DR. PRIYA  KUBENDIRAN PROF. DR. MAGESH KUMAR M 1  UNIT
The Case… <ul><li>18 Yrs old female  was admitted on 23 rd  April </li></ul><ul><li>Alleged h/o consumption of organo phos...
<ul><li>CVS: S1S2 heard </li></ul><ul><li>RS: NVBS heard, B/L crepitations  </li></ul><ul><li>P/A soft </li></ul><ul><li>C...
<ul><li>CXR: WNL </li></ul><ul><li>ECG: NSR </li></ul><ul><li>Treatment Given: </li></ul><ul><li>Supportive  </li></ul><ul...
<ul><li>DAY 4 </li></ul><ul><li>Patient was shifted to ward </li></ul><ul><li>DAY 5 </li></ul><ul><li>H/O altered sensoriu...
<ul><li>CVS:S1S2 heard </li></ul><ul><li>RS:NVBS heard,B/L Crackles heard </li></ul><ul><li>P/A:soft </li></ul><ul><li>CNS...
<ul><li>DAY 10 </li></ul><ul><li>Pt  transferred to ward </li></ul><ul><li>DAY 12  </li></ul><ul><li>Pt experienced diffic...
<ul><li>NO H/O cranial nerve involvement </li></ul><ul><li>NO H/O unsteadiness in dark,swaying, involuntary movements </li...
<ul><li>Tone  UL  N  N </li></ul><ul><li>LL  </li></ul><ul><li>Power  UL  5  5 </li></ul><ul><li>LL  hip  3  3 </li></ul><...
<ul><li>Gait  -  couldn’t be tested </li></ul><ul><li>No sensory deficit  </li></ul><ul><li>no cerebellar signs </li></ul>...
<ul><li>NEURO LOGIST’S  OPINION: </li></ul><ul><li>?post toxic demyelination </li></ul><ul><li>Suggested inj methyl predni...
<ul><li>TREATMENT  & COURSE  </li></ul><ul><li>Inj methylprednisolone  1g iv od -  5 days </li></ul><ul><li>Inj  B complex...
FINAL DIAGNOSIS <ul><li>ORGANOPHOSPHORUS  POSONING /  </li></ul><ul><li>INTERMEDIATE SYNDROME /  </li></ul><ul><li>OPC  IN...
OPC POISONING <ul><li>Very  Common  Poisoning In Tamilnadu </li></ul><ul><li>3 Million Cases, 20,000 Deaths /YR World Wide...
Mechanism of OP’s
ANS Preganglionic Parasympathetic Sympathetic Somatic Nerves   Ach   Ach  Ach   Ach   Ach Ganglion   Epi   Skeletal Muscle...
Clinical Syndrome <ul><li>Acute Cholinergic:  </li></ul><ul><ul><li>Central </li></ul></ul><ul><ul><li>Peripheral Muscarin...
Muscarinic Effects (Wadia Type 1 syndrome <ul><li>D iarrhoea </li></ul><ul><li>U rination </li></ul><ul><li>M iosis </li><...
NICOTINIC FEATURES: CENTRAL : LESS WITH CARBAMATES <ul><li>Muscle Fasciculations </li></ul><ul><li>[Striated] </li></ul><u...
DELAYED COMPLICATIONS <ul><li>Occurs 24-96hrs,  </li></ul><ul><li>Weakness of  Ocular, Bulbar, Proximal Limb Muscles, And ...
OPIDN  ( Organophosphorus induced delayed neurotoxicity) <ul><li>The underlying pathology in OPIDN involves </li></ul><ul>...
Pathogenesis <ul><li>Due to inhibition of a protein called  Neuropathy target esterase (NTE)  by phosphorylation </li></ul...
<ul><li>Organophosphates + NTE  </li></ul><ul><li>initiate unknown events </li></ul><ul><li>toxin covalently attached  to ...
Neurological dysfunction of OPIDN <ul><li>Latent period:  Days to weeks </li></ul><ul><li>Progressive phase:  Symmetric cr...
Factors involved in the Development of OPIDN <ul><li>Chemical Structure </li></ul><ul><li>Animal Species: Humans are most ...
