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We report the first case of extensive cerebral infarct in a young sportsman consuming high doses of MaHuang extract and creatine monohydrate. This should alert the sport community to possible serious adverse effects of energy supplements.
A 33 year old man had a severe aphasia on awakening in the morning of 23 January 1999. He did not complain of headache or of other symptoms. He was referred to our department on 26 January 1999. He had a Wernicke aphasia with a slight right sided face and arm weakness and a right Babinski sign. His blood pressure was 140/60 and his pulse 54 per minute. Brain CT showed signs of extensive left middle cerebral artery infarct. Cervical ultrasound duplex scanning and cerebral angiography were normal. Cerebral CSF examination was normal. There was no coagulopathy. D-dimeres were within the normal range (360 ng/ml, normal <500 ng/ml). Creatinine was in the normal range (102 μmol/litre). Transoesophageal echocardiography and ECG were also normal except for a patent foramen ovale.
The patient had no vascular risk factors, in particular no tobacco use, and he was perfectly fit until his stroke. He was a sportsman with 2 hours daily intensive training for body building. He was working as a baggage handler in an international airline company. During a recent journey to Miami, Florida, he bought tablets of “energy pills” in a shopping store to enhance his athletic performances. The first drug contained MaHuang extract (corresponding to 20 mg ephedra alkaloids), 200 mg caffeine, 100 mg L-carnitine, and 200 μg chromium per two capsules. The second drug contained 6000 mg creatine monohydrate, 1000 mg taurine, 100 mg inosine, and 5 mg coenzyme Q10 per scoop. He consumed 40–60 mg ephedra alkaloids, 400–600 mg caffeine, and 6000 mg creatine monohydrate daily for about 6 weeks before his stroke.
Although a paradoxical embolism through a patent foramen ovale in this patient cannot be ruled out as he recently returned from a transatlantic air flight, there was no deep venous thrombosis and D-dimeres were normal. However, ephedrine has an indirect sympathomimetic action and is responsible for arteriolar vasoconstriction in addition to other catecholaminergic effects. Both ischaemic and haemorrhagic stroke associated with ephedrine use have been reported.1-3 Acute myocardial infarction and acute psychosis have also been reported after taking ephedrine and other sympathomimetic drugs.3 Ephedrine and its metabolites are natural products that are used in non-prescription medicines for multiple uses. MaHuang extract, which contains ephedrine, is used among young sportsmen and sportswomen as an energy supplement in non-prescription tablets in some countries.
Although no cardiovascular side effects have been reported with the use of creatine monohydrate, this compound, used in association with other drugs as energy supplement may have deleterious side effects. This may be particularly true when used at high doses in combination with sympathomimetic drugs as in our patient. Renal dysfunction has also been reported after oral creatine supplements.4 Our patient had a slight increase in creatinine concentration although it remained in the normal range. Whether the use of high doses of caffeine can enhance the cardiovascular effect of ephedrine remains a possibility as stroke after taking a combination of caffeine and amphetamine has been reported.5
Drug addiction in sportsmen and sportswomen is becoming a major concern in our societies, involving both professionals and amateurs. As energy supplements, thought to enhance performance, are easily available in some countries without the need of medical prescription, everybody should be aware that these so called “benign” drugs may have major adverse effects.
This first case report of an extensive cerebral infarct in a young sportsman consuming high doses of MaHuang extract and creatine monohydrate should alert the sport community to this possible adverse effects of energy supplements, particularly when used in multiple combination.
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