Earl Grey tea intoxication (2022) | Hacker News Reader

Earl Grey tea intoxication (2022)

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The most House (the TV show)-like case that ever happened in my medical career was the case of the patient with liver failure due to green tea intoxication.

A young man presented in our hospital with acute liver failure. He'd just spent a month traveling through the rain forests of Brazil, Colombia and Peru. During his trip, he'd consumed unknown drugs in a Peruvian shaman ceremony and had unprotected sex with a Peruvian sex worker.

We tested him for everything obvious. He didn't test positive for any known drugs or any obvious drug-related toxins. He didn't have HIV. He didn't have hepatitis A, B, or C. He didn't have EBV, he didn't have CMV, he didn't have Dengue Fever, he didn't have Yellow Fever, he didn't have Malaria. He didn't have any sign of autoimmune conditions.

We called the institute for tropical diseases. We tested him for tropical diseases we'd never even heard of. He didn't have those. He didn't have Syphilis. He didn't have Gonorrhea. He didn't have liver cancer, or any other discernible cancers.

We called the institute for tropical diseases again. They started researching. We tested him for diseases the experts for tropical diseases hadn't even heard of. He had none of those, either.

His liver, which had started failing for no discernible reason, now stopped failing, for equally indiscernible reason. We started planning his discharge.

We had a nice final discussion. He really appreciated how hard we'd tried, he said, and he really appreciated how kind everyone had been, and sorry again about the unprotected sex with sex workers thing, that was effing stupid in retrospect. He said he was looking forward to getting home and detoxing from all this. He said he didn't think the green tea we had on the ward (cheap, shit, comes in bags, unlikely to have ever encountered a tea plant in real life) did anything much, detox-wise, and anyway he'd feel bad emptying our hot water carafe all the time.

Um. How much green tea do you drink, I asked him.

4 to 5 liters per day, he said.

I googled "green tea liver failure," with some vague memory that sometimes tea gets contaminated during the drying process and maybe he'd caught a bad batch? Turns out, green tea just... causes liver failures, occasionally, in higher doses. Probably due to the anti-oxidants.

You live and you learn.

The patient went home and limited his green tea consumption to no more than a cup per day. He checked in with me a year later, because I'd asked him for an update, and his liver was doing perfectly fine and had never failed him again.

4-5 liters! Two liters of green tea typically contains over 400mg of caffeine which is the upper limit recommended for adults. This guy was consuming around 1g of caffeine a day.

I regularly consumed in excess of 1g of caffeine during my early to mid 20s, either via coffee, green tea, black tea, or mate, or mixtures thereof. I don't think 1g is a very rare dose?

i start getting extremely nauseous if i get close to 500mg before mid-afternoon

daily coffee drinker

I seem to remember that tea has another molecule that balances the negative effects of caffeine. Now let me try to find that information back...

EDIT: It's called theanine : https://fr.wikipedia.org/wiki/Th%C3%A9anine

It doesn't really balance it all that much. I still get jitters from green tea.

Interesting.

I am quite sensitive to caffeine and yet I regularly drink green tea, typically around a liter and never get that weird anxiety I get from too much coffee. Maybe it's just that tea has less...

On the other hand green tea gives me nausea if I didn't eat anything in the morning.

No shame in missing something local among all the exotic red flags, but how does a person consume 4-5 liters of green tea per day to 'detox' while literally in a hospital? Isn't a fluids/diet survey part of admittance?

It's been a bit since my dad was in a hospital, but they wanted to know about literally everything that entered his mouth.

He didn't drink 4-5 Liters at the hospital, just a few (two or three) small cups per day. We'd asked about alcohol and drug consumption, but didn't think to ask about his normal food and drink consumption beyond asking for possible sources of infection (asking about any potential spoiled food or exotic meats he might have consumed.) In retrospect, certainly a big oversight in this case!

That's quite circumstantial evidence though. Nothing in that story tells me you've accurately concluded that it was the green tea.

Patient had unknown liver failure and drank a ton of green tea. Liver failure went away while still drinking tons of lower quality stuff. He proceeded to limit high quality green tea without it coming back, but if it was unrelated it wouldn't have come back regardless if he limited green tea or not.