Chlorpyrifos-induced delayed polyneuropathy  <ul><li>Chlorpyrifos [0,0-diethyl 0-(3,5,6-trichloro-pyridyl) phosphorothioat...
CASE REPORT -Toxin induced neuropathy presenting as acute inflammatory demyelinating polyneuropathy <ul><li>Calicut Medica...
CASE REPORT - Guillain-Barre Syndrome Due to Organophosphate Compound Poison <ul><li>D Rajasekaran et al,  JAPI  October 2...
Methylprednisolone treatment of an organophosphorus-induced delayed neuropathy <ul><li>A high-dose regimen of methylpredni...
Effects of Prednisolone and complex of vitamin B1,B2,B6 & B12 on organophosphorus compound induced delayed neurotoxicity F...
Chronic organophosphate induced neuro psychiatric disorder (COPIND) <ul><li>Is a neurodegenerative disorder that results f...
 
Upcoming SlideShare
Loading in...5
×

Unusual Complication of OPC Poisoning

3,010

Published on

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
3,010
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
69
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Unusual Complication of OPC Poisoning

  1. 1. DR. PRIYA KUBENDIRAN PROF. DR. MAGESH KUMAR M 1 UNIT
  2. 2. The Case… <ul><li>18 Yrs old female was admitted on 23 rd April </li></ul><ul><li>Alleged h/o consumption of organo phosphorus pesticide (chlorpyrifos) </li></ul><ul><li>Qty unknown; h/o vomiting present </li></ul><ul><li>O/E Pt Conscious, oriented, afebrile, </li></ul><ul><li>excesive salivation </li></ul><ul><li>Pupils miotic, 0.5mm </li></ul><ul><li>PR: 70/min </li></ul><ul><li>BP: 100/70mm Hg </li></ul><ul><li>RR: 15/min </li></ul><ul><li>Spo2: 90% </li></ul>
  3. 3. <ul><li>CVS: S1S2 heard </li></ul><ul><li>RS: NVBS heard, B/L crepitations </li></ul><ul><li>P/A soft </li></ul><ul><li>CNS: NFND </li></ul><ul><li>INVESTIGATIONS </li></ul><ul><li>Sr cholinesterase: 190 IU/L </li></ul><ul><li>CBC: </li></ul><ul><li>Hb: 10g% </li></ul><ul><li>TC: 8000/cu mm </li></ul><ul><li>DC: P60/L38/E2 </li></ul><ul><li>ESR: 4/10 </li></ul><ul><li>RFT: </li></ul><ul><li>Sugar: 90mg% </li></ul><ul><li>Urea: 20mg% </li></ul><ul><li>Creatinine: 0.5mg% </li></ul>
  4. 4. <ul><li>CXR: WNL </li></ul><ul><li>ECG: NSR </li></ul><ul><li>Treatment Given: </li></ul><ul><li>Supportive </li></ul><ul><li>Atropine </li></ul><ul><li>Pralidoxime </li></ul>
  5. 5. <ul><li>DAY 4 </li></ul><ul><li>Patient was shifted to ward </li></ul><ul><li>DAY 5 </li></ul><ul><li>H/O altered sensorium since morning </li></ul><ul><li>H/O breathlessness </li></ul><ul><li>H/O increased Salivation </li></ul><ul><li>O/E : Pt conscious, drowsy, afebrile </li></ul><ul><li>Puplils miotic 0.5mm </li></ul>
  6. 6. <ul><li>CVS:S1S2 heard </li></ul><ul><li>RS:NVBS heard,B/L Crackles heard </li></ul><ul><li>P/A:soft </li></ul><ul><li>CNS: Pupils miotic </li></ul><ul><li>Plantar B/L flexor </li></ul><ul><li>Diagnosis - INTERMEDIATE SYNDROME </li></ul><ul><li>Was shifted back to IMCU </li></ul><ul><li>Serum cholinesterase levels : </li></ul><ul><li>28/04:221 IU/L </li></ul><ul><li>29/04:310IU/L </li></ul><ul><li>30/04:331 IU/L </li></ul><ul><li>01/05:500 IU/L </li></ul>
  7. 7. <ul><li>DAY 10 </li></ul><ul><li>Pt transferred to ward </li></ul><ul><li>DAY 12 </li></ul><ul><li>Pt experienced difficulty in walking </li></ul><ul><li>H/O dragging of feet while walking </li></ul><ul><li>Had difficulty in holding slippers </li></ul><ul><li>H/O difficulty in standing from squatting posture </li></ul><ul><li>No H/O upper limb involvement </li></ul><ul><li>No H/O muscle twitching </li></ul><ul><li>NO H/O cramps </li></ul>
