Abstract
Purpose
This report describes a case of organophosphate intoxication refractory to atropine in which glycopyrrolate was used to reduce cholinergic symptoms, and describes the development of intermediate syndrome, an uncommon subacute complication of organophosphate poisoning.
Clinical features
A 44-yr-old woman presented in cholinergic crisis following malathion ingestion. Treatment was initiated with atropine and pralidoxime. Despite clinical signs of adequate atropinisation, the patient continued to have profuse bronchorrhoea, which resolved with glycopyrrolate. During her course in the intensive care unit, she displayed a subacute deterioration in neuromuscular and mental status with decrement-increment phenomenon on electromyography consistent with intermediate syndrome. The patient eventually made a complete recovery.
Conclusion
This case report describes the successful use of glycopyrrolate in organophosphate intoxication and the development of the intermediate syndrome, characterised by onset of weakness of neck flexors, proximal limb muscles, and respiratory muscles within one to four days after poisoning. Recognition of the syndrome is important in light of the potential for respiratory depression requiring ventilatory support.
Résumé
Objectif
Cette observation décrit un cas d’intoxication aux organophosphorés réfractaire à l’atropine où le glycopyrrolate a été utilisé pour diminuer les symptômes cholinergiques, et décrit aussi le développement d’un syndrome intermédiaire, une complication subaiguë non fréquente de l’empoisonnement aux organophosphorés. Éléments cliniques: Une femme de 44 ans se présente en crise cholinergique suite à l’ingestion de malathion. On débute le traitement à l’atropine et à la pralidoxime. Malgré des signes cliniques d’atropinisation adéquate, la patiente continue à présenter une bronchorrhée profuse, qui rentre dans l’ordre avec le glycopyrrolate. Durant son séjour aux soins intensifs, elle présente une détérioration subaiguë de la fonction neuromusculaire et mentale avec phénomène incrémentiel-décrémentiel à l’électromyographie, compatible avec un syndrome intermédiaire. Cette patiente va éventuellement récupérer complètement.
Conclusion
Cette observation à propos d’un cas décrit l’utilisation avec succès du glycopyrrolate dans l’intoxication aux organophosphorés et la survenue d’un syndrome intermédiaire caractérisé par l’apparition de faiblesse au niveau des fléchisseurs du cou, des muscles proximaux des membres et des muscles respiratoires survenant dans un délai de un à quatre jours après l’intoxication, (Lidentification de ce syndrome est importante à cause de son potentiel d’insuffisance respiratoire nécessitant un support ventilatoire.
Article PDF
Similar content being viewed by others
References
Marrs TC. Organophosphate poisoning. Pharmacol Ther 1993; 58: 51–66.
Kamlliedde L, Senanayake N. Organophosphorus insecticide poisoning. Br J Anaesth 1989; 63: 736–50.
Thompson DF, Thompson GD, Greenwood RB, Trammel HL. Therapeutic dosing of pralidoxime chloride. Drug Intelligence and Clinical Pharmacy 1987; 21: 590–3.
Bardin PG, van Eeden SF. Organophosphate poisoning: grading the severity and comparing treatment between atropine and glycopyrrolate. Crit Care Med 1990; 18: 956–60.
Gallagher H, Tracey JA. Organophosphorus insecticide poisoning (Letter). Br J Anaesth 1990; 65: 293–4.
Tracey JA, Gallagher H. Use of glycopyrrolate and atropine in acute organophosphorus poisoning. Hum Exp Toxicol 1990; 9: 99–100.
Senanayake N, Karalleidde L. Neurotoxic effects of organophosphorus insecticides. An intermediate syndrome. N Engl J Med 1987; 316: 761–3.
De Bleecker J, Van Den Neucker K, Colardyn F. Intermediate syndrome in organophosphorus poisoning: a prospective study. Crit Care Med 1993; 21: 1706–11.
Besser R, Gutmann L, Dillmann U, Weilemann LS, Hopf HC. End-plate dysfunction in acute organophosphate intoxication. Neurology 1989; 39: 561–7.
Joubert J, Joubert PH. Chorea and psychiatric changes in organophosphate poisoning. A report of 2 further cases. S Afr Med J 1988; 74: 32–4.
Rosenthal NE, Cameron CL. Exaggerated sensitivity to an organophosphate pesticide (Letter). Am J Psychiat 1991; 148: 270.
Bowers MB Jr, Goodman E, Sim VM. Some behavioral changes in man following exposure to anticholinesterase administration. J Nerv Ment Dis 1964; 138: 383–9.
Devinsky O, Kernan J, Bear DM. Aggressive behavior following exposure to cholinesterase inhibitors. J Neuropsychiat Clin Neurosci 1992; 4: 189–94.
Agarwal SB. A clinical, biochemical, neurobehavioral, and sociopsychological study of 190 patients admitted to hospital as a result of acute organophosphorus poisoning. Environ Res 1993; 62: 63–70.
Rodnitzky RL, Levin HS, Mick DL. Occupational exposure to organophosphate pesticides. A neurobehavioral study. Arch Environ Health 1975; 30: 98–103.
Savage EP, Keefe TJ, Mounce LM, Heaton RK, Lewis JA, Burcar PJ. Chronic neurological sequelae of acute organophosphate pesticide poisoning. Arch Environ Health 1988; 43: 38–45.
Rosenstock L, Keifer M, Daniell WE, McConnell R, Claypoole K, and the Pesticide Health Effects Study Group. Chronic central nervous system effects of acute organophosphate pesticide intoxication. Lancet 1991; 338: 223–7.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Choi, P.T.L., Quinonez, L.G., Cook, D.J. et al. The use of glycopyrrolate in a case of intermediate syndrome following acute organophosphate poisoning. Can J Anaesth 45, 337–340 (1998). https://doi.org/10.1007/BF03012025
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03012025