Intermediate Syndrome Following Acute Organophosphate Poisoning: Correlation with Initial Serum Levels of Muscle Enzymes

Suspected intermediate syndrome in a dog after organophosphate poisoning

OBJECTIVE

To discuss the clinical presentation and successful treatment of a suspected case of intermediate syndrome due to organophosphate (OP) poisoning in a dog.

CASE SUMMARY

Two dogs presented with acute cholinergic signs after ingesting an OP insecticide containing 50% acephate. Clinical signs consistent with acute cholinergic crisis resolved in both dogs within 24 hours postingestion. One dog developed an onset of neurological signs consistent with intermediate syndrome approximately 24 hours postingestion. This patient's clinical signs resolved with the use of pralidoxime chloride.

NEW OR UNIQUE INFORMATION PROVIDED

OP poisoning most commonly presents as an acute cholinergic crisis, with rare instances of animals developing intermediate syndrome. Few reports of successful treatment and recovery from intermediate syndrome exist in the veterinary literature, particularly with instances in which 2 dogs within the same exposure setting were treated for acute cholinergic signs and only 1 progressed to an intermediate syndrome. This report also highlights the importance of early intervention with pralidoxime chloride prior to the onset of aging.

Assessment of the Serum Glucose/Potassium GLU/K Ratio as a Predictor of Intermediate Syndrome Following Acute Anticholinesterase Exposure

BACKGROUND

The widespread use of anticholinesterase-containing pesticides accounts for the considerable morbidity and mortality in Egypt and worldwide.

AIM

Few studies have investigated the predictors of intermediate syndrome (IMS). Therefore, in this study, we assessed the adequacy of the serum glucose/potassium (GLU/K) ratio as an early reliable tool to predict IMS incidence following intoxication with acute anticholinesterase compounds.

METHODS

A prospective cross-sectional study was conducted among patients who presented to Tanta University Poison Control Center, Egypt, and were diagnosed with acute anticholinesterase intoxication between January and August, 2021. Patients were categorized based on the primary outcome into IMS (+) and IMS (-) groups.

RESULTS

Overall, 243 patients were included, among whom 44 (18.1%) had IMS as the complication. Younger individuals with age ranging between 18 and <25 years constituted the main exposed age category in both groups. Vomiting and abdominal colic were the most commonly noted complaints in the included patients (94.2% and 63.8% of patients, respectively). The delay, length of hospital stay, mean blood pressure, O₂ saturation, Glasgow Coma Scale score, random blood glucose level, K concentration, GLU/K ratio, and dose of atropine administered were significant IMS predictors on an individual basis, and the GLU/K ratio was the most significant IMS predictor. At a cutoff value of >41.07%, the GLU/K ratio could significantly predict IMS (areas under the curves = 0.971, p < 0.001) with 93% accuracy, 93.2% sensitivity, and 93% specificity.

CONCLUSION

Although the clear pathophysiology of IMS remains to be elucidated, our results provide insight into the significant contribution of neurological affection, apart from the well-known direct toxic effect on muscles. Moreover, we demonstrated a significant association between the development of IMS and severity of organophosphorus compounds' exposure. Physicians should be vigilant to detect IMS early upon admission using the GLU/K ratio, which is a useful early IMS predictor.

Prediction of organophosphorus insecticide-induced intermediate syndrome with stimulated concentric needle single fibre electromyography

BACKGROUND

Deliberate self-poisoning (DSP) using organophosphorus (OP) insecticides are a common clinical problem in Asia. OPs inhibit acetylcholine esterase (AChE), leading to over-activity of muscarinic and nicotinic cholinergic circuits. Intermediate syndrome (IMS) is mediated via prolonged nicotinic receptor stimulation at the neuromuscular junction and its onset is between 24-96 hours post ingestion. The aims of the present study were 1) to investigate whether neuromuscular junction dysfunction within the first 24 hours following exposure, quantified by jitter in single fibre electromyography (SfEMG), can predict IMS, and 2) to compare the changes in SfEMG jitter over the course of the illness among patients who developed IMS (IMS+) and those who did not (IMS-).