  8. 8. <ul><li>NO H/O cranial nerve involvement </li></ul><ul><li>NO H/O unsteadiness in dark,swaying, involuntary movements </li></ul><ul><li>H/O tingling sensation in the legs </li></ul><ul><li>NO H/O alteration in bladder/bowel habits </li></ul><ul><li>NO H/O fever ,head injury </li></ul><ul><li>O/E : Pt conscious ,oriented, </li></ul><ul><li>Hr functions normal </li></ul><ul><li>Cranial nerves clinically normal </li></ul><ul><li>EOM full range, pupils B/L 4mm ERLA </li></ul>
  9. 9. <ul><li>Tone UL N N </li></ul><ul><li>LL </li></ul><ul><li>Power UL 5 5 </li></ul><ul><li>LL hip 3 3 </li></ul><ul><li>knee 3 3 </li></ul><ul><li>ankle 3 3 </li></ul><ul><li>Reflexes UL + + </li></ul><ul><li>knee - - </li></ul><ul><li>ankle - - </li></ul><ul><li>plantar no response </li></ul>
  10. 10. <ul><li>Gait - couldn’t be tested </li></ul><ul><li>No sensory deficit </li></ul><ul><li>no cerebellar signs </li></ul><ul><li>Provisional diagnosis - </li></ul><ul><li>? Toxin induced demyelination </li></ul>
  11. 11. <ul><li>NEURO LOGIST’S OPINION: </li></ul><ul><li>?post toxic demyelination </li></ul><ul><li>Suggested inj methyl prednisolone </li></ul><ul><li>NCS of all 4 limbs, EEG, MRI brain </li></ul><ul><li>INVESTIGATIONS : </li></ul><ul><li>EEG : normal </li></ul><ul><li>MRI BRAIN: normal </li></ul><ul><li>LP : acellular, </li></ul><ul><li>sugar - 50 mg/dl </li></ul><ul><li>protein - 76 mg/dl </li></ul><ul><li>NCS : s/o demyelination </li></ul>
  12. 12. <ul><li>TREATMENT & COURSE </li></ul><ul><li>Inj methylprednisolone 1g iv od - 5 days </li></ul><ul><li>Inj B complex im od </li></ul><ul><li>Her power gradually improved to grade 4 </li></ul><ul><li>She was advised : </li></ul><ul><li>T.Prednisolone 60 mg od - tapering dose </li></ul><ul><li>T. Ranitidine 150 mg bd </li></ul><ul><li>BCT bd </li></ul>
  13. 13. FINAL DIAGNOSIS <ul><li>ORGANOPHOSPHORUS POSONING / </li></ul><ul><li>INTERMEDIATE SYNDROME / </li></ul><ul><li>OPC INDUCED DELAYED NEUROPATHY (OPIDN) </li></ul>
  14. 14. OPC POISONING <ul><li>Very Common Poisoning In Tamilnadu </li></ul><ul><li>3 Million Cases, 20,000 Deaths /YR World Wide. </li></ul><ul><li>1930, Schrader, German, Studied Mech of Toxicity </li></ul><ul><li>Weapon of Chemical Warfare. </li></ul>
  15. 15. Mechanism of OP’s
  16. 16. ANS Preganglionic Parasympathetic Sympathetic Somatic Nerves Ach Ach Ach Ach Ach Ganglion Epi Skeletal Muscle Ach Ach Norepi Via Bld Effector Organs + Pupil -Heartrate +Exocrine Glands +GIT Smooth Muscle +Lung Smooth Muscle +Sweatgld -Bloodvessel [Some ] - Pupil +Heart Rate -Gastrointestinal SM -Lung SM +Blood Vessels [Most] Often The Parasympathetic Features Predominates Post Ganglionic
  17. 17. Clinical Syndrome <ul><li>Acute Cholinergic: </li></ul><ul><ul><li>Central </li></ul></ul><ul><ul><li>Peripheral Muscarinic </li></ul></ul><ul><ul><li>Peripheral Nicotinic </li></ul></ul><ul><li>Intermediate Syndrome </li></ul><ul><li>OPIDN: Delayed peripheral neuropathy </li></ul><ul><li>Neurocognitive dysfunction </li></ul>+ Death Respiratory failure }
