Severe acute caffeine poisoning due to intradermal injections: Mesotherapy hazard

Abstract

Introduction. Caffeine is indicated in the treatment of migraine headaches, as well as neonatal apnea and bradycardia syndrome. In mild poisoning, the most prevalent symptoms are nausea, vomiting, diarrhea, tremor, anxiety and headache. In more severe cases, symptoms consist of heart rythym abnormalities, myocardial infarction and seizures. Due to its common lipolytic effect, caffeine is used in mesotherapy, usually in combination with drugs of similar effect. We presented a patient with acute iatrogenic caffeine poisoning. Case report. A 51-year-old woman, with preexisting hypertension and hypertensive cardiomyopathy was subjected to cosmetic treatment in order to remove fat by intradermal caffeine injections. During the treatment the patient felt sickness, an urge to vomit, and a pronounced deterioration of general condition. Upon examination, the patient exhibited somnolence, hypotension and nonsustained ventricular tachycardia, which was sufficient enough evidence for further hospitalization. On admission to the intensive care unit the patient was anxious with increased heart rate, normotensive, with cold, damp skin, and visible traces of injection sites with surrounding hematomas on the anterior abdominal wall. Paroxysmal supraventricular tachycardia (PSVT) on electrocardiographic monitoring was found. The laboratory analysis determined a lowered potassium level of 2.1 mmol/L (normal range 3,5 - 5.2 mmol/L), and a toxicological analysis (liquid chromatography with ultraviolet detection) proved a toxic concentration of caffeine in plasma - 85.03 mg/L (toxic concentration over 25 mg/L). On application of intensive therapy, antiarrhythmics, and substitution of potassium, as well as both symptomatic and supportive therapy, there was a significant recovery. The patient was discharged without any sequele within four days. Conclusion. A presented rare iatrogenic acute caffeine poisoning occured due to massive absorption of caffeine from the subcutaneous adipose tissue into the circulation when injected directly into the tiny blood vessels, as evidenced by hematoma formation. Poisoning manifestations were registered in gastrointestinal, CNS (anxiety, somnolence) and cardiovascular (hypotension, ventricular tachycardia and nonsustained PSVT) system. In this era of mesotherapeutic treatment promotion, one should keep in mind toxic prevention, with application being carried out exclusively in a specialized institutionUvod. Kofein se primenjuje u lecenju migrenozne glavobolje, a kod dece u lecenju neonatalne apneje i sindroma bradikardije. Kod laksih trovanja kofeinom najcesce se javljaju mucnina, povracanje, dijareja, tremor, anksioznost i glavobolja, a kod teskih trovanja poremecaji srcanog ritma, infarkt miokarda i konvulzije. Zbog poznatog lipolitickog efekta kofein se koristi i u mezoterapiji, obicno u kombinaciji sa supstancama koje slicno deluju. Prikaz bolesnika. Bolesnica, stara 51 godinu, sa postojecom hipertenzijom i hipertenzivnom kardiomiopatijom, bila je podvrgnuta estetskom tretmanu uklanjanja masnih naslaga putem intradermalnog ubrizgavanja kofeina. Tokom tretmana osetila je mucninu, nagon za povracanjem i izrazito pogorsanje opsteg stanja. Pri prvom pregledu utvrdjeni su somnolencija i hipotenzija, a u EKG ventrikularna tahikardija nonsustained, zbog cega je upucena na bolnicko lecenje. Pri prijemu u jedinicu intenzivne nege bolesnica je bila anksiozna, tahikardicna, normotenzivna, sa hladnom i vlaznom kozom, a na trbuhu su bili vidljivi tragovi uboda sa okolnim hematomima. Elektrokardiografskom kontrolom registrovana je paroksizmalna supraventrikularna tahikardije (PSVT). Laboratorijskim analizama utvrdjen je snizen nivo kalijuma - 2,1 mmol/L (3,5-5,2 mmol/L), a toksikoloskim analizama (tecna hromatografija sa ultravioletnim detektorom) dokazan je kofein u toksicnoj koncentraciji - 85,03 mg/L (toksicna koncentracija preko 20 mg/L). Na primenjenu intenzivnu terapiju, antiaritmike i supstituciju kalijuma, simptomatsku i suportivnu terapiju, doslo je do oporavka, te je cetvrtog dana bolesnica otpustena bez posledica. Zakljucak. Opisano retko jatrogeno akutno trovanje kofeinom nastalo je atipicno - zbog masivne resorpcije kofeina iz potkoznog adipoznog tkiva u cirkulaciju. Ubrizgavanje direktno u sitne krvne sudove potvrdjeno je prisustvom hematoma. Manifestacije trovanja bile su prisutne u gastrointestinalnom, centralnom nervnom (anksioznost, somnolencija) i kardiovaskularnom (hipotenzija, ventrikularna tahikardija nonsustained i PSVT) sistemu. U eri promocije mezoterapijskih estetskih tretmana treba imati na umu takvu opasnost i estetske intervencije sprovoditi isklju civo u visokospecijalizovanim ustanovama.