Consumers have been indulging in increased consumption of popular energy drinks. It is felt that these energy drinks are benign and are packed with good ingredients such as B vitamins and amino acids that do not have adverse effects. 
 
 6 , vitamin B 3 , vitamin B 12 , and vitamin B 9 ; the energy blend consists of citicoline, taurine, tyrosine, phenylalanine, malic acid, caffeine, and glucuronolactone; and the enzymes they contain include amylase, protease, cellulase, protease, and lactase (Table 1 Ingredients of the energy drink (serving size two fluid ounces) Amount per serving Daily value,b % Niacin 30 mg 150% Vitamin B 6 40 mg 2000% Folic acid 400 μ g 100% Vitamin B 12 500 μ g 8333% Sodium 10 mg < 1% Energy blend 1870 mg Not known Energy drinks contain a blend of B vitamins, the energy blend, and enzymes. The vitamins they contain include vitamin B, vitamin B, vitamin B, and vitamin B; the energy blend consists of citicoline, taurine, tyrosine, phenylalanine, malic acid, caffeine, and glucuronolactone; and the enzymes they contain include amylase, protease, cellulase, protease, and lactase (Table). 
 
 Vitamin B 6 is important in heme, nucleic acid, lipid, carbohydrate, and amino acid metabolism. Toxicity occurs when megadoses of vitamin B 6 (> 500 mg/day) are ingested [1]. Symptoms of toxicity include peripheral neuropathy with deficits in a stocking-glove distribution, progressive sensory ataxia, and severe impairment of position and vibration senses. Vitamin B 6 toxicity is not linked to hepatotoxicity. The treatment of vitamin B 6 toxicity is to discontinue vitamin B 6 consumption, and recovery is slow and, for some patients, incomplete. 
 
 Niacin and its derivatives are vital to cell metabolism. They have been used for decades in the treatment of patients with disturbed lipid and lipoprotein metabolism. They have been associated with skin flushing and, rarely, hepatotoxicity when used in pharmacological doses (1 g/day to 5 g/day). Hepatotoxicity manifests as a spectrum that includes mild elevation of liver enzymes, hepatic steatosis, hepatic necrosis, and, rarely, hepatic failure. Treatment includes discontinuation of niacin, and usually the liver enzymes return to normal. The smallest dose of niacin that leads to hepatotoxicity described in the literature is 1 g/day [2]. Our patient ingested around 300 mg of niacin daily (30 mg/can × 10 cans/day), making this the smallest reported dose that induced niacin toxicity. 
 
 Vitamin B 12 is involved in nucleic acid metabolism, the formation of red blood cells (RBCs), and myelin synthesis and repair. It has a very low potential for toxicity even when taken in large doses. This does not imply that it has no adverse effects. Because data on the toxic profile of vitamin B 12 are limited, consumers, especially pregnant women, should be cautious when ingesting large amounts of vitamin B 12 . 
 
 Folic acid is required for DNA synthesis, RBC synthesis, and cell growth. Since it is water-soluble and regularly excreted by the body, toxicity as a result of excessive ingestion does not commonly occur. According to the National Academy of Sciences, the daily intake of folic acid in adults should not exceed 1000 μg. Very high doses (> 15,000 μ g/day) can cause stomach problems, sleep problems, skin reactions, and seizures. 
 
 Citicoline functions as a neuro-protective agent. It exhibits a very low toxicity profile in humans. In a short-term, placebo-controlled study that compared citicoline to placebo, transient headaches occurred in patients in the citicoline group compared to the placebo group. No changes or abnormalities were observed in hematologic, biochemistry, liver function, or neurological tests in patients in that study [3]. 
 
 Taurine is a normal metabolite in humans that is involved in the modulation of neuronal excitability, membrane stabilization, production of bile salts, and the detoxification of certain xenobiotics. There have been no adequate studies done to observe toxicity and/or carcinogenicity linked to taurine ingestion. 
 
 Caffeine functions as a psychoactive stimulant and a mild diuretic in humans. In large amounts, and especially over extended periods of time, caffeine can lead to a condition known as caffeinism [4, 5]. Caffeinism refers to a wide range of symptoms that include anxiety, insomnia, headaches, respiratory alkalosis, and palpitations. Increased use over time can lead to peptic ulcers and gastroesophageal reflux disease. Acute caffeine intoxication (> 300 mg/day) leads to serious symptoms that include restlessness, arrhythmias, and psychomotor agitation. Extremely large doses of caffeine can cause acute psychosis, rhabdomyolysis, and even death. The treatment of severe caffeine intoxication is generally supportive, and dialysis may be required if the levels of caffeine are extremely high. 
 
 Tyrosine is involved in the synthesis of neurotransmitters in the brain. It has the potential for very low toxicity, and there have been very few reports of toxicity reported, none of which involved hepatotoxicity. 
 
