Late diagnosis of an outbreak of leanness-enhancing agent–related food poisoning

• Published in: The American journal of emergency medicine Vol. 31; no. 10; pp. 1501 - 1503
• Main Authors: Wu, Ming-Ling, Deng, Jou-Fang, Chen, Yi, Chu, Wei-Lan, Hung, Dong-Zong, Yang, Chen-Chang
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2013; Elsevier Limited
• Subjects: Adolescent; Adrenergic beta-Agonists - poisoning; Adult; Albuterol - poisoning; Albuterol - urine; Animals; Bans; Barium; Blood pressure; Cardiac arrhythmia; Chickens; Child; Clenbuterol; Clenbuterol - poisoning; Clenbuterol - urine; Delayed Diagnosis; Disease Outbreaks; Drug therapy; Emergency; Emergency medical care; Emergency Service, Hospital; FDA approval; Female; Food; Food contamination; Food contamination & poisoning; Foodborne Diseases - diagnosis; Foodborne Diseases - etiology; Foodborne Diseases - urine; Growth Substances - poisoning; Headaches; Hospitalization; Hospitals; Humans; Hyperglycemia; Liquid chromatography; Male; Mass spectrometry; Meat; Meat - adverse effects; Outbreaks; Poisoning; Poisons; Potassium; Taiwan - epidemiology; Veterinary medicine; Young Adult; Taiwan; China
• ISSN: 0735-6757; 1532-8171; 1532-8171
• DOI: 10.1016/j.ajem.2013.07.001

Ractopamine is a leanness-enhancing agent approved in the United States and 26 other countries to reduce body fat content, increase muscle mass, and improve growth rate of certain food-producing animals. Other β-agonists with stronger pharmacologic effects, especially clenbuterol, had been illegally used as leanness-enhancing agents in the United States, China, and the European Union, and foodborne poisonings related to clenbuterol residue in meat or liver were rarely reported in the European Union and China. We describe an unusual outbreak of leanness-enhancing agent–related food poisoning in Taiwan and its associated diagnostic challenge. Twelve patients presented to the emergency department of a regional hospital after having dinner together. Their clinical manifestations included nausea, vomiting, palpitation, facial flush, trunk or limb numbness, tremor, headache, weakness, chill, and dyspnea. Laboratory workup revealed the presence of hypokalemia, leukocytosis, and hyperglycemia. Poisoning attributable to β-agonists was suspected; however, the diagnosis of leanness-enhancing agent poisoning was delayed because there was no leftover meat for analysis and because the veterinary medicine was illegal in Taiwan. Clenbuterol and salbutamol were eventually detected in 10 patients' urine sample by using liquid chromatography–tandem mass spectrometry, and the concentrations ranged from 54 to 806 μg/L and from 0 to 4052 μg/L, respectively. β-Agonist leanness-enhancing agent–related food poisonings are rarely encountered, especially in those countries where relevant veterinary medicines are banned, and may thus pose diagnostic challenge to both emergency physicians and clinical toxicologists.