Nicotine intoxication by e-cigarette liquids: a study of case reports and pathophysiology

Abstract

Background: Electronic cigarettes (e-cigarettes), the smokeless alternative to conventional tobacco cigarettes, have become increasingly popular. E-cigarettes vaporise e-liquid, a solution of highly concentrated nicotine, propylene glycol (PG) and vegetable glycerine (VG). With the popularity of e-cigarettes, e-liquid refills have become easily accessible and several cases of intoxication due to the ingestion of e-liquid have been reported. We provide an overview of these cases, their pathophysiology and patients' characteristics. Methods: We carried out a retrospective evaluation of the scientific literature reporting on cases of liquid nicotine intoxication, using the following inclusion criteria: (1) the article is or contains a case report, (2) describes an intoxication with e-liquid, (3) the substance contains nicotine, and (4) intake is oral, intravenous or subcutaneous. Results: We found 26 case reports describing a total of 31 patients who suffered from e-liquid intoxication. All intoxications up to the age of six were reported as unintentional, whereas nearly all cases from ages 13 to 53 were due to suicide attempts. The three most prevalent symptoms of e-liquid intoxication were tachycardia, altered mental status and vomiting. Eleven cases resulted in the death of the patient. In the survivors, the highest plasma concentration of nicotine was 800 mg L À1 , while the lowest concentration in the non-survivors was 1600 mg L À1 . Conclusions: There is a mismatch between the generally accepted lethal oral nicotine dose of 60 mg, resulting in approximately 180 mg L À1 plasma concentration, and the 4.4-to 8.9-fold higher lethal plasma concentrations we found in cases of e-liquid intoxication. In these severe intoxications, plasma cotinine concentration does not act as a more reliable indicator of nicotine intoxication than nicotine itself. The ages of the patients display a bimodal distribution. In patients above the age of 10, intoxication results mainly from suicide attempts rather than accidental ingestion. The role of PG and VG in e-liquid intoxications is remarkably unclear. However, the similarity across nicotine and PG toxicity symptoms leads us to believe a cumulative effect cannot be excluded. ARTICLE HISTORY

Brain death following ingestion of E‐cigarette liquid nicotine refill solution

“…These phenomena, causing severe and diffuse brain ischemia, might have determined a worsening of the brain edema. However, in our opinion, brain damage due to mechanisms related to the direct action of nicotine on the CNS would be less likely, because nicotine usually shows early action with a rapid transition to its inactive metabolite (Figure 1); consequently, its neurological effects should also be evident at an early stage after ingestion/injection (Maessen et al., 2020), which is different from our case. At last, a large literature suggests a neuroprotective effect of nicotine, mainly in chronic neurological degenerative condition such as cognitive deterioration (Alkadhi, 2018), Parkinson's disease (Quik, Bordia, Zhang, & Perez, 2015), and Tourette's syndrome (Quik, Bordia, Zhang, & Perez, 2014).…”

Potentially fatal ingestion of heat‐not‐burn cigarettes successfully treated by gastric lavage

“…5 Possible explanations include decrease of actual intake as a result of vomiting, difference in absorption rates between cigarette sticks and nicotine liquid, and the rapid metabolism of nicotine in the liver. 1,9 Nevertheless, the present case could have been fatal given a previously reported case of lethal acute nicotine intoxication attributed to the intentional ingestion of 9 regular cigarettes. 9 Interestingly, abdominal CT imaging has been reported as a diagnostic modality to confirm recent overdose in comatose patients who had no exact evidence of overdose.…”

“…5 Generally, highly concentrated liquid nicotine or "e-liquid" that e-cigarettes aerosolize is much more hazardous because of its quick absorption. 1 However, ingestion of large amounts of HNB cigarettes can also be life-threatening because they contain as much nicotine as regular tobacco. 6 The total amount of nicotine our patient consumed was estimated as ≈ 100 mg (12.5 mg of nicotine per stick) according to data measured by an independent reviewers via the World Health Organization official method.…”

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

“…To the authors knowledge at the time of publication there are 7 reviews on e-cigarette-related health effects and case reports, each specifically focusing on one aspect of the e-cigarette-related injury: The respiratory effects [18,19], poisonings [20], burn injuries [21,22], radiologic appearance of lung injuries [23], and histologic findings [24]. The majority of those reviews were published before the 2019 e-cigarette-related injury outbreak.…”