{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T03:55:29Z","timestamp":1777694129998,"version":"3.51.4"},"reference-count":20,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Clin Med Insights Case Rep"],"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction:<\/jats:title>\n                    <jats:p>Systemic toxicity from topical epinephrine is rare because dermal and mucosal absorption is typically limited. However, application to highly vascular mucosa, particularly under occlusion, may result in clinically significant systemic absorption.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation:<\/jats:title>\n                    <jats:p>A 42-year-old woman developed severe headache, palpitations, tremor, and marked hypertension shortly after a compounded 2.5% lidocaine with epinephrine (1:2000; 0.5\u2009mg\/mL) gel was applied to the labial mucosa under occlusion during a cosmetic procedure. An estimated 0.5 to 1.5\u2009mg of epinephrine was applied. Symptoms began within 10\u2009minutes and persisted until gel removal approximately 25\u2009minutes later. On EMS arrival, heart rate was 145\u2009bpm and blood pressure 210\/110\u2009mmHg. In the emergency department, ECG showed sinus tachycardia without ischemic changes; laboratory studies were unremarkable except for mild respiratory alkalosis, and serial high-sensitivity troponin I was negative. Management included prompt removal of the topical agent, supportive care, and cardiac monitoring. Symptoms resolved spontaneously without pharmacologic intervention, and the patient was discharged after 4\u2009hours of observation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion:<\/jats:title>\n                    <jats:p>Topical epinephrine applied to highly vascular mucosal surfaces\u2014especially under occlusion\u2014can rarely cause systemic sympathomimetic toxicity characterized by hypertension, tachycardia, tremor, and anxiety. Although it may resemble local anesthetic systemic toxicity, it is clinically distinct. Careful dosing, avoidance of occlusive dressings, close monitoring, and immediate removal of the agent at the first sign of systemic effects are essential to prevent complications.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/11795476261437585","type":"journal-article","created":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T09:16:42Z","timestamp":1776763002000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Systemic Epinephrine Toxicity Following Topical Anesthetic Gel on Mucosal Surfaces: A Case Report and Literature Review"],"prefix":"10.1177","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-2369-7494","authenticated-orcid":false,"given":"Ziad W.","family":"Elmezayen","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Kafr Elsheikh University, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zeina Zakarya","family":"Marzouk","sequence":"additional","affiliation":[{"name":"Department of Dermatology, National Hospital, Latakia, Syria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0386-6742","authenticated-orcid":false,"given":"Mohammad","family":"Adi","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Damascus University, Syria"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2026,4,21]]},"reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.44844"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ando.2020.03.012"},{"key":"e_1_3_3_4_2","unstructured":"Dalal R Grujic D. Epinephrine. In: StatPearls. StatPearls Publishing; 2025. Accessed March 1 2026. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK482160\/"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.1177\/2050313X231159732"},{"key":"e_1_3_3_6_2","doi-asserted-by":"publisher","DOI":"10.1177\/0194599820915478"},{"key":"e_1_3_3_7_2","doi-asserted-by":"publisher","DOI":"10.1055\/s-0032-1329416"},{"issue":"6","key":"e_1_3_3_8_2","first-page":"393","article-title":"Local anesthetics in cosmetic dermatology","volume":"99","author":"Hashim PW","year":"2017","unstructured":"Hashim PW, Nia JK, Taliercio M, Goldenberg G. Local anesthetics in cosmetic dermatology. Cutaneous Medicine for the Practitioner. 2017;99(6):393-397.","journal-title":"Cutaneous Medicine for the Practitioner"},{"key":"e_1_3_3_9_2","doi-asserted-by":"publisher","DOI":"10.1186\/s12903-021-01691-0"},{"key":"e_1_3_3_10_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.burns.2008.10.001"},{"issue":"7","key":"e_1_3_3_11_2","first-page":"606","article-title":"Epinefrino (adrenalino) perdozavimo pasekmes [The consequence of epinephrine (adrenaline) overdose]","volume":"42","author":"Reingardiene D.","year":"2006","unstructured":"Reingardiene D. Epinefrino (adrenalino) perdozavimo pasekmes [The consequence of epinephrine (adrenaline) overdose]. Medicinar. 2006;42(7):606-609.","journal-title":"Medicinar"},{"key":"e_1_3_3_12_2","doi-asserted-by":"publisher","DOI":"10.4103\/0975-5950.201370"},{"key":"e_1_3_3_13_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2021.10.021"},{"key":"e_1_3_3_14_2","unstructured":"Henning A Krawiec C. Sinus tachycardia. In: StatPearls. StatPearls Publishing; 2025. Accessed March 1 2026. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK553128\/"},{"key":"e_1_3_3_15_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0196-0644(05)82478-3"},{"key":"e_1_3_3_16_2","unstructured":"Song K Blankenship RB Derian A. Local anesthetic toxicity. In: StatPearls. StatPearls Publishing; 2025. Accessed March 1 2026. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK499964\/"},{"key":"e_1_3_3_17_2","unstructured":"Gupta PK Marwaha B. Pheochromocytoma. In: StatPearls. StatPearls Publishing; 2025. Accessed March 1 2026. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK589700\/"},{"issue":"5","key":"e_1_3_3_18_2","article-title":"Pheochromocytoma and paraganglioma: a review of diagnosis, management and treatment of rare causes of hypertension","volume":"12","author":"Cerqueira A","year":"2020","unstructured":"Cerqueira A, Seco T, Costa A, Tavares M, Cotter J. Pheochromocytoma and paraganglioma: a review of diagnosis, management and treatment of rare causes of hypertension. Cureus. 2020;12(5):e7969.","journal-title":"Cureus"},{"key":"e_1_3_3_19_2","doi-asserted-by":"publisher","DOI":"10.1007\/s40264-020-00927-2"},{"key":"e_1_3_3_20_2","doi-asserted-by":"publisher","DOI":"10.2147\/JAA.S159851"},{"issue":"5","key":"e_1_3_3_21_2","article-title":"Systemic risks of topical anesthetics in barrier-compromised dermatologic patients","volume":"17","author":"Chamoun G","year":"2025","unstructured":"Chamoun G, Forsyth A, Kazemeini S, et al. Systemic risks of topical anesthetics in barrier-compromised dermatologic patients. 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