A Retrospective Study on the Epidemiological and Clinical Features of Emergency Patients with Large or Massive Consumption of Caffeinated Supplements or Energy Drinks in Japan

Analysis of the toxic and lethal doses of one over-the-counter drug product in humans and the ingredients that may be abused: Building a drug database to prevent drug overdoses

Pharmacists who provide medication to patients immediately before they overdose should intervene appropriately; however, little information exists on the types and amounts of over-the-counter (OTC) drugs that are dangerous. This study investigated the toxicity and characteristics of overdosing on a single package of commercially available OTC drugs in humans. We researched 14,107 OTC drugs. The number of products that could contain a lethal dose if taken as a single package was 1,223 (8.7%) and a toxic dose was 2,982 (21.1%). A single product containing a lethal dose to humans by therapeutic category included skin drugs (n = 672, 25.0%), psychotropic drugs (n = 288, 17.9%), and public health drugs (n = 92, 26.1%) in descending order. Comparing before and after April 2023, the number of OTC pharmaceuticals that contained ingredients that may be abused, significantly increased: psychotropic drugs (44.9% increase), respiratory drugs (8.2% increase), and urogenital and anal organs drugs (3.5% increase) (p < 0.05). These products had not been previously designated as hazardous despite their potential for abuse. The registrants in the "Drug Database for Overdose Prevention" that made these public included 199 pharmacists, registered sellers, and doctors as of July 31, 2024. The city with the most users was Osaka (377 users) and an average engagement time of 41.8 seconds, followed by Sapporo, Fukuoka, and Nagoya. These areas were consistent with urban centers and high numbers of emergency transports due to overdose. Our findings provide important pharmaceutical information that pharmacists can use for their gatekeeper activities.

Development of a simple estimation method of serum caffeine concentration using a point-of-care test kit for urinary caffeine

PURPOSE

Serum caffeine concentration is an indicator of caffeine intoxication; however, it is difficult to measure it in most emergency departments. We developed a simple estimation method using a point-of-care test kit for urinary caffeine.

METHODS

Caffeine-spiked human serum (100, 50, 25, and 10 µg/mL) was diluted 10-, 20-, 50-, and 100-fold with phosphate-buffered saline and applied to the kit. After 5 min incubation, the kit was scanned by a flatbed scanner and the membrane image was processed with ImageJ.

RESULTS

When the 20-fold diluted serum was applied, serum samples with initial caffeine concentration ≤ 25 and ≥ 50 µg/mL were caffeine-negative and -positive, respectively. When the 100-fold diluted serum was applied, none of the caffeine-spiked serum samples gave positive results. Therefore, we proposed the following test procedure: (i) 20-fold diluted serum was initially tested and (ii) 100-fold diluted serum was additionally tested when the initial result was caffeine positive. Using this procedure, caffeine concentration is expected to be classified into three levels: ≤ 25, > 25- ≤ 100, and > 100 µg/mL, which almost correspond to no or mild, severe, and potentially fatal intoxication, respectively. The test procedure was validated using postmortem heart blood from two cases of fatal caffeine intoxication (caffeine concentration: 276 and 175 µg/mL) and two cases of other intoxication.

CONCLUSIONS

Our developed method using point-of-care urinary caffeine test kits enabled simple estimation of serum caffeine concentration.

Non-oliguric acute renal failure secondary to a potentially lethal dose of caffeine with acute intoxication: a case report

BACKGROUND

Recently, the incidence of caffeine intoxication has been on an upward trend, with severe outcomes. However, acute kidney injury (AKI) resulting from renal pathologies secondary to caffeine intoxication is rare, and the pathophysiological mechanisms underlying AKI are unclear.

