Near fatal intoxication by nicotine and propylene glycol injection: a case report of an e-liquid poisoning

Abstract

Background Concern about intoxication by e-liquid is growing as calls to poison control centers have increased since their introduction. Only three cases of intoxication by injection have been reported worldwide. Our case is unique because of the precise follow-up of a patient who survived a lethal dose of self-injected e-liquid, without other co-intoxication. Case presentation A 51-year-old male presented to the Emergency Department after injecting himself intravenously (IV) in the forearm with 10 mL of e-liquid (1000 mg of nicotine diluted in propylene glycol). An agitation phase was followed by coma and bradypnoea requiring mechanical ventilation. The patient developed a transitory neurological impairment with the appearance of tetraparesis, gaze palsy and myoclonus due to nicotinic syndrome. The arterial blood gas (ABG) analysis confirmed uncompensated lactic acidosis with an elevated anion gap, which is an expected effect of propylene glycol. The toxicology screen indicated the presence of nicotine and cotinine in the blood and excluded the presence of concomitant intoxication. The patient recovered without sequelae. Conclusion Even a small quantity of intravenous (IV) e-liquid can lead to an acute intoxication and fatal outcomes due to the toxic effects of nicotine. This case might help emergency doctors cope with acute intoxication by injection of e-liquid and increase their comprehension of the two main substances, nicotine and propylene glycol with overview of their pharmacodynamics and kinetic effects.

The Immunogenicity of Hyaluronic Fillers and Its Consequences

“…According to the literature, one patient required mechanical ventilation due to respiratory failure which occurred as a result of the selfinjection of e-cigarette liquid including propylene glycol. 80 However, delayed reactions were also described. 81 The Italian Society of Aesthetic Medicine recommended making patients aware of the possibility of developing a reaction and developing a management regimen:…”

A Systematic Literature Review of E-Cigarette-Related Illness and Injury: Not Just for the Respirologist

“…Injection of nicotine and PG as contained in the e-liquid mixture, leads to a new type of acute intoxication, physicians should be aware of. PG intoxication leads to lactic acidosis with elevated anion gap, while acute nicotine intoxication presents in two progressively aggravating clinical phases; until the second more severe phase of Central Nervous System depression and respiratory failure supervenes, there is a 3-hour window opportunity for the physician to intervene [161]. E-liquid storage together with medications, or in empty bottles previously containing other products was the main reason for misuse, as it has been mistaken for eye drops or medical syrup.…”

Severe neurological nicotine intoxication by e‐cigarette liquids: Systematic literature review

“…Moreover, despite nicotine being currently considered the main cause of toxicity both at the CNS and PNS levels, it is not clear whether the solvents composing the e‐liquid may all contribute to the toxic effect or the mechanisms of neurological damage 8 . However, it is thought that PG may determine metabolic acidosis due to its degradation into lactic acid, and increase blood osmolarity, with further multi‐organ involvement such as the heart and kidney 8,42 . Other components of e‐liquid could contribute to clinical deterioration, by synergic effects: potentially toxic elements including formaldehyde, diethylene glycol, ethylene glycol and tobacco alkaloids, have been found in the available e‐cigarette liquids, along with the noted ingredients.…”

“…30 Seizures are rare; however, if they do occur, treatment must be prompt (lorazepam, diazepam or antiepileptic drugs). 42 Finally, nicotine is primarily metabolized in the liver by cytochrome oxidase, in cotinine. It is also imperative to maintain adequate urine output, as nicotine and its metabolites are excreted by the kidneys.…”

“…For bradycardia or dyspnoea due to pulmonary secretion, atropine should be disposed 30 . Seizures are rare; however, if they do occur, treatment must be prompt (lorazepam, diazepam or antiepileptic drugs) 42 . Finally, nicotine is primarily metabolized in the liver by cytochrome oxidase, in cotinine.…”