A Case Report of Severe Theophylline Poisoning: Management and Review of Literature
DOI:
https://doi.org/10.17140/TFMOJ-6-138Keywords:
Theophylline poisoning, Theophylline-associated seizures, Haemodialysis, Case report, Methylene blue, Venoarterial-extracorporeal membrane oxygenation, Multi-dose activated charcoalAbstract
Background
Theophylline poisoning leads to multisystem toxicity. Management of theophylline overdose is focused on stabilizing cardiovascular manifestations of arrhythmia and hypotension, correcting metabolic derangements, aborting seizures and removing the drug from the system. We present a case of refractory seizures and haemodynamic instability from theophylline poisoning and reviewed the literature to update the management of severe theophylline overdose.
Case Presentation
A 73-year-old Chinese gentleman presenting with chills and rigor was admitted for management of sepsis. While admitted suffered seizures which were refractory to benzodiazepine and anti-epileptic drugs. Based on his previous admission for theophylline overdose, serum levels were done confirming severe theophylline poisoning. He was resuscitated and subsequently started on haemodialysis following which seizures were eventually aborted when theophylline levels were successfully reduced.
Conclusion
Severe theophylline poisoning should be identified early and appropriate treatment initiated promptly. In the management of refractory hypotension, methylene blue and venoarterial-extracorporeal membrane oxygenation are reasonable rescue therapies to consider. Multi-dose activated charcoal and extracorporeal treatments for elimination of drugs should be administered in severe theophylline poisoning.
References
Tripathi KD. Drugs for cough and bronchial asthma. In: Essentials of Medical Pharmacology. 2018. doi: 10.5005/jp/books/10282_18
Journey JD, Bentley TP. Theophylline toxicity. StatPearls. Pub-lished December 3, 2021.
Paloucek FP, Rodvold KA. Evaluation of theophylline over-doses and toxicities. Ann Emerg Med. 1988; 17(2): 135-144. doi: 10.1016/s0196-0644(88)80299-3
Sessler CN. Theophylline toxicity: Clinical features of 116 con-secutive cases. Am J Med. 1990; 88(6): 567-576. doi: 10.1016/0002- 9343(90)90519-j
Shannon M. Predictors of major toxicity after theophylline over-dose. Ann Intern Med. 1993; 119(12): 1161-1167. doi: 10.7326/0003- 4819-119-12-199312150-00002
Litovitz TL, Smilkstein M, Felberg L, Klein-Schwartz W, Berlin R, Morgan JL. 1996 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 1997; 15(5): 447-500. doi: 10.1016/s0735- 6757(97)90193-5
Gummin DD, Mowry JB, Beuhler MC, et al. 2019 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phi-la). 2020; 58(12): 1360-1541. doi: 10.1080/15563650.2020.1834219
Global Initiative for Asthma. Global Strategy for Asthma Man-agement and Prevention. 2021. Web site. www.ginasthma.org. Ac-cessed December 7, 2021.
Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diag-nosis, management, and prevention of chronic obstructive pulmo-nary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013; 187(4): 347-365. doi: 10.1164/rccm.201204-0596PP
Perry H. Theophylline poisoning. 2020. Web site. https:// www.uptodate.com/contents/theophylline-poisoning. Accessed December 7, 2021.