CASE PRESENTATION

A female patient in her 20s ingested an over-the-counter drug containing caffeine. The patient was diagnosed with secondary non oliguric AKI caused by acute intoxication due to ingestion of a lethal dose of caffeine. On day 19 of hospitalization, a renal biopsy was performed to determine the etiology of her prolonged renal dysfunction. Light microscopy revealed normal glomeruli, mild inflammatory cell infiltration, and acute tubular damage. Myoglobin staining was positive within the tubules, with scattered myoglobin columns. Electron microscopy revealed loss of glomerular epithelial foot processes and inflated tubular mitochondria. After undergoing hemodialysis and continuous hemodiafiltration, the patient's overall condition stabilized. After a consultation with a psychiatrist, on her 34th day of hospitalization, she was discharged home.

CONCLUSIONS

Caffeine antagonizes adenosine receptors, stimulates ryanodine receptors, and elevates catecholamines. The onset of AKI is hypothesized to result from a combination of these mechanisms, resulting in tubular ischemia and injury, as well as renal artery constriction. The development of AKI was thought to be caused by the following factors: (1) disruption of the tubular oxygen supply-demand ratio and consequent ischemia due to adenosine receptor antagonism by caffeine, (2) tubular damage due to rhabdomyolysis and consequent ryanodine receptor stimulation, and (3) increased catecholamine levels and consequent renal artery constriction.

Severe caffeine poisoning with mexiletine successfully treated by extracorporeal methods

A 20-year-old woman was brought to the hospital in an ambulance after ingesting 18 g of caffeine and 3500 mg of mexiletine 80 min earlier. On arrival at the emergency department, her vital signs were as follows: blood pressure, 65/37 mmHg; heart rate, 140 beats/min; and Glasgow Coma Scale, E4V4M6. Laboratory analyses revealed hypokalemia and lactic acidosis. The patient was treated with mechanical ventilation after intratracheal intubation, intravenous noradrenaline infusion, gastric lavage, and activated charcoal administration. Shortly afterwards, she developed pulseless ventricular tachycardia, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. As the circulatory collapse continued, hemodialysis (HD) was performed with continuous intravenous infusion of noradrenaline. After the completion of HD, the noradrenaline dose was reduced. On hospital day 2, HD was performed on the second day of hospitalization. On hospital days 3 and 4, the patient was weaned off VA-ECMO and ventilator. The blood concentrations of caffeine and mexiletine at presentation were 387 μg/mL and 1.1 μg/mL respectively. During the first HD, blood concentrations of both drugs were markedly reduced. It has been reported that mexiletine may reduce the clearance of caffeine probably via inhibition of N-demethylation. In this case, the endogenous clearance of caffeine, calculated from blood concentrations, was considerably lower than estimated. If HD had not been performed, it may have taken longer to wean off the VA-ECMO because of reduced caffeine clearance in the presence of mexiletine. Notably, caffeine poisoning is more severe and prolonged when mexiletine is administered.

Prospective multicenter study of the epidemiological features of emergency patients with overdose of over-the-counter drugs in Japan

Aim

To investigate the epidemiological characteristics of patients presenting to the emergency department with an overdose of over-the-counter (OTC) drugs.

Methods

A questionnaire survey was conducted to examine the sociodemographic characteristics of patients with OTC drugs overdoses visiting emergency departments at eight sites across the country. The patients were divided into "habitual" and "nonhabitual" groups according to their history of OTC drugs overdose. Student's t-test or Welch's t-test was performed for numerical variables, and Pearson's χ 2 test was performed for dichotomous and nominal variables between the two groups.

Results

Of the 124 patients included in this study, 79% were women. The habitual (26.6%) and the nonhabitual (73.4%) groups showed no differences in sex, occupation, cohabitants, history of mental illness, or history of alcohol consumption or smoking; however, those in the habitual group were significantly younger. The proportion of OTC drugs obtained from physical stores was higher in the habitual group, whereas the nonhabitual group used more household medicines. Suicide and self-harm were more common reasons for overdose in the nonhabitual group. Antipyretic analgesics were significantly more common in the nonhabitual group, whereas antitussive expectorants and antihistamines were significantly more common in the habitual group.

