Citation

Wong OF, Tsui KL, Fung HT. Hong Kong J. Emerg. Med. 2010; 17(1): 66-70.

Copyright

(Copyright © 2010, Medcom Limited)

DOI

10.1177/102490791001700112

PMID

unavailable

Abstract

A 28-year-old lady presented to the emergency department after an overdose of methylphenidate. She complained of chest pain and developed an acute coronary syndrome with marked ST segment depression in the electrocardiogram and elevated troponin I level. She was closely monitored in the cardiac care unit and was treated with the standard therapy for acute coronary syndrome. Echocardiogram showed global left ventricle impairment. The follow-up echocardiogram showed that the left ventricular function normalised and the subsequent coronary angiogram was normal. The clinical use, abuse potential, toxicity and overdose treatment of methylphenidate are discussed.; Patients:One 28-year-old female outpatient.; TypeofStudy:Acute coronary syndrome (ACS) occurred following Ritalin overdose. Case report.; DosageDuration:90 mg orally, as 5 mg tablets. Duration: single dose.; Results:The patient presented to the emergency department (ED) with drug overdose for suicidal attempt. She had taken 18 tablets of Ritalin (5 mg/tablet) and a few tablets of other medications (paracetamol and 'anti-cold' remedy) 2 hours before arrival. The medication was obtained from her son who had attention deficit hyperactivity disorder treated by Ritalin. At presentation, she had Glasgow Coma Scale score of 15/15, blood pressure 147/111 mmHg, pulse rate 123 beats per minute and temperature 37.1°Celsius. She complained of chest discomfort during the ED assessment. The ECG showed sinus tachycardia with T wave inversion and ST depression in the inferior leads (II, III, aVF) and lateral chest leads (V3 to V6). The chest X-ray showed clear lung fields and normal mediastinum. She was treated with oxygen and intravenous isosorbide dinitrate infusion and subsequently transferred to the cardiac care unit (CCU) for further management. Her chest discomfort subsided soon after the initiation of isosorbide dinitrate infusion and her vital signs remained stable. The subsequent investigations showed an elevation of serum troponin I up to 7.7 ng/ml at 14 hours post-ingestion. The ST change in EGG was normalized in the CCU. The isosorbide dinitrate infusion was continued for a total of eleven hours. ECG was done on the next day of admission and showed global left ventricle impairment with ejection fraction of 30%. The blood paracetamol level was below treatment threshold (375 mcmol/L 5 hours post-ingestion). The urine toxicology screening showed positive results of Ritalin and metabolite of brompheniramine reflecting the 'anti-cold' medication exposure. She was assessed by the psychiatrist with a diagnosis of adjustment disorder secondary to stress from child care issue. She was discharged after 6 days of hospitalization and was put on acetylsalicylic acid and perindopril. A repeat ECG was done 6 months after the event and showed normal left ventricular function with ejection fraction of 76%. The coronary angiogram was normal.; AdverseEffects:1 patient had chest pain/discomfort and acute coronary syndrome associated with sinus tachycardia with T wave inversion and ST depression in the inferior leads and lateral chest leads, elevated troponin I level, global left ventricle impairment, and myocardial ischemia.; AuthorsConclusions:Toxicities from methylphenidate can be due to therapeutic errors in children and intentional abuse. We report the first case of methylphenidate-induced myocardial ischaemia secondary to oral intentional overdose in Hong Kong. Our patient presented with chest pain and evidence of myocardial ischaemia with significant EGG changes and elevated cardiac troponin. Although methylphenidate abuse is still uncommon in Hong Kong, emergency physicians should always be aware of its emergence in the future.; FreeText:Tests: Glasgow Coma Scale, ECG, troponin I blood level, echocardiography, coronary angiography, blood pressure, heart rate, Ritalin urine level. Concomitant drugs: paracetamol and brompheniramine.

Language: en

Keywords

adult; human; female; case report; stress; suicide attempt; drug overdose; Cocaine; article; drug intoxication; emergency ward; acetylsalicylic acid; paracetamol; drug blood level; follow up; Amphetamine; attention deficit disorder; heart left ventricle function; methylphenidate; electrocardiogram; adjustment disorder; Substance-related disorders; thorax pain; ST segment depression; sinus tachycardia; oxygen therapy; perindopril; acute coronary syndrome; brompheniramine; isosorbide dinitrate; heart left ventricle failure; T wave inversion; troponin; Myocardial ischemia