on whether it was manual packing or machine sophisticated one (Bulstrode et al. 2002). Latex, condom, foil, greaseproof paper, and glass ampoules were all reported (Koehler et al. 2005). Machine packing uses special techniques to prepare packs that are both safe and more difficult to detect ((Cappelletti et al. 2019).
Body packers use different cavities of the body to conceal packages. Stomach, rectum, vagina, and ear stuffing were all reported (Kashani and Ruha 2004; Cappelletti et al. 2019; Cappelletti and Piacentino 2018; MA and HP 1989). A rare case of concealing drug package behind the foreskin of an uncircumcised penis was reported (Wilcher 2011).
Simple investigations of suspected cases include urine and blood analysis. However, this can merely indicate the use of a drug rather than a leaking package. Radiological investigations are the second step in suspects and include ultrasound that is operator-dependent (Klein et al. 2000) and plain abdominal X-ray with specific signs including tic-tac, parallelism, and rosette signs (Ray et al. 2018). False negatives occur when packers use skills to mask the picture: by moving, drinking liquids to mask the densities, or taking constipating drugs to accumulate stool around the packages (Cappelletti et al. 2019; Abedzadeh et al. 2019; Cappelletti and Ciallella 2017). CT scan is the most useful technique but has the disadvantage of high radiation exposure (Heinemann et al. 1998). Drugs show different densities in CT with cocaine being less dense than fat, cannabis having the same bone density, and heroin having a density between that of fat and air (Abedzadeh et al. 2019).
Many body packers succeed in hiding the drug and reaching their goal, this is what makes it a desirable method of concealing an illicit drug. However, fatalities were reported since 1973 (Deitel and Syed 1973). A research in New York City found 50 cases with 5 fatalities, whereas a study in the UK found 180 cases with no fatalities (Bulstrode et al. 2002). Death occurs by leakage of the drug, intestinal obstruction (Hutchins et al. 2000), peritonitis (Wetli et al. 1997), perforation, or even obstruction of airways when rapidly engulfing the packages in mini packers (Introna and Smialek 1989). Death can be due to reasons unrelated to the body packing, either due to drug overdose or other causes of death with incidental finding of packages in the body during the autopsy.
In the past, surgery was the first-line management of body packers. Now, it became more conservative management with purgation or follow-up with close monitoring until expelled naturally, surgical intervention will be done only in cases with symptoms of leakage or intestinal obstruction (Klein et al. 2000; McCarron and Wood 1983; Benko et al. 2019; Beckley et al. 2009).
Up to the knowledge of authors, this is the first reported case of fatal body packer in Saudi Arabia and Arab countries, with methamphetamine and cannabis as the packed drugs.