Conclusion

This is the first multicenter study to determine the status of OTC drugs overdose patients treated at emergency departments of medical facilities in Japan. To prevent new overdoses of OTC drugs, continued detailed epidemiologic studies of patient backgrounds and drug acquisition routes, and investigation of the components of OTC drugs that cause dependency are necessary.

Severe caffeine poisoning treated with intermittent hemodialysis under circulatory support

Caffeine poisoning can cause fatal ventricular arrhythmias. In this report, we describe a case of severe caffeine poisoning with extraordinarily high blood caffeine levels. Despite developing refractory ventricular fibrillation, the patient was successfully treated with intermittent hemodialysis (IHD) under circulatory support by venoarterial extracorporeal membrane oxygenation (VA-ECMO). A 22-year-old male was transported to our hospital approximately 2.5 h after ingesting 200 highly caffeinated tablets (200 mg/tablet) (40 g caffeine total) in a suicide attempt. On arrival, the patient vomited frequently with a Glasgow Coma Scale score E3V2M5, heart rate 185 beats/min, and a blood pressure of 97/62 mmHg. Shortly after arrival, the patient developed ventricular fibrillation which was refractory either to three electrical defibrillations or antiarrhythmic drugs, resulting in endotracheal intubation for mechanical ventilation and VA-ECMO. Starting from 2 h after arrival, intermittent hemodialysis (IHD) was performed for 11 h, which markedly improved clinical symptoms and circulatory parameters. Serum caffeine level was 454.9 mg/dL upon arrival at the hospital, but it decreased to 55.5 mg/dL by the end of IHD treatment. Renal replacement therapy (RRT) including intermittent hemodiafiltration, continuous hemodiafiltration, and IHD was continued because of rhabdomyolysis with myoglobinuria and secondary caused acute kidney injury. The patient was weaned off VA-ECMO on hospital day 7, extubated on hospital day 18, weaned from RRT on hospital day 46, and was transferred to another hospital for physical rehabilitation on hospital day 113. IHD under circulatory support by VA-ECMO should be considered in severe caffeine poisoning causing potentially fatal arrhythmias.

A case of caffeine intoxication resulting in hypothermia

A 30-year-old woman arrived at our hospital with polymorphic ventricular tachycardia and hypothermia. Later, it was found that the cause was an overdose of caffeine exceeding the lethal dose. Although it is common for toxidrome caused by caffeine intoxication to produce hyperthermia, here we report a case of hypothermia.

Use of Caffeine-Containing Energy Drinks by Japanese Middle School Students: A Cross-Sectional Study of Related Factors

Excessive consumption of caffeine negatively affects individuals' health. Therefore, we studied the use of energy drinks and the conditions associated with it among Japanese secondary school students. Participants were 236 students in grades 7-9 who completed anonymous questionnaires at home in July 2018. We measured the basic attributes and dietary, sleeping, and exercise habits. We used Chi-squared tests to compare differences between users and non-users of energy drinks. Logistic regression analyses were used to elucidate the complex association between the variables. The results showed that boys were more willing to consume energy drinks than girls. The reasons were 'feeling fatigued', 'needing to stay awake', 'for curiosity', and 'to quench one's thirst'. Among boys, the following were associated with the use of EDs. Buying their own snacks , not understanding nutritional labels on foods, high caffeinated beverage intake, late bed-times on weekdays, always waking up at about the same time, and weight. Health guidance is needed to prevent overconsumption and dependence on energy drinks. The cooperation of parents and teachers is needed to achieve these goals.

