Clinical and pharmacological profile in a clenbuterol epidemic poisoning of contaminated beef meat in Italy

Long-acting beta adrenergic agonists, such as clenbuterol accumulate in the liver, but not meat of treated farm animals, and result in epidemic poisonings in consumers. We describe an outbreak of poisoning in 15 people, following the consumption of meat. Clinical symptoms (distal tremors, palpitations, headache, tachipnoea-dyspnoea, and also moderate hyperglycaemia, hypokalemia and leucocytosis) were seen in nine hospitalised patients, starting about 0.5-3 h after poisoning, and disappearing within 3-5 days later. Clenbuterol was found in the urine of all the symptomatic patients, at higher levels than pharmacokinetic computing (mean level 28 ng/ml, 36 h after ingestion), based on the levels found in the meat (1140-1480 ng/g edible tissue). Thus, epidemic poisoning can be produced following the consumption of contaminated meat. The need for a better definition of pharmaco- and toxico-kinetics, not only for drugs ingested as parent drug, but also when ingested as residues with animal tissues, is recommended.

Food poisoning by clenbuterol in Portugal

This paper describes the occurrence of four cases of acute food poisoning, involving a total of 50 people, due to the ingestion of lamb and bovine meat containing residues of clenbuterol. Symptoms shown by the intoxicated people may be generally described as gross tremors of the extremities, tachycardia, nausea, headaches and dizziness. Analytical methodology developed for the determination of clenbuterol in meat, liver and blood samples is described. Procedures are described which should be followed when the described symptoms are evident in a group of people who have ingested contaminated meat, and particularly liver of ruminants.

Myotoxic effects of clenbuterol in the rat heart and soleus muscle

Myocyte-specific necrosis in the heart and soleus muscle of adult male Wistar rats was investigated in response to a single subcutaneous injection of the anabolic beta(2)-adrenergic receptor agonist clenbuterol. Necrosis was immunohistochemically detected by administration of a myosin antibody 1 h before the clenbuterol challenge and quantified by using image analysis. Clenbuterol-induced myocyte necrosis occurred against a background of zero damage in control muscles. In the heart, the clenbuterol-induced necrosis was not uniform, being more abundant in the left subendocardium and peaking 2.4 mm from the apex. After position (2.4 mm from the apex), dose (5 mg clenbuterol/kg), and sampling time (12 h) were optimized, maximum cardiomyocyte necrosis was found to be 1.0 +/- 0.2%. In response to the same parameters (i.e., 5 mg of clenbuterol and sampled at 12 h), skeletal myocyte necrosis was 4.4 +/- 0.8% in the soleus. These data show significant myocyte-specific necrosis in the heart and skeletal muscle of the rat. Such irreversible damage in the heart suggests that clenbuterol may be damaging to long-term health.

Clenbuterol ingestion causing prolonged tachycardia, hypokalemia, and hypophosphatemia with confirmation by quantitative levels

BACKGROUND

Clenbuterol is a long acting beta2-adrenergic agonist used in the treatment of pulmonary disorders. Acute clenbuterol toxicity resembles that of other beta2-adrenergic agonists. Most previously reported cases of clenbuterol toxicity describe patients who ate livestock illicitly treated with clenbuterol.

CASE REPORT

We report a case of human clenbuterol toxicity confirmed and correlated with qualitative and quantitative serum clenbuterol assays. This poisoned patient, a 28-year-old woman, developed sustained sinus tachycardia at 140/min, hypokalemia (2.4 mEq/L, 2.4 mmol/L), hypophosphatemia (0.9 mg/dL, 0.29 mmol/L), and hypomagnesemia (1.52 mg/dL, 0.76 mmol/L) after ingesting a reportedly small quantity of clenbuterol. The patient received repeated doses of metoprolol to treat her cardiovascular stimulation and potassium chloride to treat her hypokalemia. She remained symptomatic for more than 20 hours after the ingestion. Analysis by enzyme-linked immunosorbent assay and liquid chromatography/mass spectrometry revealed a serum clenbuterol concentration of 2.93 mcg/L 3 hours after the ingestion and an undetectable serum concentration 20 hours after ingestion. It is noteworthy that at a serum concentration below the limit of detection by liquid chromatography/mass spectrometry, the patient remained symptomatic. Acute clenbuterol toxicity is rarely reported following illicit use in humans, and this is the first such case to provide confirmatory toxicological analysis.

