When chewing gum is more than just a bad habit.

Full text

Page 1

Case Report
1918
www.thelancet.com Vol 373 May 30, 2009
When chewing gum is more than just a bad habit
Francesco Natale, Chiara Cirillo, Giovanni Maria Di Marco, Lucia Scotto di Vetta, Luigi Aronne, Alessandro Siciliano, Rosa Mocerino,
Michele A Tedesco, Paolo Golino, Raff aele Calabrò
In November, 2008 a 13-year-old boy (weight 45 kg, height
160 cm) was taken by his parents to the emergency
department. His parents reported that after school the
boy had been agitated and aggressive, in contrast with
his normal mood. He denied feeling stressed or having
used drugs or stimulants. He complained of abdominal
discomfort, increased diuresis, dysuria, and prickling
sensations in his legs. On examination, he was restless,
with sinus tachycardia (147 beats per min [bpm] on
electrocardiogram [ECG]), tachypnoea (25 breaths
per min), and raised blood pressure (145/90 mm Hg).
Chest radiography and laboratory blood test results were
normal. Toxicological screen was negative for cocaine,
heroin, and amphetamine. Psychiatric consultation was
unremarkable. Our patient’s condition improved
overnight without any treatment and he was discharged
the following morning. At discharge he was noted to have
sinus bradycardia (40 bpm).
Later that day, his mother returned to the emergency
unit with two empty packets of stimulant (“energy”)
chewing gum that she had found in her son’s bag; he had
admitted consuming the confectionery at school. The
chewing gum contained 160 mg caff eine per packet
(0·57% caff eine per gum pellet) and non-specifi ed
amounts of guaraná,1 sweeteners, gum acacia, citric acid,
malic acid, glycerol, carruba wax, and food colouring.
According to the mother, her son did not usually ingest
caff eine-rich beverages or food. A few days later, the
teenager attended an outpatient appointment. Although
not complaining of any symptoms, he appeared sleepy
and sluggish. His mother stated that he had lost interest
in any activity and had been absent from school for
3 days. ECG showed sinus bradycardia (45 bpm) and low
left-ventricular ejection fraction (55%). His condition
improved over the next 5 days and when last seen in
December, 2008, the teenager was well and enjoying
normal activities.
The transient constellation of signs and symptoms in
our patient was most likely secondary to acute intoxication
of stimulant chewing gums.2 Serum caff eine was not
measured, but our patient met the criteria for diagnosis
of caff eine intoxication, defi ned as the consumption of at
least 250 mg caff eine followed by the onset of at least fi ve
specifi c features.3 Our patient admitted consuming two
packets of the chewing gum containing 320 mg caff eine
in 4 h—this is equivalent to about ten cups of tea in a
70 kg adult. Our patient weighed 45 kg, and presumably
had high caff eine sensitivity in view of his low habitual
caff eine intake, so 320 mg was a substantial amount of
caff eine. Caff eine is a methylxanthine, which is rapidly
and completely absorbed from chewing gums.4 It induces
several eff ects including stimulation of endocrine and
exocrine tissues, the central nervous system, cardiac
muscle, and skeletal muscle, relaxation of smooth
muscle, and diuresis.5 These eff ects result from intra-
cellular calcium redistribution, accumulation of cyclic
nucleotides secondary to inhibition of phospho dies-
terases, and adenosine receptor blockade.5 It was unlikely
that guaraná, or other ingredients of the chewing gum
played a part in this case, because their doses were low or
they would induce diff erent signs and symptoms from
those found in our patient.2 The use of stimulant chewing
gum should be considered in cases of caff eine
intoxication. The risk of intoxication is high in children
and teenagers in view of general caff eine-naivety, and the
unrestricted sale of these substances.
Contributors
FN, CC, GM, LV, LA, AS, MR participated in management of the patient
and writing the report. MT, PG, and RC were also involved in writing the
report.
References
1 Henman AR. Guaraná (Paullinia cupana var. sorbilis): ecological and
social perspectives on an economic plant of the central Amazon
basin. J Ethnopharmacol 1982; 6: 311–86.
2 Clauson KA, Shields KM, McQueen CE, Persad N. Safety issues
associated with commercially available energy drinks.
J Am Pharm Assoc (2003) 2008; 48: e55–63; quiz e64–67.
3 Diagnostic and statistical manual of mental disorders, 4th edn text
revision. American Psychiatric Association, Washington, DC: 2000.
212–15, 708–09.
4 Kamimori GH, Karyekar CS, Otterstetter R, et al. The rate of
absorption and relative bioavailability of caff eine administered in
chewing gum versus capsules to normal healthy volunteers.
Int J Pharm 2002; 234: 159–67.
5 Fredholm BB, Batting K, Holmen J, Nehlig A, Zvartau EE. Action of
caff eine in the brain with special reference to factors that contribute
to its widespread use. Pharmacol Rev 1999; 51: 83–133.
Lancet 2009; 373: 1918
Cardiology Department of
Second University of Naples,
Monaldi Hospital, Naples, Italy
(F Natale PhD, C Cirillo,
G M Di Marco,
L Scotto di Vetta MD, L Aronne,
A Siciliano, R Mocerino PhD,
M A Tedesco PhD,
Prof P Golino MD,
Prof R Calabrò MD)
Correspondence to:
Francesco Natale,
Cardiology Department of
Second University of Naples,
Monaldi Hospital,
Via L. Bianchi 1, 80121 Naples,
Italy
natalefrancesco@hotmail.com
Figure: “Energy” chewing gum