Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

A case of fat overload syndrome after rapid infusion of SMOFlipid emulsion in an adult?

Lipid emulsions are an important component of parenteral nutrition. In recent years, the use of Intravenous lipid emulsion as a useful adjunct to antidotal therapy in treatment of lipophilic medication overdoses has increased since first discovered. Rapid or chronic infusion of an ILE re- portedly causes fat overload syndrome. However, cases of fat overload syndrome with rapid infusion of a 20% soy oil, medium-chain triglycer- ide, olive and fish oil-based lipid (SMOFlipid) emulsion are not reported in adult patients. We reported a case of fat overload syndrome in a 72- year-old man that occurred as a result of accidental, rapid infusion of a 20% SMOFlipid emulsion. To our knowledge, this was the first case of fat overload syndrome caused by rapid infusion of SMOFlipid emulsion in an adult.

A 72-year-old man presented to the emergency department (ED) after acute altered mentation. He had a medical history of hypertension, diabetes mellitus, and multiple myeloma and had received bortezomib treatment at our hospital.

He was admitted to our ED 6 hours earlier. He noticed general weak- ness and intermittent abdominal pain about 2 weeks prior. His appetite was poor, and he reported an episode of mild diarrhea on the morning of admission. Physical examination showed that the patient was afe- brile, with blood pressure of 140/95 mm Hg and regular pulse rate of 93 beats per minute. His lungs were clear on auscultation, abdomen was soft and flat, and there was no peripheral edema. The remainder of the complete examination revealed normal findings. His son was a physician who worked for our hospital. The patient consented to nutritional support intravenously and underwent further laboratory in- vestigation. Five hundred milliliters of 20% soy oil, medium-chain tri- glyceride, olive and fish oil-based lipid (SMOFlipid) (Fresenius Kabi, Bad Homburg, Germany) emulsion was administered by infusion for 4 hours. The patient noticed an improvement in symptoms after treat- ment. He was discharged in good condition at 5 hours postadmission. However, on the way home, the patient experienced a sudden onset of myalgia and chilling, and his son was of the opinion that the patient’s judgment was clouded. After 1 hour of discharge, he developed drows- iness with fever and was brought to our hospital. He was stuporous at

? Source(s) of support: The authors have no conflict of interests, especially with the company that develops and sells the product used in this article. This work was supported by a grant funded by the Soonchunhyang University, Collage of Medicine (grant no. 20150004).

presentation with systolic blood pressure, heart rate, respiratory rate, and temperature of 130/70 mm Hg, 102 beats per minutes, and 22 breaths per minute, and 38.8?C, respectively. He had no neck stiff- ness; physical and other Neurologic examinations were normal. The patient’s white blood cell count, hemoglobin level, and platelet level were 7820/uL, 11.0 g/dL, and 252000/uL, respectively. The patient’s ala- nine aminotransferase, aspartate aminotransferase, bilirubin total, albu- min, blood urea nitrogen, creatine, and creatine kinase were 79 IU/L, 39 IU/L, 0.6 mg/dL, 3.7 g/dL, 14.0 mg/dL, 0.7 mg/dL, and 65 IU/L, respec- tively. The triglycerides were 934 mg/dL on admission, with underlying triglycerides average of 100. Fluid resuscitation was started with rapid infusion of normal saline and 2-g bolus of propacetamol. A 300-mL bolus of normal saline was injected intravenously to provide therapeu- tic hydration and within minutes, his state of consciousness had im- proved. The patient had no recollection about the event and was admitted for medical observation. On the following day, his tempera- ture dropped, and the triglycerides fell to 66 mg/dL. He made a full re- covery and was able to be discharged from the hospital.

Intravenous lipid emulsions (ILEs) are an important component

of parenteral nutrition. Recently, the use of ILE therapy has emerged as a rescue antidote for the treatment of lipophilic drug toxicities [1,2]. Fat overload syndrome is a well-known complication of ILE therapy. It is characterized by headaches, fever, jaundice, hepatosplenomegaly, respiratory distress, and spontaneous hemor- rhage; furthermore, other symptoms include anemia, leukopenia, thrombocytopenia, low Fibrinogen levels, and coagulopathy [3]. In our case, ILE was accidentally administered at 3 times faster than the recommended dosage rate. At 1 hour post-ILE infusion, the pa- tient experienced altered mentation and high fever and responded to conservative treatment with hydration.

To our knowledge, the several previously published case reports caused by rapid infusion of intravenous lipid emulsion (ILE) are limit- ed to pediatric patients, whereas only 1 case report represents fat overload syndrome after chronic infusion of ILE in an adult patient [4]. Importantly, fat overload syndrome is influenced not only by the infusion rate but also by its composition [1]. Most reports are limited to the use of soybean oil products. A recently published case series in- dicated that rapid infusion of fish oil-based emulsion was well toler- ated without sign or symptoms of fat overload syndrome [5]. Our case report indicated that fat overload syndrome could be caused by rapid infusion of fish oil-based lipid (SMOFlipid) emulsion in adults. Therefore, before initiating ILE administration, physicians should con- sider the possibility of fat overload syndrome by rapid infusion of SMOFlipid emulsions.

0735-6757/(C) 2015

Hyung Jun Moon, MD Il Woong Hwang, MD Jung Won Lee, MD*

Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea

Department of Emergency Medicine, Soonchunhyang University

Republic of Korea

*Corresponding author at: Department of Emergency Medicine Soonchunhyang University Cheonan Hospital, 8 Soonchunhyang 6-gil Dongnam-gu, Cheonan 330-721, Republic of Korea

Tel.: +82 41 570 3851; fax: +82 41 570 3879

E-mail address: [email protected]

Sae Yong Hong, MD Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea

Department of Internal Medicine, Soonchunhyang University, Republic of Korea

http://dx.doi.org/10.1016/j.ajem.2015.08.044

References

1. Hojsak I, Kolacek S. Fat overload syndrome after the rapid infusion of SMOFlipid emulsion. JPEN J Parenter Enteral Nutr 2014;38:119-21.
2. Levine M, Skolnik AB, Ruha AM, et al. Complications following antidotal use of intra- venous Lipid emulsion therapy. J Med Toxicol 2014;10:10-4.
3. Goulet O, Girot R, Maier-Redelsperger M, et al. Hematologic disorders following prolonged use of intravenous fat emulsions in children. JPEN J Parenter Enteral Nutr 1986;10:284-8.
4. Ma J, Wang Y, Zhao S, et al. Fever of unknown origin in an elderly adult with lipid overload syndrome. J Am Geriatr Soc 2012;60:984-5.
5. Gura KM, Puder M. Rapid infusion of fish oil-based emulsion in infants does not appear to be associated with fat overload syndrome. Nutr Clin Pract 2010;25: 399-402.