Case of low dose clenbuterol toxicity

We present a case of acute clenbuterol toxicity following ingestion of 20 μg of clenbuterol, resulting in symptoms of sympathetic activation, sinus tachycardia and electrolyte derangement. The patient was managed conservatively with fluid resuscitation, electrolyte replacement and monitoring, and discharged following a 5-day stay in hospital.

Clenbuterol residues in non-liver containing meat as a cause of collective food poisoning

beta 2-adrenergic agonists, particularly clenbuterol, are illegally used as growth promoters to obtain lean in meat. Their administration in feedlots can constitute a severe risk for animal welfare and exposes consumers to involuntary drug consumption at pharmacological active concentrations. Reported poisoning episodes have been associated with the consumption of beef liver where clenbuterol residues concentrate. In August 1996, 62 persons asked for medical help at the emergency rooms of 2 hospitals near the city of Caserta (Italy). Their clinical profile was characteristic of previously occurring clenbuterol intoxication, which reported superventricular extrasystoles and atrial fibrillation. All patients had non-liver beef meat consumption 10-30 min to 2-3 h before symptoms developed. An ELISA screening test specific for clenbuterol confirmed the drug's presence. Definitive confirmation of clenbuterol and determination of the drug content in meat samples were obtained by GC-MS, using 2 different derivatization. Concentrations in the meats ranged from 0.8 to 7.4 mg/kg. These analytical data provided evidence of the seriousness of the poisoning and helped the National Health System identify other possible misinterpreted cases. This case demonstrates that clenbuterol poisoning can also occur after consumption of beef meat other than liver.

[Toxicological effects of clenbuterol in human and animals]

It is reported that clenbuterol increases the lean- to fat conversion in livestock and is an illegal stimulating and growth promoter. Consumption of meat containing clenbuterol residues causes adverse health effects in human, reduces the performance in exercise and disturbs reproductive system and hormone response. The toxicity of clenbuterol and its mechanism is reviewed in this paper.

[Clinical features and treatment of acute clenbuterol poisoning in children]

OBJECTIVE

To study clinical features, treatment and curative effects in children with acute clenbuterol poisoning, in order to provide a basis for early diagnosis and treatment.

METHODS

Clinical data of 28 hospitalized children with acute clenbuterol poisoning in April 2011 were retrospectively studied.

RESULTS

Of the 28 patients, there were 15 males and 13 females, aged 1 to 13 years (mean age 6.5±4.8 years). Vomiting, palpitations and limb shaking were found as main clinical manifestations in the patients. Main changes of blood biochemical included hypokalemia, lactic acidosis, hyperglycemia, hypsocreatinkinase. Snus tachycardia and S-T segment depression were observed on ECG. Patients' symptoms were gradually alleviated after 12-78 hours by use of beta blockers, potassium supplement, protecting the heart and other symptomatic and supportive treatment. Blood biochemical indexes were improved after 48 hours of admission. All of the patients were cured after 5 days. The symptoms of the patients do not longer occur during a follow up of half a month.

CONCLUSIONS

Acute clenbuterol poisoning is characterized by vomiting, palpitations, limb shaking, hypokalemia, lactic acidosis and tachycardia in children. An early effective treatment of this disease can improve prognosis in children.

Atypical reactions associated with heroin use--five states, January-April 2005

Heroin use typically produces a well-recognized syndrome of euphoria, miosis, and respiratory and central nervous system depression; cardiovascular effects are not a common finding. In January 2005, a man aged 21 years in New Jersey was hospitalized with an atypical reaction (e.g., tachycardia and palpitations) after reported heroin use. During the next 3 months, 25 additional persons in five states were reported to poison control centers (PCCs) and local public health agencies with a similar reaction after reported heroin use; in all, 24 of 26 patients were hospitalized. Analysis of drug specimens or testing of urine was performed in certain cases; in eight patients, the veterinary pharmaceutical clenbuterol was detected. This report describes four representative cases and summarizes the investigation by state and local health and law enforcement authorities and CDC into the 26 cases of atypical reactions after heroin use reported in five states (Connecticut, New Jersey, New York, North Carolina, and South Carolina) during January 28-April 17, 2005. Unintentional or intentional adulteration of illicit drugs such as cocaine or heroin is an additional potential hazard associated with their use.