[Acute Drug Poisoning among Adolescents Using Over-the-counter Drugs: Current Status]

We discuss the current status of, and possible countermeasures for, acute drug poisoning among adolescents using OTC drugs. In the last 10 years, 36 patients aged <20 years who overdosed on OTC drugs were examined for the type of drug ingested, its active ingredients in cases of lethal dose intake, and the relevant place of purchase. Patients aged <20 years accounted for 30% of all the cases. The ingestion of multi-ingredient common-cold medication was the highest at 23%, and no ingestion of any first-class OTC drugs was observed. Caffeine accounted for 54% of the cases of lethal dose intake. At 80%, the most common method of drug purchase was from drugstores and other OTC vendors. In recent years, the number of adolescents patients who take lethal doses of OTC drugs has been increasing, and new measures are needed to avoid such cases. School pharmacists and vendors play a major role in reducing the incidences of drug poisoning. As drugs can be easily purchased over the counter, increasing the vendors' awareness of the problem throughout society may be the quickest way to reduce the incidences of acute drug poisoning among adolescents.

A successful experience using labetalol and hemodialysis to treat near-fatal caffeine poisoning: A case report with toxicodynamics

Caffeine poisoning is relatively rare, and a near-fatal caffeine overdose is highly uncommon. We present an 18-year-old male who attempted suicide with 295 mg/kg pure caffeine powder (lethal oral dose: 150-200 mg/kg) and was successfully rescued. He presented with seizures, refractory supraventricular tachycardia and hypertension for 6 h with no response to medications and cardioversion. Even with the high level of caffeine, labetalol, which is seldom administered as a treatment for caffeine poisoning-induced tachycardia, successfully relieved refractory tachycardia. Then, hemodialysis ultimately eliminated serum caffeine and completely alleviated caffeine-related central nervous system toxicity. We discuss the clinical symptoms, management and toxicodynamics based on the concentration of caffeine and its metabolites in serum and urine.

[Determination of Caffeine, Theobromine, and Theophylline in Chocolate Using LC-MS]

A simultaneous determination method for caffeine, theobromine, and theophylline in chocolate was developed. Three compounds were ultrasonically extracted twice (15 min at 50℃) in an acetonitrile-water (1 : 1, v/v). The extract was purified using Oasis HLB SPE cartridge, and the purified processed by LC-MS. The method exhibited recoveries of 97.4-100.2%, RSDs of repeatability of 1.0-2.8%, and RSDs of within-laboratory reproducibility of 2.0-7.9%. This method was simpler and more selective than existing methods, and was practical for caffeine, theobromine, and theophylline analysis in chocolate.

Caffeine-induced hypokalemia: a case report

BACKGROUND

With an increase in the global popularity of coffee, caffeine is one of the most consumed ingredients of modern times. However, the consumption of massive amounts of caffeine can lead to severe hypokalemia.

CASE PRESENTATION

A 29-year-old man without a specific past medical history was admitted to our hospital with recurrent episodes of sudden and severe lower-extremity weakness. Laboratory tests revealed low serum potassium concentration (2.6-2.9 mmol/L) and low urine osmolality (100-130 mOsm/kgH2O) in three such prior episodes. Urinary potassium/urinary creatinine ratio was 12 and 16 mmol/gCr, respectively. The patient was not under medication with laxatives, diuretics, or herbal remedies. Through an in-depth interview, we found that the patient consumed large amounts of caffeine-containing beverages daily, which included > 15 cups of coffee, soda, and various kinds of tea. After the cessation of coffee intake and concomitant intravenous potassium replacement, the symptoms rapidly resolved, and the serum potassium level normalized.

CONCLUSIONS

An increased intracellular shift of potassium and increased loss of potassium in urine due to the diuretic action have been suggested to be the causes of caffeine-induced hypokalemia. In cases of recurring hypokalemia of unknown cause, high caffeine intake should be considered.

