A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase status
A 63-year-old male was admitted to a district hospital after ingesting ethanol and pirimiphos-methyl (PM) with suicidal intentions. History included alcoholic cirrhosis with alcoholism, adiposity, diabetes with cerebral microangiopathy, chronic renal insufficiency, heparin-induced thrombocytopenia,...
| Main Authors: | , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
Frontiers Media S.A.
2022-12-01
|
| Series: | Frontiers in Pharmacology |
| Subjects: | |
| Online Access: | https://www.frontiersin.org/articles/10.3389/fphar.2022.1102160/full |
| _version_ | 1797978701938294784 |
|---|---|
| author | Tobias Zellner Christian Rabe Jens von der Wellen-Pawlowski Dagmar Hansen Harald John Franz Worek Florian Eyer |
| author_facet | Tobias Zellner Christian Rabe Jens von der Wellen-Pawlowski Dagmar Hansen Harald John Franz Worek Florian Eyer |
| author_sort | Tobias Zellner |
| collection | DOAJ |
| description | A 63-year-old male was admitted to a district hospital after ingesting ethanol and pirimiphos-methyl (PM) with suicidal intentions. History included alcoholic cirrhosis with alcoholism, adiposity, diabetes with cerebral microangiopathy, chronic renal insufficiency, heparin-induced thrombocytopenia, and status post necrotizing fasciitis. Emergency medical service reported an alert patient without signs of cholinergic crisis; activated charcoal and atropine were administered. Upon hospital arrival, he received fluid resuscitation, activated charcoal, and atropine. He was transferred to a toxicology unit the next day. On admission, he had no cholinergic signs (dry mucous membranes, warm skin, and mydriatic pupils) requiring small atropine doses (0.5 mg per hour). Four hours after admission, he developed bradycardia and respiratory distress, necessitating intubation. He received atropine by continuous infusion for 7 days (248 mg total) and obidoxime (bolus and continuous infusion). PM, pirimiphos-methyl-oxon (PMO), and phosphorylated tyrosine (Tyr) adducts derived from human serum albumin were analyzed in vivo. Cholinesterase status (acetylcholinesterase (AChE), butyrylcholinesterase (BChE), inhibitory activity of patient plasma and reactivatability, and phosphorylated BChE-derived nonapeptides) was measured in vivo. Obidoxime and atropine were monitored. PM and PMO were detectable, PM with maximum concentration ∼24 h post admission (p.a.) and PMO at ∼18 h p.a. Tyr adducts were detectable. AChE in vivo was suppressed on admission, increased continuously after starting obidoxime, and reached maximum activity after ∼30 h. AChE in vivo and reactivatability remained at the same level until the end of monitoring. BChE was already suppressed on admission; termination of the antidote treatment was possible after BChE had recovered to 1/5th of its normal value and extubation was possible after BChE had recovered to 2/5th. While a substantial part of BChE was already aged on admission, aging continued peaking at ∼24 h p.a. After initiating obidoxime treatment, plasma levels increased until obidoxime plasma levels reached a steady state. On admission, plasma atropine level was low; it increased with the start of the continuous infusion. Afterward, the level dropped to a steady state. The clinical course was characterized by bouts of pneumonia, necessitating re-intubation and prolonged ventilation, sepsis, delirium, and a peripheral neuropathy. After psychiatric evaluation, the patient was discharged to a neurological rehabilitation facility after 77 days of hospital care. |
| first_indexed | 2024-04-11T05:27:12Z |
| format | Article |
| id | doaj.art-7f8362749cb94c1788010198ebafb1e5 |
| institution | Directory Open Access Journal |
| issn | 1663-9812 |
| language | English |
| last_indexed | 2024-04-11T05:27:12Z |
| publishDate | 2022-12-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Pharmacology |
| spelling | doaj.art-7f8362749cb94c1788010198ebafb1e52022-12-23T05:56:28ZengFrontiers Media S.A.Frontiers in Pharmacology1663-98122022-12-011310.3389/fphar.2022.11021601102160A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase statusTobias Zellner0Christian Rabe1Jens von der Wellen-Pawlowski2Dagmar Hansen3Harald John4Franz Worek5Florian Eyer6Division of Clinical Toxicology and Poison Control Centre Munich, Department of Internal Medicine II, TUM School of Medicine, Technical University of Munich, Munich, GermanyDivision of Clinical Toxicology and Poison Control Centre Munich, Department of Internal Medicine II, TUM School of Medicine, Technical University of Munich, Munich, GermanyBundeswehr Institute of Pharmacology and Toxicology, Munich, GermanyBundeswehr Institute of Pharmacology and Toxicology, Munich, GermanyBundeswehr Institute of Pharmacology and Toxicology, Munich, GermanyBundeswehr Institute of Pharmacology and Toxicology, Munich, GermanyDivision of Clinical Toxicology and Poison Control Centre