METHODS AND FINDINGS

We conducted a prospective cohort study in a tertiary care hospital in Sri Lanka on 120 patients admitted between September 2014 and August 2016 following DSP by OP insecticides viz., profenofos 53, phenthoate 17, diazinon 13, chlorpyrifos 5, others 12, unknown 20. SfEMG was performed every second day during hospitalization. Exposure was confirmed based on the history and red blood cell AChE assays. IMS was diagnosed in patients who demonstrated at least three out of four of the standard IMS criteria: proximal muscle weakness, bulbar muscle weakness, neck muscle weakness, respiratory paralysis between 24-96 hours post ingestion. Respiratory failure requiring intubation occurred in 73 out of 120 patients; 64 of these were clinically diagnosed with IMS. Of the 120 patients, 96 had repeated SfEMG testing, 67 of them being tested within the first 24 hours. Prolonged jitter (>33.4μs) within the first 24 hours was associated with greatly increased risk of IMS (odds ratio = 8.9, 95% confidence intervals = 2.4-29.6, p = 0.0003; sensitivity 86%, specificity 58%). The differences in jitter between IMS+ and IMS- patients remained significant for 72 hours and increased jitter was observed in some patients for up to 216 hours. For intubated patients, the median time for jitter to normalize and median time to extubate were similar, and the two variables had a moderate positive correlation (r = 0.49, P = 0.001).

CONCLUSIONS

Prolonged jitter recorded with SfEMG <24 hours of ingestion of an OP strongly correlates with subsequent occurrence of IMS. The time course of electrophysiological recovery of the NMJ was similar to the time course of respiratory recovery in IMS patients.

Evaluation of attenuative effect of tert-butylhydroquinone against diazinon-induced oxidative stress on hematological indices in male Wistar rats

Diazinon is an organophosphate toxicant that has been identified to induce oxidative stress within biological systems through altering biochemical and hematological indices, by generating free radicals while deteriorating the cellular antioxidant defense system. The present study was designed to evaluate the effectiveness of tert-butylhydroquinone (TBHQ), a synthetic food additive, in serving as an antioxidant against sub-lethal diazinon-induced oxidative stress in male Wistar rats. Animals were randomly divided into 4 groups: Control (treated with corn oil as a vehicle), diazinon (10 mg/kg/day), TBHQ (0.028 g/kg of diet) and a combination group of TBHQ (0.028 g/kg of diet) plus diazinon (10 mg/kg/day). All animals were treated orally once a day by gastric tube and treatments were continued for 7 weeks. Hematological indices, including red blood cell (RBC) indices and white blood cell (WBC) and platelet counts, were measured at the end of the treatment schedule. On comparison of the treatment groups with the untreated control group, RBC count, hemoglobin (Hb), hematocrit (Hct), mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) were significantly decreased in the diazinon and TBHQ+diazinon groups, while MCHC in the TBHQ group and MCV in the diazinon and TBHQ+diazinon groups were significantly increased. When the diazinon and TBHQ+diazinon groups were compared with the TBHQ group, RBC, Hb, Hct, and MCHC were significantly decreased whereas MCV was increased in both groups. Additionally, when comparing the TBHQ+diazinon group with the diazinon group, MCHC was determined to be significantly decreased. The results of the current experiments suggested that TBHQ could not efficiently protect blood cells against diazinon toxicity.

Betanin reduces organophosphate induced cytotoxicity in primary hepatocyte via an anti-oxidative and mitochondrial dependent pathway

Organophosphates (OP) are potent pesticide commonly utilized in agricultural and domestic use. However, plentitude of data represent their side effects in different body tissues. We attempted to study whether betanin (a natural pigment) is able to mitigate some OPs-induced hepatotoxicity in primary rat hepatocytes. Cell viability, lactate dehydrogenase (LDH) leakage, reactive oxygen species (ROS) formation, lipid peroxidation (LPO), glutathione (GSH) depletion and mitochondrial depolarization were tested as toxicity markers. The outcomes revealed that betanin (25μM) significantly increased cell viability, plummeted ROS formation and LPO, restored cellular GSH reservoirs and protected mitochondria after chlorpyrifos (CPF) (300μM), diazinon (DZN) (600μM) and dichlrovos (DDVP) (400μM) treatment. Taken together, all data suggests the potential protective role of betanin in OPs-induced hepatotoxicity in which the mechanism appears to be inhibition of ROS formation and mitochondrial protection.

Can we predict intermediate syndrome? A review

INTRODUCTION

Ingestion of organophosphorus insecticides (OPI) is a common method of deliberate self harm in the developing world. Deaths mainly follow as a result of the respiratory failure associated with both cholinergic crisis and the intermediate syndrome. Even though death can be prevented by early mechanical ventilation of these patients, limited studies are available regarding the prediction of intermediate syndrome and subsequent respiratory failure.

OBJECTIVE

To systematically review articles that are published with regard to possible prediction of intermediate syndrome using clinical, biochemical and electrophysiological parameters.