Caffeinated energy drinks in the Canadian context: health risk assessment with a focus on cardiovascular effects

In Canada, caffeinated energy drinks (CEDs) currently sold under Temporary Marketing Authorizations must meet strict eligibility criteria. These criteria, which include compositional and labelling requirements, were developed based on the outcome of a health risk assessment conducted by Health Canada (HC) in 2013. HC updated its assessment by reviewing new information with the focus on potential cardiovascular effects associated with the consumption of CEDs available for sale in Canada. Due to limited data on CED consumption among Canadians to derive accurate exposure information, the composition of a typical CED was characterized to assess the potential effects of single ingredients and synergistic interactions between ingredients on the cardiovascular system. Surveillance data on potential adverse effects related to CED consumption was also analyzed. After extensive review, HC's updated assessment confirms the current risk management approach for CEDs is health protective for Canadian consumers, including the potential for cardiovascular effects. The available evidence supports that moderate consumption (up to 500 mL per day) of a typical CED authorized for sale in Canada is safe for the general population of healthy adults and adolescents. It also re-confirms that vulnerable sub-populations (i.e., children, pregnant and/or breastfeeding women, and caffeine-sensitive individuals) should not consume CEDs. Novelty: Consumption up to 500 mL per day of a typical CED is not associated with an increased risk of cardiovascular effects. Children, pregnant and/or breastfeeding women, and caffeine-sensitive individuals should not consume CEDs.

Need for self-medication using over-the-counter psychoactive agents: A national survey in Japan

Self-medication using over-the-counter (OTC) drugs is an option for the autonomous treatment of several health problems. However, the use of OTC drugs to treat psychiatric conditions remains controversial. To clarify opinions regarding the use of OTC drugs to treat psychiatric problems, we conducted an anonymous online survey of 3000 people in Japan. Participants were stratified into three groups according to their history of mental health problems. Few participants had engaged in self-medication using OTC drugs for psychiatric symptoms, with the exception of insomnia. Participants who had used OTC drugs reported feeling less satisfied with their experience compared with those who had consulted a specialist. Participants who had used sleeping pills were likely to hold relatively positive opinions regarding the use of OTC psychiatric drugs. In conclusion, the need for self-medication of psychiatric symptoms appears to be limited. Education and further research may be necessary to promote self-medication for proper treatment of psychiatric conditions in Japan.

Suicidal attempt with caffeine overdose treated with dexmedetomidine: a case report

Background

Caffeine is a widely used dietary stimulant, and cases of caffeine overdoses, sometimes leading to death, are increasing. We encountered a case of caffeine intoxication resolved with administration of the sedative agent dexmedetomidine.

Case presentation

We administered dexmedetomidine for sedation and to suppress sympathetic nerve stimulation in the case of an 18-year-old Japanese male who ingested a massive dose of caffeine with the intention of committing suicide. The patient was in an excited state and had hypertension, sinus tachycardia, and hypokalemia with prominent QT prolongation. After dexmedetomidine administration, the patient’s mental state, hemodynamics, and electrolyte levels were improved immediately. He was discharged without any sequelae 3 days later.

Conclusion

Cases of acute caffeine intoxication with agitation, sympathetic overactivity and adverse cardiac events would benefit with dexmedetomidine treatment.

Relationships between constituents of energy drinks and beating parameters in human induced pluripotent stem cell (iPSC)-Derived cardiomyocytes

