Discussion:
Ingestion of legal and illegal recreational substances is a common cause for hospitalization. A physician must not only be familiar with common medication intoxications and withdrawal syndromes, but also remain aware of the possibility of rare substances or additives.
A 37 year old male presented to the ER with a chief complaint of palpitations and shortness of breath after snorting cocaine and heroin. In the ER, temperature was 36.7°C, heart rate was 122, Blood pressure was 92/45 mmHg, and respiratory rate was 27. A urine drug screen found positive results for opiates and cocaine. Potassium was 2.6 mmol/L, lactate was 9.7 mmol/L, and Troponin was 2.5 ng/mL. Electrocardiogram was significant only for sinus tachycardia.
A diagnosis of Non-ST segment elevation myocardial infarction was made and felt to be attributable to acute cocaine toxicity with coronary vasospasm and supply-demand mismatch ischemia. The patient was admitted to the ICU and managed conservatively with fluids, low dose beta blockers, aspirin, intravenous heparin, and a statin. The patient’s persistent tachycardia, hypotension, lactic acidosis, and profound hypokalemia were not consistent with typical findings in acute cocaine intoxication. Further evaluation for other ingested substances prompted a urine anabolic steroid screen. After 24 hours in the hospital, the patient’s shortness of breath, chest pain, and palpitations resolved. His heparin drip was discontinued, blood pressure and heart rate returned to normal ranges, and hypokalemia resolved after aggressive supplementation. The patient was then transferred to the medicine floor on telemetry monitoring. Shortly after transfer, the patient left the hospital against medical advice.
Ten days later, a urine anabolic steroid screen returned positive for Clenbuterol. Clenbuterol is a potent Beta-2 Agonist that is used overseas by veterinarians as a bronchodilator for large animals. Additionally, Clenbuterol has both anabolic and metabolism accelerating properties that are not fully understood. Clenbuterol has also been used and abused as a performance enhancing drug with resultant discipline against several high profile athletes. Adverse effects of Clenbuterol include tachycardia, palpitations, diaphoresis, nausea, and vomiting. It remains unclear whether Clenbuterol was intentionally abused by this patient or whether it had been an unknown additive.
Conclusions:
This case illustrates the potential for cardiovascular and electrolyte abnormalities that can occur with the ingestion of Clenbuterol. Timely recognition is critical to institute appropriate medical therapy. The profound hypokalemia seen in this patient can aid in early consideration to the presence of this substance. The case also highlights the need to be mindful of the availability heuristic when taking care of patients with substance abuse disorders.
Discussion:
Ingestion of legal and illegal recreational substances is a common cause for hospitalization. A physician must not only be familiar with common medication intoxications and withdrawal syndromes, but also remain aware of the possibility of rare substances or additives.
A 37 year old healthy male presented to the ER with a chief complaint of palpitations and shortness of breath after snorting cocaine and heroin. In the ER, temperature was 36.7°C, heart rate was 122, Blood pressure was 92/45 mmHg, and respiratory rate was 27. A urine drug screen found positive results for opiates and cocaine. Potassium was 2.6 mmol/L, lactate was 9.7 mmol/L, and Troponin was 2.5 ng/mL. Electrocardiogram was significant only for sinus tachycardia.
A diagnosis of Non-ST segment elevation myocardial infarction was made and felt to be attributable to acute cocaine toxicity with coronary vasospasm and supply-demand mismatch ischemia. The patient was admitted to the ICU and managed conservatively with fluids, low dose beta blockers, aspirin, intravenous heparin, and a statin. The patient’s persistent tachycardia, hypotension, lactic acidosis, and profound hypokalemia were not consistent with typical findings in acute cocaine intoxication. Further evaluation for other ingested substances prompted a urine anabolic steroid screen. After 24 hours in the hospital, the patient’s shortness of breath, chest pain, and palpitations resolved. His heparin drip was discontinued, blood pressure and heart rate returned to normal ranges, and hypokalemia resolved after aggressive supplementation. The patient was then transferred to the medicine floor on telemetry monitoring. Shortly after transfer, the patient left the hospital against medical advice.
Ten days later, a urine anabolic steroid screen returned positive for Clenbuterol. Clenbuterol is a potent Beta-2 Agonist that is used overseas by veterinarians as a bronchodilator for large animals. Additionally, Clenbuterol has both anabolic and metabolism accelerating properties that are not fully understood. Clenbuterol has also been used and abused as a performance enhancing drug with resultant discipline against several high profile athletes. Adverse effects of Clenbuterol include tachycardia, palpitations, diaphoresis, nausea, and vomiting. It remains unclear whether Clenbuterol was intentionally abused by this patient or whether it had been an unknown additive.
Conclusions:
This case illustrates the potential for cardiovascular and electrolyte abnormalities that can occur with the ingestion of Clenbuterol. Timely recognition is critical to institute appropriate medical therapy. The profound hypokalemia seen in this patient can aid in early consideration to the presence of this substance. The case also highlights the need to be mindful of the availability heuristic when taking care of patients with substance abuse disorders.