A 16-year-old Caucasian boy with a history of attention-deficit hyperactivity disorder, asthma, and allergies presented to the emergency department with intoxication and vomiting after falling and sustaining minor head trauma. He had ingested an unknown quantity of Red Bull  mixed with vodka at a party. He denied chest pain, syncope, palpitations, shortness of breath, and fever. His home medications included amphetamine and dextroamphetamine (Adderall XL), 30 mg daily; montelucast (Singulair), 10 mg daily; loratadine (Claritin), 10 mg daily; and doxycycline, 100 mg daily for acne. Physical examination revealed an irregularly irregular heartbeat at 160 beats per minute with no murmurs. ECG showed chaotic atrial tachycardia/atrial fibrillation with rapid ventricular response (Figure 3). Blood ethanol level was 155 mg/dl. Cardiac enzymes were unremarkable, and serum electrolytes, thyroid-function tests, and a lipid profile were normal. A cardiac ECG revealed a structurally normal heart without thrombus. Computed tomography of his brain was normal. The patient was given a bolus of 2 L of normal saline, and his heart rate responded by decreasing from 160 beats per minute to 90 to 110 beats per minute. He remained hemodynamically stable and was placed on a cardiac monitor overnight with continued intravenous fluid support. Approximately 12 hours after presentation, he spontaneously reverted to a normal sinus rhythm (Figure 4). He remained asymptomatic with a normal sinus rhythm during subsequent cardiology follow-up the next week.
Of note, the Division of Pediatric Cardiology at the Stony Brook University Medical Center has cared for two other cases of atrial fibrillation in healthy adolescents after excessive caffeine consumption in the past five years. These cases were not included in this series, as the patients were unable to be located to provide their consent.