Amin DN, Henry JA. Propranolol administration in theophyl-line overdose. Lancet (London, England). 1985; 1(8427): 520-521. doi: 10.1016/s0140-6736(85)92121-x
Seneff M, Scott J, Friedman B, Smith M. Acute theophylline toxicity and the use of esmolol to reverse cardiovascular insta-bility. Ann Emerg Med. 1990; 19(6): 671-673. doi: 10.1016/s0196- 0644(05)82474-6
Demiselle J, Fage N, Radermacher P, Asfar P. Vasopressin and Case Report | Volume 6 | Number 1| Sim ZJ et al its analogues in shock states: A review. Ann Intensive Care. 2020; 10(1): 9. doi: 10.1186/s13613-020-0628-2
Holstege CP, Hunter Y, Baer AB, Savory J, Bruns DE, Boyd JC. Massive caffeine overdose requiring vasopressin infusion and hemodialysis. J Toxicol Clin Toxicol. 2003; 41(7): 1003-1007. doi: 10.1081/clt-120026526
Graudins A, Lee HM, Druda D. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016; 81(3): 453-461. doi: 10.1111/bcp.12763
Hosseinian L, Weiner M, Levin MA, Fischer GW. Methylene blue: Magic bullet for vasoplegia? Anesth Analg. 2016; 122(1). 194- 201. doi: 10.1213/ANE.0000000000001045
Kwok ESH, Howes D. Use of methylene blue in sepsis: A systematic review. J Intensive Care Med. 2006; 21(6): 359-363. doi: 10.1177/0885066606290671
Levin RL, Degrange MA, Bruno GF, et al. Methylene blue reduces mortality and morbidity in vasoplegic patients after car-diac surgery. Ann Thorac Surg. 2004; 77(2): 496-499. doi: 10.1016/ S0003-4975(03)01510-8
Warrick BJ, Tataru AP, Smolinske S. A systematic analysis of methylene blue for drug-induced shock. Clin Toxicol (Phila). 2016; 54(7): 547-555. doi: 10.1080/15563650.2016.1180390
Ozal E, Kuralay E, Yildirim V, et al. Preoperative methylene blue administration in patients at high risk for vasoplegic syndrome during cardiac surgery. Ann Thorac Surg. 2005; 79(5): 1615-1619. doi: 10.1016/j.athoracsur.2004.10.038
Fischer GW, Bengtsson Y, Scarola S, Cohen E. Methylene blue for vasopressor-resistant vasoplegia syndrome during liver trans-plantation. J Cardiothorac Vasc Anesth. 2010; 24(3): 463-466. doi: 10.1053/j.jvca.2008.07.015
Keebler ME, Haddad EV, Choi CW, et al. Venoarterial extra-corporeal membrane oxygenation in cardiogenic shock. JACC Heart Fail. 2018; 6(6): 503-516. doi: 10.1016/j.jchf.2017.11.017
Weiner L, Mazzeffi MA, Hines EQ, Gordon D, Herr DL, Kim HK. Clinical utility of venoarterial-extracorporeal membrane oxy-genation (VA-ECMO) in patients with drug-induced cardiogenic shock: A retrospective study of the extracorporeal life support or-ganizations’ ECMO case registry. Clin Toxicol (Phila). 2020; 58(7): 705-710. doi: 10.1080/15563650.2019.1676896
Upchurch C, Blumenberg A, Brodie D, MacLaren G, Zakhary B, Hendrickson RG. Extracorporeal membrane oxygenation use in poisoning: A narrative review with clinical recommendations. Clin Toxicol (Phila). 2021: 1-11. doi: 10.1080/15563650.2021.1945082
Nakada T, Kwee IL, Lerner AM, Remler MP. Theophylline-induced seizures: clinical and pathophysiologic aspects. West J Med. 1983; 138(3): 371-374.
Boison D. Methylxanthines, seizures, and excitotoxicity. Handb Exp Pharmacol. 2011; (200): 251-266. doi: 10.1007/978-3-642- 13443-2_9
Yoshikawa H. First-line therapy for theophylline-associ-ated seizures. Acta Neurol Scand. 2007; 115(4 Suppl): 57-61. doi: 10.1111/j.1600-0404.2007.00810.x
Glenn GM, Krober MS, Kelly P, McCarty J, Weir M. Pyridoxine as therapy in theophylline-induced seizures. Vet Hum Toxicol. 1995; 37(4): 342-345.
Sharma AN, Hoffman RJ. Toxin-related seizures. Emerg Med Clin North Am. 2011; 29(1): 125-139. doi: 10.1016/j.emc.2010.08.011
Hoffman A, Pinto E, Gilhar D. Effect of pretreatment with anticonvulsants on theophylline-induced seizures in the rat. J Crit Care. 1993; 8(4): 198-202. doi: 10.1016/0883-9441(93)90002-3
Position statement and practice guidelines on the use of multi-Submit your article to this journal | https://openventio.org/submit-manuscript/ dose activated charcoal in the treatment of acute poisoning. Amer-ican Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1999; 37(6): 731-751. doi: 10.1081/clt-100102451
Tenenbein M. Position statement: Whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997; 35(7): 753-762. doi: 10.3109/15563659709162571
Ghannoum M, Wiegand TJ, Liu KD, et al. Extracorporeal treatment for theophylline poisoning: systematic review and rec-ommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2015; 53(4): 215-229. doi: 10.3109/15563650.2015.1014907
Osborn HH, Henry G, Wax P, Hoffman R, Howland MA. The-ophylline toxicity in a premature neonate--elimination kinetics of exchange transfusion. J Toxicol Clin Toxicol. 1993; 31(4): 639-644. doi: 10.3109/15563659309025767
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
All content published in Toxicology and Forensic Medicine (TFM) is licensed under the Creative Commons Attribution 4.0 International License (CC BY 4.0). This license allows anyone to copy, distribute, transmit, and adapt the work — including for commercial purposes — provided appropriate credit is given to the original author(s) and source.