  18. 18. Muscarinic Effects (Wadia Type 1 syndrome <ul><li>D iarrhoea </li></ul><ul><li>U rination </li></ul><ul><li>M iosis </li></ul><ul><li>B radycardia, Bronchorrhoea, Bronchospasm </li></ul><ul><li>E mesis </li></ul><ul><li>L acrimation </li></ul><ul><li>S alivation </li></ul>
  19. 19. NICOTINIC FEATURES: CENTRAL : LESS WITH CARBAMATES <ul><li>Muscle Fasciculations </li></ul><ul><li>[Striated] </li></ul><ul><li>Paralysis </li></ul><ul><li>Muscle Weakness </li></ul><ul><li>Hypertension </li></ul><ul><li>Tachycardia </li></ul><ul><li>Mydriasis [Rare] </li></ul><ul><li>Unconsciousness </li></ul><ul><li>Confusion, Fatigue </li></ul><ul><li>Toxic Psychosis, Seizures </li></ul><ul><li>Resp. Depression </li></ul><ul><li>Ataxia, Dysarthria </li></ul><ul><li>Extra Pyramidal Features. </li></ul>
  20. 20. DELAYED COMPLICATIONS <ul><li>Occurs 24-96hrs, </li></ul><ul><li>Weakness of Ocular, Bulbar, Proximal Limb Muscles, And Respiratory Failure. </li></ul><ul><li>Common With Dimethoate, Parathion, Malathion & Methly Parathion </li></ul><ul><li>ChE Activity 20% or Less During Onset </li></ul><ul><li>Causative Factor – Inadequate Oxime Therapy / Premature DIS. </li></ul><ul><li>Recovery in 4 – 18 Days. </li></ul><ul><li>Electrophysiological study shows significant decremental response at low frequency stimulation </li></ul>INTERMEDIATE SYNDROME : [FIRST DESCRIBED IN 1987] [WADIA TY-II]
  21. 21. OPIDN ( Organophosphorus induced delayed neurotoxicity) <ul><li>The underlying pathology in OPIDN involves </li></ul><ul><li>bilaterally symmetrical degeneration of sensory and motor axons in distal regions of peripheral nerves and spinal cord tracts. </li></ul><ul><li>The distal part of longest, largest diameter fibers tend to be preferentially affected. </li></ul><ul><li>Lesions are characterized by the degeneration of axons with subsequent secondary degeneration of myelin </li></ul>
  22. 22. Pathogenesis <ul><li>Due to inhibition of a protein called Neuropathy target esterase (NTE) by phosphorylation </li></ul><ul><li>NTE is an integral membrane protein present in all neurons and in some non-neural-cell types of vertebrates. </li></ul><ul><li>Recent data indicate that NTE is involved in a cell-signalling pathway controlling interactions between neurons and accessory glial cells in the developing nervous system </li></ul>
  23. 23. <ul><li>Organophosphates + NTE </li></ul><ul><li>initiate unknown events </li></ul><ul><li>toxin covalently attached to active-site of NTE </li></ul><ul><li>Toxic gain of function of NTE </li></ul><ul><li>(delay of 1±3 weeks), </li></ul><ul><li>neuropathy with degeneration of long axons </li></ul>
  24. 24. Neurological dysfunction of OPIDN <ul><li>Latent period: Days to weeks </li></ul><ul><li>Progressive phase: Symmetric cramping, </li></ul><ul><li>numbness and tingling in feet and legs, bilateral dragging of toes (foot-drop), flaccid paralysis. </li></ul><ul><li>3. Stationary Phase </li></ul><ul><li>4. Improvement Phase: Results from regeneration of PNS; CNS damage becomes unmasked as spasticity and exaggerated knee jerk. </li></ul><ul><li>5. Prognosis: Depends on severity of initial symptoms </li></ul>
