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

doi:10.1016/j.ajem.2013.07.001

The American Journal of Emergency Medicine

Volume 31, Issue 10, October 2013, Pages 1501-1503

https://doi.org/10.1016/j.ajem.2013.07.001 Get rights and content

Abstract

Introduction

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.

Report of the outbreak

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.

Conclusion

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.

Introduction

The use of β-agonists as a growth promoter in the production of animal products for human consumptions has been an issue of public concern and debate in many countries. Although ractopamine is approved as a leanness-enhancing agent 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 (mainly cattle and swine) [1], β-agonist is not permitted in the European Union and China for growth-promoting purposes in farm animals [2]. In Europe, veterinary therapeutic use of β-agonist is approved only in the case of clenbuterol for brochodilation in horses and calves and for tocolysis in cows.

Although the use of clenbuterol as a leanness-enhancing agent is banned worldwide, foodborne clenbuterol poisoning had previously reported in Spain, Italy, France, Portugal, and China [3]. The use of various β-agonists including salbutamol, terbutaline, clenbuterol, and ractopamine has also been prohibited in Taiwan since October 2006, and there were no previous reports of relevant poisonings. We herein describe an unusual outbreak of leanness-enhancing agent–related food poisoning in Taiwan and its associated diagnostic challenge.

Section snippets

Report of the outbreak

Twelve patients presented to the emergency department of a regional hospital in Tainan, Taiwan, after having dinner together. Clinical manifestations of the patients included nausea, vomiting, palpitation, flushing, facial and/or limb numbness, tremor, headache, weakness, chillness, and dyspnea. Laboratory workup revealed the presence of hypokalemia, leukocytosis, and hyperglycemia. Because of the unusual presentations and the lack of apparent culprit toxicant, the attending physician consulted

Discussion

Leanness-enhancing agent–related β-agonist food poisoning was first reported in 1990 [4]. The clinical spectrum of β-agonist–related food poisoning in humans is characterized by palpitation, tachycardia, hypertension, tachypnea, tremor, agitation, nervousness, headache, dizziness, nausea, vomiting, peripheral vasodilatation, hypokalemia, and hyperglycemia [5]. Such foodborne poisonings, however, were rarely reported in the literature, and no similar food poisonings had ever occurred in Taiwan,

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¹: Drs Chen-Chang Yang and Dong-Zong Hung made equal contribution to this study.

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

Abstract

Introduction

Report of the outbreak

Conclusion

Introduction

Section snippets

Report of the outbreak

Discussion

Lancet

Toxicol Lett

The Facts about U.S. Beef and Ractopamine

Illegal use of adrenergic agonists: European community

J Anim Sci

Food poisoning by clenbuterol in Portugal

Food Addit Contam

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