 Phenylalanine is converted to tyrosine in the body and serves the same function as tyrosine. Toxicity symptoms include increased blood pressure, emotional agitation, insomnia, and headaches. 
 
 Malic acid is important in boosting immunity, maintaining oral health, and reducing the risk of poisoning from a build-up of toxic metals. There are no known reported contraindications or toxicities linked to malic acid. 
 
 D-Glucurono-γ-lactone is a natural metabolite of glucose and regulates the formation of glycogen. There is very little known about the toxicity of this substance. 

 Most of us have consumed energy drinks at one point or another, either because of a looming deadline or during a fun night out. Although energy drinks are often perceived as harmless, a new case report links the beverages to liver damage, after a previously healthy man developed hepatitis from consuming too many. 
 
 
 
 This is the second time acute hepatitis has been linked to energy drink consumption. This is the second time acute hepatitis has been linked to energy drink consumption. 
 
 In the United States, most energy drinks are consumed by young males between 18-34 years of age. Almost one third of teenagers between 12-17 years old consume energy drinks regularly, according to the National Center for Complementary and Integrative Health (NCCIH). 
 
 Between 2007-2011, the number of energy drink-related emergency department visits in the U.S. doubled. Main concerns regard the combined use of energy drinks with alcohol, which leads to excessive binge drinking. 
 
 As for the contents of an energy drink, it is believed that caffeine and sugar pose the greatest threat to consumers' health. 
 
 According to a new case report, however, there may be something in energy drinks that can cause liver damage. 
 
 The report details a 50-year-old man who was admitted to the hospital for acute hepatitis. The patient had reportedly consumed four to five energy drinks per day for more than 3 weeks. 
 
 This is a very rare occurrence; there is only one other case, in which a 22-year-old woman developed acute hepatitis from consuming energy drinks in excess. 
 
 Man consumed four to five energy drinks daily for 3 weeks 
 
 This latest case - reported by Dr. Jennifer Nicole Harb of the University of Florida College of Medicine and colleagues - was published in the journal BMJ Case Reports. 
 
 The man was previously healthy. He reported no changes in his diet or alcohol consumption, nor was he taking any prescription or over-the-counter medicine. He had also not consumed any illicit drugs and had no history of liver disease in his family. 
 
 However, for 3 weeks leading up to his hospitalization, he had started consuming energy drinks in order to keep up with his heavy workload as a construction worker. 
 
 After the 3-week period, he started developing symptoms such as general malaise, anorexia, acute abdominal pain, nausea, and vomiting. The patient became alarmed when these symptoms were accompanied by jaundice and dark urine. 
 
 Excess niacin to blame for acute hepatitis 
 
 Upon examination, it was revealed that the number of enzymes called transaminases was elevated, which indicates liver damage. A liver biopsy revealed acute hepatitis, and doctors also found evidence of chronic hepatitis C infection. 
 
 "Though the patient was found to have HCV [hepatitis C virus] infection, we did not think HCV was responsible for his acute hepatitis," the doctors mention in the report. 
 
 The doctors go on to explain that acute hepatitis was most likely induced by the excessive intake of vitamin B3, also known as niacin. 
 
 The patient consumed around 160-200 milligrams of niacin per day, which is twice the recommended daily dose. 
 
 Although these levels of niacin are not supposed to cause toxicity, they are similar to those reported in the only one other case of energy drink-associated hepatitis. There, the woman had consumed 300 milligrams of niacin daily, which was, at the time, the lowest reported dose to cause niacin toxicity. 
 
 In the case of the new patient, symptoms were cleared by the third day of hospitalization, following careful observation and treatment. 
 
 He discontinued the use of energy drinks and was advised to avoid any similar products that contain vitamin B3 in the future. 
 
 Dietary supplements and liver toxicity 
 
 Nearly 50 percent of the cases of liver failure in the U.S. are caused by drug-induced liver injury (DILI), according to the case report. 
 
 The authors of the case study point out that dietary and herbal supplements can be harmful to one's liver, despite their natural ingredients. Around 23,000 emergency department visits each year are related to dietary supplements. 
 
 Although vitamins and dietary supplements have been recognized as hepatotoxins, they continue to be ignored by patients and doctors alike, the authors warn. This is due to the common misconception that because they have "natural ingredients" they must be harmless. 
 
 Most of the time primary treatment for DILI simply involves stopping the intake of the substance that is causing the injury and waiting for the liver to normalize. Recovery usually takes place in a few days. 
 
 A case such as the one published in BMJ Case Reports might alert doctors of the damaging effects of energy drinks and help them eliminate the cause of hepatitis quicker and more effectively. Hopefully, doctors will treat such instances more promptly and no longer ignore the possible negative effects that vitamins, supplements, and related products can have on the liver. 
 
 Doctors recommend that patients should be educated about the risks of liver toxicity involved in energy drink consumption. 
 