[Clenbuterol poisoning. Clinical and analytical data on an outbreak in Móstoles, Madrid]

OBJECTIVE

To report the clinical manifestations and analytical findings in an epidemic outbreak of acute food poisoning with clenbuterol.

MATERIALS AND METHODS

The clinical manifestations, physical examination findings and results of complementary tests are reported of fifteen patients performed by veal liver contaminated with clenbuterol. The clinical course of patients at 72 hours is reported. A quantitative measurement of clenbuterol in urine specimens from patients and in a veal liver specimen was performed by high pressure liquid chromatography (HPLC).

RESULTS

The male/female distribution of patients was 7/8 respectively, with age ranging from 6 to 44 years. Symptoms appeared after 30 minutes to 2 hours of having ingested veal liver in 93% of cases. Patients presented at the Emergency Department with tremors, palpitations, anxiety, malaise, nausea, and pruritus as the most common complaints. On physical examination tachycardia was noted in 100% of cases. The analytical data included mild hypokaliemia (66%) and leukocytosis (28%). Only one patient required hospital admission on account of an hypertensive crisis. After 72 hours, 67% of patients were asymptomatic. The remaining patients had mild symptoms which included headache, myalgia, asthenia and anorexia. Serum potassium values returned to normality (p < 0.05). Urine measurements of clenbuterol were positive for all analyzed cases (50 +/- 42 ng/ml). The concentration of clenbuterol in a veal liver sample was 500 ppb.

CONCLUSION

Clenbuterol poisoning should be suspected when symptoms of adrenergic hyperstimulation occur after the ingestion of meal, usually liver. Common symptoms include tachycardia and mild hypopotasemia. Diagnosis is confirmed by quantitative measurement of clenbuterol in urine. Most patients improve spontaneously shortly afterwards.

[Drugs as a cause of death. A prospective quality assurance project in a department of medicine]

This study is part of a prospective quality assurance project in a Norwegian county hospital. The major aims of the study were to estimate the number of drug-related deaths; assess whether these were recognized by the clinicians, and (if not) discuss why the clinicians had difficulties in recognizing drug-related deaths. A panel of two internists, one pathologist, one pharmacologist and one pharmacist evaluated all inpatients deaths over a six-month period. Among 3,082 hospitalized patients, 169 died. Of these deaths, 20 were classified as probably (nine) or possibility (11) drug-related. Only two of the deaths were recognized as such by the clinicians in the ward. The reasons for the clinicians failure to recognize adverse drug reactions include frequent presence of multiple diseases, polypharmacy and inadequate guidelines on how to look for adverse reactions to drugs. A two-year survey aimed at studying these aspects in depth is in progress.

Metabolic effects of metaproterenol overdose: hypokalemia, hyperglycemia and hyperlactatemia

This case report of metaproterenol toxicity was associated with hypokalemia, hyperglycemia and hyperlactatemia. A similar triad has been reported in acute theophylline poisoning. Hypokalemia and hyperglycemia have been reported with other beta-agonists, but not metaproterenol. Patients presenting with the metabolic triad of hypokalemia, hyperglycemia, and hyperlactatemia should have theophylline and beta-agonist toxicity included in their differential diagnosis because the prognosis and therapy of these 2 intoxications is markedly different.

beta-blocker ingestion: an evidence-based consensus guideline for out-of-hospital management