Oh, certainly, there's nothing to prove it was the green tea. We did rule out any other cause of liver failure we possibly could, but there's nothing to say we didn't miss something. But green tea in high doses IS a known cause of liver failure (admittedly, not known to us at the time, but there's case studies on pubmed I found once I started searching), so it remained the most likely cause after eliminating anything else plausible apart from the good old doctor standby of "sometimes shit just happens, shrug emoji" also known as "idiopathic."

Oh, and I phrased that badly, but he didn't drink a ton of tea at the hospital. The hot water for tea comes in limited amounts from those samovar type things, and he didn't want to use too much of it, so he only drank 2-3 cups per day.

We were all burningly curious whether the liver failure would come back if he resumed his normal green tea consumption, especially him (very "try everything, you only live once" type of personality; see also, consumption of mysterious Peruvian rain forest drugs), thus proving whether the tea was the culprit or not, but for ethical reasons I had to caution him against experimenting on the only liver he had, and he reluctantly agreed he wasn't THAT curious. Therefore, the cause of his liver failure will never be fully and conclusively proven to be green tea.

Will tea, Earl Grey, hot, send me spiraling into a profound, dreamlike state, where I live out an entire lifetime, learning the flute and undergoing life-changing experiences, all within the span of a few real-world minutes?

It may depend on what safety settings your replicator is set to.

Not sure that there is anything interesting to be drawn from a singular anecdote that includes no conclusive medical analysis, but regardless of the type or brand of tea, drinking 4 liters of black tea per day doesn't exactly strike me as the healthiest lifestyle to begin with.

I'm far from a medical expert, but I would imagine that large quantities of tea are less unhealthy than even small quantities of alcohol, or soda.

Black tea contains caffeine and large amounts of caffeine are probably not very healthy. I assume he must have built up quite a tolerance but I would be on edge all day after such an amount.

Caffeine is one of the most studied substances that we consume and every time a new study happens they always find some new way that it is good for you.

Obviously huge quantities of anything are bad, but caffeine has virtually no downsides.

Responses to caffeine vary wildly, but personally I experience acute anxiety a couple of hours after even one cup. It took me many years as a regular coke / tea / coffee drinker to figure out that was causing daily anxiety. I do wonder what proportion of people never make the link, although it seems prevalence of high sensitivity to caffeine is rare in the general population [1]

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242593/

Responses vary by individual, and can vary by long term exposure too.

I was hospitalized for a long time because of a very serious, bad case of mumps as an adult and in the hospital I was treated they were very serious about controlling my diet so I couldn't drink coffee for a long while.

When I recovered and went back home, I started drinking the same amount of coffee I was used to, which normally wouldn't make me feel anything out of the ordinary, but because I had not been exposed to caffeine for a while, I ended up with a severe feeling of tingling in my limbs, the level of stimulation really shocked me. After a month and half (possibly a little more, I'm fuzzy on the passing of days during those times) of not drinking coffee, it was as if I had been a new coffee drinker again and my body forgot caffeine. Habitual, daily exposure can /strongly/ affect the amount of caffeine it will take for you to feel its presence at a symptomatic level, and abstaining from caffeine for a long enough period can also completely throw you back to the beginning stage.

Lots of people who drink a glass of wine a day live to 100.

And lots of people who drink 4L of wine a day are dysfunctional alcoholics who die early of liver or heart failure or various other causes.

Neither a glass of tea nor a glass of wine will kill you, but excessive consumption of just about anything can.

Outside your expertise, I know, but curious for further thoughts on: if large quantities of tea being better than small quantities of alcohol obviates the observation that large quantities of tea aren't likely to be healthy

Large quantities of any liquid can be fatal, that includes water, because that one can easily cause hyponatremia (deficit of sodium in blood).

> Hyponatremia is the most common type of electrolyte imbalance, and is often found in older adults.[11][12] It occurs in about 20% of those admitted to hospital and 10% of people during or after an endurance sporting event.[3][5] Among those in hospital, hyponatremia is associated with an increased risk of death.[5] The economic costs of hyponatremia are estimated at $2.6 billion per annum in the United States

A woman made the headlines once for dying in a contest that involved drinking absurd amounts of water in the shortest time.

https://www.cbsnews.com/news/ten-fired-after-radio-contest-t...