 The authors add: 
 
 "As the energy drink market continues to rapidly expand, consumers should be aware of the potential risks of their various ingredients. Vitamins and nutrients, such as niacin, are present in quantities that greatly exceed the recommended daily intake, lending to their high risk for harmful accumulation and toxicity." 
 
 Read about the negative effects energy drinks may have for the heart. 

 Image: AP 
 
 A 50-year-old construction worker who consumed four to five energy drinks a day for three weeks was recently diagnosed with acute hepatitis, a condition characterized by liver inflammation. While not the first case of its kind, the incident points the largely ignored dangers of excess niacin consumption. 
 
 A new case report published in the British Medical Journal highlights the need for consumers to be aware of all the ingredients found in popular food and drink items, and to avoid the over-consumption of dietary supplements. Doctors who treated the unnamed man believe his sudden bout of hepatitis was caused by his excessive energy drink consumption, which included the ingestion of copious amounts vitamin B3, also known as niacin. 
 
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 As a construction worker, the man began to consume energy drinks to help him power through his labor-intensive workday. Aside from hitting the energy drinks with unusual fervor, he didn’t make any other changes to his eating and drinking habits. Soon afterwards, the man started to become unusually fatigued, and he began to experience abdominal pain. When this turned to nausea and vomiting, he figured he had the flu—but the man became particularly alarmed when he developed dark urine and jaundice (his skin was turning yellow). Wisely, he went to the emergency department. 
 
 A physical examination affirmed the jaundice and right upper abdominal tenderness, while lab tests revealed high levels of transaminases—liver enzymes indicative of damage and evidence of chronic hepatitis C infection. A biopsy of the liver confirmed he had severe hepatitis. 
 
 Monster Energy contains 200 percent of the daily recommended intake of niacin. (Image: Flickr/homard) 
 
 Doctors who treated the man believe the hepatitis was triggered by his excessive energy drink consumption, with niacin being the key ingredient. Interestingly, the patient’s intake was around 160 to 200 milligrams (mg) daily, which is considered below the level expected to cause toxicity (a similar case was reported before, but the patient consumed 300 mg of niacin daily!). The problem, say the doctors, was that toxicity arose as a result of an accumulation effect; each bottle of his energy drink contained 40 mg of niacin, or 200 percent of the recommended daily value. 
 
 
 
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 The brand consumed by the patient wasn’t listed, but energy drinks with added niacin include Monster, Rockstar, and Red Bull. The patient was told to discontinue consumption of all energy drinks, and was advised to avoid any similar niacin-rich products in the future. 
 
 “As the energy drink market continues to rapidly expand, consumers should be aware of the potential risks of their various ingredients,” conclude the authors in the case report. “Vitamins and nutrients, such as niacin are present in quantities that greatly exceed the recommended daily intake, lending to their high risk for harmful accumulation and toxicity.” 
 
 Niacin is found in many energy drinks, and when taken in safe quantities, it can help improve cholesterol levels, lower cardiovascular risk, maintain skin health, treat headaches, and even improve liver function. But when taken in excess, it can cause nausea, stomach upset, muscle breakdown, and abnormal liver tests. Vitamin B3 can also be found naturally in food items such as yeast, meat, fish, milk, eggs, nuts, green vegetables, and beans. Vitamin B3 deficiency is rare in developed countries, leading doctors to advise against self-medicating with niacin. 
 
 Note: We changed the wording in the headline from “contract” to “develop” to better distinguish between hepatitis that’s transmissible and the kind that can result from various causes, including toxins, drugs, alcohol, various nutrient overdoses, viruses, and ischemia. 
 
 [BMJ Case Reports] 

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– For three weeks, a construction worker drank four or five energy drinks per day to help keep up with his intense workload. Then his body went haywire. In a bizarre case Florida doctors describe in the British Medical Journal, the 50-year-old man started gulping down energy drinks on the job but suddenly began vomiting after about three weeks. Soon, his skin turned yellow, but it wasn't the caffeine or even the sugar that was the problem. At a hospital, the man showed signs of liver damage, and a biopsy confirmed he had acute hepatitis, believed to have been brought on by high intake of vitamin B3, or niacin, found in his energy drink of choice. (It wasn't named.) Each bottle had about 200% of the daily recommended dose, reports Gizmodo. In safe quantities, niacin—also found in green vegetables, meat, and eggs—can improve cholesterol levels and liver function and lower cardiovascular risk. But it also wreaks havoc on the body if too much is consumed. Though the man's daily intake of 160 to 200 milligrams was below the toxic level, the accumulation of niacin over three weeks was enough to do damage; the same thing happened years ago to a woman who drank 10 energy drinks daily for two weeks, reports Medical News Today. The male patient recovered and was told to avoid similar niacin-rich products in the future. But "as the energy drink market continues to rapidly expand, consumers should be aware of the potential risks of their various ingredients," doctors say. (Even a single energy drink may be dangerous.)