Consumption of energy drinks has been associated with adverse cardiovascular effects; however, little is known about the ingredients that may contribute to these effects. We therefore characterized the chemical profiles and in vitro effects of energy drinks and their ingredients on human induced pluripotent stem cell (iPSC)-derived cardiomyocytes, and identified the putative active ingredients using a multivariate prediction model. Energy drinks from 17 widely-available over-the-counter brands were evaluated in this study. The concentrations of six common ingredients (caffeine, taurine, riboflavin, pantothenic acid, adenine, and L-methionine) were quantified by coupling liquid chromatography with a triple quadrupole mass spectrometer for the acquisition of LC-MS/MS spectra. In addition, untargeted analyses for each beverage were performed with a platform combining LC, ion mobility spectrometry and mass spectrometry (LC-IMS-MS) measurements. Approximately 300 features were observed across samples in the untargeted studies, and of these ~100 were identified. In vitro effects of energy drinks and some of their ingredients were then tested in iPSC-derived cardiomyocytes. Data on the beat rate (positive and negative chronotropy), ion channel function (QT prolongation), and cytotoxicity were collected in a dilution series. We found that some of the energy drinks elicited adverse effects on the cardiomyocytes with the most common being an increase in the beat rate, while QT prolongation was also observed at the lowest concentrations. Finally, concentration addition modeling using quantitative data from the 6 common ingredients and multivariate prediction modeling was used to determine potential ingredients responsible for the adverse effects on the cardiomyocytes. These analyses suggested theophylline, adenine, and azelate as possibly contributing to the in vitro effects of energy drinks on QT prolongation in cardiomyocytes.

LC-MS/MS method for rapid and accurate detection of caffeine in a suspected overdose case

Excessive intake of caffeine, otherwise known to be a safe and mild central nervous system stimulant, causes nausea, vomiting, convulsions, tachycardia, and eventually fatal arrhythmias and death. Caffeine intoxication, a global problem, has been increasing in Japan since 2013. Thus, there is a need for rapid and accurate diagnosis of caffeine poisoning in forensic and clinical toxicology investigations. Herein, we demonstrate rapid and accurate caffeine quantitation by liquid chromatography tandem mass spectrometry using the standard addition method in a fatal case. Biological samples were diluted 500-100,000-fold and subjected to a simple pretreatment (adding caffeine standard and internal standard and passing through a lipid removal cartridge). The multiple reaction monitoring transitions were 195 → 138 for quantitation, 195 → 110 for the qualifier ion, and 204 → 144 for the internal standard (caffeine-d9). The standard plots were linear over 0-900 ng/mL (r² = 0.9994-0.9999) for biological samples, and the reproducibility (%RSD) of the method was 1.53-6.97% (intraday) and 1.59-10.4% (interday). Fatal levels of caffeine (332 μg/mL) and toxic to fatal levels of olanzapine (625 ng/mL), along with other pharmaceuticals were detected in the external iliac venous blood. The cause of death was determined to be multi-drug poisoning, predominantly caused by caffeine. Our method is useful for not only forensic cases but also the rapid diagnosis of caffeine overdose in emergency clinical settings.

Serum potassium level as a biomarker for acute caffeine poisoning

Aim

Acute caffeine poisoning presents with hypokalemia, although a relationship between potassium levels and blood concentrations of caffeine has not been established. A correlation between serum potassium level and blood caffeine concentration could establish serum potassium as a simple marker to assess caffeine toxicity in patients with acute toxicity. We investigated whether serum potassium, a symptom of acute caffeine poisoning, could be a parameter correlated with blood caffeine levels.

Methods

We enrolled 85 patients treated for acute caffeine poisoning between January 2012 and March 2019 with blood caffeine levels measured after an overdose of a caffeine‐containing over‐the‐counter drug and for whom serum potassium levels were available. We examined the correlation between serum potassium and blood caffeine concentration. A receiver operating characteristic curve was created with serum potassium values to stratify participants into two groups by blood caffeine concentrations: <20 or ≥20 mg/L (toxic dose) and <80 or ≥80 mg/L (lethal dose). The lethal cut‐off value was calculated.

Results

The correlation coefficient between serum potassium level and blood caffeine concentration was −0.612 (R² = 0.374), indicating a negative correlation. The areas under the curve at blood caffeine concentrations of 20 mg/L (toxic dose) and 80 mg/L (lethal dose) and serum potassium levels were 0.716 and 0.888 (sensitivity, 0.829 and 0.919; specificity, 0.568 and 0.818; cut‐off, 3.3 mEq/L and 2.9 mEq/L), respectively.

