Death of an apprentice bodybuilder following 2,4-dinitrophenol and clenbuterol intake

We present the case of a 17-year-old man, who died after 2,4-dinitrophenol (DNP) and clenbuterol consumption, which he likely took for physical enhancement. Forensic post-mortem examination revealed a yellowish skin colour and nonspecific signs of asphyxia. Analytical confirmation of the intoxication was obtained in blood and urine, with high levels of DNP and clenbuterol. Both of these substances are used by bodybuilders as DNP enhance lipolysis and clenbuterol has anabolic properties, but their toxicity is underestimated. DNP uncouples oxidative phosphorylation, leading to thermogenesis and even relatively small doses can cause fatal hyperthermia. Clenbuterol is a β2 agonist that causes electrolyte disturbances (hypokalemia and hyperglycemia mostly) and death have been described through coronary vasospasm. Given the circumstances in which the body was found and toxicological results, we believe the cause of death to be fatal hyperthermia from DNP intake. These substances are illegal in many countries, but easily bought online. Through this availability, the last decades have seen an increase of fatal intoxications. Websites selling them are regularly closed by French public authorities and Interpol, but unfortunately it seems insufficient.

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.

Acute clenbuterol overdose manifestations in a suicide attempt--a case report

A 30-year-old man was admitted to the intensive care unit after a suicide attempt with respiratory difficulties, tremor, sinus tachycardia and significant hypokalemia. On examination, the patient was lucid, fully conscious and did not exhibit positive symptoms. Sings were not typical for overdosing olanzapine, alprazolam and alcohol as declared by the patient. Additional anamnesis revealed high doses of ingested clenbuterol, a selective β2-adrenergic agonist. Due to its anabolic and lipolytic properties, clenbuterol has become a commonly abused drug in bodybuilding industry and is not routinely detected by toxicology screens. This is the first known report of suicide attempt by clenbuterol overdosing.

[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.

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.

[Adrenergic beta-agonist intoxication]

The authors describe two clinical cases (father and daughter), observed in the Hospital Urgency with distal tremors, anxiety, palpitations, nausea, headaches and dizziness, two hours after ingestión of cow liver. They also had leucocytosis (with neutrophylia), hypokalemia and hyperglycaemia. After treatment with potassium i.v. and propranolol, the symptoms disappeared. The symptoms recurred at home because the patients didn't take the prescribed medication and persisted for five days, with spontaneous disappearance. The serum of both patients revealed the presence of clenbuterol (65 hg/ml - father and 58 hg/ml - daughter). The animal's liver had a concentration of 1,42 mg/kg. Clenbuterol is a ß-adrenergic agonist with low specificity, with some veterinary indications. However, this substance has been illegally used as a growth's promotor. We intend to alert doctors for this problem, particularly those that work in the Urgency.

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.

[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.

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.

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.

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.

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.

[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.

Epidemiologic study of an outbreak of clenbuterol poisoning in Catalonia, Spain

In an investigation of 113 cases of clenbuterol poisoning in Catalonia, Spain, in 1992, more than 50 percent of those affected were found to have had symptoms of nervousness, tachycardia, muscle tremors, myalgia, and headache. There was no significant difference in the distribution of symptoms according to sex (P = 0.97). The period of incubation varied between 15 minutes and 6 hours and the duration of symptoms between 90 minutes and 6 days. Clenbuterol was detected in 47 urine samples in amounts ranging from 11 to 486 parts per billion. No traces of clenbuterol were found in serum samples. Intoxication occurred in association with the ingestion of veal liver, irrespective of the way in which the liver had been cooked. The association between consuming liver and falling ill was statistically significant (P < 0.0001). In one family, the suspected source of intoxication was meat (veal tongue) and in another canneloni. None of the patients died as a result of the intoxication. The findings reinforce the need to uphold the prohibition of the use of clenbuterol in cattle farming in those countries and communities where it already exists and to contemplate a stricter regulation of its therapeutic use.

Collective human food poisonings by clenbuterol residues in veal liver

Twenty-two patients were reported to complain of tremor, headaches, tachycardia and dizziness 1-3 h after eating veal liver. As clinical symptoms were not suggestive of an infectious cause, the presence of veterinary drug residues was suspected. Clenbuterol, a beta 2-agonist, was being illegally used in cattle because of its anabolizing properties and may explain the observed effects. Assays of clenbuterol in samples of veal liver showed concentrations of 0.375 and 0.500 micrograms/g. To our knowledge, this is one of the first reports of clinical symptoms in humans associated with the consumption of veterinary drug residue-containing food.