Considering the severe hypokalaemia, the patient's urine was also tested for the presence of laxatives and diuretics, which could not be demonstrated. Further analysis of the Stacker 2® tablets demonstrated caffeine levels of approximately 400 mg in each tablet without any trace of ephedrine. No ephedrine could be traced in serum samples or in urine. After 2 days, caffeine concentration had diminished to 36 mg l −1. In total, seven serum samples at different time points were obtained for analysis. Serum collected 8 h post ingestion showed a toxic caffeine level of 110 mg l −1 ( Figure 1). Ephedrine analysis was performed with gas chromatography combined with mass spectrometry. The mobile phase consisted of a solution of water, phosphor acid, nonilamine (67%) and acetonitril (33%). Subsequently, toxicological analysis for caffeine was performed by means of high-pressure liquid chromatography UV detection: platinum enhanced polar selectivity C18 column, particles 3 µm, size 10 × 4.6 cm Alltech®, photodiode array detector (Waters®, Milford, MA, USA). The patient was transferred to the ward and discharged home 7 days after admittance. Serum lactate had decreased to 3.5 mmol l −1 ( Table 1). The serum potassium concentration had increased from 1.6 to 3.8 mmol l −1. Her respiratory rate still measured 22/min. The following day, the patient was less agitated, but still complained of nausea, vomiting and abdominal pain. Polyuria was observed with a diuresis of 250 ml h −1. The patient was transferred to the Intensive Care Unit for haemodynamic monitoring. Furthermore, sodium-potassium-phosphate was supplemented. Potassium chloride at a rate of 20 mmol h −1 was administered. Electrocardiography demonstrated sinustachycardia with ST-depression and U-waves in precordial leads V1–V3. Also remarkable was the elevated serum lactate (7.2 mmol l −1). Because of the strikingly low serum potassium concentration (1.6 mmol l −1), laboratory measurements were verified several times. Apart from modest abdominal tenderness, physical examination revealed no other abnormalities. Pupils were bilaterally dilated and responsive. Her arterial saturation was measured at 99%. Vital signs included a temperature of 37.5 ☌, blood pressure of 122/66 mmHg, a regular pulse of 110 bpm and a respiratory rate of 25/min. On examination, an anxious, hyperventilating and extremely agitated woman was observed with clammy peripheries. On arrival, she complained of thirst, headache, abdominal pain, chest pain and she vomited several times. Furthermore, she had not been exercising on the day of admission. The patient reported not having taken any alcohol or other medication. According to the label on the bottle, its main constituents were Ephedra, cola nuts and white willow bark (NVE Pharmaceuticals®, Andover, NJ, USA). She claimed to have ingested approximately 50 tablets of Stacker 2® ephedra, which had previously been provided by her gym. In the following case report we describe a remarkable, potential lethal intoxication with Stacker 2®.Ī 22-year-old woman with no previous medical history was admitted to our emergency room because of attempted suicide. Furthermore, an increase in the use of Ephedra-free fatburners, which are considered as ‘safe’ products, has been observed. However, Ephedra alkaloids can still easily be obtained through the internet or at gyms. When serious adverse events including stroke, heart attacks, cardiac arrhythmias, seizures and psychotic disorders were reported, the general sale of Ephedra-containing products was prohibited. Its pharmacological actions are diverse, but finally result in an increasing release of endogenous catecholamines and therefore augment the effect of Ephedra alkaloids.įor years, Ephedra-containing food supplements were easily available over-the-counter herbal products in the USA and the Netherlands. Caffeine (1,3,7-methylxanthine) is also a plant-derived stimulant alkaloid, which can be obtained from tea leaves, coffee beans, cacao beans and cola nuts. Ephedra, also known as the Chinese ‘Ma Huang’, is a plant-derived natural source of the sympathicomimetic substance ephedrine. The drugs are supposed to stimulate athletic performance and reduce body weight. These dietary supplements contain substances such as Ephedra and caffeine. In recent years the use of so-called fatburners such as Stacker® has gained widespread popularity in the USA.
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