METHODS

A systematic review on literature published in English language was done in the PubMed database without a date limitation. Two sets of search terms were used. The first set consisted of MeSH Terms "organophosphates", "organophosphate poisoning", "op poisoning" "organophosphate insecticide poisoning" and "organophosphorus". The second set included the MeSH Terms "Intermediate syndrome", "proximal muscle weakness", "cranial nerve palsies", "respiratory depression" and "neck muscle weakness". Articles containing at least one word from each set were reviewed.

RESULTS

At least one MeSH term from each set was incorporated in 179 articles. Of these, 69 were rejected as they were not related to organophosphate poisoning or intermediate syndrome.

PREDICTION OF IMS

Clinical prediction is mostly based on ICU scoring systems. Biochemical markers such as reduced levels of serum and erythrocyte acetylcholine esterase have been studied many times. Both clinical and biochemical markers show a modest relationship in predicting IMS. Single fibre electromyography show promising results as it directly assesses neuromuscular junction.

CONCLUSION

The intermediate syndrome which follows organophosphate poisoning still remains a significant problem with its high morbidity. Clinical and biochemical markers show modest results in predicting IMS. Neurophysiological markers such as single fibre EMG should be studied further as they measure activity of affected nicotinic receptors directly.

Serum creatine phosphokinase as predictor of intermediate syndrome in organophosphorus poisoning

Background:

Organophosphorus (OP) compounds are commonly used pesticides. In OP poisoning, intermediate syndrome (IMS) manifests between the end of the acute cholinergic crisis and delayed neuropathy. Respiratory paralysis in IMS, if identified early can reduce the need for ventilator support, morbidity, and mortality. Serum creatine phosphokinase (CPK) is elevated in IMS. The objectives of our study were to measure serum CPK level, correlate CPK levels with severity of poisoning and estimate atropine dose used.

Materials and Methods:

A prospective, observational study was conducted for 1-year. Patients diagnosed with OP poisoning were included. Demographic characteristics, type of poison, time since poisoning, Peradeniya Organophosphorus Poisoning (POP) score, serum pseudocholinesterase, CPK levels, atropine dose, and outcome of treatment were documented.

Results:

Seventy-five patients were recruited of which 57% and 43% were males and females, respectively, with a mean age of 31.48 ± 11.76 years. The most common OP compound was chlorpyriphos followed by triazophos and methylparathion. The time required to reach hospital was 181.26 ± 89.53 min. About 73.3% and 26.7% of patients had mild and moderate poisoning, respectively, as per POP scale. Pseudocholinesterase level was 364 (205–2168) IU. The amount of atropine used was 190.66 ± 78.83 mg. Serial serum CPK values were 279.72 ± 350.21 IU, 389.78 ± 376.33 IU and 163.13 ± 155.15 IU at admission, 48 h, and 96 h after admission, respectively. A weak positive correlation between serum CPK levels and severity of poisoning (r = 0.352) was observed. All patients recovered completely within 10.69 ± 5.57 days. Three patients developed IMS, and their serial CPK levels were 1837.33 ± 243.19 IU/L, 1935 ± 97.41 IU/L, and 714.66 ± 394.82 IU/L; and recovered in 17 ± 5.6 days.

Conclusion:

Increased serum CPK levels at 48 h after poisoning was observed in all the patients, but three patients had more than 1500 IU/L, who manifested with IMS. Early diagnosis of IMS by serial estimation of CPK may help in timely intervention and reduce further life-threatening complications.

Dimethoate-induced oxidative damage in erythrocytes of female adult rats

Pesticide hazards have been accentuated by the sharp rise in their agricultural, industrial and domestic use. Acute exposure to pesticides can cause oxidative damage. Our study investigated the potential ability of selenium (Se) and/or vitamin E, used as nutritional supplements, to alleviate erythrocyte oxidative damage induced by dimethoate (DM), an organophosphate pesticide. Female Wistar rats were exposed to DM (0.2g/L−1 of drinking water), DM + Se (0.5 mg/kg of diet), DM + vitamin E (100 mg/kg of diet), or DM + Se + vitamin E. Rats exposed to DM for 30 days showed an increase in malondialdehyde levels, superoxide dismutase and glutathione peroxidase activities in their erythocytes, while Na+,K+-ATPase and catalase activities, glutathione, non-protein thiol, vitamin E and vitamin C levels decreased. We also noted an increase in lactate dehydrogenase activity, marker of haemolysis and a decrease in acetylcholinesterase, the principal mode of organophosphorus action. Co-administration of Se or vitamin E to the diet of DM-treated rats ameliorated the biochemical parameters cited above. But the combined effect of Se and vitamin E was more powerful in antagonizing DM-induced oxidative stress. Therefore, our investigation revealed that both Se and vitamin E were useful elements in preventing DM-induced erythrocytes damage.