In 2003, US poison centers were contacted regarding ingestion of beta-blockers by 15,350 patients including 3766 (25%) under 6 years of age; 7415 (48%) were evaluated in healthcare facilities and 33 died. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before its distribution to secondary reviewers for comment. The panel then made changes in response to comments received. The objective of this guideline is to assist US poison center personnel in the appropriate out-of-hospital triage and management of patients with suspected ingestions of beta-blockers by describing the process by which a beta-blocker ingestion might be managed, identifying the key decision elements in managing cases of beta-blocker ingestion, providing clear and practical recommendations that reflect the current state of knowledge, and identifying needs for research. This guideline applies to ingestion of beta-blockers alone and is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use; the grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or who are the victims of a potentially malicious administration of beta-blocker should be referred to an emergency department immediately. In general, this should occur regardless of the dose reported (Grade D). 2) Patients without evidence of self-harm should have further evaluation, including determination of the precise dose ingested, history of other medical conditions, and the presence of co-ingestants. Ingestion of either an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose (whichever is lower) warrants consideration of referral to an emergency department. Ingestion of any excess dose of any beta-blocker in combination with a calcium channel blocker or the ingestion of any excess dose by an individual with serious underlying cardiovascular disease also warrants referral to an emergency department (Grade C). 3) Do not induce emesis. Consider the oral administration of activated charcoal if it is available and no contraindications are present but do not delay transportation to administer charcoal (Grade A). 4) Asymptomatic patients who ingest more than the referral dose should be sent to an emergency department if the ingestion occurred within 6 hours of contacting the poison center for an immediate-release product other than sotalol, within 8 hours of contacting the poison center for a sustained-release product, and 12 hours if they took sotalol (Grade C). 5) Ambulance transportation is recommended for patients who are referred to emergency departments because of the potential for life-threatening complications of beta-blocker overdose. Provide usual supportive care en route to the hospital, including intravenous fluids for hypotension (Grade D). 6) Follow-up calls should be made to determine outcome at appropriate intervals for up to 12-24 hours based on the judgment of the poison center staff (Grade D). 7) Asymptomatic patients who are referred to healthcare facilities should be monitored for at least 6 hours after ingestion if they took an immediate-release preparation other than sotalol, 8 hours if they took a sustained-release preparation, and 12 hours if they took sotalol. Routine 24-hour admission of an asymptomatic patient who has unintentionally ingested a sustained-release preparation is not warranted (Grade D).

Acute poisoning with clenbuterol--a case report

In the paper we have described a case of acute, unintentional intoxication with clenbuterol, a selective beta 2-agonist. A 21-year-old bodybuilder to improve his physical fitness and to increase his muscle bulk was using clenbuterol in a dose of two tablets (20 mg) daily for a week before poisoning. On a day of acute intoxication he drank orange juice containing 48 tablets (4.8 g) of clenbuterol, which had been placed there by his friends. The patient was admitted to our clinic with tachycardia at rate 160 bpm, headache, dizziness, tremor, sweats, muscle weakness, agitation. Serum potassium concentration was 2.6 mmol/L, blood glucose level 18.7 mmol/L. All the symptoms and biochemical abnormalities disappeared after intravenous treatment with propranolol (1.0 mg) and potassium chloride (60 mmol) within five hour period. This case indicates that more attention should be paid to clenbuterol widely used as a stimulant by athletes, especially by bodybuilders.

Validation of ELISA test kits for detection of beta-agonist residues in meat

Three ELISA test kits, the Randox ELISA beta-agonist test kit, Euro-Diagnostica test kit, and Ridascreen beta-agonist test kit, were evaluated for screening of meat and liver for beta-agonist residues in fortified and field-incurred samples. It was found that the Randox beta-agonist test kit was more suitable as a screening tool due to its accuracy, ease of use, and lower cost. The tests were able to detect beta-agonist residues at the minimum level of detection, as claimed by the suppliers. The performance of the method as assessed through recovery rates of beta-agonists in fortified samples was satisfactory with a low coefficient of variation (1-3%). Repeatability, as measured through the coefficient of correlation was also satisfactory. For field-incurred positive samples, the test kit showed a sensitivity of 100% and a low rate of false positives for goat and cow tissues. However, a high rate of apparent false positives was obtained for tissues of swine.

Concepts and controversies of bronchodilator overdose

Beta-adrenergic agonists and theophylline are both capable of producing tremor, agitation, tachycardia, metabolic acidosis, hypokalemia, hyperglycemia, cardiac arrhythmias, and seizures. However, theophylline preparations, especially in the sustained-release formulations, are associated with a much higher incidence of morbidity and mortality secondary to status epilepticus and cardiovascular collapse. Overdoses of sustained-release preparations place patients at exceedingly high risk. This article describes the differentiation of the patient with acute and chronic theophylline overdoses and the implications for management of both clinical states.

[Salbutamol intoxication]

A 20-year-old asthmatic woman who ingested 300 mg of salbutamol (Albuterol) and 30 g of paracetamol is presented. She had sinus tachycardia up to 160/min, hypotension (80/50 mmHg), tremor, hypokalemia (2.1 mEq/l) and hyperglycemia (12.1 mEq/l). Treatment was by gastric lavage, fluids, potassium and N-acetylcysteine. Symptoms resolved in 24 hours.