The amount? two gallons, so around 7.5 liters of water. Now, spaced around an entire day (rather than in under an hour), it's unlikely to immediately kill you, but even 4 liters of anything is going to be damaging to your health long term wise.

Alcohol certainly isn't good for you even in small amounts, but neither is drinking a lot of water, tea, coffee, soda or anything else. The human body was not made to process large amount of anything every day of the week.

There is no such a thing as a substance that is "healthy" to "abuse". Unfortunately, there are too many who believe the contrary (as evidenced by the post talking about the guy drinking humongous amounts of green tea to "detox" his body)

The desire to continuously stimulate the senses through binge drinking things (which can sometimes be water, many have damaged their body by drinking excessive amounts on a daily basis) or binge eating, well, that's a mental illness in the making.

...drinking 4 liters of black tea per day doesn't exactly strike me as the healthiest lifestyle to begin with.

I'm going to assume you're not British then.

Checking the volume of my go-to mug… I’m not far off that 4L/day. Definitely 3.

This seems quite plausible to me. My teen aged diet consisted of about that much black tea (English Breakfast, mainly) and buttered toast with Vegemite.

I stopped when my mum (a physician) pointed out that the number of tea leaves I was consuming (not deliberately, but casually) would probably cause oesophageal cancer. Perhaps she merely wanted me to vary my diet.

There is not, as far as I know, any link to esophageal cancer particular to tea, but regularly consuming hot beverages is associated with higher rates of esophageal cancer.

Isn't that only very hot (scalding) beverages like Argentinian smoked mate though? And there's evidence that smoked mate causes esophageal cancer, so have we even isolated that it's just the very hot part of mate? I haven't seen evidence of typical tea/coffee temperature beverages causing esophageal cancer.

There are studies from multiple countries around the world linking locally consumed hot beverages to higher rates of esophageal cancer. Certainly it's nothing like smoking in terms of risk or it would be much more obvious. But maybe there's something to it. Or maybe there are too many studies looking at every possible thing related to cancer and science is p hacking itself and these sorts of results tend to get widely publicized.

I don't remember how strong it is but there is evidence that consuming hot liquid, in the range of the temp to steep black tea, can contribute to esophageal cancer, So if you're pounding hot tea all day, it may be a concern.

Of all the beverages to drink, black tea is one of the most benign (usually.) Low calories and moderate amounts of caffeine (compared to coffee or many sodas). For me, tea makes water palatable - black tea with a little milk, no sugar. Fortunately, with the amount I drink, I don't like earl gray :-)

Well, any tea/infusion without caffeine is probably better, especially when consumed in high amounts. Without sweetening it, it's really close to just "water with taste".

Case study != epidemiological studies != RCTs, but they all have their place in the scientific process. Many interesting scientific discoveries started with an interesting case study.

We're not sure exactly what happened, it's a mystery, which I'd argue is inherently interesting. And not just because of human emotions, but also because of the possibility of scientific advancement.

It could be there's something unique in this case, some chemical in Earl Grey isn't being properly metabolized and that's causing the issues. Investigating further could lead to some advancement in biochemistry.

In my opinion, the chances are quite small for this to lead to any significant scientific advancement, but even so, it's still worth investigating.

"He was still drinking 2L...(his entire fluid intake)"

Isn't that low? I drink at least a gallon a day, and more during summer.

I learned the hard way via kidney stone that low fluid intake is bad. After further analysis of the stone's makeup, my doctor's prescription for avoiding future stones was stay hydrated. I have followed that advice ever since.

The idea that you need to drink liters of water a day is a modern invention due to misreading of research. It completely depends on the weather, exertion, and how much water is in the food you eat.

https://www.mcgill.ca/oss/article/health-nutrition/water-myt...

You deciding that need is a misreading is you assuming what other's lifestyles are. If you have one of your listed caveats, you need that amount. Your suggesting that it's not needed It also has to do with the person's metabolism and other factors.

You're right, I should have added genetics and disease as well! The gist is if your urine is of a light color and you have no issues there is no need to worry or try to force yourself to drink.

