An Outbreak of Beta-2 Adrenergic Toxicity from Adulterated Heroin

Low Dose Clenbuterol Toxicity: Case Report and Review of Literature

“…Clenbuterol is a long-acting β2-agonist used for asthma treatment outside the U.S. and in veterinary medicine within the U.S. 1 It is also used off-label (and illegally) for muscle-building anabolic effects by meat farmers, racehorse owners, and athletes, and as a lacing agent in street cocaine and heroin. 1,2 Previously rare in U.S. medical settings, clenbuterol overdose has become familiar enough to be described in a magazine targeting emergency medicine physicians, in multiple case reports over the last 20 years, and in case series in Australia and Virginia. 1,[3][4][5][6] The severity of the presentation varies widely.…”

“…Labs might show hyperglycemia, hypokalemia, hypophosphatemia, lactic acidosis and rhabdomyolysis. 2,8 However, these general symptoms and signs may be confounded by the simultaneous ingestion of other substances. For example, hypotension may be absent due to concurrent cocaine use, or heroin may cause miosis.…”

“…For example, hypotension may be absent due to concurrent cocaine use, or heroin may cause miosis. 2 Cardiac complications include not only chest pain but also supraventricular tachycardia (SVT) and atrial fibrillation (AF) with a rapid ventricular response (RVR). 5 This was first reported in 2007 in a 31-year-old male with an SVT of 254 bpm that did not respond to adenosine 6mg and 12mg but did decrease to 150 bpm with intravenous diltiazem 10mg and then converted to AF with RVR of 125-147 bpm.…”