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BACKGROUND
Water pipe (hookah) smoking has become a common activity in Germany, particularly among adolescents and young adults; in 2011, its lifetime prevalence was as high as 68.8%. Similar trends can be seen in other European countries. Water-pipe smokers are exposed to the same health-endangering substances as cigarette smokers, and the inhaled amount of carbon monoxide (CO) can be as much as ten times as high. In CO intoxication, carboxyhemoglobin is formed and causes direct injury at the cellular level, leading to hypoxia and nonspecific neuro logical manifestations. There have only been ten reported cases around the world of CO intoxication due to the use of a water pipe, and none of these were fatal. It should be recalled, however, that accidental CO intoxication is common and is associated with high morbidity and mortality.

CASE PRESENTATION AND COURSE
We present a series of four young adults, aged 16 to 21, three of whom were hospitalized because of transient unconsciousness. The carboxyhemoglobin (CO-Hb) content of the blood in the symptomatic patients ranged from 20.1% to 29.6%, while the asymptomatic patient had a CO-Hb content of 16.7%. Water-pipe smoking was the cause of CO intoxication in all four cases. The CO-Hb values were successfully brought down by the administration of highly concentrated oxygen and all patients were discharged in asymptomatic condition.

CONCLUSION
This case series reveals that CO intoxication due to water-pipe smoking is probably more common than is generally realized. Emergency room staff should be aware of this problem and inquire specifically about water-pipe smoking in patients with nonspecific neurological manifestations.