Munich, Department of Internal Medicine II, TUM School of Medicine, Technical University of Munich, Munich, GermanyA 63-year-old male was admitted to a district hospital after ingesting ethanol and pirimiphos-methyl (PM) with suicidal intentions. History included alcoholic cirrhosis with alcoholism, adiposity, diabetes with cerebral microangiopathy, chronic renal insufficiency, heparin-induced thrombocytopenia, and status post necrotizing fasciitis. Emergency medical service reported an alert patient without signs of cholinergic crisis; activated charcoal and atropine were administered. Upon hospital arrival, he received fluid resuscitation, activated charcoal, and atropine. He was transferred to a toxicology unit the next day. On admission, he had no cholinergic signs (dry mucous membranes, warm skin, and mydriatic pupils) requiring small atropine doses (0.5 mg per hour). Four hours after admission, he developed bradycardia and respiratory distress, necessitating intubation. He received atropine by continuous infusion for 7 days (248 mg total) and obidoxime (bolus and continuous infusion). PM, pirimiphos-methyl-oxon (PMO), and phosphorylated tyrosine (Tyr) adducts derived from human serum albumin were analyzed in vivo. Cholinesterase status (acetylcholinesterase (AChE), butyrylcholinesterase (BChE), inhibitory activity of patient plasma and reactivatability, and phosphorylated BChE-derived nonapeptides) was measured in vivo. Obidoxime and atropine were monitored. PM and PMO were detectable, PM with maximum concentration ∼24 h post admission (p.a.) and PMO at ∼18 h p.a. Tyr adducts were detectable. AChE in vivo was suppressed on admission, increased continuously after starting obidoxime, and reached maximum activity after ∼30 h. AChE in vivo and reactivatability remained at the same level until the end of monitoring. BChE was already suppressed on admission; termination of the antidote treatment was possible after BChE had recovered to 1/5th of its normal value and extubation was possible after BChE had recovered to 2/5th. While a substantial part of BChE was already aged on admission, aging continued peaking at ∼24 h p.a. After initiating obidoxime treatment, plasma levels increased until obidoxime plasma levels reached a steady state. On admission, plasma atropine level was low; it increased with the start of the continuous infusion. Afterward, the level dropped to a steady state. The clinical course was characterized by bouts of pneumonia, necessitating re-intubation and prolonged ventilation, sepsis, delirium, and a peripheral neuropathy. After psychiatric evaluation, the patient was discharged to a neurological rehabilitation facility after 77 days of hospital care.https://www.frontiersin.org/articles/10.3389/fphar.2022.1102160/fullorganophosphatepesticideobidoximeatropinecholinesterase |
| spellingShingle | Tobias Zellner Christian Rabe Jens von der Wellen-Pawlowski Dagmar Hansen Harald John Franz Worek Florian Eyer A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase status Frontiers in Pharmacology organophosphate pesticide obidoxime atropine cholinesterase |
| title | A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase status |
| title_full | A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase status |
| title_fullStr | A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase status |
| title_full_unstemmed | A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase status |
| title_short | A case report of severe pirimiphos-methyl intoxication: Clinical findings and cholinesterase status |
| title_sort | case report of severe pirimiphos methyl intoxication clinical findings and cholinesterase status |
| topic | organophosphate pesticide obidoxime atropine cholinesterase |
| url | https://www.frontiersin.org/articles/10.3389/fphar.2022.1102160/full |
| work_keys_str_mv | AT tobiaszellner acasereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT christianrabe acasereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT jensvonderwellenpawlowski acasereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT dagmarhansen acasereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT haraldjohn acasereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT franzworek acasereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT florianeyer acasereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT tobiaszellner casereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT christianrabe casereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT jensvonderwellenpawlowski casereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT dagmarhansen casereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT haraldjohn casereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT franzworek casereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus AT florianeyer casereportofseverepirimiphosmethylintoxicationclinicalfindingsandcholinesterasestatus |