Severe rhabdomyolysis following massive ingestion of oolong tea: Caffeine intoxication with coexisting hyponatremia

A 36-y-o patient with schizophrenia, who had consumed gradually increasing quantities of oolong tea that eventually reached 15 L each day, became deli rious and was admitted to a psychiatric hospital. After abstinence from ool ong tea his delirium resolved. He was transferred to our hospital when he w as discovered to have acute renal failure with hyponatremia (118 mEq/L) and severe rhabdomyolysis (creatine phosphokinase, 227,200 IU/L). On admission rhabdomyolysis had begun to improve despite a worsening of the hyponatremi a (113 mEq/L). With aggressive supportive therapy, including hypertonic sal ine administration and hemodialysis, the patient fully recovered without de tectable sequelae. The clinical course suggests that caffeine, which is pre sent in oolong tea, was mainly responsible for the rhabdomyolysis as well a s the delirium, although severe hyponatremia has been reported to cause rha bdomyolysis on rare occasions. We hypothesize that caffeine toxicity injure d the muscle cells, which were fragile due to the potassium depletion induc ed by the coexisting hyponatremia, to result in unusually severe rhabdomyol ysis. The possibility of severe rhabdomyolysis should be considered in a pa tient with water intoxication due to massive ingestion of caffeine-containi ng beverages.