eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Theophylline: Differential Diagnoses & Workup

Author: Greg Hymel, MD, Consulting Staff, Department of Emergency Medicine, Saint Vincent Mercy Medical Center
Contributor Information and Disclosures

Updated: Sep 2, 2009

Differential Diagnoses

Alcoholic Ketoacidosis
Shock, Septic
Anxiety
Status Epilepticus
Asystole
Subarachnoid Hemorrhage
Atrial Fibrillation
Subdural Hematoma
Atrial Flutter
Toxicity, Carbon Monoxide
Delirium Tremens
Toxicity, Cyanide
Diabetic Ketoacidosis
Toxicity, Disulfiram
Epidural Hematoma
Toxicity, Iron
Gastroenteritis
Toxicity, Monoamine Oxidase Inhibitor
Hypercalcemia
Toxicity, Toxaphene and Organochlorine
Hypophosphatemia
Ventricular Fibrillation
Multifocal Atrial Tachycardia
Ventricular Tachycardia

Workup

Laboratory Studies

  • Obtain serum theophylline level upon presentation and then every 2 hours until the level falls.
    • This is especially important following ingestion of extended-release formulations.
    • Theophylline can form bezoars, resulting in ongoing absorption and toxicity despite general measures at GI decontamination.
  • WBC can be elevated (due to increased catecholamine activity).
  • Obtain acetaminophen (paracetamol) level.
  • Obtain aspirin (ASA) level, particularly in patients with history and findings suggestive of aspirin toxicity, including but not limited to metabolic acidosis, respiratory alkalosis, and change of mental status.
  • Order electrolytes and glucose tests to evaluate for the following:
    • Hypokalemia (serial testing of serum potassium levels may be required)
    • Hyperglycemia
    • Metabolic acidosis (lactate) 
    • Hypocalcemia/hypercalcemia
    • Hypophosphatemia
    • Ketosis
  • Test for pregnancy in women of childbearing age.

Imaging Studies

  • Obtain a CT scan of the brain if seizures occur.

Other Tests

  • Electrocardiogram, looking for evidence of electrolyte abnormalities and dysrhythmias. Also, ECG should be used to evaluate for the signs of TCAs or other cardioactive drug toxicity.
  • Lumbar puncture may be required for the evaluation of new-onset seizures.

More on Toxicity, Theophylline

Overview: Toxicity, Theophylline
Differential Diagnoses & Workup: Toxicity, Theophylline
Treatment & Medication: Toxicity, Theophylline
Follow-up: Toxicity, Theophylline
References
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References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline]. [Full Text].

  2. Seneff M, Scott J, Friedman B, Smith M. Acute theophylline toxicity and the use of esmolol to reverse cardiovascular instability. Ann Emerg Med. Jun 1990;19(6):671-3. [Medline].

  3. Kearney TE, Manoguerra AS, Curtis GP, Ziegler MG. Theophylline toxicity and the beta-adrenergic system. Ann Intern Med. Jun 1985;102(6):766-9. [Medline].

  4. Brashear RE, Aronoff GR, Brier RA. Activated charcoal in theophylline intoxication. J Lab Clin Med. Sep 1985;106(3):242-5. [Medline].

  5. Charytan D, Jansen K. Severe metabolic complications from theophylline intoxication. Nephrology (Carlton). Oct 2003;8(5):239-42. [Medline].

  6. Cooling DS. Theophylline toxicity. J Emerg Med. Jul-Aug 1993;11(4):415-25. [Medline].

  7. Gaudreault P, Harwood-Nuss. Methylxanthines, Toxicology. In: Clinical Practice of Emergency Medicine. 4th ed. 2005:1649-1652.

  8. Henderson A, Wright DM, Pond SM. Management of theophylline overdose patients in the intensive care unit. Anaesth Intensive Care. Feb 1992;20(1):56-62. [Medline].

  9. Kallstrom TJ. Evidence-based asthma management. Respir Care. Jul 2004;49(7):783-92. [Medline].

  10. Marshall H, Emerman CL, Tintinalli J. Theophylline, Toxicology and Pharmacology. In: Emergency Medicine, A Comprehensive Study Guide. 6th ed. 2004:1098-1101.

  11. Medical Economics Staff. Drugs. In: Physician's Desk Reference. Medical Economics Co; 1997.

  12. Micromedex. Theophylline. In: Micromedex. 1974-2008:36.

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Further Reading

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Keywords

theophylline overdose, theophylline poisoning, theophylline exposure, acute theophylline overdose, chronic theophylline intoxication, methylxanthine, asthma treatment, chronic obstructive pulmonary disease treatment, COPD treatment, theophylline adverse affects, methylxanthine derivative, 1,3-dimethylxanthine, angina pectoris treatment, peripheral vascular disease treatment, bronchial asthma treatment

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Contributor Information and Disclosures

Author

Greg Hymel, MD, Consulting Staff, Department of Emergency Medicine, Saint Vincent Mercy Medical Center
Greg Hymel, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Fred Harchelroad, MD, FACMT, FAAEM, FACEP, Chair, Department of Emergency Medicine, Director of Medical Toxicology - Allegheny General Hospital, Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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