Xylometazoline poisoning: A 40-fold nasal overdose caused by a compounding error in 3 children

Abstract

The imidazoline derivative xylometazoline, an alpha-2-adrenergic agonist, is used as non-prescription nasal preparation due to its vasoconstrictive and decongestive properties. Especially in children, an overdose can quickly cause severe central nervous system depression and cardiovascular adverse effects. In three 3-year-old boys (triplets) a xylometazoline intoxication was diagnosed by toxicological analysis. On admission to an emergency unit all three children were still unresponsive. One triplet showed respiration of 15–20 breaths/min and required oxygen support (3 L/min) via face mask; his electrocardiogram revealed sinus bradycardia of 64 beats/min with supraventricular extrasystoles. However, no interventions were necessary except fluid management via intravenous lines. Eleven hours after the event, two of the triplets were awake but still not fully oriented. The third triplet woke up 20 h after instillation of nose drops. Intoxication was caused by a compounding error in a pharmacy resulting in a concentration 40 times above the adequate dosage for children. In general, physicians, pharmacists and the public should be educated about the toxicity of over-the-counter preparations.

Introduction

Xylometazoline is a vasoconstricting substance of the imidazoline group. Due to its primarily local α-adrenergic effect it is particularly suitable for topical use on the nasal mucous membranes. The drug causes vasoconstriction, reduces oedema, inhibits hyperaemia of the mucous membranes of the nasopharyngeal cavity, and decreases the amount of secretions. Indications are acute rhinitis of viral or bacterial aetiology, acute or chronic, exacerbating paranasal sinusitis, or allergic rhinitis. In patients with a common cold it provides fast and effective relief of nasal congestion and is well tolerated [1]. For the use in children, the nasal drops or sprays are available in different strengths. In Germany, 0.1% xylometazoline solutions are available for adults and at 0.05% for children (one drop per dose) over the counter.

The drug is instilled into each nostril: children between 4 months and 2 years of age one drop of a 0.05% solution every 8–12 h; children between 2 and 12 years old 2–3 drops or 1 spray of the 0.05% solution every 8–10 h, adults and children aged over 12 years 2–3 drops or 1 spray of the 0.1% solution every 8–10 h. As rarely occurring side effects irritation, burning, and dryness of the nasal mucosa are described.