title: A Case Series of Clenbuterol Toxicity Caused by Adulterated Heroin.
abstract: BACKGROUND
  Adulteration of drugs of abuse may be done to increase profits. Some adulterants are relatively innocuous and others result in significant toxicity. Clenbuterol is a β2-adrenergic agonist with veterinary uses that has not been approved by the U.S. Food and Drug Administration for human use. It is an infrequently reported heroin adulterant. We describe a cluster of hospitalized patients with laboratory-confirmed clenbuterol exposure resulting in serious clinical effects.
  
  
  METHODS
  Ten patients presented with unexpected symptoms shortly after heroin use. Seven evaluated by our medical toxicology service are summarized. Presenting symptoms included chest pain, dyspnea, palpitations, and nausea/vomiting. All patients were male, with a median age of 40 years (interquartile range [IQR] 38-46 years). Initial vital signs included a heart rate of 120 beats/min (IQR 91-137 beats/min), a respiratory rate of 20 breaths/min (IQR 18-22 breaths/min), a temperature of 36.8°C (IQR 36.7-37.0°C), a systolic blood pressure of 107 mm Hg (IQR 91-131 mm Hg), and a diastolic blood pressure of 49 mm Hg (IQR 40-70 mm Hg). Serum potassium nadir was 2.5 mEq/L (IQR 2.2-2.6 mEq/L), initial glucose was 179 mg/dL (IQR 125-231 mg/dL), initial lactate was 9.4 mmol/L (IQR 4.7-10.5 mmol/L), and peak creatine phosphokinase was 953 units/L (IQR 367-10,363 units/L). The median peak troponin level in six patients was 0.7 ng/mL (IQR 0.3-2.4 ng/mL). Three patients underwent cardiac catheterization and none had significant coronary artery disease. Clenbuterol was detected in all patients after comprehensive testing. All patients survived with supportive care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Atypical presentations of illicit drug intoxication may raise concern for drug adulteration. In the case of heroin use, the presence of adrenergic symptoms or chest pain with hypokalemia, lactic acidosis, and hyperglycemia suggests adulteration with a β-agonist, such as clenbuterol, and patients presenting with these symptoms often require hospitalization.
authors.affiliation: Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia.
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Hieger
authors.affiliation: Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Emswiler
authors.affiliation: Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia.
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Maskell
authors.affiliation: Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia.
authors.forename: John T
authors.initials: JT
authors.lastname: Sentz
authors.affiliation: Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia.
authors.forename: Kristin B
authors.initials: KB
authors.lastname: Miller
authors.affiliation: Toxicology Laboratory, Departments of Pathology and Forensic Science, Virginia Commonwealth University, Richmond, Virginia.
authors.forename: Carl E
authors.initials: CE
authors.lastname: Wolf
authors.affiliation: Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia.
authors.forename: Kirk L
authors.initials: KL
authors.lastname: Cumpston
authors.affiliation: Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia.
authors.forename: Brandon K
authors.initials: BK
authors.lastname: Wills
mesh_terms: D000318:Adrenergic beta-Agonists / Q000506:poisoning*; D000328:Adult; D002976:Clenbuterol / Q000506:poisoning*; D004340:Drug Contamination; D006556:Heroin Dependence; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D019966:Substance-Related Disorders / Q000209:etiology*
chemical_list: D000318:Adrenergic beta-Agonists; D002976:Clenbuterol
keywords: adulterated; clenbuterol; heroin; hypokalemia; illicit drug use; methylxanthine