Lush Ice High: A Rare Case of Nicotine E-Liquid-Induced Toxic Encephalopathy

E-cigarette consumption has increased globally, partly due to its perceived role as a harm-reduction alternative to conventional cigarettes. It has been linked to various neurotoxic pathologies including stroke, cognitive dysfunction, and neurodevelopmental disorders. Acute e-liquid intoxication can lead to a fatal syndrome of respiratory failure, cardiovascular instability, acute encephalopathy, and gastrointestinal distress. We present a case of toxic encephalopathy due to e-liquid intoxication directly from an e-cigarette device. Our patient is a 59-year-old man who presented to the hospital with signs of tachycardia, tremors, paranoia, disorientation, hypervigilance, physical hostility, and aphasic mutism, was unable to provide any history, and was treated on suspicion of acute encephalopathy and possible delirium tremens. Imaging including CT brain and chest X-ray was unremarkable. Laboratory tests were significant for leukocytosis (16.4 x 10³/mcL), hypernatremia (157 mmol/L), acute kidney injury (blood urea nitrogen (BUN) 26 mg/dL, creatinine 1.70 mg/dL), anion gap metabolic acidosis (18 mEq/L), and urine toxicology screen positive for cocaine and benzodiazepines. He was thereafter managed in the intensive care unit for close monitoring with an uncomplicated course. On the second day, he was found to be awake, alert, oriented, and without any focal neurological deficits. The patient claimed that prior to the emergency room (ER) visit, he orally consumed 4 mL of e-liquid from a 5% nicotine e-cigarette pen through an opening in the device. Serum analysis was significant for cotinine concentration of 30 ng/mL (primary metabolite of nicotine) and nicotine concentration of 2 ng/mL. No symptomatic sequelae were reported for the rest of the hospital course, and the patient was discharged on the fourth day after laboratory tests showed a resolution of earlier findings. This case of moderate e-liquid intoxication showed acute encephalopathy with resolution significantly different from the classically described biphasic pattern of nicotine intoxication-an initial stimulatory syndrome of nausea, hypertension, tachycardia, tremor, and seizures followed by depressor symptoms including hypotension, bradycardia, weakness, and CNS and respiratory depression. The neurotoxic effects of nicotine and non-nicotinic substances in e-cigarettes need to be investigated further to develop standardized management guidelines for acute e-liquid intoxication.