  25. 25. Factors involved in the Development of OPIDN <ul><li>Chemical Structure </li></ul><ul><li>Animal Species: Humans are most sensitive </li></ul><ul><li>Individual differences </li></ul><ul><li>Dose or Concentration at Neurotoxicity Site: </li></ul><ul><li>a. Exposure dose </li></ul><ul><li>b. Frequency of exposure </li></ul><ul><li>c. Duration of exposure </li></ul><ul><li>d. Route of Exposure </li></ul><ul><li>e. Other chemical exposure </li></ul><ul><li> f. Stress </li></ul>
  26. 26. Chlorpyrifos-induced delayed polyneuropathy <ul><li>Chlorpyrifos [0,0-diethyl 0-(3,5,6-trichloro-pyridyl) phosphorothioate] caused delayed polyneuropathy in man. Chlorpyrifos was slowly absorbed after single oral doses and the threshold of inhibition (>70%) of neuropathy target esterase (NTE) , the putative target for delayed neuropathy, was reached within 5–6 days </li></ul>Eugenio Capodicasa et al, Archives of Toxicology Volume 65, Number 2 ,
  27. 27. CASE REPORT -Toxin induced neuropathy presenting as acute inflammatory demyelinating polyneuropathy <ul><li>Calicut Medical Journal 2010 (Manthappa M et al) </li></ul><ul><li>An adult male patient presented to us with with </li></ul><ul><li>bilateral symmetric polyneuropathy resembling </li></ul><ul><li>acute inflammatory demyelinating neuropathy </li></ul><ul><li>(AIDP). On further questioning, patient gave </li></ul><ul><li>history of exposure to organophosphate </li></ul><ul><li>insecticides. Sural nerve biopsy revealed </li></ul><ul><li>features consistent with toxin induced </li></ul><ul><li>neuropathy. </li></ul>
  28. 28. CASE REPORT - Guillain-Barre Syndrome Due to Organophosphate Compound Poison <ul><li>D Rajasekaran et al, JAPI October 2009 </li></ul><ul><li>Clinical features and investigations of our patient strongly indicated that GBS that he had manifested as a sequelae of OPC poisoning which is possibly toxin induced delayed demyelination </li></ul>
  29. 29. Methylprednisolone treatment of an organophosphorus-induced delayed neuropathy <ul><li>A high-dose regimen of methylprednisolone started 30 to 40 min after DFP exposure and lasting for 20 days prevented the development of OPIDN. </li></ul>Thomas Baker and Anna Stanec Toxicology and Applied Pharmacology Volume 79, Issue 2 , 30 June 1985,
  30. 30. Effects of Prednisolone and complex of vitamin B1,B2,B6 & B12 on organophosphorus compound induced delayed neurotoxicity Fengyuan Piao et al, J Occup Health 2004 <ul><li>It was observed that delayed neuropathy induced by OPs could not be resisted completely by the treatment with prednisolone or vitamin b complex, but clinical signs of OPIDN and pathological changes in hens that received these 2 protective agents after OPs were less severe than those in hens that received only OPs </li></ul>
  31. 31. Chronic organophosphate induced neuro psychiatric disorder (COPIND) <ul><li>Is a neurodegenerative disorder that results from large toxic or small subclinical doses of OPCs. </li></ul><ul><li>Clinical signs, which continue for weeks to years, consist of neurological abnormalities </li></ul><ul><li>drowsiness, </li></ul><ul><li>confusion, lethargy, anxiety, emotional lability, </li></ul><ul><li>depression, fatigue ,irritability, memory disturbances </li></ul><ul><li>Neuronal cell death is seen in various brain areas including cerebral cortex, hippocampal formation and cerebellum. </li></ul><ul><li>Cell death results from early necrosis or delayed apoptosis. </li></ul>
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×