title: Recalcitrant Supraventricular Tachycardia: Occult Albuterol Toxicity Due to a Factitious Disorder.
abstract: BACKGROUND
  We report a case of a factitious disorder presenting with recurrent episodes of supraventricular tachycardia (SVT).
  
  
  METHODS
  A 26-year-old woman presented with recurrent episodes of SVT. Medical history included SVT, asthma, anxiety, depression, type 2 diabetes, and migraine headaches. The patient had frequent emergency department (ED) visits with complaints of chest pain, palpitations, and heart rates typically between 130 and 150 beats/min. Electrocardiograms revealed sinus tachycardia; laboratory studies were consistently normal except for periodic episodes of hypokalemia. Over the 3 years, the patient had more than 50 visits for health care and underwent multiple diagnostic evaluations, including comprehensive laboratory testing, echocardiography, Holter monitoring, and event monitoring. Given the constellation of clinical features, a plasma albuterol concentration was obtained during an ED visit for SVT, which was 17 ng/mL (reference range for peak plasma concentration after 0.04-0.1-mg inhaler dose = 0.6-1.4 ng/mL). A subsequent ED visit with a similar presentation revealed a plasma albuterol level of 11 ng/mL. The patient adamantly denied using this medication. Due to concerns about a factitious disorder, a multidisciplinary hospital discussion was planned for subsequent interventions; however, the patient was lost to follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is a compelling case report of a factitious disorder and occult albuterol abuse resulting in recalcitrant SVT with numerous ED visits and interventions. Patients with factitious disorders can have multiple visits for emergency care and are challenging to evaluate and treat. Albuterol toxicity can present with pronounced sinus tachycardia, fine tremor, and often with transient hypokalemia.
authors.affiliation: Department of Emergency Medicine, VCU Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia.
authors.forename: Brandon K
authors.initials: BK
authors.lastname: Wills
authors.affiliation: Department of Emergency Medicine, VCU Medical Center, Richmond, Virginia.
authors.forename: Constance
authors.initials: C
authors.lastname: Kwan
authors.affiliation: Department of Emergency Medicine, VCU Medical Center, Richmond, Virginia.
authors.forename: Michael
authors.initials: M
authors.lastname: Bailey
authors.affiliation: Madigan Army Medical Center, Tacoma, Washington.
authors.forename: Leigh
authors.initials: L
authors.lastname: Johnson
authors.affiliation: Madigan Army Medical Center, Tacoma, Washington.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Allan
mesh_terms: D000328:Adult; D000420:Albuterol / Q000009:adverse effects*; D001993:Bronchodilator Agents / Q000009:adverse effects*; D005162:Factitious Disorders / Q000150:complications*; D005260:Female; D006801:Humans; D063487:Prescription Drug Misuse / Q000009:adverse effects*; D013617:Tachycardia, Supraventricular / Q000139:chemically induced*
chemical_list: D001993:Bronchodilator Agents; D000420:Albuterol
keywords: albuterol; factitious disorder; toxicity