Doi:10.1016/s0140-6736(04)17111-0

Case Report
Coca-Cola and kangaroos
Lancet 2004; 364: 1190
Department of Nephrology,
In March, 2002, a 44-year-old ostrich farmer from D W Johnson PhD) Princess
outback Australia experienced a sudden onset of muscle Alexandra Hospital, Brisbane,
weakness after returning home from an evening of Queensland, Australia
shooting kangaroos. He had difficulty getting out of his bath, and had to wait on the floor for assistance because dmudge@mail.rah.sa.gov.au
he was unable to stand. Over the following hour hisweakness progressed, and he was taken by ambulance to the local hospital. He had no other symptoms and denied any history of recent drug use, alcoholconsumption, or exposure to toxins. He had beenpreviously fit and well, with no significant, medical Figure: ECG at presentation, showing T-wave flattening and U waves
On examination we found generalised muscular Hypokalaemic myopathy has been reported to occur weakness (grade 2/5). All deep tendon reflexes were following excessive consumption of cola.1,2 In this present, and sensation was normal. Over the next case, the severe hypokalaemia was multifactorial. few hours, his respiratory function deteriorated, Firstly, cola contains a lot of sugar (11 g/dL, osmolality necessitating endotracheal intubation and artificial 430 mOsm/kg) and negligible potassium. Our patient’s excessive consumption probably caused the osmotic (1·4 mmol/L), and increased serum creatine kinase diuresis, and the accompanying potassium loss and (289 U/L). Simultaneous urinalysis showed inappro- his inadequate dietary intake resulted in a potassium priate kaliuresis (17·4 mmol/L) and osmotic diuresis deficit. Secondly, cola contains caffeine; in Coca-Cola (1160 mOsm/24 h). Thyroid function tests, urine drug the concentration is 97 mg/L.3 Caffeine’s pharma- screens, ACTH stimulation testing, plasma renin cological effects occur via antagonism of adenosine activity, and plasma cholinesterase concentrations were receptors in many organs, including the kidney.4 all normal. An ECG showed T-wave flattening and Adenosine receptor antagonism contributes to excessive U waves (figure). We treated him with intravenous loss of urinary potassium in favour of sodium retention, fluids, and his serum potassium concentration thus exacerbating hypokalaemia. Caffeinated and/or normalised within 24 h. He was extubated the next day hyperosmolar beverages should be considered as a cause and rapidly regained normal muscle strength. On of unexplained hypokalaemia with osmotic diuresis and further questioning, the patient admitted consuming kaliuresis. Patients need to be warned that immoderate approximately 4 L of Coca-Cola most days, and up to soft drink consumption may cause severe or recurrent 10 L when he went kangaroo shooting at night.
Kangaroos are considered to be agricultural pests in this References
region, and deliberate culls are done on a regular basis.
Appel CC, Myles TD. Caffeine-induced hypokalemic paralysis in He had been drinking these quantities of cola for the pregnancy. Obstet Gynecol 2001 May; 97 (5 Pt 2): 805–07.
Rice JE, Faunt JD. Excessive cola consumption as a cause of previous 3 years, and admitted to having polyuria and hypokalemic myopathy. Int Med J 2001; 31: 317–18.
nocturia over the same period. We advised him to curtail Anonymous. Your health and our beverages - the facts. The Coca- his cola drinking, and over the next few days, his serum Cola Company. http://www2.coca-cola.com/ourcompany/hal_facts_caffeine.html (accessed Feb 7, 2004).
potassium remained normal on an ad-libitum diet, Mandel, HG. Update on caffeine consumption, disposition and without requiring supplementation. When last seen, in action. Food Chem Toxicol 2002; 40: 1231–34
October, 2002, he had continued to avoid soft drinks andwas healthy, with no further complaints.
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