On an average day working my office desk job, my hydration goal is 2L and it's plenty. I often have to force myself over the finish line. (And I was a trained healthcare professional in a former life; I know how to judge hydration and I'm plenty well hydrated.) I cannot even remotely imagine drinking 4L of water in a day unless I was doing manual labor in warm weather for most of the day.

Climate also plays into this. I live in the pacific northwest, and I need to drink VERY little liquid go stay hydrated - there are plenty of days where I drink less than 1L and feel fine. But when i go anywhere dryer - e.g. southern california - I’m constantly dehydrated. England is pretty humid most of the year, a lot like the PNW.

I'm going to assume you live west of the Cascades... east of the Cascades I drink like a fish because the air is so dry.

Is the hydration the problem here? I presumed the caffeine content (or some other chemical; I guess other people cite bergamot?) was the issue. My Google searches seem to suggest 2L – 4L of Earl Grey works out to about 400 – 800mg of caffeine/d, which is "pushing the upper daily limit" to "way over a sane daily limit".

I didn't think the hydration was the issue at hand in the OP.

I wasn't focusing on the issue. I was just asking if 2L/day is normal when I'm much closer to 4L/day. I can now recognize when I'm low on my intake, and 2L is definitely low for me. So I was asking more from curiosity if I'm the outlier or if the 2L/day is the outlier.

As with all things medical, it looks like the answer is "it depends on the specific patient"

That would depend on the size of the person, and water loss. Over hydration is taxing on the kidney as well, not to mention the fact that the patient in that study was drinking tea.

I'm surprised that the doctor didn't mention drinking plain water, or perhaps it was rejected by the patient, and it's customary to exclude that from these kind of report?

The TFA said that at some point he went 1 week without any tea and just water as part of the testing, so yeah, the doctor DID have him drink plain water

Reminds me of chifir, which is still popular in Russian and easter-euro prisons

"Ultimately, making chifir involves brewing a great deal of black tea and for a long time. It may be left to brew overnight and drunk either hot or cold."

They use it as some sort of substate for alcohol but I'm not sure of exact effect. I know it causes extremely bad teeth rot after multi year consumption.

https://en.wikipedia.org/wiki/Chifir

You know the saying, "anything in excess is bad".

Also I've never been fond of the Twinings brand of teas. They always had a super strong flavor.

At work we just cost-optimized away the better teas like Tazo and Stash but one station, interestingly in the blue-collar facilities area, started stocking Twinings. I do go down there for Earl Grey but was reminded that that particular one always seemed too bergamotty to me.

We ran a bakery for a while and sold a chocolate shortbread with bergamot oil, now I wonder if anyone ever had a reaction from our cookies. Probably not, I'm guessing you'd have to eat about $50 worth...

sounds like a allergy to oil of bergamot.

Could be chronic fluoride toxicity.

Coincidentally, I had occasion to post this in another thread just a couple of days ago: https://journals.sagepub.com/doi/full/10.1177/14034948219902...

Black tea contains a lot of fluorine, so if you're drinking a gallon a day, you're deep into hyperfluorosis territory.

He had no issues with pure black tea (and switched back to it in fact), so it must have been something to do with the bergamot.

Ah, right, so on to the next possibility.

Bergamot contains a chemical, a sort of terpene, aptly named "bergamottin." https://en.wikipedia.org/wiki/Bergamottin

Bergamottin famously inhibits a major liver enzyme inelegantly named CYP3A4. CYP3A4 is responsible for metabolizing a huge number of drugs and other substances. (e.g., endogenous steroid hormones.) This is what's responsible for the "grapefruit juice effect." https://en.wikipedia.org/wiki/Grapefruit%E2%80%93drug_intera...

Bergamottin also inhibits CYP1A1, which metabolizes theophylline, and CYP1A2, which metabolizes caffeine.

The most likely possibility is that consuming that much bergamottin, together with caffeine, disrupted the metabolism of the latter, leading to caffeine-induced toxicity in skeletal/cardiac muscle. (Cramps, fasciculations, etc.)

But it could also be that the inhibition of CYP3A4 messed with the metabolism of something else the man was ingesting.

wow this is interesting to me.

I'm so curious how this effects dental health in people where daily tea drinking is common. tea stains your teeth a bit but does it also strengthen enamel with the flouride?