Conclusion

Serum potassium levels are associated with blood caffeine concentrations; K⁺ of 3.3 mEq/L and 2.9 mEq/L indicate acute caffeine poisoning in the toxic and lethal dose, respectively.

Caffeine Overdose Complicated by Acute Kidney Injury despite Mild Creatine Kinase Elevation

Caffeine is a commonly used stimulant in our society. Prior case reports have described acute caffeine overdose resulting in rhabdomyolysis and acute kidney injury (AKI). We present the case of a 29-year-old man who presented to the emergency department after ingesting 20.1 g of caffeine in a suicide attempt and experienced AKI with only mildly elevated creatine kinase (CK). This case highlights the possibility that AKI can result from a caffeine overdose, even if the patient’s CK is only slightly elevated.

Urinary glucose and ketone bodies as indicators of acute caffeine poisoning

AIM

In various countries, many fatal health problems have been reported due to high intake of caffeine-rich energy drinks, tablets, and powders. In patients with acute caffeine poisoning, determination of blood caffeine concentration is an important yet difficult task. We aimed to assess whether the presence of glucose and ketone bodies in urine reflected the blood caffeine concentration in patients with acute caffeine poisoning.

METHODS

From April 2010 to March 2018, 25 patients with an overdose of only caffeine-rich tablets were admitted to our hospital. Their clinical features were investigated. In addition, we investigated whether the glucose and ketone bodies in the urine reflected blood caffeine concentration in 23 patients who underwent the urine qualitative test at admission.

RESULTS

The majority of the patients were young healthy women, whose average caffeine ingestion was 15.6 ± 8.1 g. Initial urine examinations showed glucose in 60% (14/23) of patients and ketone bodies in 57% (13/23) of patients. Ketone bodies or glucose were found in 78% (18/23) of the patients. The correlation between blood caffeine concentration and urinary glucose was R = 0.625, blood caffeine concentration and ketone bodies was R = 0.596, and blood caffeine and both was R = 0.76.

CONCLUSION

Urine qualitative test is effective for differential diagnosis and severity assessment of acute caffeine poisoning in patients.

Pill-induced esophagitis caused by ingesting excessive caffeine tablets

A 19-year-old woman with suicidal thoughts consumed 24 anhydrous caffeine tablets and was admitted to our hospital. After being discharged from the hospital, her oral intake remained impaired because of retrosternal pain and she was readmitted. An upper gastrointestinal endoscopy revealed diffuse ulcers throughout the mid-to-lower esophagus; the patient was diagnosed with caffeine-induced esophagitis. She recovered soon after conservative treatment. A follow-up endoscopy performed 1 month after the patient was discharged showed that the ulcers had healed. This case highlights the risk of esophageal injuries after ingesting excessive caffeine tablets, which were sold as dietary supplement without a prescription. Our experience indicates that endoscopic surveillance is advisable to prevent severe complications if a patient presents with esophageal symptoms suggestive of chemical esophagitis.

Beware Energy Drinks: A Case of a Toxic Triad Syndrome in a Diabetic Patient With Nonalcoholic Fatty Liver Disease

Energy drinks are widely used and very popular. They are touted as "harmless" energy boosters for use in professional, recreational and domestic settings. They are typically high in monosaccharides, and caffeine with other assorted products like ginseng. Careful study of the potential risks of their use is nonexistent while rigorous documentation of their touted energy boosting capacity is also meagre. We present the cautionary case of a 46-year-old Caucasian man with well-controlled type 2 diabetes and nonalcoholic fatty liver disease who developed a toxic triad syndrome of gastritis, hepatitis and pancreatitis within 4 months of commencing daily consumption of 2-3 160z cans of the energy drink Monster Energy. His clinical symptoms and biochemical derangements promptly resolved with stopping the beverage. We discuss the potential risks inherent in unsupervised liberal consumption of energy drinks and the need for both caution and vigilance among clinicians and patients.