Never knew this. Thanks for the reading material.

Earl gray with real bergamot oil is really expensive and hard to find nowadays. Most brands use “natural flavors”

Huh, that's somewhat surprising given bergamot fruit is not all that expensive. We may be spoiled in the UK but you can buy Earl Grey with real bergamot oil for a reasonable price here https://www.waitrose.com/ecom/products/brew-tea-co-earl-grey...

This was Twinings earl grey. Sure it's not high end stuff, but it's still no dollar bin tea. Royal warrant and all that.

This case is also from 20 years ago so I do think that it was real bergamot.

Yeah - my mother has this (symptoms similar to the article) - annoyingly more teas seem to be including small amounts of bergamot in - currently Twinings English Breakfast in the uk is fine though - so we stock up when on special offer.

I only drink green and oolong teas, but another commenterr pointed out to a study that it might've be flouride content of the tea

What strength of earl grey tea? My grandmother never drank water, insisting only tea. But she drank seriously week tea, more like tea-flavored water. I've seen other people (brits) drink tea so dark it looks like coffee.

Brits drinking tea is one of the clearest examples of food consumption by one group being toxic for another group (see https://en.wikipedia.org/wiki/First_Opium_War).

Scarry.

I grew up on Black Tea sorts. I drank a similar amount to the patient above, with far too much sugar and lemon juice. Stopped because I wanted to reduce my sugar consumption and to have white teeth again.

Earl Grey tea intoxication [pdf] - https://news.ycombinator.com/item?id=8155176 - Aug 2014 (39 comments)

Your comment was downvoted, possibly because the URL submitted at that HN discussion is down.

Here's an archived copy of that PDF, which is the same case: https://web.archive.org/web/20140912083558/http://www.docent...

Who can say! But those 'related' links are mostly intended for looking at past HN comments in any case.

Sometimes I add an archive link to old threads whose URLs have rotted. I'll do that there. Thanks for the link!

I would investigate dehydration from caffeine, caffeine intoxication, or antinutrients or adulterants from the bergamot.

So to be clear, the dude was drinking the equivalent of one of these every day:

https://d2d8wwwkmhfcva.cloudfront.net/800x/d2lnr5mha7bycj.cl...

I'm not sure the average person could drink a gallon of water a day without any ill effects, much less tea.

I drink aprox 1.5 gallons per day. I am fine.

I drank that much for 30 years.

This guy seems to be special. My side effects were "only" the sugar related teeth problems (coloring and decay).

It was tough, but I've reduced the sugar in my iced tea. I grew up in the South where sweet tea is just part of the culture. It took a while, but I'm now acclimated to unsweet tea. I realized that if I could acclimate to the taste of beer, I could handle tea too

I'm on a quite nice white tea mix now. I always had the issue of not being able to handle the bitterness of most of the teas. Especially after they got cold. This one goes quite well without any sugar.

Tea will discolor teeth even without sugar.

True, but the mix of black tea with lemon and sugar was overkill. It cost me a lot.

Instead of guessing and posting as if this was _very weird_ you could just have done a quick google search and found that yes, most likely they could? It's not needed but spread over a day, sure they could.

Sweet tea is very different from an average tea drinker who might (as is common) use no sweetener at all.

That’s not really that extreme if you’re a habitual tea drinker in a cold climate (that amount of sugar is insane though, if we’re talking about Arizona sweet tea).

I think it’s just a rare sensitivity and it sounds like it was the majority of his fluid intake.

Definitely not true. I used to regularly drink 1.5 gallons a day.

A gallon is a recommended daily intake for men:

https://www.health.harvard.edu/staying-healthy/how-much-wate....

A gallon of water. Not a gallon of Earl Grey tea…

(I do agree that the parent's Arizona might not be quite comparable, given the sugar content in those drinks.)

I believe their point is that it is possible to consume over a gallon of {liquid} per day, and as someone who used to drink unhealthy amounts of soda, I promise it is possible to do it with even sugary, fizzy beverages let alone tea. Caffeine also has addictive properties which can override rational thoughts.

It's 4 litres, and it was Earl Grey tea, not a sugary tea drink thing.

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